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Impotence, or erectile dysfunction, is unfortunately a commonly identified risk of radical prostatectomy. The nerves that supply the penis and that are involved in the erectile process lie along each side of the prostate and the urethra. They may be taken deliberately by the surgeon (non-nerve-sparing radical prostatectomy), or they may be injured permanently or transiently. The decision to try to spare one or both nerve bundles varies with your surgeon's expertise, your Gleason score, your PSA level, and the volume of tumor on the biopsies. The incidence of postoperative erectile dysfunction may be as low as 25% in men younger than 60 years who undergo bilateral nerve-sparing radical prostatectomy, or it may be as high as 62% in men older than 70 years who undergo unilateral nerve-sparing radical prostatectomy. Many factors can affect your erectile function after surgery, including your erectile function before surgery, your age, your pathological tumor stage, and the extent of preservation of the nerves. Erectile dysfunction after radical prostatectomy may resolve over the first year or two after surgery. During that time and if the trouble persists, you may seek treatment for it (see Part Three section on erectile dysfunction). After a radical prostatectomy, you have no ejaculate because the sources of the fluid are either removed (prostate and seminal vesicles) or tied off (the vas deferens). However, you should still experience climax (reach an orgasm).
Urinary incontinence is another risk of radical prostatectomy. Incontinence may vary from none to persistent incontinence, such that every time you move you leak urine. The more common type of incontinence is stress-related incontinence, leakage that occurs when you increase the pressure in your abdomen, such as when you bear down, pick up something heavy, laugh, or cough. The incidence of incontinence varies from 1 to 58%, and one of the reasons for the wide range in the reported incidence of incontinence is that the definition of incontinence varies. If one considers any leakage to be incontinence, then the incidence would be higher than if incontinence were defined as leakage sufficient to change a pad a day. As with erectile dysfunction, incontinence may improve or resolve over time. Risks for incontinence after surgery include prior pelvic irradiation and older age. Many options are available for the treatment of urinary incontinence after radical prostatectomy (see Question 24).
Bladder Neck Contracture
A bladder neck contracture is scar tissue that develops in the area where the bladder and urethra are sewn together. This problem occurs in about 1 in every 20 to 30 prostatectomies. The signs and symptoms of a bladder neck contracture include decreased force of stream and straining (pushing) to urinate. The bladder neck contracture is identified during an office cystoscopy, in which a cystoscope, a telescope-like instrument, is passed through the urethra up to the bladder neck and the narrowed area is visualized. If the opening is very small, a small wire can be passed through it and the area dilated using some metal or plastic dilators. Before the procedure, the urethra is numbed with lidocaine jelly to decrease discomfort. Usually, once the bladder neck is dilated, it remains open; however, in a small number of men, a repeat dilation or an incision into the scar under anesthesia is needed. A complication of treatment for bladder neck contracture is urinary incontinence.
Deep Venous Thrombosis
A deep venous thrombosis (DVT) is a blood clot that develops in the veins in the leg or the pelvis. People with cancer and those who are sedentary are at increased risk for such blood clots. Thromboembolic (TED) hose and Venodynes (pneumatic sequential stockings that inflate and deflate to keep blood flowing) are often used during surgery and the postoperative period to decrease the risk of forming such blood clots. DVTs may cause swelling of the leg, which often resolves when the blood clot dissolves. A more serious risk posed by a DVT is that a piece of the clot could break off and travel to the heart and lungs. This is called a pulmonary embolus. A pulmonary embolus can be life threatening if the fragment is large enough to block off blood flow to the lung.
The incidence of rectal injury during a radical prostatectomy is less than 2%. There is a slightly higher risk of rectal injury with the perineal approach (1.73%) than with the retropubic approach (0.68%). In most cases, if the injury is small and you have performed the bowel prep and no stool is visible, then the area can be closed and should heal. For large injuries that occur with bowels that are not well prepped, a temporary colostomy is made to decrease the chances of stool leakage and abscess formation; the colostomy can be taken down later.
Miscellaneous Complications Related to the Radical Prostatectomy
The retropubic prostatectomy has a higher risk of cardiovascular, respiratory, and other medically related complications, primarily gastrointestinal, such as slow return of bowel function, than the perineal approach. The perineal approach has a higher risk of miscellaneous surgical complications, such as rectal injury and postoperative infections. The perineal approach may also be associated with an increased risk of incontinence of stool. The incidence of complications and mortality increases with patient age at the time of surgery.
The mortality rate associated with radical prostatectomy is less than 0.1%.