Laparoscopic and robotic surgery: Into the 21st Century

What about impotence and incontinence?

Robotic surgery is really only the performance of a radical prostatectomy with better tools. These tools are specifically designed to let us perform a more elegant surgery in a small space with better vision. And although most robotic surgeons do believe that this leads to a minimization of impotence and incontinence, unfortunately these two side effects are a part of every man's recovery after any prostatectomy, regardless of how it is performed. Many men will recover quickly and completely, but this should not be expected as the norm at all. Drs. Engel and Frazier still have patients that leak permanently, and certainly have men that have permanent erectile dysfunction after surgery and need help. We just believe we have less of them, and we are committed to providing that help.

We find that it is very important that the patient has a clear understanding of what average results are, and not outlying examples of what the best results are. We also find that a patient's attitude and willingness to accept and positively work on these two post-operative problems very much affects the eventual outcome. A major problem today is the fact that several websites quote success rates that are generated by defining these problems in a way that overestimate success in these areas. Although this certainly attracts patients to these centers, it tends to create disappointment among these men during their recovery.

Let's talk about impotence. Quoting absolute rates unfortunately is very difficult to do. This is because there are several factors that affect impotence after prostatectomy. Although the sparing of the erectile nerves is often stressed, and we firmly believe that robotic surgery allows us to do that more consistently and elegantly, unfortunately this is not necessarily the most important factor in recovery of erections after surgery. We have found, as have others, that partner interest in sexuality is perhaps the strongest factor, followed by how good that patient's erections are before surgery, whether there is any pre-operative need for medicines to aid erection, obesity, smoking, and general cardiovascular health. In addition, mood and depression play a role, as does the health of the patient's relationship with their spouse. Most rates that are quoted on the internet are select groups of patients that are optimal in all of these categories, and potency is defined very loosely and not in a way a patient would usually define it.

Unfortunately, most men in their fifties and sixties are not optimal in all of these categories. This is the major challenge of impotence after prostatectomy. The reality is that although we can affect outcome here to some degree by the skill of our surgery and the sparing of the nerves, most of the parameters above are outside of our control. Drs. Engel and Frazier firmly believe that our erection rates rival anyone's in the country, but we are very careful to be honest about the difficulties of getting erections back after surgery for all those men that are not optimal in all of these categories.

The reality is that all men will suffer some form of erectile dysfunction immediately following surgery, and the hope is that erections return, with or without the use of medicines such as Viagra, Levitra or Cialis, over 1-2 years. Current thinking is that men can affect this length of time and overall impotence rate by rehabilitating their penis by taking medicines soon after the surgery, nearly every day for the first year after surgery. We believe that the primary problem after prostatectomy is decreased blood flow, and actively working on erections during the recovery period promotes improved blood flow and thus its recovery. Blood flow is why younger men and those with better pre-operative cardiovascular status fare better, so this approach makes sense and is actively practiced by most high volume robotic surgeons.

Men that are very interested in sex during that first year or two should expect to need help, but the help is certainly there to override the system and achieve erection so a healthy sex life can be maintained. We find that many men and/or their partners lack the interest in sex to ask for this help, and that many patients feel as if the need to use such help in the form of a drug called MUSE, injections or a pump represents failure. If men view the use of this help as simply a part of their normal recovery, we find that men are far less disappointed and may have better eventual outcomes. It should be noted that since the seminal vesicles are removed during surgery, an orgasm will not produce semen. The pleasurable experience of orgasm remains, however.

With regards to incontinence, we inform patients that all men will have incontinence to varying degrees after surgery. Men will need to use pads, and how much leakage there will be after surgery is highly variable. Unlike impotence, where most men will have some degree of impairment that lingers, most men will find incontinence to be a self-limited phenomenon. There will be a few men (less than 1%) with significant permanent incontinence, and we encourage surgical correction for those men. Typically, 5% of men expericene mild stress urinary incontinence requiring some form of pad use.

As with erections, patients can affect their outcome by putting effort and a good attitude into their recovery. We have found that there are men that even before surgery simply cannot use their pelvic floor musculature properly. We strongly emphasize before surgery the need to practice using these muscles, largely so we can determine who needs help with a physical therapist to learn how to use these muscles properly. And although we believe the ease with which we can suture and reconnect the bladder to the urethra improves incontinence, unfortunately once again we find the largest determinant of post operative continence is out of our hands.

We call the act of squeezing the muscles that a man would use to cut off his urinary stream, squeeze out the last few drops of urine at a urinal, or to pinch off his anus, a "kegel exercise". We also have given this technique the nickname of "turtle". That is because when a man is using these muscles correctly, he will be able to see his penis draw back towards his abdomen. This should be obvious, and should not involve the abdominal or thigh muscles at all. It should not require a man to strain or hold his breath. Patients must actively master this skill and practice it before surgery. Also, they must be able to hold their penis in the retracted position for a full three seconds, which is usually the hard part. The ability to do this act will not be injured by surgery. Permanent incontinence is exceedingly rare in those patients that can master this skill pre-operatively. Those patients that show confusion over this or can't do it because they never learned in their lifetime will be referred to a physical therapist to learn. After surgery, patients will be tested for their ability to do a "turtle" perfectly, and then be instructed to apply this act of squeezing these muscles and holding them for a full three seconds just before they do things such as standing up, sitting down, coughing, sneezing, getting into or out of a car or bed, etc. If done religiously, this should cause the patient to perform this act hundreds of times a day. This is known as a Kegel exercises in medical textbooks, and we insist that they be performed in this way. If done this way, and if the patient is able to do this act pre-operatively, most patients are continent by the three month visit. Many patients beat this goal, but nevertheless having a healthy expectation of this time frame leads to less disappointment.

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