All operations can have complications such as deep vein thrombosis (blood clots), infection, heart attack, stroke, pneumonia, bleeding and ileus (bowel not functioning after surgery). Specific complications for robotic prostatectomy include impotence, incontinence, rectal injury and strictures. There is also a risk of conversion to an open operation as a result of anatomical problems or technical issues.
Following the robotic prostatectomy surgery, you will have a catheter in your bladder for a week. Most men have difficulty with urinary control initially after the catheter has been removed and will require a pad that fits inside the underwear for a period of time. You should bring adult urinary pads with you the day the catheter is removed.
You will notice that during the night, when you are lying down and the effect of gravity on the urine in your bladder is less, your control will be better than when you are up and about during the day.
You will likely have more leakage with straining, coughing, or reaching down to lift something (stress incontinence). This can be particularly so if the bladder is full, if you become tired at the end of the day or drink alcohol. The degree of urinary control varies greatly but most men will have achieved reasonably good control within one to three months and require minimal protection, if any at all.
The recovery of continence is sometimes slower, but rarely more than three to six months. Around 1% of patients may still have incontinence at 12 to 18 months. The chance of recovering urinary control depends on your age, whether the nerves were preserved, and whether you develop a rare stricture (or narrowing) at the anastomosis (where the bladder is sewn to the urethra).
If problems persist, something can be done. Although rarely needed, placement of a male urethral sling or rarely an artificial urinary sphincter will almost always restore satisfactory control. Some success has also been achieved with injections of collagen beneath the sphincter.
The operation removed your prostate and bladder neck – the secondary (internal) sphincter muscle responsible for holding in the urine. Now the primary (or external) sphincter muscle has to provide continence. This muscle can by trained and strengthened by performing pelvic floor exercises, which can result in improved continence and earlier return of continence.
It is ideal that you learn the exercises and start doing them before the procedure in order to strengthen the pelvic floor muscles prior to surgery. You will meet with our physiotherapist prior to surgery who will teach you how to do pelvic floor exercises.
Once the catheter comes out, these exercises can and should then resume. These exercises can be done for many months and certainly until full continence is achieved. Should you experience pain or an ache below the scrotum when you do these exercises, it is best to stop and recommence a day or two later.
The operation will affect sexual function in several ways, but it does not prevent you from enjoying a rich sex life when you recover. Sexual function in men has three components: erection, ejaculation and climax (orgasm). Although these three normally occur together, they are separate and independent functions.
Erection of the penis occurs because of the stimulation through the cavernous nerves, which send signals to dilate the blood vessels in the penis allowing it to fill with blood and become rigid. The two nerve bundles responsible for erection run along either side of the prostate, only a few millimetres away from the area where prostate cancer most commonly occurs.
Unfortunately, cancer cells tend to migrate toward the main cavernous nerves along the branches that penetrate the prostate. Preserving these nerves at the time of surgery is usually achievable. It is not always favourable however as the less tissue that is removed around the prostate, the greater the chance that cancer cells will remain.
Since the primary goal of the operation is to remove all of the cancer, one or both of these nerves may have to be resected in some patients. Unless both nerves are resected, the chance of recovering erections definitely exists, but recovery may be slow. Nerve tissue, even when spared, takes time to recover from the trauma, inflammation and scarring that can occur after surgery.
The average time until recovery of erections sufficient for intercourse is 4-9 months, but in some men it takes longer. Erections can continue to improve for up to 2-3 years after the operation, because nerve fibres grow slowly.
Of course, the operation will not make your erections better than they were before surgery, even if both nerves are spared! Even with full recovery, most men find the erections a bit less firm and durable than before. Younger men recover sooner than older men; those with stronger erections before the operation have a better chance of recovery than if the erections were weak. The chance of regaining erections also depends on whether none, one or both neurovascular bundles were saved at the time of surgery.
