Effect of radical prostatectomy on anxiety, depression, and quality of life in patients diagnosed with prostate cancer

Abstract

BACKGROUND

Prostate cancer is common among men, and radical surgery is the primary treatment. Surgery, however, can affect both physical and mental health, including anxiety, depression, and quality of life (QoL).

AIM

To assess the effect of radical prostatectomy on psychological status and QoL in patients with prostate cancer.

METHODS

This observational study included 102 patients undergoing radical prostatectomy between June 2024 and April 2025. Pain (numerical rating scale), Hamilton Anxiety Scale, Hamilton Depression Scale, and QoL (European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 and short-form 36) were evaluated before and after surgery.

RESULTS

At one month postoperatively, the mean European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 score increased significantly from 60.72 ± 5.37 preoperatively to 86.48 ± 7.52 (P < 0.001), indicating marked improvement in overall QoL. Psychological assessments revealed significant reductions in anxiety and depression: The mean Hamilton Anxiety Scale score decreased from 23.36 ± 5.15 preoperatively to 12.15 ± 4.36 (P < 0.001), and the mean Hamilton Depression Scale score declined from 22.61 ± 5.02 to 13.83 ± 4.54 (P < 0.001). Pain levels, as measured by the numerical rating scale, decreased significantly from 7.68 ± 2.17 preoperatively to 2.67 ± 0.72 (P < 0.001). Additionally, the urinary incontinence rate dropped from 20.59% (21/102) preoperatively to 11.76% (12/102) (P < 0.05), showing a statistically significant reduction.

CONCLUSION

Radical prostatectomy improves psychological health and the QoL of patients with prostate cancer. These results may help to inform future therapies.

Key Words: Quality of life; Anxiety; Radical prostatectomy; Depression; European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30; Prostate cancer; Short-form 36; Hamilton Anxiety Scale; Hamilton Depression Scale

Core Tip: This observational study evaluated the impact of radical prostatectomy on psychological status and quality of life (QoL) in 102 prostate cancer patients. Using pre- and one-month postoperative assessments (numerical rating scale pain, Hamilton Anxiety, Hamilton Depression, European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30, and short-form 36 questionnaires), results showed statistically significant (P < 0.05) improvements in QoL scores alongside significant reductions in pain, anxiety, and depression. The study concludes that radical prostatectomy significantly enhances psychological well-being and QoL one month post-surgery, providing valuable insights for therapeutic considerations.

INTRODUCTION

Prostate cancer is the second most prevalent cancer among men globally, with increasing rates of incidence and mortality[1,2]. Its prevalence has increased in China, causing significant public health issues[3]. The 2019 Global Burden of Disease Study noted a 95.2% increase in age-standardized incidence in China from 1990 to 2019, with Jiangsu Province experiencing an annual increase of 11.25% from 2009 to 2019[4]. A survey from eastern China found an age-standardized prevalence of 0.91% among men ≥ 60 years of age[5]. Research has shown that genetic factors, gene interactions, and environmental factors significantly affect prostate cancer susceptibility and characteristics[3]. Oxidative stress promotes disease progression by affecting the tumor environment and regulating microRNA expression, with microRNA-21 and microRNA-21 being notably upregulated in cancer tissues, suggesting their potential as diagnostic markers[6,7]. Incidence varies by age and region, especially in older adults[8]. Early screening, particularly for high-risk groups, such as the elderly and obese, is advised at the community health level[9]. Developing targeted and effective interventions is, therefore, crucial for reducing the impact of this disease.

Radical prostatectomy remains the cornerstone of prostate cancer treatment and significantly improves patient survival. Although surgical removal effectively controls tumor progression, it can also be associated with postoperative complications and functional impairments. Advances and developments in surgical techniques, especially robotic-assisted procedures, have markedly enhanced the safety and efficacy of prostatectomy[10,11]. Robot-assisted radical prostatectomy (RARP) is now a standard treatment that offers benefits over traditional open approaches, including reduced intraoperative bleeding, shorter hospital stay, and faster recovery[10,12]. In addition, RARP has yielded better results in those with postoperative urinary incontinence and sexual function recovery, mainly due to the protection of the neurovascular bundle and delicate treatment of the anatomy during surgery[11]. While RARP demonstrates comparable or even superior outcomes in certain clinical metrics compared to traditional open surgery, its high costs, lengthy learning curve, and potential mechanical failure risks should not be overlooked[13-15]. Such malfunctions may lead to procedure interruptions or delays, increasing both anesthesia duration and postoperative complication risks[16-18].

