January 26, 2001
New surgery called less invasive for prostate patients
By Richard Saltus, Globe Staff
It may be the operation that men fear the most.
Having a cancerous prostate gland removed means enduring a large incision in the lower abdomen so that surgeons can work deep in the pelvis. Patients may bleed a lot, usually requiring several weeks to recover their strength. And many are left impotent when doctors, cutting and stitching by touch at times, inadvertently damage nerves. Some patients are even left incontinent.
Yet, tens of thousands of men undergo radical prostatectomy every year, because the operation has the best track record for beating a disease that kills nearly 40,000 men annually.
Now, a few surgeons in this country are pioneering a new, less frightening approach to prostate removal that avoids large incisions, reduces blood loss, and gets patients back on their feet quicker.
Such a laparoscopic prostatectomy is carried out using slender tubes inserted through five small holes in the abdomen and tipped with cameras, miniature scalpels, and tweezers.
''It's unbelievable how good it was,'' said Philip Bedard, 59, a Boxford construction company owner who underwent laparoscopic prostatectomy at UMass Memorial Medical Center in Worcester last June. ''In five days I was back in the office, and in 10 days I was operating a backhoe.''
Doctors don't say that the new procedure reduces the dreaded side effects - impotence and incontinence - but they do say there is real hope it can, because the new procedure is so precise.
The video camera beams a bright, magnified view of the pelvic organs to surgeons so they can watch their progress on monitors over the operating table.
"It allows us to see in these deep areas of the male pelvis and do a more careful operation," Dr. Douglas M. Dahl, a urologist at UMass Memorial Medical Center, said earlier this week as he performed a lap prostate, as it's termed. ''And the patients have less pain.''
While the operation may make prostate cancer less frightening to patients, it's very demanding for surgeons, said Dahl, 35, as he took a break in the four-hour operation to wiggle his cramped fingers and flex his neck. Concentrating so long while using the pistol-grip triggers of the instruments takes its toll.
Hardest of all is suturing inside the body with the new tools. It's like tying knots with tweezers attached to the end of long chopsticks, surgeons say. Putting in the six or more stitches to reconnect the severed urethra, the tube that carries urine, can take an hour. That's one reason the new surgery initially takes longer - sometimes hours longer - than a conventional, or ''open,'' prostatectomy.
The prostate - a muscular gland somewhat bigger than a walnut that holds sperm and seminal fluid before it is expelled during orgasm - is the second leading site of cancer in men, after the skin. Some 180,000 cases are diagnosed yearly, usually through a PSA blood test, and 37,000 men die, generally because the cancer has spread by the time it's found.
Radical prostatectomy is the gold standard in treatments and is usually chosen by younger, healthy men, because the long-term chances of a cure are highest. It carries the risks of impotence and incontinence, and there's a slight risk of death from the surgery. An estimated 2 to 4 percent of men have permanent trouble controlling their urine, and the rate of potency after the most careful operations ranges from about 40 to 70 percent, depending on the patient's age.
However, there are other choices. Older or unhealthy men often receive the less-invasive external beam radiation treatment, which seeks to contain the cancer, rather than eliminate it. It requires weeks of daily treatments and can cause urinary and rectal problems.
Radioactive seed implants, tiny pellets of radioactive metal inserted into the prostate gland, have become an increasingly popular alternative to surgery. The implants are relatively painless and quick, but they remain controversial because their long-term effectiveness is not known. Moreover, the implants, once thought to have minimal side effects, are proving to affect potency and continence, as well.
UMass and the Cleveland Clinic are among a handful of US centers that are trying the new prostate surgery, which was pioneered by French surgeons in 1998. The prostate operation is perhaps the most difficult of the many laparoscopic operations being done in a new, high-tech wave of surgeries aimed at greater patient comfort.
During last Monday's surgery on George Forman, 59, a specialist in childhood development at the University of Massachusetts at Amherst, Dahl worked closely with Dr. Matt Shahbandi and Dr. Vernon Pais at UMass Memorial. Controlling five instrument handles among them, they sometimes gave the impression of an intense Foosball game.
Together they snipped, pushed organs out of the way, probed, and carefully cut around the two nerve bundles needed for erectile function. Such nerve-sparing measures don't always work.
Four hours after they started, one of the surgeons inserted a plastic bag through a tube, unfolded it, and Dahl dropped the excised prostate into the bag. It was withdrawn through a slightly enlarged incision.
Forman had to stay three nights at UMass because of a common problem, anesthesia having slowed his intestinal function. But he happily went home Thursday, saying he was in no pain and needed no painkillers. A second patient operated on the same day went home Wedneseday.
Dahl and Dr. Robert Blute, chief of urology, said they are happy with the results of the 35 lap prostates they've done since last spring. Patients usually go home after two nights in the hospital and quickly return to work.
It's too soon to determine the rates of incontinence or impotence with the new surgery. ''It's not worse, and it may be better,'' Dahl said.
Bedard, the construction company owner, said that he was incontinent only briefly and that his potency ''is coming back more slowly, but it's getting there.''
''The big advantage is that at two weeks after surgery, my laparoscopic patients are doing everything: shopping, working in the garden,'' said Dr. Craig Zippe, a urologist at the Cleveland Clinic, where the procedure has been done more than 60 times.
''It really takes about six weeks for a guy who's had the [standard] open procedure'' to regain his previous strength, Zippe said.
The Boston medical community, which often takes a ''show me'' attitude toward novel treatments, has so far remained on the sidelines. Among other concerns, doctors here say they aren't sure the minimally invasive surgery does as good a job of ensuring that cancer hasn't escaped from the tough capsule covering the prostate gland.
''I think it's a work in progress,'' said Dr. Jerome Richie, head of urology at Brigham and Women's Hospital. He says the standard operation has been getting better, with smaller incisions and shorter hospital stays, but he agrees that the at-home recovery period is shorter with the lap prostate.
At Massachusetts General Hospital, Dr. Frank McGovern, a urologist, said the minimally invasive operation ''may provide a short-term gain, but the long-term results need to be studied.''
He said he plans to learn the new technique once he's convinced it provides results equal to the standard operation.
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