Robotic Nerve-sparing Radical Prostatectomy

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For patients with clinically localized prostate cancer, nerve-sparing robotic prostatectomy provides patients with a safe and minimally invasive approach to remove the prostate gland and seminal vesicles, while aiming to preserve as much of the surrounding nerves responsible for erections.

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This minimally invasive approach has the advantage of smaller incisions, reduced pain, blood loss, transfusion rates and hospital stay, as compared to conventional open surgery with a similar cure rate. In select patients with locally invasive or metastatic cancer, morbid obesity, bleeding tendencies, or severe heart or lung problems, robotic prostatectomy may not be advised.

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The Surgery

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Robotic prostatectomy requires that patient undergo a general anesthesia. While operative time varies from one individual to another, the average operating time is approximately 4 hours.

During robotic prostatectomy 6 small keyhole (< 1cm) incisions are made in the abdomen (Figure 1), through which trocars are placed to allow passage of instrumentation into the abdomen.

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Figure 1. Trocar configuration for robotic prostatectomy.

The abdomen is filled with carbon dioxide gas to create a larger working space for the surgeon to accomplish the operation. This gas is later evacuated from the abdomen at the conclusion of the procedure. The surgeon controls 3 multi-jointed robotic instruments to accomplish the tasks of dissection, cauterization, cutting and suturing with the same dexterity as the human wrist (Figure 2).

 

 

 

 

 

 

 

 

 

 

 

 

Figure 2. Multi-jointed robotic instruments allow the surgeon to operate within the body with the same facility as tiny human hands.

 

In addition, the surgeon controls a stereoscopic lens connected to a high definition camera which provides a three dimensional, high definition view of the internal anatomy. A highly skilled surgical assistant stands at the operating table assisting the surgeon by exposing and retracting tissue using instrumentation inserted through two of the trocars. The da Vinci Surgical Robotic System is assembled to the trocars prior to commencing the operation.  With the operating surgeon seated a few feet away at the surgeon operating console, the robotic instrumentation is controlled by the surgeon in real time with highly precise motion scaling.

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Figure 3: Schematic View of the operating room configuration for robotic prostatectomy.

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Figure 4. The prostate gland, seminal vesicles and vas deferens are then dissected and exposed.

Schematic diagram showing a side view of the anatomic relationship between the bladder, prostate, neurovascular bundle, pubic bone, rectum and vas deferens. 

 

The prostate is detached from the bladder and urethra, preserving the surrounding delicate cavernous nerve tissues when indicated in efforts to preserve the patient’s ability to achieve spontaneous erections following recovery from surgery.

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Figure 5. Artist depiction of the approximate location of the neurovascular bundles on the lateral aspect of the prostate

 

Pelvic lymph nodes that may be involved by cancer are removed when indicated to better stage the extent of tumor involvement. Lastly the bladder is sewn back to the urethra to restore continuity of the urinary tract.  Thermal energy is minimized during dissection of the prostate so as to avoid injury to the delicate nerve fibers and muscles involved in penile erections and urinary control. Once the prostate and lymph nodes are removed, they are immediately placed within a plastic sack which is later removed intact at the end of the operation through an extension of one of the existing abdominal incision sites. A small drain is left at the end of the procedure exiting one of the keyhole incisions along with a urethral catheter (called foley), which is used to bridge the connection created between the bladder and urethra (called the anastomosis). Finally the specimens are removed from the abdomen through the plastic entrapment sack and the skin incisions closed using plastic surgery techniques to minimize scarring. Abdominal incisions at one month following surgery are generally barely visible.

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Continence Outcomes

 

Although most patients experience some degree of urinary leakage (i.e. incontinence) following robotic prostatectomy, most patients quickly regain control by 3-6 months following surgery.

