1. Q: Is frequent urination normal after a radical prostatectomy?
A: Yes, but it’s usually only a matter of time before urination returns to normal. Bladder capacity is usually reduced somewhat by the surgery, but the main cause is that, after surgery; the bladder wall is swollen and thickened and irritable. Normally, the bladder wall is thin and elastic and maintains a low pressure until it has stored 8 to 10 ounces of urine. After surgery, the swollen bladder does not store much urine at a low pressure. As soon as it starts to fill, the pressure goes up and you feel the need to urinate. In the great majority of cases, this situation gradually improves with time, but it can take more than a year in some cases. Some patients are left with a smaller capacity bladder because scar tissue limits the elasticity of the bladder. Medications that sometimes help are Ditropan and Detral, but since these medicines work by “quieting” the bladder’s irritability, they do not solve the underlying problem: It takes time for swelling to subside and for scar tissue to stretch. Avoiding diuretics such as alcohol and caffeine diminishes the symptoms. The situation is worse at night, because after surgery, some fluid that is retained in the lower half of the body during the day gets redistributed at night and is excreted by the kidneys at night. This phenomenon of making more urine at night is called “nocturnal polyuria.”
2. Q: I understand that scar tissue can form after a radical prostatectomy and cause urinary flow problems. What are the symptoms of such scar tissue formation and what are the possible treatments?
A: Scar tissue can form between the bladder and urethra. The symptoms usually include a slow urinary stream, increased urinary frequency, painful urination, or urinary retention. Treatment includes dilation (stretching the tissue under anesthesia with an instrument that is passed up the urethra). In severe cases, it may require cutting the scar tissue away (under anesthesia) and injection of a cortisone-like drug.
3. Q: How do injections work to make the sphincter muscle stronger after a RRP? And are there medications which do the same thing?
A: The sphincter muscle produces continence after a radical prostatectomy. When the walls of the urethra are drawn together by the sphincter muscle, a watertight seal is created. Kegel exercises work by strengthening the muscle and increasing its bulk. Sometimes, injections of a liquid protein called collagen can provide the necessary bulk to approximate the walls of the urethra (about 25 % chance). For men whose incontinence is due to an overactive bladder, bladder-relaxing medications can help in most instances.
4. Q: Please describe the proper way to do kegel exercises after a RRP?
A: Kegel exercises work by increasing the bulk and strength of the one remaining sphincter muscle. There are disagreements about what is the “proper” way. We like to have patients do Kegel exercises by imagining that they are urinating and then contracting the muscles to “cut off” the stream. They should hold for only a second or two. Then they should let the muscle rest for 5-10 seconds and repeat the contraction. We advise patients to do a set of 10 contractions four times a day – usually at breakfast, lunch, dinner, and bedtime. This schedule allows the muscles to rest between exercise periods so the muscles do not remain in a fatigued state. In addition, we like patients to actually stop the urinary stream once or twice when urinating to determine whether they are contracting the right muscles. If the stream stops, they are contracting the right muscles. Taken together, this schedule leads to about 50 contractions per day. The exercise will strengthen the muscles if done faithfully. More than 50 contractions may be too much and may leave the muscles fatigued – resulting in worse continence.
5. Q: Is there any benefit beginning Kegel exercises prior to radical prostatectomy?
A: The short answer is “yes.”We believe that it will pay dividends to strengthen the muscles before surgery. 6. Q: How much bladder control can I expect to have after a RRP and is it going to change with time? A: With an experienced surgeon, about 92% of patients regain normal control. Although some patients continue to have improvement in continence for up to 18 months after surgery, if a man has not gained any control whatever after 6 months, it is unlikely that he will spontaneously achieve complete control. The actual recovery time varies from immediately after the catheter is removed to about 18 months, at which point it is about as good as it is going to be. Sometimes it can take months for the sphincter muscle to become strong enough to control urination. Kegel/sphincter exercises are important for restoring continence. Of the remaining 8% of men who have not regained normal control, most have mild stress incontinence that requires minimal protection (a pad). Only 1-2% have severe incontinence that a procedure to tighten the sphincter or artificial sphincter implantation.
7. Q: What is the recommended time period for removal of the catheter after a RRP?
A: Different surgeons have different recommended times. In our practice, if the bladder and urethra come together nicely, without any tension, the catheter can be removed after one full week. If some tension is pulling the bladder down to the urethral stump, the catheter remains in place for 10 days. If it is difficult to approximate the bladder neck to the urethra, the catheter must remain for two weeks or more. The main concern about early removal is that there could be edema (swelling) at the junction of the bladder and urethra that obstructs the flow of urine, and it might be necessary to replace the catheter. Another possible concern would be that if the anastomosis (junction between the bladder and urethra) is not healed, there could be leakage of urine at the time of urination.
8. Q: What is your opinion on the polypropylene sling of the bulbar urethra for post-radical prostatectomy incontinence and erectile dysfunction? And which specialist performs this procedure?
