Surgery Restoring Penis After Prostate Cancer IncreasingJason Gale
Chris Love shows how he can restore the hydraulics of the penis -- and men’s self-esteem -- by manipulating a rubbery jumble of hoses and inflatable tubes.
Love, a Melbourne urological surgeon, squeezes an acorn-sized pump and demonstrates how the inflatable device, which he likens to “an inner tube in a car tire,” helps men recover erectile function damaged by prostate cancer treatment.
Removing the prostate, the most common surgical remedy for tumors of the gland, causes impotence in about half of men. Love is among a growing network of doctors practicing “penile rehabilitation,” which uses pharmaceutical and mechanical means to help the male member heal after blood vessels and nerves in the pelvic cavity are damaged. Restoring erectile function can also improve the mental health of cancer patients, studies show.
“It’s about quality of life,” Love said in an interview at his office, pressing a pump to show how the two soft tubes that are inserted in the penis begin to engorge with a saline solution stored in a reservoir next to the bladder. “If you’re having your prostate out to cure you of cancer, you’ve got to know what the effect on your life is and what can be done to fix it. And we can fix it.”
The prosthetic devices he mostly implants are made by Coloplast A/S, based in Humlebaek, Denmark, and AMS, a Minnetonka, Minnesota-based unit of Endo Health Solutions Inc., and cost about $12,000 apiece. Love, 58, says he performed 70 such surgeries last year.
Coloplast, which also makes ostomy care products, climbed to the highest since 1983 last week, ending trading at 322.10 kroner in Copenhagen on March 22. The stock has surged 72 percent the past year, making it the best performer on the 10-member Bloomberg Europe Health Care Index, which has increased 21 percent. Endo Health gained 1 percent to $30.85 in Nasdaq trading on Friday and has jumped 18 percent so far in 2013.
Demand is increasing as more men undergo treatment for prostate cancer and then seek help for the side effects, which can include urinary incontinence. More than 2 million men in the U.S. count themselves as survivors of prostate cancer, estimated to afflict one man in six during his lifetime.
After skin cancer, prostate cancer is the most common malignancy in American men, the American Cancer Society estimates. This year in the U.S., 238,590 men will be diagnosed with it and 29,720 will die, according to the society.
Almost a third of prostate cancer patients have the cancerous organ removed in a procedure called a radical prostatectomy.
While early detection and improved surgical precision have lowered rates of cancer regrowth and urinary incontinence, progress in enabling men to recover sexual function has been “disappointing,” said Declan Murphy, an associate professor of surgery at the University of Melbourne and director of outcomes research with the Australian Prostate Cancer Research Centre.
“Probably about 50 percent of all men will have erection problems in the long term” after the procedure, said John Mulhall, director of the male sexual and reproductive medicine program at New York’s Memorial Sloan-Kettering Cancer Center, the world’s oldest and largest private cancer hospital.
Only 10 percent of men treated for early prostate cancer could sustain an erection sufficient for sex 15 years later, according to a study published in the New England Journal of Medicine in January.
The consequences on relationships and mental health can be devastating, said Addie Wootten, a clinical psychologist in the urology department at the Royal Melbourne Hospital.
“Even men who are not sexually active in their 70s or 80s talk about how it changes something,” she said in an interview. “There is an identity or core feeling of being a man that changes.”
Godfather of Rehab
Men whose prostate cancer is advanced or has spread to other tissues are twice as likely to attempt suicide as men the same age without the disease, a 2010 study in the journal European Urology found.
Mulhall’s research into ways to maximize erection recovery following radical prostatectomy has made him the “godfather of penile rehabilitation,” according to Love.
“Your penis is like your biceps,” Mulhall said in an interview. “If you don’t use it, you get atrophy. Except in your penis, that atrophy is permanent.”
Mulhall’s approach is inspired by nature. An adult male will typically get three erections per night. “The purpose of those, we believe, is to keep erectile tissue healthy,” he said.
