This image shows an earlier nerve-sparing technique
(left) and the new nerve-sparing technique (right). Credit: UCLA
Prostate cancer is the most commonly diagnosed
non-skin cancer in the U.S., and radical prostatectomy, the surgical removal of
the prostate gland, remains the most popular therapeutic option, accounting for
half of treatments.
The procedure, however,
is not without possible side effects, primarily erectile dysfunction and
incontinence. But a good nerve-sparing surgical technique can lessen the likelihood
of these undesirable outcomes, as can the skill and experience of the surgeon,
according to a new UCLA study that focused on robotic-assisted prostate
surgery.
The study findings are
published in the June 2012 print edition of the international peer-reviewed
journal European Urology.
Based on their research,
the study authors recommend that men undergoing robotic-assisted surgery for
prostate cancer should look for a doctor who has performed at least 1,000
surgeries and who actively seeks to improve and enhance his/her surgical skills
to help ensure a successful post-surgery recovery of erectile function.
The authors also found
that new, refined techniques that prioritize the gentle handling of the
delicate nerves around the prostate also make a difference in improved erectile
function.
The study is one of the
first to characterize a surgeons' learning curve for improving erectile-potency
outcomes and to demonstrate and quantify gentler handling techniques that
involve minimizing stretch injury to the nerves around the prostate as the
gland is removed, the researchers said.
"It would be helpful
for men who seek a surgical cure for their prostate cancer to
appreciate the nuances required by a surgeon to successfully protect erectile
function," said Dr. Jim Hu, director of minimally invasive surgery in
the department of urology at the David Geffen School of Medicine at UCLA and lead
author of the study. "Like improving a golf swing, a technique for
nerve-sparing surgery has many subtleties that are influenced by training,
talent, a desire to improve, and meticulous review of technique and
outcomes."
The research team
developed a video demonstrating the new techniques so that robotic-assisted
surgeons may achieve better outcomes more quickly and potentially shorten their
learning curves. Hu noted that the anatomic concepts and techniques extend to
traditional, non–robotic-assisted surgery as well.
For the study, the team
looked at nerve-sparing techniques and maneuvers used in the operating room in
400 surgeries performed by Hu over a two-year period at Brigham and Women's
Hospital in Massachusetts. Hu tracked his patients' erectile-potency recovery
outcomes by groups of 50 up to one year after surgery.
While this is a
single-surgeon study during robotic-assisted surgery, Hu used standardized
questionnaires to quantify patient-reported recovery of erectile function,
which is not often done by individual surgeons and which helped in assessing
outcomes.
Researchers found that
greater surgeon experience and more delicate handling of the nerves to minimize
stretch injury helped improve erectile function significantly. At five months
post-operatively, patients went from zero to as high as 33 percent in erectile-function
recovery and at 12 months post-operatively, they went from 15 percent to as
high as 59 percent.
"These are very good
outcomes for the early months after surgery," Hu said. "Most men will
continue to see erectile-potency improvements up to two years after surgery, so
we would expect to see even better outcomes by then, especially if surgeons are
effectively adopting the newer nerve-sparing techniques."
Hu adds that one of the
goals of the study is to develop and share these optimal techniques with other
surgeons.
These findings were
combined with the results of an earlier study of Hu's that assessed his work on
an additional 600 cases. The researchers found that surgeon improvement hit a
plateau after 950 cases.
However, other factors
also contribute to a surgeon's skills, said Hu, who carefully tracked his
surgical outcomes, diligently reviewed videos of his operations and studied
with a pioneering surgeon in nerve-sparing techniques.
"In addition to
performing many cases, surgeons really need to have the desire to improve, take
the time to learn new techniques and actively pursue quality improvement,"
Hu said. "Similar to golf, if you're only a weekend golfer and don't keep
score, watch videos and analyze your swing, you may not get better, even after
playing 1,000 games."
Hu also notes that other
surgeons who are dedicated to surgical improvement may find that they may hit
the plateau sooner than 1,000 cases.
In addition, Hu found
that younger patient age and better pre-operative erectile function were
associated with better five- and 10-month erectile function after surgery.
The traditional
nerve-sparing technique, which involves peeling nerves from the prostate,
similar to peeling an orange, was associated with the worst five-month
sexual-function outcomes. The newer, gentler approach uses less peeling to
minimize displacement of the nerves.
Surgeries performed as a
trainee were associated with the worst 12-month erectile-function outcomes.
According to Hu, more simulated robotic surgery may help trainees learn key
techniques before operating with patients.
Provided by University
of California, Los Angeles
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