Quality of Life

Quality of Life

All prostate cancer treatments and their outcomes demand integration with the patient’s quality of life after treatment.
Quality of life (QOL) issues represent the subjective interpretation of expectations for well being by the patient (not the surgeon’s) and after prostate cancer treatment this is all about how a man and his wife or partner handle the residual adverse effects from his treatment.

Although all of the treatment options for localized prostate cancer (HIFU, cryoablation,radiation options,conventional surgery,robotic surgery, as well as active surveillance) have associated complications (see table 1 ) it is the following list of four from that table that have the most miserable lasting effects on a man and his partner. These four distinctly unfavorable effects are more common after surgery and especially after robotic surgery.

IMPOTENCE unable to engage in effective sexual activity.

SHORTENED PENIS embarrassing if not well endowed to begin with

INCONTINENCE the need to wear pads and or diapers

RESIDUAL CANCER or POSITIVE MARGINS cancer remaining after surgery and usually requiring additional treatment

The first two complications of impotence and shortened penis have the biggest impact on manhood and self esteem. The following two complications of incontinence and residual cancer are commonly associated with the first two complications. It is therefore quite easy to understand why a man can feel completely crushed after first getting a diagnosis of prostate cancer and then being left with several woeful complications after surgery that make him feel like the treatment was worse than the disease.
That these four complications are more common after surgery is hardly surprising when you understand that the surgical removal of the prostate (no matter how technologically advanced the procedure) still requires the division of the prostatic apex from the very intricate urinary sphincter that controls urination and the delicate adjacent nerves that effect erections.

How any man is continent and potent after this procedure is absolutely amazing to say the least and to imply that “reconstruction” with continence and “nerve sparing” to preserve erections are usually achieved, is overtly disingenuous. Similarly hollow is suggesting that after surgery many of these men can get additional improvement in their non existent or weak erections and incomplete urinary control by participating in post operative “penile rehabilitation” clinics as well as adopting Kegel’s exercises and bio feedback programs. Some men afflicted with these complications will choose to suffer their impotence and incontinence in silence because they feel intensely embarrassed. Some men may go on to choose additional surgical options to try and resolve their impotence and incontinence in a desperate attempt to resurrect their self esteem.

Another taxing issue common after surgery (and robotic surgery) is that of having a shortened penis. This adverse effect is also hardly surprising in that 2″ or so of prostate are removed during it’s extrication and then the urethra joined to the bladder neck. There are no reliable remedies for curing this shortcoming.

The coup de grace for guaranteed misery after surgical removal of a man’s prostate is finding out that he still has residual cancer left in the pelvis at the margins of where the prostate was excised (if you had this surgery check your pathology report). This problem occurs in about 20-40% of all men having surgery for prostate cancer (may also suggest inappropriate patient selection) and will usually require additional treatment. So,in summary,many of these men who have undergone surgery for prostate cancer, will still have residual prostate cancer as well as also having a good chance of incontinence,impotence and a shortened penis. No wonder a man and his wife’s QOL are commonly miserable after selecting surgery for treating his prostate cancer.

Nowadays, the first place most people turn to for information on their disease and treatment is the web. However,it can be a difficult exercise to sort out what is truthful for QOL issues associated with the various treatment options for localized prostate cancer. Even most urology textbooks fail to discuss QOL issues after the various treatments for prostate cancer. Disappointingly,there are few really unbiased studies reporting on complications associated with localized prostate cancer treatments and even fewer long term studies reporting on QOL issues after surgery and especially after robotic surgery.

In addition,many of the studies reporting on complications after prostate cancer surgery are misleading and irrational with the use of unusual and self serving definitions of impotence and incontinence eg incontinence defined as “using more than one pad per day”.Finally,few studies have been taken out long enough to really assess QOL issues on a man and his partner as satisfaction of outcomes often worsens over time.

