Conversations With Prostate Cancer Experts

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Penile Prosthesis For ED

Dr. Jean-Francois Eid, of New York City’s Advanced Urological Care, is a urologist who specializes in treating advanced erectile dysfunction.

Prostatepedia spoke with him recently about penile prostheses after prostate cancer.

How did you became involved in treating men with erectile dysfunction (ED)?

Dr. Jean-Francois Eid: When I was a third-year medical student, I did a general surgery rotation in urology, and I went to a lecture about penile implants. I was fascinated that such a device could be made. Because I have an engineering background (I’m a material science engineer), I felt then it would be a dream to work with the industry that produces these magnificent devices, to continue to improve them, and invent surgical equipment to facilitate implantation. My dream came true.

I work with Boston Scientific and Coloplast, companies that make penile implant devices for men who suffer from ED. I’m on their advisory committee, and we collaborate in order to improve these devices. I have a few patents to my name as well. It’s been a great ride for the last thirty years.

I, of course, learned from a lot of many great implant surgeons and have benefited from their experience. I also felt that it was time for me to give back and I was very honored when I was asked to write a chapter on penile implants in the Campbell- Walsh urology textbook, required reading for all Urology Residents.

How common is ED after prostate cancer?

Dr. Eid: It varies depending on the treatment that the patient received and the level of erectile function the patient had before treatment. For example, if a patient had normal erections before radical prostatectomy, studies show that about 7 to 10% of these patients will have normal unassisted erections after the prostate operation. About 30% of these gentlemen will respond to oral therapy such as sildenafil or tadalafil. The remaining 60% will need a more advanced ED treatment option, such as a penile self-injection or a penile implant.

Patients who undergo radiation therapy fair a little bit better. They develop ED about a year to a year and a half after the radiation, and about 50% of these patients will respond to oral medications. The remaining will also need more advanced treatment options such as penile self-injection or penile implant.

What is the progression? You try medication first, and if that doesn’t work, then you go to injections, and finally something like a prosthesis?

Dr. Eid: Exactly. Patients who undergo radical or robotic prostatectomy tend to be younger and healthier, and we recommend a period of penile rehabilitation with either oral therapy, vacuum device or penile self-injections. The data supporting penile rehabilitation is not very robust, nevertheless if a patient had normal unassisted erections prior to the cancer treatment, I would recommend a 12 to 18 month waiting period before proceeding with a penile implant. He is unlikely to recover spontaneous erections beyond the 2-year period, however. Conversely, if a patient relied on oral medications or penile self-injection for satisfactory sexual intercourse prior to the prostatectomy, it is then very unlikely for erectile function to return. In that case, one may proceed with a penile implant before the 12 month waiting period. Oral medications and a trial of penile self-injection is always recommended before proceeding with a penile implant.

If a man struggled with ED before going into prostate cancer treatment, will that impact if he has ED after treatment?

Dr. Eid: Yes, the ED is more likely to be advanced and be more difficult to treat. Penile atrophy, deformity and permanent shrinkage are more likely to occur. Early placement of a penile implant may in that circumstance be a better option as it will prevent further penile deformity and shrinkage while restoring erectile function.

What is penile implant prosthesis, and what are the different types?

Dr. Eid: There are basically two types of penile implants: malleable and inflatable implants. Malleable implants are always firm and positional so that they can be concealed by manually bending it down when not in use. These are the simplest of the penile implant devices. However, the feel of the penis is not as natural as for the inflatable devices. Because the shaft of the penis is always firm, pressure atrophy of the flesh of the penis will occur over the long run.

The inflatable devices can be further divided into two groups: devices with a self-contained reservoir, also referred to as a two-piece implant and the multi-component implant with cylinders, pump, and a separate reservoir referred to as the three piece implant. The reservoir is needed in order to store the saline when an erection is not desired. The two-piece devices are comprised of a pair of penile cylinders with a small saline reservoir built into the back of each cylinder and a scrotal pump. To obtain an erection the scrotal pump is squeezed, transferring the saline from the reservoir into the cylinders. The volume of saline is limited, which means there’s a compromise between penile rigidity when inflated, and the flaccidity of the penis when the cylinders are deflated.

The three-piece inflatable implants are the more physiological devices with a better erection when inflated and better flaccidity when deflated. The separate reservoir is easily concealed and because it contains a much larger volume of saline it enables the bearer to have a much firmer erection.

