What is a robotic prostatectomy?
Radical prostatectomy (RARP surgery) is the surgical removal of the prostate, vas deferens (the tube that carries sperm from the testicles) and seminal vesicles (glands that store semen).
Am I eligible for a radical prostatectomy?
All patients diagnosed with prostate cancer are discussed in a multi-disciplinary meeting where various healthcare professionals, urologists, radiologists, and oncologists, determine the treatment options available. Depending on your medical conditions, cancer type and stage, the treatment options available for you will be recommended. One is always encouraged to have honest conversations with realistic expectations with your doctor.
Recent advances show an essential role of radical prostatectomy in localised disease (prostate cancer that has not gone through the capsule) and locally advanced disease (prostate cancer that has gone through the capsule). The role of the operation in the metastatic setting (cancer that has spread) is under investigation. The more advanced the disease is, the more likely that a multi-modality approach (using different treatments such as radiotherapy, hormones and novel medications) is undertaken. This means that the indications for radical prostatectomy will soon be expanded to those that, up to recently, were not considered.
What does Robotic-assisted surgery mean?
Robotic-assisted surgery is a minimal access (keyhole) approach. This means multiple small incisions (typically six) are used to perform the surgery. The robot has three main components, a patient-side cart, a visual cart and the surgeon console.
The robotic patient cart has four arms; one holds a high-magnification 3D camera, and the other robotic arms can hold specific surgical instruments to carry out the operation. The instruments are smaller than those used for traditional open surgery. The surgeon console is where the surgeon controls the robotic arms to carry out your surgery. Your surgeon will be in the same room but away from you. The robot is not performing the surgery. The robot allows more controlled and precise movements and better visualisation.
6 illustrations of steps for prostate surgery
What will you expect during the consultation with your prostate cancer surgeon?
I encourage you to write any questions you and your family may have and bring them to the surgeon's attention.
The surgeon will take your history and discuss your urinary voiding habits and the quality of your erections.
The type of radical prostatectomy offered will be based on the individual’s circumstances discussed with you. In principle, it involves the removal of the prostate, seminal vesicles and vas deferens. Surgery typically takes between 2 to 4 hours. You will be transferred to the recovery unit, where you'll spend around 2 hours; afterwards, you will go to the ward. We recommend a light diet (unless the surgeon specifies otherwise) to minimise nausea and feeling sick. Typically you will stay one night in a hospital, but they last longer in a small number of patients.
Will my erectile nerves (neurovascular bundle) be spared?
Nerves pass along both sides of your prostate. These are responsible for erections and may contribute to continence. These form part of the Neuro-vascular Bundles. Depending on how your erections are and the prostate cancer stage, a decision will be taken whether to perform a nerve-sparing procedure (on one side or both sides) or a non-nerve sparing procedure. Men who have their neurovascular bundle preserved have better chances of achieving erections after the surgery and gaining continence earlier. When sparing the nerves, there is an increased risk of a positive surgical margin (failure to remove all cancer cells).
Will I have my lymph nodes removed?
Lymph nodes are small structures located in different parts of our body that filter a fluid called lymph. They are the sentinel of our bodies. All our organs are connected to this system. The lymph nodes contain immune cells. During this filtration process, our immune system picks up any threat to our body from bacteria, viruses, cancers and other insults. Most cancers have a tendency to spread to the lymph nodes. If the prostate cancer is at increased risk of spreading to the lymph glands that drain your prostate, your surgeon will recommend their removal.
What are the alternatives to a robotically assisted radical prostatectomy?
§ Open approach. This is done through a large incision that may extend from the belly button (umbilicus) to the pelvis. Associated with prolonged length of hospital stay and increased blood loss. Oncological and functional outcomes are the same as other approaches.
§ Laparoscopic approach. This is also a minimally invasive procedure, but nowadays, most centres have replaced it with a robotic approach. Oncological and functional outcomes is the same as other approaches.
