Robotic prostatectomy is a minimally invasive procedure performed by an experienced laparoscopic surgery team with the assistance of advanced surgical technology.
Robotic-assisted radical laparoscopic prostatectomy is accomplished using the da Vinci® Surgical System, a sophisticated robotic surgery system that allows surgeons to operate on the prostate with enhanced vision, control and precision.
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Before Robotic-assisted radical laparoscopic prostatectomy
What is a radical prostatectomy?
A prostatectomy is an operation to treat localised prostate cancer (cancer that has not spread outside the prostate gland). Surgery is also increasingly performed for locally advanced prostate cancer (where the cancer has started to break out of the prostate, or has spread to the area just outside the prostate) as well as localised disease. It is performed under a general anaesthetic, which means you are asleep for the whole procedure.
‘Radical’ means that the whole of your prostate, rather than just a part of it, is removed. The surgery involves removing your prostate gland, seminal vesicles (glands that store semen) and possibly blood vessels, nerves and fat around the prostate. Removing these structures may increase the likelihood of removing all the cancer cells. The urethra is cut during the operation and then re-attached to your bladder.
What is laparoscopic surgery?
Laparoscopic surgery is also often called keyhole surgery. A laparoscopic prostatectomy is the same as an open prostatectomy, except that the surgery is carried out using several small incisions (also called keyholes or port holes) rather than one large incision.
Six incisions are made in total. One is made just above your belly button, where a telescope like instrument is inserted. This transmits the inside view of your body to monitor screens in the operating room. This magnifies the view of your pelvis, so your surgeon has a detailed view.
The remaining keyholes allow access for the surgical instruments used during the procedure.
Most of the incisions are 1cm in length but one is 3–5cm to allow specimens to be removed. Special plastic tubes (ports) are placed through each incision to help the laparoscopic instruments pass through easily.
What is Robotic-assisted Laparoscopic Surgery?
Robotic-assisted surgery is a laparoscopic technique that uses a robotic console (the daVinci® system) to help your surgeon during the operation. Your surgeon is in the same room, but away from you, and controls the robotic arms to perform the operation. It is important to understand that the robot is not performing the surgery. The surgeon still carries out the procedure, but the robotic console allows more controlled and precise movements during the operation.
The robotic console has three arms; one holds a high magnification 3D camera, which is inserted into your abdomen through one of the keyholes. This allows your surgeon to see inside your abdomen. The other robotic arms can hold various instruments, which your surgeon will use to carry out the surgery. The instruments are smaller than those used for traditional open surgery. Robotic-assisted surgery has a number of advantages over traditional open surgery.
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What are the advantages of robotic surgery compared to traditional open surgery?
Robotic surgery results in:
. Less blood loss. Blood loss is typically about 200 to 300mls for robotic-assisted surgery, whereas in a traditional open prostatectomy it can be more than 1,000mls. This means the risk of needing a blood transfusion is smaller with robotic-assisted surgery.
. Less pain after the operation, because there is no large abdominal wound. Patients rarely need strong painkillers, and can return to normal activities and work sooner compared with traditional open surgery.
. Shorter hospital stay. Most patients go home one or two nights after robotic-assisted surgery, compared to an average of three or four nights for traditional open surgery.
. Smaller scars. It avoids the large scar from traditional open surgery, although you will have smaller scars from the keyholes.
. A greater likelihood of sparing the nerves and blood vessels attached to the prostate gland. These nerves and blood vessels control erections and urinary continence (ability to control when you pass urine).
What are the disadvantages of robotic surgery?
This operation needs specialised training, as the surgeon is unable to ‘feel’ your tissues or organs as in traditional open surgery. Although rare, it may be necessary to convert to traditional open surgery if there is a lot of bleeding or for other technical issues. This happens in one in 100 cases.
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Risks and Side effects
Risks of Robotic-Assisted Laparoscopic Radical Prostatectomy
The potential risks of robotic-assisted laparoscopic radical prostatectomy include the following:
. Infection at the surgical site
. Adjacent tissue/organ damage
Side Effects of Robotic-Assisted Laparoscopic Radical Prostatectomy
The rates of major side effects from robotic-assisted laparoscopic radical prostatectomy are about the same as open surgical approaches. The most common side effects include the following:
. Urinary incontinence (inability to control urine): Similar to open surgery, urinary incontinence can occur following a robotic prostatectomy. However, this side effect often improves over time.
