What is a Robotic Prostatectomy?
I have been diagnosed with prostate cancer, what are the basics of a robotic prostatectomy?
For the purpose of this post, I am going to talk about what is a robotic prostatectomy in the context of prostate cancer. This is a surgery done in the operating room for men with localized prostate cancer, which means prostate cancer that has not spread.
So let’s go through the nitty gritty details. For a patient undergoing a prostatectomy they will be brought back to the operating room suite. You will have a breathing tube (intubation) placed and be totally asleep (general anesthesia).
Technically speaking, the surgery is called a robotic-assisted laparoscopic prostatectomy. Let’s break this term down. Prostatectomy means removal of the prostate. The prostate gland will be removed with some of its surrounding structures that includes a portion of the vas deferens as well as the seminal vesicles. Laparoscopic means there will be multiple small incisions made in the abdomen. Through those incisions there will be trocars that are placed and the abdomen will be insufflated, or filled, with CO2 gas. This allows for increased space in the abdomen as well as better exposure.
This is in contrast to the traditional open prostatectomy in which an incision is made from the belly button down. Robotic-assisted is when, at my institution, the DaVinci Surgical robot is used to perform essentially an advanced form of laparoscopy. The way I explain it to my patients, in traditional laparoscopy we are working with chopsticks and with a robotic prostatectomy, the ends of the instruments move around like your hand and really help the urologist do some slick work.
Once the prostate is removed, there are sutures (or stitches) that will reattach the bladder to the urethra. At the end of a robotic prostatectomy a catheter will be placed to help drain the bladder.
What preparation do I need to do before having a robotic prostatectomy?
For the weeks leading up to surgery, focus on your strength. Try and walk or exercise every day. Even just a little bit of extra activity will give you the strength and stamina to really make your recovery stronger.
Additionally, if you can do Kegel exercises (see below), this will make a big help to quicken how fast your bladder will recover back to normal.
In the days prior to the surgery the hospital will call you. They will tell you to go to the lab to give a sample to test for your blood type in the rare instance that you would need a blood transfusion. They will also tell you where to go and what time to come into the operating room. Please note, you are not to eat after midnight the day before surgery.
Let's talk about the surgery itself
You will come to the preoperative holding area and meet a whole bunch of people. You will meet the nurses who will review your medical chart, place an IV in your arm, and check bloodwork. You will then meet the Anesthesiologist who is the one in charge of putting you to sleep and managing that during the case. Lastly you will meet the operating room nurses who will then take you to the operating room.
Once you are off to sleep, we will get the case started and once the robotic instruments are ready, the urologist will sit at the surgeon’s console, which is like an arcade machine the controls the robot. We will sit down and toggle the joysticks which will help manipulate the robotic arms.
The surgery itself can be broken down into several steps
- Exposure of the bladder, prostate, and urethra
- Separating the prostate from the pelvic floor muscles
- Disconnecting the prostate from the bladder
- Disconnecting the vas deferens
- Freeing up the seminal vesicles to be removed with the prostate
- Disconnecting the blood supply to the prostate
- Freeing up the prostate from the rectum
- Preserving the nerve and vascular tissue surrounding the prostate (optional)
- Cutting through and tying off the venous blood vessels on top of the prostate
- Disconnecting the prostate from the urethra
- Suturing the urethra to the bladder and placing a foley catheter
Here is a good video showing the steps of a robotic prostatectomy by Dr. Vip Patel.
What is the initial postoperative recovery like?
Phew, that’s a lot of steps. This surgery typically takes between 3-4 hours. When the surgery is done, you will have several small incisions covered with surgical glue. There will be a foley catheter, which is a tube coming out the penis that will drain urine from the bladder. Depending on the surgery and the surgeon, you may have a surgical drain coming out of one of the incisions. The purpose of this drain is to monitor the fluid in the pelvis to make sure there is no leak from where the bladder was connected to the urethra.
After the surgery is over, you will initially wake up in the recovery room and after the first couple hours you will head to your hospital room. The first night after surgery is typically the worst when it comes to discomfort. You will have soreness by the incisions, especially when you get in and out of bed.