§ Radiotherapy with or without hormonal treatment. The oncological outcome is similar to the surgical procedure in the long term. There are different modalities of radiotherapy (external or brachytherapy). You will have a dedicated appointment with an oncologist to discuss this treatment in depth.
§ Active Surveillance. Men with low-risk prostate cancer may have the option to defer active treatment and enrol in close follow-up (each centre has its own protocol) with a blood test (PSA), imaging, biopsies and clinical. If, during follow-up, there are signs of cancer progressing or if the patient wishes something to be done, active treatment is offered.
§ HIFU (high-intensity focused ultrasound). Ultrasound energy is used to heat and destroy cancer cells in the prostate. Indicated in localised disease or if the prostate cancer recurs after radiotherapy. Long-term data is still awaited. This treatment is provided in a few centres. Another option would ne Nanoknife.
Preoperative Optimisation - recovery starts before your surgery
Fitness
To maintain optimum health, the World Health Organisation recommend that adult individuals do 150 minutes of moderate exercise a week (e g brisk walking) or 75 minutes of strenuous exercise per week (e g Running).
Improving your fitness levels has many benefits in preventing complications during and after surgery and promoting recovery. Investing in your fitness is a crucial step to success.
Stop smoking and drinking alcohol.
I strongly advise you not to smoke. If you continue to smoke, this will reduce the chance of successful treatment and increase the likelihood of complications, for example, chest infection, wound healing impact and others.
If you drink alcohol, consider reducing your drinking amount and/or stopping in the weeks leading up to your surgery. Do not drink any alcohol for at least 24 hours before your operation.
Mental Strength is an essential investment in your path.
The mental problems that arise from cancer are too often ignored. Common reactions include fear, anxiety, sadness, guilt and anger. When you are diagnosed, you’re likely to worry about cancer's impact on you or a loved one/s. Doubt about the future is a heavy burden. Looking after your emotions is as much as important as your physical needs. Mindfulness has been shown to help rebuild your inner mental strength.
Pelvic Floor Muscle Training should start before your surgery
The pelvic floor muscles act like a scaffold in supporting the bladder and bowel in their daily functions. Once you have decided to undergo surgery, start performing the exercises. Research has shown that men who practice before surgery gain continence faster.
Prostate Cancer UK created a nationally recognized leaflet about pelvic floor muscle exercises. We encourage all our patients to read it. This can be accessed through the following link.
https://prostatecanceruk.org/media/975926/pelvic_floor_exercises-ifm.pdf
Many patients in the UK found the squeezy app for men very helpful for their pelvic floor muscle training.
Giving my consent (permission) for surgery
The operating surgeon will go through the procedural steps, associated risks and complications. The following points will be discussed;
Specific risks for a robotic-assisted radical prostatectomy
§ Recognised or unrecognised other organ injuries to other organs (bowels/ureters/nerves/vessels) inside your abdomen that may need repair/ removal/ bowel bag/reoperation. Some injuries show themselves during the surgery, so they can be addressed during your surgery. Others mask themselves and only become apparent later. This means that further investigations and treatment may be required.
§ Urinary anastomosis (joint) related issues; the joint can fail to heal, leading to urine leakage. In some patients, this can be managed conservatively by keeping the catheter in for extended periods. In a few patients, this needs further surgery to be rectified. With time the joint can narrow, impairing the passage of urine. One may experience decreased urinary flow, urinary tract infection or inability to void completely. This will need further surgery to be addressed.
§ Shoulder tip pain is a reflective type of pain. Carbon dioxide is the gas used during surgery to inflate the abdomen allowing the surgeon to operate robotically. Some residual carbon dioxide gas trapped in the upper abdomen can irritate the nerves near your diaphragm (the muscle underlying the lungs), leading to this pain. This can cause pain in one or both shoulders. As the gas is reabsorbed by your body, the pain will disappear.