. Erectile dysfunction (impotence): The return of erectile function following prostatectomy is based on the patient’s age, degree of preoperative sexual function and whether the nerves were spared during surgery. Unless cancer is suspected in the nerve tissue, surgeons will use nerve-sparing techniques during robotic prostatectomy to minimize the surgical impact on sexual function.
Preparing for your surgery
We will send you a date to come to the pre-assessment clinic before your surgery. You must come to this appointment, as this is when we will assess your suitability and fitness for surgery and anaesthetic. We will carry out a number of tests to make sure that your heart, lungs and kidneys are working properly. You may have a chest X-ray, ECG or electrocardiogram (which records the electrical activity of your heart) and some bloods taken. Your nurse will explain any tests you need.
Your nurse specialist will discuss the details of the procedure with you before, and as part of your consent.
If you smoke, you should try to stop smoking, as this increases the risk of developing a chest infection. Smoking can also delay wound healing.
Please tell your doctor or the nurse if you are taking any regular medicines and if you have any allergies to any medicines. If you are taking any medicines that thin your blood, such as aspirin, warfarin, clopidogrel or rivaroxaban, please tell your doctor or the nurse as you may need to stop them temporarily before your surgery. Also tell your doctor or nurse if you have diabetes as you may need to alter the dose of your diabetes medicines, as you will need to fast before the procedure.
. Fasting instructions
Fasting means that you cannot eat or drink anything (except water) for six hours before surgery. It is important to follow the instructions given. If there is food or liquid in your stomach during the anaesthetic it could come up to the back of your throat and damage your lungs. The nurses on the ward will tell you when you must stop eating and drinking.
During Robotic-assisted radical laparoscopic prostatectomy
Using the advanced surgical system, miniaturized robotic instruments are passed through several small keyhole incisions in the patient’s abdomen to allow the surgeon to remove the prostate and nearby tissues with great precision. This is much less invasive than a conventional radical retropubic prostatectomy, which involves an abdominal incision that extends from the belly button to the pubic bone.
During robotic-assisted radical prostatectomy, a three-dimensional endoscope and image processing equipment are used to provide a magnified view of delicate structures surrounding the prostate gland (e.g., nerves, blood vessels and muscles), allowing optimal preservation of these vital structures. The prostate is eventually removed through one of the keyhole incisions.
For most of the surgery, the surgeon is seated at a computer console and manipulates tiny wristed instruments that offer a range of motion far greater than the human wrist. The surgery is performed without the surgeon's hands entering the patient’s body cavity.
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What are the alternatives?
Robotic-assisted prostatectomy is just one of the available treatment options. Your surgeon will discuss the alternatives below with you if they are appropriate for your grade and stage of cancer:
. Open radical retropubic prostatectomy, traditional open surgery to remove the prostate.
. Laparoscopic radical prostatectomy, similar to traditional open surgery but involving several small incisions rather than one large incision.
. High intensity focused ultrasound therapy (HIFU), where ultrasound waves are used to heat and destroy the affected prostate tissue.
. Brachytherapy, where radiotherapy ‘seeds’ are implanted into the prostate to destroy the cancer cells.
. External beam radiotherapy, where beams of radiation are used to destroy the cancer cells.
. Active surveillance/monitoring. In some cases it may be an option not to treat your cancer. This is referred to as active surveillance or monitoring. Some cancers need to be treated more urgently than others, depending on how aggressive they are. If a very aggressive cancer is not treated, it may spread to other parts of the body. Your doctor or specialist nurse will tell you if active surveillance is an option for you, but please do not make any decisions before speaking to your doctor or specialist nurse.
After Robotic-assisted radical laparoscopic prostatectomy
What to expect afterwards
You will be taken to the recovery room and remain there until the anaesthetic wears off. This may take an hour or two. You will then be taken back to your ward.