Additionally, the catheter is pretty annoying. It will feel as if you have to urinate all the time and occasionally people will have spasms with pressure feeling in the bladder and genitals. The first day after surgery, we will get you up and moving around and usually after lunch you will be able to head home.
Typically, after the first couple days, the intensity of this discomfort lessens. The other major discomfort comes from waiting for your bowels to wake up. Everyone is different in this regard. For those whose bowels take longer, your belly will get pretty distended until you start to fart and poop. Most patients are able to go home the day after surgery and will see the urologist back in 7-10 days to get the catheter out.
When you come for the catheter removal, expect to have some leakage or incontinence. There is still lots of healing to take within the pelvis and you will need to wear a diaper until that healing is over. For some people, this recovery is pretty fast. For others this can take up to a year. Afterwards, some men will need to wear a liner or a small pad in his underwear when the cough, sneeze or lift something heavy. The frequency of really bad bothersome leakage is <5% of the time.
When you go home, you will be given activity restrictions. Usually this means no heavy lifting for more than 10-15 pounds for about three weeks. The reason for this is to let all the incisions heal up and decrease the chance of getting a hernia.
How do interpret the pathology report after the robotic prostatectomy?
Just like we reviewed your pathology after the prostate biopsy, we will have to review the pathology after the prostatectomy.
The first thing I will review with the patient is the Gleason Score. Now that we have the whole prostate and not just the biopsy samples, the pathology will give the final pathology score.
The next thing we will review are the surgical margins. This can potentially indicate whether there is any cancer left behind. Sometimes based on the margin status, we may recommend adding radiation therapy in the future.
Afterwards, I will review if the cancer has grown into the seminal vesicles. These are the glands that insert into the prostate and if there is cancer present in these glands it is a sign of more aggressive disease and again the urologist should the option of adding radiation therapy in the future.
Lastly we will review the lymph nodes. There was a group of lymph nodes removed in the pelvis and the pathologist will see if there is any sign of cancer that has spread into the lymph nodes.
In terms of follow-up to see if the cancer has been cured we will periodically check a PSA. Usually this will be checked 2-3 months after surgery and it should become “undetectable” or less than 0.1.
What are my urinary symptoms like after the catheter comes out?
Now when you go home, you will be given a pad or a diaper to wear. Most men will have some leakage in the beginning.
One way to help minimize the leakage is to do Kegel exercises. I always found this confusing to describe to patient’s and this is the best analogy that I can give. Now, pretend you are sitting next to someone and you have to fart really bad and you are trying to hold it in. Those are the muscles that you need to focus on. So, to do the exercises, imagine pulling those muscles in and holding it for five seconds and then relaxing. If you can do a set of 5 or 10 every day, this will really help build up your pelvic floor support and allow for the reduction in leakage.
Sometimes, I will even refer patients to pelvic floor physical therapy. This is where you will work in a dedicated fashion with a physical therapist and they will really help home in on your pelvic floor support.
What is the sexual and erection recovery like in the first year?
Lastly, there are several ways to focus on your sexual health.
Initially, there may be some benefit from taking a Cialis or tadalafil pill daily. The thought process behind this is to increase blood flow and oxygen into the penis to allow for recovery or rehabilitation after surgery. At your next follow-up, if this isn’t cutting it, you can talk about penile injections to see if that can help with erections as well. Another option is to buy a penile traction or a vacuum erection device. These devices can also help to restore blood flow to the penis as well as to preserve penile length.
Please note, it can take up to a year or two for the erections to fully recover. Make sure you ask your urologist if they were able to, and how successful, they were able to spare the nerves that help with erections during your surgery. This will be a factor in how well your erections can recover. Additionally, how strong your erections were before the surgery plays a huge factor. If you have weak erections going in, the odds of your erections being preserved after surgery are much less overall.
Dr. Jafri Wrapup
A robotic prostatectomy is a great option for patients with prostate cancer. After the catheter comes out, most people feel much much better because the catheter can be pretty annoying.
If you are struggling with deciding between a robotic prostatectomy versus radiation for prostate cancer, then click over here to understand the pros and cons with both treatment choices. Also, you can head over to the Prostate Cancer Foundation for a good resource on prostate cancer.