ORLANDO--Impotence and incontinence, the radical prostatectomy
complications that patients fear most, can be reduced through
simple modifications in surgical technique without compromising
cancer control, according to two reports presented at the American
Urological Association's 91st annual meeting.
Previous anatomic refinements had brought the positive margin
rate down to 8%, but had also resulted in a marked reduction in
potency, down to approximately 20%, said Peter T. Scardino, MD,
professor and chair of the Scott Department of Urology, Baylor
College of Medicine, Houston.
Thus, he developed a new technique, first used in November 1993.
"I felt it was very important, if patients were to continue
to accept this kind of surgery, to go back and preserve some of
the nerve tissue and allow more patients to recover potency while
maintaining a low rate of positive margins," he said.
Dr. Scardino noted that the nerves controlling erection lie immediately
adjacent to the prostate, near the posterior-lateral area of the
prostate, where cancers tend to arise and extend. A major concern,
he said, was "whether nerve-sparing to preserve potency could
become cancer-sparing," a problem borne out in some series.
His technique permits careful nerve dissection away from the prostate
near the apex of the urethra, while getting completely around
the cancer. In his analysis of the first 450 patients treated
with the new technique, the positive margin rate has remained
low overall, at 12%.
"We were able to increase the potency rate at 1 year in men
under age 65 to around 58%, rising to 65% at 2 years," he
said. In men over age 65, one third were found to be potent after
surgery. Age was the second most important determinant of postoperative
potency after technique in the multivariate analysis.
"Men need to understand that age is a powerful predictor
of recovery of erections," Dr. Scardino said, adding that
younger men can afford more compromise in potency because their
erections tend to be stronger before surgery. Indeed, preoperative
erectile function was the third most important factor linked to
postoperative potency in this series.