At the time of radical prostatectomy, the lymph glands (nodes) are generally removed, and sometimes this can lead to the collection of lymph fluid in the pelvis area, known as a lymphocele. It is not well known what percentage of patients actually have a lymphocele present. To answer this question, every patient undergoing radical prostatectomy would need to have a CT scan or an MRI in the first weeks after surgery, and this is not done. However, lymphoceles, for the most part, do not cause any symptoms, but some do cause problems (some lymphoceles may get infected and others may cause leg swelling) and need to be drained for complete resolution. This involves the placement of a narrow tube through the abdominal wall into the fluid collection; sometimes, this tube will need to stay for a few days to ensure complete drainage.
Because the prostate is removed, the bladder at its neck needs to be joined to the urethra (the urine channel). Where these structures are joined is called an anastomosis. This is achieved by using sutures. Sometimes one of these sutures breaks, and a leak of urine occurs behind the bladder. This is known as an urinoma. Again, this is very uncommon in the hands of an experienced and technically proficient surgeon, but all the same it is a recognized complication. More common in the old era and rare now is injury to the rectum. Remember, the prostate sits on top of the rectum as you lie on your back and upon its removal, particularly if there is a lot of scarring around the back side of the prostate, an injury to the rectum can occur. In the vast majority of cases, this can be repaired at the same time in the operating room without any problems.
These complications are generally experienced in the early stages after surgery and, after several weeks, most of these are fully resolved, with the exception of erectile dysfunction and, sometimes, urinary incontinence. However, some people are innately adverse to the concept of surgery because of the fear of needles, incisions or bleeding.
Radiation therapy, whether external beam or seed implantation, is also associated with erection and urinary problems.There are others that are specific to radiation as well. Because of the close proximity of the rectum to the prostate, radiation to the prostate and the surrounding 1 cm will include the front wall of the rectum. This can result in a condition known as proctitis. Proctitis is typically associated with mucous passage in the stool, some bleeding and urgency for passing stool.
One of the differences in complications between surgery and radiation therapy is that proctitis and urinary problems with radiation therapy may occur early on (the latter particularly with seed implantation) and may take several months to resolve as opposed to the several weeks that most men after surgery take to resolve any potential complications. In contrast to surgery, when most men in the earliest stages after surgery have erection problems, most men in the first year after radiation do not have erection problems but may develop these erection problems between years one and five after treatment. In fact, the low point in erectile function after radiation probably is between three and five years after completion of the radiation therapy.The reason for such a delayed effect on erectile function is due to the slow and progressive damage that radiation can cause in the endothelium (lining of the blood vessels). This may lead to a steady reduction in blood flow into the penis over the first five years after treatment.
IV. Factors to Consider when Deciding on Treatment
The first factor that needs to be given consideration to when diagnosed with prostate cancer is the availability of treatment. For example, there are medical centers where expertise in IMRT is extremely limited. The equipment required for this is not available at every single medical center in this country. Likewise, a particular region may have little expertise in seed implantation. Likewise, certain areas of the country may have surgeons who have limited experience or expertise in nerve sparing radical prostatectomy. Even if you opt for watchful waiting, you need to be monitored by somebody with significant expertise in this approach for prostate cancer. And so, you have to decide, if all options are not available to you in your area, whether you wish to pursue one of the available options or you are willing to travel to an area where other options are available.
In trying to identify whether there are experts in your area, utilizing the list of physicians covered under your insurance plan is generally not an excellent way to define this. Even though all urologists are trained in the performance of radical prostatectomy, for instance, not all of them do it in practice. Indeed, the majority of urologists in the USA perform none or very few radical prostatectomies. It is estimated that if a surgeon performs more than 10 prostatectomies a year, he is in the tenth percentile for performance of radical prostatectomy in the United States. Likewise, there are radiation oncologists who have a particular focus on an area other than the prostate, such as head and neck cancer, bowel cancer or breast cancer, and may have had little experience in the management of prostate cancer after they graduated from residency training. Finding out who the top-level experts are is not difficult. Most major medical centers have at least one expert in surgery or radiation. Scanning through “Best Doctors” lists may also help you find an expert. This is not to say that physicians not on these lists are not excellent doctors; however, most doctors who make these lists are superior in the eyes of their peers. I would certainly never remove a surgeon or radiation oncologist from your list because he or she did not appear on one of these lists.
While checking out the medical literature (www.pubmed.org) may help you see who has written papers on prostate cancer treatments, this does not guarantee that the surgeon or radiation oncologist with the most papers is the best in his or her chosen field, nor does it mean that physicians who do not publish papers are not capable of giving you state-of-the-art medical care.
Asking your primary care clinician who he or she recommends you speak to is also sometimes fraught with problems. For example, the clinician that you are speaking to may be good friends with the local urologist or radiation oncologist, or may have a very close working relationship with him or her, so your clinician bias in favor of a particular physician may not be based upon outcomes after the treatment. It is said in medicine that the plural of anecdotes is not evidence, and by this, it is meant that speaking to family members or friends who have positive experiences from a particular surgeon does not necessarily mean that your outcomes will be identical.
Many world-class radical prostatectomists or radiation oncologists are difficult to make an appointment with, some do not take any form of insurance, their businesse are purely cash-based. However, it is not absolutely essential for you to see a world-renowned surgeon to obtain good outcome, provided that the physician who is conducting your treatment has good experience and significant expertise in the procedure that he or she is performing. Sometimes getting the best treatment requires that you move away from home base, and while there is a certain comfort level in using the medical center that you routinely use for your general medical care, this does not always translate into the best outcome for surgical or radiation treatment.
Another factor that is important to evaluate involves cancer statistics. On prostate biopsy there are three major factors that need to be evaluated. The first one is the Gleason grade, as we previously mentioned. The higher the Gleason grade, the more aggressive the cancer is, the more likely it is to spread rapidly, the more likely it is to be outside of the prostate, and the lower the survival is in general terms. Ten years after the diagnosis of prostate cancer, dying from the disease occurs in about 5% of men with a Gleason 5 tumor, 15% with a Gleason 6 tumor, 50% with a Gleason 7 tumor, and with a Gleason 8 cancer, it approaches 80% of men. It is also important to understand that in approximately one-third of cases, the Gleason score will be upgraded when the pathologist looks at the radical prostatectomy specimen if you have had surgery. That is, there are many men who have a Gleason 6 tumor on prostate