Episode 10: Prostate Cancer-Making Decisions...Surgery/Robotic Prostatectomy and ED

Part 2 of my 3 Part Discussion with Dr. David Ahlborn on Prostate Cancer. In this episode we will address Surgical Treatment, including Robotic Assisted Prostatectomy. We also talk about Erectile Dysfunction and Sexual Issues that are associated with surgery. We will also speak about the different treatment and therapies for this post-operative sexual dysfunction.

Transcript

SPEAKER_02 0:00

This podcast is not intended to be a substitute for professional medical advice, diagnosis, or treatment. It is for informational purposes only. Always consult with a qualified healthcare professional for any health concerns or before making any decisions related to your health. Thank you.

SPEAKER_01 0:17

When you're in trouble and you need help, go to your inlucknowstreaming.

SPEAKER_02 0:29

Hello there and welcome back to You're in Luck Now Streaming. This episode is episode two of my three-part series on prostate cancer, which is inclusive of my discussion with my esteemed colleague, Dr. David Alborne, graduate of Harvard University, Columbia University Medical School, Mount Sinai Hospital residency in urology, and then fellowship at Hartford Hospital in Robotic Surgery and Urological Oncology. In the previous episode, we spoke about breaking the news of prostate cancer, the Gleason score after you get a prostate biopsy, active surveillance of prostate cancer, along with other treatment options. In the next two episodes, we'll dig deeper and focus on making decisions for treatment. This episode, we'll focus on surgical treatment, including robotic prostatectomy, erectile dysfunction related to surgery, and its treatments. And in the next episode, we'll focus on radiation options and hormone deprivation therapy. We'll pick up where we left off. So now let's get into the flow.

SPEAKER_00 1:41

Not all robotic surgeries are the same, even with the same surgeon. When I do a surgery, I spare different tissue as I'm operating based on where the patient's cancer is. I take more tissue and potentially nerves on the side where there's aggressive cancer. If there's not a lot of cancer, then I spare the tissue there. So, you know, I think of the prostate in like eight segments. And I, using the pathology, the MRI, and my exam, I break down that surgery into those eight quadrants of the prostate and I spare tissue accordingly. Because the goal is to get rid of the cancer and preserve everything else.

SPEAKER_02 2:23

Right.

SPEAKER_00 2:24

And that's challenging.

SPEAKER_02 2:25

What about um what would determine what would make you determine uh your lymph node dissection when you were doing a prostatectomy?

SPEAKER_00 2:37

We used to do lymph node dissections on everybody. And the you know, the trend in our field is to do fewer and fewer lymph node dissections. And there's you know scholarly papers coming out on a regular basis looking at this. The kind of key is does doing a lymph node dissection improve your overall survival? If I take out your lymph nodes, have I bought you any more years of life? And we're sort of finding that that isn't really the case. Maybe it was true years ago, but now we have PSMA PET scans, and we have, you know, PSA is very sensitive, and we have other good treatments for advanced prostate cancer that even if you have a recurrence or lymph node positive disease, we can catch and still preserve your length of life. So for me personally, I tend to follow you know the guidelines. I think it's you know, the guidelines are there for a reason. Um it's okay to go off of guidelines. They're not laws, they're not rules, uh, but they're good suggestions. And the current NCCN recommendations is to do a lymph node dissection for unfavorable intermediate risk or higher. High risk, you should probably do it. Sure. Unfavorable intermediate risk, you know, intermediate risk in general is a complicated risk category. And unfavorable intermediate risk, you know, probably would benefit from a lymph node dissection. Um, what's the rationale for not doing it? And the answer is that there are side effects of doing a lymph node dissection. It's not just you know symptom-free. You can get leg swelling, you can get leakage of lymph fluid, you can have complications. They're not common, but when they happen, that's another notch against your quality of life.

SPEAKER_02 4:35

Right. Um, when you do prostate surgery, since we're now talking about prostate surgery, um, you are a robotic surgeon and you do robotic radical prostatectomies, you do robotic simple prostatectomies. Um, for the radical prostatectomy, which is the kind that we do for a patient with prostate cancer. Tell me about the recovery. What should patients expect when they're recovering from this versus say uh radiation treatment?

