Better understanding of the anatomical terrain also led to another important bonus: Surgeons now knew exactly where the scalpel could and could not go. So, depending on the extent of a man’s cancer, it became possible for them either to save these nerves deliberately, or to remove more tissue by cutting these bundles away—in surgical terms, to create “wider margins of excision”— than they previously had believed possible. (Before this discovery, surgeons routinely gave this area a wider berth because they were afraid of injuring the patient’s rectum.) Which means that with these anatomical techniques, surgeons now have a better chance of removing all the cancer.
Today at Johns Hopkins (the hospital is noted here because results vary worldwide, depending on a range of factors including the surgeon’s skill and the selection criteria for patients), in men aged 50 to 59 who undergo anatomical radical retropubic prostatectomy, 75 percent regain potency. (Overall, at ten years or more after surgery, only 4 percent have local recurrence of cancer, and only 7 percent develop distant metastases; and 70 percent have an undetectable level of PSA.) Important determinants in the return of sexual function include age, the stage of cancer, and the extent of nerve loss—whether one or both nerve bundles remain, or whether they had to be removed during surgery.
We used to say, “If we make a diagnosis and you’re going to need surgery, it may make you incontinent and impotent.” And patients said, “Hold the phone! I’d rather have the disease.” Now, when we talk to patients, we tell them we have three goals: Removing all of the tumor, preserving urinary control, and preserving sexual function. Sexual function is number three because, if it is lost, there are many ways to restore it.
Men who are impotent following radical prostatectomy have normal sensation, normal sex drive, and can achieve a normal orgasm. The one element they may be lacking is the ability to have an erection sufficient for intercourse, and that can be restored by means including a vacuum erection device, injections, even a penile prosthesis.
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