Incontinent after prostate surgery?

Interview with Dr. Stephan Neubauer and Dr. Pedram Derakhshani from the West German Prostate Center in Cologne

Prostate cancer is still the most common cancer of men. About 58,000 men contract a malignant tumour of the prostate gland every year. If the first shock is halfway over, many men are hit hard once again after surgical removal of the prostate gland: They lose their urine unintentionally and suffer from erectile dysfunction and impotence. We spoke with urologists Dr. Stephan Neubauer and Dr. Pedram Derakhshani from the West German Prostate Center in Cologne about the possible consequences of prostate surgery and alternative treatment options.

What is the risk of incontinence or impotence after prostate cancer surgery?

Dr. Neubauer: Incontinence and impotence after radical removal of the prostate varies depending on the surgical method and the surgeon's experience. However, the figures are very high overall, despite the fact that the techniques are gentle on the nerves. As the German Society of Urology has published in its current guideline for the treatment of prostate cancer, at most one in two patients can no longer hold the urine and 30 to 100 percent lose their erectile function after surgery. 

Does incontinence persist after surgery?

Dr. Derakhshani: In many cases, pelvic floor training or medication can improve the symptoms. However, approximately 10 percent of those who have undergone surgery will continue to suffer from incontinence. The problem of not being able to hold the urine can vary in intensity and ranges from a slight loss of urine and wearing pads to the permanent use of diapers. In any case, however, it significantly impairs the quality of life of those affected. This ranges from general insecurity to the loss of social contacts and activities. Some men don't dare to go on holiday or even leave their flat for a longer period of time. 

And the impotence?

Dr. Neubauer: Nearly three out of four men suffer from impaired postoperative stiffness of the limb, as the vessels and nerves important for erection are injured during the operation. If the erection is no longer possible after the operation, medication or technical methods such as vacuum pumps or injections can help. Impotence after radical prostatectomy, however, not only affects sexual life but may also have effects on the male psyche. 

Is there an alternative to prostate surgery with fewer risks?

Dr. Derakhshani: Yes, absolutely! For a long time, radical surgery was considered the only successful treatment for prostate cancer, despite its serious consequences. However, this has long since become obsolete. A far gentler and yet equally effective method for treating prostate cancer is the radiation of the tumor from the inside, known as brachytherapy. Numerous studies have shown that patients whose tumor is limited to the prostate can achieve the same healing rates with surgery and brachytherapy, with significantly lower side effects.

How does brachytherapy work?

Dr. Neubauer: Under constant ultrasound control, up to 80 short-radiating, very small iodine-based radiation sources ("seeds") are inserted directly into the prostate via the perineum under full or partial anaesthesia. This is done with the help of puncture needles, which are placed at precisely pre-calculated positions in the prostate. The seeds are deposited at the desired position in the prostate, where they remain in order to exert their radiation effect on the prostate carcinoma. The tumor tissue is destroyed from the inside by high-dose, targeted radiation. 

In addition to seed implantation, there is another procedure from brachytherapy known as HDR afterloading for patients who have a more aggressive tumor or a later stage of cancer. Here, an even higher dose of radiation source is briefly introduced into the prostate and focused at precisely calculated points for a certain period of time. This treatment is carried out 2 to 3 times under a short anaesthetic every 1 week and is often combined with external radiation.

Why is brachytherapy the gentler method compared to surgery?

Dr. Derakhshani:"The advantage of brachytherapy is that we can use imaging methods and computer technology to precisely place the radiation dose in the tumor. This completely destroys the tumor without damaging surrounding tissues such as the intestine and urinary bladder. Side effects such as incontinence and impotence are therefore much less common than after radical prostate surgery. 

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