Complications

Surgical removal of the prostate carries the same risk of complications as does all major surgery. These include infection, post-op bleeding, and the ultimate complication, death. The death rate in the first thirty days following prostatectomy, according to a 2005 Canadian study, is less than 2 in 1,000 for men under age 60, and 6 in 1,000 for men 60 to 79.11 The most important cause of death is thrombosis (clots) of the veins in the legs, which often causes tenderness in the calf or leg swelling; when clots break free, they may travel to the lungs and heart as emboli and cause shortness of breath, chest pain, and sometimes sudden death. The best prevention is to get patients up and walking soon after surgery and to maintain regular walking and leg exercises for several weeks.

While the catheter is in place, a small number of men have bladder spasms, which are painful contractions of the bladder as it tries to expel the catheter. Korda describes these in Man to Man; in most cases, the spasms can be alleviated with medication. Some men develop a narrowing of the urethra where it is surgically attached to the bladder, and thus a narrowing of the urinary stream. Severe cases of this bladder neck obstruction require surgical dilation, which can be done as an outpatient procedure.

The three most common complications of all treatments for prostate cancer are urinary incontinence, impotence, and bowel dysfunction. Incontinence rates after surgical removal of the prostate vary widely and are a source of spirited debate among urologists. Some of the differences are due to variable levels of skill among surgeons. Some result from different definitions of incontinence; for example, some researchers use ''frequent leakage'' as a definition, whereas others use ''wears pads.'' One man's definitions of ''frequent'' and ''leakage'' may differ substantially from another man's definitions, and one man may wear a pad for occasional, minimal leakage while another may not wear one despite having copious leakage.

Incontinence rates also vary depending on whether the physician is making the assessment or whether the information comes from questionnaire self-reports from the patients. As one publication noted: ''Treating physicians in these studies report complication rates that are generally low, but may be inaccurate because patients may minimize complication of treatment to their doctors, who in turn may subconsciously discount patient reports of symptoms.''12

Finally, incontinence rates vary depending on the patient group being followed, with young men with low-grade tumors having the fewest problems.

The lowest rates of urinary incontinence following prostate surgery have been claimed by the Johns Hopkins University group who, for a small group of fifty-nine patients, reported that only 7 percent were wearing pads eighteen months after surgery. This was a highly select group of patients, however, with an average age of 57 and early stage tumors (88 percent Gleason 6 or less; 85 percent PSA less than 10). A much more representative group of patients is the 1,291 men from six different areas in the United States surveyed by the Prostate Cancer Outcomes Study. At two years following prostate surgery, 22 percent were wearing pads. This group was substantially older (72 percent age 60 and older) and had had more advanced cancers (only 56 percent Gleason 6 or less) than the Johns Hopkins cohort. Other studies that have assessed urinary continence in men following prostate surgery have reported results closer to those of the Prostate Cancer Outcomes Study.13

It thus appears that some degree of urinary incontinence is a common complication following prostatectomy. Approximately 20 percent of men use pads for at least occasional leakage, although studies suggest that the incontinence is severe in fewer than 10 percent of men. There is also consensus that the incontinence is most likely to occur in the early months after surgery and usually improves over time.

Impotence is a common complication of prostate surgery and, like incontinence, its assessment is made more difficult by varying definitions and the selection of patients. Should impotence be defined as inability to have an erection at all? An erection firm enough to have intercourse? With or without pharmacological help?

When we review the varied and contradictory studies on impotence that have been published, three findings stand out. First, the younger a man is at the time of surgery, the better are his chances of regaining potency. Second, a man who had satisfactory sexual function prior to surgery is much more likely to have a favorable outcome after surgery. Third, erectile function can return very slowly following surgery; according to one review, it ''continues to improve after radical prostatectomy up to at least 2 years after treatment.''14 This slow rate is consistent with what is known about nerve regeneration after nerves have been traumatized, even when they have not been severed.

That being said, let me emphasize that, in the words of one research group, ''few men undergoing radical prostatectomy eventually achieve the preoperative level of erectile function.''15 Impotence is a major complication—for most men, the major complication —of prostate surgery. The reported rates of impotence vary widely, however, and are hotly disputed.

At one end of the spectrum is the Johns Hopkins University study described above, which included a small, select sample of young men with early-stage prostate cancer. Walsh and his colleagues claimed that the impotence rate among these men was 62 percent at three months post-op; 46 percent at six months; 27 percent at twelve months; and 14 percent at eighteen months. Elsewhere, Walsh has claimed that, if both nerves are preserved during surgery, the rate of impotence should be no higher than 20 percent for men in their forties and fifties, and no higher than 40 percent for men in their sixties.16

Other researchers have claimed that the Johns Hopkins numbers represent select patients and are unrealistically optimistic. The large and more representative Prostate Cancer Outcomes Study reported an overall rate of impotency of 60 percent eighteen months after surgery; the rate for men who had had both nerves preserved was 56 percent, only slightly better than the overall rate. Other studies have reported even higher rates of impotence, including rates of 75 percent and 80 percent at twelve months post-op.17 Most of these studies defined men as potent if they were able to achieve an erection sufficient for intercourse, with or without the assistance of sildenafil (Viagra) or other oral medication.

It is clear that nerve-sparing surgery is effective in decreasing the rate of postsurgical impotence. Although little advantage was reported by the Prostate Cancer Outcomes Study, other studies have disagreed. A large study of 1,014 men aged 60 to 70 reported that 92 percent of the men were impotent when neither nerve was preserved during surgical removal of the prostate, but that only 66 percent were impotent when one or both nerves were preserved. The authors concluded: ''Most of the studies using patient-report, validated, questionnaire methodology have corroborated that nervesparing technique is associated with better sexual . . . recovery after radical prostatectomy than the non-nerve sparing technique.''18 Because of the size of the cancer, it is sometimes not possible to spare both nerves.

In summary, impotence is a serious problem for men following prostate surgery. For men in their 60s in whom one or both nerves have been preserved, the impotence rate ranges between 40 and 80 percent. Younger men fare somewhat better, especially those who had satisfactory presurgical sexual function. Men in whom both nerves have been cut during surgery will almost all be impotent.

The third major complication of prostate cancer treatment is disturbance in bowel function, such as crampy pain, diarrhea, and bowel urgency. For individuals who elect surgery, this is usually not a significant problem. A large study of 1,296 men who had surgical treatment for prostate cancer reported minor bowel symptoms in some men and found that ''this is short-lived, and during the first 3 months after surgery bowel function improves significantly'' and essentially returns to normal.19

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