Choosing between Radiotherapy and Surgery
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 prostatic cancer. The object of both is to cure the disease. However, there are pros and cons to each one.
Surgical Options and It’s Side-Effects:
1 – Erectile Dysfunction
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. That can occur even when we spare the nerves. These are the nerves which travel right alongside back of the prostate and 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. This can be either temporary or even permanent. This can then lead to erectile dysfunction. 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.
2 – Urinary Incontinence
So if we’re going to do surgery and not radiotherapy, 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. Because erectile dysfunction is very common it needs to be fully understood by the patient before they make any decisions. Another potential complication of radical prostatectomy is urinary incontinence.
Almost all men after having surgery will initially have a degree of leakage of urine or urinary incontinence. However, at least 90% of men will eventually regain full control of their bladder. This means that they don’t need to wear any pads at all. However, that can take weeks, sometimes it can even take months. So there’s gonna be a period where that man is gonna have to wear pads and do pelvic floor exercises. These exercises will help to accelerate the recovery of their bladder control.
So these are really the two main risk factors, or complications, that can occur with radical prostatectomy.
Radiotherapy Option and It’s Side-Effects:
1 – Erectile Dysfunction is Possible but Not Always
Now, there are different side effect profiles between surgery and radiotherapy. If we compare it to brachytherapy, which is implantation of radioactive seeds, actually there are some similarities. This includes there being 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. However, that dose might also affect the erectile nerves and so erectile dysfunction is very common as well.
2. Lowered risk of Urinary Incontinence
Urinary incontinence, though, 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 boarders of the prostate, it can affect the surrounding organs. We’ve talked about the erectile nerves, but it can also affect the bladder base.
3 – Increased Risk Bowel Weakness
As a result of this affect you can get what’s called radiation cystitis, or radiation inflammation of the bladder and that can cause irritation of the bladder. This irritation 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. There is now available longterm or longitudinal quality of life data that demonstrates that and similarly for the bowel. Because 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. Again this can lead to urgency and frequency of opening one’s bowels. Lastly, 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 two options he’s likely to be able to tolerate better.
Associate Professor Dr. Jeremy Grummet – Urological surgeon and Director of Clinical Research in Urology at Alfred Health. Member of Australian Urology Associates private practice group