Understanding the range of risks associated with prostate cancer surgery today


It would certainly be difficult (and arguably impossible) for us to provide a newly diagnosed prostate cancer patient with a  comprehensive list of all the possible side effects and complications that might be associated with every type of first-line treatment for prostate cancer. However, given the high risk of complications and side effects that are known to be associated with surgical treatment for localized prostate cancer, and also given the fact that a very high percentage of men initially diagnosed with low-risk prostate cancer are well advised to avoid any immediate form of curative therapy (because it may have no impact whatsoever on their prostate cancer-specific or their overall survival), it is worth summarizing all of the reasonably well-known and possible side effects and complications of surgical treatment for localized prostate cancer.

So let’s start with the standard complications and side effects associated with any form of surgery that needs to be done under general anesthesia.

According to the Mayo Clinic web site, general anesthesia itself, today,

is overall very safe; most people, even those with significant health conditions, are able to undergo general anesthesia itself without serious problems.

In fact, your risk of complications is more closely related to the type of procedure you’re undergoing and your general physical health, rather than to the type of anesthesia.

However, most men being diagnosed with prostate cancer are aged between 60 and 80 years of age, and the Mayo Clinic does go on to point out the following:

  • If you are older, or you have other significant medical problems (so-called “co-morbid conditions”) and you are undergoing an extensive surgical procedure such as a radical prostatectomy, you may be at increased risk of postoperative confusion, pneumonia, or even stroke and heart attack (although the degree to which any of these complications is associated with a radical prostatectomy is not well known).
  • Other things that can increase your risk of complications during or shortly after surgery under general anesthesia can include a history of smoking, seizures, heavy alcohol use, or sleep apnea; being severely overweight (obesity); having a high blood pressure or diabetes; other clinical conditions affecting your heart, lungs or kidneys; the use of drugs like aspirin or warfarin that can increase prevent blood clotting; and certain drug allergies.

A recent article on the MedPage Today web site, in particular, gets into the detail about post-surgical mental function (post-operative cognitive decline or POCD) and whether information about this should be included in the “informed consent” documents that patients are asked to sign prior to any surgery requiring general anesthesia. There are clearly professional differences about just how serious this condition is (or isn’t)! And, again, the degree to which this may be specifically correlated with radical prostatectomy is unknown.

The side effects and complications associated with radical prostatectomy itself are much better understood.

  • The vast majority of men (of the order of 90+ percent) will have short-term urinary incontinence immediately following radical prostatectomy. Most of those men will recover reasonably good (but not necessarily perfect and pad-free) continence within 1 to 6 months, but some men (around 9 to 10 percent) do have severe, long-term continence problems after a radical prostatectomy, and the older the patient at time of surgery the higher the likelihood of longer-term problems with recovery of good continence.
  • The majority of men who have good, i.e., functional, erectile capability prior to their surgery (probably 75+ percent) will lose some or all of that erectile capability in the short-term and in the long-term — even if they are able to have a so-called nerve-sparing surgical procedure designed to help them maintain their erectile function.
  • All men who have a radical prostatectomy will lose the ability to impregnate a woman normally. If having children (or more children) is an issue for a man diagnosed with prostate cancer and his spouse/partner, he would be wise to bank sperm prior to any form of treatment (and certainly prior to surgery).
  • An unknown percentage of men (perhaps as high as 40 or 50 percent, but we really don’t know) will at least perceive significant shrinkage of their penis (by anything from 0.2 to 1.6 inches) following surgery. For some this may not be permanent; for some it is permanent; and some men really don’t care because their erectile/sexual function was minimal or non-existent anyway prior to their surgery.
  • A small percentage of men (of the order of 10 percent) experience severe or significant pain associated with orgasm post-radical prostatectomy (and the nature of orgasm is significantly changed anyway because a man with no prostate no longer ejaculates semen in the way he used to because the mechanism required to make that happen — the prostate — is no longer present).
  • Some 25 to 40 percent of men who are sexually active post-surgery will experience a condition known as climacturia — in which urine as opposed to semen is expelled at the time of orgasm because of limited control over the urinary tract (even if the man has good continence after surgery).
  • A relatively small percentage of men will experience a condition known as Peyronie’s disease (curvature of the penis during erection); we know that this is more common among men after a radical prostatectomy than in the general male population (see this paper by Tal et al.).
  • A high percentage of men go through a period of very real and sometimes severe depression associated with their sense of loss of their masculinity; we really do not have a good understanding of the incidence or prevalence of this problem because an awful lot of men are unwilling or unable to discuss this at all.

