Continence rates from several institutions are represented in the table (above). In general, >90% of patients are continent by their reckoning at 12 months. Most men report little bother from urinary symptoms after RRP with socially acceptable continence achieved usually within 3-6 months of surgery, although, for some patients, regaining control can take up to 18 to 24 months. Factors influencing continence include maintaining the integrity of periurethral support, the precision of the vesicourethral anastomosis, patient age and co-morbidities, including pre-prostatectomy detrusor dysfunction which may persist post-operatively. Return of urinary control is considered to take longer in men over 65 years. Patients with atherosclerotic and diabetic vasculopathy are more prone to prolonged incontinence, probably the result of poor vascularization and healing of the periurethral and sphincteric tissues. Biofeedback and Kegel exercises have been reported to hasten the return of urinary control (480). If urinary control does not return, and the incontinence is demonstrated to be sphincter failure by urodynamics investigations, an artificial urinary sphincter may resolve the problem (481).

Bladder neck contractures occur in less than 10% of patients and can cause symptoms ranging from poor urinary flow to complete incontinence (482, 483). Bladder neck contractures can result from non-mucosa-to-mucosal anastomosis, following heavy intraoperative bleeding and after prolonged urinary extravasation, with a previous transurethral resection of the prostate possibly predisposing to this problem. Treatment can consist of simple dilatation, although surgical incision of the scarred tissue is usually performed. Urethral stricturing can also require dilatation and/or incision with formal urethroplasty rarely warranted.

Spontaneous post-prostatectomy erectile function depends upon preservation of at least one neurovascular bundle. While surgical skill is an important factor in the successful outcome of nerve-sparing prostatectomy, patient selection is paramount. Younger men (<60-65 years old) with small, non-palpable, and low-grade tumours have the best outcomes (421). Phosphodiesterase inhibitors (e.g.sildenafil/Viagra™, tadalafil/Cialis™, vardenafil/Levitra™), intracorporeal injection of vasoactive drugs such as prostaglandin E1 or Alprostadil, transurethral vasodilators (medicated urethral system for erection [MUSE]) and vacuum constriction devices (VCD) all have a role in erectile rehabilitation (484, 485). Although patients clearly prefer oral medications (391), these may be less effective in the short term, particularly if temporary neurovascular damage (neuropraxia) is present following RRP (485) as well as following external beam radiotherapy, (389).

The results of the various treatment approaches were reviewed recently by Raina et al (2005) (485). They reported that VCD efficacy rates range from 60-80% with compliance at 12 months between 50% and 70%. Tightness or pain from the constriction ring and decreased sensation of the penis, in particular the glans, were common causes for noncomliance. Approximately 50% of men were afforded benefit from MUSE using Alprostadil with some non-nerve sparing RRP patients also able to achieve tumescence satisfactory for vaginal penetration. In addition to not achieving satisfactory penile tumescence, urethral pain and burning were cited causes for discontinuation. Intracorporeal penile injection therapy with PGE1 or Alprostadil is claimed to provide adequate rigidity in >75% of patients but ~50% of men do not continue with the treatment long-term. In addition to a lack of success with the technique, physical and emotional problems in addition to pain with with the injection were promoted as reasons for discontinuation. Penile fibrosis is reported to occur in up to 15% of men (485).

Avoidance of penile hypoxia through regular tissue oxygenation via erections is considered to lessen the likelihood of lacunar fibrosis and, ultimately, erectile incapacity. Thus, there is a vogue currently to advocate a return to penile tumesence with the early commencement of one or a combination of the above treatments following RRP. Not unexpectedly, the use of oral phospodiesterase inhibiting drugs is most popular in this regard but, especially in the early post-operative period, other methods may be more effective. Despite high (>75%) efficacy and satisfaction rates, penile implant surgery is restricted to only those men with persisting erectile failure after having exhausted all less invasive options and all hope of spontaneous erectile recovery (485, 486).

The anatomic approach to RRP has improved awareness of, and abilities to control, the venous plexuses surrounding the prostate. Consequently, massive blood loss is rare. nevertheless, during nerve-sparing surgery it is not uncommon for 600-1200 mL of blood to be lost. Many patients are encouraged to donate autologous blood preoperatively in case a transfusion is required intraoperatively or in the immediate post-operative period. The need for transfusion may be lessened by the use of a ‘cell-saver’ during the operative procedure.

Despite using an iodine or alcohol-based skin preparation preoperatively, any time a skin incision is made there is the risk of both local and systemic infection. For this reason, it is usual to administer antibacterial drugs prophylactically. During RRP, the bladder is opened and, inevitably, urine spills into the surgical field. Several strategies can be used to diminish the risk of infection. Preoperative urinalysis and urine cultures identify patients with potential urinary tract infections which can be treated. After the vesicourethral anastomosis is completed, lavaging the pelvis with saline may help and post-operative drainage as a routine decreases the likelihood of localised sepsis occurring.

Rectal injuries occur in under 1% of RRPs and may be more likely subsequent to previous rectal surgery or pelvic irradiation (415, 448, 482). If a rectal injury does occur, it can be repaired easily in most instances by oversewing the rectal wall. It is for this reason that some surgeons suggest that all patients are given a bowel preparation prior to surgery, to minimise wound contamination and lessen the need for a covering colostomy should an injury occur. Although extremely rare, ureteric injuries can happen during transection of the bladder neck and dissection of the seminal vesicles. Correction usually consists of a ureteroneocystotomy with insertion of a ureteric stent.

Deep vein thrombosis and pulmonary embolus are diagnosed in approximately 1% of men having a RRP (415, 448, 482, 487). Their probability can be reduced by ensuring adequate hydration peri-operatively, using elastic compression stockings with sequential compression applied during and after surrgery and encouraging early ambulation. Subcutaneous heparin or clexane is also commonly used.

All peri-operative complications are increased in patients with conditions characterised by impaired healing or reduced pelvic tissue vascularity (482). Thus, prior pelvic radiation, previous rectal surgery, inflammatory bowel disease, past procedures on the prostate, urethra, or bladder, diabetes mellitus, and vasculopathies can contribute to prolonged incontinence, impotence, hemorrhage, infection, and visceral injuries. In addition, co-morbid cardiac and respiratory conditions can contribute to perioperative morbidity and mortality.