Robotic-assisted (Da Vinci®) laparoscopic radical prostatectomy

What is this?

Keyhole surgery to remove the prostate gland using robotic-assisted techniques

What alternatives are there?

Active monitoring (watchful waiting), open radical prostatectomy, external beam radiotherapy, brachytherapy, hormonal therapy, open perineal prostatectomy, open retropubic surgery or conventional laparoscopic (telescopic or minimally-invasive) approach. At Addenbrooke's Hospital, we have introduced a new operation to remove the prostate gland (robotic-assisted laparoscopic prostatectomy). This leaflet is designed to give you information on why this procedure may be suitable for you and what to expect from it. It outlines the advantages & possible risks. It will, hopefully, answer the common questions usually raised. More detailed information is available from your Consultant If you wish. About regular radical prostatectomy You will have had a discussion with your urologist and oncology nurse about prostate cancer. Please remember that early prostate cancer can be effectively treated. Most men with early prostate cancer will remain alive & healthy for many years to come. 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 & surrounding tissues are removed to provide the best possible chance of removing all the cancer. What & where is my prostate? Your prostate is a small, walnut-sized gland that is situated at the base of your bladder. Its main function is to add liquid to your ejaculate (semen). What is a standard open retropubic radical prostatectomy? This is an operation to remove the prostate but via an incision of approximately 10-15 cm in length. During the operation, the surgeon will usually 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 10-15 days to allow the join to heal. The operation is very safe and will be performed by a surgeon who is skilled & experienced. As with any operation, there are small risks of general complications such as bleeding, infection but death is extremely rare (less than 2 in 1000). You may experience some loss of urinary control which tends to settle by 3-6 months after the surgery but may require you to wear pads. A few men have long-term problems with incontinence (less than 5 in 100) which may require other treatments. The operation is designed to remove the prostate & 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. There are several ways of doing a radical prostatectomy. These include: Open radical prostatectomy Laparoscopic radical prostatectomy carried out in the standard way carried out using a robotic assistance The decision about which operation to have is one that you should make and no-one will mind which operation you have. If you need further information, please contact either the Urology Surgical Care Practitioner or the Prostate Nurse Practitioner. What is laparoscopic surgery? Laparoscopy (otherwise known as "keyhole surgery") is a form of minimal access surgery. This involves performing operations which are traditionally done by an "open" method but using "keyholes" instead. A number of urological procedures are now being performed by this method. The method of doing a radical prostatectomy by means of keyhole surgery at Addenbrooke’s is performed with a robotic assistant (the da Vinci machine). In recent years, it has been shown to be safe & effective; for some operations, it is now the method of choice. Laparoscopic procedures are normally performed under general anaesthetic. They involve the use of a number of "ports" which allow access to the diseased organ. The length of time taken to perform the surgery varies between procedures but recovery is usually quicker than in open surgery. Your fitness for such an operation will be assessed and discussed by your urologist. Your urologist will discuss the details of the procedure with you whilst you are an outpatient, outlining the procedure as part of your consent. You should be aware that there is a small chance (less than 2%; 1 in 50) that your procedure may need to be converted to an open procedure. For this reason, If you are insistent that you would not agree to an open operation under any circumstances, we would be unable to proceed with the robotic operation. Be assured that the decision about which operation to have is one that you will not make alone and no-one will mind which operation you have. If you want more information, please contact the Urology Surgical Care Practitioner or the Prostate Nurse Practitioner who can put you in touch with other sources of information

What to expect before procedure

You will usually be admitted on the day before your surgery. You will normally receive an appointment for pre-assessment, approximately 14 days before your admission, to assess your general fitness, to screen for the carriage of MRSA and to perform some baseline investigations. After admission, you will be seen by members of the medical team which may include the Consultant, Specialist Registrar, House Officer and your named nurse. One important fact that you must do is to 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 or drink for 6 hours before surgery and, immediately before the operation on the day of surgery, you may be give a pre-medication by the anaesthetist which will make you dry-mouthed and pleasantly sleepy. You will be given an injection under the skin of a drug (Clexane) which, together with the help of elasticated stockings provided by the ward, will help 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.

What happens during the procedure?

Normally, a full general anaesthetic will be used and you will be asleep throughout the procedure. In some patients, the anaesthetist may also use an epidural anaesthetic which improves or minimises pain post-operatively. You will be transferred to the operating theatre on your bed and you will be taken first to the anaesthetic room. 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 robotic arms; two for instruments and one for a high-magnification 3-D camera to allow the surgeon to see inside your abdomen. The two robotic arms have the ability to hold various instruments attached to hem and allow the surgeon to carry out your operation. The instruments are approximately 7mm 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 3-D 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 & 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.

After the procedure

Once your surgery is complete, you will be taken to the recovery area. Although you have had minimally-invasive surgery, it is still possible that you may have some pain. You will wake up with a catheter in your bladder, a wound drain from your abdomen and 6 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 & nursing staff have agreed that your condition is stable, you will be transferred back to the ward. You will be encouraged, even in the recovery area, to sit out of bed in a chair. Once back on the ward, you must be prepared to mobilise actively. Ideally, we would like you to go home the day after your operation. Your catheter will remain in for approximately 7 days to allow the new join (anastomosis) between your bladder and urethra to heal. Your abdominal drain will generally be removed after 12 hours (if one was put in). The average length of stay for this procedure is 48 hours, with the majority of patients being discharged within 24 hours of surgery. You will be discharged once you have had your bowels open, are mobilising safely as you did before your admission, are able to care for your catheter/leg bags and your pain is well-controlled on appropriate tablets taken by mouth

Potential side effects