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Interventional physiatrist Francisco M. Torres discusses his article, “A doctor’s own prostate cancer recovery.” He shares his vulnerable story of undergoing a robot-assisted radical prostatectomy and the unexpected shame and “erosion of dignity” caused by severe urinary incontinence. Francisco explains how his medical assumption that anatomical knowledge would ensure a fast recovery was wrong, and how pelvic floor physical therapy with biofeedback finally restored his function. The conversation advocates for a systemic shift toward “prehabilitation,” arguing that men should start pelvic floor training weeks before surgery rather than being sent home with a pamphlet and diapers.

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Transcript

Kevin Pho: Hi. Welcome to the show. Subscribe at KevinMD.com/podcast. Today, we welcome back Francisco M. Torres. He is an interventional physiatrist. Today’s KevinMD article is “A doctor’s own prostate cancer recovery.” Francisco, welcome back to the show.

Francisco M. Torres: Thank you for having me, Kevin.

Kevin Pho: All right. For those who didn’t read your KevinMD article, tell us a little bit about this most recent story and what the article is about.

Francisco M. Torres: This article grew from a live experience based on notes I wrote regarding conversations with my pelvic floor therapist. It is a reflection on decades of teaching about recovery after a radical prostatectomy, which I have to admit, I was completely ignorant about regarding the rehab of this condition.

Kevin Pho: This happened just recently: this diagnosis of prostate cancer and, of course, the radical prostatectomy. Before talking about the rehab, tell us a little bit about that experience, the diagnosis, and the surgery for the prostate cancer.

Francisco M. Torres: I have already published two essays on your platform. I started with the one about when I was diagnosed. It was a very interesting situation regarding how to handle the pre-op before the biopsy, the options, and the choices. Then, after the biopsy, making the decision to have the surgery. Those two little essays talk about that. Then this third one was about recovery after the surgery and things that I had no idea that I needed to do.

Kevin Pho: Tell us about the experience of what you went through during the surgery. Tell us about some of the things that you had to encounter after the surgery that you said you didn’t have much of an idea about.

Francisco M. Torres: I was focused on complications and selecting the right urologist to do the procedure. I was not aware that, even in robotic-assisted surgery, there are different procedures or techniques that can limit the amount of complications. I was more focused on that and totally forgot that the preparation for the surgery included training of those pelvic floor muscles. So I brushed them aside.

After two months, I went back to the urologist, and I had to publicly apologize because he asked: “Are you doing your Kegel exercises?” I said: “Hey, I am a physiatrist. I know exercise. I am an exercise enthusiast. I know my stuff.” But after not improving, finally my wife convinced me to go and see a pelvic floor physical therapy specialist. That blew me away. When she connected me to that biofeedback machine and I was finally able to discover my pelvic floor muscles, it was a life-changing experience. Before, it was: “Do your Kegels.” But how do you even recognize if you are doing them correctly? Even with the biofeedback, I was still not able to recruit the muscles correctly. That was my revelation there.

Kevin Pho: After a radical prostatectomy, for those who aren’t familiar with the procedure, tell us the type of complications you were experiencing.

Francisco M. Torres: One of the complications occurred a week after. I told my doctor I am very into exercise. I was just hungry for exercise, so I was walking 10,000 steps even after the surgery during the first few days. A week later, I started having this horrible, terrible back pain that was not responding to anything. Eventually, to make the story short, they found out I had an accumulation. It was like a fistula in the pelvic region, and I had 1,000 mL of fluid accumulated there. They had to drain it. That delayed the process of removing the Foley catheter, and I think that was part of the problem. I was not training my muscle during that time, so that wasn’t the major complication.

Kevin Pho: You said that you had trouble with the Kegel exercises and recruiting the pelvic floor muscle. Tell us a little bit about Kegel exercises for those who aren’t familiar with them. How did you know it was affecting the muscles that needed to be affected?

