Radical prostatectomies: What they are, what to expect, and what we can do.

“No one told me about that.”

Let me tell you a story that has played out multiple times in my career. I’m evaluating a new patient after his radical prostatectomy surgery and, after he gives me his history, I go over some fundamentals: what’s different before and after surgery, what pelvic PT looks like, and general timelines. It’s during that discussion when I often hear some variation of the quote above: “My surgeon never mentioned that.” “Really??” “I had no idea.” Which – given the large number of appointments required in the process of undergoing this surgery – is always a little shocking to me. So, let’s go over radical prostatectomies: what they are, what to expect, and how pelvic PT can help.

A radical prostatectomy is a surgery that removes the prostate, usually in the case of localized prostate cancer.

The technology and techniques involved have advanced a lot since the first radical open prostatectomy was performed 120 (!!!) years ago. For decades these procedures were performed at the perineum (the region between the scrotum and anus), but some surgeons began using a retropubic approach (similar to a C-section) in the 1940s. Techniques were further refined with more sparing of nerve and vascular structures.

Up until the 1990s, these procedures were open – meaning surgeons made an incision and directly operated on the prostate and used their naked eye to see what they were doing. In the 90s, minimally invasive, laparoscopic approaches gained popularity. Now, instead of a large incision, you would have multiple smaller incisions which generally came with fewer complications and surgeons now had cameras that enabled them to see much more closely what they were doing. Most recently, robot-assisted procedures like the da Vinci have become more standard with >85% of prostatectomies now performed with robot assistance. This has reduced complications and improved outcomes. I will say in my career it is very rare to come across individuals who have had open surgeries.

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That describes what radical prostatectomies are and a bit of the history. Now let’s talk about what happens and what to expect.

They remove more than your prostate. They also remove the part of your urethra that runs through the prostate and your internal urethral sphincter. The former results in a loss of penis length of usually 1-2 cm in the majority of patients. Some men will experience a return to more normal length after a couple of years but on average most patients will still lose some length. I will tell you this comes as a great and deeply unpleasant surprise to people who have not been forewarned.

The loss of the internal urethral sphincter means that your body’s self-regulating, autonomic mechanism to keep you continent is gone. Thankfully, you’ll still have your external urethral sphincter which means your voluntary control of when to empty your bladder is still intact. This means urinary leakage (incontinence) is very common after this surgery but it will get better.

You lose the ability to ejaculate during orgasm and now will have “dry orgasms.” Because the prostate is responsible for the production of semen (not sperm, that’s in your testes) and the surgery also removes the seminal vesicles (tubes that carry sperm from the testes to your urethra) it is no longer possible to ejaculate or get someone pregnant during sexual intercourse.

The surrounding tissues are often affected during the procedure. One urologist I know summed it up thusly: “we stretch the hell out of everything in there.” Even with nerve-sparing surgeries and all the technology, surgeons still need to move other stuff out of the way in order to operate on the prostate. This means the nerves, surrounding muscles, and connective tissue need to be physically pulled away from the prostate during surgery. This can result in at least a little injury to these tissues which affects recovery.

The majority of patients will experience some amount of urinary incontinence after surgery but most people regain full or almost full control after a year. It is very common to go from wearing adult diapers all the time to pads in the day and diapers at night to eventually just pads to full independence. Erectile dysfunction is also very common after surgery but patients are usually given an ED medication such as tadalafil (Cialis) to maintain penile function after surgery, promoting blood flow and muscle tone. Most who have normal erectile function before surgery will regain function after surgery.

*Random tidbit that can save you some pain after surgery; surgeons inflate the abdomen with CO2 gas during surgery to help separate the tissues and better see what they’re doing. That extra gas in your abdomen often causes shoulder pain after surgery. Get a heating pad that goes over your shoulders for those first few days at home while the extra gas eventually disperses. It can really soothe a lot of that pain.

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There’s a lot involved in this surgery but now let’s talk about how we can improve recovery from this surgery.

Preoperative pelvic floor therapy improves post-operative outcomes and speed of recovery. Since many patients wait for months for their surgery, that is time that can be used to work on pelvic floor muscle control and strength which they can then use post-operatively to manage their symptoms. Additionally, seeing a pelvic physical therapist prior to surgery can give patients knowledge and reasonable expectations for how things will go after surgery.

Post-op pelvic floor therapy is beneficial to help patients regain urinary and global function. Guided exercises, manual therapy, and education to understand how to modify daily or work activities to manage symptoms in the short term are some of the ways pelvic PT can help. I always tailor the exercises I give to what the individual experiences. An electrician and an optician have different tasks in the day and require different approaches and strategies. A pelvic PT can also help set meaningful, realistic goals and expectations. I’ve found myself many times reminding patients that they had major surgery. Expecting to return to normal work and activity routines in a month or two is just unrealistic despite what they read on reddit forums or Facebook groups. On the human side, it’s often nice to just have someone to talk to about what you’re going through. Recovery from any surgery is tough, both physically and emotionally. Even more so when that surgery affects something so personal and intimate. Taking care of your mental health while dealing with a major health issue and surgery is something I always recommend.

Sadly, I’ve heard from patients who had to seek my out themselves that their doctor just told them to “do some kegels” or “wait it out” and their symptoms would improve. But the truth is many of us haven’t really thought about or focused on using our pelvic floor muscles, ever. Most patients I see the first time execute a kegel poorly or compensate in ways that would actually worsen symptoms like urinary incontinence. Thankfully, more urologists are aware of the benefit of pelvic physical therapy and refer their patients but it is still common that patients have to seek out help on their own.

Even if you had surgery years ago but are still experiencing residual symptoms, pelvic floor therapy can help. I’ve treated men who are two or twenty years from surgery and they saw improvements with some education, muscular retraining, and functional strategies.

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Bottom line, radical prostatectomies are major surgeries that affect many aspects of patients’ lives. Pelvic PT can make a huge impact on recovery whether you get treatment two months before surgery or 20 years after. Be patient. Healing takes time and remember to trust the biology. You may have to advocate for yourself to see a pelvic PT. It is important to remember that you have the right to see a PT in all 50 states without a referral, for 10 visits or 30 days, whichever comes first. If you have further questions, click the Book an Appointment button or call us at (860) 281-2441.

Unbound Physio PLLC provides one-on-one pelvic health, balance, and orthopedic physical therapy in West Hartford and the Greater Hartford area.