Complications of Prostate Cancer Treatment

1. Complications of Prostate Cancer Treatment David D. Thiel MD Mayo Clinic Florida Department of Urology

2. What about pain? • Pain is not an element of prostate cancer unless there are bone metastasis • Treated with androgen deprivation, steroids, etc

3. Watchful waiting Active surveillance Surgery Retropubic Perineal Robotic Radiation Therapy External beam Brachytherapy Proton Beam Cryotherapy HIFU Cyber knife Androgen deprivation (ADT) Prostate Cancer Options

4. Prostate Cancer Therapy Goals • Eradicate Cancer • Preserve Continence • Prevent Regret • Preserve Erections Quality of Life

5. Quality of life does Matter!!! • HRQOL is #1 concern of men electing therapy for Pca (JUrol 2003) • AUA survey (2000) of 1000 men • 74% of men over 50 are “afraid” to have PSA checked due to possible side effects of Pca treatment. • ITS NOT THE BIOPSY THEY ARE SCARED OF

6. No free lunch • There is no such thing as treatment for prostate cancer that doesn’t have the risk of incontinence and erectile dysfunction

8. “The Trifecta” • The 3 C’s • Cure – Is psa unetectable • Continence • Coitus

9. Continence What is continence? No pads ever Is “insurance pad” continence? “Social continence” Surgical intervention? If no surgery needed, incontinence isnt that bad Return to baseline urinary fx Some studies use AUA score!!!!

10. Continence • Everyone’s true fear • Seldom marketed. Why? • NOT COMMON

12. 3 Types of incontinence • 1. Stress incontinence • Cough and sneeze • 2. Urge incontinence • Cant get there in time • 3. Mixed incontinence

13. Stress Incontinence • Is a sphincter problem • See in all patients following RRP • Occurs following XRT as well

14. Incontinence • All men are incontinent following surgery • Continence must be regained • Incontinence rates following RALP around 1-3% • 7% require an insurance pad

15. Kegel excercises

16. True Trifecta(RALP) • Eliminate high grade disease (G8, 9, 10) and metastatic disease • Eliminate obesity (BMI >35) • Eliminate SHIM score <20 • Eliminate hormones • Eliminate neurologic diagnosis • TRUE TRIFECTA 50-55%

19. Published results on patients achieving and maintaining social continence (significantly improved) after AUS for post prostatectomy incontinence : Gundian et al. 90% J. Urol. 142: 1989 Marks et al. 95% J. Urol. 142: 1989 Perez et al. 85% J. Urol. 148: 1992 Singh et al. 96% BJU 77 : 1992 Litwiller et al. 90% J. Urol. 156: 1996 AUS: Treatment Outcomes

21. Urge Incontinence • More common after radiation • Is a sign of obstruction or bladder irritation • Surgery removes obstruction

22. Is Brachy a Kinder and Gentler Option? • “Brachytherapy is the most convenient treatment and has lowest rates of long-term complications compared to RRP or XRT” - Grills, et al. (William Beaumont Hospital) J Urol 2003

23. Table 6

24. Grade 2 Toxicity Refresher • Dysuria – relieved with medication • Incontinence – some control • Hesitancy requiring I/O cath or indwelling catheter • Urgency – Increased but not more than once an hour • Hematuria not requiring tranfusion

25. Table 7

26. Grade 2 Toxicity Refresher • Diarrhea – 4- 6 stools per day. Not incontinent of stool • Rectal Pain – Pain requiring analgesics that does not interfere with quality of life • Rectal Bleeding – Requires medication but not transfusion

27. Incontinence following radiation(Urge and/or stress) • Also operator dependent • Seeds in wrong place (brachytherapy) • Radiate wrong place (XRT)

28. Urinary bother after radiation • Alpha blocker therapy • Flomax, Rapaflow, Uroxatrol, etc. • Anticholenergic Therapy • Detrol, Enabelex, Ditropan, etc • O2 Chamber

29. Worse-case scenario • Urinary diversion • Stool diversion • Double bag

30. RUG

31. Devasting Comlications

36. The best treatment for Radiation Induced voiding dysfunction • PREVENTION • Avoid big prostates • Avoid those with urinary bother • Avoid those with inflammatory bowel disease (rectal bother) • Avoid those with high residuals • Avoid those with “prostatitis”

