Deciding to proceed with surgery to cure cancer can be a daunting task. This decision can be even more difficult in the case of prostate cancer. With so many treatment options available and, for some, even a viable option of not treating the cancer, the decision to go ahead with prostatectomy is certainly not one that anyone takes lightly. As a result, when counseling my patients about surgery and other treatment options for prostate cancer, I try to be very thorough about explaining all the potential risks of the procedure. That way, they really have an understanding of what they can be potentially getting themselves into. The purpose of this post is to review the various risks of prostatectomy, both traditional and robotic. Many of the risks of these two types of surgery are identical. However, I will point out any disparity in risks between the two surgeries when, in fact, there is one. For the purpose of clarity, I have divided the complications into three types:
- Long Term
Intra-operative Complications: These are the problems that could potentially occur at the time of surgery.
1. Bleeding: Radical prostatectomy, the traditional surgery for prostate cancer, has always been associated with bleeding. As the procedure has been refined, the average blood loss has decreased but remains significant. On average, a radical prostatectomy tends to result in a loss of about 500-900 milliliters of blood. While young, healthy people can usually tolerate such blood loss without any untoward effects, older, sicker men may not tolerate this type of blood loss as well. As a result, most men that undergo traditional surgery donate a unit of their own blood a few weeks prior to surgery so that they may receive it back at the time of surgery and not need to rely on blood from the blood bank ( with its associated very low risk of communicable diseases). Robotic surgery, in contrast, usually results in significantly less bleeding (about 100-200 milliliters). This difference is accounted for by the fact that the robotic surgery involves a process called insufflation in which the abdominal cavity is stretched with gas to allow for room for the surgeon to see and work. This gas creates pressure which stops minor bleeding from veins that would otherwise bleed freely during open surgery. As a result of this decreased bleeding risk, many robotic surgeons do not request patients to donate blood prior to the procedure.
2. Damage to the bladder or ureters: Because the bladder sits right on top of the prostate, removal of the prostate sometimes leads to injury of the bladder. Most of these injuries are pretty minor and can be fixed at the time of surgery pretty easily. One injury that is a little more complicated is the type that occurs to the ureters, the tubes that carry urine from the kidneys to the bladder. Sometimes, during prostatectomy, the surgeon inadvertently cuts the ureter or the opening of the ureter into the bladder. If this occurs, the surgeon would need to repair this injury by reconnecting the ureter tube to another location in the bladder. This type of procedure, called ureteral reimplantation, is something that urologists are very comfortable doing and, so, usually does not result in any long term problems after surgery.
3. Damage to the Rectum: For those of you who have had a prostate biopsy, you probably remember that the biopsy was done through the rectum. The reason for this approach is that the rectum sits right behind the prostate and is separated from it by a thin lining of tissue. During a prostatectomy, the prostate is occasionally very stuck to the rectum and, upon trying to separate the prostate from the rectum, the surgeon can make a hole in the rectum. If the hole is small and the patient has had a bowel preparation (enemas and oral laxatives) the surgeon can often just repair the hole with some stitches. If the hole is big or the patient has not had a bowel preparation, however, a colostomy occasionally needs to be performed. A colostomy is a procedure where the colon is separated from the rectum (where the hole is) and brought out to the skin to a bag. The stool is collected in a bag and prevented from going down to where the hole in the rectum is located, allowing the hole to heal. After a few months, a surgeon can then reverse the colostomy by reattaching the colon back down to the rectum and allowing the patient to, once again, have normal bowel movements. Fortunately, this type of complication occurs less frequently than 1% of the time. However, this is not much consolation if you are one of those few people who have to defecate into a bag for a few months.
4. Complications of Anesthesia: Any surgery requiring general anesthesia carries the risk of serious complications related to the anesthesia. These potential problems include heart attack, stroke, a blood clot in the lungs, aspiration of stomach contents (i.e. food) into the lungs, and even death. Prevention of these complications requires a thorough evaluation prior to surgery to assess medical and anesthesia risks.
Postoperative Complications: Even when a prostatectomy is carried out without a hitch, occasional problems can be noted from the time immediately following surgery to a few weeks following surgery.
1. Infection: Infections are not a common problem after prostate cancer surgery. With adequate antibiotics around the time of surgery, most patients do quite well in avoiding infections. For some patients, however, infections do occur. Most commonly, an infection occurs in the incision, making it red, hot, and occasionally leaking pus. For others, infections can occur in the urine as demonstrated by cloudy or bloody urine and pain over the bladder. Both of these types of infections can be successfully managed with antibiotics.
2. Hematoma: Sometimes bleeding is not noted at the time of surgery, allowing blood to accumulate over time within the area where the surgery was performed. This large accumulation of blood and clot is called a hematoma. While such collections are sometimes not even noticed by patients, occasionally they can cause a great deal of pain and discomfort. Rarely, they can even push so much on the bladder as to tear the anastamosis (the surgical connection made between the bladder and urethra tube). This can be a very serous complication requiring surgery to re-establish the connection. Many times, however, less severe hematomas can be managed conservatively with rest, pain medicine, and time.
