Dr Jeremy Grummet, Urological Surgeon
Choosing between surgery or radiotherapy can be a very difficult process for patients. Both of them are recognised as very viable options for treatment of localised prostate cancer and the object of both is to cure the disease, but there are pros and cons of each.
So, for example, if we talk about the surgical option and removal of the prostate, one of the commonest side effects of that is erectile dysfunction, and that’s even when we spare the nerves. So there are nerves which travel right alongside the back of the prostate which actually supply the penis with erectile function.
When you remove the prostate those nerves can get damaged. Even if we make a special effort to preserve those nerves, because they’re so fragile they can still have damage, either temporary or even permanent, which can lead to erectile dysfunction and if a man is in his middle age and is very sexually active, that can obviously be a real impact on his quality of life.
So if we’re going to do surgery, we need to be pretty sure, or very confident, that this surgery really needs to happen in order to improve that man’s outcome in terms of prostate cancer. So erectile dysfunction is very common and needs to be fully understood by the patient before they make any decisions.
Another potential complication of radical prostatectomy is urinary incontinence. In fact, almost all men initially after having surgery will have a degree of leakage of urine or urinary incontinence. However, at least 90 per cent of men will eventually regain full control of their bladder such that they don’t need to wear any pads at all. But that can take weeks, sometimes it can even take months. So there’s going to be a period where that man is going to have to wear pads and do pelvic floor exercises to accelerate that recovery of their bladder control. So they’re really the 2 main risk factors, or sorry, complications that can occur with radical prostatectomy.
So there are different side effect profiles between that and radiotherapy. If we compare it to say brachytherapy, which is implantation of radioactive seeds, actually there are some similarities in as much as there is a risk of erectile dysfunction, particularly for tumours that are occurring around the posterior aspect of the prostate, which is right alongside the nerve. A good dose of radiotherapy is going to be required in that area in order to kill the cancer cells, but that dose might also affect the erectile nerves and so erectile dysfunction is very common as well. Urinary incontinence, however, is less. That’s a clear advantage of radiotherapy because you’re not actually affecting the sphincter, which is the circular muscle which actually controls continence.
However, one of the disadvantages of brachytherapy is because radiation can spread outside the borders of the prostate, it can affect the surrounding organs. We’ve talked about the erectile nerves, but it can also affect the bladder base and as a result of that you can get what’s called radiation cystitis, or radiation inflammation of the bladder and that can cause irritation of the bladder, which then leads to urgency and frequency of urination.
Now whilst that’s not a common side effect, if it occurs it can be quite impactful in terms of quality of life and we’ve got longterm or longitudinal quality of life data that demonstrates that and similarly for the bowel. So the prostate sits right in front of the rectum and, therefore, that front wall of the rectum can also potentially receive a dose of radiotherapy, or radiation. As a result, you can get radiation proctitis, or inflammation of the rectum, due to radiation, and again that can lead to urgency and frequency of opening one’s bowels. You can also have, occasionally, bleeding from either the bowel or the bladder from that. So the patient has to weigh up in his mind which of these 2 options he’s likely to be able to tolerate better.