SPEAKER_00 5:08

Yeah, so robotic radical prostatectomy is a major surgery. It's a three or sometimes four hour surgery. It's complicated. And you're working in a very delicate organ space. Like any robotic surgery or major surgery, you there is a recovery period. Now, one of the benefits of doing robotic versus open is we go through smaller incisions. So that real discomfort you get from like going through muscle in the abdomens makes recovery a little bit better. You know, people are up walking around the afternoon of their surgery. Some surgeons will discharge, will do it as an outpatient. They'll send you home the day of surgery. Wow. So this isn't a lie in bed and feel sick type of surgery, but there can be discomfort. You have a catheter in the bladder when you're going home. That's usually a new experience for most men. That can be annoying. Um, and then you can have issues with your bowels. It can take time, you know, you haven't eaten anything since the night before. We've pumped all this air into your abdomen, your intestines can go to sleep. So constipation and gas pains is also really common and can last for a couple of days after the procedure.

SPEAKER_02 6:27

Right.

SPEAKER_00 6:29

So that first week, when you go home, even though you're up kind of walking around, you you feel off. Then the catheter comes out, you start having bowel movements, and you really start progressing. I usually tell people you'll be back to 80% of your health by two weeks after the surgery, and you should be back to 100% of your health by four weeks. But everybody heals differently. Sure. And, you know, complications can happen. They're statistically low, but you take 100 people, even a statistical event that is supposed to happen 1% affects one person in 100. So, and that can alter your recovery, you know, period.

SPEAKER_02 7:14

Um something that patients are always concerned about is leakage after prostate surgery. So tell me what is the percentage of patients who will get urinary leakage after prostate surgery, and does it get better over time?

SPEAKER_00 7:33

Um leakage is an important um thing to talk about. I tell people you should expect some degree of leakage after surgery. Now, in practice, not everybody does have leakage, but I tell everyone to expect it because you don't want to be told, oh, you're not gonna have leakage, and then now you're you're leaking. That's not fun. Um it really depends on your body habitus, the degree of your cancer, how aggressive your cancer is, and what kind of tissue is preserved at the time of surgery. If you have you know really aggressive disease and you're overweight, there's a good chance you're gonna have leakage. It could be complete florid incontinence. If you're on the other end of the spectrum, you may not have any leakage, or you may have a little bit of dribbling if you cough or sneeze. But I tell everyone to expect some degree of leakage immediately after the catheter comes out. Now that for the vast majority of people recovers pretty quickly within the first couple of months. By one year, the vast majority of people are dry or happy with their urination. Like over 90% of people. It's a very small subset of people who are unhappy with their degree of urination. Now, one of the benefits of surgery is anything that goes wrong with surgery or any you know complication or uh negative side adverse effect, you can correct it. It's usually done with surgery, or you know, if it if it's mild, you can do it with pelvic floor physical therapy. Uh, and if it's really significant, you can put in artificial urinary sphincter. Right. So there are ways to correct those problems. It'd be great if it didn't happen, but again, statistically, some people will experience this. It's important to know there are options for correcting it.

SPEAKER_02 9:44

Changes the patient's outcomes dramatically, or is it actually the the surgeons' experience themselves?

SPEAKER_00 9:52

Versus open?

SPEAKER_02 9:54

Yeah.

SPEAKER_00 9:57

We've done a lot of research on this. And the outcomes between robotic surgery and open surgery are very similar. It's never been well proven that robotic surgery is much better than open surgery in terms of cancer control, urination, erectile function, where robotics has been repeatedly shown to be better is things like length of stay, need for transfusion, and kind of like the short perioperative issues. But in the long run, they're pretty equivalent. But what is far more important is what you alluded to, which is surgeon experience. If your surgeon does only open surgery, you want him to do his open surgery on you. You don't want to force this person who doesn't do robotics to try it robotically, and vice versa.

SPEAKER_02 10:54

So, you know, it's funny. I did have a patient a couple of years ago who did not want any treatment for prostate cancer because they would possibly not be able to get an erection or have an ejaculation. He wasn't that young, or he wasn't that old, I should say, and he wasn't that sick, but he really didn't want the prostate cancer to affect his ability to have intercourse. So, what do you do for a patient like that?

SPEAKER_00 11:23

Yeah, I mean, these these patients exist. I mean, every vast majority of men think about erections and how treatment is going to affect them. Where on the spectrum of how important, like, I cannot live without this is different for everybody. I think it's important to have a very good understanding as the physician about how aggressive the cancer is, what realistically the outcome for that patient is going to be if they do nothing and relay that to the patient.

SPEAKER_02 11:56

Sure.

SPEAKER_00 11:57

And to also reassure them that, you know, yes, you may experience erectile dysfunction, but we have good treatments for erectile dysfunction. Ejaculation, that's a different story. The treatment of prostate cancer is going to affect your ejaculation. We don't really have good treatments for that.

SPEAKER_02 12:16

Even with radiation.

