Dr. Joseph Diaz shares his story about treating his prostate cancer through the help of renowned robotic urologic surgeon, Dr. Naveen Kella.

It is a daunting statistic, but according to the American Cancer Society, one out of every six men in the United States will be diagnosed with prostate cancer. Fortunately, robotic urologic surgeon Dr. Naveen Kella is posting some remarkable statistics of his own.

With more than 2,000 robotic urologic surgeries under his surgeon’s cap, Kella is the most experienced robotic surgeon in the region, as well as one of the top surgeons in the nation, having performed live cases for national urologic conferences and training urologists nationwide

San Antonio men now have access to a urology program boasting the most experienced physicians in the state, as Kella recently introduced the Urology and Prostate Institute (UPI). UPI is the region’s first private practice to provide general urology in conjunction with a comprehensive medical, radiation and urologic oncology program.

Knowing that experience is paramount when it comes to his field of robotic surgery, Kella is comfortable performing six to 10 prostatectomies per week. He is recognized as a Texas Super Doctor, but more importantly, he is known as a super doctor to his patients, who happen to include other physicians in San Antonio.

As a surgeon, gaining the trust to perform surgery on a fellow physician can prove to be a delicate duty. Nonetheless, local physicians such as allergy, asthma and immunology specialist Dr. Joseph Diaz have confided in Kella’s skill in robotic surgery.

Diaz was diagnosed with prostate cancer and had his prostatectomy performed by Kella in March. Five months later, as a thriving survivor, Diaz summited Mount Kilimanjaro – the highest mountain in Africa – and is en route to compete in the prestigious Boston Marathon in April 2013.

“I had a fabulous recovery,” Diaz said. “It was extremely difficult after surgery because I do not like pain; [but] I have had great recovery in erectile function and without incontinence, which were the two big things that were worrisome to me.”

Kella is honored each time a man elects for him to perform his surgery; but as a doctor treating a doctor in this case, this time he was humbled.

“It is a very humbling feeling when another physician believes you are the best person to do his procedure,” Kella said. “As a doctor, I know that I would do my research to not only find the best doctor for my condition, but also find someone that I feel personally cares about me. I am honored that Dr. Diaz did that same research and placed his trust in me to perform his surgery.”

“I was absolutely comfortable with Dr. Kella’s experience with robotic surgery and his reputation in the community,” Diaz said. “Especially once I sat down with him; I had that immediate reassurance that I needed.”

Diaz has suggested Kella to other men who are going through what he experienced just a short time ago, and he makes sure to tell it exactly how it is.

“I told them they were not alone,” Diaz said. “I also told them that I absolutely think that the best person in town is Dr. Kella because he is local and you are close to your family and your friends, so it makes recovery easier. Staying local is important because you do not have to go to meccas such as MD Anderson or Mayo Clinic when there is the same level of expert care here by a surgeon who is more experienced.

“I tell people that Dr. Kella always followed up on my questions, and he even has a great bedside manner. In retrospect, I made the absolute right choice.”

To give more information to his current and prospective patients, Dr. Naveen Kella maintains a blog at www.texasroboticsurgery.com.

Dr. Naveen Kella shares how doctors now are using the power of their patients' bodies to successfully treat--and even cure--cancer.

What is cancer? In the simplest of terms, cancer refers to cells in the human body growing out of control. The body, unable to regulate these cells, eventually succumbs to the chaos associated with uncontrolled growth. Man has long struggled with this disease; physicians from 3000 BC report burning the external manifestations of cancer with a “fire drill” and despairingly wrote that there was no successful treatment.

The famous Greek physician, Hippocrates, described the tentacle-like growths he noted in patients with the disease and is credited with calling it cancer, using the Greek word “carcinos,” which means crab.1

Treatments Numerous therapies have been developed since, but many were pitched by grifters and pseudo-scientists looking to capitalize on the hopeful desperation of victims and their families. Even the best scientists developed theories that seem outlandish today. Hippocrates declared that the body “humors,” blood, phlegm and yellow-and-black bile, needed to be in “balance.” This theory persisted for more than 1,300 years! Later claims still seem equally far-fetched, but were advanced by some of the most respected minds of the times.