 

Potency Outcomes

 

Return of sexual function following nerve-sparing robotic prostatectomy is more challenging to define and assess as results depend on multiple factors including patient age, preoperative sexual function, percent of nerves spared during surgery, recovery time after surgery and presence of pre-existing medical conditions such as hypertension, heart disease, diabetes, obesity, smoking and high cholesterol. Based upon validated quality of life surveys and of patients who were fully potent preoperatively who underwent bilateral nerve preservation, 50%, 73% and 88% of patients reported successful intercourse with or without the use of phosphodiesterase 5 inhibitors (i.e. Viagra, Cialis, Levitra, Stendra) at 3, 6, and 12 months postoperatively. (Willis DL, Gonzalgo ML, Brotzman M, Feng Z, Trock B and Su LM. Br J Urol Int 109: 898-905, 2012).

 

Potential Risks and Complications

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As with any major surgery, complications, although rare, may occur with robotic prostatectomy. Potential risks and complications with this operation include but are not limited to the following:

• Bleeding: Blood loss during this procedure is typically less than 100 cc with the rare need for a blood transfusion (<2% of patients).

• Infection: With the use of intravenous antibiotics, the risk of skin infections is extremely rare. However, if you develop any signs or symptoms of infection after the surgery (fever, drainage from or redness around your incisions, urinary frequency/discomfort, pain) this should be evaluated as soon as possible.

• Incisional Hernia: Because of the small laparoscopic incisions, hernias at these sites occur rarely. In addition, larger incisions are closed carefully prior to the completion of your surgery to minimize the risk of hernias.

• Adjacent Organ Injury: As robotic prostatectomy is performed under continuous visualization, the risk of inadvertent injury to adjacent organs is uncommon. Nevertheless, the colon, small intestines, bladder, urethra, blood vessels and nerves are all in close proximity to the prostate.  Transient nerve and muscle injury to the extremities can rarely occur as a result of patient positioning.

• Conversion to Conventional Laparoscopic or Open Surgery: In the rare event of complications or due to difficulty in dissecting by means of robotic surgery, conversion to conventional laparoscopy or open surgery is sometimes required (<1% of patients). This could result in a larger standard open incision and possibly a longer recuperation period.

• Urinary Incontinence: Although most if not all men will suffer from temporary stress urinary incontinence following any form of prostatectomy surgery including robotic prostatectomy, this improves with time over the course of months following your surgery. You will be instructed either pre-operatively or during your first postoperative visit on the importance of performing Kegel exercises as well as be given the opportunity to participate in pelvic floor rehabilitation training to strengthen the pelvic floor muscles integral in the recovery of urinary control.

• Erectile Dysfunction: As with open prostatectomy surgery, erectile dysfunction can often be a more significant and longer lasting side effect as compared to urinary incontinence even despite a nerve-sparing procedure. The return of erectile function following prostatectomy is multifactorial and is dependent on factors including the age of the patient, degree of preoperative sexual function, technical precision of the nerve-sparing technique, and time.

• These microscopic and delicate cavernous nerve fibers responsible for spontaneous erections may take up to 12-18 months to recover. You will be instructed during your first postoperative visit on various treatment options including medications (e.g. Viagra, Cialis, Levitra, Stendra) as well as the use of a vacuum erection device or penile injections as part of penile rehabilitation program that we offer. These therapies are often used to maintain the blood supply to the penile tissues while awaiting the recovery of cavernous nerve function.

• Urethrovesical Anastomotic Leakage: At 7-10 days following surgery the urethral catheter is removed in the office. In some cases with extensive bladder neck reconstruction a specialized bladder xray, called a cystogram, will be performed prior to removal of your urethral catheter. On rare occasions, a small leak is detected on the cystogram that may require a longer duration of catheter drainage. These anastomotic leaks often resolve spontaneously with no further surgical intervention

 

What to Expect After Surgery

 

After a period of recovery in the recovery room, you will be transported to your hospital room once you are aware and your vital signs stable.

• Postoperative Pain: Although most patients in the first few days after surgery experience mild pain at their incision sites, this is generally well controlled by use of intravenous pain medication and/or oral pain medication provided by your nurse. You may experience some minor transient shoulder pain (1-2 days) related to the carbon dioxide gas used to inflate your abdomen during the robotic surgery.

• Nausea: Nausea can occur following any surgery especially those procedures that require general anesthesia. This is usually transient and controlled by medication which can be administered on an as needed basis by your nurse.