The rehabilitation of erectile function is quite like a sporting injury – conditioning and medical treatment promptly after surgery is recommended to speed up potential recovery, though it is not guaranteed. If you see any fullness in your erections in the weeks after surgery it is a positive sign that some of the nerves are working and recovering.
As part of the preoperative preparation patients are requested to see Dr Michael Gillman, a specialist in erectile function, prior to surgery and also very soon after surgery. The importance of preoperative counselling for the patient and spouse cannot be underestimated. Helping understand what to expect and how to cope with changes in your sex life equip you mentally and physically to deal with the mostly temporary constraints in your sexual welfare. You will be guided when to start medications and also when to embark on sexual activity again.
Several practical methods are available for assisting erections; the most popular and widely known is the pill, Viagra. Viagra is one tablet in a class of drugs known as phosphodiesterase inhibitors and are taken orally either just before sexual activity or on a regular daily basis. Other similar drugs are Cialis and Levitra.
Dr Gillman will encourage you to begin using one of these medications as soon after your operation as you are comfortable. By stimulating erections in the early weeks after the operation, you are more likely to recover better erections sooner than if you simply wait for erections to return on their own.
Healthy functioning of the penis seems to require regular, frequent erections, which may be why men normally have erections off and on during sleep. In addition to the oral medications there are medications that can be injected into the penis such as Caverject (Alprostadil) or a mixture of drugs that dilate the blood vessels (Trimix). There is also available a vacuum erection device (VED).
Generally, the phosphodiesterase inhibitors will not give you a full erection until you begin to have some fullness of the penis or partial erections on your own. However, injections work in most patients regardless of any spontaneous partial erections you are having.
If you are not getting a good response from the oral medications, Dr Gillman may recommend that you commence injection therapy early in an attempt to kick start your erections.
Very often patients will commence on injections with a fantastic result and are then able to stop the injections after a time and recommence on the oral medications as their erectile function improves. If none of these conservative options prove satisfactory after 2-3 years, a penile prosthesis can eventually be used to restore erectile function.
Seminal fluid expelled during ejaculation is made and stored in the prostate and seminal vesicles, therefore, removal of these organs means that a climax will be accompanied by a sensation of ejaculation but no fluid will come out (dry ejaculation). The vas, which transports the sperm, is now divided so you will not be able to father children. Some men notice a small amount of fluid from the glands within the urethra (urinary channel) and occasionally, a small amount of urine is released from the bladder during ejaculation. If this is troublesome, a condom can afford protection.
Men can still orgasm after a robotic prostatectomy however it may be different in several ways. An orgasm is not dependent on an erection and some men report being able to have an orgasm without a full erection.
As discussed above the orgasm will not result in expulsion of seminal fluid and will be dry. Some men also report that the quality and intensity of their orgasm is slightly diminished although this is not common.
Patients will be infertile following the surgery. Men who wish to keep open the option of fathering children after surgery should consider storing frozen semen samples, collected before surgery.
If you do not arrange to have semen samples stored before surgery, it might still be possible to collect sperm samples by needle aspiration from the testis after surgery, for use in an in vitro fertilization (IVF) procedure.
The rectum (the lower end of your bowel) sits in very close relation to the prostate. Very rarely when removing the prostate this can be damaged. It is an extremely rare complication. It occurs in less than 0.2% of cases. If this occurs, generally the bowel can be repaired without any further issues. Occasionally patients need a colostomy (bowel contents diverted to the skin and collected in a bag) for a period of 3 months but this is rare.
After surgery there is a small risk of scar tissue forming in either the urethra or at the junction of the urethra and the bladder (anastomosis). This can prevent normal flow of urine from the bladder and may require further surgery to rectify the problem. Should your flow start to deteriorate at any time after the operation, you need to let Dr Swindle know as soon as possible. This complication rarely occurs after robotic radical prostatectomy.
There are many rare complications which can also occur post surgery and the above list is a summary of the most common potential complications. If you wish to discuss all potential complications please let Dr Swindle know.