SPEAKER_00 12:17

Even with radiation. So, you know, that that is a consideration. But if you have um a patient who's not that old, who uh says, you really I really don't want to do anything because sex is so I have sex every day and it's the most important thing in my life, you have to really evaluate how aggressive that patient's cancer is. If they're on the lower end of the spectrum, that's somebody I who would absolutely be perfect for active surveillance.

SPEAKER_02 12:51

Right.

SPEAKER_00 12:51

If they're on the higher end of that spectrum, it's your duty to explain to them, like, yes, you know, I understand sex is important to you, but if we do nothing, there is a good chance in the next 10 years you come back to me and now it's in your bones. So you're, you know, you're 60 now, because that's not that old.

SPEAKER_02 13:14

Yeah.

SPEAKER_00 13:14

And if we do nothing now, now we have a chance to cure it, but if you come back to me in 10 years, it may be metastatic. And now we're not going to be talking about doing radiation or surgery to try to cure you. We're just going to be talking about hormonal therapy to control your symptoms, your bone symptoms, or um, you know, or the disease. But even then, you know, they may come back to you in 10 years. Now they've got metastatic disease, and they said, I had I had a good life having sex every day, and I and I don't have regrets. But it is your job as the physician to kind of explain that to them.

SPEAKER_02 13:51

Sure.

unknown 13:52

Sure.

SPEAKER_00 13:53

Because if you know, if sex is, if he just wants to get an erection, you can do even if he has any person who has complete erectile dysfunction, whether this is post-surgery, post-radiation hormones, or just organically, they don't have prostate cancer. Yeah, we have surgical procedures to help make erections. And they're excellent. They're really good.

SPEAKER_02 14:18

These are the intrapenal prostheses that you're talking about. And that's extreme, right?

SPEAKER_00 14:22

That's that's extreme, but we have treatments short of that that are also excellent. We have yeah, we have oral medications and they work pretty well. They don't work great if you really don't have any functionality. Right. They just don't. But we can do injections, you know, combination of medications that you inject that will give you excellent erections.

SPEAKER_02 14:44

And we do see patients who are post-operative, who have poor erectile dysfunction after, that get an amazing erection with the intracavernosal injections, even on a very low dose. Usually I see it's those patients who are postoperative that don't have decent erections right after the surgery that are very receptive to the intracavernosal injections and get a fantastic erection. And then several months later, they don't even need to use the injection therapy because they have a good response to the surgery.

SPEAKER_00 15:21

Yeah. We were speaking about incontinence after surgery earlier. Um erectile dysfunction is another thing that I tell all my patients they should expect some degree of erectile dysfunction after surgery. Because the nerves that go to the penis and allow for erections make a hammock that the prostate sits on, and you have to peel those nerves off, even if you can save the nerves, and you can't always save the nerves. You have to peel those off, and nerves don't like to be touched or looked at, they want to be left alone. So now you went in there and you touched them and they're asleep now. So I tell people expect some degree of erectile dysfunction. The good news is that there is recovery and regeneration of those nerves. It typically lags behind return of continents, though. Nerves are more finicky than, say, muscles, which you just go to the gym and work out your muscle, you know, you get that back. Nerves take take their time. The number one predictor of erectile function after surgery is how your erectile function is before surgery. So if you have good erectile function before surgery, there's a good chance you'll have decent erectile function after surgery, assuming you know you don't have the you know terrible disease, very aggressive disease where we're kind of cleaning everything out.

unknown 16:45

Sure.

SPEAKER_00 16:46

And then those injections or pills are good in the immediate post-op period where, like you said, your erectile function is still recovering.

SPEAKER_02 16:57

Right.

SPEAKER_00 16:57

But many people don't require long-term treatment of erectile dysfunction, you know, after surgery.

SPEAKER_02 17:07

Um how do you balance curing cancer while maintaining a patient's quality of life?

SPEAKER_00 17:14

That's the million-dollar question, right? Sure. That's because it's That's why I asked it. That's why you asked it. It's we can you know cure uh speaking, I guess, about surgery primarily here. Sure. You can go in there and clean out everything, right? The more tissue you take out, the higher the chance there's a cure. But the consequences of that can be significant if you're not careful about what you're cutting out.

SPEAKER_02 17:45

Sure.

SPEAKER_00 17:46

Florid incontinence, complete erectile dysfunction. Those are pretty significant changes in your quality of life that are gonna be annoying to you know fix. Um and that's why doing some of these techniques like nerve spares, bladder neck preservation, doing different approaches on the robot, they're all designed to help preserve the tissue that helps to maintain your quality of life. But the balance is it's not like color in the lines. You know, it's not like the cancer's blue and everything else is red, and you can, you know, see you just cut in between them, right? It's it's not that simple. And that's where a good understanding of each patient's disease and where it is based on biopsy imaging and and whatnot comes into play there. And then it's statistics. What's the probability that the cancer that's on the left side of your prostate is eating into the nerves? And do I have to take some of the nerves there to try to get you a cure?

