Erectile Function and Continence After Robotic Prostatectomy

Erectile function after robotic prostatectomy is highly variable. It can return as early as four to six weeks, sometimes takes three months or a year, and in some men does not return. Dr. Yajvender Pratap Singh Rana ties recovery to three factors: how sexually active and fit the man was before surgery, the stage of the tumour, and whether the nerves could be preserved.

Dr. Yajvender Pratap Singh Rana is Senior Director - Urology, Uro-Oncology, Andrology and Kidney Transplant at BLK-Max Super Speciality Hospital, New Delhi, India. The question came up repeatedly when international doctors joined his Jivo Masterclass, because it is the question their patients ask most often. One referring doctor put it plainly: before agreeing to prostatectomy, most men want to know how well, and how easily, they will return to normal erectile function. This article sets out how Dr. Rana answers it, how he protects urinary continence, and why he considers the robot better than open or laparoscopic surgery for nerve sparing. The surgical steps themselves are described in the technique article, and the wider treatment picture in the complete guide to robotic radical prostatectomy.

The prostate cancer trifecta: cancer, continence, then erections

Dr. Rana frames counselling around the prostate cancer trifecta, three outcomes in order of priority:

1. Cancer control.
2. Urinary control, meaning continence.
3. Sexual function.

Sexual function is third, and he is explicit that counselling should say so. The cure of the cancer is the most important thing. A man has to survive before he can enjoy sex; that, he said, is the bottom line, and it is how doctors should counsel their patients.

That order is not a dismissal of sexual function. It means that when the tumour lies close to the nerves, the surgeon removes the cancer completely first and accepts the consequences for erections, which can be treated later.

What determines erectile function after robotic prostatectomy

Dr. Rana identified three determinants of erectile recovery:

• Function before surgery. Recovery depends on how sexually active and how strong a man is beforehand. A man with good erections before the operation has the most to preserve.
• Stage of the tumour. In early tumours, Dr. Rana is able to preserve the nerves fully. In locally advanced disease, where the tumour has reached or crossed the capsule, the nerves often cannot be spared.
• The nerves themselves. The neurovascular bundles, which carry the nerves for erection, run in a thin layer along each side of the prostate. Whether they survive the operation depends on the tumour and on the precision of the dissection.

For a man whose prostate-specific antigen (PSA) level was very high and whose disease was locally advanced or oligometastatic, meaning limited stage 4 spread, the nerves usually cannot be saved. Even then, Dr. Rana noted, the patient still has good options for sexual function later.

Is robotic prostatectomy better for nerve sparing?

In Dr. Rana's experience, yes: robotic surgery preserves sexual function better than both laparoscopic and open surgery. When the moderator asked whether robotic prostatectomy is safer than open surgery for preserving erectile function, his answer was unequivocal: it is safer. He gave three reasons:

• The neurovascular bundles are easier to locate. The robot's view is highly magnified, so the bundles can be identified and followed.
• The dissection is very precise. The surgeon can follow the plane between the prostate and the bundles under high magnification.
• Hydrodissection. Sometimes his team injects fluid to open the plane around the neurovascular bundles, preserving it and the neurovascular plexus within it.

On every count, he said, robotic surgery scores over other treatment options in the preservation of sexual function.

Nerve sparing after HIFU or radiotherapy

There is a further reason Dr. Rana steers suitable patients towards surgery first. After radiotherapy or focal therapy such as high-intensity focused ultrasound (HIFU), a later robotic prostatectomy becomes difficult, nerve preservation becomes difficult, and so does keeping sexual function. A man choosing focal therapy to protect his erections may, if the cancer returns elsewhere in the gland, face salvage surgery with poorer odds of nerve sparing. The comparison between focal therapy and surgery is set out in the complete guide.

Case: sexual activity four weeks after robotic prostatectomy

Dr. Rana described a man of about 60 who had been under his follow-up for several years for benign disease: a stricture and stone disease with hydronephrosis (swelling of the kidney from blocked drainage), which had been managed endoscopically, including removal of the stones. At a routine annual review the stricture was stable, but his PSA was raised at 6.5. Biopsy showed a Gleason score of 4 + 4, a high-grade tumour; the Gleason score grades how aggressive the cancer cells look under the microscope.

Two points shaped the decision:

• Active surveillance was not an option. Active surveillance means monitoring with regular tests instead of immediate treatment. A Gleason 4 + 4 cancer is a significant tumour, even with a modest PSA.
• The patient's priorities were clear. He was very active, including sexually, and told Dr. Rana he was ready to do anything, but wanted his sexual function back as soon as possible.

Dr. Rana gave him guided reassurance that his chance of good erections afterwards was about 80%. He started tadalafil before surgery to prime the tissue, performed a robotic prostatectomy, and removed the catheter. Four weeks after surgery the patient had resumed sexual activity with his wife. He told Dr. Rana that he had been cured of cancer and could enjoy sex too.

The case illustrates the best end of the range: a sexually active man with a PSA that was, in Dr. Rana's words, luckily only 6.5.

Penile rehabilitation after prostatectomy, step by step

Dr. Rana's rehabilitation sequence escalates only when the previous step is not enough:

1. Tadalafil from the start. He gives tadalafil, a phosphodiesterase-5 inhibitor that improves blood flow to the penis, before surgery and continues it through rehabilitation.
2. Self-stimulation after the catheter is removed. Patients are taught self-stimulation once the catheter is out, and many are able to achieve erections this way.
3. Intracavernosal injections. If tablets and stimulation are not enough, there is nothing to worry about. Once the pain of surgery has settled, after a few weeks, the patient can use injections into the penis that produce an erection directly.
4. Penile implant. For advanced cases where the nerves could not be preserved and erections do not return, a penile implant restores sexual function.

The message to patients is that a loss of erections after surgery is a treatable problem, and that curing the cancer comes first.

Urinary continence after robotic prostatectomy

Dr. Rana considers urinary control after robotic surgery quite acceptable; it is the second element of the trifecta. Two technical points from his demonstration bear on it:

• Bladder neck preservation. In the video of a locally advanced case, the bladder neck was almost fully preserved, and he predicted good continence for that reason.
• A watertight anastomosis. The join between bladder and urethra is tested with saline at the end of the operation. When there is no leak, he removes the catheter with very good confidence after 7 to 10 days.

Patients typically go home three days after surgery and keep the catheter for two weeks, at most 20 days.

How to counsel patients about erections before prostatectomy

Drawing the threads together, Dr. Rana's counselling for referring doctors comes down to a few honest statements:

• Timing varies. Erections may return in four to six weeks, three months or a year, or may not return. There are multiple factors.
• Early disease gives the best odds. When the tumour is early and the nerves are spared, a strong chance of good erections is realistic.
• Advanced disease does not end sexual life. If the nerves cannot be saved, injections and implants remain available.
• The cancer comes first. Cancer control and continence take priority over sexual function.

Every question raised on this subject in the session, with Dr. Rana's answers, is on the Live Discussion page. Erectile dysfunction outside cancer surgery is covered in the article from Dr. Rana's earlier urology masterclass on erectile dysfunction and male infertility. Approximate costs of the operation for international patients are on the robotic radical prostatectomy cost page.