Therefore, the psychological health of patients with prostate cancer merits increased attention. Mental health issues are prevalent among prostate cancer patients and are associated with treatment inequity. Research indicates that those with mental health disorders have lower access to essential treatments, which may be linked to multiple structural, social, and health-related factors[19]. Studies have revealed high prevalence rates of anxiety and depression, which significantly affect quality of life (QoL)[5]. A notable proportion of patients undergoing androgen deprivation therapy do not receive adequate mental health support, and some are prescribed benzodiazepines without sufficient psychiatric evaluation[20]. Moreover, post-treatment psychological symptoms can adversely impact health-related QoL and long-term recovery, influencing not only patients but also their spouses[15-17]. Consequently, routine mental health screening is essential to identify high-risk individuals and implement appropriate interventions[21,22]. As such, the present study aimed to evaluate the effects of radical prostatectomy on patient anxiety, depression, and overall QoL, providing insights into optimizing minimally invasive treatment strategies and facilitating faster recovery.

MATERIALS AND METHODS

Study design and participants

This observational study included data from 102 patients who underwent radical prostatectomy at the First Hospital of Shanxi Medical University between June 2024 and April 2025. The sample size was calculated using the equation: N = Z²_a/2(1-P)/ ε²P. where a = 0.05, Z_a/2 = 1.96, ε = 0.25, and P = 0.40. P is the proportion in the target population. Preliminary clinical observations from our institution suggested that approximately 40% of patients showed measurable changes in psychological outcomes or QoL indicators during the perioperative period. The calculated minimum sample size was 92, and, with a projected drop-out rate of approximately 10%, at least 102 participants were enrolled.

Inclusion and exclusion criteria

The inclusion criteria were as follows: (1) Confirmed diagnosis of prostate cancer with clinical stage III or IV based on ultrasound and biopsy; (2) Age > 18 years; (3) Clear consciousness and normal communication; and (4) Voluntary participation and willingness to cooperate. Individuals with serious physical diseases, such as heart, liver, and kidney diseases, other tumors, and previous neurological and/or psychiatric diseases were excluded.

Ethics approval

All participants provided informed consent. This study was approved by the Ethics Committee of the First Hospital of Shanxi Medical University (No. KYLL-2024-100) in accordance with the Declaration of Helsinki.

Data collection and outcome measures

All patients underwent radical prostatectomy using a standardized surgical approach. Specifically, each patient was placed in a supine position with legs separated. The radical prostatectomy was performed via an anterior approach. After the prostate gland was resected, a vesicourethral anastomosis was conducted, and a routine leak test was performed to ensure the anastomosis was watertight. Upon completion of the vesicourethral anastomosis, hemostatic patches were applied to each lymph node dissection field. The distal aspects of the obturator fossa and femoral canal, as well as the proximal aspects of the common iliac bifurcation and internal iliac artery, were thoroughly covered with the hemostatic patches. The patches were kept dry until contact with the tissue; after tissue contact, pressure was applied to the patch surface for two minutes. Finally, a pelvic drainage tube was inserted before the completion of the surgery. Baseline demographic and clinical data, including age, body mass index, sex, prostate volume, and preoperative prostate-specific antigen level, were collected from electronic medical records.

QoL: Assessed via the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30) (version 3.0), which encompasses 5 functional domains: Physical, role, cognitive, emotional, and social. Each domain score ranges from 0 to 100, with higher scores indicating better QoL[23].

Psychological status: Measured using the Hamilton Anxiety Scale (HAM-A) and Hamilton Depression Scale (HAM-D)[24]: The HAM-A includes 14 items scored from 0 to 4; higher scores indicate greater anxiety severity. The HAM-D includes 17 items, with some scoring from 0 to 4 and others from 0 to 2. Higher scores reflect more severe depression.

Urinary incontinence: Postoperative urinary incontinence was evaluated based on daily pad usage: 0-1 pad indicating normal continence; 2-3 pads indicating mild incontinence; and ≥ 4 pads indicating severe incontinence.

Pain level: A numerical rating scale (NRS) was routinely used to evaluate the pain level of patients within 24 hours after surgery, with a score of 0 indicating no pain and a score of 10 indicating unbearable, severe pain. The use of salvage analgesics and the NRS score were extracted from the e-health system, and the NRS score was ≥ 1 point for the presence of pain[25].