Until recently, the accepted treatments mainly involved surgery, chemotherapy and radiation. Surgery attempts to remove the faulty deadly tissues, whereas chemotherapy and radiation destroy the engines in these rapidly growing cells, thereby preferentially killing cancer cells. Through decades of research, variations of these treatments have become more sophisticated, more precise and more successful.

For example, patients with testicular cancer can actually be cured with these existing treatments. Collateral damage and side effects can be minimized with successful cancer treatment, as well. Patients cured surgically for prostate cancer can hope for recovery of urinary and sexual function, especially if a surgeon experienced and skilled in robotic techniques performs the surgery.

Immunotherapy The notion of using the immune system to fight the body’s cancer is not new. The value of proper nutrition and exercise has been advocated for years as a way to keep the body and its immune system primed for such struggles. However, cancer can often elude even the stoutest defenses if the immune system doesn’t know what to seek.

Science has developed biologics such as cytokines and interferons, which serve as stimulants or a “volume knob” for the immune system. These treatments are used to treat patients with advanced kidney cancer. However, an immune system that has its volume “turned up” with no directed target puts the entire body at risk, and the increased stress to the system often makes patients very sick.

Immunotherapy was given a boost when scientists discovered how to mass-make antibodies in the 1970s. As understanding of various cancers progressed, studies were launched to see if the antibodies could be used to more precisely recognize antigens present on the cancer cells.

Antigen recognition led to breakthroughs in the imaging and treatment of different cancers. The first therapeutic monoclonal antibodies, Rituxan and Herceptin, were approved during the late 1990s for the treatment of lymphoma and breast cancer, respectively. Monoclonal antibodies are like soldiers deployed to recognize and defeat a specific enemy. They now have a defined role against many cancers and are undergoing study in the treatment of other cancers.

Of course, relying on outside soldiers to fight cancer seems less ideal than triggering one’s own immune system to create an army of its own fighters. In 2009, scientists reported the first successful tuning of the immune system in a study showing that immunotherapy-treated lymphoma patients lived longer. In 2010, the Food and Drug Administration (FDA) approved Provenge as the first and only immunotherapy for the treatment of advanced prostate cancer.2

Provenge is an autologous (pronounced aw-tol-uh-guhs) treatment, which means that the immune cells activated to fight the prostate cancer come from the patient himself. Normally, once prostate cancer spreads to the bone, treatment focuses on castration or eliminating testosterone, which serves as fuel for this cancer. At a certain point, prostate cancer cells outwit castration and lead to the patient’s death. With Provenge, patients can call on their immune system to jump into battle once castration no longer works.

Treatment with Provenge
During the course of a month, patients receive three personalized doses of Provenge. To make each dose, blood is drawn and a machine collects a fraction of the immune cells present. These cells are then sent to a facility where they are stimulated and exposed to an antigen associated with prostate cancer. A few days later, the patient receives the personalized dose, now rich in activated T cells, trained and prepared to fight the prostate cancer cells.

Patients can live longer with Provenge. A clinical study showed a 22.5 percent reduction in the risk of death. Less than 1.5 percent of men had to stop treatment due to side effects, which were usually temporary chills, fatigue, nausea or fever associated with the infusion of the cells.3

Understanding and interpreting the success of treatment is slightly different than with surgery or castration, which can immediately drop blood levels of PSA – a marker associated with prostate cancer. Immunotherapy takes time to start working, and changes in PSA levels do not fully deduce the immediate success of the treatment.

Immunotherapy represents an exciting new frontier in the treatment of prostate cancer. History has shown that cancer treatments are ever evolving, but the change usually generates great success.

Sources:

1. www.cancer.org/Cancer/CancerBasics/TheHistoryofCancer
2. Provenge is immunotherapy for the treatment of asymptomatic or minimally symptomatic patients with metastatic prostate cancer not responding to conventional castration therapy.
3. www.provenge.com

Naveen Kella, M.D., is the director of robotic surgery and a board-certified urologist at the Urology and Prostate Institute. For more information or to schedule a consultation with him, please contact the institute at 210-284-6640.

