What are the potential side effects and postoperative considerations of radical prostatectomy, including nerve‑sparing options, for a medically fit man with localized Gleason 7 (3+4 or 4+3) prostate cancer?

Radical Prostatectomy Side Effects for Gleason 7 Prostate Cancer

Primary Side Effects and Complications

Radical prostatectomy for Gleason 7 prostate cancer causes erectile dysfunction in approximately 80% of men and urinary incontinence (leakage) in approximately 49% of men, though these rates may be lower at high-volume surgical centers. 1

Sexual Dysfunction

• Erectile dysfunction occurs in 80% of patients compared to 45% with watchful waiting, representing a 35% absolute increase in risk 1
• Recovery of erectile function is directly related to three factors: age at surgery, preoperative erectile function, and degree of cavernous nerve preservation 1
• Nerve-sparing techniques can be considered for selected patients to preserve erectile function, particularly when preoperative MRI suggests the tumor is confined and does not involve the neurovascular bundles 1
• Nerve grafts to replace resected nerves have not been shown to provide benefit 1
• Early restoration of erections may improve late recovery 1

Urinary Complications

• Urinary incontinence (leakage) occurs in 49% of patients versus 21% with watchful waiting, representing a 28% absolute increase 1
• Incontinence can be reduced by preserving urethral length beyond the prostate apex and avoiding damage to the distal sphincter mechanism 1
• Bladder neck preservation may decrease incontinence risk 1
• Anastomotic strictures increase the risk of long-term incontinence 1
• Patients are discharged with an indwelling urethral catheter for 1-2 weeks to temporarily drain the bladder 1

Perioperative Complications

• Blood loss can be substantial but is reduced by careful control of the dorsal vein complex and periprostatic vessels 1
• Hospital stay is typically 1-3 days for healthy patients; longer for those with significant medical illnesses or complications 1
• Minimally invasive (laparoscopic/robotic) approaches are associated with shorter hospital stays, less blood transfusion need, and fewer surgical complications compared to open surgery 1

Gleason 7-Specific Considerations

Risk Stratification Impact

• Gleason 3+4=7 versus 4+3=7 matters significantly for prognosis and should influence treatment intensity 1
• Bone scintigraphy should be considered if the Gleason score is 4+3 or PSA >10 ng/mL 1
• Intermediate-risk patients (which includes Gleason 7) should have discussion about risk/benefit of lymph node dissection based on nomogram estimates 1

Pathologic Findings and Outcomes

• Among men undergoing radical prostatectomy for Gleason 7 disease, extracapsular extension increases risk of death from prostate cancer 5-fold 2
• Cribriform growth pattern in Gleason grade 4 is a strong adverse prognostic marker, present in 81% of cases with metastasis versus 38% of controls 3
• The 15-year prostate cancer-specific mortality after radical prostatectomy is approximately 12% overall, with only 5% for low-risk patients 1

Quality of Life Considerations

Comparative Morbidity

• Overall quality of life appears similar between radical prostatectomy and radiotherapy, despite differences in specific side effect profiles 4
• These toxicity rates may not be generalizable to high-volume surgical centers where outcomes are typically superior 1
• High-volume surgeons in high-volume centers generally provide better outcomes 1

Long-term Functional Recovery

• Recovery patterns vary significantly by technique (open, laparoscopic, robotic-assisted) and surgeon experience 1
• Minimally invasive approaches show higher rates of incontinence and erectile dysfunction in some registry data, though oncologic outcomes appear comparable 1

Critical Pitfalls to Avoid

Surgical Technique Considerations

• Avoid damage to the distal sphincter mechanism during apical dissection to minimize incontinence 1
• Preserve maximum urethral length beyond the prostate apex 1
• Perform extended pelvic lymph node dissection when indicated (approximately 5-10% risk of nodal metastasis in intermediate-risk disease) 5

Patient Selection

• Radical prostatectomy should be reserved for patients with life expectancy ≥10 years due to perioperative morbidity 1, 5
• For Gleason 3+4=7 with favorable characteristics (PSA ≤10, ≤2 positive cores, PSA density <0.2), active surveillance might be considered in selected patients with comorbidity or shorter life expectancy 6
• Gleason 4+3=7 should not be managed with active surveillance in patients with life expectancy >10 years 7

Postoperative Management

• PSA should become undetectable (<0.2 ng/mL) within 2 months after surgery 5
• Salvage radiotherapy is most effective when initiated early (PSA <0.5 ng/mL) for biochemical recurrence 1, 5
• Adjuvant radiotherapy immediately following radical prostatectomy has not been shown to improve survival or freedom from metastatic disease in unselected patients 1