Radical prostatectomy, preservation of sexual function, cancer control. The controversy

In this article, I have addressed some of the important controversies regarding the safety and efficacy of radical prostatectomy with the preservation of sexual function: (1) How often is sexual function preserved? (2) Does preservation of sexual function interfere with cancer control? (3) Are there tricks to performing the operation? and (4) Who is a candidate? Overall, 72 per cent of patients are potent postoperatively. The probability of return of sexual function correlates with the age of the patient and the stage of the lesion. In addition, it appears that only one neurovascular bundle is necessary for the return of sexual function because 69 per cent of men who undergo wide excision of one neurovascular bundle are potent postoperatively. The question whether preservation of sexual function compromises the removal of tumor can be analyzed in several ways. On the basis of operative descriptions and the evaluation of whole-mount cross sections of prostates removed by standard radical perineal and radical retropubic techniques, it appears that the neurovascular bundles were not completely resected in the past using standard techniques. However, with knowledge of the location of these neurovascular bundles, they can now be excised more widely when necessary than was previously possible. Furthermore, evaluation of surgical margins of excision gave no indication that the nerve-sparing modification compromises the adequacy of the removal of cancer, which is determined primarily by the extent of the tumor rather than by the operative technique. However, controversy surrounding this procedure will not be settled until long-term follow-up data are available to determine whether the control of local disease and distant metastases is similar to that achieved with standard radical prostatectomies. To aid in this comparison, we have been careful not to use postoperative adjuvant hormonal or radiation therapy, so that we will be able to evaluate the true impact of radical prostatectomy on the control of cancer. To preserve sexual function, a variety of fine points in surgical technique must be observed. These have been discussed in detail. It is my opinion that any patient who is a candidate for radical prostatectomy is a candidate for intra-operative assessment of the extent of tumor and the location of the neurovascular bundles. Based on this information, the surgeon can make an informed decision whether the neurovascular bundles can be safely preserved or excised widely with the specimen. In all surgical approaches to prostatic cancer, the primary goal must be excision of all tumor; preservation of sexual function should be of secondary concern. However, if candidates are selected carefully using these criteria, most patients would be potent postoperatively. With a reduction in overall morbidity, it is hoped that more men with localized disease will accept radical prostatectomy as the form of treatment with the greatest likelihood for cure.