Robotic assisted laparoscopic prostatectomy
The prostate is a plum-sized organ found only in men. The prostate lies just below the bladder and surrounds the urethra (bladder tube). The prostate produces nutrients for your sperm and contributes some parts of the fluid that you ejaculate.
The prostate is removed with the use of keyhole surgery and by using the Da Vinci® robotic system. The procedure is performed for prostate cancer.
How is the procedure performed?
The operation is done in the hospital under general anaesthesia. Once you are asleep your legs will be put in stirrups and your legs will be opened slightly.
6 Small holes of 1 - 3cm will be made in your abdomen that will allow the instruments to pass into the abdomen. One incision is made right above the belly button where the telescope will be inserted.
This telescope will transmit and enlarge the inside view onto monitors. The instruments and telescope are connected to the console with 3 or 4 robotic arms. The instruments have a greater range of movement than the human hand and with the help of the 3D camera with the magnification of the system, the operation can be performed with precise accuracy.
There will be a doctor and a sister sitting next to you. The urologist performing the operation will sit on the console system in the same room but some distance away from you.
The robot is not doing the operation - The urologist is doing it using the robot!!
After the operation, you will have a catheter in your bladder draining the urine from the bladder into a bag. The catheter will remain in your bladder after you have been discharged from the hospital.
Your urologist will remove the catheter after a week – please phone the doctor’s rooms to make an appointment.
You will also have a drainage tube coming out of one of the holes. The drainage tube will stay in for one day.
You will go to the high care for one night. Thereafter you will go to the ward where you will be encouraged to walk, and you can eat. If all goes well, you will be able to go home 2 – 3 days after your operation.
What are the other treatment options for localised prostate cancer?
Robotic-assisted prostatectomy is one of the treatment options for prostate cancer. Treatment options will be discussed by your urologist. The type of treatment for your cancer is influenced by several factors like your stage of cancer, previous surgery, and other medical conditions.
- Open radical retropubic prostatectomy, a cut is made on the lower abdomen to remove the prostate. This was the traditional method of treatment that is still performed very often.
- Laparoscopic radical prostatectomy, small incisions is made to pass long instruments and a camera. The prostate is removed inside the abdominal cavity. This procedure is only performed by very few urologists in the country. No urologist in our practice performs laparoscopic prostatectomies.
- Brachytherapy, radiotherapy seeds is implanted into the prostate to radiate the prostate from inside and kill the cancer cells.
- External beam radiotherapy, radiotherapy beams are sent into the prostate from outside to kill the cancer cells.
- Active surveillance. Sometimes prostate cancer is exceptionally low grade and treatment might not be necessary or not immediately. You will be monitored regularly, and the prostate biopsy will be done again after 1 year to check for any cancer progression. If at any stage it seems like your cancer is growing or you are not happy with the option, one of the other treatment options will be performed.
What are the advantages of robotic surgery compared to traditional open prostate removal?
- Less painful procedure: because there are no big abdominal wounds but small incisions for the instruments. You will only need some pain killers after the procedure to take when necessary.
- Normal activities can be resumed sooner, and you can return to work sooner compared to traditional open surgery.
- Less blood loss than open surgery. Very rarely a blood transfusion is needed after robotic surgery.
- Shorter hospital stays. After robotic surgery, you can go home after 2 to 3 days. After traditional robotic surgery patients normally stay in hospital for 3 to 5 days.
- Earlier removal of your catheter. Your catheter will stay in for 7 days after a robotic prostatectomy. With traditional open surgery, your catheter will be removed after 14 days.
What are the side effects and possible complications of the procedure?
- Urinary incontinence. All forms of prostate surgery for prostate cancer have a risk of temporary urine leakage. The leakage improves over time and you will be given pelvic floor exercise to help you train the bladder again.
- Erectile dysfunction. The nerves responsible to get erection and sustain erections can be damaged during surgery and cause erectile dysfunction. The risk of erectile dysfunction is much higher than the risk of leaking. Many factors may play a role in the return rate of erections, like age, degree of preoperative erectile function and time. There are treatment options if you have problems with erections – medication (Viagra, Cialis and Levitra) the use of penile vacuum erection device or penile injections. If your problem persists, we can also implant a penile prosthesis.
- Your penis may appear to be shorter after the surgery. With removal of the prostate the urethra is shorter. The length of your penis will improve as your erections return, either normal with medication or a penile vacuum device.
- Bleeding. Blood loss associated with this type of surgery is normally little. If for some reason you do loose more blood than normally, we will have to give you a blood transfusion, BUT the risk is exceptionally low.
- No ejaculation. Because of the removal of the structures which produce seminal fluid (seminal vesicles), you will not be able to father a child again.
- Damage to other organs. Organs and other structures that are close to the prostate might be injured. The operation is done under continuous visualisation and the risk is very low. These organs and structures include the bladder, rectum, small bowel, blood vessels, nerves and kidney tubes (ureters). These injuries, if occur will be fixed immediately.
- Scarring can develop at the bladder connection. This might cause weakening of the urinary stream and might require additional surgery.
- Hernia formation. Sometimes a hernia can form where the small incisions were made.
- Conversion to traditional open operation. Your urologist can encounter difficulties during the operation that makes it impossible to continue with the robotic procedure. You will have a bigger cut on the abdomen if the decision is made to abort the robotic procedure and continue with the open approach.