A: It works in some cases to correct urinary incontinence, but the result is not always durable. It does not correct sexual dysfunction. A urologist who specializes in post-prostatectomy incontinence usually performs this procedure.
9. Q: Please provide me with literature available regarding the implantation of an artificial urinary sphincter
A: We recommend that you search on the internet for American Medical Systems, the company that manufactures the artificial sphincters (http://www.visitams.com/). The artificial sphincter consists of: a cuff that wraps around the urethra, a pressurized reservoir that holds the hydrolic fluid and a pump that allows the cuff to inflate and deflate so the urine can start and stop. We think it is a great solution for men with severe urinary incontinence, but I would advise this procedure be performed by a doctor who specializes in incontinence surgery.
10. Q: Could you please explain how injections work to make the sphincter muscle stronger after a RRP? And are there medications which do the same thing?
A:The sphincter muscle produces continence after radical prostatectomy. When the walls of the urethral are drawn together by the sphincter muscle, a water-tight seal is created. Kegel exercises work by strengthening the muscle and increasing its bulk. Sometimes, injections of a liquid protein called collagen can provide the necessary bulk to approximate the walls of the urethra (about 25% chance). For men whose incontinence is due to an overactive bladder, bladder relaxing medications can help in most instances.
11. Q: After my RRP, I have had problems with urine blockage. I have had my catheter replaced four times. Each time I could urinate on my own for a couple of days, and then the blockage started again. What are the possible causes of this problem?
A: One of the complications that can occur after radical prostatectomy is the formation of scar tissue between the bladder and the urethra. (When the prostate is removed, the bladder and the urethra must be connected, sewn together, to fill the empty space.) Mild scarring can be treated by simply replacing the catheter for a few more days to allow the healing to become more complete. Slightly more severe cases can be treated by the doctor dilating the stricture or scars with a dilating instrument. More severe cases require the patient to perform intermittent self catheterization to keep the stricture open. Even more severe cases require the scar tissue to be incised by a procedure that is performed through a scope with the patient under anesthesia. Usually, a catheter is left in place for several days after this procedure. The most severe cases require the scar tissue to be trimmed out with a resectoscope (a scope designed to remove tissue). When this procedure is performed, it is often helpful to inject a cortisone-like medication into the scar tissue to prevent another stricture from re-forming. The bottom line is that this problem can be fixed, but it sometimes takes patience on the part of the patient and the doctor alike.
12. Q: My Husband had a radical prostectomey 6 months ago. He has not gained any control of his bladder. Are there specialists who could help?
A: Although some patients continue to have improvement in continence for up to 18 months after surgery, if he has no control whatever 6 months after surgery, it is unlikely that he will spontaneously achieve complete control. We would recommend that he have another operation for the implantation of an artificial urinary sphincter. It will dramatically improve his life. Your husband should go to an expert who specializes in this type of reconstructive surgery.
OTHER QUESTIONS FOLLOWING RRP SURGERY
1. Q: Is it normal for a patient to feel anxious or depressed after prostate cancer surgery?
A: Yes, it is human nature. Being diagnosed with cancer is traumatic and nobody can appreciate it fully unless they have experienced it first hand. First, it is stressful just learning that you need a prostate biopsy. Then, it comes as a blow when you learn the biopsy shows prostate cancer. Then the patient has in sequence: the metastatic workup (finding out if the cancer has spread beyond the prostate), the decision about treatment, the logistics of planning surgery, the wait before surgery, the operation itself with its attendant postoperative discomfort. After all this stress and anxiety, it’s natural for a man to feel emotionally traumatized. However, these feelings pass with time, and men resume their regular activities and lives.
2. Q: What are some of the side effects from removing a prostate?
A: The two most feared side effects of total prostate removal (radical prostatectomy) are permanent impotency (loss of erections) and permanent urinary incontinence. These side effects can occur but, in fact, seldom do with an experienced surgeon. But, they can also occur, regardless of the surgeon. Other more common side effects are as follows: Sometimes, the bladder capacity is smaller after prostate removal and, therefore, urination is more frequent. Some patients have urgent urination if they try to hold it too long. Other possible problems are scar tissue formation (stricture) between the bladder and urethra that causes blockage of the urinary stream. Sometimes it is detected years after the operation. Also, after total removal of the prostate, there is little, if any, ejaculate, although there is the sensation of climax and orgasm. In many patients, there is retraction of the penis that gives the appearance of shortening; however, with return of erections, this retraction diminishes.
3. Q: After a radical prostatectomy, my erections came back but not quite as good as before the surgery. I tried making love without a firm erection and now my penis bends to the right when erect. Will the peyronies ever go away?
A: Normally, all of the tissues of the penis are elastic and during erection, they expand equally in all directions. In men who have vigorous intercourse without a firm erection, the tissues can be injured. This injury causes minor bleeding into the tissues and results in scar formation. Initially, the scar is not as elastic as the normal tissues, so it does not elongate with an erection. This situation causes curvature. With time, scar tissue gradually matures and becomes more elastic. Therefore, Peyronie’s disease usually improves very gradually over several years. Often, though, it does not return to complete normalcy, but it can become much better. It is important to avoid repeated injury to the penis, taking care to have sufficient lubrication. To the extent that Viagra-like drugs create more rigid erections, their use is also helpful.
