By Alexandra “Xan” Oakley, PCRI Educational Writer
Surgery and radiation are the most commonly administered prostate cancer treatments. There are many factors to consider before making a treatment choice. Every man’s prostate cancer case is different, so the same treatment(s) can lead to different outcomes, especially when it comes to side effects. Often, men undergo surgery or radiation (or both) without being fully informed of the long-term implications. Many men are under the impression that recovery will be like other types of operations. The problem is that one’s busy medical team may fail to fully convey a realistic outlook on the possible (and likely) outcomes. We have said it before and we continue to say it: Prostate cancer is the slowest growing cancer, and thus, there is plenty of time to weigh the options, the outcomes, and the side effects. The survival rate for men with non-metastatic prostate cancer receiving standard therapy is 96% at 15 years!
What You Need to Know About Surgery
The radical prostatectomy is removal of the entire prostate gland. Due to the location of the prostate, beneath the bladder and in front of the rectum, and with the urethra and ejaculatory ducts running through the center, as well as the bilateral nerve endings, removing it is a delicate process. The bilateral nerve-sparing radical prostatectomy is an attempt to remove the prostate while preserving as much of the surrounding nerve structures responsible for penile erections. The robotic approach reduces the recovery time after surgery compared to the older open surgical approach. Unfortunately, the risk of incontinence and sexual dysfunction is the same.
For the procedure, the patient is placed under anesthesia. After the surgeon removes the prostate, a catheter is placed in the penis to help drain the bladder. The catheter usually stays in for 1-2 weeks while the patient heals. The patient may stay in the hospital for several days after the procedure. One fairly frequent problem with surgery is the possibility of leaving cancer behind (called a positive margin). Top surgeons (urologists) leave cancer behind 10% of the time. However, others, even at reputable centers, can leave cancer behind up to 50% of the time.
Prostate cancer is the only cancer primarily managed by surgeons. Since surgery is their specialty, there can be some bias in treatment recommendation. Combined with the fact that the “c” word is terrifying, a patient’s very first and very natural reaction to a diagnosis of prostate cancer is to cut it out! However, all of the complications need to be considered. Due to the challenging nature of the operation, at least half the men are rendered impotent.
All men are at least temporarily impotent after surgery, with perhaps 50% recovering some degree of function eventually. Even this recovery does not mean a man will be able to get or even keep a full erection. Shrinkage and shortening of the penis can also occur. Ultimately, many men who are candidates and who desire full functionality will need to be taught how to self-inject themselves with prostaglandins.
Other Problems with Surgery
A quarter of men leak urine after surgery. Loss of bladder control (urinary incontinence) can be expected for the first few months following radical prostatectomy. Unfortunately, in some men, incontinence persists beyond the usual three to six-month recovery period. Also, since there is no ejaculatory apparatus to produce or deliver semen, men experience dry ejaculations. The muscles surrounding the urethra still contract at the time of orgasm, so the genital sensation that men experience at orgasm should remain.
However, after surgery, some men may ejaculate urine, termed “climacturia” by Dr. John P. Mulhall, author of the excellent book, Saving Your Sex Life: A Guide for Men with Prostate Cancer. Although the exact number of cases of climacturia after radical prostatectomy is unknown, estimates indicate that it occurs in more than 20 percent of men. As a result, many men suffer from decreased libido and decreased sexual satisfaction. Treatment suggestions for climacturia include behavior modification (urinating and refraining from drinking water before sexual activity) and the use of condoms. Although the results of these various treatments have not been well studied, patients should be informed that ejaculating urine is a rather common post-treatment complication of radical prostatectomy.
In the wake of a prostate cancer diagnosis patients feel pressure to act quickly. Prostate surgery is a life changing event, so decisions should be made carefully. It is more important to act decisively, taking the time to research all the unexpected side effects that may have been glossed over by one's physician. When choosing surgery it is important to be prepared for the life changes that will inevitably occur, and weigh these against the different options that are available.