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Robotic-assisted (Da Vinci®) laparoscopic radical prostatectomy
A. It is a minimally invasive (Keyhole) surgery to remove the prostate gland using robotic assisted techniques.
During the operation, the surgeon will also sometimes remove some lymph glands from the side of the prostate. The surgeon then proceeds with removal of your prostate and the two sacs behind the prostate (seminal vesicles). The bladder is then joined to the water pipe (urethra) which runs along the penis so that you can pass urine normally. A tube (catheter) is left in place for 14 to 21 days to allow the join to heal.
A. The alternatives depend on the stage of the cancer and may include:
A. Early prostate cancer can be effectively treated. Radical prostatectomy is an operation which aims to remove the cancer and the prostate completely. The main advantage of surgery is that the cancer can be removed completely.
A radical prostatectomy is an operation carried out to remove the prostate for patients who have prostate cancer. The prostate, seminal vesicles and surrounding tissues are removed to provide the best possible chance of removing all the cancer.
A. The operation is very safe and will be performed by a surgeon who is skilled and experienced. As with any operation, there are small risks of general complications such as bleeding or infection but death is extremely rare (less than two in 1000).
You may experience some loss of urinary control which tends to settle by three to six months after the surgery but may require you to wear pads. A few men have long-term problems with incontinence (less than five in 100) which may require other treatments.
The operation is designed to remove the prostate and all the cancer. Sometimes, after the procedure, it is found on examination of the prostate by the pathologist that the cancer has grown beyond the covering of the prostate gland. If this is the case, your urologist will discuss with you whether you need additional treatment such as radiotherapy. This will also depend on your PSA (prostate specific antigen) level which is monitored in all patients at frequent intervals. In the majority of men, your PSA will be close to zero at all times and you will not require further treatment.
A. You will usually be admitted a day before your surgery. You will normally undergo pre assessment on the day of your clinic or an appointment for pre assessment will be made from clinic, to assess your general fitness and to perform some baseline investigations. After admission, you will be seen by members of the medical team which may include the consultant, junior urology doctors and nurse.
You must prepare yourself to mobilise immediately after the operation. You should try to walk at least 10 lengths of the ward before your operation. You will be asked not to eat for six hours before surgery. You will be measured for elasticated stockings, which you will be asked to put on to prevent thrombosis (clots) in the veins of your legs.
Before your procedure, the anaesthetic team will visit you to ensure that they have no concerns about anaesthetizing you. You are encouraged to ask them questions at this stage about any concerns or issues you have concerning the anaesthetic.
You will need to have a small enema in the morning prior to surgery. Once your bowels have been opened, you can have a shower and prepare yourself in a clean gown.
Please be sure to inform your urologist in advance of your surgery if you have any of the following:
A. Normally, a full general anaesthetic will be used and you will be asleep throughout the procedure.
They may put a drip into your arm or neck to allow them access to your circulation during the operation. You will be anaesthetised and taken into the operating theatre. During the surgery you will be given antibiotics by injection; if you have any allergies, be sure to let the anaesthetist know.
The Da Vinci® prostatectomy is an operation to remove the prostate using laparoscopic techniques but with smaller incisions to remove the gland. A robotic console is placed beside you in the operating theatre. Attached to the console are three or four robotic arms; two or three for instruments and one for a high magnification 3D 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 seven mm 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 3D imaging in a small space within the body.
With robotic surgery, the instruments are placed on to the robotic arms through small port holes into your abdomen. The operating surgeon sits in the same room but away from the patient and is able to carry out more controlled and precise movements using robotic assistance. The robot does not, of course, do the operation. The instruments are controlled by the surgeon (who does the operation) and the robot cannot work on its own.
A. Once your surgery is complete, you will be taken to the recovery area. Although you have had minimally invasive surgery, you will have some pain and pain killers will be given accordingly. You will wake up with a catheter in your bladder, a wound drain from your abdomen (not in all cases) and six small incisions where the robotic port sites have been closed.
You will be given clear fluids to drink. It is very important that, whilst you are in the recovery area, you let the staff know if you feel any pain or become nauseous so that they can administer the appropriate medication. Once the anaesthetic staff, surgeons and nursing staff have agreed that your condition is stable, you will be transferred back to the ward.