In the absence of regular, spontaneous erections in prostatectomy patients, he recommends a group of medications known as phosphodiesterase type 5 inhibitors. These include Pfizer Inc.’s Viagra, Eli Lilly & Co.’s Cialis and Bayer AG’s Levitra, which cause blood vessels in the penis to dilate.
Men who don’t respond to the pills when introduced about six weeks after surgery are advised to switch to a hormone-based therapy that’s injected directly into the penis. The hope is that, as the penile nerves recover, the response to pills will improve such that the injections can be stopped, Mulhall said.
“People go white in the face when we even mention penis injections, and then they try it and say this isn’t that bad,” he said. Even injection-induced erections bring fresh blood to the penis, aiding its recovery.
“I don’t care if you have intercourse or just an erection, we have to get the muscle stretching and the blood flow of those muscles,” Mulhall said. While there isn’t robust scientific evidence to determine when to start rehabilitation and how, “the signal from all the literature is that there is no harm to rehabilitate and there appears to be a significant benefit.”
The cost of twice-a-week injections and low-dose Viagra on other nights can run up to $2,500 for two years of rehabilitation, “which is a lot of money,” Mulhall said. “But what I tell patients is that, if you are 50 years of age, you have 25 years of sex ahead of you. That breaks down to about $100 a year.”
The prostate is attached to bundles of nerves and blood vessels linked to the penis. Even with careful nerve-sparing surgery, these are disturbed during a radical prostatectomy, according to Love. Studies in rats have shown that clamping the nerves, without severing them, causes cells in the penis to die within weeks and fibrous scar tissue to form, he said.
Fibrosis, which can lead to a condition called Peyronie’s disease, can shorten the male member and lessen rigidity, Love said.
Sixteen percent of prostatectomy patients develop Peyronie’s, or curvature of the penis, after the operation, said Darren Katz, a urology fellow at Freemantle Hospital in Perth, Western Australia. At least half of those men will become depressed as a consequence and some may need corrective surgery.
“The normal mechanism of erection is the arteries open up, blood goes into the penis, the penis starts to swell and it passively squashes off the veins, so you get a closed system,” Love said. “If you get structural changes in the penis -- a bit of fibrosis -- it can’t swell properly and the veins can’t close off.”
When that condition -- called veno-occlusive disease -- occurs, pills and injections aren’t likely to work. If there’s no erectile recovery after 12 months, Love recommends a Doppler ultrasound scan of the arteries and veins of the penis to see if veno-occlusive disease is the problem. If it is, an implant may help, he said.
Surgeons could do more to follow up with patients and enquire about their wellbeing, Love said. “I’m really keen for them not to hang around forever, losing confidence, having their relationship upset, when there is an answer,” he said. “I also don’t want to be overly aggressive and start talking about these too early.”
The procedure, which Love says takes him 35 to 40 minutes under general anesthesia, is done via a small incision at the base of the penis. Inflatable cylinders are used to replace the corpus cavernosa -- two tubes running along the sides of the penis that cause an erection when filled -- either naturally with blood or artificially with saline. The manual pump, which has an inbuilt release valve, is inserted in the scrotum.
The operation should only be performed as a last resort because afterwards men can never again have a natural erection.
Ninety-five percent of the devices are still functional at 10 years and 70 percent are working after 15 years, Love said.
About $500 million of penile implants are sold in the U.S. and $1.7 billion worldwide each year, according to Endo. Demand for its urological therapies are “supported by the baby boomers population providing us with a long-run rate for growth,” AMS President Camille Farhat said in a presentation to investors last October.
“We foresee increased growth in the erectile restoration market as we increase patient awareness and as the implant option becomes more desirable,” Farhat said. “It’s well accepted that 65 percent of men over 65, and 75 percent of men over 75, and 85 percent of men over 85 will need a prostate treatment.”
Love says he tries to give patients a fair picture of what to expect after the procedure. “I get pretty blunt,” he says. “I say to them, ‘It’s not going to make you more attractive, it’s not going to make you a better lover. But if you want to have penetrative sex, it’s a good way to go.’”