Francisco M. Torres: The data that we have says that if we do training of the pelvic floor before the surgery and after, the complications are fewer and recovery time is very fast. That is very solid. The problem with the Kegel is that people tend to mention it casually. They were created by a doctor in 1948 in California. At that time, when he treated a postpartum patient, he developed a tool for biofeedback to know that they were recruiting the muscles correctly. Think about 1948. I don’t know where we dropped the ball such that we don’t demand that to be part of the preparation before surgery.

I think that if we don’t include that into the surgical consent form, we are probably classifying that we can be doing harm by not showing that to the patient. That was my discovery. I went back to my papers for pre-surgery, and I found two pages merely describing Kegel exercises. Obviously, like I said, even though I feel that I know the anatomy, I do my exercise, and I am a physiatrist, I had no clue how to activate those muscles. Even after going through physical therapy for almost a month and a half, I still compensate by activating my hip and my glutes. I am not able to isolate those pelvic floor muscles correctly. We need to emphasize that. That is why part of the book that I am writing says that we should have a protocol where we measure with biofeedback the quality of those muscles before we do the surgery. It is OK to be free of the cancer, but I think we are neglecting the recovery and the restoration.

Kevin Pho: When you went to this pelvic floor specialist and they did the biofeedback, what exactly did that entail? What kind of special exercises or treatment did they incorporate to finally recruit the right muscles?

Francisco M. Torres: It is when you visualize in the monitor how you activate the pelvic floor. They put recording electrodes around your anus. That is a way that you can see the waveform. It is very tricky because you try to compensate with the glutes in the hip muscle, and then you don’t have the same strength of the curve. That gives you feedback. Every time you go and try to see if you are getting better, you have a visual that you can tell: “Yes, I am 20 percent better or 30 percent better.”

Then you decide if you want to use all the devices that they sell. I got one that you can sit on. It vibrates when you are activating the muscles. So that helps you to retrain the pelvic floor muscles. Also, you know that pelvic floor muscles are incredibly important for sexual health as well. There are a lot of studies done for just that. That is another part of the surgery that affects you. I think we have to normalize the conversation so we can talk to the patient openly about that.

Kevin Pho: How long did it take you working with the pelvic floor therapist to finally notice some improvement?

Francisco M. Torres: To be honest with you, I felt some improvement immediately. In the first session, I could activate it, and I could feel a little bit more power in controlling it. But it is a slow process. Even the last time I went to check, I was only 20 percent better, even though I was doing my exercise for a whole month. So it is very tricky. It is not an easy muscle to recruit.

Kevin Pho: You talked about prehabilitation or exercises before the surgery. Give us more detail. Exactly what do you mean by that? What kind of exercises are they? Is it just simply the Kegel? What would you recommend patients do now, or what would you have done knowing what you know now?

Francisco M. Torres: Knowing what I know now, I would have paid attention to physical therapy six weeks before the surgery. That would be ideal because these are elective surgeries. You need a physical therapy facility that is specialized because you can go to a general one (I have physical therapy in my facility), but they don’t have biofeedback. They don’t spend time recruiting those muscles. You want to go to one that specializes so you can do the biofeedback to have a baseline.

After that, they put together a group of exercises besides the Kegel to strengthen your hip abductors and flexors as well as your gluteus medius and maximus. It is a combination that you do. It probably takes at least 30 or 35 minutes to go through that routine if you want to do it on a daily basis. For me, it is just awareness. One of the things that I do here with my pain management patients before I do an epidural is try to train the patient to say: “You need proper nutrition. You need to do this supplementation.” I can predict who is going to get better or not by just knowing they are putting the effort prior to the procedure.

I think that we need to continue to do this across the board, not just for prostate cancer. There was a recent study I was reading today about doing prehabilitation before any surgery that is elective. They found that the immune system goes up. That was published just recently in this month in JAMA. The immunological system gets better, and also the cognitive function and the complication rate drops significantly.

Kevin Pho: You saw a pelvic floor therapist after your surgery, but that’s not standard of care, right? Most patients who undergo a radical prostatectomy don’t necessarily automatically see a pelvic floor specialist. Am I correct?

