When Andrew Lloyd-Webber spoke publically about his impotence following prostate cancer surgery, the 63-year-old composer opened up an important yet often hidden issue.
This type of is the most common male cancer in the UK, with 34,000 men developing the disease every year. Approximately one third of them will be treated by prostate surgery.
The traditional operation for cancer of the prostate is known medically as a radical prostatectomy, involves removing the whole prostate using wide margins. While this approach is very successful in terms of treating the disease, it causes irreparable damage to the bundle of erectile nerves which lie next to the prostate and normally results in long term impotence.
In recent years, a small number of specialist surgeons have developed what is known as the nerve-sparring prostatectomy. If the cancer is caught at an early stage and confined to the prostate itself, a man may be suitable for this procedure. A nerve-sparing prostatectomy may be undertaken as open surgery, laparoscopic surgery or using the da Vinic robot (robot assisted surgery).
Having this potential option is incredibly important for men. Although half of all men diagnosed with prostate cancer are aged over 70, it should not be seen simply as an ‘old man’s disease’. Many men treated for it are in their fifties and sixties – indeed this kind of cancer in a younger man is likely to be a more aggressive form of the disease. Equally, surveys show that sex often remains important to men’s overall well being and sense of self well into their seventies.
However patient experience remains mixed. Many surgeons do not offer nerve-sparing prostate surgery because it is extremely difficult to do. It involves carefully dissecting the tiny nerve-bundles lying next to the prostate and ensuring no cancer cells are left behind. Surgeons believe it is not possible to perform safe and effective nerve-sparing surgery unless you are what is known as a ‘high volume’ surgeon, performing 50 to 100 prostate cancer operations every year.
Equally, among surgeons who do offer surgery for prostate cancer, results are mixed and often not clearly published. Some surgeons use terms like ‘erectile recovery’ after surgery, indicating there may be some degree of penile engorgement but this may not be in any way sufficient for sexual intercourse. There is no standard system for publishing erectile function following this surgery, although some surgeons do publish their results and ensure the terms they use and are clearly understood. The most experienced surgeons in nerve-sparing surgeons publish results which show a 73 per cent sexual intercourse rate at 12 months for patients having optimal nerve-sparing surgery. This means of the study group whose cancer is at an early stage and who have good erectile function before surgery, 73 per cent have erections sufficient for full intercourse a year after surgery.
Mr Lloyd-Webber speaks openly about his dislike of the idea of medication for erectile dysfunction and horror of devices such as a penile vacuum pump. Even men who have had optimal nerve-sparing surgery typically need to take erectile dysfunction medication such as Cialis, Viagra or Levitra for a period of time. This supports men in the return to sexual relationships in the short term, with a gradual reduction in the need for such medication.
Of course Mr Lloyd Webber is not alone in finding the idea of taking medication or using devices to enable sex a difficult and distressing idea. Research shows many men would like to return to having normal sex after prostate cancer surgery, but find the process of talking medication off-putting and become discouraged when they are unable to have sex in the same way as before. It is clear men and their partners need dedicated advice and support throughout the first year after prostate cancer surgery in order to keep taking the medication and maintain confidence. Sadly, many find it too difficult and give up.
Naturally, when a man first faces a cancer diagnosis, sex is pretty far from his first priority. It is difficult to focus on anything other than survival. However, early stage prostate cancer is very treatable with excellent overall survival rates. Many men diagnosed with prostate cancer have an active sex life and resuming their sex life after treatment is very often an important factor in enabling a couple to feel life is beginning to return to normal and achieving an overall sense of well being. Therefore it is important to ask your surgeon whether your staging and grading of prostate cancer is suitable for a nerve-sparing procedure. If your surgeon does not perform nerve-sparing surgery, ask for a referral to a surgeon who does, in order to discuss all options. If you see a surgeon who says he can do nerve-sparing prostate surgery, ask him how many procedures he has carried out ask about his results, including the definitions he uses. Prostate cancer treatment is an area where patients find the choice is often widespread and bewildering – unlike some other cancers, there is no single treatment pathway. However it is important to be aware of all the different options and to be confident enough to ask your surgeon about his experience and results. After all, long term erectile dysfunction is a devastating condition but not an inevitable consequence of prostate cancer surgery.