Treatment Option Overview for Prostate Cancer
Table 9. Treatment Options by Stage for Prostate Cancer continued...
Complications of radical prostatectomy
Complications of radical prostatectomy include the following:
- Morbidity and mortality associated with general anesthesia and a major surgical procedure.[31,32,33]
- Urinary incontinence and impotence.[34,35,36,37,38,39,40,41]
- Penile shortening.[42,43,44]
- Inguinal hernia.[45,46,47,48,49]
- Fecal incontinence.
Morbidity and mortality associated with radical prostatectomy
An analysis of Medicare records on 101,604 radical prostatectomies performed from 1991 to 1994 showed the following:
- A 30-day operative mortality rate of 0.5%.
- A rehospitalization rate of 4.5%.
- A major complication rate of 28.6%.
Over the study period, these rates decreased by 30%, 8%, and 12%, respectively.
Prostatectomies done at hospitals where fewer of the procedures were performed than those done at hospitals where more were performed were associated with the following:[32,33]
- Higher rates of 30-day postoperative mortality.
- Major acute surgical complications.
- Longer hospital stays.
- Higher rates of rehospitalization.
Operative morbidity and mortality rates increase with age. Comorbidity, especially underlying cardiovascular disease and a history of stroke, accounts for a portion of the age-related increase in 30-day mortality.
In a cohort of all men with prostate cancer who underwent radical prostatectomy from 1990 to 1999 in Ontario, 75-year-old men with no comorbidities had a predicted 30-day mortality of 0.74%. Thirty-day surgical complication rates also depended more on comorbidity than age (i.e., about 5% vs. 40% for men with 0 vs. ≥4 underlying comorbid conditions, respectively).
Urinary incontinence and impotence
Urinary incontinence and impotence are complications that can result from radical prostatectomy and have been studied in multiple studies.
(Refer to the PDQ summary on Sexuality and Reproductive Issues for more information on impotence and erectile and urinary dysfunction.)
Evidence (urinary incontinence and impotence following radical prostatectomy):
- A large case series of men undergoing the anatomic (nerve-sparing) technique of radical prostatectomy reported the following:
- Approximately 6% of the men required the use of pads for urinary incontinence, but an unknown additional proportion of men had occasional urinary dribbling.
- About 40% to 65% of the men who were sexually potent before surgery retained potency adequate for vaginal penetration and sexual intercourse. Preservation of potency with this technique is dependent on tumor stage and patient age, but the operation probably induces at least a partial deficit in nearly all patients.
- A national survey of Medicare patients who underwent radical prostatectomy in 1988 to 1990 reported more morbidity than in the case series reported above.
- More than 30% of the men reported the need for pads or clamps for urinary wetness, and 63% of all patients reported a current problem with wetness.
- About 60% of the men reported having no erections since surgery; about 90% of the men had no erections sufficient for intercourse during the month before the survey. (Refer to the PDQ summary on Sexuality and Reproductive Issues for more information on erectile dysfunction.)
- About 28% of the patients reported follow-up treatment of cancer with radiation therapy and/or hormonal therapy within 4 years after their prostatectomy.
- A population-based longitudinal cohort (Prostate Cancer Outcomes Study) of 901 men aged 55 to 74 years who had recently undergone radical prostatectomy for prostate cancer reported the following:
- 15.4% of the men had either frequent urinary incontinence or no urinary control at 5 years after surgery.
- 20.4% of those studied wore pads to stay dry.
- 79.3% of men reported an inability to have an erection sufficient for intercourse.
- A cross-sectional survey of prostate cancer patients who were treated with radical prostatectomy, radiation therapy, or watchful waiting and active surveillance in a managed care setting showed substantial sexual and urinary dysfunction in the prostatectomy group.
- Results reported by the patients were consistent with those from the national Medicare survey.
- In addition, although statistical power was limited, differences in sexual and urinary dysfunction between men who had undergone either nerve-sparing or standard radical prostatectomy were not statistically significant. (Refer to the PDQ summary on Sexuality and Reproductive Issues for more information on sexual and urinary dysfunction.) This issue requires more study.
- Case series of 93, 459, and 89 men who had undergone radical prostatectomy by experienced surgeons showed rates of impotence as high as those in the national Medicare survey when men were carefully questioned about sexual potency, although the men in these case series were on average younger than those in the Medicare survey.[39,40,41] One of the case series used the same questionnaire as that used in the Medicare survey. The urinary incontinence rate in that series was also similar to that in the Medicare survey.