Francisco M. Torres: You are absolutely correct. By not including that part, knowing that the outcome of the recovery restoration improves 80 percent, I think you are definitely doing harm by not allowing the patient to have that exposure or mandatory evaluation by a physical therapist. We are so precise about the surgical techniques. I have to give credit to my urologist. When I saw him, I said: “Hey, the PSA went to zero. The margins were free. I consider the surgery successful.” But he said: “No, no, you are still incontinent. You are still having sexual dysfunction. So we are not there yet.” I think that is the mentality we should have.

Kevin Pho: So what more needs to be done? Should all urologists automatically send people to physical therapy or a pelvic floor therapist after a procedure like a prostatectomy?

Francisco M. Torres: I think that yes, that is for sure. But I think that they should do it before because of all the data that we have reducing the complication rate and improving the recovery time completely.

Kevin Pho: Now for other men who are diagnosed with prostate cancer, and as you know, this is a relatively common cancer. Just give us some other lessons that you’ve learned outside of what we’re talking about today that you want to share with the other men who may have gone through your journey.

Francisco M. Torres: This is a very interesting question. From the moment my PSA went up like three years ago, I refused to just do a blind biopsy because I thought that the results of a blind biopsy are very questionable. So I said: “I is going to follow with an MRI.” I had MRIs done two years in a row, which were negative until the third one came back positive with a dubious lesion. Then I decided to do the biopsy. The biopsy was guided by that MRI, and it was very precise. It was definitely very localized at Gleason 6. So the prognosis was excellent.

I think because I was on top of it, I did well. People don’t understand that. I have patients that have gone for biopsies and they say: “Negative biopsy, negative.” And all of a sudden, three years later they have cancer. I think that the standard of care should be guided biopsy with MRIs. That was something I learned. The second thing was, after you have the diagnosis, they give you the options, but they don’t explain to you what the pros and cons are. For example, they told me I could wait, do radiation, do cryotherapy, or do biopsy. I didn’t know I was lucky. I had a friend who was an oncologist, and he guided me through the different options. Based on my age and what I do, yes, the surgery was the best thing for me.

Kevin Pho: You had to rely on a friend to go over all the options. You are a physician yourself. So patients who aren’t physicians and they’re confronted with just a menu of prostate cancer treatment options—like you said, it could be surgery, watchful waiting, brachytherapy, radiotherapy—how could we expect patients just to navigate something that is so life-changing?

Francisco M. Torres: I really don’t know, because like you said, I am a physician. I thought I knew it, and I was completely lost. There are so many decisions you have to make. It is not only that. After you go through the surgery, you should be aware of the complications, like the incontinence and the level of that, because it affects your dignity. I wrote one essay about me traveling to Italy on a pilgrimage with the diapers and the whole situation. It is pretty hard. If you are vulnerable, you can definitely collapse while trying to figure this out by yourself.

The mistake I made was fighting my doctor because he was telling me to take medication (antimuscarinics). I was fighting: “Oh no, those are side effects, and what you are doing is covering the symptoms.” I didn’t understand the value of retraining the bladder with those medications, even with the penile clamp. These are things that you fight because nobody tells you and you are afraid of asking. But now that I realize it is worth retraining the bladder, now I know. I think we just have to have all that information available for the patient visually.

Kevin Pho: We are talking to Francisco Torres. He is an interventional physiatrist. Today’s KevinMD article is “A doctor’s own prostate cancer recovery.” Francisco, let’s end with some take-home messages that you want to leave with the KevinMD audience.

Francisco M. Torres: My number one message would be pertaining to prostate cancer surgery. You need to be sure that you are seen by a pelvic floor therapist that has biofeedback to measure your baseline so you know that by training those muscles, the recovery time and complications are going to be less. That is critical for me. You should continue with that program even after the surgery. Also, how soon do we start that? At least seven or ten days after they remove the Foley catheter. The sooner you get into that, the better.

Kevin Pho: Francisco, thank you so much for sharing your story, time, and insight. Thanks again for coming back on the show.

Francisco M. Torres: Thank you for having me again.