Prostate Complications

Complications of Treatment

Surgical Complications

  • Complications of surgery
    • Operative mortality 0.5%
    • MI (within 30 days) 8%
    • Pulmonary emboli 3%
    • Symptomatic lymphocele 2%
    • Require Transfusion (bleed) 20%
  • Expected Side-effects
    • Urine catheter for 1-3 weeks post-surgically
  • Postop Complications
    • Incontinence requiring pads or clamps 30% (patient survey)
    • Incontinence requiring pads or clamps 30% (physician record)
    • Stress Incontinence 40%
    • Require treatment for stricture 20%
    • stool incontinence
  • Erectile dysfunction - overall 60%
    • 20-90% (50%) impotence rate with nerve sparing technique
    • complete impotence without nerve sparing procedure
    • Able to have intercourse 11%

Radiation Complications: Chronic

Radiation Proctitis

  • Hydrocortisone and anti-inflammatory suppositories and changes in diet
  • Rectal bleed (2-10% in 6-18 months)
  • Consider conservative management (refrain from biopsy) then formalin instillation of the rectum and therapeutic endoscopic interventions (eg, ablation with argon, Nd:YAG laser, bipolar circumactive probe [BICAP], argon plasma coagulator).

Proctitis Management

Anal Incontinence

  • Diet, Biofeedback and possible surgery

Rectal Cancer (0.5% increase compared to surgery alone but data is controversial)

  • Surveillance

Erectile Dysfunction / Dry ejaculation

  • Medications
  • Penile Implants
  • Mechanical Devices (ex: tension rings and vacuum pumps)
  • Psychological Counseling

Radiation Cystitis

  • Treatment with HBO can potentially reverse the changes caused by radiation. HBO therapy stimulates angiogenesis, which reverses the vascular changes induced by ionizing radiation. Preservation of bladder function and the noninvasive nature of treatment (30 sessions total) favor its use. Some reports claim 70% response with HBO. However, if significant fibrosis and ischemia have already occurred, HBO therapy does not reverse the changes and only prevents further injury.

Hemorrhagic cystitis

  • Hemorrhagic cystitis is a more serious complication of radiation cystitis. Once all clots have been evacuated and adequate drainage achieved, medical options to control the bleeding include continuous bladder irrigation alone, a 1% alum bladder installation, a 1-10% formalin bladder installation, aminocaproic acid (Amicar) bladder installation, sodium pentosanpolysulphate, HBO therapy, and oral estrogens.

Comparisons of Radical Prostatectomy and EBRT

Surgical Risks

  • Myocardial infarction 0.7%
  • DVT 0.8%
  • Pulmonary Embolism 1%

EBRT risks

  • Seconary Malignancy: questionable 0.5% rectal cancer risk (conflicting studies of SEER data)

Rectum

  • RPRP: rectal injury 0.5%
  • EBRT: grade 2/3 injury 16% with V70 < 25%

Urianry function

  • RPRP: Urinary incontinence 6% (significant incontinence)
  • RPRP: Urinary incontinence 97% (some incontinence)
  • EBRT: <1% Grade 3 urinary toxicity at 81 Gy

Post treatment impotence rates per Robinson meta-analysis (IJROBP 2002)

  • brachytherapy alone 24%
  • brachytherapy + EBRT 40%
  • EBRT 45%
  • nerve-sparing RPRP 66%
  • non-nerve-sparing RPRP 75%
  • Cryosurgery 87%

Institutional Reports of Impotency (Gunderson)

  • with nerve-sparing RPRP 32-41%
  • without nerve-sparing RPRP 100%
  • EBRT 40-50%
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