THE PROMISE OF PRESERVATION
The CaverMap surgical aid is the latest weapon against a problematic outcome of prostate surgery-impotency, or erectile dysfunction. by Paul DingsdaleFor men with prostate cancer, survival may be the first issue that stirs fear and uncertainty. Arousing emotions nearly as intense as survival is the potential for severe side effects of treatment, chiefly impotence. "One of the fears associated with any treatment for prostate cancer is the loss of normal sexual function," says Gary Lieskovsky, M.D., USC/Norris Comprehensive Cancer Center urologist. "If you can offer men surgery with better preservation of potency, then perhaps more of them will be willing to undergo screening, and more lives will be saved."
New technology seeks to offer that promise of preservation.
A device known as the CaverMap surgical aid utilizes a probe to stimulate nerves that travel along the prostate, and guides the surgeons where the nerves are located that produce erections. By sparing these nerves as they remove the prostate, they hope to preserve sexual potency.
USC/Norris is one of about 80 hospitals in the U.S. to use the CaverMap device, and Lieskovsky, professor of urology and the Donald G. Skinner Chair in Urology at the Keck School of Medicine, is one of the most prolific and enthusiastic users of the new technology. "Any surgical aid that has no down side and which could potentially improve a patient's quality of life has to be welcomed," says Lieskovsky.
Now, with a double strategy of "nerve-sparing" surgery, a technique pioneered in the 1980s, and this new device that helps surgeons locate and avoid these critical nerves, there is growing expectation that the previous hit-and-miss record in preserving erectile function will improve further.
According to the National Cancer Institute, prostate cancer is the most commonly diagnosed malignancy in men in the United States and the second leading cause of cancer death in men. More than 25 percent of patients given a diagnosis of prostate cancer will die from it, although the five-year survival rate is nearly 100 percent for early-stage cancer.
The main problem rests in the complex anatomy of the area. The prostate gland is located at the base of the bladder and is involved in semen production. Running along each side and below the prostate are two nerves, the cavernous nerves. When these nerves become stimulated through sexual arousal, they kick off a series of events that results in the penis becoming erect. If one or both of the nerves are removed or damaged during surgery, the likelihood of maintaining this normal physical sequence is dramatically reduced.
"The great thing about the new technology is that it allows me to test the nerves during surgery to see if they respond to stimulation. When the probe has located the cavernous nerve, an applied electrical current results in an increased blood flow to the penis, mimicking an erection, and a light appears on the screen," says Lieskovsky. "This way we can tell patients right away whether or not their nerves remain in working order, because there's a highly favorable correlation between the response obtained in the operating room and recovery of sexual function later."
One man who was enormously relieved to learn, only hours after the operation, that he would in all likelihood be able to enjoy a normal sex life was 45-year-old attorney Robert Miller.
Miller recalled that after reading a Time magazine article on high-profile prostate cancer cases, "my wife and I thought it would be a good idea for me to get regular PSA blood tests once I reached my 40s. I have three children, and you can't be too careful when you've got a family to look after."
In October 1999, Miller's prostate specific antigen (PSA) blood test revealed the devastating news that he had prostate cancer. "My previous tests showed slightly rising PSA levels, but I didn't expect cancer," says Miller. "I've never spent a night in a hospital in my life, and to say I was terrified and surprised by the news would be an understatement. I thought it was an old man's disease."
Fortunately for Miller, the cancer was small and confined, and the prognosis was excellent. But the specter of impotence still loomed large in Miller's mind as an all-too-common side effect of treatment. Thanks to Lieskovsky's skill and with the help of the CaverMap device, Miller's potency was spared and he now enjoys full erectile function. "When the catheter came out after two weeks, my potency and continence began to return virtually immediately. Now, four months down the line, I'm back to normal," Miller says. "Where once I felt cursed, now I feel blessed."
Not every patient facing total prostatectomy for cancer can be helped using the CaverMap aid, Lieskovsky cautions. An important limiting factor: spread of the cancer beyond the capsule and involvement of tissue along the pathway of the nerves. "Doctors often have to remove the prostate and one or both of the nerves because an aggressive tumor has spread," he says. Lieskovsky also stresses the importance of careful selection of patients for surgery. Younger patients with good erections before surgery are least likely to become impotent after nerve-sparing surgery.
Yet, even with its limitations, the CaverMap surgical aid offers another hopeful option for many men diagnosed with early stage prostate cancer.
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