Composer Andrew Lloyd Webber last week revealed he’d been left impotent following prostate cancer surgery. He is one of 37,000 men who are diagnosed with the disease each year in the UK.
There are various treatment options available, but which is best and what are the implications for your sex life?
“There are three considerations when it comes to treatment,” says David Neal, professor of surgical oncology at Addenbrooke’s Hospital in Cambridge. “We need to remove the cancer, prevent urinary incontinence and preserve sexual function - and the majority of patients agree this is the order of importance.
“However, the key indicator of what your sex life will be after the operation is what it was like before. Remember also that sexual function may begin to wane naturally once a man reaches his 50s and 60s.”
John Anderson, vice president of the British Association of Urological Surgeons, agrees. “It’s important to look at the demographic of many men who get prostate cancer. It is typically a disease of older men and, in these men, erectile function is not always at its best anyway.
“Then there is the tumour itself; your risk of impotence depends on the extent of the disease, which dictates how much treatment you will need.”
Your choice of surgeon is also “critically important - more so than the technique you undergo,” says Professor Neal. “You really want a surgeon who performs at least 80 to 100 procedures a year for your best chance of success on all fronts.”
Professor Roger Kirby, director of The Prostate Centre in London, says: “If the cancer was localised and the nerves were preserved, there is a good chance of regaining some sexual function.
“Many men find that things slowly begin to improve months, even years afterwards, as the nerves regrow.”
Here, with the help of the country’s leading prostate experts, we examine the pros and cons of each treatment and their possible effect on sex life.
ACTIVE SURVEILLANCE
The patient receives no treatment but is closely monitored every three to six months in case the cancer becomes more aggressive. “Many prostate cancers are slow-growing; we are getting much better at sorting the aggressive tumours from the slower growing ones,” explains Professor Kirby.
SUITABLE FOR: Low-risk, early-stage prostate cancer that is contained within the prostate. Patients with a Gleason score of six or less.
This measures the aggressiveness of the cancer from a tissue sample. A score of six and under is the least aggressive cancer; seven indicates a middle-ranking cancer; eight and above is the most aggressive.
WHAT IT INVOLVES: Regular hospital tests. These include a prostate specific antigen test to detect a protein linked to prostate cancer (rising levels could indicate the cancer has become more serious), digital rectal examinations, magnetic resonance imaging (MRI) scanning and biopsies.
PROS: “It can be ideal for those men with low-risk prostate cancer who are happy to defer treatment unless absolutely necessary,” says Mr Anderson.
“And more and more men are opting for this over treatment,” says Professor Kirby. “Of the 37,000 men diagnosed with the disease each year, only around a third will die from it.”
CONS: Some men may become anxious about their cancer changing. Occasionally, the cancer may change or grow faster than expected.
EFFECT ON SEX LIFE: The best outcome of all the options - there is no risk of damage to the nerves that assist sexual function. “The problem is, the nerves that enable a man to become aroused are very close to the prostate - this is why surgery can cause problems,” explains Professor Neal.
OPEN RADICAL PROSTATECTOMY
The most common type of surgery to remove the prostate gland and some surrounding tissue.
SUITABLE FOR: Cancers with a Gleason score of six and above which have not spread beyond the gland, with the patient being relatively fit and healthy.
WHAT IT INVOLVES: A two to three-hour operation where the prostate is removed following a 6-7cm incision in the lower abdomen under general anaesthetic.
PROS: “The aim is to remove the cancer completely,” says Mr Anderson. “If this is successful, and the cancer has not spread outside the prostate, it will return you to normal life expectancy.”
CONS: Overnight stay in hospital with greater risk of bleeding and a longer recovery period.
EFFECT ON SEX LIFE: A quarter to a third of men will lose sexual function due to damage to the surrounding nerves and small blood vessels responsible for erections. “In men who have good function beforehand, there is on average a 66 to 75 percent chance they will be able to perform afterwards,” says Professor Neal. “But remember that it takes a good 12 to 15 months to recover from prostate surgery. Pretty much everyone is impotent straight after.”
“It’s fair to say that a man in his 50s has a better chance of retaining function than a man in his 70s,” adds Professor David Gillatt, director of the Bristol Urological Institute.
Nerve-sparing prostate surgery is where the surgeon tries to avoid damaging the two nearby bundles of nerves that control erections, explains Mr Anderson. It may be possible if the cancer has not spread too far. Studies show that for every ten men with both nerve bundles spared, between three and eight regained erections.
KEYHOLE RADICAL PROSTATECTOMY
The prostate gland is removed through tiny cuts in the abdomen rather than one large one. This is the treatment Andrew Lloyd Webber had.
SUITABLE FOR: A similar group to open surgery, but is becoming the preferred method for many surgeons.
WHAT IT INVOLVES: There are two methods - by hand or using a Da Vinci robot (a relatively new technique). The surgeon makes five or six small cuts in the abdomen and inserts a camera through a tube that magnifies everything ten-fold.
Tiny instruments go through the other holes and the operation takes two to three hours. In robotic surgery, the camera used is 3D and high-definition, explains Professor Prokar Dasgupta, of Guys and St ThomasÕ Hospital, who pioneered robotic surgery in the UK eight years ago.
PROS: “As with many types of keyhole surgery, there is a quicker recovery time, less pain, bleeding and scarring,” says Professor Kirby (who has performed more than 800 robotic removals). ÔBecause the structures can be seen so much more clearly, robotic surgery should be more effective than open prostatectomy, but this needs confirmation from long-term studies.