• Urinary Catheter: A urinary catheter (also called foley catheter) is placed to drain your bladder at the time of surgery while you are asleep. This is in efforts to monitor your urine output following surgery. Upon awakening from anesthesia, patients often notice an urge to urinate as a result of the catheter. This sensation often resolves with time. It is not uncommon to have blood-tinged urine for a few days after your surgery while your catheter is in place.

• Bladder Spasms: Frequently after prostate or bladder surgery, the bladder becomes irritated and undergoes frequent contractions called bladder spasms. This can be felt as intermittent sharp shooting pain or spasms in the lower abdomen. Often with time alone these spasms will resolve. On occasion an antispasmodic can be provided if severe spasms are experienced.

• Pelvic Drain: A small clear tube called a Jackson Pratt or JP pelvic drain will be placed during surgery exiting out of the side of your pelvis. The drain output will appear blood tinged but should be minimal. The drain primarily serves to identify any excessive bleeding, lymphatic leak or a urine leak from the anastomosis. On occasions your surgeon may advise that the drain remain in place for one week after surgery to be later removed in the clinic.

• Diet: Your diet will be advanced slowly following surgery from liquids to solids as tolerated. It is often the case that your appetite will be poor for up to a week following surgery. In addition, your intestinal function is often sluggish due to the effects of surgery and general anesthesia. It is for these two reasons that we recommend taking only small amounts of liquids by mouth at any one time until you begin to pass flatus and your appetite returns. In the meantime, your intravenous catheter will provide the necessary hydration to your body as your oral intake improves.

• Constipation/Gas Cramps: You may experience sluggish bowels for several days following surgery as a result of the anesthesia. Suppositories and stool softeners are usually given to help with this problem. Taking a teaspoon of mineral oil daily at home will also help to prevent constipation. Narcotic pain medication can also cause constipation and therefore patients are encouraged to discontinue any narcotic pain medication as soon after surgery as tolerated.

• Fatigue: Fatigue is quite common following surgery and should subside in a few weeks following surgery.

• Incentive Spirometry: You will be expected to do some very simple breathing exercises to help prevent respiratory infections through using an incentive spirometry device (these exercises will be explained to you by the nursing staff during your hospital stay). Coughing and deep breathing is an important part of your recuperation and helps prevent pneumonia and other pulmonary complications.

• Ambulation: On the evening of surgery it is very important to get out of bed and begin walking with the supervision of your nurse or family member to help prevent blood clots from forming in your legs. You can also expect to have SCD’s (sequential compression devices) wrapped around your lower legs and calf area to prevent blood clots called deep vein thrombosis from forming in your legs. In the days that follow surgery, patients are advised to walk at least 6 separate times a day in the hallways. This serves to further reduce the change of deep vein thrombosis and speed the return of bowel function.

• Hospital Stay: The length of hospital stay following robotic prostatectomy is generally 1 day, however, certain situations may require a longer hospital stay.

 

What to Expect After Discharge from the Hospital

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• Pain Control:  For the majority of patients, one to two days of oral narcotic pain medication may be necessary after which Extra Strength Tylenol is usually sufficient to manage their pain. Again, narcotics should be minimized to avoid constipation and oversedation.

• Showering:  Patients can shower immediately upon discharge from the hospital allowing their incisions to get wet. Once out of the shower, pad your incision sites dry and avoid any heavy creams or lotions. Tub baths or hot tubs in the first 2 weeks are discouraged as this will allow for prolonged soaking of your incisions and increase the risk of infection. You may shower after returning home from the hospital. Your wound sites can get wet, but must be patted dry immediately after showering. The sutures underneath the skin will dissolve in 4-6 weeks.

• Activity:  Walking 6 times a day for the first two weeks after surgery on a level surface is strongly encouraged as prolong sitting or lying can increase your risk of pneumonia and deep vein thrombosis. It is permissible to climb stairs. No heavy lifting or exertion for up to 4 weeks following surgery.  Patients may begin driving once they are off of narcotic pain medication and have full range of motion at their waist. Most patients can return to full activity including work on an average 3-4 weeks after surgery.