You will wake up with:
. A catheter. This is a tube inserted into the bladder through your penis and is attached to a leg bag. This will collect your urine so you will not need to leave your bed to pass urine. We will leave this in place for five to 14 days to allow your wound between your bladder and urethra to heal. Please make sure you are given a date to come back to have it removed before you leave hospital.
. A drain. This is a plastic tube that comes out from one of the small keyhole incisions. It prevents blood and urine collecting inside your wounds after surgery. It is normally removed the morning after surgery.
. Stitches/glue or staples closing your wounds. Some of these dissolve and do not need to be removed. Others will be removed when your catheter is removed.
. Dressings. These small plasters cover the keyhole sites and are generally removed 48 hours after surgery.
. A drip to prevent dehydration. You will be able to start drinking clear fluids when you come round from the anaesthetic. The drip is usually removed the day after your surgery.
You may have discomfort bending at the waist and your scrotum or penis may be tender and swollen. However, most men find they do not need strong pain relief after the operation.
Your penis may appear shorter following surgery because the urethra will be shorter once the prostate has been removed. The urethra is quite elastic and can be stretched out by exercising the penis with a vacuum device. This will help restore the length.
You will need to remain in bed at first. We will ask you to move your feet and ankles and wiggle your toes to help encourage circulation in your legs. This will also reduce the risk of blood clots in your legs. You should be able to start walking around within a few hours.
You will be able to leave hospital when:
. You can move around as well as you did before you came into hospital.
. You are able to care for your catheter and your leg bags.
. Your pain is well-controlled using the appropriate tablets taken by mouth (orally), where necessary.
. You may also be given a daily blood-thinning (anticoagulant) injection. This reduces the risk of you developing a DVT (blood clots in the leg).
What can I expect when I get home?
The most common complaint after surgery is tiredness. Even though you will have small wound sites, you should not forget that you have had major surgery. You will need time to recover before returning to your normal activities.
Some men experience bladder spasms (contractions) caused by the catheter rubbing against the trigone (muscle) inside of your bladder. This can result in urine passing down the sides of the catheter or give you the urge to pass urine, which can be uncomfortable. These spasms should reduce over time.
You may also feel bloated and your clothes may feel tighter than usual. Wear loose clothing and try to walk around the house, which will help you to pass wind. It can be uncomfortable if you have not had a bowel movement for a few days. Exercise such as walking will help to get your bowel moving again after your surgery. If you have not opened your bowels for a few days then we suggest you try lactulose (a laxative) – this can be bought over the counter at your local pharmacy or you can get a prescription from your GP. If this does not work or you have any concerns, please contact your GP.
You might find after the first few days that you notice some urine bypassing around the sides of your catheter. This is perfectly normal and may happen because your bladder is not used to having the catheter tube in place and is irritated by it. Your district nurse will supply you with some pads during this period to keep yourself dry. If you become very uncomfortable, contact your ward or specialist nurse who will give you advice. You may also leak some blood around the catheter when you first open your bowels after the procedure.
You will need to:
. Carry out twice-daily catheter care to help reduce the risk of infection. We will show you how to do this before you leave hospital.
. Eat a light, soft diet until your bowel movements are back to normal.
. Take it easy. Do not lift anything heavy or do anything too energetic for example, shopping, mowing the lawn, lifting weights or running, for at least two to four weeks after your surgery. Doing these things may put too much strain on your stitches and could make your recovery take longer.
. Give yourself a couple of weeks rest before returning to work. If your work involves heavy lifting or exercise, please speak to your consultant.
. Only start driving again when you are able to perform an emergency stop without feeling hesitant.
Looking after your wounds
When bathing or showering, please rinse soap thoroughly from your body as this may irritate your wounds. Keep your wounds clean and dry at all other times. Please do not use lotions or creams while they are healing, as this may cause irritation and increase the possibility of infection.
When can I have sex again?
You may begin sexual activity again two weeks after your operation, as long as you feel comfortable. You may not be able to achieve an erection in the early stages of your recovery, but you can experience arousal and even climax without an erection.
It will be harder for you to have an erection than before your surgery while you are recovering. How difficult it will be will depend on many things such as:
. The extent of the cancer
. How much of the area and surrounding structures were removed during surgery
. Whether or not your surgeon was able to spare the nerves.
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