What about Impotence and Incontinence after a Robotic Prostatectomy?
Robotic surgery is really only the performance of a radical prostatectomy with better tools. These tools are specifically designed to allow for 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 or who performs it. Many men will recover quickly and completely, but this should not be expected as the norm at all. Dr. Engel is very experienced, but still has patients that leak permanently, and certainly has men that have permanent erectile dysfunction after surgery and need help. Highly skilled robotic surgeons like Dr. Engel just have fewer of them, and he is committed to providing help to those who need or want it.
It is very important that the patient and his family have 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 centers quote success rates that are generated by defining these problems in a way that overestimate success in these areas, or report outcomes only on select groups. Although this certainly attracts patients to these centers, it tends to create disappointment among many men during their recovery.
Let’s talk about impotence. Quoting absolute rates unfortunately is very difficult to do, and this can be frustrating to patients who are trying to compare surgeons. This is because there are several factors that affect impotence after a robotic prostatectomy. Although the sparing of the erectile nerves is often stressed, and Dr. Engel firmly believes that robotic surgery allows him to do that more consistently and elegantly, unfortunately this is not necessarily the most important factor in recovery of erections after surgery. Dr. Engel believes that the primary problem after prostatectomy is decreased blood flow. Blood flow is why younger men and those with better pre-operative cardiovascular status fare better, and it is why men as they age tend to lose erectile function naturally. Aging does not cause erectile nerve dysfunction. In fact, it was the advent of robotic surgery, where suddenly the nerves are spared perfectly in nearly every case that caused the factors leading to erectile dysfunction after prostatectomy to be re-examined by many. Before, in open surgery, visualization of the nerves was poor, so when a man regained his erections one assumed the nerves had been spared. Now, with robotic surgery, even though nerves are nearly always spared, all men still will have erectile problems after surgery. Dr. Engel has thus come to the conclusion that nerves alone cannot be the answer.
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Dr. Engel has found, as have others, that beyond blood flow in general, partner interest in sexuality is perhaps the strongest factor, followed by how strong and reliable a 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. Therefore, for a surgeon to quote success rates in terms of impotence, he/she would have to know how well a patient is doing in each of these categories to give an accurate estimate.
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 a surgeon can affect outcome here to some degree by the skill with which the surgery is performed and the sparing of the nerves, most of the parameters above are outside of the surgeon’s control. Dr. Engel firmly believes that his erection rates rival anyone’s in the country, or the world for that matter, but he is 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 severe erectile dysfunction immediately following surgery, and the hope is that erections return, likely with the use of medicines such as Viagra, Levitra, Cialis or Stendra, over 1-2 years. Current thinking holds 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. However, Dr. Engel’s large multi-institutional study on this topic comparing MUSE (an intra-urethral suppository for erection) with Viagra, published in the Journal of Urology, did not support this hypothesis. Even larger, more powerful studies came to the same conclusion. This literature has caused Dr. Engel to abandon this approach. Instead, Dr. Engel has found that motivation tends to drive success here. With PDE-5 inhibitors costing over $40 a pill around the Washington D.C. region, and with very few insurances covering any of it, Dr. Engel usually encourages motivated couples to look to injections to achieve usable erections in the first year. A vacuum erection device is another alternative, but Dr. Engel’s own landmark study on the topic suggests this not to be a reliable solution until some of the patient’s own function returns, perhaps after six to nine months from when the robotic prostatectomy was performed.
Couples that are very interested in sex during the first year after surgery should expect to need help, but the help is certainly there to override the system and achieve erection so that a healthy sex life can be maintained. Dr. Engel finds 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 injections or a pump represents failure. If men more correctly 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. Generally Dr. Engel offers injections or a vacuum pump at three months after surgery when the patient is usually out of pads and mentally ready. One’s own function usually gradually starts to return between 6-12 months, and when almost having an erection PDE-5 inhibitors are encouraged. 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, almost all men will find incontinence to be a self-limited phenomenon. Dr. Engel has noticed four patterns of return of continence after prostatectomy. 15-20% of men will have very early continence, and be out of pads within a few weeks. This should never be expected by a patient, though, and such patients should just be pleasantly surprised. The typical pattern, seen in perhaps 70% of men, is a scenario where they must use four to five pads a day with gradual improvement until six weeks or so when dramatic and steady improvement is seen. These patients are usually ready to stop wearing pads by three months. Another 10% or so will take longer than three months to get dry. These typically are patients that had significant voiding symptoms before surgery, or a longer catheterization time after surgery. Unfortunately, regardless of surgical modification, there will be approximately 5% of patients that will be left with some degree of permanent incontinence, typically 1-2 pads per day that remains at one year. At that point, Dr. Engel aggressively pursues surgical treatment of incontinence with either an AdVance Male Sling for 2 pads per day or less, or an artificial urinary sphincter for the much rarer moderate to severe incontinence. Both will yield greater than 90% cure rate of incontinence in such cases, and Dr. Engel performs these surgeries himself.
Pelvic Floor or Kegel Exercises
Let’s talk about pelvic floor exercises, or Kegel exercises. As mentioned above, at the six day visit after surgery, the catheter is removed. As part of that process, patients will be asked to demonstrate that they know what their urinary sphincter is and that they can use it to hold their urine and then stop their urine flow midstream. 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”. Dr. Engel has given this technique the nickname of a “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. Doing a “turtle” is not a new skill at all. It is something a man does every day of his life, and the ability to do it is not affected by a robotic prostatectomy. The key is for a patient to simply be conscious of the act so it can be done on demand. The rare patient that shows confusion over this or can’t do it because they never learned in their lifetime will be referred to a physical therapist to learn.
Leakage is usually predictable and not constant. It tends to come with activity or straining, acts like standing up or bending over, or coughing or sneezing. It is for this reason that incontinence resolves first at night when one is lying down and sleeping. What Dr. Engel asks his patients to do is simple, and follows common sense. Now that the patient is aware that he can hold his urine for 3-5 seconds successfully, he simply must squeeze his sphincter just before performing the activity that might cause leakage. It is a function of anticipating leakage and stopping it before it happens. It must be understood though that following this strategy will not get one out of pads. It will only lessen leakage. Time and healing of the bladder is what gets one dry.
Dr. Engel does not prescribe Kegel exercises or the act of squeezing ones sphincter repeatedly to strengthen the sphincter. This might make sense to do in women so that a sagging pelvic floor and vagina can be bulked up to better support the bladder in a woman. This is the cause of stress urinary incontinence in women. However, Dr. Engel has observed that incontinence after a prostatectomy has nothing to do with a weak pelvic floor or sagging vagina. It happens because the bottom of the bladder, or the bladder neck, which normally puckers on its own relaxes after surgery. It senses trauma, may have blood clots around it, has stitches through it and has had a catheter crossing it. Really, what a man is waiting for after prostatectomy is for his bladder neck to wake up, or “pucker”. Until it does, a man will leak. Thus, Dr. Engel really only uses the Kegel or “turtle”, applied at the right time, as a crutch to be used until the bladder heals itself. This is why patients get dry at different rates. Those who do not get dry have bladder necks that never fully closed. The amount of residual leakage relates to how open the bladder neck is, and the surgeries used to fix post-prostatectomy incontinence basically either add another bladder neck or add more pucker to it.
The final message Dr. Engel wants patients to know then is that no matter how much they leak, or how well they anticipate their leakage and squeeze, it is never their fault, or a sign that the patient is doing anything wrong. Surgical skill does play a role, but in large part the timing of getting dry has a lot to do with plain luck. Just as with erectile dysfunction after prostatectomy, proper education and expectation is the key to avoiding disappointment.