Prostate surgery saves lives; advances curb incontinence and impotence

November 26, 2018

Providence Health Team

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When Garrett S. Matsunaga, M.D., speaks to prostate cancer patients facing the likelihood of surgery, he can offer encouraging news thanks to advancements in surgical techniques.

Besides addressing patients’ chief concern about removing cancerous cells and starting down a road to remission, Dr. Matsunaga knows there are two secondary but important areas of interest. His patients want to know what they may expect with respect to bladder control, or incontinence, and they want to know whether the potentially life-saving surgery may render them impotent, or unable to achieve an erection.

Dr. Matsunaga, emphasizing that the most important mission is to thwart the cancer’s spread, tells his patients there is hope on both fronts of incontinence and impotence.

The main type of surgery for prostate cancer performed is a radical prostatectomy. In this operation, the surgeon removes the entire prostate gland plus some of the tissue around it, including the seminal vesicles. Dr. Matsunaga, a urologist who specializes in robotics and laparoscopy at Providence Little Company of Mary Medical Center and South Bay Urology in Torrance, CA, says a variety of techniques have “resulted in much higher success rate for continence both short-term and long-term.”

In fact, he says, “at one year post-surgery, the risk of a patient having incontinence is generally less than 1 percent.”

Because of improved surgical techniques, he says, only about half of men will experience some urine leaking a week after the procedure. This will typically occur “when you stress the abdomen,” Dr. Matsunaga says. “It’s usually not severe leakage but rather some limited spotting of the underwear which a light pad is sufficient to absorb and conceal.”

In addition to improved surgical techniques, patients can also improve their recovery time by performing Kegel exercises to strengthen the muscles below the bladder.

“Within three to six weeks we will get the patient dry, either with him doing Kegels on his own or referring him to a physical therapist that specializes in pelvic health,” he says.

The second potential change after radical prostatectomy is impotency, also known as erectile dysfunction. A man’s ability to achieve an erection after the surgery is affected by the closeness of nerve bundles to the cancerous tissue that must be removed.

There are three key factors to consider before surgery to help determine whether it is likely a patient may resume some ability to have an erection, Dr. Matsunaga says.

“Age coming into the surgery, the quality of erections coming into surgery, and the extent of the disease are the primary factors,” he says.

“The younger the patient, the more he will be able to maintain or regain” sexual function, says Dr. Matsunaga. “With men in their 40s, their success rate is going to be upwards of 95 percent. That number will gradually diminish as they get older.”

A man in his 50s, for example, has an 85 to 90 percent chance of regaining function; it’s 80 to 85 percent for a man in his 60s.

“When you get to your 70s,” he says, “then the probability gets to be around 50 percent. The issue is that the nerves just don’t recover as well as they do in someone younger. So, age plays a factor.”

Resuming sexual function also depends to a significant extent on performance pre-surgery, Dr. Matsunaga says. “A man who is not experiencing erections beforehand is unlikely to have them after surgery regardless of the other achievements of the procedure,” he says.

"The challenge of the radical prostatectomy is to remove all of the prostate cancer while not interrupting the urinary sphincter that lies in front of the prostate or the erectile nerves which lie beneath the prostate,” Dr. Matsunaga explains. A pre-surgery magnetic resonance imaging offers clues about the extent of the disease and whether the nerve bundles can be spared.

The priorities in a radical prostatectomy, however, are clear.

“When we enter the surgery, first and foremost, the priority is cancer control,” Dr. Matsunaga says. “We want to remove all of the cancer, even at the risk of erectile dysfunction post-operatively, as opposed to leaving the nerves behind and as a consequence leaving cancer behind and requiring the patient to undergo further treatment.”

A post-surgical regimen of drugs that could increase blood flow to the penis, such as Cialis of Viagra, typically is prescribed.

Usually, sexual function can be achieved in six months to a year though in some cases it’s been known to take two years, Dr. Matsunaga says.

“Although there is no guaranteed perfect treatment option for prostate cancer which has preventive cancer control benefits and no side effects, the field is advancing and benefitting patients,” he says.

For example, robotic prostatectomy, in which a precisely guided robot assists the surgeon in performing the procedure, is becoming the standard of care. “Robotically assisted prostate surgery means a shorter stay in the hospital, and a quicker return of continence and the ability to resume normal activities,” says Dr. Matsunaga. It’s vital for a man considering prostate cancer surgery to educate himself about the disease and the procedure, and to ask his doctor questions so they can discuss what’s best for him and what the expectations are after surgery in light of his individual case and preferences.”

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Garrett Matsunaga, M.D., on prostate cancer: