Frequently Asked Questions - Conditions After a Radical Prostatectomy

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Questions & Answers

Is it normal for a patient to feel anxious or depressed after prostate cancer surgery?

Yes, it is human nature. Being diagnosed with cancer is traumatic and nobody can appreciate it fully unless they have experienced it first hand.

First, it is stressful just learning that you need a prostate biopsy. Then, it comes as a blow when you learn the biopsy shows prostate cancer. Then the patient has in sequence: the metastatic workup (finding out if the cancer has spread beyond the prostate), the decision about treatment, the logistics of planning surgery, the wait before surgery, the operation itself with its attendant postoperative discomfort.

After all this stress and anxiety, it’s natural for a man to feel emotionally traumatized. However, these feelings pass with time, and men resume their regular activities and lives.

What are some of the side effects from removing a prostate?

The two most feared side effects of total prostate removal (radical prostatectomy) are permanent impotency (loss of erections) and permanent urinary incontinence.

These side effects can occur but, in fact, seldom do with an experienced surgeon. But, they can also occur, regardless of the surgeon.

Other more common side effects are as follows: Sometimes, the bladder capacity is smaller after prostate removal and, therefore, urination is more frequent. Some patients have urgent urination if they try to hold it too long. Other possible problems are scar tissue formation (stricture) between the bladder and urethra that causes blockage of the urinary stream. Sometimes it is detected years after the operation. Also, after total removal of the prostate, there is little, if any, ejaculate, although there is the sensation of climax and orgasm. In many patients, there is retraction of the penis that gives the appearance of shortening; however, with return of erections, this retraction diminishes.

After a radical prostatectomy, my erections came back but not quite as good as before the surgery. I tried making love without a firm erection and now my penis bends to the right when erect. Will the peyronies ever go away?

Normally, all of the tissues of the penis are elastic and during erection, they expand equally in all directions. In men who have vigorous intercourse without a firm erection, the tissues can be injured.

This injury causes minor bleeding into the tissues and results in scar formation. Initially, the scar is not as elastic as the normal tissues, so it does not elongate with an erection. This situation causes curvature.

With time, scar tissue gradually matures and becomes more elastic. Therefore, Peyronie’s disease usually improves very gradually over several years. Often, though, it does not return to complete normalcy, but it can become much better.

It is important to avoid repeated injury to the penis, taking care to have sufficient lubrication. To the extent that Viagra-like drugs create more rigid erections, their use is also helpful.

Am I fertile or infertile after a radical prostatectomy?

Following a successful, nerve-sparing radical prostatectomy, most men will have return of erections but will not be able to have children by natural means.

There should be no seminal fluid after the prostatectomy, so they will be “infertile” by natural means but with in vitro fertilization techniques, it is still possible for a man to father a child after a radical prostatectomy.

Storing sperm in a sperm bank before the operation is a recommended procedure for those men hoping to father children after the operation.

Can swelling in the groin area be a result of a radical prostatectomy?

This swelling could be related to lymph node dissection, which sometimes causes swelling in the groin, penis, scrotum, and pubic area. In such circumstances, I recommend a visit to the surgeon and perhaps a CT scan of the abdomen and pelvic region.

After my surgery, it seems as if my penis is drawn up most of the time. Is it normal?

Yes. After the prostate has been removed, there is a gap between the bladder neck and the urethra that has to be bridged.

In some men, the bladder is mobile and easily reaches the urethral stump. In this case, there is little retraction of the penis.

In other cases, it is a “stretch” to pull the bladder and urethra together, and the penis gets “pulled up” inside. With time and return of regular erections, this retraction often corrects itself, which is why I encourage men to have erections naturally or artificially, early and regularly after a radical prostatectomy.

What is the frequency of treatment-related complications from a radical prostatectomy?

I can speak to my overall rates of treatment-related complications, which are 7%. An overall complication rate of 7% is considered very low. Few surgeons have that low a rate, especially when some of the complications include many minor problems. My continence rate is over 90%, and for men in their 40s and 50s is 95%. For the others, almost all have what I call “normal” female continence; that is, when they cough or sneeze, they lose a few drops of urine. In those instances, they wear a light pad in their underwear. My overall potency rate is 60%, also excellent considering that we include a group of men in their 50s through 80s. The results are 85-95% for men in their 40s and 50s but only 50% for men in their 70s.

If a man is facing the decision about possibly not treating a potentially lethal cancer or facing a zero risk of dying from the operation, the odds related to the prostatectomy look pretty good.

What does it mean when my pathology report after an RRP said: No cancer in the lymph nodes or seminal vessels with clean specimen margins but extensive perineural and perivascular invasion? Are these findings a reason to worry?

All the reports are good. Perineural invasion is present in all radical prostatectomy specimens. Small nerve fibers in the prostate gland secrete a growth factor that attracts prostate cancer cells, so when pathologists look at sections of the prostate gland, they frequently see the tumor cells surrounding the nerve fibers. This is called perineural invasion.

Perivascular invasion does not have much significance unless tumor cells are seen inside blood vessels or lymphatic channels, in which case it means there is a greater chance of recurrence of cancer and a greater likelihood that the cancer might spread to lymph nodes or distant sites.

Since my radical prostatectomy two years ago, I’ve had several PSA tests with no indication of recurrence. I have been getting these about every 8 months.
But I have not had a follow- up digital rectal exam and you indicated it was important. Why is it important?

Some low-PSA producing cells in some prostate cancers (usually high Gleason grade or neuroendocrine elements) can cause a recurrence of the cancer without elevating the PSA level early on.

These recurrences can sometimes be detected as a small BB-like lump on the rectal examination. It is important to detect them early so they can be treated early, usually with radiation therapy. Although these occurrences are rare, they are important to diagnose as early as possible.

In addition, an annual rectal examination is also a screen for rectal cancer.

Perivascular invasion does not have much significance unless tumor cells are seen inside blood vessels or lymphatic channels, in which case it means there is a greater chance of recurrence of cancer and a greater likelihood that the cancer might spread to lymph nodes or distant sites.

I had an RRP 21 months ago followed up by radiation 3 months later. Now, I need a colonoscopy. I’ve heard that radiation weakens the colon’s wall and that a colonoscopy can be dangerous if you’ve had radiation to the prostate bed. If so, should I get a virtual (non-invasive) colonoscopy?

In my opinion, it is safe to have colonoscopy as early as 3 to 6 months after prostatectomy and/or radiation therapy.

But if polyps have to be removed, then there is an increased risk for poor healing and the development of a fistula so it is essential to advise the GI doctor that you have had radiotherapy. It should be obvious to the doctor, though, because radiation usually induces changes in the appearance of the colon that are characteristic for prior radiotherapy.

I had a radical prostectomy 12 months ago. It was a small cancer and my current PSA reading has been .1 the last two checkups. I have now been diagnosed with low testosterone. What is your opinion of testosterone replacement therapy?

Testosterone replacement therapy should be used with caution.

If there are any cancer cells remaining in your body, testosterone replacement therapy could stimulate their growth.

However, if you wish to take the risk, you should monitor your PSA monthly for at least 6 months, in my opinion.

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