Non Nerve Sparing Surgery: is erection recovery possible?
Professor Declan Murphy is a Urology Surgeon and Director of Genital Urinary Cancer at Peter MacCallum Cancer Center. He has performed over 2,000 Prostatectomies during his career and now specialises in Prostate Cancer full time. In this interview, we talk about nerve-sparing surgery and sexual function expectations.
What is non-nerve sparing surgery?
In the same way that we have two kidneys, two breasts, two testicles and so on, we have nerve bundles that run on the left and right side of the prostate up to the penis. When we talk about nerve-sparing, it’s not an all or nothing process...it can be done in a few ways:
Bilateral - both sides have full nerve preservation
Unilateral - where the tumour is predominantly on one side and we want to clear it.
Non-nerve sparking - no nerves remain
Say for example there may be a significant cancer on the left. But if we think that we can safely preserve those nerves while removing the cancer, then we will do partial nerve-sparing.
How often in your experience do you do surgery where you cannot spare any of the nerves at all?
In up to half of my patients, I don’t do complete nerve-sparing. That is partly because we try not to do surgery on patients unless they have a reasonable amount of cancer that is quite aggressive. In this case, more often than not we are quite close to the nerves..
Five or 10 years ago it was different...we often operated on patients with insignificant cancer. In those men, it was smaller tumours away from the nerves and we could do very aggressive preservation of those nerves.
Now, we have to work a little harder to make sure we adequately deal with those cancers.
Is there absolutely no chance at all of any erectile function returning after a non-nerve sparing procedure?
It’s not that black and white. In fact, it’s not rare that a patient will come back two years later and say, "My erections have come back. I had no expectations. How is that possible?"
Other times, we complete the procedure and say, "Oh we've done a beautiful job preserving these nerve bundles . I'm sure it'll do very well." But that patient has no return of erections, two years later.
It’s not just the physical preservation of the bundles, but small subtleties.
It’s an ongoing area where we will always have some surprising results in terms of preservation and non-preservation.
However, we want to set realistic expectations for patients.
If we're not doing full preservation or if the patient is older, we know this can mean it’s difficult to recover erections.
If you’re more than 70 years old, it is still very difficult to recover erections, even if the nerves are beautifully preserved.
Or, if the erections aren't great beforehand anyways.
These are all the things that will impact the end result.
I like to give a figure when letting patients after non-nerve sparing know the likelihood of recovering spontaneous erections, often less than 20% or less than 10%. Then, if that patient comes back 2 years later and says they’re having some recovery, they’re pleased because they’ve exceeded the expectation.
If you have unrealistic expectations, either because of something you’ve been told or something you’ve read and you don’t get your erection back, it can be a shock.
So I think the theme of setting realistic expectations and rolling out the best you can do, high-quality surgery, high-quality support for sexual rehabilitation is what we need to do.
What should healthcare professionals and urologists check up on with prostate cancer patients?
After surgery, the patient’s perspective will change. The realisation comes that they’re probably not going to die from prostate cancer. Then other things that are valued become a priority to focus on and they may realise they’re struggling a bit.
As healthcare professionals and urologists we need to constantly check in with our patients to see how they’re feeling about that aspect and offer appropriate support.
We need to constantly ask the question about sexual health and sexual wellbeing. Not just at 3 or 6 months, but each time we meet with them. We need to make it clear that it is okay that their values and priorities have changed. That we will work with them towards whatever is their focus at that point
For example, a couple in their late 60s early 70s with a wonderful relationship may see me and say, "we're not sexually active". But, he may still be enjoying erections, waking up with erections. Maybe enjoying masturbation and pornography. But their relationship is not built on the penetration they might have enjoyed previously.
They have made a statement as a couple that's not the most important part of their quality of life. For the patient though, who enjoys erections and may enjoy masturbation, three months later, six months later, he may well be suffering greatly because he's lost that quality of life.
Even though as a couple, their relationship wasn't dependent on them having penetrative sex, their intimacy changes.
This is something we speak to our patients about a lot. The re-navigation of intimacy and relationship in the absence of rigidity and penetration.
I need to check in with the man because while they’re both happy the cancer is gone, he’s missing waking up without an erection. That’s a physical part of his body.
Even if you don’t know whether the erections are going to come back naturally there is a lot that can be done to achieve an erection:
Strategies involving pumps and viagra, implant surgery, and injections. There are options to create that rigidity of an erection when you want to. And there are options of enjoying sexuality and pleasure without an erection too.
Join the Online Rehab Program to learn more strategies (it’s free!)