Although radical prostatectomy (complete surgical removal of the prostate) is the best way to cure cancer that is confined to the prostate, many men choose not to undergo the procedure to avoid the possibility of side effects--in particular, impotence and/or incontinence. But a new study shows that when the procedure is done by a highly experienced surgeon, "side effects are minimal and the outcome is quite good," says lead author Dr. Patrick Walsh, director of the Brady Urological Institute at Johns Hopkins Medical Institutions in Baltimore. Some centers report that only 50% of their patients are continent and 10-30% are potent after radical prostatectomy, but many centers of excellence report "much higher" potency and continence rates, he asserts.
Why the discrepancies? Until now, they were attributed to differences in data collection, Dr. Walsh explained in an interview. It seemed that patients reported worse side effects on anonymous questionnaires than when they spoke directly to their doctors, and this was said to influence side effect rates.
But when Dr. Walsh and colleagues used anonymous questionnaires to assess side effect rates in 64 of their radical prostatectomy patients, they found that 98% had only minor problems, if any, with urinary control one year after the operation. Potency was assessed a year and a half after the procedure, and the results varied with age; 100% of men 30-39 years of age were potent, as were 88% of men aged 40-49, 90% of men aged 50-59, and 75% of men aged 60-67. The results appear in the January issue of the journal Urology.
"Radical prostatectomy is a difficult, demanding operation," Dr. Walsh observes. "Patients who feel that the procedure is the best treatment for their condition should seek out physicians who do a lot of them."
In a separate study in the same journal, the researchers found that videotaping surgery provides an opportunity for surgeons to improve their outcomes. By comparing videotaped surgery of 10 men who remained continent and potent 3 months later with 10 men who were not potent a year after the procedure, Dr. Walsh identified four small variances in surgical technique that were associated with better outcomes; the small changes in technique were needed because of subtle anatomical differences among patients. Videotapes can be used for review by individual surgeons to compare their technique in patients with different outcomes, and also could be swapped among institutions to improve outcomes overall.
Until the advent of PSA testing in the early 1990s, prostate cancer was rarely diagnosed at a curable stage, so the potential benefits of radical prostatectomy did not outweigh the possible side effects. But today, he says, "we're diagnosing most men in the United States with curable disease. Many are young, potent, and have a sexual partner. So the good news is, men diagnosed with early prostate cancer can be saved from dying of metastatic cancer 10 or 15 years later. Now the side effects of this operation should be reduced to the point where you have both extension of life and quality of life."