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Procedures & Information

 

Robot-Assisted Radical Prostatectomy

 

Procedure
The operation is carried out under general anaesthetic at Grace Hospital. You will be admitted on the morning of the surgery. It is desirable, although not critical, for you to have a bowel motion some time in the 12 hours prior to surgery and we will give you a microlax enema to help you with this in the evening prior if required.

It is important that you have nothing to eat or drink for at least 6 hours prior to your operation.

After you are anaesthetized, the operating table is tilted head down/feet up to help make access to the pelvis easier. Five small cuts are made in the abdomen and the robotic camera and arms are placed in the lower abdomen. The abdomen is then filled with air, and the surgeon sits at the robotic console. The operation is then carried out by the surgeon controlling the tiny robotic instruments in the abdomen from the console. The prostate and seminal vesicles are removed, and the prostatic nerves are spared if appropriate. In some cases, lymph glands are also removed. The bladder is reattached to the urethra and a catheter is placed in the penis. A drain is placed through one of the existing abdominal incisions. The operation usually takes less than two hours.
Post Procedure
The next morning most men are comfortable enough that pain is controlled with paracetamol and non-steroidal medications such as ibuprofen. The abdominal drain is usually removed the next morning, and the urethral catheter usually stays in for 10 days. Some men feel nauseated on the evening of surgery, and so fluids rather than food are recommended until the morning after. You will be encouraged to mobilise out of bed a few hours after your surgery. A subcutaneous anticlotting injection will be used on the day of surgery to prevent blood clots forming in your legs and lungs. You will be taught how to manage the catheter, which you will go home with and have removed about 10 days later at the rooms.
Results
We usually have the cancer results within 7 to 10 days after the procedure. We usually like to see you back in the rooms about 3 weeks after the procedure.
Complications
Although complication rates with robotic surgery are reduced, they are not eliminated and there is always risk associated with surgery. General risks include bleeding, wound infection, pneumonia, and blood clot formation, but in practice these are rare.

Intraoperative Complications
Significant blood loss is extremely rare with robotic prostatectomy, but is theoretically possible.
The posterior surface of the prostate is in close proximity to the lower bowel and there is a small risk of injury to the rectum. This is uncommon, happening to less than 1% of patients. It is usually easily recognized and is repaired at the time. You might need to be on antibiotics for a week or so in the unlikely event that this happens but there are usually no long-term problems as a result.


Bladder neck contracture, or scarring of the join between the bladder and urethra causing problems with urination has been almost eliminated with robotic surgery. It has been reported in rare circumstances, but is extremely rare.

 

Post-operative Complications
The two main risks following this procedure are urinary incontinence, and impotence.

 

Incontinence
Normal continence is controlled by a circular muscle that surrounds the urethra called the external urethral sphincter. This muscle is closely associated with the apex of the prostate and can be damaged to a degree during removal of the gland. It is very common therefore for patients to have some urinary leakage following the procedure. This can be quite severe in the first week or two after the catheter comes out but usually rapidly improves and by 6 to 8 weeks most men have reasonable control. By 3 months about 95% of men are essentially dry. There is a higher rate of continence in men after robotic surgery in general than after open prostate surgery. A minority of men never regain normal continence. If you are in this group you will not have to put up with incontinence forever as there are various, relatively minor procedures which can resolve this problem.

 

Impotence
The nerves responsible for normal erections are the cavernous nerves. They run very close to the sides of the prostate and are therefore at risk of damage during radical prostatectomy. Nerve sparing surgery is possible but preserving the nerves is of secondary importance compared to ensuring the cancer has been removed. Some patients will have high-risk disease, and in these, nerve sparing would not be appropriate as there is a high chance of leaving cancer behind.
Even with nerve sparing there is no guarantee of maintaining erections, even with robotic surgery. Return of erections depends on a number of other factors besides the nerves including patient age and preoperative erection quality. A young patient with good erectile function and bilateral nerve sparing however has a good chance of regaining normal erectile function, somewhere in the order of around 80%.

It is important to note that it can take some time for erections to return. This is because the nerves don't like being handled or manipulated and develop something called neuropraxia. It can take one or two years for normal erections to fully return. During this time you will be offered active erectile rehabilitation.
It is also worth noting that the erectile nerves are different than the sensory nerves. You will still be able to have an orgasm after radical prostatectomy. There is of course no ejaculate and you will be unable to have children.

Return to Work
This depends on your job. Robotic surgery reduces both pain and recovery time compared to open prostatectomy, but there is still a period of fatigue following the operation. If you have a sedentary job you could be back at work after a week or two, if you do hard physical labour, up to 6 weeks may be required.
Follow Up
The removed prostate will be examined by the pathologist and we will let you know the results as soon as we have them. This is usually within two weeks post operatively. 

Further management from the cancer point of view depends a little on the riskiness of your disease. Some patients may need further procedures such as post-operative radiotherapy although we usually have an idea of who is likely to need this prior to carrying out the robotic prostatectomy in the first place.

In others usually all that is needed is regular PSA monitoring. The prostate is the only organ to make PSA and if you have had a cure for prostate cancer your PSA should drop to undetectable levels (less than 0.02). It is important not to do a PSA blood test too early post operatively as sometimes it takes a while for the existing PSA in the blood to be cleared from the bloodstream.

If your PSA should start to climb following surgery then it is important that we know about this as soon as possible as salvage radiotherapy, given early, is often a potentially curative second-line option.

 


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