FAQs what to expect after prostate cancer surgery

Below you will find answers to frequently asked questions about what to expect after surgery at the Smilow Center.

How do surgeons predict the return of urinary continence and potency after radical prostatectomy?

When seeking an opinion from a urologic surgeon, it is important to determine the basis for his or her predictions about the return of urinary continence and potency after prostatectomy. Is the surgeon quoting his own personal outcomes, or those of experts reported in the scientific literature? If reporting personal outcomes, how were the data collected? Did the surgeon use validated, objective questionnaires that were collected without prompting? Have the outcomes been published in peer-reviewed journals?

The Smilow Center employs a full-time research database manager to support objective collection of data after radical prostatectomy. Since October 2000, over 1,700 men have consented to participate in our prospective longitudinal clinical outcomes database. To date, we have monitored continence, potency and other quality-of-life factors for up to 9 years. Using validated questionnaires, we have collected a large series of data that have been recorded and analyzed by the independent database manager. Our analyses of these data have been published in the most prestigious scientific journals in the field of urology. Our rigorous clinical outcome research program has provided the opportunity to continually assess and improve our methods of treating prostate cancer.

How long does it takes to regain urinary control (continence)?

Smilow Center surgeons have reported that 80% of men regain continence after 3 months, 90% after 6 months, 93% after 12 months and 97% after 24 months. A small subset of men will regain complete urinary control immediately after the catheter is removed (Lepor H, Kaci L, Xue X. J Urol. 171(3):1212-5 (2004); Abraham H, Makarov D, Laze J, Lepor H. J. Urol. 181(4)(Suppl. 1):670 (2009)).

Do Kegel exercises facilitate the return of urinary control?

Kegel exercises are a way to rehabilitate the sphincter mechanism after radical prostatectomy. Before surgery, a nurse specialist instructs all patients on the proper method of performing these exercises. Although there is no definite proof that Kegels are effective, the exercises are simple to perform, and they add no cost.

Are there surgical options to restore urinary continence?

Permanent urinary incontinence is rarely encountered by men who undergo open or robotic surgery by Smilow Center surgeons. In rare cases, stress incontinence may require surgical correction using either a male sling or an artificial sphincter, depending on the degree of incontinence. Dr. Victor Nitti, the Director of Voiding Dysfunction at NYU Langone Medical Center, is one of the world’s leading authorities on the treatment of male incontinence. In the rare event that a patient has a problem regaining continence, a consultation will be arranged with Dr. Nitti. In virtually all cases, continence can be restored or markedly improved with a male sling or artificial urinary sphincter (Kumar A, Litt ER, Ballert KN, Nitti VW. J. Urol. 181(3):1231-5 (2009); Fischer MC, Huckabay C, Nitti VW. J. Urol. Apr; 177(4):1414-8 (2007)).

Does radical prostatectomy have an effect on pre-existing lower urinary tract symptoms?

Approximately 40% of men who undergo radical prostatectomy have bothersome lower urinary tract symptoms prior to surgery. The most effective treatment for lower urinary tract symptoms secondary to benign prostate enlargement is a transurethral resection of the prostate, which resects the ‘obstructing’ benign prostate tissue. Therefore, it is reasonable to assume that a radical prostatectomy would also alleviate these pre-existing symptoms.

Smilow Center surgeons were the first to report the beneficial effects of a radical prostatectomy on lower urinary tract symptoms (Lepor H, Schwartz E. J. Urol. 161(4):1185-1188 (1999); Lepor H, Slova D. J. Urol. 178(6):2397-2400 (2007)). Approximately 80% of men will experience significant improvement of lower urinary tract symptoms after radical prostatectomy. For men with these symptoms, the overall urinary quality of life is likely to improve after prostatectomy.

How long does it take to regain erectile function?

Unlike the restoration of urinary continence, the return of erectile function is typically a more protracted process. Very few men spontaneously regain erectile function immediately after radical prostatectomy. Erectile function typically begins to return between 3–12 months after surgery and typically becomes adequate for penetration within 1 to 2 years.

When assessing the credibility of potency outcomes, it is imperative to know:

  • The characteristics of the patient cohort
  • If a validated questionnaire was utilized to assess potency
  • If the data were captured using a self-assessment methodology
  • The definition of potency
  • The interventions used to promote potency
  • The involvement of the surgeon in data collection, entry and retrieval
  • Whether the potency outcomes were reported in a peer-reviewed publication

Smilow Center surgeons have published the most rigorous and credible assessment of potency from their prospective longitudinal outcomes database. Of all men who engaged in sexual intercourse preoperatively, Smilow surgeons have reported that approximately 60% will regain the ability to have intercourse within 2 years, with or without the assistance of PDE-5 inhibitors like Viagra, Cialis or Levitra (Marien T, Sankin A, Lepor H. J. Urol. 181(4):1817-22 (2009)). Men who are willing to embark on a regimen of penile injections may regain the ability to have sexual intercourse immediately after surgery.

It should be noted that although many urologists assume that maximal return of erectile function is achieved by 2 years after surgery, surgeons at the Smilow Center have found that this is not the case. In one of the recent Smilow Center publications, over 50% of men reported some degree of improvement in their erections between 2 and 4 years after surgery, and 20% indicated that the degree of improvement over this interval of time was moderate to marked (Glickman L, Godoy G, Lepor H. J. Urol. 2009 Feb; 181(2):731-5).

Is there any way to predict if I will regain erectile function after surgery?

