What does the procedure involve?
A radical prostatectomy is an operation carried out to remove the prostate for
patients who have prostate cancer. The prostate, seminal vesicles & surrounding tissues are removed to provide the best possible chance of removing all the cancer.
Robotic prostatectomy is a specialised type of laparoscopic (keyhole) operation to remove the prostate gland using robotic assisted techniques. You should be aware that there is a small chance (less than 2%; 1 in 50) that your procedure may need to be converted to an open procedure and this is included as a standard part of consent
What are the alternatives to this procedure?
Active monitoring (watchful waiting), open radical prostatectomy, external beam radiotherapy, brachytherapy, or conventional laparoscopic (telescopic or minimally-invasive) prostatectomy.
What should I expect before the procedure?
Please be sure to inform Professor Vale in advance of your surgery if you have any of the following:
- an artificial heart valve
- a coronary artery stent
- a heart pacemaker or defibrillator
- an artificial joint
- an artificial blood vessel graft
- a neurosurgical shunt
- any other implanted foreign body
- a regular prescription for Warfarin, Aspirin, Clopidogrel, or Rivaroxaban (blood thinners)
- a previous or current MRSA infection
What happens during the procedure?
Normally, a full general anaesthetic will be used and you will be asleep throughout the procedure. In some patients, the anaesthetist may also use an epidural or spinal anaesthetic which minimises pain post-operatively.
Robotic (da Vinci®) prostatectomy uses 6 small laparoscopic incisions to remove the prostate gland, although the incision based on the umbilicus (tummy bottom) is elongated to 3-4cm to remove the prostate specimen and one of the other keyhole incisions is used to place a drain at the end of the surgery. A robotic console is placed beside you in the operating theatre. Attached to the console are four robotic arms; three for instruments and one for a high-magnification 3-D camera to allow the surgeon to see inside your abdomen. The robotic arms have the ability to hold various instruments attached to them and allow the surgeon to carry out your operation. The instruments are approximately 7mm in width. The instruments have a greater range of movement than the human hand and, because of their size, they allow the surgeon to carry out the operation using 3-D vision in a small confined space
within the body. The operating surgeon is able to carry out more controlled & precise movements using the robotic assistance. The robot does not, of course, do the operation and cannot work on its own.
What happens immediately after the procedure?
Although you have had minimally-invasive surgery, it is still possible that you may have some pain. You will wake up with a catheter in your bladder, a wound drain from your abdomen and 5 small incisions where the robotic port sites have been closed. You will be given clear fluids to drink.
Your abdominal drain will generally be removed after 12-24 hours. Your catheter will remain in for approximately 10 days to allow the new join (anastomosis) between your bladder and urethra to heal, and you will be taught how to manage the catheter before you go home.
You will be discharged once you have started to pass flatus (wind), are mobilising safely as you did before your admission, are able to care for your catheter/leg bags and your pain is well-controlled on appropriate tablets taken by mouth.
Are there any side-effects?
Common (greater than 1 in 10)
- Temporary difficulties with urinary control after the catheter has been removed, necessitating the use of pads
- Impairment of erections even if the nerves can be preserved (20-50% of men with good pre-operative sexual function)
- Inability to ejaculate or father children because the structures which produce seminal fluid have been removed (occurs in 100% of patients)
- Discovery that cancer cells have already spread outside the prostate requiring further treatment
Occasional (between 1 in 10 and 1 in 50)
- Scarring at the bladder exit resulting in weakening of the urinary stream and requiring further surgery (2-5%)
- Severe urinary incontinence (temporary or permanent) requiring pads or further surgery (2-5%)
- Blood loss requiring transfusion or repeat surgery
- Further treatment at a later date, including radiotherapy or hormone treatment
- Lymph collection in the pelvis if lymph node sampling is performed
- Some degree of mild constipation can occur; we will give you medication for this but, if you have a history of piles, you need to be especially careful to avoid constipation
- Apparent shortening of the penis; this is due to removal of the prostate gland causing upward displacement of the urethra to allow it to be re-joined to the bladder neck
- Development of a hernia related to one of the incision sites
- Development of a hernia in the groin area at least 6 months after the operation
Rare (less than 1 in 50)
- Anaesthetic or cardiovascular problems possibly requiring intensive care admission (including chest infection, pulmonary embolus, stroke, deep vein thrombosis, heart attack and death)
- Pain, infection or hernia at incision sites
- Rectal injury requiring a temporary colostomy
What should I expect when I get home?
You will need someone at home with you for the first few days after you are discharged.
A 2-4 week convalescence period is usually necessary after robotic prostatectomy, but return to normal activities may be delayed further if you suffer with significant temporary urinary incontinence.
Light walking is encouraged straight after the procedure.