Una dieta favorable para todos los hombres interesados en la salud de la próstata es la Mediterránea Modificada. El beneficio de este tipo de régimen incluye la salud de corazón, la salud de la próstata y qué actúa como un mecanismo para desacelerar el proceso de envejecimiento. La cardiopatía es prevaleciente en todas las edades pero más comúnmente en hombres entre 40 y 70 años de edad. Similarmente la enfermedad de la próstata es prevaleciente en todas edades comenzando tan pronto como nuestra adolescencia y prolongando a lo largo de nuestras vidas de adulto. La dieta es recomendada idealmente para todos los hombres que desean prevenir la enfermedad cardiaca y enfermedad de la próstata al paso de los años. Para hombres que ya tienen la enfermedad cardiaca o enfermedad de la próstata nunca es muy tarde para empezar una dieta apropiada. Aparte de este comentario alimenticio, animo el apoyo nutritivo de vitaminas para la próstata, también ejercicio regular diariamente, y reducción del estrés.

Frutas Frescas
Los ejemplos incluyen pero no se limitan a: naranjas, mandarinas, plátanos, cerezas, toronjas, sandía, melón, guayaba, Kiwi, fresas, arándanos, frambuesas, zarzamoras, arándanos rojos, papaya, uvas, manzanas, granadas, y ciruelas. Pienso que la fruta fresca entera es mejor que beber el jugo de fruta.

Verduras Frescas
Frescas, nunca enlatadas con la excepción del puré de tomate y tomates cocidos. Los ejemplos incluyen pero no se limitan a: Las verduras crucíferas perteneciendo a la clasificación Brassica incluyendo - el brócoli, broccolini, col de Bruselas, colirrábano, col rizada, berza, col china, espinacas de mostaza, Col, Coliflor; Verduras que tienen la clasificación Brassica, incluyen pero no se limitan a: Los tomates y los productos derivados del tomate incluyendo lo antedicho, puré de tomate, tomates cocidos y salsa de tomate; Los chiles incluyendo chile pimiento, chile ancho, chile Habanero, etcétera; cebollas, chicharos, zanahorias, espinacas, betabeles, ejotes, hongos (Shitake, Portabella, Cagarria, Maitake, Ostra, Porcini etcétera.); Las verduras cocidas al vapor, sofritas o salteadas (a la sartén) son más nutritivas; Limite el consumo de elote, el uso de sus productos y recetas relacionadas al elote. Evite aros de cebolla fritos.

Aceites para Cocinar
El aceite de oliva es mejor; El aceite de canola es una alternativa cuándo el aceite de oliva no puede ser utilizado; Evite el aceite de palma, aceite de coco, aceite de maíz y aceite vegetal.
Use como aderezo e / o intégre cualquier platillo con ajo, pepino, lechuga, apio, curcumina, cilantro, pimienta, orégano, jengibre, romero, tomillo, perejil, salvia, mostaza, pepinillos en vinagre, y aceitunas. Evite la mayonesa y alimentos untables cremosos.

Fuentes de Proteina
Pescado de aguas frías incluyendo pero no limitado a: atún fresco o enlatado (en agua o aceite de oliva), el salmón silvestre siempre que sea posible, fletán, sardinas, y verdel; El pavo y el pollo (sólo la carne blanca, sin pellejo),tocino de pavo, salchichas de pavo, frijoles (todos los tipos), claras de huevo y mantequilla de cacahuete; Las vieiras, camarón, cangrejo, langosta y calamar están bien dependiendo en como son preparados;

Evite: La carne roja, incluyendo Hamburgesas, perros calientes (hot dogs), chorizo, chile con carne, carne roja asada, Bistecs, costillas, carne de cerdo o carnero, carne de animal silvestre, alitas de pollo, Sloppy Joe (sandwich de carne molida con salsa de tomate y especies), tocino, salchichoneria de puerco, jamon de pierna (paletilla), pepperoni, salame, mortadela, queso de puerco, despojos (hecho de menudencias), Spam
jamón, carnes ahumadas; El pescado que debe evitar incluye: Tilapia, pescado Espada y Salmón criado.

