Why do most men get ED after Nerve Sparing Prostatectomy?
Declan Murphy is a Urology Surgeon and Director of Genital Urinary Cancer at Peter MacCallum Cancer Center. He has done just over 2,000 Prostatectomies during his career and now specialises in Prostate Cancer full time. In this interview, we talk about nerve-sparing surgery and sexual function expectations.
What is a Nerve-Sparing Prostatectomy?
When we do a prostatectomy it's because that patient has prostate cancer. So one of the first goals of the surgery is to make sure that we adequately manage that prostate cancer by taking it out.
But unfortunately, the prostate lives in a very difficult part of the world.
It lives in an area that really wasn't meant to be interfered with. And there are two very important structures nearby that concern us as prostate cancer surgeons.
The first of those is the sphincter muscle, the urethra sphincter, the valve that opens and closes to allow a man to pass his urine and that's actually attached onto the prostate. So we have to be very careful in how we remove that sphincter from the prostate.
But the second area of interest for us around the prostate are these nerves, the famous nerves. These nerves run from the spinal cord down alongside the prostate and up to the penis. They are responsible for erections.
And unfortunately, they are very, very close to the prostate. I often say they are like skin attached onto the prostate and when we want to do nerve sparing surgery we're trying to preserve those nerves.
We have to be very close to the prostate and peel off that skin if you like, and leave those nerves behind.
Where happens to these nerves that are ‘spared’?
The nerves tend to sit within a kind of a bundle - a nerve bundle. And within the bundle there are fat and blood vessels and nerves and so on. So they tend to run like a train track.
When we do nerve sparing, it's always a planned thing. We take into account what sort of cancer the patient has got, is it close to the nerves or away from it. And also, how important are these nerves to the patient? Is the patient sexually active and so on and so forth.
Why is it that most men, even when they have nerve sparing, straight after surgery usually have erectile dysfunction?
Yes, this is true, it's almost a miracle in my experience if a patient gets reasonable erections anytime within months after this type of surgery. And those same patients may have very good return of their erections two years after surgery, but they are not getting erections in the early months after surgery.
We believe this is because these nerves are not meant to be touched on. You're not supposed to get near them. So even if they are physically intact and they haven't been removed or divided and so on, they do not like being anywhere near a Prostatectomy.
So even though we can see things really well and we can be very careful in how we preserve those nerves, they go into kind of shock afterwards and they just are paralysed and they're not working.
We've studied the nerves very intensely so we have precautions we can take about how we handle them. But even if you do all that on the nerves, sometimes they never get going again. So there's a lot we don't understand still.
That’s why I think we have to make sure our patients have realistic expectations about the short term and the long term likelihood of return of sexual function.
What do you tell patients to expect after nerve-sparing Prostatectomy?
The two expectations I give are
It is a miracle if you get an erection in the early few months. So if a patient does get erections within those first months they're very pleased. They go, "Wow, I wasn't expecting this." Whereas if your expectation is, "Well, I'm having nerve sparing, I think my reactions will be the same next Saturday night." No, they won't be.
Then I adjust expectations for the individual patient based on his age and the quality of his erections already and the amount of nerve sparing we can do. What are the expectations down the line one year later, two years later, because it can take that long.
I believe we need to give realistic predictions tailored to that patient about what the return of erections might be like or might not be like.
Do we have any way of directly measuring nerve recovery after surgery?
A lot of my patients ask that, is there a test we can do to see if the nerves are working? and the answer is no.
We published a paper a couple of years ago about using intra-operative nerve stimulation because of course we're always trying to find ways of improving nerve preservation.
There's a technology called ProPep that's FDA approved in the US so we did a prospective study where we used this nerve stimulation technology in theater in the robot to see if we could identify these nerves to improve outcomes.
And what we concluded was, first of all, the nerve supply is very variable. It's not like there's a freeway down there and that's the way that Google Maps will take you. Nerves tend to move around.
And secondly, we show that it was a really nice technology but it didn't help. It didn't improve the quality of the nerve sparing.
We were still very optimistic about future technologies to help, but I think we still have a way to go to improve technical aspects beyond where we currently are.
Plus, I don't think gadgetry necessarily will do that. I think the single best way to maintain erectile function in a patient with prostate cancer is not to have any treatment at all.
And hence we do a lot of active surveillance now. We have a lot of men with prostate cancer who do not need surgery. And then they maintain their quality of life from sexual function.
The big message here is if you do anything to the prostate, whether it's surgery, even high quality surgery done by experts in big centers, radiotherapy, or even some of the novel treatments like focal therapies. Any of those things will impact sexual function to some degree and we must be accepting of that.
What do you feel it’s important every patient talks to their urologist about before treatment?
Men, if they're diagnosed early, have a low chance of dying of their prostate cancer if they're managed well. And that tends to be the main focus - the cancer.
But, I think it's really, really important that we have that conversation with patients to say, "Yes, we'll probably be able to manage this cancer. We'll do a nice job on this. But how do you feel about sexual function? How do you feel about at least temporary urinary incontinence?"
Because everyone gets blindsided by the cancer in the beginning.
So a very typical story for me is six months or a year after surgery, a patient has done really well, the cancer is gone, it's undetectable, the continence has come back really quickly and they're doing great, but no erections.
And you know what, the same patient would have sat in my office before surgery and said, "No, no, I just want to make sure I don't die of this prostate cancer. My mate died of it and I've got grandkids"
But then you refocus, because it's still the same 61-year-old patient who's now cured of cancer, continent again, but has had no erections for six months.
We really try and get patients to understand the impact of surgery and radiation treatment on short term and long term function.
Big complications are very rare with high quality surgery, but sexual function at least short term, often longterm, is very common.
So what we need to do is support patients better. We need to prepare people beforehand, and we need to have options available to say: "Here's what you can try to support this very predictable, at least in the short term, part of your recovery."