There seem to be small differences between the numbers of men affected by some of the forms of erectile/sexual dysfunction after open surgery and after robot-assisted laparoscopic surgery (as discussed in this article by Capogrosso et al. and in an associated Reuters report on the Medscape web site). However, most of the differences are small — even though they may be statistically significant.

The bottom line to all this is that, while radical prostatectomy is a highly effective surgical procedure for the treatment of carefully selected patients with clinically significant, localized prostate cancer that comes with a real, long-term risk for future development of metastatic disease and prostate cancer-related mortality, the value of this procedure in men with lower levels of risk for progressive disease and in older men who still value their quality of life as much as the length of that life is far less evident today. Radical prostatectomy is quite certainly not a “quality-of-life-sparing” form of surgery. It is an operation that was originally developed to try to extend the lives of men with progressive, clinically significant prostate cancer, and its most valuable use today is in selected men with intermediate and high-risk, localized prostate cancer — with the patient’s full understanding and recognition that the complications and side effects of treatment are potentially significant, and that the primary goal is to prevent his death from metastatic prostate cancer.

19 Responses

  1. Great post.

  2. Excellent commentary! I would love to see AUA guidelines (or NCI rules) that call for this (perhaps expanded to include quantitative estimates and low probability events like hernias, fistulas and seeding of the cancer) to be given as a handout to all men consulting with a urosurgeon. After discussing it (as well as active surveillance, and referrals to specialists in other therapies), the patient should be told that he cannot give informed consent to prostatectomy for at least a month.

    I know I’m pipe dreaming, but the FDA demands this for medicines. Everytime I get a prescription, there’s a flyer that lists all the adverse incidents found in clinical trials, grouped by the percent affected by each, with highlighting of the more serious ones.

    Lest anyone think I’m picking on surgeons, I think ASTRO and ASCO should do this as well.

  3. Thanks for this careful and thorough post! It squares precisely with my experience of a prostatectomy (da Vinci process at Mayo, AZ) 6 years ago and the subsequent conditions of life since, including “salvage radiation” 2.5 years afterwards and now ADT therapy (so far taking an intermittent approach). I would hope that this very frank essay, or a version thereof, would become standard information for every man facing a decision about prostate surgery. This cuts through a lot of the complexity of separate research papers focusing on discrete aspects of post-surgical life and it does not hedge on any of the “facts of life” that, for so many men, have become, well, the facts of life!

  4. An important, effective, and sobering warning label regarding the iatrogenic risks of radical prostatectomy. Allen is on the mark with the suggestion that patients be provided an oral and written statement with quantitative estimates of each outcome. The site master has again provided patients and partners a succinct summary of major issues in care which they’ll never find among the sports magazines and informational flyers in the clinic. Thanks!

  5. Picking up on the prudent commentary from Allen (“I think ASTRO … should do this as well”), could you write a similar commentary on understanding the range of risks for radiation therapy? I recently had a consult with a rad/onc on the risks of rectal toxicity and he replied, “Well, you may have some loose stools for a week or two, but then it will improve.”

    As John McEnroe used to say — “You CAN NOT be serious?!!”

  6. I found it interesting, but correct, that you used the word “perceive” when explaining that many men “perceive” significant shrinkage of their penis (by anything from 0.2 to 1.6 inches) following surgery.