Productos Lácteos
El yogur bajo en grasa, claras de huevo o las mezclas de huevo, leche desnatada, queso descremado, requesón descremado; Evite las grasas asociadas con productos lacteos incluyendo queso, leche entera, lechecrema, crema, helado, yemas de huevo, y salsas de crema incluyendo pero no se limitan a la salsa Holandesa, salsa bearnesa y la salsa de menudillos.
Pasta y / o Carbohidratos
La harina integral o el arroz son mejores aunque los panes de grano entero tambien se recomiendan; Modere su consumo de Pizza, aunque si la va a consumir, es mejor que sea de pan de trigo entero y que sea servido con salsa de la tomate o Marinara; El Arroz Integral; Los camotes se prefieren mas que las papas blancas aunque la piel de ambas son nutritivas; Procure no comer pastas simples como espagueti y fideos, y evite los aperitivos de pan (breadsticks), pan blanco, arroz blanco y azúcares simples como el azúcar blanca refinada y miel; Evite: Papas fritas a la francesa. Substitutos de azúcar incluyen: Splenda, la cual se puede usar para cocinar

Ensaladas
Verduras frescas de hoja con pepinos, tomates, aguacate, pasas, rábanos, cebollas, pimientas, aceitunas, zanahorias, frutas secas y verduras frescas a su gusto; El mejor aderezo es el aceite de oliva extra virgen con vinagre balsámico; Evite otros aderezos. Evite cubitos de pan frito.

Galletas
La harina integral es mejor; Evite galletas saladas hechas con aceites parcialmente hidrogenados incluyendo pero no se limita a: aceite de algodón y aceite de soja (las transgrasas).

Sopas
De tomate con verduras, tomate, pollo con arroz, fideo de pollo; Evite sopas cremosas.

Postres
Las moras de temporada o un pedazo de chocolate negro. Evite reposterías, pastel de queso, galletas, helado y pasteles.

Soja
Minimice o modere el insumo de soja que contiene los componentes Genistein y Diadzein; Soja adicional que puede ser consumida incluye leche de soja descremada, miso, y tofu. Evite salsa de la soja con contenido alto de sal.

Aperitivos (en moderación)
Un pretzel bajo en grasa, cacahuates, avellanas, pistachos, nueces de Brasil, almendras, nueces persas, nueces lisas, avellanos, uvas, chocolate negro, mezcla de frutas secas y nueces (hecho en casa), frutas secas, palomitas de maíz cocinadas al vapor, un pedazo de fruta fresca; Evite refrescos, papas fritas, fritos de maíz, dulces, leche con chocolate, chicharrones, palomitas de maíz hechas en horno de microondas, galletas.

Bebidas
Un vaso de vino tinto está bien; Disminuya su consumo de cualquier bebida alcohólica incluyendo vodka, whisky, tequila, ginebra, whisky escocés (scotch), ron, cerveza.

Evite: Malteadas de leche, refrescos y licores de crema.

Nutrición
Considere los suplementos disponibles en tiendas de vitaminas. La investigación detrás de la gran colección de suplementos disponibles es escasa. Además, los métodos de producción pueden diferir ampliamente. Soy un partidario de Theralogix, el cual es poseído por un urólogo quien hace el esfuerzo de sólo incluir aquellos ingredientes mejor respaldados por literatura disponible. Además, el control de producción es acentuado.

Evite freir y en lugar asar a la parrilla o asar al horno
Si usted está tratando de perder peso, especialmente para la cirugía, empiece cada comida con un vaso de agua de 8 onzas.

Si usted cocina sus alimentos a la parrilla, asegurese de no recocer o quemar lo que desea comerse.
Evite el uso de mantequilla o margarina.

Nutrition for Prostate Health
A favorable diet for all men concerned about prostate health is a Modified Mediterranean. The benefit of this type of diet includes heart health, prostate health and as a mechanism to slow the aging process. Heart disease is prevalent in all ages but most commonly in men aged 40- 70. Similarly prostate disease is prevalent in all ages beginning as early as our teen years and extending throughout our adult lives. The diet is ideally intended for all men who want to prevent heart disease and prostate disease as they age. For men who already have heart or prostate disease it is never too late to start with a proper diet. Beyond the dietary commentary, I encourage prostate nutritional support with vitamins, regular daily exercise, and stress reduction.