“I believe it’s the best way to treat prostate cancer and have abandoned open surgery because of this.”
Professor Dasgupta adds: “The cancer control is good and we can often spare the nerves responsible for continence.”
CONS: Similar long-term risks of impotence and incontinence problems with manual keyhole as for open surgery but robotic operations, with an experienced surgeon, may dramatically reduce this.
EFFECT ON SEX LIFE: “We find that many younger patients recover their potency very quickly after robotic surgery,” says Professor Dasgupta.
EXTERNAL BEAM RADIATION
High-energy X-ray beams are directed at the prostate gland to eradicate the cancer cells by stopping them from dividing and growing.
SUITABLE FOR: Older patients and those with more aggressive locally advanced cancer with a Gleason score of seven or above; patients health conditions that make them unfit for surgery.
WHAT IT INVOLVES: The most common type is 3D conformal radiotherapy. This directs beams to fit the size and shape of the prostate while helping to avoid damaging the healthy tissue around the prostate.
The new intensity-modulated radiotherapy can deliver different doses of radiation, meaning less risk to surrounding tissue.
PROS: Painless and requires neither general anaesthetic nor overnight hospital stays.
CONS: Daily trips to hospital for seven weeks. “There is always the danger with leaving the prostate inside the body that some residual cancer may remain,” says Professor Kirby. “Radiotherapy can also cause an irritated bladder and bowel - many patients complain they feel the urge to ‘go’ all the time,” explains Professor Gillatt.
EFFECT ON SEX LIFE: Sexual dysfunction rate is the same as after surgery: between a quarter and a third of men will be impotent. “However, with surgery the body recovers over time,” says Professor Neal, “whereas radiation damage can continue occurring for two to three years after the treatment.”
BRACHYTHERAPY
Tiny radioactive seeds - the size of a grain of rice - implanted in the prostate emit radiation to the surrounding tissue, destroying cancer.
SUITABLE FOR: Men with smaller and localised tumours that are low-medium risk (Gleason grade seven). Not suitable for those with large prostates or men with urinary problems, as it will make the problem worse. High-dose brachytherapy may be offered for higher risk cancers, but this is not widely available.
WHAT IT INVOLVES: The seeds are inserted via needles close to the tumour, with an epidural or under sedation. (They remain in the body permanently, becoming inactive after eight to ten months.)
PROS: “Treatment is rapid, taking just two days,” explains Professor Neal.
Because the radiation doesnÕt travel very far in the body, the healthy tissue around the prostate gland gets a much smaller dose of radiation and so may cause less damage to bladder and urethra resulting in fewer incontinence problems.
CONS: “It can cause problems with urination if the prostate swells - a common side-effect of this treatment,” explains Professor Gillatt. (The prostate surrounds the urethra, the tube that delivers urine out of the body, like a doughnut.)
EFFECT ON SEX LIFE: “Some doctors say this has a lower risk of impotence, but the evidence is not there,” says Professor Neal.
And, adds Professor Gillatt, just like conventional radiotherapy, the effects on sexual function may take time to appear.
HIGH INTENSITY FOCUSED ULTRASOUND
A relatively new treatment that heats and destroys cancer cells in the prostate.
SUITABLE FOR: A minority of men for whom loss of potency is their paramount concern. May also suit men unhappy with active surveillance, or older men unsuitable for surgery.
WHAT IT INVOLVES: A probe inserted into the rectum passes ultrasound waves through the wall of the back passage and into prostate gland. The ultrasound energy causes the prostate cells to heat up, destroying both the healthy and cancerous cells.
PROS: Can focus on certain parts of the prostate gland where the cancer is, potentially avoiding damage to other nearby organs and nerves responsible for sexual function. No scars, and can be performed as a day case. If unsuccessful, it is still possible to undergo surgery or radiotherapy at a later stage.
CONS: Widely considered an experimental treatment Ñ no long-term results have been published yet, says Mr Anderson. Professor Neal adds: ÔThe concern with HIFU is that it focuses a beam on the prostate and burns selected areas where the cancer is. But there may be other areas of cancer in the prostate that do not appear on an MRI scan and therefore may not be treated.Õ
EFFECT ON SEX LIFE: More evidence is needed.
HORMONE TREATMENT
Controls testosterone, the male hormone that fuels prostate cancer cell growth.
SUITABLE FOR: The gold standard for patients with advanced prostate cancer that has spread beyond the gland and is untreatable using surgery.
WHAT IT INVOLVES: Drugs called LHRH analogues, such as Zoladex, are given as an injection every one or three months, depending on the dose. There are also anti-androgen tablets such as Casodex, taken daily that stop testosterone from reaching the cancer cells.
PROS: While not a cure, hormone therapy can be a lifelong treatment. It slows tumour growth, reduces symptoms and shrinks the cancer. For this reason it’s also commonly used before radiotherapy and sometimes afterwards to help improve the effects of treatment.
CONS: Testosterone is important for bone health; by reducing it, this raises the risk of osteoporosis.
EFFECT ON SEX LIFE: “Treatments such as LHRH analogues destroy your sex drive,” says Professor Kirby. “They lower libido because they lower testosterone, the driving force behind it.” However, taking anti-androgen tablets may allow a man to preserve his hormone levels - or at least stop his libido being quite so battered - as they don’t actually stop testosterone being produced, says Mr Anderson. - Daily Mail