What progress and benefits did robotic surgery have in Urology?
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What is a radical prostatectomy?
A radical prostatectomy is a type of prostate surgery where the prostate gland, vas deferens and seminal vesicles are removed under general anaesthetic. It is significant surgery recognised by the health and care excellence (NICE) to treat prostate cancer.
A radical prostatectomy is a treatment option for patients with localised or advanced prostate cancer patients. Depending on the aggressiveness of the prostate cancer, the surgical procedure may include a lymph node dissection.
The surgical procedures includes:
- Robotic surgery or laparoscopic surgery also include known as keyhole surgery.
- Open surgery (open radical prostatectomy) is still is offered in centres.
How is a robotic prostatectomy performed?
There are various robots available on the market, but the one typically used to perform this surgical technique is the Da Vinci Robot. Under general anaesthetic six small incisions, a 3D camera and robotic arms (surgical instruments) are positioned into the pelvis. The surgeon then sits at the console to control the surgical instruments.
This minimally invasive approach offers robotic urological surgeons detailed, unique views of the prostate and neighbouring structures, along with a highly precise and unparalleled wide range of movements to perform prostate cancer surgery.
This robotic method has revolutionised radical prostatectomy, leading to a significant reduction in side effects like blood loss. It has also lowered the hospital stay for patients as opposed to open surgery whilst giving the surgeon a precision of movement not previously possible by either the open or laparoscopic radical prostatectomy.
Is RARP a prostate cancer surgery?
RALP means robotic assisted laparoscopic radical prostatectomy. This was the original short form used to refer to the keyhole surgery approach; robotic prostatectomy. The first robotic equipment to be launched in the market was by Da Vinci.
Nowadays the modern term RARP is being used. This means Robotic-assisted radical prostatectomy. The term has changed, but the operation is still the same. The urological surgeons control robotic arms through a console to perform prostate surgery. As opposed to traditional open surgery, where the surgeon is standing next to the patient with the robotic prostatectomy, they can be in the same operating room or another room adjacent to the theatre performing the prostate surgery.
Is there another robotic system other than Da Vinci robot one?
The market was always dominated by the Da Vinci robotic system but many companies are launching their own robotic system. An example of such robotic system is the Versius by CMR.
More data is needed to see if there is a clear advantage in terms of cancer outcomes, side effects and more between Da Vinci and other robotic systems.
How can I prepare myself for surgery?
Together with my nursing staff we are offering RARP school sessions to support men in preparation for their surgery. Lately we are employing the use of fitness trackers to understand more what level of fitness is needed to be achieved.
Invest in improving fitness levels
To keep in good health, the World Health Organisation (WHO) recommend that adult individuals perform 150 minutes of moderate exercise a week (e g brisk walking) or 75 minutes of strenuous exercise per week (eg: running).
Improving your fitness levels has many benefits in preventing complications during and after surgery and promoting your recovery.
Stop smoking and drinking alcohol
I strongly advise you stop smoking. If you continue to smoke, this will increase the risk of complications for example chest infections, wound healing impact, and others.
Consider cutting down the amount of alcohol you drink and/or stopping in the weeks preceding your surgery and following your surgery. If you find it difficult to cut down; make an effort not to drink any alcohol for at least 24 hours before your operation.
It is not physical preparation but mental as well
The mental problems that arise as a result of 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.
Looking after your emotions is just as important as your physical needs. Mindfulness has been shown to help rebuild your inner mental strength.
Pelvic Floor Muscle Training (PFMT)
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 these exercises. Research has shown that men who perform the exercises before surgery gain continence faster.
Where are the incision sites for robotic prostatectomy?
Robotic assisted prostate cancer surgery is commonly performed using six small abdominal incisions. These are typically one to two cm long and just above your belly button, with each incision about six to eight cm apart.
At the end of the surgery, one of the incisions will need to be increased to remove the prostate gland.
Da Vinci company has created a single-port robot. This is still in its early phase and is limited to certain countries. This means that the entire operation is done through one incision just above the belly button. Da Vinci has always been at the forefront in robotic surgical systems.
Even though this is keyhole surgery, there is always a small risk that it can be converted to open. This can happen if the anatomy can be complex or challenging or a complication has arisen that cannot be sorted out through a minimally invasive surgical approach.
Can I have nerve sparing prostate surgery?