37. Erections“The soul of man” • The biggest misconceptions • The biggest marketing target • The only reason men make bad choices • In life • AND in prostate cancer

38. Marketing“Guaranteed erections” • HIFU • Selective cryotherapy • Gamma knife • All pray on the “super-educated” • Too smart for their own good

39. Significant VariablesP value Age 0.0008 Full potency preoperatively 0.0039 Neurovascular bundle (NVB) status 0.0204 Surgical technique (pre- and post-1993) 0.0001 Not Statistically Significant Variables Pathological stage 0.1279 Tumor volume 0.1483 Preoperative prostate-specific antigen 0.3336 UICC stage 0.5605 Surgical margins 0.7534 Defining ED in the Setting of Radical Prostatectomy Multivariate Analysis: Clinical and Pathologic Factors • UICC=Union Internationale Contre le Cancer. • Quinlan et al J Urol 1991; 145(5):998. • Rabbani, Stapleton, Scardino. J Urol 164:1929, 2000.

42. Erectile DysfunctionOne Pitfall After Another • What is potency? (PDE5 use, etc.) • When is potency defined? (1 day vs 18 mos, etc.) • How is potency assesed? • Who is reporting the potency? (Marketing of technology)

43. Sexual Dysfunctions Following Radical Prostatectomy • Changes in penile morphometry • Penile length alterations • Penile curvature • Anejaculation • Changes in Orgasmic function • Anorgasmia • Dysorgasmia (pain) • Increased intensity • Climacturia (sex specific urine leakage) • Erectile Function • Complete ED • Partial erections • Change in pharmacologic responsivity

44. Quality of Life Depends on Prostate Cancer Procedure Brachytherapy Prostatectomy Radiotherapy 100 100 100 Radiotherapy alone Brachytherapy alone Nerve-sparing Radiotherapy plus NHT 80 80 Brachytherapy plusradiotherapy, NHT, or both Non-nerve-sparing 80 † † † † 60 60 * * 60 * * * Sexual Score Sexual Score Sexual Score 40 40 * 40 * * * 20 20 20 * * * * * * * * * * 0 0 0 0 2 6 12 24 0 2 6 12 24 0 2 6 12 24 Follow-up(months) Follow-up(months) Follow-up (months) N=1201 *P<0.01 †Significant, but below the threshold of clinical relevance NHT = neoadjuvant hormone therapy Scores based on the Expanded Prostate Cancer Index Composite (0-100) Sanda MG, et al. N Engl J Med. 2008;358:1250-1261.

45. Percentage of Prostatectomy Patients Reporting Specific Levels of Distress 100 90 80 70 60 50 40 30 20 10 0 Baseline 2 Months 6 Months Poor erections Difficulty with orgasm % Erections not firm Erections not reliable Poor sexual function Overall sexuality problem 24 Months Adapted from Sanda MG et al. N Engl J Med. 2008;358:1250-1261.

46. ED Before Prostatectomy Over 50% of men undergoing RP will already have ED Comorbidities 30%-40%: HBP 25%-35%: HL 5%-10%: DM 20%-30%: Smoking 30%-40%: Obesity 1.00 0.90 0.80 0.70 0.60 Complete Moderate 0.50 Minimal 0.40 None 0.30 0.20 0.10 0.00 40 45 50 55 60 65 70 Association of age with probability of impotence in MMAS Probability Feldman HA et al. J Urol. 1994;151:54-61. Johannes CB et al. J Urol. 2000;163:460-463.

47. Recovery of Erections According to Preoperative Sexual Functioning Rabbani F, et al. J Urol. 2000;164:1929-1934.

48. My line • Radiation is better up front for erections • Surgery data catches up at 3 years • “At 3 years, there is not going to be a statistical difference”

49. Erectile Rehabilitation • “Use it or loose it” • “Does surgery or radiation shrink the penis” • Knee replacement analogy

50. What Choices Do We Have for Rehabilitation During the Period of Profound Neurapraxia after NSRP?