SPEAKER_02 19:01

Yeah.

SPEAKER_00 19:02

And and that's really the that's the art of surgery right there.

SPEAKER_02 19:07

Sure. Is there something that you can do to help men recover after surgery, their their uh erectile function and their um level of incontinence postoperatively?

SPEAKER_00 19:22

It all starts at um at the time of surgery. I don't rush through surgery. Surgeons shouldn't shouldn't rush, you shouldn't want your surgeon. Somebody who says they're the fastest surgeon in the world, it may not be what you want. I can do surgery really fast. It's not gonna be a great surgery, though, right? Like it's a meticulous surgery. So your recovery starts there. After we're done with surgery, I'm a big fan of pelvic floor physical therapy. You can do kegel exercises, right? That's kind of easy, right? You just Google Kegel exercises, you know. But I worked at and when I was in a previous, you know, when I was working at a previous hospital, I actually worked very closely with the pelvic floor physical therapist. She would come into the operating room so she could see what I was doing, and we would talk about how we can, you know, uh optimize return to urinary control. And she would tell me the biggest problem she sees is everyone's pelvis is really tight right after surgery. Right. We need to relax, break that down first and rebuild specifically where we want the tone. And that's why I like pelvic floor physical therapy, because if I just tell you to do Kegel exercises, you miss all of that. And half the people who do kegel exercises do it wrong. And you know, half the people who are supposed to do it don't even do it. Probably more than half.

SPEAKER_02 20:50

We see this every day.

SPEAKER_00 20:51

Exactly. So that's um that's as it pertains to consonants. Now, the other thing, if you did none of that, you probably would just regain your continents anyway. It's just a matter of timing, it's just gonna take longer.

SPEAKER_02 21:05

Right.

SPEAKER_00 21:06

Which is the nice thing about that. As it pertains to erectile function, there's data to support taking like a Viagra or a uh Cialis in the immediate postoperative period to kind of promote uh you know the blood return and keeping the penis plastic, you know, through this period of time where it's not really functioning that much. The data is not astounding. If you don't do it, you're not doomed to never get another erection. So it's you know, everybody you take everyone differently. Um but that is kind of the best way thing we have for trying to promote erectile recovery outside of the techniques that we do during the surgery.

SPEAKER_02 21:55

They talk about prehabilitation, which is prehabilitation. Much exactly what you're saying. Start a patient on a low dose tadalafil, uh like five milligrams every day, to increase blood flow to the penis and to encourage erectile function so that postoperatively you regain that function much quicker than um if you didn't take it. Plus, the pelvic floor physical therapy is fantastic. I mean, every I think everybody should be getting this pelvic floor physical therapy before and after the procedure.

SPEAKER_00 22:27

Yeah. I used to refer uh patients pre-op to pelvic floor physical therapy. There's uh then insurance kind of gets in the way, right? Because these patients don't carry a diagnosis of anything pre-operatively. It's not until post-op when they have now incontinence that they like qualify. So there's a little bit of that going on. But there's also, I don't want to say a stigma, but there's this sense that physical therapy doesn't work in the American population, that it's like hocus pocus. And I was guilty of this myself, actually. Like early on in my career, you know, you hear about pelvic floor physical therapy, phys physical therapy, blah, blah, blah. And you're like, there's just no way this works, right? Like, it's all about surgery. But doing a lot of this and working closely with pelvic floor physical therapists and seeing patients who I was felt like the only way we're gonna fix this is surgery, making complete recoveries has certainly made me a believer.

SPEAKER_02 23:25

Sure. Sure.

SPEAKER_00 23:27

It's just hard to convince other people, you know. I even if I tell them that, then there's yeah, yeah. It's up to them to make the leap.

SPEAKER_02 23:35

Thank you again, Dr. Alborn, and I hope you enjoyed our discussion of surgical options and robotic prostatectomy. Don't forget to tune in for the next episode, which will focus on radiation options and hormone deprivation therapy. And remember, you should never feel that a diagnosis of prostate cancer is a death sentence. There are many treatments available, and through shared decision making with your provider, you can choose treatment that suits you. And don't forget, if you're in trouble and you need help, go to your in luck. Thanks for listening and subscribing.

SPEAKER_01 24:14

When you're in trouble and you need help, go to your in luck now streaming.