    Yes, there appears to be shrinkage, and most men feel positive it is because with the prostate removal and a portion therein of urethra, this was the result. However, the shrinkage has nothing to do with the prostate/portion of urethra removed. The shrinkage, rather, is from the trauma of the procedure, and that shrinkage can be “recovered” with subsequent exercise of the penis, wherein the use of a vacuum erection device (VED) can provide that exercise. Use of the VED is not a procedure for penile rehabilitation of arterial blood flow and oxygenation (use of PDE5 inhibitors — Cialis, Viagra, Levitra — provide that rehabilitation) but it is of significant help in “length/girth” return from pumping in venal blood and stretching the penis. The old “use it or loss it” adage.

  7. Len,

    If you were talking to your rad/onc about treatment with a modern IGRT/IMRT technique, he’s right about the expected acute rectal symptom severity, which is most often Grade 0 or Grade 1, but there are a few other acute rectal symptoms that may crop up. I think he should tell you about those too, so you can expect them and not be alarmed if they occur. In <a href=http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3840044?a recent study, over 98% of the men had no Grade 2 or higher rectal toxicity. And he’s quite right too that those symptoms generally resolve quickly. Grade 1 rectal toxicity also may include a small amount of rectal bleeding or mucus discharge, tenesmus, soreness, and constipation.

    Newer linear accelerators (LINACs) have very tight tolerances, and it is not unusual for the rad/onc to set a 0 mm margin at the rectum. They also set low dose constraints for the rectum. With faster speed LINACs (e.g., VMAT), prostate movement is lower.

    You may have read my recent commentary where I questioned the need for expensive rectal spacers, at least in most men. It’s a cure for a non-problem. Of course, if you suffer from chronic bowel inflammation, it’s a godsend.

  8. Dear Allen,

    After having read your advice to Len, posted on 15 December 2015, regarding rectal problems after pelvic beam radiation I thought I should seek your help too since you appear to have sound knowledge on the subject.

    For my organ-confined prostate cancer diagnosed in February 2015 at the age of 68 years, I underwent retropubic radical prostatectomy in March 2015. T2N0M0, Gleason 4 + 5 = 9, positive surgical margins; PSA before surgery, 11.7 ng/ml. One week after surgery, my was 0.079ng/ml I was started on ADT after one1 month, and current PSA is 0.003 ng/ml. Radiation therapy was done from June 15 to September 4, 2015 (38 treatment sessions with a total dose of 74 Gy). It was IMRT and 3D conformal radiation with CT imaging — the latest available in my country (Sri Lanka). I did not suffer any side effects during the radiation period. But about 1 week after completion of radiation I started experiencing pain when passing stool. No diarrhoea or bleeding. I had known about radiation proctitis. My radiation oncologist advised me to ignore it since we have used an advanced technology with minimum side effects. However, since the soreness during defecation continued I consulted a gastroentrologist and showed him all my reports, including the radiation. He examined me and said I have an anal fissure and gave me 0.2% nitroglycerine ointment to apply inside the anus. This treatment didn’t heal the condition even after 1 month. There was no bleeding at all. Only the soreness during defecation, and also tenesmus. I tried my best to avoid constipation by taking always a fiber-rich diet with more liquid. I consulted a more experienced gastroentrologist who is a professor, and told him about everything too. he examined me very carefully and told me that I have no anal fissure and it is due to the inflammation of the rectum due to radiation. He advised me to stop applying the nitroglycerine and gave me Xylocaine Jelly 2% and also showed me how to apply this. Within 2 weeks of application I was completely relieved and could pass out stool without any anal pain. Although the problem was with the rectum the pain/soreness I used to experience in the anus. Since I didn’t have any detail information regarding the ointment I checked the name in the internet. It is lidocaine hydrochloride which is a topical anesthetic used in cases like catheterization, endoscopy (spray) etc. It did not appear to be a curative medicine. Even after 1 month of application, when I stopped application, I started getting the same soreness/pain during defecation. The doctor said I can continue to apply it until the rectum settles down. But I decided to stop since it is acting only as a pain killer and might hide the sensing of other possible and harmful developments. Sometimes continuous desensitizing of of the anus might affect the the muscles of the internal and external anal sphicters. ( I only guess.)

