A New Technology May Avert Impotence After Prostate Surgery

FRIDAY, OCTOBER 15, 1999 © 1999 Dow Jones & Company, Inc. All Rights Reserved.

HEALTH JOURNAL

By MARILYN CHASE

A DEVICE that helps doctors determine the location of nerves may make a dreaded operation a little bit less dreadful for men.

Surgical removal of a cancerous prostate gland has saved many men 5 lives. But as doctors scoop out the walnut-size organ, they can accidentally cut nerves and cause impotence. Fear of this complication has discouraged men from seeking cancer-screening tests and led many of them to choose nonsurgical treatments like radiation and watchful waiting. in recent years, surgery that places a premium on sparing nerves has trimmed the risk of impotence, but its success rate varies with the surgeon's expertise.

Now a device called CaverMap aims to refine nerve-sparing surgery and reduce impotence still further. The tool, made by Blue Torch Corp. of Needham, Mass., is available in about 80 hospitals around the country.

CaverMap is designed to locate the cavernosal nerves, which act as sexual telegraph wires, transmitting the signals that spark an erection. The nerves them­selves are too small to see, and they're entwined with blood vessels in a skein of tissue called the "neurovascular bundle." Determining where the tiny nerve fibers lie requires a combination of still and educated guesswork.

During CaverMap surgery, the surgeon points a slender wand with an electronic probe at the bundle and triggers a mild electrical current If a nerve is correctly located, the current stimulates an erection and illuminates lights on a monitor screen. With the nerves in sight, the surgeon can more easily sculpt around them without severing connections.

CAVERMAP'S TRACK RECORD isn't perfect But a recent randomized study of 60 potent men with prostate cancer found that one year after surgery, 71% of the men who had the CaverMap procedure were potent, compared with 62% of the men who had conventional nerve-sparing surgery. in the same group, nighttime erections lasted an average of 16 minutes in men whose sur­geons had used the device, compared with two minutes in men with conventional surgery. The study, by Laurence Klotz of the University of Toronto, was sponsored by UroMed.

The CaverMap device has several drawbacks. For one thing, it is available only to men with early prostate cancer. More advanced cases require removing a wider area around the tumor, making it risky to spare the nerves.

Using the device also lengthens the two to four-hour surgery by 15 to 30 minutes. in addition, the CaverMap procedure adds $600 to $1,200 to the cost of the $15,000-to-$50,000 operation (the cost varies widely by region). And the device itself costs a hospital almost $20,000, while disposable equipment used with each surgery runs $595.

William Catalona of Washington Univer­sity in St Louis feels the device as presently configured is "not a home run." He'd like to see the probe tip made smaller, and have the monitor provide continuous real-time readings throughout the surgery. Sometimes surgery's effects on blood vessels, muscle or bladder tissue include tumescence, and he worries that could give surgeons a false positive reading. The company says it has already incorporated some of his suggestions. Finally, Dr. Catalona, who has performed about 2,400 prostate operations himself, isn't convinced that the device gives an edge to surgeons who are already expert at the surgery. He does say that for those who are less experienced, "it may be a good teaching tool."

Others are more enthusiastic. Peter Scardino, the chairman of urology at Memorial Sloan-Kettering Cancer Center in New York, says he has done 1,500 nerve-sparing prostatectomies in his career and used the CaverMap about 140 times. He says the device helps him learn about subtle differences in patients' anatomy that can affect surgery, and reassures him that difficult cases have succeeded.

"Like an ostrich," Mr. Fenner says, he had avoided PSA testing. After the diag­nosis came back, he and his wife hurled themselves into research on prostate cancer. One source of information was a book by Patrick Walsh, a Johns Hopkins University pioneer in nervesparing surgery. Hopkins referred Mr. Fenner to surgeon James Brooks of Stanford.

Choosing surgery "was as radical as you could get, but it seemed like it offered the best outcome," Mr. Fenner says. "I didn't know about CaverMap. I selected Dr. Brooks, and this came with it"

Dr. Brooks, who has done 500 nerve sparing surgeries including 50 operations with the CaverMap, says the device isn't a panacea but he likes it because "it gives you immediate feedback of how you did. I think it'll speed the learning curve."

Even when nerves are spared, other factors can foil sexual function, including a patient's blood flow and psychological state. Nerves can also remain traumatized for six months to two years after surgery. Only 5% to 10% of men are potent right after an operation, Dr. Brooks says.

After his surgery, Mr. Fenner says, he was advised not to attempt sexual rela­tions for six weeks. He had low expecta­tions, so he was delighted when his potency returned almost immediately. "I was amazed I didn't have any problems," he says. "Everying was working."

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