Sex, and Life after Surgery

BY MARK SCHOLZ, MD

After prostate surgery only 5-15% of men describe their sexual function as unchanged.¹ And I’ll venture that zero percent describe it as improved. For an average man with good preexisting sexual function, the best surgeons preserve some level of function about half the time—with the aid of copious Viagra. (Just so you know, the medical definition of function is anything adequate to “be stuffed in.” Seriously!) And erectile dysfunction isn’t the only way to ruin intimacy. Dr. John P. Mulholl, author of the excellent book, Saving Your Sex Life: A Guide for Men with Prostate Cancer, has coined the term “climacturia” to describe the distressing news that, after surgery, some men ejaculate urine rather than sperm.

Prostate Cancer Surgery is Difficult, Robotic or Otherwise
These sad results are not due to lack of effort. Over the last five years, prostate operations are up 50%. Every year, more than 70,000 men are taking a ride on the wild side.² The primary reason for all the excitement is robotic surgery. Can the robotic approach justifiably claim any advantages over older methods? Yes, scars are smaller; hospital stay is shorter and serious bleeding less frequent. However, for all its popularity, studies confirm that robotic surgery serves to preserve bedroom bliss just as poorly as the older standard techniques.

What About the “Average Surgeon?”
Quality control for prostate cancer surgery is nonexistent. The above statistics are for the most practiced and skilled surgeons.  Studies show that with average surgeons, results vary widely. For example, at reputable large academic institutions the likelihood incomplete removal of the cancer varies between 11 and 50%!³

What then might we anticipate from the “silent majority” of urologists at the community hospitals? If the number of operations is any indication, we need to be seriously concerned. In New York for example, for the whole year of 2005, one in five urologists only performed a single prostatectomy, while 80% of the urologists did less than 10.⁴ 

Does Surgery Save Lives?
The frightening risks of prostate surgery would certainly be justified if survival was increased dramatically. Yet despite an explosion in the use of surgery, prostate cancer death rates in the United States have only improved about half of a percent compared to 30 years ago. And experts aren’t entirely sure that surgeons can take credit for these slight benefits. Estimates indicate that on average surgery adds at most a couple months to a man’s life expectancy.

If Not Surgery, What?
Almost any other kind of treatment—seed implants, radiation, focal cryotherapy, hormone therapy, or active surveillance—is just as effective as and considerably less dangerous than surgery.  Consider that prostate cancer is the only remaining type of cancer where surgeons (urologists) are acting as the primary doctor. Men with other common cancers, say of the lung or colon, benefit by consultation with cancer experts called medical oncologists. Beware of indulging your initial gut reaction to “just cut it out.” Instead of saving your life from cancer, all you may be accomplishing is the eradication of your sex life.    

1. Harin Padma-Nathan, Journal of Urology, Abstract 1402, 2003.
2. Barbash, Gabriel, New England Journal of Medicine, 363:701, August 2010.
3. Eastham, James, Journal of Urology, 170:2292, December 2003.
4. Savage, Caroline, Journal of Urology, 182:2677, December 2009.