    So my current position/worry is still I have the same soreness experienced in the anus when passing stool. It is more when the stool become harder. (Only once I experienced constipation and had a severe pain and felt the anal canal injured.) Tenesmus has almost disappeared. No bleeding or mucus discharge. I want to continue without any applications and see notwithstanding the soreness.

    (1) Is my condition what you have referred to as Grade 1 rectal toxicity?
    (2) Taking into consideration the timing of the radiation treatment I have received, how long it may take for this disturbing condition to heal?
    (3) Is it necessary for me to take treatment to get rid of this condition and are there standard treatments available?
    (4) Can this lead to a chronic side effect of radiation that doctors are unable to cure?

    Your advice on the above four questions will be greatly appreciated.

    Sisira

  9. Dear Sisira:

    I am not sure what Allen will tell you, but in my opinion you got very good guidance from the second gastroenterologist. However, recovery from this type of relatively mild complication of radiation therapy takes time above all else, and how much time can be difficult to predict. It has only been 3 months since you completed the radiation therapy. A 2% lidocaine gel is a very mild, topical anesthetic with very few significant side effects. In my view you should continue to use it to avoid real pain while making sure you are using as little as possible. If you use the lowest dose you can to limit the pain, you will simultaneously be able to determine when you can stop using it altogether without having significant pain. You could also go back to the gasteroenterologist and ask him specifically whether he can prescribe a lower dosage of lidocaine. For example, it may be available in Sri Lanka at a 1% formulation. Of course you also need to continue with a diet that will minimize your risk for constipation.

  10. I agree with everything the sitemaster said. Use the lidocaine cream until the symptoms pass, certainly. I also wanted to answer your other questions, and a few you didn’t ask.

    First, let me say that salvage radiation, which is what you had, is different in its side effect profile from primary radiation therapy, which is what Len asked about. Salvage, without the prostate in place, tends towards more serious complications. IMRT and 3D Conformal Radiotherapy are two different kinds of of radiotherapy — you would have had one or the other. 74 Gy is a hefty dose for salvage RT, and may carry additional toxicity.

    As to your questions:

    (1) This would be categorized as acute grade 2 rectal symptoms. Grade 2 means “moderate; minimal, local or noninvasive intervention indicated.”

    (2) There’s no way of predicting when it will go away. It usually heals within a couple of months, but that varies from person to person.

    (3) It sounds like the treatment you were given is working just fine and has minimal side effects. You might ask your doctor if a stool softener like Colace is appropriate.

    (4) Chronic rectal side effects are rare but can occur. There are other treatments useful for grade 3 rectal side effects. Another thing that can occur is what is called “late term” side effects that only occur about a year or more after treatment. They are also typically transient, but are rarely chronic.

  11. Dear Sitemaster / Allen,

    This is the first time I posted my questions at this prostate cancer site. I was too glad to learn the sitemaster providing the answers so fast. Is that the usual way and can similar questions be sent to him?

    I must thank both of you equally for making everything very clear to me. Especially your answers to my four questions were complete and definitely I will follow your advice.

    Actually the type of radiation therapy I received is “TomoTherapy”, which is described as a form of CT-guided IMRT. Before every treatment, advanced technology provides 3D imaging of the treatment area. It is also 360o helical and delivers minute beamlets very accurately with varying intensity and computed doses. I paid a high price for this.

    I was of the opinion “salvage radiation therapy” refers to radiation done at a much later sage when recurrence of cancer takes place after initial treatment. In other words after a biochemical relapse. This situation arises when one decides to receive only androgen deprivation therapy after Prostatectomy or only stop at the prostatectomy and postpone or not do radiation fearing the side effects. I think mine is adjuvant radiation therapy. However I understand very clearly the situation you refer to “the radiation done when the prostate gland is not in place”. The pelvic radiation done to the prostate bed can cause more toxicity to the rectum.

