Robotic Radical Prostatectomy
The Prostate gland occurs only in men. It is located just below the bladder and surrounds the urethra – the tube that carries urine from the bladder to the outside. The function of the prostate gland is somewhat mysterious, although we do know that it produces fluid to aid the sperm transport. In all men beyond the age of 40 years, the prostate begins to enlarge. The reason for this enlargement is due to some imbalance of sex hormones; it may be similar to the ovarian changes that occur in women at the same age. The enlargement of the prostate continues throughout the rest of a man’s life. At least 90% of men will have symptoms of obstruction due to the enlarged prostate compressing the urethra and interfering with the urine flow, and almost one man in five will need surgery for prostatic obstruction by the time he reaches 70 years of age. In about 10 % of men, the enlargement will contain cancerous elements.
How is cancer of the prostate detected?
There are several tests used to diagnose cancer in the prostate gland. Firstly the doctor will conduct a physical examination and will feel the prostate by placing a gloved finger in the back passage or rectum. Prostate cancer usually feels much firmer than normal prostate tissue and, depending on where the cancer is located and the size of the cancer, it may sometimes be felt during this rectal examination.
A blood test for a hormone called the “Prostate Specific Antigen” (PSA) is a screening test for cancer. An elevated level of this hormone may indicate cancer, however the PSA may also be elevated in other conditions related to the prostate.
Ultrasound of the prostate is another means of detecting prostate cancer. An ultrasound is performed by inserting a probe into the rectum. Sound waves are then used to scan the prostate and many show up areas in the prostate that appear to be cancerous. Biopsies of these areas can be taken during this investigation and the tissue analysed by a pathologist.
If it is felt that the cancer is contained entirely within the prostate gland, surgery to remove the prostate, and hopefully provide a cure, may be recommended. This operation is called a radical prostatectomy.
Robotic surgery is similar to laparoscopic or “keyhole surgery” where the surgeon operates through several small incisions using the cameras and instruments rather than making a large incision. The robot allows the surgeon to operate these instruments remotely making finer movements than the surgeons hands alone could perform and with a greatly magnified operating field.
What happens before surgery?
Generally speaking patients are admitted to hospital the afternoon prior to surgery if morning surgery is scheduled or mid-morning if surgery will be in the afternoon. This allows time for routine preparation for anaesthesia and surgery.
This preparation includes questions being asked by nurses and/or doctors to obtain a medical history. Temperature, pulse and blood pressure will be checked and there will be additional blood tests, ECG and x-rays. The anaesthetist usually visits before the operation to discuss the anaesthetic.
What happens during surgery?
The operation usually takes between 2.5 to 4 hours. The patient is given a general anaesthetic and is completely unaware of anything that is happening. An intravenous drip is routinely placed in a vein in the arm. The abdomen is distended with carbon dioxide to allow a clearer picture of the intra-abdominal and pelvic organs. The surgery is then performed through small incisions or “ports”. The prostate gland is completely removed via a small incision near the umbilicus and the urethra is joined back to the bladder. During this operation a urinary catheter is inserted into the bladder to protect this join (anastomosis). Routinely a drain tube is inserted to drain away the excess fluid which accumulates at the site of the surgery. The prostate gland is sent to the pathologist for examination. Blood loss during surgery is minimal, but occasionally a blood transfusion may be required.
Following surgery the patient is observed in the Recovery Room for a short period of time, after which he is transferred back to the ward for ongoing observation.
After a general anaesthetic the patient will feel drowsy for upto 12 hours. During this time and over the post-operative period the nurses and physiotherapist will encourage the patient to deep breathe and cough and to perform gentle leg exercise to avoid complications such as chest infection and clots in the lung. Thick supportive leg stockings are worn to assist the circulation in the legs, again to prevent blood clots forming.
Because there is not a large incision, there is usually only minimal abdominal pain experienced after surgery. Most patients describe discomfort, rather than pain. Some patients may experience shoulder tip pain for a day or two after surgery. Painkilling injections may be required for the first 24 hours.
The patient is usually able to get out of bed, walk around and shower the day after surgery and commence a light diet and fluids.
The drain tube will be removed when there is little drainage, usually within 2 days. The urinary catheter usually remains in place for 7 days, occasionally longer. The patient is sent home with the catheter draining into a leg bag with an appointment for catheter removal in the surgeon’s rooms. Before leaving hospital there will be instructions provided about care of the catheter at home. Once the catheter has been removed there is often some difficulty controlling urine flow. The muscles of the pelvic floor play an important role in this function and instructions will be given about how to do exercises regularly, commencing before surgery. It may take several weeks to months to regain full control.
Following radical prostatectomy, erectile dysfunction may result, as the nerves which are responsible for potency lie directly behind the prostate and may be disrupted during surgery. Surgeons now generally try to preserve these nerves but even if preserved they may “go on strike” for some time after surgery due to handling during the surgery. These days there are treatment options available for impotence, and these can be discussed and considered once the patient has recovered from the surgery.
Recovery After Discharge From Hospital
It is important not to overexert during the recovery phase. Full recovery from surgery will take 2-4 weeks. Visible blood in the urine is quite common for 4-6 weeks.
There should be relief of the obstructive urinary symptoms after this surgery. Occasionally scar tissue may form in the urethra, causing the channel to narrow. This is called a “urethral stricture” and is the result of instruments being passed during the operation, or by the catheter irritating the urethra following surgery. Any deterioration in the urinary stream should be reported so that it can be investigated. If necessary these strictures can be corrected in the surgeon’s office.
Constipation can occur after this surgery. It is recommended that you take stool softeners like Senokot tablets (available over the counter from the chemist) for a week or two, until you resume normal activity.
Regular follow-up appointments with the doctor will be made and further blood tests to measure PSA will be performed.
This document is intended for informational purposes and is not intended to be a substitute for the advice of a doctor or healthcare professional or a recommendation for any particular treatment plan. Like any printed material, it may become out of date over time. It is important that you rely on the advice of a doctor or a healthcare professional for your specific condition.
Diagrams used are courtesy of Astra-Zeneca and Intuitive Surgical Pty Ltd, 2004.