July 31, 2014

   A Publication of the James Buchanan Brady
   Urological Institute Johns Hopkins Medical Institutions

Volume V, Winter 2000
Continence and Potency After Radical Prostatectomy
Hopkins Study Finds Best Rates Ever

When radical prostatectomies are performed by experienced surgeons, "the results can be excellent," says Patrick Walsh. He recently has worked to make a good operation even better.

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As surgical procedures go, radical prostatectomy is one of the most delicate, intricate, and flat-out difficult to perform correctly. Proof of this can be found in the widely varying rates of success of surgeons at hospitals throughout the world -- not simply in controlling cancer, but in preserving a man's quality of life in two major areas: Urinary continence and sexual potency.

Postoperative PSA levels give doctors an excellent grasp of a patient's cancer status; they provide a definitive means of knowing whether all of the tumor has been removed. But there aren't such objective ways to tell how a man's doing in the other important areas: Often, it's up to the patient to report his success in continence and potency -- and very often, these are the last things men want to discuss, even with their doctors.

Recently, before they underwent radical prostatectomy at Hopkins, 64 men agreed to participate in a health-related quality of life survey, to be sent to an independent third party, a data analyst who had no access to their patient records. (All of the men reported that they were potent and that they had a sexual partner before the surgery.)

By one year after surgery, 93 percent of the men reported that they were dry -- that during the previous four weeks, they had not needed a pad or adult diaper to control urinary leakage. When the men were asked to say how much their urinary continence bothered them, 98 percent said they had either a small bother, or none at all. In terms of potency, at 18 months after surgery, 86 percent of the men were able to have intercourse. When asked about difficulty with erections, 84 percent of the men said they had either a small bother, or none at all. Looking at the potency rates by age, at 18 months after surgery, 100 percent of men in their thirties were potent; 88 percent of men in their forties, 90 percent of men in their fifties, and 75 percent of men in their sixties were potent.

Urologist-in-chief Patrick C. Walsh, M.D., who led the study, was not surprised at the success with urinary continence; he has reported the same results for many years. "In the long run," he says, "only about 2 percent of patients have significant long-term problems with urinary control" (defined as needing to change a pad more than once a day). "We are currently trying to eliminate that 2 percent." (See "Perfecting the Radical Prostatectomy.") The men's results with sexual potency, however, "are better than we've ever reported," says Walsh. They are also the highest potency rates reported at any academic medical center.


Urinary Continence and sexual Function After Radical Prostatectomy
3 months     6 months 12 months 18 months
Continence
No pads 54 percent 80 percent 93 percent 93 percent
No/small bother 96 percent 93 percent 98 percent 95 percent
Sexual Function
Potent 38 percent 54 percent 73 percent 86 percent
No/small bother 49 percent 64 percent 76 percent 84 percent
Used Viagra 7 percent 13 percent 33 percent 33 percent*
*Only two men cannot have intercouse without Viagra.


Walsh credits this to several factors: "One is that patients are being identified with smaller tumors, which permits us to preserve both neurovascular bundles without compromising cancer control." In this study, both neurovascular bundles were preserved in 89 percent of the men; this was accomplished without incurring positive surgical margins. There was only one positive surgical margin (which means that cancer cells were found in the edge of the removed prostate tissue) in this series of patients. (Cancer cells were found at the bladder neck in a man who had extensive disease.)

Also, Walsh adds, "over time the surgical technique has gradually improved, and finally, today Viagra is available." In the study, at 18 months after surgery, one third of the men said they were using Viagra, although only two patients said they could not have intercourse without it.

"I believe that most men who are incontinent or impotent following surgery want help. If the urologist poses these questions with the intention of helping the men overcome these problems and get their lives back to normal, I believe men will tell the truth."

Although the Hopkins radical prostatectomy results are the best in the world, other experienced surgeons at large referral hospitals and academic medical centers have obtained similar rates for urinary continence, and potency rates as high as 68 percent. Unfortunately, however, the success of radical prostatectomy is not uniform; patients at some centers report much greater trouble with side effects. For example, a study from Harvard recently reported in the Journal of the National Cancer Institute that only 50 percent of their patients were continent, and fewer than 20 percent were potent after radical prostatectomy. These authors suggested that the poor results were not because the surgery by urologists in Boston was faulty, but because their outcome studies were -- as opposed to other centers'-- truly objective. They concluded that nerve-sparing surgery doesn't work, dismissing the far better results achieved at Hopkins and at other centers as unreliable, suggesting that because patients were reluctant to disappoint their surgeons, they were not truthful in discussing their side effects.

"There is always a concern," says Walsh, "that patients may try to minimize their problems to their physicians, or alternatively, that there may be an unconscious bias on the part of the surgeon toward minimizing adverse outcomes." But he does not buy the idea that patients would rather spare their surgeons' feelings than regain urinary continence and sexual potency. "I believe that most men who are incontinent or impotent following surgery want help. If the urologist poses these questions with the intention of helping the men overcome these problems and get their lives back to normal, I believe men will tell the truth."

The Hopkins study shows that when radical prostatectormies are performed by experienced surgeons, major side effects are infrequent. Walsh hopes that these findings will encourage urologists to work on improving their technique. "The study from Boston led many urologists who had poor outcomes to believe that no one had good results. I hope those surgeons will now understand that the results of surgery can be excellent, with proper surgical technique."

The message from both of these studies is, says Walsh: "Patients who believe that radical prostatectomy is the best form of treatment for prostate cancer should seek out centers where experienced surgeons perform many of these procedures, and where the results can be documented through validated, independent outcome studies."