This depends on your prostate cancer type, stage, and erectile function. The nerves responsible for erections pass in close proximity to the prostate gland. After this prostate cancer treatment approach there is between 50 to 70 percent chance of regaining your erection if nerve sparing is done.
When nerves are spared there is an increased risk of positive surgical margin. This is a failure to remove all the cancer cells.
Is the urethra cut during robotic prostatectomy?
During a radical prostatectomy, the surgeon cuts off the prostate, the seminal vesicles, the Vas deferens, and, if indicated, the lymph nodes (lymph node dissection).
The urethra that passes through the prostate is removed as well. The bladder and remaining urethra are sewed back together, and a catheter is introduced to allow the joint to heal.
How long does radical prostatectomy take?
The average operating time is between two and four hours. The operative time will depend on your surgeon's ability, if additional procedures are done like nerve spare or lymph node dissection and what challenges are encountered during your surgery (this will vary from one individual to another).
Can robotic prostatectomy be done as a day-case procedure?
Some centres are providing day-case robotic surgery; however one needs to be eligible (average body weight, medically fit, physically active, live less than one hour from the operating hospital, and many more criteria need to be in place). If you wish to explore this option discuss it with your NHS urologist / consultant, specialist nurse, or private urologist.
How long does it take to recover from robotic prostate surgery?
Robotic prostatectomy is a minimally invasive surgery that guarantees an earlier recovery than open surgery. The hospital stay is typically one night. The day after, you go home with a catheter. The specialist nurse will explain good catheter care and give you the date for your catheter removal. This is generally removed within seven to ten days. Different operating surgeons have their own opinion when the catheter is removed.
After prostate cancer treatment It is generally recommended to wear your support stockings for twenty-eight days after the day of surgery.
You will be given a medication that thins the blood for twenty-eight days to prevent the side effect of blood clots (deep vein thrombosis).
Pain is minimal. For pain relief, you will be asked to take medication like paracetamol and codeine regularly for a few days. You will also be given a laxative to help you open the bowels to avoid straining.
You will be asked to walk very early on after the prostate surgery. This helps you breathe better decreasing the risk of chest infection and improving your circulation, lessening the risk of deep vein thrombosis. The walking distance is increased daily with most men reaching an average activity level six to eight weeks following their operation.
Driving depends on how your surgery went and your medical fitness. The UK's Driving and Vehicle Licencing Agency (DVLA) guidelines recommend that you do not drive until you are confident that you can drive safely and make an emergency stop. This varies from individual to individual and can usually take from ten days to twenty days after surgery. Always check with your insurance company before you start driving again.
How painful is robotic prostate surgery?
Minimally invasive surgery operates through small incisions. This allows faster recovery. Keyhole surgery carries less postoperative pain than open surgery. Simple pain medication with paracetamol and codeine suffices.
How long do you have a catheter after robotic prostate surgery?
In general, the urethral catheter stays between seven to 10 days. Different surgeons will have their protocol when the urinary catheter is removed. If there is a urine leak, the surgeon will ask for the urine catheter to stay longer. A test called a cystogram, where a dye is passed through the catheter to check if the leakage is resolved can be ordered.
What are common problems after surgery?
When will my erections return after radical prostatectomy?
If you had nerve-sparing surgery, the chances of your erectile function recovering are fifty to seventy per cent. Men younger than sixty-four with good preoperative sexual function, meaning good strong erections have a better chance of getting their erections back if a nerve-sparing prostate surgery procedure is done. The surgeon will preserve the blood vessels that are responsible for supplying the penile tissue.
Some men can achieve an erection immediately. Others need time for the nerves to recover. This can take just a few weeks or as long as four years.
Will I be infertile after robotic prostatectomy?
After a radical prostatectomy you will experience dry orgasms and will not be able to conceive naturally.
Urinary incontinence
Once the catheter is removed some patients are immediately dry, others need to wear one pad, and some need to wear up to five. Urinary incontinence is quite distressing.
Start performing your pelvic floor exercises. The aim is to be dry, or wear one pad as reassurance, by six months from your surgery. Most men achieve this in three months.
What improves the urinary control?
The urological surgeons will attempt to perform multiple techniques that allow men undergoing prostate cancer surgery to become drier quicker, these include:
- full functional urethral length preservation (the longer the urethra the better)
- nerve-sparing (when nerve sparing surgery is done
- Rocco stitch allows reconstruction of the posterior aspect of bladder and urethra. This allows better bladder and urethra joint reconstruction, support and reduce blood loss.