The Smilow Center has conducted one of the largest studies examining the return of erectile function after radical prostatectomy (Marien T, Sankin A, Lepor H. J. Urol. 181(4):1817-22 (2009)). In this study, men who had undergone prostatectomy completed questionnaires about their erectile function in the months and years after surgery. This cohort included all men who indicated their ability to have penetrable sex prior to surgery, regardless of the quality of their erections.

The study showed that the return of erectile function was related to age, a history of diabetes, high blood pressure or coronary artery disease, the baseline quality of erections, the use of PDE-5 inhibitors, and whether a nerve-sparing surgical procedure was attempted.

Smilow Center surgeons have also reported potency rates of 80% for men under 50 years of age who undergo a bilateral nerve-sparing radical prostatectomy (Twiss C, Slova D, Lepor H. Urol. 66(1):141 (2005)). This is the cohort in which we expect the best potency outcomes.

Does taking a PDE-5 inhibitor facilitate regaining potency?

NYU Langone Medical Center urologists pioneered the use of PDE-5 inhibitors such as Viagra, Cialis and Levitra for the treatment of erectile dysfunction (McCullough A, Barada J, Fawzy A, Guay A, Hatzichritsou D. Urol. 2002; 60:28-38). These agents were subsequently found to be effective for the treatment of erectile dysfunction after radical prostatectomy (Montorsi F, Nathan HP, McCullough A et al. J. Urol. 172:1036 (2004); Montorsi F, McCullough A. J. Sex. Med. 2:6458-667 (2005)). NYU Langone urologists were the first to demonstrate that PDE-5 inhibitors taken daily for 9 months immediately after radical prostatectomy facilitate the return of spontaneous erections at one year (Padma-Nathan H, McCullough AR et al. Int. J. Impot. Res. 20(5):479-86 (2008)). On the basis of this study, Smilow Center physicians incorporate the use of daily PDE-5 inhibitors in their penile rehabilitation program.

Is it possible to have a pleasurable orgasm without the ability to have erections?

Male sexual function may be broken down into three components: erection, ejaculation and orgasm.

  • Erection is the increase in blood flow to the penis resulting in a ‘hard’ penis, which is required for penetration. Erection may be affected by radical prostatectomy.
  • Ejaculation, which occurs at the time of climax, is the expulsion of seminal fluid produced by the prostate and seminal vesicles. After radical prostatectomy, there is no longer ejaculation associated with orgasm.
  • Orgasm is the pleasurable sensation associated with a sexual climax. Most men retain the ability to experience a pleasurable climax with sexual stimulation, even if they are unable to have an erection.

What is penile rehabilitation?

Smilow Center surgeons, in collaboration with leading experts in male sexual health at NYU, have devised a protocol that combines pharmacologic and mechanical intervention to facilitate return of erectile function (McCullough AR. Asian J. Androl. 2008; 10(1):61-74). There is increasing evidence that ‘sexual rehabilitation’ regimens after prostate cancer surgery can help prevent irreversible long-term functional damage to the penis. We recommend that men and their partners meet with one of our sexual medicine experts before surgery (see the Smilow Center’s brochure on "Sexual Rehabilitation After Prostate Cancer Surgery"). At this visit, surgical candidates will undergo a comprehensive interview, physical exam, blood work and/or other diagnostic tests. The sexual medicine experts will then discuss realistic goals and expectations for your recovery of sexual function and develop an individualized rehabilitation plan. The plan typically includes the use of Viagra, a vacuum erection device (VED), MUSE (a urethral suppository) and penile injections.

How will I know if my cancer recurs after prostatectomy?

The likelihood of disease progression after radical prostatectomy can be predicted based on several pathological parameters derived from examination of the surgical specimen (Godoy G, Tareen BU, Lepor H. BJU Int. published online 22 June 2009). The earliest sign of disease recurrence is a steady increase in the serum PSA. Smilow physicians have shown that very early trends in ultrasensitive PSA may predict eventual relapse (Shen S, Lepor H, Taneja SS. J. Urol. 173(3):777-80 (2005)). A rise in the PSA in almost all cases precedes radiographic or clinical evidence of disease recurrence. Until recently, there was not a uniform definition of a biochemical or PSA recurrence. There is now a consensus that a rising PSA and two consecutive PSA measurements above 0.2 ng/ml constitute disease recurrence. Smilow physicians routinely use ultrasensitive PSA in monitoring all men after prostate cancer surgery.

What are the options for managing a recurrence of cancer?

A ‘biochemical recurrence’ of prostate cancer is defined by an elevated PSA. The major challenge when this occurs is to determine the site of the disease recurrence. Research by the Smilow Center has shown that imaging studies such as MRIs, bone scans and ProstaScint scans rarely identify the site of recurrence (Lepor H, Perlmutter MA. Urol. 71(3):501-5 (2008)). If the disease recurrence is localized (confined to the area of the prostatic bed), then salvage radiotherapy is likely to cure the disease. On the other hand, if the recurrence is due to systemic disease, salvage radiotherapy will fail, and hormonal therapy may be offered.

The likelihood that salvage radiotherapy will be effective depends on a host of factors (Stephenson AJ et al. JAMA. 291(11):1325-32 (2004); Patel R, Lepor H, Thiel RP, Taneja SS. Urol. 65(5): 942-6 (2005)).

These factors include:

  • The presence of positive surgical margins
  • Whether the cancer had invaded the seminal vesicles
  • The Gleason score on the surgical specimen
  • Whether the PSA was undetectable immediately after the initial surgery
  • Time elapsed between the initial treatment and the discovery of the recurrence
  • The absolute level of the PSA at the time treatment is considered
  • How fast the PSA levels doubles over time