After two weeks, jogging and aerobic exercise is permitted.
After six weeks, you may resume heavy lifting.
How much pain will I experience?
Since the surgery is performed through small incisions, most patients experience much less pain than with open surgery. Patients tend to need less pain medication and, after one week, very few men feel any pain at all.
When can I resume sexual activity?
This will depend on whether a nerve-sparing procedure was possible at the time of surgery. We ask that you take particular note of any erections or feelings you do have and report them on your follow-up appointments to the consulting team.
If a nerve-sparing procedure has been performed, we will normally start you on medication such as Viagra or Cialis when you return for your results 6-8 weeks after surgery. We would recommend that you take this initially 2-3 times per week in order to help improve the blood flow into the penis for rehabilitation of your erections. We would not expect this to result in erections immediately and, in fact, some patients may take as long as 24 months to recover erectile function. Additionally, vacuum devices may be used either alone or in conjunction with the above. If oral medication proves to be unsuccessful, we can arrange for you to be seen by an erectile dysfunction specialist nurse to discuss other alternatives (such as injection treatment).
When can I return to work?
Please allow a couple of weeks’ recuperation before returning to work. If your work entails heavy lifting, please speak to Professor Vale about this prior to leaving hospital.
What else should I look out for?
If you develop a temperature, increased redness, throbbing or drainage at the site of your operation, please contact Professor Vale. If you have problems with your catheter (especially if it falls out), please contact Professor Vale as soon as possible. If you become unable to pass urine after your catheter has been removed, you should return immediately to hospital for further treatment.
Are there any other important points?
Prevention of Deep Vein Thrombosis
All patients undergoing pelvic surgery are at increased risk of developing a clot in one of the deep veins of the leg (deep vein thrombosis). Whilst you are in the hospital you will be started on regular daily injections of Enoxaparin to reduce this risk, and current guidelines recommend that wherever possible, patients should continue this for 28 days after discharge. It is a very simple technique and as the needles are tiny, it is almost painless. The nurses on the ward are trained to discuss this with you and teach you how to inject yourself if you are able and willing.
Preparation for removal of the catheter
To be prepared for your catheter removal and any potential temporary urine leakage, you should ensure that you have your own personal supply of bladder weakness products (pads designed for male underwear) at home prior to attending for your trial without catheter. You will need to bring two pads with you to your appointment for catheter removal.
These pads can be obtained from various sources:
- Your local pharmacy or supermarket – they may need to be specially ordered.
- Order by phone. You can place an order by calling Tena Direct on 0800 393431 (this is a Freephone number). You can pay by credit or debit card. Lines are open Monday to Friday 09.00hr to 17.00hr (enquiries may be diverted to an answer machine if all lines are busy).
- Order on-line at www.tenadirect.co.uk where you can select the products you need and complete your purchase using the secure on-line payment system.
The ward will provide one small pack of pads prior to your discharge so we advise that you obtain an additional supply in adequate time so that you have them at home following surgery; you may find it difficult to obtain them in the short period between discharge and your appointment for catheter removal.
It is common to experience some temporary loss of control over the passage of urine. This tends to settle within 3-6 months but, during this period, you may need to continue to wear absorbent pads. As discussed before your operation, a small minority of patients will experience severe incontinence after the procedure; if this is the case, additional support and follow-up can be arranged.
To improve urinary control, pelvic floor exercises are helpful. You will have been to see Jane Simpson, Continence Advisor, prior to your surgery. They will need to be continued after the catheter has been removed.
You may find that you have difficulty achieving an erection in the longer term even if a nerve-sparing approach has been used, and this is more likely if you have had previous problems with your erections or if it was only possible to preserve one set of nerves at surgery. The risk of this problem varies:
- Very high (more than 80%; 8 out of 10 men), if the erections were not good beforehand and the characteristics of the tumour mean that it was not advisable to preserve the nerves.
- Moderately high (60%; 6 out of 10) if only one nerve could be saved
- Moderate (30-40%; 3-4 out of 10) if both nerve bundles were saved.
Erection problems can be helped by treatments ranging from tablets to injections (see above). It is highly unlikely that you will lose your sex drive (libido) as a result of the operation.
Professor Vale will usually discuss the results of the pathology of your prostate specimen at the time of catheter removal.
After that, you will receive an appointment to attend the outpatient clinic approximately 6 weeks after surgery. This is to allow Professor Vale to find out how you are recovering and to discuss the findings of the pathology report in more detail if there were any concerns indicating that additional treatment may be appropriate.
You will be followed up closely after the operation, chiefly by means of the prostate blood tests (PSA). This level should remain near zero after surgery but, if the PSA rises, this indicates a return of the cancer which may require further treatment in the form of radiotherapy or drugs.