March 6, 2000 (Mill Valley, Calif.) -- Frank Luton was in his mid-40s when he had to make a harrowing choice. During a routine physical examination, Luton's doctor discovered a hard spot in his prostate -- a lump that proved to be malignant. Luton opted to have his prostate removed, even though he knew there was a chance the surgery could leave him impotent and incontinent.
Today, at age 57, the former corporate executive from Stone Mountain, Ga., is alive and well and traveling the world as a business consultant. But just as he feared, the operation that saved his life left him incontinent for the first six months and permanently impotent. He now uses a penile implant to restore sexual functioning.
Doctors have long known that both impotence and incontinence can result from prostate cancer surgery. Unfortunately, a recent study suggests that these consequences may be more common than previously thought. A report in the January 19, 2000 issue of the Journal of the American Medical Association detailing the Prostate Cancer Outcomes Study indicated that 59.9% of men studied were impotent and 8.4% were incontinent for at least 18 months after surgery.
"Impotence as a result of radical prostatectomy is a much larger problem than is often quoted in the media," says Janet L. Stanford, Ph.D., of the Fred Hutchinson Cancer Research Center in Seattle and co-author of the study. Indeed, impotence was common even when doctors used new surgical techniques designed to spare nerves near the prostate that control urine flow and erections.
The study looked at 1,291 men, aged 39 to 79, who had surgery within six months of their prostate cancer diagnosis. Based on the extent of the cancer, patients received one of three procedures: non-nerve sparing, unilateral nerve-sparing (which tries to minimally disturb nerves on one side), or bilateral nerve-sparing (which tries to avoid nerve damage on both sides of the gland). Nerve-sparing surgery might be expected to reduce the rate of impotence as a side effect. Yet in the study the rates didn't vary dramatically: 65.6% after non-nerve sparing, 58.6% after unilateral, and 56.0% after bilateral nerve-sparing procedures.
"It was a surprise to see that the rates of impotence among men receiving nerve-sparing versus non-nerve sparing surgery were not that different," comments Barry Kramer, M.D., an oncologist and deputy director for the division of cancer prevention at the National Cancer Institute in Washington, D.C.
Surgery isn't the only treatment for prostate cancer, of course. Other approaches include radiation, chemotherapy, or even "watchful waiting" -- postponing treatment and monitoring for changes. "While the treatment decision is up to the patient, the dominant factor is ultimately what treatment will cure the cancer," says LaMar McGinnis, senior medical consultant for the American Cancer Society (ACS) and a surgeon himself. He points out that while radiation therapy leads to survival outcomes approximately equal to surgery, many men feel more confident having the prostate gland removed. Despite the troubling risk of impotence and incontinence, 71.5% of men in the Prostate Cancer Outcomes Study reported they would choose radical prostatectomy again.
Besides overall health and the extent of the cancer, age appears to play a major role in the development of side effects. In the Prostate Cancer Outcomes Study, researchers found that after 24 months, 39% of men under 60 were able to get erections, compared with only 15.3 to 21.7% of older men. Only 0.7 to 3.6% of younger men experienced incontinence, compared with 13.8% of men aged 75 to 79.
Both Kramer and McGinnis believe that there's a connection between side effects and surgical expertise. McGinnis says, "The side effects of prostate surgery are well known and can be minimized if surgery is performed during the early stages of cancer and done by surgeons who have been trained in nerve-sparing techniques and have gained expertise through experience. By preventing excess manipulation of nerves, a man has a good chance of returning to the same [level of] sexual function as prior to surgery."
If Luton were faced with choosing prostate surgery today, he says he would study his options more carefully and explore the possibility of the nerve-sparing procedures (not widely available at the time of his surgery). "When it comes to survival, however, there's no question about giving up some sexual functioning." And Luton is certainly living life to its fullest: he recently spent a week in Belize building a dental clinic.
Mari Edlin is a freelance journalist and marketing communications consultant specializing in health care. She contributes regularly to Healthplan Magazine, Modern Physician, and Managed Care Magazine, and works with many health care organizations in the San Francisco Bay Area.