There are approximately 25,000 implants performed in the United States every year of which 90% are the multi-component inflatable devices. These devices were invented in 1973, and they’ve been refined since. There are only two companies that make them: American Medical Systems, (Boston Scientific), and Coloplast. Both are excellent companies and current implants have an average life expectancy of 8 to 12 years. When they fail, they are easily replaceable. The procedure to remove and replace it is a lot less cumbersome for the patient because the space inside the penis is already fashioned. There’s less pain and swelling than for the original implant placement.

Is there a difference in performance between the two types of devices?

Dr. Eid: The multi-component inflatable devices give the most natural feel of the erection and are a lot more comfortable when the patient no longer wants to have an erection. The malleable implants have a very firm and abnormal feel to them. Over time, the flesh of the penis will become looser over the rigid cylinders. This renders the malleable implant to be less firm than the inflatable device. On the other hand, when the inflatable devices are deflated the cylinders no longer apply pressure on surrounding penile flesh, preventing long-term penile atrophy

When is a penile implant prosthesis a possible solution for men with ED? When is it not a viable solution?

Dr. Eid: Any man that can have an erection on his own or respond well to oral medications may forgo the need for a penile implant

We don’t expect patients who rely on penile self-injections to stay on them for the rest of their lives, and even if the response to injections is very good, it is not unreasonable to proceed to a penile implant. There are very few circumstances that contraindicate placement of a penile implant; these are the presence of an infection or in situations where the patient is medically unstable.

What is the procedure once he decides this is what he wants to do?

Dr. Eid: It is most important to seek the most experienced surgeon that one can find. That surgeon may not be necessarily the one closest to one’s home or in one’s insurance plan. A penile implant specialist is preferable to a general urologist. A penile implant specialist has a much greater success with fewer complications. Each specialist will have their individual pre-operative protocol.

Not a member? Join us to read the rest of Dr. Eid’s conversation about the penile prosthesis.


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How A Urologist Approaches ED

Dr. R. James Yu is a urologic oncologist with MarinHealth Urology | A UCSF Health Clinic in Marin County, California.

He spoke with Prostatepedia about he approaches erectile dysfunction after prostate cancer treatment.

Why did you become a doctor?

Dr. James Yu: My parents always engrained in me the importance of helping others. When I was younger, my mom was also diagnosed with a rare thymus cancer that metastasized to her lung. I got to see first-hand the impact cancer had on someone’s life and on the people around them. I saw her going through chemotherapy and the recovery from surgery. It created an instinctive affinity and empathy in me towards cancer patients. As a result, going into medicine was an easy decision for me, specifically in the field of urologic oncology. I was specifically drawn to urology because of the relationships that I could develop with the patients, which I don’t feel is a common thing in surgical subspecialties.

Have you had any patients over the years who have stood out in your mind as either changing how you think about your own role or how you view the art of medicine?

Dr. Yu: Definitely, but I think my mom had the biggest impact. That’s because I got to see cancer from the other side of the exam room, from the patient’s perspective. I learned from her the importance of having a team when fighting cancer. Everyone has a role to play: the patient, spouse, kids, church, friends, surgeon, medical oncologist, and radiation oncologist. It’s because of her team that helped her beat that cancer.

I see my role in a few different phases when treating prostate cancer. The first phase is when you initially get diagnosed. Of course, my job is to educate about the disease, the treatment options, and all the pros and cons of each modality; but my other job is to help alleviate the anxiety when hearing the C word in their body. Most patients have already done their preliminary research when they come to see me. Their minds have already naturally jumped to conclusions. That is what I saw my mom go through. Dealing with that emotional side of things is important. Until you’ve done that, patients won’t hear what you’re saying. That is why we spend so much time with patients at that initial consultation.

The second phase is actually doing the technical part of the surgery, which is critically important. It requires a lot of experience and expertise to deliver great results. The last phase is the survivorship. This part of the patient’s journey is often overlooked. Patients are having to continue surveillance for their cancer, and are sometimes dealing with some of the side effects of treatments. They always tell me they are super anxious to see their PSA results. But as time passes, they gain more confidence in their cancer control, and also see their side effects improve or resolve. You start to see the tension melt away in their faces. It really brings me a lot of joy to see my patients go through that growth and evolution.

How do you approach the subject of erectile dysfunction after surgery with your patients? Do you introduce the subject in that initial consult?

