Commentary (Soloway): Morbidity of Contemporary Radical Retropubic Prostatectomy for Localized Prostate Cancer

Radical prostatectomy is not only the most common operation performed by most urologic oncologists, but also probably now represents the most common open operative procedure performed by all urologists in the United States. Much of this dramatic increase is due to the use of prostate-specific antigen (PSA) as a method for early diagnosis. My own experience is not unusual, in that approximately 50% of my male patients who underwent a radical prostatectomy last year had clinical stage T1c prostate cancer, meaning that the digital rectal exam was normal. The diagnostic biopsy was performed because of an elevated PSA.

Five years ago it was unusual to detect prostate cancer in men 50 to 60 years old. Now it is not uncommon. Until there is evidence to the contrary, most urologists perceive that total prostatectomy is the best method to cure prostate cancer in men under age 70 years. Other alternatives explored with the patient who has apparent organ-confined prostate cancer include external-beam radiation therapy, the experimental approach of cryotherapy, and, possibly, interstitial radiation therapy. In patients over 75 years of age who have any significant comorbidity, watchful waiting is discussed, and in this circumstance may be the most reasonable choice.

Increasingly, patients are aware of the side effects associated with total prostatectomy. Not infrequently, a newly diagnosed patient will have spoken with someone who has undergone a radical prostatectomy. Thus, it is imperative that clinicians have an excellent understanding of the side effects associated with total prostatectomy and the other treatment options.

Dramatic Decline in Perioperative Morbidity

The perioperative morbidity of total prostatectomy has declined dramatically in the last few years. It is remarkable that Dr. Lerner and his fellow Mayo Clinic urologists did not have a single operative death in 1,000 consecutive procedures. In their review, they report that only 22% of patients required a blood transfusion. Many urologists request that the patient donate one or two units of blood prior to surgery. If this is done, the likelihood of receiving blood from a blood bank is very low. In my last 100 consecutive radical prostatectomies, no patient required other than autologous blood.

The hospital stay for this procedure also has declined. My experience in Miami is not dissimilar from that of Lerner et al. Patients are often admitted on the day of surgery, and the average stay has decreased from 6 to 4 days. The reasons for the reduction in hospital stay include early ambulation, initiation of a liquid diet on postoperative day 1 or 2, a reduction in the use of narcotics for pain management, and pressure from third-party payors. Encouraging patients to aim for discharge on day 3 or 4 is an important strategy toward achieving that goal.

Urinary Incontinence an Important Issue

With the dramatic reduction in perioperative morbidity, the two primary concerns are urinary incontinence and erectile dysfunction. Although both are important, significant urinary incontinence is perhaps the most important quality-of-life issue. Men who have significant incontinence are depressed and actively seek treatment. Unfortunately, if incontinence is severe, the treatments, although helpful, are usually imperfect. These include periurethral injection of collagen or Teflon and the placement of an artificial urinary sphincter. Although the success rate of these measures is reported to be between 60% and 90%, rarely do the results meet the expectations of the patient.

Thus, it is imperative to minimize the chance of significant urinary incontinence. Fortunately, there are some technical modifications that, I believe, can reduce the risk of "significant" urinary incontinence. The surgeon should minimize dissection of the urethra distal to the apex of the prostate, as well as strive to gain adequate urethral length distal to the apex.

Although some of my colleagues disagree, I believe that bladder neck preservation is important. Preservation of the proximal urethra as it exits from the urinary bladder reduces the likelihood of an anastomotic stricture. Of my last 134 consecutive patients who underwent a radical prostatectomy with bladder neck preservation, only 2 (1.4%) developed an anastomotic stricture. Such stricture is often accompanied by some degree of urinary incontinence and may require surgical correction for voiding complaints. The fibrosis contributes to the incontinence. In addition, maintaining an intact bladder neck and proximal urethra may facilitate the early return of continence.

We recently conducted a quality-of-life analysis of 79 patients who underwent radical prostatectomy [1]. Among the 51 patients evaluated 12 months after radical prostatectomy, when asked "How often are you wet with coughing or sneezing?", 67% said never, 29% said occasionally, and 4% indicated always. In response to the question, "How often does a drip occur without warning?", 61% said never, 33% indicated occasionally, and 6% said always. With regard to whether they wear a pad, 78% of the patients indicated that this was never necessary, while 10% reported needing pads occasionally and 12% constantly. When asked, "How do you feel about wetting as an issue in your life?", 61% stated it was no problem, 33% rated their minor incontinence on a scale of 1 to 5 and only one scored it as a 5 (terrible), and 6% regarded it as a big problem. This indicates that in a small percentage of patients (approximately 5% to 10%), urinary incontinence is a quality-of-life issue.

Rate of Erectile Dysfunction Varies

The published incidence of erectile dysfunction following radical prostatectomy varies considerably. Several factors correlate with the likelihood of erectile dysfunction, including the patient's age, whether or not the neurovascular bundles were preserved, and, importantly, preoperative potency. Few studies have examined penile tumescence before and after surgery. Most studies have relied on questionnaires filled out by patients.

Fowler et al [2] reviewed a Medicare population in the New England area and found that 11% of radical prostatectomy patients were able to achieve erections sufficient for intercourse. In our study, 65% of patients described their sexual function as unsatisfactory [1]. Fortunately, with the increasing use of intracavernosal vasoactive substances, most interested men can achieve erections sufficient for intercourse.

We analyzed the age of patients reporting sexual dysfunction. We anticipated that, as patients get older, the risk of preoperative impotence would rise, and the role that sexuality plays in a relationship would therefore fall. This was not supported by our data. Men over 65 years old were as likely to regard postoperative impotence as a major issue as men under the age of 65. Accordingly, many people appear to have sexual relations well into their 70s. As the number of patients analyzed was small, the impact of aging on sexuality was difficult to detect statistically.