Short-form 36 health survey score: The short-form 36 (SF-36)[26] questionnaire was administered preoperatively and one month postoperatively, with scores ranging from 0 (worst) to 100 (best). It evaluates 8 dimensions: Physical functioning, role limitations due to physical and emotional problems, bodily pain, general health, vitality, social functioning, and mental health. The overall score is the mean of these 8 domains[27].

Statistical analysis

Data were analyzed using SPSS version 26.0 (IBM Corporation, Armonk, NY, United States). Continuous variables are expressed as mean ± SD. Paired t-tests (or Wilcoxon signed-rank tests for non-normally distributed data) were used to compare preoperative and postoperative continuous variables. Categorical data were analyzed using the McNemar’s test. Changes in psychological scores (HAM-A and HAM-D) and QoL dimensions were evaluated using appropriate statistical tests based on the data distribution. Multivariate regression analyses identified the factors associated with improvements in psychological health and QoL. Differences with P < 0.05 were considered to be statistically significant.

RESULTS

Baseline characteristics

Data from 102 patients (mean ± SD age, 68.71 ± 5.35 years; body mass index, 22.17 ± 2.72 kg/m²) were included in this study. The mean prostate volume was 40.12 ± 13.48 cm³, with a mean preoperative prostate-specific antigen level of 27.75 ± 4.82 ng/mL (Table 1).

Table 1 Demographic characteristics.

Variable	Patients (n = 102)
Age (years)	68.71 ± 5.35
BMI (kg/m2)	22.17 ± 2.72
Prostate volume (cm3)	40.12 ± 13.48
Preoperative PSA (ng/mL)	27.75 ± 4.82

BMI: Body mass index; PSA: Prostate-specific antigen.

Comparison of EORTC QLQ-C30 scale scores before and after treatment

One month postoperatively, mean EORTC QLQ-C30 scores increased significantly, from 60.72 ± 5.37 preoperatively to 86.48 ± 7.52 (P < 0.001), indicating marked improvement in overall QoL (Figure 1).

Figure 1 Comparison of European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 scores. ^aP < 0.001 vs control. EORTC QLQ-C30: European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30.

Comparison of HAM-A and HAM-D scores

Before treatment, the mean patient HAM-A score was 23.36 ± 5.15, and after one month of treatment, it was 12.15 ± 4.36. Anxiety and depression scores improved significantly (P < 0.001). Before treatment, the mean HAM-D score was 22.61 ± 5.02 and, after one month of treatment, was 13.83 ± 4.54, indicating a significant improvement in depressive symptoms (P < 0.001) (Table 2).

Table 2 Comparison of anxiety and depression scores.

Group	Before operation	After operation	P value
HAM-A	23.36 ± 5.15	12.15 ± 4.36	< 0.001
HAM-D	22.61 ± 5.02	13.83 ± 4.54	< 0.001

HAM-A: Hamilton Anxiety Scale; HAM-D: Hamilton Depression Scale.

Urinary incontinence

Before treatment, the incontinence rate was 20.59% (21/102), with 6 patients using 0-1 pad, 12 using 2-3 pads, and 9 using ≥ 4 pads. One month postoperatively, the incontinence rate declined to 11.76% (12/102), which was a statistically significant reduction (P < 0.05) (Figure 2).

Figure 2 Comparison of urinary incontinence in patients. ^bP < 0.001 vs control.

Pain level

The mean NRS score decreased significantly, from 7.68 ± 2.17 preoperatively to 2.67 ± 0.72 one month postoperatively (P < 0.001) (Figure 3).

Figure 3 Comparison of numerical rating scale scores. ^cP < 0.001 vs control. NRS: Numerical rating scale.

SF-36 scores

Mean preoperative SF-36 scores ranged from 26.95 ± 18.05 (physical function) to 65.4 ± 19.22 (mental health). All dimensions exhibited significant improvement one month postoperatively (P < 0.001) (Table 3).

Table 3 Preoperative and postoperative short-form 36 scores, mean ± SD.

