Incontinence and Surgical Technique

As I was learning about prostate surgery one fact that I encountered over and over in books and articles was the importance of the surgeon's skill in preserving the external urethral sphincter located just below the prostate.

It was emphasized that the surgeon must cut out all the prostate, but be careful to not cut any of the urethral sphincter, which is all that is left after prostatectomy to control urine flow. This is a delicate part of the operation, requiring exquisite skill. 

I talked to my urologist at length about this aspect of the surgery beforehand, as well bilateral nerve-sparing.  He agreed that saving the entire urethral sphincter is crucial to regaining continence. I'm wondering if my quick recovery of continence was in part due to my urologist's surgical skill.

A number of men I talked to who were operated on by the same urologist stated that relatively good continence returned within weeks after surgery 

Hi TimG,   The skill of the surgeon is sooooo important! And your commitment to getting this little guy in shape for his new job is equally important!   An **excerpt from Dr. Walsh’s Guide to Surviving Prostate Cancer has been highlighted in our book!!!!   **Men are equipped with three separate anatomical structures that control urine – a sphincter at the bladder neck, the prostate itself, and the external sphincter.   Radical Prostatectomy knocks out two of these—the sphincter at the bladder neck and, of course, the prostate—leaving only the external sphincter to do the work of three.   **Because of the powerful structures upstream, this (external sphincter) is never tested or even used much in most men….   So you guys better take good care of (him)!!!   This is why the exercises (kegels, walking, stairs) are soooooooo important to strengthen this little muscle before surgery.   So ~ when it’s time for him to kick in and start working…. He will be ready!   The main thing our urologist told us is to “not overwork him”!!!   Nice topic Tim and a very important one J   Take care, Lee & Buddy

In my  last post-operative visit, I mentioned to the urologist that I did Kegel exercises while urinating.  She said that I should not do them while urinating because it can cause bladder problems.  Other times are okay, and stopping and starting urine flow does help to identify which muscle(s) to exercise. She added that many men (and women) think that they are doing the exercise correctly, but in fact are not.  It is difficult to describe the exercise exactly. 

I have a new primary urologist because my former urologist moved last month to California from the Pacific Northwest. My new urologist assisted with the surgery.  I really like her comfortable conversational style and her up-to-date expert knowledege of  prostate cancer.  She went to University of Michigan medical school, graduating in 1999.  I also appreciate the fact that she involves me directly in the decision-making process. My wife likes her, too.

Hi Ed NJ…. The most important answer is … What does your doctor tell you to do? Obviously there are different opinions…   I would think this holds true for all… Before surgery get this guy in shape…. Like any type of exercise… you can over do it.   But since he’s never had to work before you better get him learning the ropes J   (I will check my previous postings to make sure they are clearer as to what and when we did them.  I will say that what ever we did prior and post has worked.  Buddy has had wonderful control from day 1 and continues to do so....)   Before surgery: Our urologist said to work the muscle when urinating… the start, stop, hold, start several times during urination.   This strengthens the muscle.   Also, walking stairs is a really good exercise.     After surgery we were to still do the kegels when urinating and stairs during his regular workout.   This is the only time Buddy does them.   EXCERPT:…..On page 247 of Dr. Walsh’s book he states: Exercises you can do :   Every time you urinate, do it standing up.   You can’t practice the following exercises, which strengthen the external sphincter and speed up your recovery of urinary control, while you’re sitting down.   Start your stream, and once it’s in full force, stop the stream by contracting the muscles in your buttocks --- not your abdominal muscles, not the muscle “up in front” around the penis.   Tighten your buttocks: imagine you’re trying to hold a quarter between your cheeks.   Hold the urine back for 5 or 10 seconds, and repeat as many times as you can.   Note: Only perform these exercises when you’re urinating; if you keep contracting these muscles throughout the day, you’ll overdo it—the sphincter tires easily—and you’ll end up wetter than you would otherwise.   Previous paragraphs address… things to speed up your urinary control.   One is not using any artificial devices…… and certain high blood pressure medication relaxes this muscle so you may need to check with your doctor.   Hope this helps!!! J Lee  

Tim G
where in the NW is your new doctor.
DWT

Hey Tim....

Right on!!!..... It works..... and that's a POSITIVE... 

Oh! by the way I say "Tater"... nice light laughter....

Take care and stay dry  :)  Lee

Hi Ed NJ,

Buddy says his first urination in the morning is a nice long steady flow!!!!!  Then the rest of the day he does his start / stop / start /stop.

No doubt in our mind that the kegels, walking, and stairs have been instrumental in our continued recovery of urinary continence. 

