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Some Nerve

A new procedure for prostate removal might make life without it more worth living.

Leigh Gallagher, 04.14.03

A new procedure for prostate removal might make life without it more worth living. The quarter-million American men who will be diagnosed with prostate cancer this year face an agonizing choice: Have the prostate removed and risk impotency; go for radiation and face a higher risk of not getting rid of all the cancer; or let the cancer go untreated and risk death. The dilemma is most harrowing for the 30% of these patients under 65.

Surgery to remove the prostate is generally the most effective means to eliminate the cancer and by far the most common choice for those who elect treatment, says the National Prostate Cancer Coalition. But surgery comes with as much as an 80% likelihood of impotence, caused by damage to one or both of the adjacent cavernosal nerves that are responsible for erectile function.

Now a procedure called sural nerve grafting is gaining in popularity for its ability to make surgery a more sex-life-friendly choice. By taking a piece of the sural nerve--a long, straight stretch of nerve that runs alongside the back of the calf and ankle--and stitching it into the pelvis between the severed cavernosal nerves, surgeons say they are able to preserve erectile function in patients who have had one or both nerves severed.

"You've completely changed the rules of the game," says Andrew Elkwood, a plastic and reconstructive microsurgeon at Jersey Shore Medical Center in Neptune, N.J. He performs the procedure with Matthew Tobin, the Harvard-trained director of urologic oncology. "Now you can have the surgery without side effects."

A small but growing number of specialists now perform the procedure (a urologist and a reconstructive surgeon usually work in tandem) at, among other places, New York's Memorial Sloan-Kettering Cancer Center, the University of Washington Medical Center, and the M.D.Anderson Cancer Center and Baylor College of Medicine, both in Houston.

Until recently the best chance to avoid post-op impotence was so-called nerve-sparing surgery, a procedure pioneered in 1982 by Patrick Walsh, director of the Brady Urological Institute at Johns Hopkins Hospital. In this delicate procedure the prostate is removed while every effort is made to keep one or both nerves intact. But some patients are ineligible for nerve-sparing surgery, as the cancer resides too close to the nerves to spare them.

Walsh has criticized sural nerve grafting, contending that it encourages people to damage or remove nerves unnecessarily. "I've never cured anybody by removing both nerves. I would want to see the results," he says. "I think it's something that's been hyped."

All told, some 1,000 men have had the surgery, and the data are trickling in. In one Baylor study of 66 potent men who had one nerve severed and regrafted, the estimated potency rate after two years was 86%, compared with 39% for a control group who had no sural nerve graft. In a group of 12 men who had both nerves severed and regrafted, 4 were able to have Viagra-free erections one to three years later; five more were able to have partial erections. The dozen men in the control group with no regrafting showed no return to potency.

A study last fall at Memorial Sloan-Kettering Cancer Center found that 80% of men who had both nerves preserved during surgery recovered potency. That figure dropped to 40% in men who had one nerve severed without a nerve graft, but shot back up to 60% of men who had one nerve severed and regrafted.

"If you take an attitude 'let's be sure we get the cancer out,' you're going to end up [severing] more nerves than someone who takes an attitude of 'let's spare these nerves at all costs,' " says Peter Scardino, chairman of Sloan-Kettering's department of urology.

[A first-person story of the procedure is at Phoenix5 as well as an Associated Press story.]

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