Dr. Yu: Sexual health, in general, is a delicate and sensitive topic for many patients and their partners. That’s especially true when discussing the sexual impacts that prostate cancer treatments can have on patients. In some cases, the embarrassment in talking about sexual health can negatively impact the patient’s overall recovery. That’s why communication before and after treatment is so important for erectile function. That communication needs to exist between the patient and his doctor AND the patient and his partner. My advice to patients is to not assume the other party knows what you are thinking, or that you know what they are thinking. Only talking about these issues can make things better.

Of course, urologists also know that there’s a natural barrier to talking about these topics. As a result, we give patients a questionnaire that prompts us to start the conversation. These questions usually ask about your sexual activity, confidence level, libido, need for medication, and if other medical problems exist that might impact erectile function. This helps to establish a baseline, which impacts treatment results. I also am very proactive in discussing the potential effects of erectile and ejaculatory dysfunction after prostate cancer treatments in our initial discussions. However, despite these tools, and the doctor asking specific questions, it still requires the patient to engage and answer openly and honestly.

You’re saying that some people are reluctant to talk about it no matter how much you press?

Dr. Yu: Sometimes. But everyone processes things differently and on different timelines. Sometimes, we just need to circle back at a later time to address this issue.

What kinds of questions do you suggest men ask their urologists about ED before they have surgery?

Dr. Yu: First, I believe it is up to the surgeon to bring up the specific risks to erectile function related to any prostate cancer treatment. That’s part of informed consent. From the patient’s standpoint, the main questions I would be asking include, “What is your plan for me before, during, and after surgery to optimize my erectile function recovery?” Related to that is, “Do you recommend a specific regimen for penile rehabilitation protocol? Also ask about specific erectile function recovery rates after surgery specifically for that surgeon. But having a specific plan for what’s going to happen after surgery helps alleviate some of the anxiety related to that potential side effect.

I also think the patient should ask themselves and their partner, some questions: “What is the level of intimacy that we have right now? What do we want it to be in the future?” A change in the way couples are intimate can definitely affect a relationship. I recommend that patients bring their partners into the appointment to not only serve as another set of ears, but also to participate in discussions about issues like this.

Some recommend that men seek out a sexual medicine expert before surgery. Do you think that’s warranted? Or would you only recommend that once a man is already having problems?

Dr. Yu: That is always an option. I don’t usually send patients to sexual medicine experts because I’m comfortable having that open discussion with them.

Is there anything men can do before surgery to prevent potential erectile dysfunction after treatment?

Dr. Yu: There aren’t really any studies that show specifically treating men before surgery with a drug regimen actually improves erectile function after surgery. However, there are many strategies to optimize their overall health which will improve their chances—like eating a healthier diet, losing weight if you’re overweight, and improving your exercise tolerance. Quitting smoking is important because that also impacts vascular disease. Lower your stress levels. Drink less alcohol. Manage the things we know directly impact erectile function like diabetes, cardiovascular disease, and hypertension.

Doing these things are not only good for erectile function, but also good for overall longevity. I tell patients that a cancer diagnosis is oftentimes a wakeup call, and they should take this opportunity to adopt healthier lifestyles.

Are there any ED treatments that are more effective than others after surgery?  

Dr. Yu: I don’t think one ED treatment is more effective than another after surgery. However, doing something is better than doing nothing. Also, the sooner you do it, the better, in order to reduce the risk of poor oxygenation, fibrosis and scarring in the penile tissue. It’s very much a “use it or lose it” mentality. I recommend whichever treatment best enables the patient to resume sexual activity quickly after treatment.

Most men start with medications, because that is the easiest to administer. Published studies don’t show a difference between taking it daily versus on demand, although both regimens are most effective when used consistently in the first year. Some men also use a vacuum erection device (VED) to help them have penetrative intercourse sooner after surgery. VEDs have also been shown to reduce penile length loss after surgery, So again, doing something is better than doing nothing. I tend to recommend a daily regimen post-operatively in combination with vacuum device therapy. Every patient has a different mentality about how aggressive they want to be with their rehab. Some couples are not active at all, so they only do on-demand therapy. Others stick with medications, VED, and some of the other treatments out there in combination. These include intra-urethral alprostadil, or intracavernosal injection therapy with either Caverject or Bimix or Trimix.