• Diet:  Patients may resume a regular diet once they begin to pass flatus and their appetite improves.

• Follow-up Appointment:  Patients should make a follow-up appointment with their surgeon. Your surgeon will let you know the timing and schedule of clinic visits following surgery.

• Pathology Results: The pathology results from your surgery are usually available within a week following surgery. Your results will be discussed with you either by phone or directly in the office during a follow-up clinic appointment.

 

Frequently Asked Questions (FAQ)

What type of patients are candidates for robotic prostatectomy?

 

Robotic laparoscopic prostatectomy is used to treat patients who have clinically localized prostate cancer. Most patients who are candidates for open radical prostatectomy are also excellent candidates for the robotic approach. In many centers the robotic approached is the treatment of choice for the surgical management of clinically localized prostate cancer.

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What patients are not considered good candidates for the robotic technique?

 

Patients with a history of extensive abdominal surgery, radiation, pre-existing heart or lung disease, morbid obesity, or bleeding tendencies may not be the best candidates for robotic prostatectomy. Patients with known metastatic or recurrent prostate cancer are not candidates for robotic prostatectomy. Although patients with very large prostate glands (e.g. > 100 grams) can undergo robotic prostatectomy, operative times are generally longer than in patients with smaller prostate gland sizes.

 

What are some of the benefits of robotic prostatectomy?

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• Small incisions and less scarring

• Less blood loss (< 100-200 mL) and rarely the need for blood transfusions (<1-2%)

• Short hospital stay (1 day for most patients)

• Less postoperative pain and usually minimal need for pain medication

• Short recovery time and quick return to normal activity (two to three weeks) and work (three to four weeks)

 

What is the advantage of robotic over open prostatectomy surgery?

 

The primary advantages of robotic prostatectomy are a result of the high tech equipment used to accomplish this surgery. First, there is improved visualization with 10-12 X magnification and a high definition view of the internal anatomy as a result of the use of a specialized stereoscopic endoscope lens which is connected to a high definition camera.

 

Second, robotic surgeons operate with multi-jointed 8 mm instruments which have the same dexterity as the human wrist. Taken together robotic surgery provides better visualization of the critical structures surrounding the prostate gland and allows surgeons to operate with the same flexibility and ease as an open surgeon has when performing open prostatectomy, while at the same time accomplishing this through smaller incisions with significantly reduced blood loss.

 

How long does this surgery take?

 

Robotic prostatectomy generally takes 3-4 hours depending on many factors including size of the prostate gland, presence of obesity, prior abdominal surgery and scar tissue, and other factors. Many of these pre-existing factors mandate a longer operative time. We focus on performing a thorough and meticulous surgery and not on speed of the operation.

 

What happens if complications arise and conversion to open surgery is required?

 

Although extremely rare, conversion to open surgery may be required if difficulty with dissection or extensive bleeding is encountered during the robotic approach. We are trained in open surgical approaches as well as laparoscopy and robotic surgery and therefore are well equipped to complete the surgery in a laparoscopic or open fashion if needed.

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What is the overall success rate in terms of cancer cure for robotic prostatectomy?

 

Success rate in complete removal of cancer is similar to the open surgical approach.  Prognosis of cancer-free survival is multifactorial and is based in part upon the grade and stage of your cancer and will be discussed with you following surgery during review of the pathology report. 

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What is the overall success rate in terms of potency and continence following robotic prostatectomy?

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The timing and extent of return of urinary continence and sexual potency following prostatectomy is a complex process that is time dependent and multifactorial.  Some of the factors that influence the success of return of these quality of life issues include patient factors such as age, preoperative urinary and sexual function, and presence of medical conditions such as hypertension and diabetes. In addition, surgical factors such as quality and quantity of nerve preservation can influence outcomes.

 

Will I need further treatment such as radiation or chemotherapy following surgery?

 

For patients with organ confined prostate cancer that has not spread beyond the prostate capsule or into the lymph nodes or seminal vesicles, prognosis remains excellent as most are cured with surgery alone. In cases where more invasive or metastatic disease is found, additional treatments including radiation and hormonal therapy may be required.