3. Wound Issues: The most common problem with surgical wounds is infection (as described above). Less commonly, wounds can start draining fluid. Occasionally this leakage is due to a fluid collection the builds up underneath the skin called a seroma. This usually needs to be drained by your surgeon in the office. More rarely, the leakage can be due to a tear in the deep closure of the wound. This type of leakage may require a return visit to the operating room to re-close the deep parts of the wound. Either way, leakage from the wound should ALWAYS be reported to your surgeon.
4. Catheter Malfunction: After prostate surgery, the catheter in place which drains urine from the bladder really serves as a lifeline for the bladder. If the catheter stops working, there is no way for the urine to drain. Removing or replacing the catheter incorrectly can jeopardize the anastamosis between the bladder and the urethra, resulting in the potential need for repeat surgery and severe, chronic leakage of urine. As a result, I tell my patients after prostatectomy that the ONLY person who should remove or replace a urinary catheter in a man after prostate cancer surgery should be a urologist.
5. Bloody Urine: Occasionally, for a few days after prostatectomy, blood in the urine could be noted. This can be due to irritation of the bladder from the catheter or to some minor oozing after surgery. Either way, this blood in the urine can usually be managed conservatively, with periodic flushing of the catheter with saline. Rarely does blood in the urine remain a long term problem.
6. Blood Clots in Leg Veins: Any surgery that involves a patient lying down for prolonged periods of time could predispose him to blood clots in the veins of the legs. This is especially true of surgeries performed in the pelvis, like prostatectomies. A blood clot in a leg vein, otherwise known as a deep vein thrombosis (DVT), often presents itself as pain in the calf or behind the knee, swelling of the calf or leg, or redness of the leg. Men with these symptoms after prostate surgery should notify their surgeon or another medical doctor immediately because these clots can progress and travel to the lungs, which can be fatal. Once diagnosed through an ultrasound of the leg, a DVT is treated with several months of blood thinning medication.
Long Term Complications: While the complications mentioned above sound frightening, they fortunately occur fairly rarely. Long term complications, in contrast, occur much more frequently BUT are a lot less scary.
1. Impotence: About half of men undergoing prostatectomy develop erectile dysfunction following surgery. Younger men and those with strong erections prior to surgery are more likely to maintain some erections after surgery. Regardless of the extent of impotence after surgery, most men are able to sustain erections again after surgery with the variety of treatment options available for this problem. I have covered the management of erectile dysfunction following prostatectomy in a previous post and you are welcome to review it if you are interested:
2. Incontinence: Leakage of urine is also a common occurrence after prostatectomy. Incontinence occurs because the mechanism that controls urination is intimately associated with the prostate. During a prostatectomy, when the prostate is removed, this mechanism can be damaged, leading to leakage of urine in the short or long term. Approximately 15% of men demonstrate long term incontinence after prostatectomy. Most men are able to become dry with a combination of Kegel exercises and time. Kegel exercises are performed by squeezing the muscle that you normally use to hold in urine when you have the strong desire to urinate. I advise my patients to perform these exercises even PRIOR to surgery and to continue performing them over 100 times per day following surgery. I have found that men that start early and are diligent with the exercises tend to regain their continence sooner and more effectively. Urinary leakage can continue for months after surgery. By about 6 months to a year, most men have attained a level of dryness that will most likely remain chronically. For most men, this usually means either complete dryness or the need to wear a light pad in the underwear for some minor leaks during rigorous activity. For 10-15% of men, however, urinary leakage can be much worse, requiring diapers. For these men, a surgery can be performed to insert a device called an artificial urinary sphincter. This device can be used to mechanically overcome leakage of urine.
3. Dry Ejaculate: Even for those men that regain complete erections after surgery, sex is never exactly the same. As you may remember from my previous posts, the prostate and seminal vesicles produce most of the semen that men ejaculate when reaching an orgasm. During surgery, the prostate and seminal vesicles are removed and the connection to the testicles is severed (like a vasectomy). As a result, when men have an orgasm after surgery, they have a dry ejaculate. While they still feel enjoyment from an orgasm, it feels a little different. Because no semen is ejaculated, men are also considered infertile after prostatectomy.
4. Bladder Neck Contracture: About 5% of men undergoing prostatectomy develop scar tissue at the connection between the bladder and urethra tube (where the anastamosis was performed). As a result, these men may experience difficulty emptying their bladders or leakage of urine after a period of dryness. Fortunately, this complication can be repaired fairly easily with a minimally invasive, outpatient procedure.
While this post is not a completely exhaustive list of surgical complications after prostatectomy, I feel that it definitely provides a pretty comprehensive and objective view of all the major things that COULD go wrong during or after prostatectomy. The purpose of this post was not to scare anyone away from surgery. I just feel that with all of the options available to men with prostate cancer, anyone deciding on a particular treatment option needs to feel very comfortable with his choice. This comfort, in my experience, comes with knowledge of what he is getting himself into. In addition, for those men that proceed with prostatectomy, an understanding of potential complications can help reduce anxiety if and when these problems occur. For other men, having enough information to identify serious complications in a timely fashion can be the key to a successful outcome.
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