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The results of the study assessing the success rate of a new surgical technique to restore sexual function after prostate surgery are now published.

PCFA Staff
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 This is an update to an article written by Wendy Winnall in 2017: Promising early results for a new surgical technique to restore sexual function after prostate surge...

A significant proportion of men experience impotence after prostate surgery. Although there are drugs and devices that can help improve this condition, there remain thousands of Australian men with long-term impotence who are not helped by these options.

A new surgical technique is now being performed in Australia to restore sexual function for men who have long-term impotence after prostate surgery. We wrote about the early results of this research providing hope to men with this terrible burden to you in September 2017.

It is common for men to experience problems achieving erections immediately after prostate surgery. Sexual function should gradually return in the months after surgery, but unfortunately this is not the reality for many men. Results from the ProtecT trial indicate that six years after surgery for localised prostate cancer, only about 20% of men could achieve erections firm enough for sex (in this trial, 67% of these men had firm erections before the surgery).

There are a number of options to help men with erection problems after prostate surgery. These include medications, such as tablets or injections, and vacuum pumps. If these treatments are not adequate, men may opt for surgically inserted implants. A sex therapist may also be able to provide help. Unfortunately, there is a risk of side effects and complications from these medical and surgical treatments. They are not suitable for everyone, and they don’t work for everyone.

Many men continue to suffer from long-term impotence that is not helped by these options. Up until now, these men have had little hope that their sexual function could be restored. This situation has often come about because of the damage to nerves that are necessary for erections, caused by prostate surgery. Despite advances in nerve-sparing surgery, prostate surgery can still lead to impotence.

In 2017, a ground-breaking surgical technique was developed in Brazil aiming to restore sexual function lost through nerve damage. The Brazilian team consisted of urologists and plastic surgeons from the State University of São Paulo and the University of Campinas. Their technique involves a nerve-graft. Small sections of nerves are surgically removed from the lower leg and used to reconnect the penis nerves. This procedure essentially bypasses the damaged section of nerve, near the prostate. About 50 patients have had the experimental surgery in Brazil, to treat their impotence that started after prostate surgery. Only the results of the first 10 men in their pilot study were reported in the publication. These men were an average age of 60 years old and had prostate surgery at least two years previously. All of the men had satisfactory sexual performance prior to surgery. They were followed-up with surveys to report on their sexual function over the next three years. The results were very promising. Six of the ten men were able to achieve full penetrative sex. It took an average of 13 months for this to happen. Complications of the surgery were minimal for these patients.

Back in 2017, we wrote about a similar technique pioneered in Australia by urologist Dr David Dangerfield (Complete Care Urology, Cabrini Brighton Hospital, VIC), and plastic surgeon Prof Christopher Coombs (Southern Plastic Surgery, Brighton, VIC). Prof Coombs travelled to Brazil to study the new technique. The initial pilot study results were presented by Dr Coombs, Dr Dangerfield and Dr Jeanette Reece, from the University of Melbourne, at the 2017 Asia-Pacific Prostate Cancer Conference (APCC).

The Australian surgeons have made considerable modifications to the Brazilian nerve-grafting method. Prof Coombs described their changes. ‘We perform an “end-to-side” nerve grafting procedure in Australia. Our method increases the likelihood of nerve regeneration into the penis’. The surgery takes about two and a half hours to perform and consists of a few minor incisions. An overnight stay in hospital after surgery is usually all that is needed.

The study, now complete, has been published in European Urology. It involved 17 patients (49-69 yo), 12 of which were able to again experience an erection with sufficient firmness for full penetration after the nerve-grafting surgery. Seven out of these twelve patients didn’t need Viagra-like drugs for an erection to happen. Of the 12 men, two had suffered erectile dysfunction for over ten years. The study found that surgery had a 60 per cent success rate across ten patients.

Patients were asked to fill in questionnaires before and after surgery. Questionnaires were also filled in 3-6 monthly intervals and up to three years after the surgery. This allowed the researchers to assess changes in erectile performance and sexual quality of life. The results are comparable with the results of the Brazilian study first pioneered by Professor Fausto Viterbo.

Success was defined as either:

  • Restoration of spontaneous erectile function
  • Restoration of erectile function with the use of drugs such as Viagra, Cialis or Levitra, when these were not effective before nerve-grafting
  • Restoration of erectile function with the injected drugs into the base of the penis, when these were not effective before nerve-grafting

As this is a case series, there is no control group for this study. But we know that impotence that continues for two years after prostate surgery, that is not improved by any drug treatments, is usually permanent. So, it’s reasonable to predict that none of these men would have seen any improvements without the nerve-graft surgery.

When we first spoke to the team of researchers, we were told that improvements in sexual function usually took between six and twelve months to become apparent. Prof Coombs explained it took time for erections to return. ‘The delay in return of potency after nerve-grafting occurs as grafted nerves take about a month to start growing and then grow at approximately 1mm per day. The nerve grafts are like electrical extension cords and the nerve fibres are like the copper wires. The “copper”, or nerve fibres, need to grow along the nerve graft to the penis’.

The team has performed 40 operations and would like to extend the study to at least 100 patients in an effort to understand why 30% of the patients do not benefit from this surgery.

It’s important to recognise the success rate for this procedure. These men were chosen specifically as good candidates for the procedure. Considerable research is needed to determine the success of the procedure in a larger scale and to determine who it is best suited for. A larger study would be also of great benefit allowing for a longer and better assessment of quality of life of the patients after surgery.

 “This procedure could influence the decision of men with localised prostate cancer to go ahead with a prostatectomy if they knew there was a minimally invasive procedure available that could potentially restore their ability to have an erection.” The researchers said for The Conversation last week

Patients eligible for this new nerve grafting surgery must:

  1. Be aged younger than ~70 years
  2. Have had satisfactory erectile function prior to radical prostatectomy surgery
  3. Have PSA levels <0.1ng/ml in their most recent test following radical prostatectomy
  4. Have moderate to severe erectile dysfunction prior to novel nerve graft surgery with or without oral and/or injectable therapies
  5. Have had their radical prostatectomy within the last 5 years
  6. Have no hormonal-related conditions or insulin-dependent diabetes
  7. Have not had radiotherapy to treat prostate cancer (external beam and/or brachytherapy)
  8. Have never taken androgen deprivation therapy

 

NOTE

 Professor Coombs and Dr Dangerfield offer this operation in private practices.

The first author of the paper, Dr Jeanette Reece, is a NHMRC Research Fellow at the Melbourne School of Population and Global Healt...

PCFA promotes peer reviewed research and does not act as a coordinator of any other research featured in this article. If you have any questions regarding this procedure, please get in touch with the research team directly.

 

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