Presented at the 4th Urological Research Forum, 28–30 January 2000, Okinawa, Japan.
Correspondence: Yoichi Arai MD, Department of Urology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki 710, Japan. Email: email@example.com
Abstract In recent years, increased screening for prostate cancer, primarily with prostate-specific antigen testing, has led to an apparent increase in the incidence of prostate cancer and resulted in a shift to an earlier patient age and tumor stage at diagnosis. From the early 1980s, there have been great advances in surgical technique. In the 1990s, radical prostatectomy gained popularity among Japanese urologists. Time trends and morbidity of contemporary anatomical radical prostatectomy in Japan are reported here. In addition, the quality of life in men undergoing radical prostatectomy is discussed.
The incidence rate of prostate cancer in Asia has been reported to be the lowest among many ethnic groups.1,2 In Japan, the estimated number of deaths from pros-tate cancer is relatively low, but has constantly increased from 1736 in 1980 to 6006 in 1996.2 The age-adjusted death rate per 100 000 people almost doubled (from 4.4 to 8.2) during the same period. In 1996, prostate cancer was the ninth leading cause of cancer death among Japanese men. In recent years, increased screening for prostate cancer, primarily with prostate-specific antigen (PSA) testing, has led to an apparent increase in the incidence of prostate cancer and resulted in a shift to an earlier age and stage at diagnosis.
From the early 1980s, there have been great advances in surgical technique: the anatomical approach by Walsh, the bunching technique by Myers and various continence-sparing procedures.3 In the 1990s, radical prostatectomy gained popularity among Japanese urologists. The most recent technique, laparoscopy, has been developed by French urologists. Time trends and morbidity of contemporary anatomical radical prostatectomy in Japan are reported here. Next, the quality of life in men undergoing radical prostatectomy is discussed.
Time trends and morbidity
Reports in English-language literature suggest varying complications and death rates from radical prostatectomy.4 Independent knowledge of the true complications of a contemporary series of anatomical radical prostatectomies is essential, especially when decision analytic models are to be applied effectively to the problem of managing early stage prostate cancer in different countries. I recently evaluated the time trends and morbidity of contemporary anatomical radical retropubic prostatectomy in a multi-institutional study in Japan. The records of more than 600 patients, who had undergone radical retropubic prostatectomy at 7 urologic centers between January 1991 and August 1998, were reviewed.
The number of radical prostatectomies performed dramatically increased more than sevenfold from the first year (1991–1992) to the most recent year (1996–1997), mainly due to an increase in the number of patients in their 60s. The contribution of T1c disease increased in absolute terms as well as relative terms, rising from 14% in 1991 to 51% in 1998 (Fig. 1). Over time, the average blood loss and the allogeneic transfusion rate decreased steadily. There was a trend toward more favorable outcomes for pathologic parameters (increased percentage of organ-confined disease, decreased margin positivity and decreased incidence of positive lymph node metastasis; Fig. 2). Data from the morbidity assessment are displayed in Tables 1 and 2.
Table 1. Perioperative complications in 638 patients undergoing radical prostatectomy
Major vessel injury
Obturator nerve injury
Prolonged lymph drainage
Pelvic abscess or hematoma
Urinary tract infection
Impaired renal function
Table 2. Cardiopulmonary complications in 638 patients undergoing radical prostatectomy
Deep venous thrombosis
Transient cerebral ischemic attack
Lower extremity artery occlusion
Death within 30 days (cerebral hemorrhage)
Intraoperative complications were noted in 3.8% (3.0% rectal injury); intraoperative complications other than rectal injury were rare. The most common surgical complications were wound-related ones (7.5%) and anastomotic leakage (4.1%).