§ Failure to clear all your cancer despite the surgery. This is known as a positive margin. Depending on each clinical picture, one may be asked to monitor closely with a blood test (PSA) or undergo additional radiotherapy (with or without hormone treatment).
§ Sexual dysfunction. This can range from diminished sexual desire, impotence and dry orgasms. A nerve-sparing procedure increases the chance of achieving an erection. However, this may not be possible in every case. Most men find that their erectile function gradually improves with time. Natural recovery of erections can take up to four years. For those that may achieve an erection, it may not be the same as before. Keeping open communication with your partner and your doctor or nurse about these changes is essential. Some men suffer from climacturia, which is passing urine when achieving an orgasm. This, in the absolute majority, is self-limiting. We do run dedicated erectile dysfunction clinics; do not hesitate to enquire more.
§ Incontinence. Once the catheter is removed, every man experiences a different outcome with voiding. Some men are immediately dry or wear a couple of pads; others initially need five to six continence pads. This can be pretty distressing. It is important not to judge the operation outcome as it is still early days. Gaining back your continence does improve with time. Performing pelvic floor exercises is vital. These exercises should be started immediately when you decide to go ahead for surgery as it has been found that men who do so gain their continence faster. It is imperative to continue them regularly after your catheter has been removed. In our unit, only one men who undergo a robotic radical prostatectomy yearly need further surgery to address their incontinence. The remainder is either dry or wear one pad as a reassurance. If you are still incontinent at 6 months post-surgery, do speak up.
When one lifts heavy objects or involves themselves in arduous exercise, it is not uncommon to experience a dribble (stress urinary incontinence). This is self-limiting and does not affect your quality of life.
§ Penile Shortening. Men can notice a decrease in their penile length of 1 to 2 cm, typically at 10 days post-surgery. This can have an impact on one self-esteem. Reassuringly this loss is naturally gained back in 6 to 12 months post-surgery. If, during your recovery, you feel that this change is affecting you in any way, we encourage you to contact us as we can help.
§ Paralytic ileus (failure of your bowel to work) for several days, causing nausea, bloating & vomiting. Good fluid intake, small but frequent portions of food, and keeping active help get your bowels going.
§ There may be a need to convert to laparoscopic or open surgery in the rare event of a surgical problem or failure of the robot. These conversions are extremely rare.
§ If your surgery involves the removal of the lymph glands that drain the prostate, one can
¨ Develop a temporary swelling of the penis and scrotum. This resolves by itself
¨ Develop a lymphocele. This is a collection of lymph fluid. Most collections are small, and self resolve others can be extensive. Patients who develop a large lymphocele typically experience generalized abdominal or pelvic pain, leg swelling, or a change in their bowel habits. These collections can get infected, and one can experience fever, chills and rigors. If the collection is large, these are drained under local anaesthetic by an interventional radiologist, and an antibiotic is prescribed if infected. If it persists or your condition does not improve, it will be managed surgically.
General risks for a robotic-assisted radical prostatectomy
§ Blood clots in your lower leg/deep veins (deep vein thrombosis or DVT) could pass to your lung. We will give you special stockings, an injection to thin your blood (unless contraindicated) and encourage early mobilisation to minimise the risk.
§ Chest infection. Performing breathing exercises can minimise the risk.
§ Hernia. The wounds from the outside heal fast; those on the inside require time to heal to achieve good tissue strength. Do not involve yourself in heavy lifting/ straining / arduous exercises for at least 8 weeks to minimise this risk.
§ Wound infection or a wound breakdown that will require antibiotics or further surgery.
