What are the common complications of radical prostatectomy surgery?

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Elsevier ClinicalKey Clinical Overview

Treatment Subsubsection Title: Procedures: Subsubsection Title: Radical prostatectomy: Subsubsection Title: General explanation: Complete surgical removal of prostate May be done by perineal or retropubic approach Use of laparoscopy and robotic assistance has replaced open procedure in many centers Length of hospital stay and transfusion requirements are lower in laparoscopic and robot-assisted procedures than in open procedures Pelvic lymph node dissection may be done in conjunction if risk of nodal metastasis is calculated (by nomogram Provides staging information but not consistently associated with improvement in metastasis-free or overall survival Subsubsection Title: Indication: Potentially curable disease in patients with life expectancy of 10 years or more Subsubsection Title: Contraindications: Poor functional status Presence of comorbidities that pose unacceptable anesthesia risk Locally invasive disease (eg, involvement of adjacent organs) Subsubsection Title: Complications: Erectile dysfunction Urinary incontinence Subsubsection Title: External beam radiation therapy: Subsubsection Title: General explanation: Use of image-guided external beam radiation therapy to destroy malignancy Rapidly evolving newer techniques may reduce collateral tissue damage and duration of treatment Subsubsection Title: Indication: Potentially curable disease Palliative therapy for bone metastases Subsubsection Title: Contraindications: Previous radiation therapy to pelvic area Active inflammatory disease of rectum (eg, ulcerative colitis) Permanent indwelling urinary catheter Subsubsection Title: Complications: Urinary incontinence Erectile dysfunction Lower urinary tract symptoms (eg, urgency, frequency, hematuria) Rectal bleeding and diarrhea; latter may become chronic Subsubsection Title: Brachytherapy: Subsubsection Title: General explanation:

Treatment May be offered to the following groups: Very-low-risk patients with life expectancy of 20 years or more Low-risk patients with life expectancy of 10 years or more Treatment options Radical prostatectomy (perineal, retropubic, laparoscopic, or robot-assisted) May include pelvic lymph node dissection in patients with 2% or greater chance of lymph node involvement Risk is assessed by nomogram Most common adverse effects Stress urinary incontinence Erectile dysfunction Lymphedema and/or lymphocele may occur if lymphadenectomy is performed Systematic review of laparoscopic, robot-assisted, and open prostatectomy found no high-quality evidence comparing with long-term oncologic outcomes Overall complication rate and urinary and sexual quality of life were similar Length of hospital stay and transfusion requirements were greater in open procedures Definitive radiation therapy External beam radiation therapy Several techniques are available: intensity modulated, stereotactic, or hypofractionated Hypofractionation entails delivery of higher doses per fraction (ie, session), thus shortening duration needed to administer total dose; it may be offered to patients in lower-risk categories who have opted for treatment with selected external beam radiation therapy Associated with small increased risk of early gastrointestinal adverse effects, but long-term toxicity appears similar to that in conventional external beam radiation therapy Long-term efficacy data are not yet available, but 5-year outcomes for hypofractionation appear similar to those for conventional radiation therapy May be an appropriate choice in the following additional groups: Select patients with unfavorable intermediate-risk disease and life expectancy of less than 10 years Select patients with high- or very-high-risk disease and life expectancy of 5 years or less

Prostate cancer exhibits extensive clinical heterogeneity, and some men may be treated aggressively for cancers that will never cause clinical symptoms. Treatment decisions are based not only on risk stratification and the stage of disease but also on the side effects of treatment (Table 186-3).,Localized DiseaseA number of treatment options are available for patients who have localized prostate cancer (Table 186-3).Watchful Waiting and Active SurveillanceObservation (watchful waiting) is an option for men who have competing causes of death that are likely to shorten life-expectancy to less than 10 years.Another strategy is active surveillance, which includes PSA testing every 6 months, a digital rectal examination once a year, repeat prostate biopsies potentially every 12 months, and consideration of MRI spectroscopy.,Ki-67 is a marker of proliferation, and high staining for Ki-67 and/or loss of PTEN may identify patients who may require more aggressive treatment.Curative TherapyBoth radical prostatectomy and radiation therapy can achieve a high cure rate for early disease. The preferred option should consider the patient’s wishes, experience, and expectations. Referral to the appropriate specialist or team is highly encouraged to provide a balanced explanation of the impacts of each option on bowel, bladder, and sexual function, as well as other systemic side effects.Radical prostatectomy is an option for patients who have clinically localized disease and a life expectancy of more than 10 years.Laparoscopic and robot-assisted radical prostatectomy are commonly performed rather than open radical prostatectomy to reduce the length of hospital stay as well as blood loss, surgical complications, urinary incontinence, and erectile dysfunction.In patients in whom the probability of nodal involvement is high, a pelvic lymph node dissection should be performed, typically at the time of prostatectomy.