Does pelvic floor muscle training (PFMT) help with incontinence?
- Pelvic floor exercises performed before the surgery allow faster recovery. These should be stopped when you have a catheter. Once the urine catheter is removed these exercises should be resumed and performed religiously. You should have an appointment with a physiotherapist before and after that will guide you how to perform them effectively.
- Many patients in the UK find the squeezy app for men very helpful for their pelvic floor muscle training. It is easy to download and very user friendly.
Positive margins
Once the prostate gland is removed, it is then sent to a pathology lab for evaluation.
The prostate gland surface is painted. This indicates the outside edges of the prostate gland called surgical margin. The next step is to cut thinly the prostate gland and review the slices under the microscope.
If prostate cancer cells are touching the ink mark on the outside this is known as a positive surgical margin.
How common are positive surgical margins (PSM) after radical prostatectomy?
This will depend on your prostate cancer stage (the more advanced the higher the risk), if a nerve-sparing procedure is done, as well as your surgeon's expertise.
Between ten to thirty per cent of men undergoing surgery have a positive surgical margin.
How many men need treatment if they have a positive surgical procedure?
Thirty-three per cent of men with a positive surgical margin need further treatment (radiation therapy combined with hormonal therapy) compared to ten per cent of men with negative margins.
If you have a high PSA prior to surgery, more aggressive cancer or advanced stage you have more chance of undergoing additional treatment if you have a positive margin.
What if you have a positive surgical margin?
The first reaction is to be concerned. This is a normal human reaction. The first step is to keep a close eye on your PSA blood test. Based on the RADICAL study if you have three results of PSA above 0.1 or your initial PSA is 0.2 or above then you will be asked to undergo additional treatment.
How successful is a radical prostatectomy?
Men who undergo the removal of prostate cancer have a reasonable survival rate and low rates of their cancer coming back, spreading, or dying directly from prostate cancer.
Radical prostatectomy is indicated for localised prostate cancer or locally advanced prostate cancer. There are various treatment options for this stage of prostate cancer. These are active surveillance, radical prostatectomy, radiation therapy, and focal therapy. There is no single best treatment.
Your health, medical condition/s, prostate cancer type, and lifestyle have to be factored in. Choosing the treatment options can be challenging so always discuss with your operating surgeon, NHS consultant, private urologist or nurse.
Which is better, laparoscopy, open or robotic surgery?
All three treatment options in cancer control are equivalent as long as the operating surgeon and the centre are experienced in performing that approach.
Conventional laparoscopic and robotic surgery is minimally invasive surgery. This means;
- less postoperative pain,
- smaller incisions (less scarring),
- short hospital stays,
- less blood loss, blood transfusion is rare
- earlier return to daily life.
- There is always a minimal risk that, from the keyhole approach, it is converted to open.
The above outcomes are based on Da Vinci robot radical prostatectomy approach however new robots used to treat cancer are showing similar outcomes. More research projects are needed.
Is there a life after prostate cancer?
An affirmative yes.
Advances in care have lead to men with prostate cancer to live longer. Both assisted laparoscopic radical prostatectomy or open radical prostatectomy treatment options are no exceptions.
Survivorship can be a challenging part of your prostate cancer journey. This is subjective. Everyone has to find their own route, and plod through the challenges from the moment of the workup, diagnosis, treatment and changes that happen after prostate surgery or other treatment you have chosen.
There are various support groups or an online community of survivors. This provides the opportunity to talk with people who are facing similar or different challenges.
Regular physical activity is crucial to rebuild your strength, energy and protect your mental well being. Take regular power naps. Look after your diet, limit your alcohol intake and if you smoke stop smoking.
What loved ones and family members experience
Family members and friends also experience changes during your cancer journey. The natural instinct is to hold everything inside not to cause additional stress or sadness. The opposite should happen, talking about how you feel and sharing the pain and difficulty. Together you are stronger.
What questions should I ask?
- How many radical prostatectomies are performed in the unit?
- What is the robotic prostatectomy urinary continence outcome in the unit?
- What is the robotic prostatectomy positive surgical margin rate in the unit?
- Apart from robotic surgery does the unit have an enhanced recovery approach?
- Apart from robotic assisted laparoscopic prostatectomy are there alternative treatments?
- Does your unit have preoperative support?
- Does your unit have a survivorship programme?
- Can you give me contact details of prostate cancer nurse specialist (CNS) ?