SF-36 component	Preoperative	Postoperative	P value
Physical function	26.95 ± 18.05	52.35 ± 27.09	< 0.001
Role physical	34.14 ± 23.66	58.26 ± 30.23	< 0.001
Bodily pain	30.19 ± 17.88	57.46 ± 27.16	< 0.001
General health	60.03 ± 21.4	72.2 ± 23.12	< 0.001
Vitality	42.67 ± 20.29	55.1 ± 22.06	< 0.001
Social function	54.24 ± 28.89	75.78 ± 29.03	< 0.001
Role emotional	64.1 ± 33.81	76.2 ± 30.74	< 0.001
Mental health	65.4 ± 19.22	75.37 ± 19.44	< 0.001
Total	47.6 ± 16.79	65.6 ± 20.9	< 0.001

SF-36: Short-form 36.

DISCUSSION

Radical prostatectomy has evolved as a cornerstone of curative treatment for localized prostate cancer, with surgical approaches advancing significantly over the past three decades - from traditional open surgery to minimally invasive laparoscopic techniques and, more recently, robot-assisted procedures. These technological advancements have aimed to reduce perioperative complications, shorten recovery times, and preserve functional outcomes, all of which indirectly influence patient psychological health and QoL. This study included various surgical approaches (open, laparoscopic, and RARP) to evaluate their effects on patient psychological health and QoL. Findings demonstrated that within one month postoperatively, patients experienced significant improvements in QoL, as evidenced by increased scores across multiple domains of the EORTC QLQ-C30 and SF-36 scales (P < 0.05). These results align with those of previous research, indicating substantial enhancements in health-related QoL, particularly in mental health and social functioning, following radical prostatectomy[28]. Additionally, although postoperative urinary incontinence and sexual dysfunction remain concerns, the overall QoL tends to improve over time[29].

Psychological evaluations indicated a substantial decrease in anxiety and depression, as evidenced by a marked reduction in HAM-A and HAM-D scores one month after surgery (P < 0.001). These results align with those of previous studies demonstrating psychosocial enhancements at 3, 6, and 12 months postoperatively[30]. These findings imply that, in addition to physiological advantages, radical prostatectomy positively affects patients’ mental health. Moreover, psychological care interventions implemented after surgery effectively alleviate distress and enhance overall well-being, underscoring the significance of comprehensive postoperative management[31]. Pain levels, as assessed using the NRS, exhibited a statistically significant decrease one month postoperatively (P < 0.001), predominantly indicating the alleviation of incision-related discomfort. This finding is consistent with previous research that demonstrated that postoperative pain progressively decreases over time, a trend associated with reduced opioid usage and enhanced pain management strategies[32]. Importantly, preoperative pain and psychological stress were strongly linked to the severity of postoperative pain, suggesting that preoperative evaluation can be instrumental in identifying patients at risk for experiencing persistent pain.

Statistically significant improvements (P < 0.001) across all dimensions of the SF-36, including physical, social, and mental health, were observed one month after surgery. These results align with those of previous research, underscoring the recovery of functional domains and overall health status after surgery[33]. The enhancement of self-care and psychological resilience plays a crucial role in this positive trajectory, with evidence suggesting that high self-efficacy is associated with improved mental health and QoL outcomes[34]. Furthermore, social functioning and psychological well-being typically exhibit substantial improvement within six months postoperatively, offering a comprehensive perspective on the recovery process[35].

Limitations

The present study had several limitations. First, the follow-up duration was only one month, and there was a lack of assessment of urinary incontinence, sexual dysfunction, and their long-term psychological effects. Longer observation periods are necessary to evaluate sustained recovery. Second, although the results were statistically significant, the sample size of 102 patients may limit generalizability; as such, larger multicenter studies are warranted for validation. Third, individual differences, including preexisting medical conditions, medication history, and psychosocial factors, may influence outcomes, potentially introducing confounding variables. Future research should address these limitations by incorporating larger, multicenter samples, extending follow-up periods to at least 6-12 months, and conducting subgroup analyses by surgical approach to better elucidate the nuanced relationships between surgical techniques, psychological health, and long-term QoL.

CONCLUSION

In summary, radical prostatectomy not only addresses the physiological aspects of prostate cancer but also significantly alleviates anxiety and depression symptoms, thereby enhancing overall patient QoL. Efforts should focus on refining surgical techniques and postoperative rehabilitation, emphasizing comprehensive care that integrates physical and mental health. Personalized multidimensional approaches in precision medicine are crucial for optimizing recovery outcomes in patients with prostate cancer.