§ Bleeding requiring the need for a blood transfusion or re-operation
§ COVID
§ Anesthetic
§ Cardiovascular (heart attack/stroke)
What to expect after your operation
Enhanced recovery
Your chosen centre to be operated at should practice Enhanced Recovery After Surgery (ERAS) principles. When ERAS is applied, it impacts positively in terms of shorter hospital stays, lower complication rates and faster return of quality of life. This success is only achieved through a multidisciplinary approach that involves the whole urology team, ERAS nurse, ward nurses, and other paramedical healthcare professionals if needed. Your family and loved ones should have a participating role as well. The ERAS approach incorporates a plan for your nutrition, pain control, mobilisation, breathing exercises, and more. Not everyone recovers at the planned rate. If your recovery is rapid or delayed, your care plan will be adapted accordingly. You must always be in control of your care.
Your recovery and expected length of stay
After surgery you will wake up in the recovery area of the operating theatre. Once stable you
will be transferred to the ward. Most patients spend one night in the hospital after their operation. Some centres are discharged on the day. Some people need to stay longer. Only once stable should you be discharged. This means that you should be mobile, pain is controlled, and able to eat and drink. Your recovery will continue at home, which can take a couple of months.
Pain control
Your pain must be controlled so you can walk about, breathe deeply, eat and drink, feel relaxed and sleep well, all of which will aid your recovery. You may be given pain-relieving medication via a drip into a vein or a fine plastic tube in your back (Epidural), which allows a continuous supply of pain-relieving medicine. The doctors will also prescribe other types of pain-relieving medicines which work in different ways, and you will have these regularly (three or four times a day). If you feel your pain is not well controlled, you must inform the nursing staff. We have a dedicated pain team service who will contribute to your care if needed.
Nutrition
You may be able to drink clear fluids a few hours after your operation. If you tolerate clear liquids, you can go on a light diet. You must eat and drink early after your procedure. This aids in your recovery. Once oral intake starts, the recommendation is to have small portions but frequently. Chewing your food correctly aids your digestion.
This helps your bowel recovery.
I am commonly asked if there are foods that prevent or protect against prostate cancer. Data is unclear on this matter.
Tubes and drips
You will have a catheter in the urethra (the water pipe via which you usually pass urine from the bladder). This will help the joint between the bladder and urethra to heal. Depending on your surgery outcome and surgeon preference, the catheter's removal day varies. Typically it can range between 7 to 14 days. Clear instructions should be provided about catheter care and removal date.
You will have a tiny tube (drip) put into a vein (blood vessel) in your arm. This will be removed when your oral intake is well tolerated.
You may be given extra oxygen to breathe after surgery until you are up and about.
On rare occasions, you will have a tube in your abdomen (tummy) to drain excess fluid from the operation site. This will be removed as soon as drainage has subsided.
Mobilisation – Life is movement. Movement is life.
I encourage activity as soon as possible after your operation. After you wake up from your procedure, you must start deep breathing exercises. This should reduce your risk of developing a chest infection. You should also point your feet up and down and circle your ankles to reduce the risk of blood clots forming in your legs from inactivity.
The staff will help you out of bed after your operation. You will be encouraged to walk (mobilise) short distances. By being out of bed in a more upright position and by walking regularly, lung function is improved, and there is less chance of a chest infection. In addition, mobilisation improves your circulation; this also helps with blood clot prevention and assists with the healing process. In addition, you should be given a daily injection to prevent blood clots from developing. You will continue to have this injection for 28 days post-operatively; it is supplied in a small prefilled syringe with a tiny needle. The ward nursing staff will teach you how to self-administer the injection before you are discharged home.
It is a good idea to wear your day clothes after your operation, as this can help you stay more active and feel optimistic about your recovery. Select comfortable and loose-fitting clothes to wear whilst you are in the hospital.
Catheter care
Even though you have a catheter, you will still experience the sensation of emptying your bladder. As long as the catheter drains well, there is nothing to be concerned about. Do not push for urine to come out when you need to pass urine. The catheter will empty your bladder.