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Elsevier ClinicalKey Clinical Overview

Treatment Urinary, rectal, and sexual adverse effects of treatments for localized prostate cancer Urinary Incontinence can occur with either surgery or radiation Radiation cystitis can lead to intermittent or chronic hematuria, blood clots that may obstruct passage of urine, and urinary frequency, in addition to urge incontinence Urethral strictures can develop after radiation or surgery; strictures can result in urinary obstruction Rectal Radiation proctitis manifests as rectal pain, tenesmus, increased stool frequency, and/or rectal bleeding Risk of radiation therapy–induced chronic rectal or bladder sequelae—including rectourethral fistula or urethral stricture—is less than 10% Sexual Sexual effects can occur with surgery, radiation, or androgen-deprivation therapy and include erectile dysfunction, decreased libido, and retrograde ejaculation Although erectile dysfunction that starts after surgery or radiation is sometimes associated with gradual improvement over time, some patients have residual dysfunction on a more chronic basis Nerve-sparing surgical techniques are associated with lower risk of erectile dysfunction Short- and long-term toxicities of androgen-deprivation therapy Short term Sexual adverse effects, including decreased libido, erectile dysfunction, and decreased penile size Changes in body composition, including decreased muscle mass, increased fat mass or weight gain, increased abdominal girth, decreased penile size, and gynecomastia Vasomotor symptoms such as hot flashes and body chills Psychosocial impacts including anxiety, fatigue, depression, feelings of loss of masculinity, sleep disturbances, and caregiver distress Long term Decreased bone density and increased risk of osteoporotic fractures compared with age-matched control populations Alterations in insulin resistance and lipid levels with increased risk of diabetes and metabolic syndrome Cardiovascular disease, including increased risk of myocardial infarction, arrythmias, and stroke. This risk appears to be highest in those with a recent cardiovascular event

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Kadono Y, Nohara T, Kawaguchi S, et al. Cancers. 2022;14(13):3050. doi:10.3390/cancers14133050. Copyright License: CC BY

Publish date: June 2, 2022.

During radical prostatectomy, the prostate is removed along with the seminal vesicles, and the urinary tract is reconstructed by dropping the bladder onto the pelvic floor and suturing the bladder and urethra together. This process causes damage to the pelvic floor and postoperative complications due to the anatomical changes in the pelvic floor caused by the vesicourethral anastomosis. Urinary incontinence and erectile dysfunction are major complications that impair patients' quality of life after radical prostatectomy. In addition, the shortening of the penis and the increased prevalence of inguinal hernia have been reported. Since these postoperative complications subsequently affect patients' quality of life, their reduction is a matter of great interest, and procedural innovations such as nerve-sparing techniques, Retzius space preservation, and inguinal hernia prophylaxis have been developed. It is clear that nerve sparing is useful for preserving the erectile function, and nerve sparing, urethral length preservation, and Retzius sparing are useful for urinary continence. The evaluation of pre- and postoperative imaging to observe changes in pelvic anatomy is also beginning to clarify why these techniques are useful. Changes in pelvic anatomy after radical prostatectomy are inevitable and, therefore, postoperative complications cannot be completely eliminated; however, preserving as much of the tissue and structure around the prostate as possible, to the extent that prostate cancer control is not compromised, may help reduce the prevalence of postoperative complications.