4. Q: Am I fertile or infertile after a radical prostatectomy?
A: Following a successful, nerve-sparing radical prostatectomy, most men will have return of erections but will not be able to have children by natural means. There should be no seminal fluid after the prostatectomy, so they will be “infertile” by natural means but with in vitro fertilization techniques, it is still possible for a man to father a child after a radical prostatectomy. Storing sperm in a sperm bank before the operation is a recommended procedure for those men hoping to father children after the operation.
5. Q: Can swelling in the groin area be a result of a radical prostatectomy?
A: This swelling could be related to lymph node dissection, which sometimes causes swelling in the groin, penis, scrotum, and pubic area. In such circumstances, we recommend a visit to the surgeon and perhaps a CT scan of the abdomen and pelvic region.
6. Q: After my surgery, it seems as if my penis is drawn up most of the time. Is it normal?
A: Yes. After the prostate has been removed, there is a gap between the bladder neck and the urethra that has to be bridged. In some men, the bladder is mobile and easily reaches the urethral stump. In this case, there is little retraction of the penis. In other cases, it is a “stretch” to pull the bladder and urethra together, and the penis gets “pulled up” inside. With time and return of regular erections, this retraction often corrects itself, which is why I encourage men to have erections naturally or artificially, early and regularly after a radical prostatectomy.
7. Q: What is the frequency of treatment-related complications from a radical prostatectomy?
A: We can speak to our overall rates of treatment-related complications, which are 7%. An overall complication rate of 7% is considered very low. Our continence rate are over 90%, and for men in their 40s and 50s is 95%. For the others, almost all have what we call “normal” female continence; that is, when they cough or sneeze, they lose a few drops of urine. In those instances, they wear a light pad in their underwear. Our overall potency rate is 60%, also excellent considering that we include a group of men in their 50s through 80s. The results are 85-95% for men in their 40s and 50s but only 50% for men in their 70s. If a man is facing the decision about possibly not treating a potentially lethal cancer or facing a zero risk of dying from the operation, the odds related to the prostatectomy look pretty good.
8. Q: What does it mean when my pathology report after an RRP said: No cancer in the lymph nodes or seminal vessels with clean specimen margins but extensive perineural and perivascular invasion? Are these findings a reason to worry?
A: All the reports are good. Perineural invasion is present in all radical prostatectomy specimens. Small nerve fibers in the prostate gland secrete a growth factor that attracts prostate cancer cells, so when pathologists look at sections of the prostate gland, they frequently see the tumor cells surrounding the nerve fibers. This is called perineural invasion. Perivascular invasion does not have much significance unless tumor cells are seen inside blood vessels or lymphatic channels, in which case it means there is a greater chance of recurrence of cancer and a greater likelihood that the cancer might spread to lymph nodes or distant sites.
9. Q: Since my radical prostatectomy two years ago, I’ve had several PSA tests with no indication of recurrence. I have been getting these about every 8 months. But I have not had a follow- up digital rectal exam and you indicated it was important. Why is it important?
A:Some low-PSA producing cells in some prostate cancers (usually high Gleason grade or neuroendocrine elements) can cause a recurrence of the cancer without elevating the PSA level early on. These recurrences can sometimes be detected as a small BB-like lump on the rectal examination. It is important to detect them early so they can be treated early, usually with radiation therapy. Although these occurrences are rare, they are important to diagnose as early as possible. In addition, an annual rectal examination is also a screen for rectal cancer. Perivascular invasion does not have much significance unless tumor cells are seen inside blood vessels or lymphatic channels, in which case it means there is a greater chance of recurrence of cancer and a greater likelihood that the cancer might spread to lymph nodes or distant sites.
10. Q: I had an RRP 21 months ago followed up by radiation 3 months later. Now, I need a colonoscopy. I’ve heard that radiation weakens the colon’s wall and that a colonoscopy can be dangerous if you’ve had radiation to the prostate bed. If so, should I get a virtual (non-invasive) colonoscopy?
A:In our opinion, it is safe to have colonoscopy as early as 3 to 6 months after prostatectomy and/or radiation therapy. But if polyps have to be removed, then there is an increased risk for poor healing and the development of a fistula so it is essential to advise the GI doctor that you have had radiotherapy. It should be obvious to the doctor, though, because radiation usually induces changes in the appearance of the colon that are characteristic for prior radiotherapy.
11. Q: I had a radical prostectomy 12 months ago. It was a small cancer and my current PSA reading has been .1 the last two checkups. I have now been diagnosed with low testosterone.
What is your opinion of testosterone replacement therapy?
A:Testosterone replacement therapy should be used with caution. If there are any cancer cells remaining in your body, testosterone replacement therapy could stimulate their growth. However, if you wish to take the risk, you should monitor your PSA monthly for at least 6 months, in my opinion.