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Restoring Erectile Function in Patients Treated for Prostate Cancer: Efforts across Disciplines Address Physical, Psychological, and Emotional Factors Related to Sexual Potencyby Mariann Crapanzano
The message for men facing prostate cancer and its treatment is clear: erectile dysfunction, a major morbidity associated with radical prostatectomy and radiation therapy, can be effectively treated. At The University of Texas M. D. Anderson Cancer Center, health-care professionals across disciplines work with patients to restore erectile function after treatment for prostate cancer, addressing the physiological, psychological, and emotional factors involved in penile erection from the time of surgery through rehabilitation. The results are promising. In the effort to maintain or restore spontaneous erectile function in patients after prostatectomy, surgeons have devoted considerable attention to the preservation of nerve function, a fundamental component of tumescence. Radical prostatectomy involves removal of the prostate, surrounding lymph nodes and tissue, and occasionally, the surrounding cavernous nerve bundles that play a central role in penile erection. A nerve-sparing surgical technique that has been widely used since the 1980s for patients with localized prostate cancer has helped to increase the number of men who recover potency—defined as the ability to sustain an erection sufficient for sexual intercourse—after surgery. The results with nerve-sparing surgery vary by patient, said Richard J. Babaian, M.D., a professor in the Department of Urology at M. D. Anderson, but three factors that help determine the outcome are the patient’s age, the disease stage, and the degree of erectile function before the surgery. Younger age, organ-confined disease, and good preoperative function lead to better results. Some patients, such as those whose cancer is locally advanced, may not be candidates for the nerve-sparing technique because of the risk of positive surgical margins. For these patients, a surgical procedure in which the sural nerve from the leg is grafted to the cavernous nerve stumps provides promise. In a study reported in the March 2003 issue of Plastic & Reconstructive Surgery, Dr. Babaian and his colleagues at M. D. Anderson evaluated the effectiveness of sural nerve grafting of the cavernous nerve bundles in preserving postoperative erectile function while providing the highest level of cancer control. The results were encouraging. Among 30 patients who underwent non–nerve-sparing prostatectomy and a bilateral sural nerve graft, 18 (60%) had spontaneous erectile activity during a mean follow-up period of 23 months after surgery. Thirteen (72%) of these 18 men were able to engage in sexual intercourse either spontaneously or after taking sildenafil.
According to Dr. Babaian, the recovery period after the nerve graft is necessarily longer than it is after nerve-sparing surgery because it takes time for the nerve to grow. The sural nerve that is grafted is not itself a live, functioning nerve; instead, it acts as a scaffold upon which the two ends of the cavernous nerve will regenerate and complete the path to the innervated tissue. This process takes 15 to 18 months. Christopher G. Wood, M.D., a surgeon and assistant professor in the Department of Urology at M. D. Anderson and a coinvestigator in the bilateral sural nerve graft study, said that some patients who are not candidates for bilateral nerve-sparing surgery can undergo unilateral nerve-sparing surgery. According to Dr. Wood, biopsy results determine whether the patient has high-grade or locally advanced disease that would preclude sparing the nerve. Those who require unilateral nerve resection for cancer control are eligible for a phase II, randomized trial that is currently recruiting patients at M. D. Anderson to determine the benefits of unilateral sural nerve grafting. Potential participants are patients 65 years of age or younger who are candidates for unilateral nerve-sparing surgery and who have not received pelvic radiation therapy or hormone therapy for their prostate cancer. Participants will be randomly assigned to receive postoperative erectile-function therapy only or erectile-function therapy plus a unilateral nerve graft. Preserving the nerves responsible for tumescence is just one method of recovering erectile function after prostate cancer treatment. Rehabilitation is an integral part of this recovery, regardless of the cancer treatment, and at M. D. Anderson, programs are in place to help patients not only physically but also psychologically and emotionally. Dr. Wood, who recognized years ago that early erectile function rehabilitation is critical to the recovery and maintenance of spontaneous penile erections after treatment for cancer, was instrumental in developing the erectile dysfunction clinic in the Department of Urology. Here, patients with erectile dysfunction caused by their cancer treatment undergo therapy that includes one or more of the following regimens: oral sildenafil, penile injections, intra-urethral suppositories, vacuum erectile devices, and penile implants, all of which help patients to achieve erections and thus exercise function during recovery. The success of this therapy is explained physiologically, said Run Wang, M.D., an assistant professor in the Department of Urology and director of the erectile dysfunction clinic at M. D. Anderson. According to Dr. Wang, the penile erections caused by the therapy mimic the spontaneous nocturnal tumescence that occurs in healthy adult males; this increases blood flow to the penis, helping to prevent hypoxia and thus fibrosis, collagen formation, and loss of tissue