Fresh Fruits
Examples include but are not limited to: Oranges, Tangerines, Bananas, Cherries, Grapefruit, Watermelon, Cantaloupe, Guava, Kiwi, Strawberries, Blueberries, Raspberries, Blackberries, Cranberries, Papaya, Grapes, Apples, pomegranate, and plums. I think fresh whole fruit is better than drinking juice.

Fresh Vegetables
Fresh, never canned with the exception of tomato paste and stewed tomatoes. Examples include but are not limited to: Cruciferous vegetables belonging to the Brassica classification including - Broccoli, Broccolini, Brussels Sprouts, Kohlrabi, Kale, Collard Greens, Bok Choy, Mustard Greens, Cabbage, Cauliflower; Non-Brassica vegetables include but are not limited to: Tomatoes and Tomato related products including the aforementioned Tomato Paste, Stewed Tomatoes and Tomato Sauce; Peppers including Chili Pepper, Bell Pepper, Habanera Pepper etc; Onions, Peas, Carrots, Spinach, Beets,
String Beans, Mushrooms (Shitake, Portabella, Morel, Maitake, Oyster, Porcini etc.); Steamed, sautéed or Wok prepared vegetables are most nutritious; Limit Corn and Corn related products and recipes. Avoid fried onion rings.

Cooking Oils
Olive Oil is best; Canola Oil is an alternative where Olive Oil can’t be used; Avoid Palm oil, Coconut oil, Corn oil, Vegetable oil.
Garnish and/or integrate any dish with Garlic, Cucumbers, Lettuce, Celery, Curcumin, Cilantro, Pepper, Oregano, Ginger, Rosemary, Thyme, Parsley, Sage, mustard, relish pickles, olives. Avoid Mayonnaise and Creamy bread spreads

Protein Sources
Cold water fish including but not limited to: Tuna fresh or canned (in water or olive oil), Wild Salmon whenever possible, Halibut, Sardines, and Mackerel; Turkey and Chicken (white meat only, without skin), Turkey bacon, Turkey sausage, Beans (all types), Egg whites and Peanut Butter; Scallops, Shrimp, Crab, Lobster and Calamari are OK depending on the preparation;

Avoid: Red Meat including Hamburgers, Hot Dogs, Sausage, Chili with ground beef, Barbecued beef, Steaks, Prime Rib, Pork or Lamb, Wild Game, Chicken Wings, Sloppy Joes, Bacon, Pork Roll, Prosciutto, Pepperoni, Salami, Bologna, Head Cheese, Organ Meats, Spam,
Ham, Smoked Meats; Fish to avoid includes: Tile Fish (Tilapia), Sword Fish and Farm Raised Salmon

Dairy
Non-fat Yogurt, Egg Whites or Egg Beaters, Skim Milk, Non-Fat Cheese, Non-fat Cottage Cheese; Avoid Fat associated with dairy including cheese, whole milk, half & half, cream, Ice cream, egg yolks, and cream sauces including but not limited to Hollandaise, Béarnaise, and Giblet gravy

Pasta and/or Carbohydrates

Whole wheat or rice is best while whole grain breads are encouraged; Moderate consumption of Pizza, while Whole Wheat crust is best when served with Pizza Sauce or Marinara; Brown Rice; Sweet Potatoes are preferred over white baking potatoes although the skins of both are nutritious; Skip simple pasta like spaghetti and noodles and avoid bread sticks, white bread, white rice and simple sugars such as refined white sugar and honey; Avoid: French Fries. Sugar Substitutes include: Splenda could be used for cooking

Salads
Fresh garden greens with cucumbers, tomatoes, avocado, raisins, radishes, onions, peppers, olives, carrots, nuts and fresh vegetables to suit; the best dressing is extra virgin Olive oil and balsamic vinegar; Avoid other dressings. Avoid croutons.

