What are the risks of surgery How are they treated

All surgical procedures have risks, and the common ones are infection, bleeding, pain, and anesthetic complications. Larger surgical procedures, which involve lengthier operative times and decreased postoperative mobility, have the risk of blood clots in the legs (deep venous thrombosis), pulmonary embolus, pneumonia, and stress-related stomach ulcers. Complications of radical prostatectomy include hernia, significant bleeding requiring blood transfusion, infection, anesthetic-related complications, impotence, urinary incontinence, bladder neck contracture, deep venous thrombosis, rectal injury, and death.

Hernia

A weakening in the muscle that leads to a bulge, often in the groin.

Bleeding

In most cases, the blood loss is less than one pint (unit) of blood, but in about 5 to 10% of cases, a blood transfusion is required. The amount of blood loss tends to be lower with both laparoscopic and robotic-assisted radical

Unit

Term referring to a pint of blood.

prostatectomies, compared to open radical retropubic prostatectomy.

Infection

Several different types of infections can occur with this surgery. A skin infection (cellulitis) may occur at the incision, an abscess may occur under the skin or deep in the pelvis, or a urinary tract infection may occur. A skin infection at the incision typically presents with redness, swelling, tenderness, and occasionally, drainage at the incision. In the absence of pus, this usually can be treated successfully with oral antibiotics; rarely, intravenous antibiotics are indicated.

Abscesses are collections of pus and may occur just under the skin or deeper in the pelvis and require drainage. More superficial abscesses can be treated by opening the incision, draining the pus, and packing the wound with sterile gauze. The packing is continued until the area heals. If the abscess is in the pelvis, it can often be treated by placing a drain through the skin into the abscess and draining the pus. This is often done under X-ray guidance by an interventional radiologist.

Urinary tract infections result from the catheter, which drains the bladder during the healing process. The risk of a urinary tract infection increases with the number of days that the catheter is in place. Because most urologists leave the catheter in for 1 to 2 weeks after the surgery, your urologist may have you drop a urine sample off at the lab 2 to 3 days before the catheter is removed so that they can detect whether any bacteria is present and if so, treat the bacteria to prevent an infection after the catheter has been removed. Signs of a urinary tract infection include frequent urination, urgency and discomfort with urination, and sometimes a low-grade fever.

Anesthetic Complications

Most patients undergo general anesthesia for their radical prostatectomy; however, the procedure may be performed under spinal anesthesia. Epidural anesthesia may be used frequently to improve postoperative pain control and decrease intraoperative anesthetic requirements. The most commonly encountered side effects of general anesthesia are scratchy throat, nausea, and vomiting, but significant anesthetic complications are rare. With epidural catheters, potential side effects include lowering of the blood pressure and muscle blocks, which may affect movement of a leg.

General anesthesia

Anesthesia which involves total loss of consciousness.

Epidural anesthesia

A special type of anesthesia whereby pain medications are placed through a catheter in the back, into the fluid that surrounds the spinal cord.

Impotence

Impotence, or erectile dysfUnction, is unfortunately a commonly identified risk of radical prostatectomy. The nerves that supply the penis and that are involved in the erectile process lie along each side of the prostate and the urethra. They may be taken deliberately by the surgeon (non-nerve-sparing radical prostatectomy), or they may be injured permanently or transiently. The decision to try to spare one or both nerve bundles varies with your surgeon's expertise, your Gleason score, your PSA level, and the volume of tumor on the biopsies. The incidence of postoperative erectile dysfunction may be as low as 25% in men younger than 60 years who undergo bilateral nerve-sparing radical prostatectomy, or it may be as high as 62% in men older than 70 years who undergo unilateral nerve-sparing radical prostatectomy. Many factors can affect your erectile function after surgery, including your erectile function before surgery, your age, your pathological tumor stage, and the extent of preservation of the nerves. Erectile dysfunction after radical prostatectomy may resolve over the first year or two after surgery. During that time and if the trouble persists, you may seek treatment for it (see Part Three section on erectile

Erectile dysfunction

The inability to achieve and/or maintain an erection satisfactory for the completion of sexual performance.

Urinary incontinence

The loss of control of urine.

dysfunction). After a radical prostatectomy, you have no ejaculate because the sources of the fluid are either removed (prostate and seminal vesicles) or tied off (the vas deferens). However, you should still experience climax (reach an orgasm).