mass. “Patients should start this rehabilitation as early as possible,” said Dr. Wang, who also serves as chief of urology at Lyndon B. Johnson General Hospital and assistant professor of surgery at The University of Texas Health Science Center at Houston Medical School. “With nerve-sparing or non–nerve-sparing surgery, every patient should do this to maintain the healthy tissues, to facilitate early recovery of their erection, and to make it easier for them to receive possible surgical help, such as penile implants, in the future.” How successful is the therapy? It depends on the patient and the regimen, said Dr. Wang. As an example, he said, patients who undergo non–nerve-sparing prostatectomy have a 0% to 5% rate of spontaneous erections without therapy versus a rate of erections as high as 80% with the aid of penile injections. Patients may also receive psychological support to guide them through the restoration of sexual potency. Leslie R. Schover, Ph.D., a professor in the Department of Behavioral Science, is developing intervention programs to address the emotional and relationship issues faced by men with erectile dysfunction and help couples return to full, satisfying sexual intimacy after prostate cancer. As recognized by both Drs. Babaian and Schover, physiologic function is but one aspect of recovery. Dr. Schover’s studies are designed to educate men and their partners about their medical options and to give them the tools to help overcome the inevitable hurdles they will face on the road to recovery. In one pilot study, men who had undergone either radical prostatectomy or radiation therapy for localized prostate cancer and who were not receiving hormonal treatment for their cancer participated with their wives or partners in a four-session intervention program with a counselor. Filling out questionnaires before and after the counseling, the men and women reported on their sexual function and activity. The sessions focused on helping couples enhance their communication about sex and their sexual enjoyment, advising them about available medical treatment options for erection problems, and teaching them to troubleshoot in the event a particular treatment plan is unsuccessful. The preliminary results showed that couples who participated in the program experienced improved sexual function and satisfaction by three months after treatment and that a greater percentage of the men were successfully using a medical treatment to restore erectile function.
Dr. Schover and her colleagues were encouraged by these positive changes but recognized some barriers to providing this type of program: not all communities have the resources to provide such an intervention, many trained mental health professionals are not knowledge-able about both sex therapy and cancer, insurance does not always cover such specialized services, and many patients perceive a stigma associated with visiting a mental health professional. With an eye to overcoming these barriers and with the preliminary results of the pilot intervention in hand, Dr. Schover and her colleagues obtained funding from the American Cancer Society to develop a Web-based version of the intervention. Aimed at couples, the Web-based intervention contains separate online bulletin-board-like support groups for men and women and provides medical information about the effects of cancer treatment and rehabilitative therapy for erectile dysfunction as well as exercises to improve sexual communication and enjoyment between couples. The participants complete the exercises and report their progress to a therapist via e-mail, who then replies with feedback. To evaluate the effectiveness of this intervention, couples are randomly assigned to see a counselor in person or participate in the Web-based version of the intervention program. “If the Web-based treatment works almost as well or as well as face-to-face [treatment], then we’ll have an intervention that’s much more easily disseminated to the public,” said Dr. Schover. Dr. Schover and her coinvestigators are currently recruiting for this study, which is community based and not limited to M. D. Anderson patients. To be eligible, prostate cancer survivors must be between three months and five years beyond cancer treatment and not receiving hormonal therapy. They also must have a partner who is willing to participate in the study. Ask Dr. Schover, and she will tell you that communication is the key to a successful outcome—honest communication between the health-care professionals and the patient and between the patient and the patient’s partner. Nelda J. Huber, P.A., who worked closely with Dr. Wood to develop the erectile dysfunction clinic and who now sees patients in the clinic with Dr. Wang, stressed that each patient requires individualized therapy. In many cases, the rehabilitation takes months, and it is imperative that patients be persistent in the therapy, be willing to try different methods, and not give up. “Each patient is different,” Huber said. “It’s important to let patients know that we’re going to get through this, together. We’re going to keep at this, together. If (the first therapy) doesn’t work, we’ll do something else. But here’s your likelihood of this being successful.” Dr. Wang agreed. “Erectile dysfunction can be cured,” said Dr. Wang. “If the patient is motivated to get treated, we can help him, there’s no doubt.” For more information on this topic or for questions about M. D. Anderson’s treatments, programs, or services, call the M. D. Anderson Information Line at (800) 392-1611 (in the United States) or (713) 792-3245 (in Houston and outside the United States) Other articles in OncoLog, October 2003 issue:
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