- Urine leak at bladder and urethra connection. The prostate and urethra (bladder tube) are reconnected after the prostate is removed. A catheter is inserted to allow the area to heal. If there is a prolonged leakage you will have to keep the catheter in for a bit longer. These leakages resolve spontaneously.
- Shoulder pain. The use of carbon dioxide to inflate the abdominal cavity might cause pain in the shoulders. This pain resolves within a day or two as the gas is reabsorbed.
- Additional cancer treatment is needed. After the prostate is removed, the pathologists will look at the prostate under the microscope. Sometimes they will see that the prostate is not confined to the prostate or at the surgical margin. In such cases, it might be necessary for additional treatment like radiotherapy or anti-hormone tablets or injections.
- Lymphatic fluid collection. If your pelvic lymph nodes are removed it might cause leaking of lymphatic fluid and a build-up of the lymphatic fluid. It is normally clear up spontaneously but sometimes it is necessary to place a drain into the collection to drain it out of the body.
- Eye problems or weakness might be caused due to nerve compression and the specific position that your head is placed – head down.
Important information about prostate cancer surgery
Any prostate cancer treatment has the risk of leaking urine and/or weak penile erections. If you decide to have surgery, robotic surgery or traditional open surgery, your surgeon will consider whether or not to try and preserve the nerves responsible for erections. These nerves run along the sides of the prostate. Surgery to remove the prostate inevitably cause some form of erectile dysfunction but preserving the nerves will help to get normal erections afterwards.
Factors that will influence the urologist’s decision to do a nerve-sparing prostatectomy in the location of the cancer in the prostate and the grade of the cancer. By doing a nerve-sparing prostatectomy there is a risk of leaving some cancer cells behind.
Men younger than 60 years old with normal erectile function before the surgery have higher likelihood of normal erections after the surgery if they get a nerve sparing prostatectomy. There is unfortunately no guarantee! If you already have problems with erections before the surgery, you are more likely to have erectile dysfunction after the surgery. Other factors that will negatively affect your erections include high blood pressure, diabetes, obesity and smoking.
Achieving orgasm after a prostatectomy is still possible but you will not ejaculate any semen. The reason is that your prostate is responsible for the production of most of your ejaculation fluid that mixes with the sperm. For this reason, you will be infertile after the surgery.
What should I know before the procedure?
- Stop any medication that might be thinning your blood (Warfarin, aspirin, clopidogrel). Your urologist will tell you when you should stop this medication and if you should take anything else in its place.
- Stop eating and drinking 6 hours before your surgery.
- Your Dr might request blood tests and x-rays on the day of the surgery.
- Your urologist will send you to a specialist physician that will do a pre-operative assessment to make sure your heart and lungs is strong enough for the procedure. Inform your urologist if you already have a physician.
- If you are smoking, you may be asked to stop smoking. Smoking increases your risk of developing chest infections and blood clot formation. It also delays wound healing.
What happens after the procedure?
When you are awake from the anaesthesia you will be taken to either the ward or high care for a day.
- You will have a catheter. The catheter will stay in your bladder for 7 days. The catheter might cause an initial sensation of a full bladder and feeling like you want to pass urine. The sensation will pass after a while.
- A drainage tube will be coming out through one of the keyholes. The drain will remove any access blood or urine from the operation area. The drain will be removed after 24 – 48 hours.
- The 6 keyhole incisions will be closed with sutures or metal clips and covered with dressings. The dressings can be removed after 48 hours and then kept clean and dry. The surgical clips or sutures will be removed when the catheter is removed.
- You will have a drip in the arm to give you fluid until you can eat and drink normally. Pain medication will also be given through the drip.
You will be given clear fluids to drink. If you do not feel nauseas and your pain is well controlled, you can start eating the following day.
- Initially, after the surgery, you will have to stay in bed. You have to move your feet and ankles to promote blood flow in the legs and prevent blood clots. When your pain is under control the physiotherapists will help you to get out of bed and walk around.
- You will experience discomfort at the waist. Your penis and scrotum might be tender and swollen. The swelling will subside after a day or 2. Pain medication will be prescribed and given regularly. Please tell the nursing staff if you still have pain.
Leaving the hospital
You will be able to leave the hospital when:
- You are fully mobile
- You know how to clean the catheter and knows how the catheter bag is changed and emptied.
- Your pain is controlled with only oral pain medication.
- Your bowel is working, and you have passed stools.
You will need to continue with the blood-thinning injections after you are discharged. The nurse in the hospital will show you how to inject yourself. The injections are to prevent blood clots from forming in your legs.
Follow up and results
Make an appointment with your urologist to see him 1 week after your surgery. Your catheter and surgical clips when then be removed. We will discuss the final results from the prostate cancer analysis. These results will determine the way forward.
Your first PSA will be done 3 months after the surgery. Make sure you get the laboratory request form for the first blood test.
- Fluid hernia or congenital hydrocele
- JJ-stent placement
- JJ-stent removal
- Kidney stone manipulation
- Laparoscopic nephrectomy
- Percutaneous Nephrolithotomy - PCNL
- Prostate ultrasound and biopsy
- Robotic assisted laparoscopic prostatectomy
- Testicular torsion repair
- Transurethral resection of prostate (TURP)
- Urodynamic and Incontinence Unit