Crackers
Whole Wheat is best; Avoid crackers made with partially hydrogenated oils including but not limited to cottonseed oil and soy bean oil (trans-fats)

Soups
Tomato with vegetables, Tomato, chicken with rice, chicken noodle; Avoid creamy soups.

Desserts
Seasonal berries or a piece of dark chocolate. Avoid pastries, cheese cake, cookies, ice cream and pies

Soy
Minimize or moderate intake of soy including Genistein and Diadzein components; Additional soy that may be consumed include low fat soy milk, miso, and tofu. Avoid soy sauce based on high salt content

Snack Foods (in moderation)
Non-fat Pretzels, Peanuts, Hazelnuts, Pistachios, Brazil Nuts, Almonds, Walnuts, Pecans, Filberts, Grapes, Dark Chocolate, Trail Mix (homemade), Dried Fruits, air-popped Popcorn, , a piece of fresh fruit; Avoid soft drinks, potato chips, corn chips, candy, milk chocolate, pork rinds, microwave popcorn, cookies.

Beverages
A glass of red wine is fine; Minimize the intake of any alcoholic beverage including vodka, whiskey, tequila, gin, scotch, rum, beer.

Avoid: Milk shakes, soft drinks, cream liquors.

Nutrition
Consider supplements available in the vitamin store. The research behind the array of supplements available are sparse. In addition, production methods can vary widely. I am a supporter of Theralogix, which is owned by a urologist and takes the effort to only include agents best supported by the available literature. In addition, control of production is stressed.

Avoid frying in favor of broiled or baked
If you are trying to lose weight, especially for surgery, start every meal with an 8 ounce glass of water.

If you grill your dinner, do not over cook or burn what is to be consumed
Avoid the use of butter or margarine.

This will serve as a guide to your recovery following your robotic treatment for Prostate Cancer with Dr Kella. While current technologies and practices have made significant improvement on the long term complications following your Prostate Cancer treatment, it is still possible there could be resulting erectile function complications. We have developed this Erectile Function Rehabilitation program in an effort to minimize the potential for immediate and long-term erectile function complications following your treatment or procedure.

The following information is designed to answer any questions about your current penile rehabilitation program. This is a multi-faceted approach that includes both therapeutic and physical therapy components. It is important that you make every effort to adhere to the program as outlined herein. Each medication and physical therapy component plays a specific role and each must be taken as directed whenever possible.

We are pleased that you have entrusted us with your prostate cancer care and look forward to working with you on your recovery.

Click here to view the protocol.

Sincerely,

Naveen Kella MD
Director of Robotic Surgery
Urology San Antonio

Dr Kella's Erectile Preservation Protocol

Two weeks prior to surgery:

• MUSE Intraurethral Suppository: Begin with 125 mcg suppository three times weekly on the days that PDE5 Inhibitor is not used. The goal with use of this product (at this low dose) is to produce some erectile action, not necessarily sufficient for sexual intercourse. Starting the suppository now will help you comfortably continue treatment after surgery and possibly get your nerves and blood flow in "better shape." If possible, Dr Kella will provide you some samples (keep them in the refridgerator) to get started.
• Continue what you do already if you have erectile dysfunction.

After surgery:
Wait until the foley catheter is removed and until Dr Kella gives you the go ahead to start rehabilitation.

