More than 250,000 new cases of prostate cancer is being diagnosed each year in the U.S. Due to the development of screening projects based on the use of PSA (prostate specific antigen), a very powerful tumor marker which is found in the blood, the majority of patients with prostate cancer receive their initial diagnosis when the disease is still confined within the prostate.
More than 250,000 new cases of prostate cancer is being diagnosed each year in the U.S. Due to the development of screening projects based on the use of PSA (prostate specific antigen), a very powerful tumor marker which is found in the blood, the majority of patients with prostate cancer receive their initial diagnosis when the disease is still confined within the prostate.
This is of crucial importance because only in this setting patients may receive different forms of curative therapy which may guarantee them prolonged survival. The two main options for treating clinically localized prostate cancer are surgery (radical prostatectomy) and radiotherapy (conformal radiotherapy or brachytherapy).
Radical prostatectomy includes the removal of the lymph nodes located in the obturator fossa which drain the lymph produced by the prostate, together with the prostate and seminal vesicles which are removed en bloc.
In the early 1980s the so called "nerve sparing" radical prostatectomy technique was developed in Baltimore by Dr. Patrick Walsh. The advantage of the technique included the preservation of the cavernous nerves which carry the signals to the penis to start and maintain the erections and which are essential for having a normal erectile function.
The advent of this technique allowed to maintain a good erectile function in almost 50 percent of the men undergoing this procedure. Why the success rate was only 50 percent?
Most probably during the dissection of the gland the cavernous nerves are somehow slightly damaged and this causes the temporary disappearance of erotically stimulated and sleep associated (spontaneous) erections in the early postoperative period.
This lack of erections is associated with reduction of blood circulation and oxygen transport within the penile tissue; corporeal smooth muscle cells may then be altered and erectile dysfunction may develop.
At our center in Milan, we demonstrated that by treating patients receiving a nerve sparing radical prostatectomy with intracavernosal injections of alprostadil (a powerful vasodilating agent) early after surgery, we were able to stimulate the circulation of blood and oxygen within the corpora cavernosa tissue and facilitate the recovery of spontaneous erections. However, we were successful in only 70 percent of our patients. With the advent of sildenafil, a new and effective oral therapy for erectile dysfunction (Viagra), patients who receive a nerve sparing radical prostatectomy could potentially respond to this drug.
We tested this hypothesis in a series of 25 patients who underwent a nerve sparing radical prostatectomy during the early months of 1998. After surgery, all of them received a course of eight intracavernosal injections of alprostadil (twice a week for four weeks) and were then given sildenafil on demand. We found that 85 percent of our patients were able to obtain a good erection with sildenafil; 100 mg was the most effective dose although we had two patients who responded well to the 25 mg dose.
Prostate cancer is a disease of major importance, as in most of the cases it causes patients' deaths. In clinically localized prostate cancer, radical prostatectomy seems to be the most effective therapy in terms of cure of the disease. We now know that by performing a nerve sparing radical prostatectomy followed by a brief course of intracavernosal injections and with the aid of sildenafil, almost all men can retain their erectile potency. If one considers that urinary continence is maintained in the overwhelming majority of patients, we are now able to say that quality of life of these patients after surgery is no more a concern.
