Hi, I'm Dr. Scholz. Let's talk about prostate cancer.

In this video we're going to cover urinary side effects from prostate surgery. I'm always surprised when patients are unaware of the difference in urinary side effects between surgery and radiation - the two most popular types of treatments for prostate cancer. Urinary side effects from surgery are dramatically more severe than anything that radiation causes. In this video, we'll focus just on surgery, and in a subsequent video we'll talk about side effects from radiation.

When people have a radical prostatectomy, the surgeon removes the prostate and has to sew the ends of the urinary passage together. Since this is not stable immediately after surgery, a catheter is placed and this remains in place for up to a week after the operation. When the catheter is removed, almost 100% of men are incontinent of urine. That means they can't control their urine - the urine just flows out unimpeded. And of course, they have to use either diapers or pads to manage this situation until the situation corrects. On average, it takes anywhere from two weeks to three to four months or even longer for control of the urine to return. Unfortunately, urinary control doesn't return in everyone. In the hands of highly skilled surgeons, somewhere between 5 and 10% of men will remain permanently incontinent. This numbers are going to be worse in men that are older, or in men that have pre-existing problems.

When we talk about incontinence we're talking about two types of incontinence. One we call stress incontinence. That means that men are more or less under control, but when they jump, laugh, cough they have little squirts of urine. This is called stress incontinence.

Overt incontinence means that there is leakage occurring all the time.  

Stress incontinence is much more common than overt incontinence. Stress incontinence occurs in about 50% of men who have surgery, and men learn to live with it. The types of things that you can do for stress incontinence include something called Kegel exercises. You can google that and learn how to strengthen the muscles that control urination. Stress incontinence can also be managed by certain medications called anticholinergic medications. There's a variety of products such as Detrol, Enablex, Ditropan, Myrbetriq. And these medications may help men with stress incontinence. They can also have side effects such as dry mouth, constipation, and insomnia. But this is a balancing act as to which side effect is worse - the stress incontinence  or the pills. And, sometimes one pill will work better than another.

 Overt incontinence, where leakage occurs all the time, is what most people think of when they talk about incontinence. The quality of the surgery is very important, and in less skilled operators, the incidence of overt incontinence can range as high as 30-40%. But if you go to a large center of excellence where a lot of radical prostatectomies are being done, they typically can hold the risk of overt incontinence down to less than 10%. So what can you do about overt incontinence? Overt incontinence is managed typically with some sort of a surgical procedure such as a sling procedure or an artificial sphincter. Let's talk first about the sling procedure, which is a much milder and easier proposition than doing an artificial sphincter. Not being a urologist myself, I can't tell you all the details, but sling procedures are recommended for men that have relatively mild incontinence; this means perhaps 2-3 pads of leakage per day. Typically, since the procedure is easier to perform, this might be tried first before people would move on to the more invasive operation of an artificial sphincter.  

Artificial sphincters involve the placement of a cuff around the urethral passage, with a controlling device placed in the scrotum, and a pressure point placed in the lower abdomen. So this is a much more invasive and extensive operation. These types of operations should only be performed by specialists who do this particular type of surgery frequently. The success rates, in the hands of experts, is around 80-85%. So the results are pretty good, and many people are satisfied after this type of an operation.

Two last things should be mentioned when we're talking about urinary function after surgery. The first is a phenomena called climacturia. This means the ejaculation of urine after having had a radical prostatectomy. This isn't talked about very much, but it occurs in about 20% of men that have a radical prostatectomy, and it's certainly a problem. It's not quite clear that it is correctable in any fashion, but it's a situation that has to be managed. Some men use condoms and some men avoid sexual activity altogether. So, when thinking about surgery, be aware and discuss the possibility of climacturia with your surgeon and the difficulties that can impose on your sex life after treatment.

Lastly, let's talk about urethral strictures. Strictures can also occur after radiation. Think of excess scarring that occurs when they reconnect the urethra at the time of surgery. If that scarring is excessive it can literally block the urethra. Strictures are treated with metal stents that are inserted through the penis to stretch out the area of tightness in the urethra. Unfortunately, scar tissue often will not stretch very effectively, and sometimes permanent damage is done and strictures can therefore be converted into incontinence. So, the risk of strictures after radical prostatectomy is estimated to be around 2 to 3 to 4%. So, while these men may not have immediate incontinence, over a period of a year or two after surgery, if stricture occurs, those individuals will also be placed at risk for developing incontinence down the line.

Radical prostatectomy for the treatment of prostate cancer is unique in causing the type of problems we've been discussing with urinary incontinence. Other popular forms of therapy, such as seed implants, radiation therapy, proton therapy - typically don't cause incontinence, or if it occurs it's very, very rare. Cure rates with surgery compared to these other types of radiation, are just as good with either approach. So when considering therapy, it's logical to consider side effects as being equally important with cure rates, since the side effect profile of surgery compared to the other options, especially in the department of urinary function is quite different.

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