• Fill the prescription (provided during the post-operative visit) for the Vacuum Erection Device (VED). Prescription devices are more durable and carry a lifetime warranty. Over the counter devices are available at a lower price point if cost considerations or insurance coverage become an issue. Dr Kella's office will submit the initial paperwork on your behalf. You should follow-up with a phone call a few days later to the company to inquire on the status of your insurance coverage. We will provide you a booklet and video along with teaching to use the device successfully.
• Complete "Pump and Release" 5 repetitions every morning and evening with your VED. This is intended to mimic the penile nocturnal erection function that is usually disrupted early after surgery. Use the VED without the constriction bands. A "repetition" is to pump the device 3-4 times then pause for a count of 5, then pump 3-4 more times, stopping for another count of 5. Continue this process until the penis is reasonably full. At this point, count to 10 and press the release button on the pump mechanism itself. The erection will go down quickly. Repeat this process for a total of 5 repetitions every morning and evening. It is expected to feel some tightness and pressure, but don't pump as to cause pain.
• Start Muse 250 mcg every other day or at least three times a week. Vivus has generously provided a toll-free line 888.367.6873 to provide patients with trained healthcare staff to answer questions about MUSE and guide you through the administration process. Of course, you can always make an appointment with Dr Kella's office. In addition, with the expensive cost of medications like Viagra to consider, Vivus has started the Apricot program, which will try to get pre-authorization for coverage from your insurance company.
• PDE-5 drugs like viagra, cialis, and levitra can be used but may not be efficacious at this early stage of healing.
• If your erections are sufficient for intercourse, Dr Kella suggests avoiding vigorous activity until your body has had more time to heal.

6 weeks post-surgery:

• Evaluate progress and responses to previous regimen.
• Increase MUSE to 500 mcg dose if erection obtained is not yet sufficient for meaningful sexual activity. Continue at three times weekly.
• Continue VED daily. At this point, the constriction bands can be utilized for maintaining the erection for sexual activity.
• Sexual activity at this time should be fine.

3 months after surgery:

• Evaluate progress and responses to previous regimen.
• If erection is not yet sufficient for meaningful sexual activity, consider increasing MUSE to 500 or 1000mcg does for "on demand" function. For scheduled preservation, continue at the 250mcg dose.
• Penile Injection therapy with penile duplex ultrasound should be considered at this point.
• PDE5 Inhibitors (Cialis, Levitra, Viagra) can be added to the regimen if not being used already. Full dose tablets can be used at most once a day. Dr Kella generally recommends at least twice a week. Discuss this at the 3 month follow up if necessary with Dr Kella.

6 months after surgery:

• If erections are sufficient for sexual activity spontaneously (or with assistance), consider stopping scheduled MUSE dose and continue with PDE5 Inhibitor and VED.
• If erections are not yet satisfactory, discuss further therapy at your follow-up appointment.
• Continue regular MUSE, POE5 Inhibitor, VED, with possible addition of penile injections.
• This can be tailored to each individual person at this point, as penile injections can be used in low dose on schedule for "rehab" purposes. This may require the elimination of some options and substitution of others in their place.

Final Note:
After nerve sparing surgery, erections and orgasmic function should only continue to improve with time. Most patients start reporting erections Most healing takes place by 1 - 2 years. Factors to consider include your function before surgery, your general health, and Dr Kella's ability to spare your nerves.

Dr Kella has performed over 1500 robotic procedures, with over 350 last year, ranking him as the busiest surgeon in Texas for 2009. Surgical experience, using the latest techniques, and usage of the newest Da Vinci Si, while not a guarantee, can help your odds of recovering as much of your original sexual function as possible.

Good luck through your rehabilitation!!

Useful reference:
Rev Urol.2008 Fall. Renewing intimacy: advances in treating erectile dysfunction postprostatectomy. Lepor H, Engel JD.

Over the past years, I have been amazed at how fast robotic surgery is becoming the standard for patients who need surgery for their prostate cancer. Even surgeons who don't perform robotics have decided to refer patients to me as a service to their patients. Initially, I thought that the learning curve for robotics would be too steep for busy surgeons to fully master. That's why I took a year to do a fellowship and travel to see expert surgeons perform cases. Now that I have done hundreds of cases and travel to "proctor" new robotic surgeons as they do cases, my original opinion has changed a bit.

If a surgeon is dedicated enough, there are finally enough good surgical videos and trained proctors available to considerably shorten the learning curve. How many cases? I'm not sure, but I still would not want to be one of the initial 25 patients or so. The robot is just a fancy powertool. If you know how to use it, you can do great things. Otherwise you could risk a lot of damage to the patient and to yourself. A useful website by Intuitive Surgical lists surgeons who have done at least 20 cases. Now that I have been doing this for a while, I can tell you that is a ridiculously low number and the literature supports a much higher number. 

I suggest that you should look for surgeons who have done at least a thousand cases!