Hi, I'm Dr. Scholz. Let's talk about prostate cancer.
In this video, we're going to cover urinary side effects from prostate surgery. I'm always
surprised when patients are unaware of the difference in urinary side effects between
surgery and radiation, the two most popular types of treatment for prostate cancer. Urinary
side effects from surgery are dramatically more severe than anything that radiation causes.
In this video, we'll focus just on surgery and in a subsequent video, we'll talk about
side effects from radiation.
When people have a radical prostatectomy, the surgeon removes the prostate and has to
sew the ends of the urinary passage together. Since this is not stable immediately after
surgery, a catheter is placed and this remained in place for up to a week after the operation.
When the catheter is removed, almost 100% of men are incontinent of urine. That means
they can't control their urine. The urine just flows out unimpeded, and of course, they
have to use either diapers or pads to manage the situations until the situation corrects.
On average it takes anywhere from two weeks to three to four months or even longer for
control of the urine to return. Unfortunately, urinary control doesn't return in everyone.
In the hands of highly skilled surgeon somewhere between 5-10% will remain permanently incontinent.
Those numbers are going to be worse in men that are older, or in men that have pre-existing
problems.
So, when we talk about incontinence we're talking about two types of incontinence. One
we call "stress incontinence." That means that men are more or less under control, but
when they jump, laugh, cough they have little squirts of urine. This is called stress incontinence.
"Overt incontinence" means that there'es leakage occurring all the time. Stress incontinence
is much more common than overt incontinence. Stree incontinence occurs in perhaps about
50% of men who have surgery. And men learn to live with it. The type of things that you
can do for stress incontinence includes something called Kegel exercises. K-E-G-E-L. You can
Google that and learn how to strengthen the muscles that control urination. Stress incontinence
can also be managed by certain medications called anticholinergic medications. There's
a variety of products such as Detrol, Enablex, Ditropan, Mybetriq, and these medications
may help men with stress incontinence. They can also have side effects such as dry mouth,
constipation, and insomnia, but this is a balancing act as to which side effect is worse:
the stress incontinence or the pills, and sometimes one pill will work better than another.
Overt incontinence, where leakage occurs all the time is what most people think of when
they talk about incontinence. The quality of the surgery is very important, and unless
skilled operators the incidence of overt incontinence can range as high as 30-40%, but if you go
to a large center of excellence where a lot of radical prostatectomies are being done,
they typically can hold the risk of overt incontinence down to less than 10%.
So what can you do about overt incontinence? Overt incontinence is managed typically with
some sort of a surgical procedure such as a sling procedure or an artificial sphincter.
Let's talk first about the sling procedure, which is a much milder and easier proposition
than doing an artificial sphincter. Not being a urologist myself, I can't tell you all the
details, but sling procedures are recommended for men that have relatively mild incontinence.
This means perhaps 2 to 3 pads of leakage per day. Typically, since the procedure is
easier to perform this might be tried first before people would move on to the more invasive
operation of an artificial sphincter. Artificial sphincters involve the placement of a cuff
around the urethral passage with a controlling device placed in the scrotum and a pressure
pump placed in the lower abdomen. So this is a much more invasive and extensive operation.
These types of operations should only be performed by specialists who do this particular type
of surgery frequently. The success rate in the hands of experts is around 80 to 85%,
so the results are pretty good and many people are satisfied after this type of an operation.
Two last things should be mentioned when we're talking about urinary function after surgery.
The first is a phenomenon called "climacturia." This means the ejaculation of urine after
having had a radical prostatectomy. This isn't talked about very much, but it occurs in about
20% of men that have a radical prostatectomy and it's certainly a problem. It's not quite
clear that it's correctable in any fashion, but it's a situation that has to be managed
and so men use condoms and some men avoid sexual activity altogether. So when thinking
about surgery be aware and discuss the possibility of climacturia with your surgeon and the difficulties
that can impose on your sex life after treatment.
Lastly, let's talk about urethral strictures. Strictures can also occur with radiation.
Think of excess scarring that occurs when they reconnect the urethra at the time of
surgery and if that scarring is excessive it can literally block the urethra. Strictures
are treated with metal sounds that are inserted through the penis to stretch out the area
of tightness in the urethra. Unfortunately, scar tissue often will not stretch very effectively
and sometimes permanent damage is done and strictures can, therefore, be converted into
incontinence. So the risk of strictures after a radical prostatectomy is estimated to be
around 2 to 3 to 4%, so while these men may not have immediate incontinence, over a period
of a year or two after surgery if stricture occurs those individuals will also be placed
at risk for developing incontinence down the line.
Radical prostatectomy for the treatment of prostate cancer is unique in causing the type
of problems we've been discussing with urinary incontinence. Other popular forms of therapy
such as seed implants, radiation therapy, proton therapy typically don't cause incontinence
or if it occurs it's very, very rare. Cure rates with surgery compared to these other
types of radiation are just as good with either approach, so when considering therapy it's
logical to consider side effects as being equally important with cure rates since the
side effect profile of surgery compared to the other options and especially in the department
of urinary function is quite different.
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