Failing to secure the urinary catheter appropriately can result in complications. Before discharge, the nurse will explain good catheter care. The basic principles are to always check that the catheter is not under tension, that there is no kinking of the tubes, and that the catheter drains well. To reduce the risk of infection, keep a good fluid intake (not more than a glass an hour) and empty the bag when it reaches three-quarters full. It is common to observe small blood clots, debris/ sediment or blood passing through the catheter. If, with good fluid intake, these do not resolve, you should seek medical attention.
Bladder Spasms
Bladder spasms can cause urine to leak around the catheter. Typically they are caused by the catheter rubbing against the inside of your bladder. Sometimes this spasm can be distressing, especially if it becomes more frequent. Avoid caffeinated beverages like tea, coffee and fizzy drinks, as these can exacerbate bladder spasms. If these become persistent, seek medical care. Certain medication/s help the bladder to relax, easing off the inconvenience.
How long does it take to recover from robotic prostate surgery?
Exercise
You should plan to undertake regular exercise several times a day and gradually increase during the six weeks following your operation until you are back to an average level of activity. This can take up to twelve weeks. Common sense will guide your exercise and rehabilitation.
Do not undertake heavy lifting until eight weeks following your surgery. If your wound is uncomfortable, go easy with your exercise. Once your wound is pain-free, you can undertake most activities. It is generally recommended to wear your support stockings for twenty-eight days after the day of surgery.
Hobbies/ Activities
You can take up hobbies and activities as soon as possible after your surgery. This will benefit your convalescence. However, do not do anything that causes significant pain or involves heavy lifting for the six to eight weeks following your surgery.
Driving
As per Driving and Vehicle Licencing Agency (DVLA) guidelines in the UK, do not drive until you are confident you can drive safely and make an emergency stop. This varies from individual to individual and usually takes 2 to 3 weeks after surgery. Always check with your insurance company before you start driving again.
When can I return to work?
Returning to work can vary from person to person and depends on the extent of the surgery. If your job involves heavy lifting, you cannot return to work for approximately 12 weeks following surgery. This is to minimise the risk of hernia/s.
When can I travel?
It is commonly recommended you not fly (long haul) for at least 6 weeks after your surgery. This will give you ample time to recover and address any issue that arises in your early recovery phase. Always inform your travelling insurance company and tell your GP you are travelling.
Bowel function
I recommend small but frequent portions of food for the first couple of weeks. Chewing your food correctly aids your digestion. This helps your bowel recovery. Daily exercise and good fluid intake are crucial elements in your bowel recovery. Until your bowels adapt, you may find that you go to open your bowels more frequently or notice that your bowel movements are ‘looser’. Some patients may experience constipation for which laxatives may be prescribed.
Sexual Intercourse
You may begin sexual activity again three weeks after your operation as long as you feel comfortable. At first, it will be more challenging to have an erection than before your surgery. Your ability to have an erection may be affected as the nerves that control erection can be damaged during surgery. If one can still achieve an erection after surgery, you may notice that they are not as rigid or last as long as before, and you will experience a dry orgasm. Without a prostate, you will not be able to produce semen fluid. Sperm cells can still be produced in the testicles, but you cannot make a partner pregnant by sexual intercourse. If fertility is a concern, speak to your operating surgeon to explore options.
For men who have a nerve-sparing procedure, unless contraindicated, we recommend them to be on pro-erectile PDE 5 inhibitor medication like sildenafil or tadalafil and others. The dosage, frequency and duration will be guided by your surgeon. These drugs help preserve the penile erectile chambers and possibly shortened the time to the return of erectile function. Further data is awaited in the coming years regarding the role of these medications in aiding erectile function recovery. Recent research looks at low-dose shock wave treatment in assisting the return of natural erections.
One is expected to be referred to a dedicated erectile dysfunction clinic where various options can be explored, ranging from medications (oral/ injections/ locally applied drops or pellets), vacuum pump, or a penile prosthesis (you will need to be referred to a specialist centre for insertion of this implant).
Keeping open communication with your partner is key. Do not hesitate to talk to your medical caring team if this is an issue.
