Complications of radical prostatectomy can include urinary incontinence, urethral stricture, impotence, and the morbidity associated with general anesthesia and a major surgical procedure. A national review of 10,600 radical prostatectomies determined that 30-day mortality and cardiovascular morbidity rates were 2% and 8%, respectively.[19] Morbidity and mortality rates increase with age and were appreciably greater in those patients older than 75 years.[19] In 1 large case series of men undergoing the anatomic (nerve-sparing) technique of radical prostatectomy, only about 6% of men required the use of pads for urinary incontinence, but an unknown additional proportion of men had occasional urinary dribbling. About 40% to 65% of men who were sexually potent before surgery retained potency adequate for vaginal penetration and sexual intercourse.[23] Preservation of potency with this technique is dependent on tumor stage and patient age, but the operation probably induces at least a partial deficit in nearly all patients.[23] A national survey of Medicare patients who underwent radical prostatectomy in 1988 to 1990 reported more morbidity than in the case series.[24] In that survey, over 30% of men reported the need for pads or clamps for urinary wetness and 63% of all patients reported a current problem with wetness. About 60% reported having no erections since surgery; about 90% had no erections sufficient for intercourse during the month prior to the survey. About 28% reported follow-up treatment of cancer with radiation and/or hormonal therapy within 4 years after their prostatectomy. Reasons for the difference in outcomes between the national survey and previous case series could include: 1) the older Medicare population in the former, 2) surgical expertise at the major reporting centers, 3) selection factors, 4) publication bias of favorable series, or 5) different methods of collecting information from patients. Case series of 93, 459, and 89 men who had undergone radical prostatectomy by experienced surgeons showed similarly high rates of impotence as in the national Medicare survey when men were carefully questioned about sexual potency, although the men in the case series were on average younger than those in the Medicare survey.[25-27] In 1 of the case series the same questionnaire was used as in the Medicare survey.[25] The urinary incontinence rate in that series was also similar to that in the Medicare survey.

A cross-sectional survey of prostate cancer patients who had been treated in a managed care setting by either radical prostatectomy, radiation, or watchful waiting showed substantial sexual and urinary dysfunction in the prostatectomy group.[28] Results reported by the patients were consistent with those from the national Medicare survey. In addition, though statistical power was limited, differences in sexual and urinary dysfunction between men who had undergone either anatomic (nerve-sparing) or standard radical prostatectomy were not statistically significant. This issue, therefore, requires more study.

Radical prostatectomy may also cause fecal incontinence, and the incidence may vary with surgical method.[29] In a national survey sample of 907 men who had undergone radical prostatectomy at least 1 year prior to the survey, 32% of the men who had undergone perineal (anatomic "nerve-sparing") radical prostatectomy and 17% of the men who had undergone retropubic radical prostatectomy reported accidents of fecal leakage. Ten percent and 4%, respectively, reported moderate to large amounts of fecal leakage. Less than 15% of men with fecal incontinence had reported it to a physician or health care provider.

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