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.

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.

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."