On the day after surgery (and in some instances the evening of surgery), you must be prepared to mobilise actively. Ideally, we would like you to go home in 2 to 3 days after your operation.
Your catheter will remain in for approximately 14 to 21 days to allow the new join (anastomosis) between your bladder and urethra to heal. Your abdominal drain will generally be removed the morning after surgery (if one was put in). The average length of stay for this procedure is 48 to 72 hours.
You will be discharged once you are mobilising safely, are able to care for your catheter/leg bags and your pain is well controlled on appropriate tablets taken by mouth. You may take some time to commence passing wind and a few days before your bowels open.
A. Most procedures have a potential for side effects. You should be reassured that, although all these complications are well recognised, the majority of patients do not suffer any problems after a urological procedure.
Common (greater than one in 10)
Temporary difficulties with urinary control
Impairment of erections even if the nerves can be preserved (20-50% of men with good pre-operative sexual function)
All men have permanent inability to ejaculate or father children because the structures which produce seminal fluid have been removed.
Discovery that cancer cells have already spread outside the prostate, including a positive surgical margin whereby cancer cells are present on the surface of the prostate. This may less commonly require further treatments such as radiotherapy or hormone treatment
Occasional (between one in 10 and one in 50)
Rare (less than one in 50)
A. Before you leave hospital, the team will ensure you are safe to be discharged home. In order to reduce your risk of developing deep vein thrombosis (clots), we will teach you to self-inject Low Molecular Weight Heparin (LMWH) under your tummy skin, once daily for two to four weeks after discharge. LMWH is a drug that helps keep your blood thin to avoid clot formation. We also recommend that you wear the elasticated (TED) stockings for four weeks post discharge. When you leave hospital, you will be given a discharge summary of your admission. This holds important information about your inpatient stay and your operation.
When you are discharged from the ward, you will need some comfortable, loose clothing as you may find that your abdomen is uncomfortable and swollen.
You will need someone at home with you for the first few days after you are discharged. A two to four week convalescence period is usually necessary after laparoscopic surgery. During this time, it is not unusual to feel weak and tired.
A. Since the surgery is performed through a small incision, 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.
A. Light walking is encouraged straight after the procedure. After two weeks, jogging and aerobic exercise is permitted. After four weeks, you may resume light lifting.
A. Yes. We recommend that you rinse any soap thoroughly from your body as this may irritate the wounds. You should gently pat yourself dry to minimise the risk of infection.
A. When you are comfortable to do so (usually about two weeks post-surgery) and when you feel able to make an emergency stop.
A. 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. Nearly all men will lose all erectile function in the first few months after surgery while the nerves start to recover (if nerve sparing has been possible).
If a nerve-sparing procedure has been performed, we will normally start you on medication such as sildenafil or tadalafil when you return for your results six weeks after surgery. We would recommend that you take this as prescribed 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 two years to recover any natural 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 discuss other alternatives (such as injection treatment).
A. Please allow a couple of weeks’ recuperation before returning to work. If you work entails heavy lifting, please speak to your consultant about this prior to leaving hospital.
A. When you have:
A. Incontinence: It is common to experience some temporary loss of control over the passage of urine. This tends to settle within three to six 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 shown how to do these before your surgery and it is beneficial to have started these exercises in the period before your operation. They will need to be continued after the catheter has been removed, but not while your catheter is in.
Follow up: It will be at least 14 to 21 days before the final pathology results on your prostate are available.
You will receive an appointment to attend the outpatient clinic in the first week after surgery, then at 3 weeks and at approximately six weeks after surgery. This is to allow the consultant or specialist registrar to find out how you are recovering and to discuss the findings of the pathology report on your prostate specimen.
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. Patient Information
Erectile function: Depending on your erectile function before the operation, and whether it was possible to preserve these nerves, problems with erection can occur.
The risk of this problem varies:
Erection problems can be helped by treatments ranging from tablets to injections. It is highly unlikely that you will lose your sex drive (libido) as a result of the operation.