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!