Prostate cancer treatment options include open or robotic radical prostatectomy, radiation with external beam radiation and/or brachytherapy, also known as radioactive seed implantation, and high intensity focused ultrasound, also called HIFU. Prostate radiation side effects and prostate surgery side effects, in addition to erectile dysfunction, include:
Urinary incontinence in men is generally associated with prior prostate surgery or radiation. Often, the severity of radical prostatectomy incontinence diminishes with time, and may resolve completely. In other cases, including incontinence after radiation, there is continued leakage and treatment options include urinary sphincter surgery such as placement of an AMS 800 artificial urinary sphincter.
Bladder Neck Contracture – Urethral Stricture
Another possible complication is a narrowing of the urethra, and this is generally called urethral stricture disease. However, when the narrowing occurs where the bladder meets the prostate (after radiation) of the urethra (after the prostate is removed), this narrowing and blockage is called a bladder neck contracture. The symptoms of obstruction from a bladder neck contracture or a urethral stricture include a diminished urine flow rate, an intermittent start-stop stream, straining to urinate and a sensation of incomplete emptying.
A less common but very debilitating complication, especially after radiation, is a rectal-urethral fistula. A fistula is an abnormal hole connecting 2 structures that should be separate. A rectal-urethral fistula is a hole connecting the rectum and the prostate. Feces then enters the urinary tract and/or urine enters the rectum. A fistula is suggested by pneumaturia. This refers to air coming from the penis in addition to urine during urination. Alternatively there can be urine output into the rectum or fecal material in the urine. In other cases, urinary tract infections can be the caused by a fistula.
At the Center for Reconstructive Urology, most of our patients are referred by their local Urologists for complex problems and complications after prostate cancer treatment as we are a tertiary referral center for male urethral and penile disorders. We are seeing more patients now than in the past for the treatment of complex recurrent bladder neck contractures in particular after radiation therapy for high intensity focused ultrasound (HIFU) for prostate cancer treatment. We have noticed that websites promoting HIFU treatment suggest “pinpoint accuracy .. without adverse effects to the surrounding tissues”. We do not see patients with successful outcomes and therefore can not determine the complication rate. However, we have seen patients with devastating complications. In these cases, there were impressive debilitating effects to the surrounding tissues (examples can be found in the bladder neck contractures section). A common presentation is a history of radiation therapy or HIFU followed by the development of difficulty with urination along with possible incontinence. A “stricture” is diagnosed and treated (often without prior urethral imaging) with dilation using instruments called urethral sounds and/or surgery through the penis to “scrape out” the tissue causing blockage, only for the blockage to recur. In some cases, the patient is advised to perform self catheterization to keep the urethra open. At that point, the patient and his Urologist feel a more definitive treatment should be considered, and we are consulted.
Although most our our patients have been referred to the Center for Reconstructive Urology by their Urologists in the past, men have been recently contacting our Center with increasing frequency requesting a cure for complex prostate cancer treatment complications such as urethral obstruction after radiation or HIFU. They are under the impression that if they travel to our Center, we can perform surgery to effectively treats their urethral obstruction. It is true that many patients who travel to the Center for Reconstructive Urology for the treatment of strictures unrelated to prostate cancer treatment have urethral imaging and subsequent surgery during the same trip, and the cure rate is extremely high. However, complications of prostate cancer treatment, other than distal strictures related to catheters or instrumentation, are an entirely different and more complex disease process. In some cases, we can restore normal urination. In other cases, urethral reconstruction is not a reasonable option. If you are a man who is suffering from recurrent bladder neck contractures or a very complex and recurrent problem after prostate cancer treatment, we do not want you to have the impression that if you travel to the Center for Reconstructive Urology, we will be able to simply perform a surgery and cure your problem. Our approach is to first perform a complete evaluation of the urethra to determine the exact location and length of the blockage, and the function of the urinary sphincters responsible for continence along with the ability of the bladder to properly store urine and empty during urination. Many patients who contact us do not clearly understand where their blockage is located, or the length of the blockage, or if they have a urethral stricure or a bladder neck contracture. Many patients have been treated without prior imaging and these details may be unknown. Therefore, it iis difficult and often impossible to suggest what can or can not be done before we perform a urethral evaluation. What we can offer with certainly is clarity regarding the specific portions of the urethra affected and the risks and benefits of each treatment option. If we can offer a surgery that will, if successful, restore normal urination, then that is generally the best option. However, if that is not possible or practical, we then explore the possibility of an alternative that is better than the current situation.
Click on the sub-sections to the left to obtain information about the diagnostic evaluation that is indicated prior to treatment, and the options to treat male incontinence, bladder neck contractures, urethral strictures, and rectal-urethral fistulas after radical prostatectomy and/or radiation therapy for prostate cancer.