Then, of course, if all those fail, you can always consider a penile implant. We usually wait for one to two years before talking about the penile implant, just because the expectation is that we will see patients continue to improve for the first one to two years. Nerves don’t regenerate that quickly. Doing something as permanent as a penile implant that quickly after the surgery is usually discouraged.

Are these treatments covered by insurance?

Dr. Yu: It depends on the insurance. The costs of medications was definitely more prohibitive three to five years ago, but many of these medications are now offered as a generic. This makes it more affordable for patients to pursue even if their insurance does not cover it. The VED and injections usually are not covered as well, so patients pay out of pocket for those regimens. A surgical approach like the penile implant is usually covered by insurance.

There has been a lot of recent publicity for low intensity penile shock wave therapy in patients with de novo erectile dysfunction. This treatment has not been studied in patients with ED after prostate cancer surgery so we don’t know its applicability, safety or effectiveness.

Is that painful?

Dr. Yu: Usually not. A numbing medicine is applied to the penis before the shockwave treatments are given.

Do you have any advice for men who are either worried about ED before surgery yet or who are already struggling with ED after treatment?

Dr. Yu: One thing to keep in mind is to look at the big picture and maintain perspective. We need to really consider the prostate cancer first. The reality is that sometimes we need to be aggressive with our treatments for prostate cancer in order to preserve your life. That may come at the risk to certain functions. In other cases, we can offer active surveillance of prostate cancer because we don’t want to risk impacting erectile function while treating an insignificant cancer. Treatment needs to be individualized to the patient.

For patients who have some baseline erectile dysfunction, there is definitely the risk of persistent or worsened erectile function after surgery or radiation. The good news about erectile function is that even if there is poor recovery, there are still many ways for patients get their sexual function back. It may require some inconvenience, but that’s something that the urologist on your team can help you with. Having a proper expectation going into treatment and recovery helps: understand that recovery takes 12 to 24 months in some cases. And that recovery process can be frustrating because things do not feel natural at first. That’s why it is important to keep the lines of communication open. This is not something that is easily tackled alone. Seek help, even though it is such an intimate topic.

Not a member? Join us to read the rest of this month’s conversations about erectile dysfunction after treatment.

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Chemotherapy: An Infusion Nurse’s Experience

Catherine Guider is an infusion nurse with Kaiser Permanente in Sacramento, CA.

She offers Prostatepedia her perspective on chemotherapy for prostate cancer.

Why did you become an oncology nurse?

Ms. Catherine Guider: I was interested in oncology even back in nursing school. I had a grandfather who had cancer and was given a very short timeline of survival, and he was one of those that beat the odds and made it to 93. I got to see a side to cancer that some people don’t get to see.

In nursing school, I did some time on an oncology inpatient floor and found it challenging and rewarding when it came to the personal relationships that I got to build with patients and their families.

When I came to Kaiser, I didn’t start in that department, but after a couple of years, I took an opportunity to move to the floor that does inpatient chemotherapy. A short time later, I was certified with chemotherapy and biotherapy, and I stayed there for many years. Now, I’m in the outpatient infusion oncology clinic.

Have you had any patients over the years who changed how you see your own role or how you see nursing in general?

Ms. Guider: Because I was in the inpatient side where sometimes people stayed for longer than a day or two, I saw the impact that we can have on their lives. I would spend my lunchbreak with some of our oncology patients, sharing lunches and time together, and I noticed that sitting with them would help them eat more and make them feel lighter. It’s gone both ways; they have enriched my life also.

There are definitely some who have impacted me. Being on the infusion oncology team, I’m part of a patient’s cheer group and their support group. When they cry, sometimes I cry, and sometimes that’s difficult. It’s definitely made nursing more personal for me.

What’s the process like for getting chemo for men with prostate cancer?

Ms. Guider: We have a good process here when it comes to onboarding new chemotherapy patients. Our doctors work with our nurse navigators, who then work with our triage on our medical assistance to get the patient scheduled for their chemo class and their first chemo treatment. All these people make sure that labs, pre-med home medications, and post-treatment meds are ordered with support. Overall, there are a lot of people involved to make sure that the patient and their family are well-informed. When they come in, they already have an idea of what that day and treatments are going to be like.

When they arrive, we make sure that a patient is up to chemotherapy. We make sure that they are physically and mentally well, and then we notify our pharmacy to make the medication. We have our own pharmacy within our department. If there is anything questionable, we get in contact with the patient’s oncologist, and they’re directly across the hall from us, so it’s very easy to do. All of that is addressed right then and there.

