"I was very fearful that the surgery would affect my sexual function and bladder control," says Mr. Daly.

He was referred to Herbert Lepor, MD, a urologic surgeon at NYU Medical Center with an international reputation for performing radical prostatectomy using nerve-sparing techniques that greatly reduce the risk of complications.

Prior to this breakthrough, impotence invariably followed radical prostatectomy. The conventional wisdom was that this operation unavoidably caused injury to neurological or vascular pathways or both. This would severely impair normal erectile function.

A series of important clinical observations and advances in surgical technique in the late 1970s established the foundation for the nerve-sparing radical prostatectomy. Urologic surgeons had been working to reduce blood loss during prostatectomy by careful dissection and ligation of the dorsal vein complex to control bleeding. This allowed the surgery to be performed in a relatively bloodless field, in which even more meticulous dissections could be completed.

Following the surgery, younger patients began to report that they were still sexually potent, which indicated that the nerves stimulating erectile function can be preserved.

Unfortunately, a detailed anatomic description of the nerves could not be found in the literature. Preliminary anatomical research, however, confirmed that these hair-thin nerves (the cavernous nerves) were located outside the capsule of the prostate gland.

Delineating the Anatomy
A major effort was launched by Dr. Walsh to modify the procedure to avoid the cavernous nerves while maintaining adequate surgical margins. A central task, undertaken by Dr. Lepor, was the painstaking effort to accurately chart the complex anatomy encompassing the prostate. This involved dissection and three dimensional reconstruction of the adult human pelvis in minute detail to determine precisely where the microscopic cavernous nerves are located.

Perfecting Surgical Technique
These advances made it possible to greatly reduce the rates of impotence following radical prostatectomy for patients with localized prostatic cancer. However, knowledge of the anatomy and procedures alone is insufficient. To perform this operation successfully requires a great deal of surgical experience and skill. Dr. Lepor performs over 200 radical prostatectomies at NYU Medical Center annually; his patients are usually ready to go home within two days after surgery.

Dr. Lepor's work has made it much easier for the patient to accept a recommendation of surgery. "The best chance of curing this cancer is to have the surgery, and now the operation is much safer and less traumatic than ever before," he says. "The risk of impotence is greatly reduced, and the likelihood of speedy and full recovery is extremely high." Additionally, NYU's physician-scientists are doing pioneering work in treating impotence, so even if this problem occurs, expert care is available to assist in the restoration of sexual function. A leader in this field is urologist Andrew McCullough, MD, who is investigating pharmacological and surgical therapies for erectile dysfunction.

Improvement of surgical technique in prostatectomy has led to another important benefit: reduction in incontinence. In fact, none of Dr. Lepor's patients has experienced total urinary incontinence.

"I was totally relieved," Mr. Daly recalls, "when I saw my wife and family, and the doctors indicated that everything went very, very well. Dr. Lepor was confident that he had spared the nerves, and he had left my lymph nodes intact."

The pathology report confirmed that Mr. Daly's cancer had been confined within the prostate gland. About two months after the operation, he was back playing four-wall handball three times a week.

"Physically, I'm in very good shape. My continence is excellent, and my sexual function returned very quickly. I really feel lucky that Dr. Lepor was able to remove all the cancer, while avoiding significant side effects.