Nerve graft can restore function for men having prostate surgery

UW surgeons have performed the region’s first two operations of their kind yesterday to help men avoid their greatest fear about prostate cancer surgery: impotence.

During separate surgeries at UW Medical Center in January, doctors grafted nerves from two men’s legs into their pelvic area in order to preserve their ability to have an erection.

The surgery is currently performed at less than a half dozen sites in the United States in conjunction with prostatectomies, the removal of a cancerous prostate gland. The procedure involves grafting the sural nerve from the man’s leg and ankle in place of the erection-producing nerves that run along the right and left sides of the prostate.

In more than half the cases at other sites, the new nerves grow back in place of the old nerves, restoring potency. It can take up to a year for the nerves to grow back.

“There’s no question that this procedure will become widespread. It offers prostate cancer patients even greater hope of preserving erectile function,” says Dr. Paul Lange, professor and chair of the Department of Urology at the University of Washington School of Medicine. He is internationally known for his clinical and research work in prostate cancer.

Two other faculty members assisted in the operations: Dr. Bill Ellis, a urologist, and Dr. Michel Kliot, a neurosurgeon.

Nerve grafts are quite common in many circumstances, Lange said, such as after hands, arms or legs are severed by trauma. They are far less common when the autonomic nervous system is involved, such as the prostate nerves. (Autonomic nerves are nerves that are not under our conscious control, such as nerves around the stomach.) The prostate nerve graft has been around for a few years. The Baylor College of Medicine in Houston pioneered it.

The reason for the graft is that surgery to remove the prostate can damage the microscopic nerves that carry the signal for an erection between nerves in the spinal cord and the penis. Those nerves pass close to the prostate. In cancers where the surgeon must resect a large area, about an inch of the nerve may be removed. If that happens, the signal is unable to jump from the one severed nerve end to the other end.

During the graft procedure, doctors use microscopes and an electric nerve probe to locate the two ends of the nerves, one end near the bladder and the other at the base of the penis, during the prostatectomy. The location of the nerves varies from person to person. When they’ve found the ends, doctors sew the sural nerve between them.

The body’s natural healing process then is often enough to join the ends together. “Nerve endings have growth substances that make them find their way, and they grow back,” Lange says.

The sural nerve, which is used in the graft, affects the ankle. It is harvested while the doctors are removing the prostate. Removing it causes a small patch of numbness near the ankle, but the feeling often goes away after other nerves compensate for the loss.

The nerve grafts can be performed on men who are likely to lose their nerves during the prostatectomy. In cases where the cancer has not spread far, the nerves are often preserved. At UW Medical Center, patients having nerve-sparing prostatectomies have preservation of their potency 60 to 70 percent of the time, Lange says.

The graft surgery is not performed on men who’ve already had prostate removals. There are other solutions for men who’ve lost the ability to have an erection because of the surgery, Lange says, including shots to the penis that last for about an hour; a vacuum device; or a prosthesis that operates with a pump. ¶

Walter Neary