What is the infusion like? Is it painful?

Ms. Guider: No. You have to start an IV or access a port, which could be painful. But the majority of people don’t feel the chemotherapy. There’s always a potential reaction to certain medications, but we are good about how we handle those. We already have medications ordered that we can administer if someone has a side effect on the premises, and we can get that side effect reversed.

How long does the actual infusion last?

Ms. Guider: It all depends on the regimen. With prostate cancer, that’s normally Taxotere (docetaxel), and that is an hour infusion.

I have only given Jevtana (cabazitaxel) once or twice before, but I believe that’s an hour also. Taxotere (docetaxel) is still the first choice IV treatment.

What kinds of side effects have you seen patients deal with after chemo?

Ms. Guider: The normal: nausea. We send patients home with a list of medications to use for the nausea, and we recommend smaller meals throughout the day to stay ahead of it. There’s the hair loss, nailbed changes. You can have peripheral neuropathy with the chemotherapy. There’s fatigue, of course, and the impact on white blood cells, red blood cells, and platelets that we’re watching for as well.

Do you have any tips or advice for men to make the whole process of getting chemo easier?

Ms. Guider: Somebody’s mindset has a lot to do with how they come into it and how they handle it.

Somebody who’s active, eating a well-balanced meal, and good on their hydration normally does better than someone who isn’t. Some people don’t like to take additional medication, and so there is not that adherence there.

We give patients a list of antiemetics to use if they become nauseated. Sometimes, they take them that first or second day, just as a safety measure to keep the nausea away. Some people don’t like to do that. But it’s always better to stay ahead of the nausea than let the nausea set in because it’s hard to play catch-up and get it to go away once it’s there. Nausea doesn’t only make patients feel unwell, but they’re not going to drink the amount of fluids that they need or eat the meals that they need if they’re nauseated. Coming in with all of that already in place, makes somebody tend to do better.

What role do you see the caregivers playing in the whole chemo process?

Ms. Guider: We invite caregivers to the chemo class. It’s always up to the patient if they want their caregiver to come to join them. Sometimes people and their family members come for the first appointment, and then after a while, the patients come by themselves. We have other people whose family members come every time. It all depends on the role that they already have in the relationship.

Sometimes caregivers are more of the voice for the patient. Sometimes they speak up and say that the patient is having a difficult time getting their food in, or they’re having this nausea afterwards, but the patient is not telling us.

Other times, caregivers are the cheerleaders who will bring a sandwich, and when the patient eats half, they’re the cheerleader saying “why don’t you take just one more bite? Don’t quit yet.” They all have different roles.

We also have caregivers who take an unproductive role, and that’s probably been in the relationship. Encouraging people to do better or take that next bite is very different than a person saying: “you need to eat that.”

Presentation can be huge, and if that avenue isn’t already developed between them, then sometimes we’ll see people bicker over how much they drank the day before.

I guess any conflicts that are already in the relationship will be highlighted by a situation like this, right?

Ms. Guider: Yes, along with the stressors of all of it.

Any other tips you have for men who are about to get chemo or maybe have already had chemo and are struggling with side effects?

Ms. Guider: When it comes to the side effects, you don’t have to struggle through them. Your team is there for you if you speak up. We can change pre-medications around. We can change medications at home. We can try completely different meds. We also have a social worker. We have nutrition. We have mental health. We have various support groups. Be open to reaching out.

Be open to asking questions, getting things clarified, and gathering more information, especially if it’s researched-based. There’s a lot of misinformation on Google that can backfire. You need to make sure that your information is based on research.

We all come in with a different knowledge base, so when it comes to what’s on the internet, sometimes it’s written for a certain group only, and at times there’s not even anything factual.

It’s great to talk to other people who have gone through cancer and treatment, but always keep in mind that every body is different. You could have the same people going through the same exact treatment, and for whatever reason, their side effects will be different, and how they handle them will be different. It’s not a cookie cutter.

Just like everybody comes in with a different level of fitness and a different mindset, right?

Ms. Guider: Yes, and it’s the history of how they took care of their bodies. The other comorbidities that they might have will factor in how they’re going to physically handle the chemotherapy. There’s the whole emotional side of handling the cancer itself. Just the word brings so much with it.