Urinary Incontinence

Urinary incontinence is another risk of radical prostatectomy. Incontinence may vary from none to persistent incontinence, such that every time you move you leak urine. The more common type of incontinence is stress-related incontinence, leakage that occurs when you increase the pressure in your abdomen, such as when you bear down, pick up something heavy, laugh, or cough. The incidence of incontinence varies from 1 to 58%, and one of the reasons for the wide range in the reported incidence of incontinence is that the definition of incontinence varies. If one considers any leakage to be incontinence, then the incidence would be higher than if incontinence were defined as leakage sufficient to change a pad a day. As with erectile dysfunction, incontinence may improve or resolve over time. Risks for incontinence after surgery include prior pelvic irradiation and older age. Many options are available for the treatment of urinary incontinence after radical prostatectomy (see Question 24).

Cliff's comment:

I feared this risk the most. I remember getting the diapers and pads the day I had my catheter removed. "My God," I thought, "I am 60 years old and I'm going to be wearing diapers. " Needless to say, my wife has no sympathy when I moaned about the possibility of having to wear a pad. I was lucky, however; I had two small ""spills" at night and that was it for my incontinence. I discarded all of those diapers and pads within a week.

Bladder Neck Contracture

A bladder neck contracture is scar tissue that develops in the area where the bladder and urethra are sewn together. This problem occurs in about 1 in every 20 to 30 prostatectomies. The signs and symptoms of a bladder neck contracture include decreased force of stream and straining (pushing) to urinate. The bladder neck contracture is identified during an office cystoscopy, in which a cystoscope, a telescope-like instrument, is passed through the urethra up to the bladder neck and the narrowed area is visualized. If the opening is very small, a small wire can be passed through it and the area dilated using some metal or plastic dilators. Before the procedure, the urethra is numbed with lidocaine jelly to decrease discomfort. Usually, once the bladder neck is dilated, it remains open; however, in a small number of men, a repeat dilation or an incision into the scar under anesthesia is needed. A complication of treatment for bladder neck contracture is urinary incontinence.

Bladder neck contracture

Scar tissue at the bladder neck that causes narrowing.

Cystoscope

A telescope-like instrument that allows one to examine the urethra and inside of the bladder.

Deep Venous Thrombosis

A deep venous thrombosis (DVT) is a blood clot that develops in the veins in the leg or the pelvis. People with cancer and those who are sedentary are at increased risk for such blood clots. Thromboembolic (TED) hose and Venodynes (pneumatic sequential stockings that inflate and deflate to keep blood flowing) are often used during surgery and the postoperative period to decrease the risk of forming such blood clots. DVTs may cause swelling of the leg, which often resolves when the blood clot dissolves. A more serious risk posed by a DVT is that a piece of the clot could break off and travel to the heart and lungs. This is called a pulmonary embolus. A pulmonary embolus can be life threatening if the fragment is large enough to block off blood flow to the lung.

Deep venous thrombosis (DVT)

The formation of a blood clot in the large deep veins, usually of the legs or in the pelvis.

Colostomy

A surgical opening between the colon (large intestine) and the skin that allows stool to drain into a collecting bag.

Gastrointestinal (GI)

Related to the digestive system and/or the intestines.

Mortality

Death related to disease or treatment.

Rectal Injury

The incidence of rectal injury during a radical prostatectomy is less than 2%. There is a slightly higher risk of rectal injury with the perineal approach (1.73%) than with the retropubic approach (0.68%). In most cases, if the injury is small and you have performed the bowel prep and no stool is visible, then the area can be closed and should heal. For large injuries that occur with bowels that are not well prepped, a temporary colostomy is made to decrease the chances of stool leakage and abscess formation; the colostomy can be taken down later.

Miscellaneous Complications Related to the Radical Prostatectomy

The retropubic prostatectomy has a higher risk of cardiovascular, respiratory, and other medically related complications, primarily gastrointestinal, such as slow return of bowel function, than the perineal approach. The perineal approach has a higher risk of miscellaneous surgical complications, such as rectal injury and postoperative infections. The perineal approach may also be associated with an increased risk of incontinence of stool. The incidence of complications and mortality increases with patient age at the time of surgery.

Death

The mortality rate associated with radical prostatectomy is less than 0.1%.

Dealing With Erectile Dysfunction

Dealing With Erectile Dysfunction

Whether you call it erectile dysfunction, ED, impotence, or any number of slang terms, erection problems are something many men have to face during the course of their lifetimes.

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