Most doctors can tell you that undergoing a radical prostatectomy—removal of the prostate gland—to treat prostate cancer will result in some degree of sexual dysfunction, either temporarily or permanently. However, that message doesn’t seem to be reaching all patients who undergo prostate cancer surgery, says a new study. Many men have unrealistic expectations about their future sexual performance.
While it’s true that nerve-sparing surgery—in which a skilled surgeon preserves the nerves needed to achieve a natural erection—has improved the likelihood that patients will regain erectile function, recovery of spontaneous erectile function can take time. It’s common for patients to experience some level of erectile dysfunction (ED) following prostate removal.
Researchers at Memorial Sloan Kettering Cancer Center in New York surveyed 336 patients (with an average age of 64) who had undergone either robotic radical prostatectomy or a traditional open prostatectomy and who visited a sexual medicine clinic one to five months after their procedure.
At the time, only 38 percent of the men could recall whether they had nerve-sparing prostate cancer surgery that would have helped preserve their sexual function. Many respondents did not even recall being told about potential treatment-related side effects, such as changes in penis length and shape.
The researchers did not analyze the information surgeons conveyed to patients, but they cited a similar 1997 survey in which 100 percent of the doctors felt they had adequately addressed patient concerns. The researchers also suggested that patients often don’t remember or understand what their doctors said, and they might have been too anxious to comprehend what they were being told.
“As the study authors note, disclosure does not equate to understanding,” says H. Ballentine Carter, M.D., professor of urology and oncology, and director of adult urology at Johns Hopkins University School of Medicine in Baltimore. “While radical prostatectomy is necessary to treat prostate cancer successfully in some men, others may walk away from the surgery wishing they had never had it done. Sexual dysfunction can take a large toll on a man’s quality of life.”
In the Memorial Sloan Kettering study, published in the December 2015 issue of BJU International, patients who underwent robotic radical prostatectomy were less likely to be happy with the postsurgical results than men who had traditional open surgery.
Many had unrealistic expectations about how robotic-assisted surgery could help them, assuming a faster recovery and fewer side effects than open prostatectomy. Their heightened expectations might have been influenced by persuasive marketing of robotic radical prostatectomy even though no scientific evidence shows that the procedure results in better sexual function than open surgery.
The price of surgery
Erectile dysfunction can occur when the nerves necessary for erections are removed or damaged during prostatectomy. Microscopic bundles of nerves pass along either side of the prostate, running into the corpora cavernosa (tissue that fills with blood and expands during an erection) of the penis.
These nerves are partly responsible for triggering an erection. If the nerve bundles are damaged or removed because they’re cancerous, a spontaneous erection may be impossible. ED can also be triggered if the blood supply to the penis is compromised during surgery.
To preserve the nerves during traditional open radical prostatectomy or robot-assisted laparoscopic radical prostatectomy, surgeons preserve the tissue (consisting of blood vessels and nerves) that’s close to the prostate. Still, despite the use of nerve-sparing techniques, sexual dysfunction is common following surgery. And surgeons don’t know before the procedure how successful nerve preservation will be.
“The amount of time it takes for a man’s sexual function to return depends not only on nerve preservation during surgery but also on several other factors, including the quality of erections and the level of sexual activity prior to surgery, the cancer stage, and the skill of the surgeon,” Carter says. “Age is perhaps one of the biggest determinants, with younger patients in their 40s and 50s generally achieving return of erections more quickly as compared to older men.”
What you should know
Even an expertly performed nerve-sparing radical prostatectomy causes some degree of trauma to nerve bundles. Below are some important facts about sexual function and what to expect after robotic-assisted or traditional open radical prostatectomy:
• You can no longer produce ejaculate after radical prostatectomy. However, you can still have a normal sensation and sex drive. This change, which is permanent, occurs because ejaculatory fluid is produced in the prostate, and the seminal vesicles—glands next to the bladder—are removed during surgery. This also results in a loss of fertility. Almost half of all patients in the survey were unaware that they would no longer be able to ejaculate.
• You can still achieve pleasurable, though dry, orgasm. However, the surgery puts you at risk for leakage of urine during orgasm (called climacturia). Most men who achieve urinary control do not have climacturia long term.
While the ability to have an erection sufficient for intercourse is common in the immediate period after surgery, it can be enhanced with oral or injectable ED drugs or a vacuum pump.
• You’ll typically recover erectile function within six months. On average, as many as 40 percent of patients who have a nerve-sparing radical prostatectomy do, if function was good before surgery and sexual activity was an important part of life.
• The surgery shortens penile length by up to 1 to 2 centimeters (2.5 centimeters is approximately 1 inch). However, if you undergo a nerve-sparing operation, the reduction in length is often temporary.
• The surgery puts you at risk for a condition called Peyronie’s disease, which can cause penile curvature upon erection and difficulties achieving an erection. Though it improves on its own in 50 percent of men, Peyronie’s disease can require treatment with surgery or medication if it’s long lasting or interferes with penetration.
The good news is that if a surgeon skilled in nerve-sparing prostatectomy performs the operation, most men will eventually recover satisfactory erectile function—often with an oral ED drug or some other therapy.
What you should do
Radical prostatectomy can cure prostate cancer when the disease is detected in its early stages. Because prostate cancer progresses more slowly than some other types of cancer, you can take some time to consider your treatment options carefully, especially if you have prostate cancer that’s categorized as very low risk or low risk.
To avoid the risk of misunderstanding or not remembering what your doctor tells you during counseling for prostate cancer surgery, Carter suggests that you:
1. Ask your doctor to put what he or she is telling you in writing.
2. Bring your partner or a loved one with you to your appointment, so he or she can take notes and ask questions.
3. Have an in-depth discussion with your urologist about your treatment options if you’re concerned about the side effects of surgery. For men with low-risk cancer, especially older patients, active surveillance may be an alternative to immediate surgery. Radiation is another possible treatment for some men, although this, too, carries its own risks of side effects, and research hasn’t proven it to be equally or more effective than surgery.
Learn Four Risk Factors for Prostate Cancer and How to Cut Your Risk.