FURTHER READING:
"Patient-Reported Urinary Continence and Sexual Function Following Anatomic Radical Prostatectomy" Patrick C. Walsh, M.D., Penny Marschke, MSN, Deborah Ricker, Ph.D., and Arthur L. Burnett, M.D., Urology Vol. 55 (1): 58- 61, 2000.

 


Everything You Wanted to Know About Prostate Cancer, But Couldn't Find in One Place

"Thorough ... Easy to read. I urge urologists to read this book or risk facing a patient more knowledgeable than you."

  -- Mitchell C. Benson, MD., in a review from The Journal of Urology

"Men wondering where to turn for treatment would do well to start their search by reading this important book, which is not only comprehensive and authoritative, but a model of clarity."

  -- William Whitworth, editor The Atlantic Monthly

"Before Dr. Walsh I wasn't even aware that I had a prostate. Now that I have read this book, I know all about it, and he and Janet Worthington made it so easy for me to understand. This is a book that the prostate did not want the public to see."

  -- Art Buchwald

"The diagnosis of a is a terrifying thing, made worse by misinformation and myth. Men -- and the women who care about them -- will find no better guide than Dr. Patrick Walsh."

  -- John A. Meyers, Chairman Emeritus, TIME, Inc.

The Prostate: A Guide for Men and the Women Who Love Them, the best-selling health book written by Patrick C. Walsh, M.D., Urologist-in-Chief, and Janet Farrar Worthington, tells you everything you need to know about the prostate and its disorders, including detailed, groundbreaking information about every stage of prostate cancer. Now in its fourth printing at The Johns Hopkins University Press (1-800-537-5487), and in a pocket-sized edition by Warner Books (1-800-222-6747). Available in bookstores everywhere.



Perfecting the Radical Prostatectomy

Baseball pitchers use videotape to perfect their fastball; tennis players use it to get a better spin on their serve. The video camera is a staple for most athletes, in fact: No respectable football coach would dare contemplate next week's game without spending hours seeking wisdom from hindsight, going over this week's effort on the gridiron play by play.

So why don't surgeons do the same thing, wondered Urologist-in-chief Patrick C. Walsh, M.D.? "How are we ever going to improve our technique if we don't analyze our own work this way?" An excellent question, yet no one seems to have asked it before.

Over the years, Walsh says, he has come to believe that "very small differences in surgical technique can have a major impact on outcome." In a groundbreaking study, he put his theory to the test, watching his own operations. Using a high-quality, three-chip video camera, Walsh videotaped the operations on the men discussed in the story "Continence and Potency After Radical Prostatectomy: Hopkins Study Finds Best Rates Ever" . Then, 18 months after that study began, he reviewed these tapes. His goal was to make a good operation even better, by minimizing the operation's two major side effect -- incontinence and impotence: "When a patient is continent and potent immediately after surgery, what made the difference in this man?" Walsh spent his summer vacation examining these videotapes, sometimes stopping them frame by frame looking for insight. (Another bonus of the video camera is that it allows a view of the entire operative field, Walsh says, "and not just the small area where you have been working.") It took hours of intense scrutiny to watch a single two-hour operation, but the hard work paid off: He was able to identify four slight variations in his technique - in controlling bleeding from the dorsal vein and dividing the sphincter-that appeared to make the difference in the men who recovered sexual potency the soonest.

But most exciting was that Walsh -- who discovered the neurovascular bundles years ago -- found that some men had a significant anatomical variation. "Previously, everyone believed that the neurovascular bundle took a rather straight pathway from its origin in the sacrum along the lateral surface of the prostate to the urethra," explains Walsh. "But I learned that in many patients, the bundle curves around the apex of the prostate, and is tucked just beneath the sphincter and held there by a small group of vessels.

And that, if one attempts in good faith to preserve as much of the sphincter as possible, the neurovascular bundle can be damaged, and recovery of sexual function delayed." indeed, the eight men who at 18 months had not yet recovered full sexual function all seemed to have this variant curve.

Part two of the Walsh's self-imposed exercise was to make the study "blind." He went back over the operations yet again -- this time without identifying the patient or the outcome -- to see if the steps he had identified checked out. They did.

Incontinence is a long-term significant problem for only about two percent of his patients, and Walsh was unable to find evidence that anything he did or did not do during surgery would make a difference there. "Clearly, it had nothing to do with preservation of the sphincter," he says. "There was one man with perfect preservation of the sphincter who was still wearing a pad one year after the surgery." For this reason, Walsh is working to refine the procedure for reconstructing the bladder neck during radical prostatectomy.

Walsh believes many surgeons could benefit from regularly reviewing their operations in this way: "Because many surgeons use different techniques, it's likely that each surgeon may be able to identify other important, arbitrary variations that may help patients." Also, for surgeons whose patients seem prone to more side effects than usual, "the review of early successful cases may help them identify ways to modify their technique, and improve the outcome of future patients."

It took hours of intense scrutiny, but surgeon Patrick Walsh examined videotapes of dozens of radical prostatectomies he performed, sometimes stopping the two-hour operations frame by frame. The hard work paid off with a surprising discovery: Walsh -- who discovered the neurovascular bundles years ago -- found that some men have a significant anatomical variation. Until now, it had been widely assumed that the neurovascular bundle traveled in a straight line at the apex (left). But in some men, the nerve bundle makes a detour (arrow, right) -- and surgeons, not realizing this, can inadvertently damage the nerves responsibe for erection, and delay recovery of sexual function.


FURTHER READING
"The Use of Intraoperative Video Documentation to Improve Sexual Function Following Radical Retropubic Prostatectomy," Patrick C. Walsh, M.D., Penny Marschke, MSN, Deborah Ricker, Ph.D., and Arthur Burnett, M.D., Urology, Vol. 55 (1): 62-67, 2000.
 

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