Major cardiopulmonary complications occurred in only two patients (0.3%): two pulmonary embolisms. One patient died of cerebral hemorrhage within 30 days postoperatively, representing a mortality rate of 0.2%. Generally, 30 day mortality is less than 1% and rarely exceeds 0.5%.4–6 With regard to the causes of perioperative death, risks from thrombo-embolic and ischemic heart disease have been reported to be the most serious complications. In the present study, the incidence of major cardiopulmonary complications was lower than those previously reported from Western countries. No patient died of cardiopulmonary complications, such as myocardial infarction and pulmonary embolism. When the incidence of major cardiopulmonary complications is discussed, epidemiological background should be considered. Pulmonary embolism is reported to be the third most frequent cause of death in the USA. But, in Japan, pulmonary embolism accounted for only 0.7% of major contributing cause of death.7 Furthermore, the death rate from ischemic heart disease is substantially lower in Japan.2
Our study indicates the trend toward selection of a patient population most likely to benefit from radical prostatectomy. Although the procedure is technically demanding, it can be performed with acceptable low morbidity. Catastrophic thrombo-embolic and cardiac complications appear to be lower in Japanese patients. The data may be useful in decision analytic models evaluating the role of therapy for Japanese men with early stage prostate cancer.
Quality of life
Although new operative techniques have greatly reduced the complication rate of radical prostatectomy and the operation has gained increasing popularity as treatment of choice for localized prostate cancer, the success or failure of prostate cancer treatment should be reported not only in terms of disease-free survival, but also in terms of patient attitudes to treatment and side-effects. Increasingly, quality-of-life (QOL) assessments are receiving greater attention in the management of prostate cancer.8 We recently reported a cross-sectional study on patient-reported QOL after radical prostatectomy.9 However, prospective, longitudinal data collection is always best, because this approach can reveal time-dependent evolution among health-related QOL domains. In 1996, we started longitudinal data collection for patients undergoing radical prostatectomy.
Time-dependent change in general health-related QOL domains showed that return to a baseline level was rapid, except for within the sexuality domain, which is to be expected. Urinary incontinence, one of the most disabling complications of radical prostatectomy, has become an increasingly rare complication with advances in techniques. Urinary function continued to improve through the year. More than 80% did not use pads at all at 1 year postoperatively. With regard to degree of bother from incontinence, more than 90% had no or very slight problems even early at 3 months, suggesting a rapid return of urinary function by recently developed surgical techniques (Fig. 3). In contrast to urinary function, significant deterioration of sexual function was observed. Of the postoperative patients, less than 30% had sex, but most of them felt their erections to be inadequate for intercourse. Preoperatively, 50% were satisfied with their sex life, but many of the postoperative patients stated that they were mostly or very dissatisfied (Fig. 4). When asked ‘If not completely satisfied with your treatment, what has bothered you the most?’, 30% of patients listed erectile dysfunction, suggesting that postoperative sexual dysfunction is a big problem. However, it is encouraging to know that more than 80% of our postoperative patients stated they would undergo surgery again if given a second chance, despite such post-surgical effects as erectile dysfunction.
Our longitudinal QOL data show that return to a baseline general health-related QOL is rapid following surgery. Patients are willing to accept some morbidity for a perceived survival benefit. Urinary function rapidly returns and incontinence is minimal, but most patients are dissatisfied with postoperative sexual function.
What has changed after Viagra?
Recently, use of sildenafil citrate (Viagra, Pfizer Pharmaceuticals, Tokyo, Japan) has created a new era for the prostate surgeon.10 Viagra has been available since March 1999 in Japan. We tested it for 25 patients with erectile dysfunction following radical prostatectomy. As shown in Table 3, the non-nerve-sparing group showed no response to Viagra. Overall, 65% of patients with nerve-sparing were able to produce an erection firm enough for intercourse. Interestingly, even the unilateral nerve-sparing group responded equally to Viagra. Assessment of the International Index of Erectile Function (IIEF) also confirmed the efficacy of Viagra. Scores significantly increased in both groups (bilateral and unilateral nerve-sparing) on the IIEF.
Table 3. Response to Viagra after radical prostatectomy
Erection firm enough for intercourse (%)
Incomplete erection (%)
No erection (%)
Based on our experience, Viagra improves erectile function in more than 60% of men after nerve-sparing radical prostatectomy. This has important implications in the surgical management of prostate cancer at a time when the morbidity of radical prostatectomy is of concern. The attitudes of physicians to the nerve-sparing procedure might be changed in the future.
Outcome research is very important. With richer information on QOL in addition to duration of survival, patients will be able to make more informed decisions. Further studies are needed that more accurately document the benefits of treatments for early stage prostate cancer, such as radical prostatectomy, radiation and watchful waiting.