POTENCY: AN ANATOMICAL APPROACH TO SURGERY
The late 1970s saw important modifications in the retropubic approach. For the first time, the anatomy of the venous drainage surrounding the prostate was understood, and with this knowledge evolved new surgical methods to lessen the awful blood loss. The new techniques did two things: With less bleeding, the operation became safer; and with what surgeons call “a bloodless field,” it became possible for surgeons actually to see what they were doing—a major improvement! In the process, critical structures could be looked for and saved that previously had been unrecognized and damaged as surgeons blindly felt their way. More precise dissection and reconstruction reduced the likelihood of troublesome urinary incontinence from as high as 15 percent to 2 percent, and even those 2 percent are not incontinent all the time.
But what about impotence? It had been widely assumed that penile nerves inevitably were damaged by the radical prostatectomy. Previously, many people thought the nerves to the erectile tissue in the penis ran through the prostate and would be damaged as a necessity when the prostate was removed. It didn’t make sense, that the nerves from one organ would run through another organ, but this had always been the assumption—even in medical textbooks. One highly respected anatomy textbook, for example, reported helpfully that the nerves that enable erection were “extremely small, difficult to follow in the adult cadaver,” and that their location was known “merely through experimental studies.”
Meanwhile, something unusual was taking place: Gradually, as one urologist began using the new techniques, his patients began reporting that their potency had returned. What was happening? Insight came with the discovery that the nerves that run to the corpora cavernosa, the spongy, erectile bodies in the penis, sat outside the capsule of the prostate. Which meant that it should be possible to preserve sexual function in men undergoing this operation. Until that time, these tiny nerves had almost always been inadvertendy destroyed during surgery because doctors didn’t even know of, and therefore couldn’t appreciate, their existence. The nerves were never removed, but were damaged and left in place.
In the early 1980s at Johns Hopkins, this new knowledge—that these microscopic bundles of nerves on either side of the prostate could be preserved—was first put into action. The patient, a 52-year-old psychology professor, regained his sexual function within a year after the modified, “nerve-sparing” surgery. (Actually, this term only tells part of the story, but this description has stuck, and many people use it. The operation’s proper name is the anatomical radical retropubic prostatectomy.) Twelve years later, this patient is alive and cancer-free; his quality of life remains excellent.
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