The side effects of radical prostatectomy: a new review

A new review article by a Danish research team in the Journal of Sexual Medicine has (arguably) brought a degree of clarity to what the authors refer to as “neglected” side effects consequent to radical prostatectomy. Unfortunately the average urologist probably doesn’t read the Journal of Sexual Medicine on a regular basis.

Frey et al. carried out a systematic review of the available literature, identifying 43 published papers that met the predetermined search guidelines.

We assume that the standard side effects of short- and long-term incontinence and loss of erectile/sexual function in men who have non-nerve-sparing surgery are the ones that the authors did not consider to be “neglected”.

Here are the core findings reported in their review:

  • Two well-known side effects of radical prostatectomy — orgasm-associated incontinence (OAI) and urinary incontinence in relation to sexual stimulation (UISS) are experienced by 20 to 93 percent of RP patients at least a few times after surgery.
    • A prior transurethral resection of the prostate (TURP) is the only known predicting factor for OAI and UISS (but these side effects occur even in men who have never had a TURP).
  • Alterations of orgasmic function are experienced by approximately 80 percent of patients after radical prostatectomy.
    • Erectile dysfunction seems to play an important role in waning orgasmic function.
  • Orgasm-associated pain (OAP) is experienced by a subset of the patient, with reported rates varying between 3 and 19 percent.
    • Sparing of the tips of the seminal vesicles has been shown to double the risk of OAP.
  • Penile shortening (PS) occurs in 15 to 68 percent of patients.
    • Nerve-sparing surgery and preservation of erectile function may help preserve penile length.

The authors also state that:

With regard to all side effects, studies indicate that they are reduced over time.

However, The “New” Prostate Cancer InfoLink would note that it may be more accurate to interpret this to imply that it is the impact of these side effects that is reduced over time as men (and their spouses/partners) gradually adapt to the inevitability of the problems. That is rather different to the idea that the side effects themselves become less of a problem.

It has to be said that it has become increasingly hard, over the years, to understand why and how so many urologists apparently “neglect” to tell men diagnosed with prostate cancer about all of these side effects prior to their surgery. It’s not as though it wouldn’t be simple enough to provide a simple printed list of even the most common ones. Such a list might not discourage men from having surgery, but it would certainly make it easier for men to understand the risks they were taking and it would remove the possibility for men to argue that they weren’t told about these risks prior to their surgery. It might also make it a lot easier for some men to understand the potential benefits of active surveillance if they are diagnosed only with very low- or low-risk prostate cancer.

It should also be noted that this review does not seem to address the psychological side effects on radical prostatectomy on “what it means to be a man” and how this can affect a patient and his spouse/partner. The fact that this is a very real side effect of treatment for prostate cancer is well understood. The lack of any real guidance about the possibility of this effect prior to surgery is unfortunately all too common, let alone our general failure to be able to offer good care and help to couples for whom it is such a problem — and often a very serious one.


6 Responses

  1. ‘why and how so many urologists apparently “neglect” to tell men diagnosed with prostate cancer about all of these side effects prior to their surgery.’

    Because they honestly believe they are better than the rest. I suspect there is a very different face to face report from patients to urologists who did the surgery, than patients reporting to anyone who did not do the actual surgery.

  2. Thank you for drawing much needed attention to these matters. As you say, the psycho-social dimensions are as important, and are much neglected. The authors also did not mention Peyronie’s, which has been reported in the same journal. As you say, it is a shame that the urological clinical community is not giving these matters greater attention. They are seldom addressed in the bigger journals and they are not routinely measured in any of the standard sexual function questionnaires (e.g., EPIC or SHIM) that are used after treatment.

    I also applaud your idea for a “side effect fact sheet” to be given to men considering surgery or other treatments. They do this for prescription medications all the time — it’s hard to see why they wouldn’t do the same for treatments.

  3. Thanks for again shining a light on the shadowy side of “informed consent” that seems corrupted by the fee-for-service model.

    I have always tried to be honest with my patients but find that there will always be a urologist at a competing hospital who will tell the patient they don’t see those kind of side effects.

    My practice is to prove as strongly as possible that the patient has a potentially lethal prostate cancer and that treatment is justified. This is a distinct minority of those men who are diagnosed in my practice.

    Since so many of my patients have well-demarcated tumors from their high-quality mp-MRI, I am only treating high-risk targets.

    I am very satisfied with the oncological outcomes and the tolerability of this approach.

  4. The side-effect sheet is an excellent idea. I know one Dutch prostate cancer site, where the comments are largely about these effects. As if survival were a minor matter. In one sense it might be, to some men. For sexual problems arise quickly. But the indignation on this site might well indicate lack of information in the Netherlands, for whatever reason. The Swedish urologist answered my question about side effects immediately: “impotency after at most 4 years.”

  5. Reblogged this on social media for patient care in urology and commented:

    Les effets secondaires de la prostatectomie radicale sont bien connus (dans la littérature). Est-ce que les urologues sont sensibilisés avant de proposer la chirurgie?

    Orgasme douloureux et globalement fonction orgasmique diminuée? Fuites urinaires lors de l’orgasme? Diminution de la longueur du pénis? Une très belle revue danoise nous donne des chiffres ahurissants! Lise la suite…

  6. This strikes me as a pretty lame article. Indeed … “that it is the impact of these side effects that is reduced over time as men (and their spouses/partners)” … as they resign themselves to a life without sex or intimacy, or have a partner who leaves or finds sex elsewhere.

    And they probably should have mentioned … what percent of men give up, withdraw completely, without partner consultation.

    As usual, they seen content to “cure” the cancer, and leave behind an unexamined disaster.

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