Since most treatment options for localized prostate cancer (listed earlier at start) appear to have similar SURVIVAL BENEFITS,it behooves a man and his wife to do their homework together and attempt to critically examine the information on the web (as well as the material provided by your doctor) for the adverse effects of your PROPOSED treatment and especially after robotic surgery was suggested. Although there is a distinct lack of veracity in many of the studies and advertisements you will be exposed to,one should be able to mine the web and get sufficient circumstantial evidence from a variety of sites and be able to get a more creditable impression of treatment risks and benefits for the different treatment options. These sites should include those detailing surgery, radiation options and focal therapy options such as cryoablation and HIFU. Focal therapy sites should provide also, additional information on the current use of techniques that enhance potency and continence. Cryoablation and HIFU reports should outline the special precautions undertaken to preserve one or both neurovascular bundles for maintaining erectile function in addition to maintaining integrity of the sphincter for urinary control. With HIFU,the neurovascular bundles can be identified with Doppler ultrasound and spared while during cryoablation, extra warming probes can be placed along the posterolateral margins of the prostate to prevent one or both neurovascular bundles from freezing.

With similar survival benefits for the various treatment options for localized prostate cancer,your treatment choice for prostate cancer does not have to come at the expense of your QOL after treatment. No man wants to compromise his manhood and suffer with impotence as well as having a shortened penis and then further aggravated with urinary incontinence. Being denied normal sexual activity and having to wear a pad or diaper are absolutely wretched complications that often bring about low self esteem and a poor QOL score and are more commonly seen after surgery and robotic surgery for prostate cancer. In fact,one European study suggested that about 20% of all men who had undergone robotic surgical removal of his prostate for cancer had regretted his decision for surgery. The results of this study simply underscore the fact that technological advances do not necessarily lead to less complications and improved QOL outcomes and men who opt for this surgery should temper their expectations for better results. That these expectations for superior QOL were not realized by many men who underwent surgical removal suggests that the surgical technique and or patient selection warrant further review and refinement. A review that demands focus on QOL issues so regrets like those expressed below will become regrets of the past.

“that surgery was the worst decision of my life”

“surgery changed my life forever,in a bad way”

“I am still wearing pads 10 years after my surgery. Not only that but I had no more erections, got a penile prosthesis and eventually got divorced”

or read the “I want my prostate back” article in the March 2010 article in MensHealth.

Getting a diagnosis of cancer usually leaves a patient stunned and in disbelief and most probably emotionally vulnerable making him more easily steered towards certain treatment choices by his surgeons. Therefore,if the true incidence of impotence and incontinence have not been clearly detailed to the patient as well as its effects on QOL it is easy to see why men often feel misled about the benefits of surgery for prostate cancer and regret their choice for this treatment. In fact,of all the different surgical procedures we do in urology,hands down,the one operation associated with the highest incidence of regret is the surgery (including robotic) for prostate cancer removal. Even those who had the procedure performed in high volume institutions can express regret about their outcomes from this surgery.

The total care and medical support of a patient with cancer encompasses not just the treatment option for his cancer but also the TOTAL care for ALL the stages of the treatment process in the journey forward. These stages of the whole treatment process include the emotional issues after receiving the diagnosis of cancer,the subsequent imaging investigations and staging,his own research on his disease including getting second and possibly third opinions,choosing a treatment as well as choosing a surgeon,recovering post surgery/treatment,rehabilitation,dealing with possible complications and additional costs for their correction,psychosocial issues (including those of your spouse), follow up and more evaluations as well as dealing with fears of possible recurrence.

Every patient has a right to expect not only the best survival benefits from his proposed cancer treatment but also the very best QOL outlook (discussed with honesty by the physician) for him and his partner. Long term blinded QOL studies in men after treatment for localized prostate cancer (and especially so after robotic prostatectomy) are sorely overdue. That this is overdue is evidenced by the frequency of QOL complaints after surgery. Therefore, the concern that men are being mislead about true QOL results from prostate surgery as compared to the QOL results of current focal therapy options and even radiation options, appears fairly evident.

TABLE I

Possible complications associated with Prostate Cancer Treatment

The following list of complications is more common after SURGERY for prostate cancer

IMMEDIATE

blood loss

rectal injury

recto urethral fistula

ureteral injury

mortality

PERIOPERATIVE

deep vein thrombosis (DVT)

pulmonary embolus (PE)

lymphocele

urinary anastomosis leak

residual cancer at margins

LATE

urinary incontinence

impotence

shortened penis

bladder neck contracture

membranous urethral stricture

hernia

urinary tract infection

epididymitis

orchitis

radiation cystitis

radiation proctitis

irritable bowel

irritable bladder

fecal incontinence

fatigue

psychosocial issues

possible slight risk for rectal/bladder cancer after radiation

cancer recurrence