I will tell you this... the sound of the early morning stream is music to my ears.... and the start / stop / start brings a smile to my face.  Things seem to be working quite nicely. :)

Interesting thought about Depends....... hmmmmmm

Take care,  Lee

Hello Ed,

If it has been 17 days since your DaVinci procedure, and you have blader control enough to get up to go at night; then you are way ahead of the curve. Don't forget RLP is still a major shock to your body, and it will take a little time to repair itself, and re-regulate all of the diff. functions. I had the same experience, but my recovery was slower. Now everthing is about back to normal.

I found that walking was the best theropy, and going up and down steps was suggested by another member (if you don't have a bad knee like me). You must be doing the right things if you can lose 10 pounds, and keep it off. So I hope you continue to have a speedy recovery, and good luck.

Glen

Hi, Ed. My husb. is post-surg. five weeks now and still urinating much more frequently than before - a LOT in fact and during the night as well. Not drinking huge amounts of liquids, either, other than he's added apple juice to the routine. We are assuming it's going to slow down a bit as the healing completes itself.

Hi All,
It's been 9 weeks to the day since I had my operation and at last I think that things are starting to improve in I heading toward achieving full urinary control. I'm down to using just two pads a day now, and I'm finding that the Fleming Exercises ( you call them Kegels) are starting to pay dividends. I still get the odd bit of leakage every now and then, but that seems to be improving as time goes by.

I went back to my Urologist/Surgeon on 29th August and he told me that my PSA level was 0 and that the cancer had been encapsulated within the Prostate, and then he told me that I was basically cured. I still have to go back and see him at the end of February next year for a check up, but, basically that seems to be that!

As for getting an erection, well, that's taking a bit of time. I do get sensations down in that area every now and then, which hopefully means that things are heading back to normal. I haven't used any medications for it, my Urologist told me that if things weren't getting back to normal after 3 months or so that I should go back and see his specialist treatment nurse. Hopefully, I won't need to!

Regards to you all
Tim

After reading books and pamphlets, I expected that the Bladder Sphincter would be lost and the urethra would be reattached directly to the bladder.

My first face to face meeting with my surgeon, Dr. Mark Kawachi of City of Hope National Medical Center, Duarte, CA was the day before surgery.  I came from New Mexico for the De Vinci Robotic Laparoscopy procedure so the hospital was very respectful of my time and costs and handled preliminaries over the phone and mails.  I talked with the Doctor over the phone but we didn't get into too many details. During my face to face meeting, I asked him about the urethra reconstruction and he explained that there is about 1" between the Bladder Sphincter and the External Sphincter with the other "plumbing" in that space.  During his procedure the prostate is depressed to expose the urethra which is cut it between the two sphincters.  This allows him to eventually reconnect the urethra leaving about 3/8" between the sphincters.

I was very pleasantly surprised how procedures have advanced beyond the reading I had done.  My experience has been 99% continence immediately after removal of the catheter and with some leakage with stress in difficult sitting positions.  But this is only day 17 and I haven't worn depends since day 10 and didn't really need them.  But everybody is different and maybe I am a lucky case.

Has anyone else had this procedure?

Good healing,

Steve Bradley

Dear Ed,

Sorry, I copied that post from an earlier posting trying to get some understanding on how different doctors are doing the urinary track hook up. I had the operation on July 27th so it has been 7 1/2 weeks now.

I had the catheter in 7 days. The only problems I have with urinary control is that I must think when I do certain things such as yawning when I am sitting or testing my lower bowel for fullness when I am standing. I will lose a little urine if I am not careful. Honestly, I can go for a week without any leakage. I think what is happening is that I now have a little urine captured between the two sphincters and I relax the external sphincter for an instant. Before the operation the prostate was squeezing the urethera between the two sphincters and there was little urine captured or I learned as a child to drain the system properly.

It took my bowels about 5 weeks to get back to close to normal. I have passed some stringy dried blood and the other day I passed a bit of suture that was decomposing as was planned I guess.

It took me close to 6 weeks to get my energy level strong again. I am 68 and today I spend a full day doing carpentry on a commercial project. I live at 7300 feet and that job was at 5000 feet so that helped. I am tired, but not unusually so. I did a lot of bending, twisting, turning and carrying tools and stuff up to 35 lbs. I can probably lift 50 lbs without straining something for a short interval. I expect to be back at normal capacity of 60 to 75 lbs in two or three more weeks, but I am not pushing it. Pretty amazing really considering all of the work done.

Good healing,

Steve Bradley