    Could you please explain to me further, what has really happened to the rectum by this toxicity and how this pain is produced and in which part of the rectum? Are there wounds at the place of joining the anal canal? Or rectal tissues are cracked? Or any other abnormal changes? Why is the soreness is felt in the anal area during defecation?

  12. Tomotherapy is a form of IMRT — just with an imaging system that uses the “waste” X-rays from treatment — a very nifty design, IMHO.

    Adjuvant means added to the previous therapy — not waiting for signs of recurrence. It is typically done within 3 months of RP to allow for healing. Early salvage does not wait for the arbitrarily-defined biochemical recurrence, but treats at a lower value. But my point was that side effects are worse than what Len could reasonably expect.

    Radiation is irritative. It irritates blood vessels and enteric tissue. You would have to ask your gastroenterologist what the specific adverse tissue effects were in your case. Basically, if you touch or put pressure on irritated tissue, you feel some pain.

    I think it’s a good idea to write all your questions down and discuss them with your doctor. That’s the kind of relationship a patient should have with his doctor. I am not a doctor, and nothing I say should be construed as medical advice.

  13. Dear Allen,

    Thank you very much for your excellent advice and the clarifications.

    I have already booked appointments next week with my radiation oncologist and a new gastroentrologist. Both are well qualified and experienced. I have noted to ask all relevant questions during the consultations and thank you for the insights provided.

    From your description “Tomotherapy” sounds a very inferior and a shoddily designed beam radiation delivery system! I have seen in some websites describing same as a state-of-the art new and advanced radiation technology. I have made it a special point to ask from my radiation oncologist who speaks high of Tomotherapy and what has he got to say truly about the down grading.

    Yesterday I was sad to learn my much respected gastroentrologist had passed away just a week ago. He was in his late 60s and was a senior professor who has produced many able doctors practicing in Sri Lanka and abroad. All these are lessons in life! And should place the emphasis on the purpose rather than the material benefit. He will be remembered by many as an eminent doctor who was dedicated to the purpose beyond his professional achievements.

    I wish you a Merry Christmas!

    Sisira

  14. Dear Sisira:

    I am not sure why you get the impression that Allen was suggesting that tomotherapy is a “shoddily designed” radiotherapy system. That’s not what he was saying at all.

    He described the system as being “very nifty”. The word “nifty” is an older slang term in English used to mean more like the modern “cool”. In other words Allen was actually praising tomotherapy as beinga very cool form of radiation therapy!

  15. Dear Sitemaster,

    Thank you for correcting my perception. Allen’s phraseology starting with ‘just with an imaging system that uses the “waste” x-ray from treatment …’ gave me the first impression that some kind of rubbish is used in Tomotherapy!

    I really don’t know, there is much boasting being used by the vizards in the medical research field and many of us become the victims of the circumstances. This is the order of the day. I try my best to protect myself by learning as much as possible from reliable sources.

    With your explanation and after having interpreted Allen’s words in the proper context, I feel happy to have chosen Tomotherapy for my radiation treatment.

    Sisira

  16. Sorry for the miscommunication, Sisera. I think Tomotherapy is a very good system. What I meant was that the X-rays that are not absorbed by the tumor pass through the body and reach a detector where they form a useable image. They are “wasted” in the sense that they were not used to kill cancer cells. So Tomotherapy provides both treatment and image detection at the same time. Other IGRT techniques rely on a separate on-board cone beam CT or stereoscopic X-ray to accomplish much the same thing.

  17. Dear Allen,

    Thank you very much for your time and the interest shown even in a trivial matter where poor souls like us worry in confusion.

    I will certainly count on your vast knowledge though you are not a doctor and will not hesitate to seek your help in case of need.

    Your generosity is very much appreciated.

    Sisira

  18. Dear Sisira,

    My 74-year-old father has high-grade, metastatic prostate cancer. Can I know who is your doctor in Sri Lanka?

    Thanks a lot,

    Perera

  19. Dear P

    Thank you for your request.

    Please write to my address ksisira1947@gmail.com

    Sisira

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