Robotic-Assisted Laparoscopic Radical Prostatectomy

What is the Robotic Prostate Removal Surgery?

The prostate gland is part of a man's reproductive system. It is located in front of the rectum and under the bladder. It surrounds the urethra, the tube through which urine flows. The prostate, along with the seminal vesicles, produce most of the fluid that comes out when ejaculation occurs. During ejaculation, seminal fluid helps carry sperm out of the man's body as part of semen. Substances produced by the prostate and seminal vesicles are important for reproduction.

Men who develop prostate cancer may choose to have a specialized surgery to remove the prostate. It's called robotic-assisted laparoscopic radical prostatectomy (RALP). Laparoscopy is at type of surgery that is done by filling the belly with carbon dioxide gas so that a working space can be created. Small incisions are created through which instruments are passed. During the surgery, six - 1/4 inch to 3/4 inch punctures are made in the abdomen. A thin tube with a camera on the end is placed into one of the punctures to help the surgeon see inside the body. Long thin instruments are placed in the other punctures to help your surgeon manipulate organs and perform surgery.

The robotic-assisted laparoscopic radical prostatectomy was first reported in 2001. Since then, the robotic prostatectomy has become one of the preferred methods for radical (aka total) removal of the cancerous prostate. Dr. Gorbatiy is one of the few Fellowship-trained urologists in Broward County to do extra 2 years of training in robotic surgery. He has been trained to operate on the prostate, bladder, ureters, kidney and bowel with the use of the robotic surgical approach. The robotic machine has 4 arms, one for holding the camera and 3 which have instruments attached. The surgeon controls all of these arms. The robotic arms are placed through four punctures, and an assistant surgeon will work through the remaining two punctures.

What is accomplished with the operation?

The surgeon will separate the prostate from the bladder, remove the seminal vesicles and a portion of the sperm ducts, separate the prostate from the rectum, perform nerve-sparing in some men and divide the urine channel again at the tip, or apex, of the prostate.

After the prostate and seminal vesicles are disconnected, your surgeon will place the prostate inside a small plastic bag while it is still inside your body. The bag will be removed by enlarging one of the punctures. The bladder will be reconnected to the urine channel by suturing the two together. A catheter (small rubber tube that allows urine to drain) - will be left in place to help this area heal. The specimen will be sent to a pathologist who will carefully examine it under a microscope. Your surgeon may decide to remove lymph nodes at the time of your surgery. If so, these will also be placed in the specimen bag for examination by the pathologist as well.

A small plastic tube, called a drain, will be placed outside the bladder to collect fluid that can accumulate after surgery. This drain is usually removed before you are discharged from the hospital, but in some cases it may need to stay in longer. If so, the nursing team will show you how to manage the drain, and your surgical team will give you follow up instructions for an appointment to remove the drain.

The following section will explain how several important structures near the prostate may be affected during surgery.

Urinary Control

The urethra, or urine channel, exits the bladder and runs directly through the prostate. After the urethra exits the prostate it goes through the pelvic diaphragm, which is the muscle that will help with urinary control after surgery. The urethra then enters the penis. After your surgeon has removed the prostate, the bladder is sutured to the urethra to restore the flow of urine. A catheter, or a small plastic tube, will be placed through the penis and into the bladder to allow urine to drain freely into a bag.

During the healing process you will wear the catheter to allow this area to heal. Your nursing team will teach you how to care for the catheter while you are in the hospital. The catheter is usually removed within one week.

After the catheter is removed you will be taught to do a special exercise, called a Kegel exercise, which may help speed the recovery of urinary control. All men will have some loss of urinary control in the beginning. For most men, this improves quickly, within a few weeks. But, for others, improvement takes longer - a few months. By the end of the first year, >90% of men will have full control.

Erectile Function

The nerves that control erections may also be affected during surgeries such as RALP. These nerves control only the ability to obtain an erection of the penis, and do not affect sexual desire, frequency of intercourse, sensation in the penis, ability to experience climax or bladder control. Their sole function is creating a stiff erection.

In order to preserve the ability to have erections after surgery, some men may be candidates for a "nerve-sparing operation”. Along with large blood vessels, the microscopic nerves travel on both sides of the prostate and are located in structures called "neurovascular bundles”. The nerve sparing operation is a very delicate surgery that gently 'peels' the neurovascular bundle away from the surface of the prostate (like peeling the yellow cover off an onion), allowing the prostate to be removed while minimizing the effect on erections. The decision on whether to spare the nerves depends on the proximity of cancer to the neuromuscular bundles. In some men, by sparing the nerves, we run the risk of leaving some microscopic cancer behind.

Sparing the nerves does not guarantee the preservation of erections but does give most men a chance to recovery. Men under 60 years of age who had good erections before surgery and in whom both sides of the neurovascular bundles are spared have the best chances for recuperating erections after surgery. Older men and those who do not have rigid erections before surgery, or who are unable to sustain an erection during intercourse, may not have satisfactory return of erections even when both neurovascular bundles are spared. Some men who have just one side spared and the other side removed may also recuperate erections, but usually to a lesser degree. Erectile dysfunction - the inability to have a spontaneous erection - will occur if both nerves are removed. However, nerve removal does not necessarily eliminate all chances of getting erections. Treatments such as penile injection therapy, vacuum erection device therapy and penile implant surgery do not depend on the nerves and are available for men with erectile dysfunction.

The Gleason score, location of cancer on biopsy, PSA and digital rectal exam may help us. Here is the general breakdown of organ confined disease by Gleason score, assuming a PSA <10:

  • Gleason 3+3, organ confined close to 95%
  • Gleason 3+4, organ confined 90%
  • Gleason 4+3, organ confined 60%
  • Gleason 4+4 or higher, organ confined 30%

Thus, most all patients with 3+3 and 3+4 may be good candidates for bilateral nerve sparing. For Gleason 4+3 or higher, select patients can have nerve sparing, and most can at least have 1 nerve bundle spared, depending on location of their disease.

It is important for you to remember that the full recuperation of erections can take up to 2 years. During this time your urologist can offer you a variety of treatments for penile rehabilitation (pills, injections and vacuum device), which may both improve the recovery of your erections and allow you to become sexually active during this active period of healing. While a nerve-sparing operation may be planned for both sides, it is important to remember that at the time of surgery your surgeon may encounter situations that will make nerve-sparing difficult on one or both sides or find that nerve-sparing may compromise the cancer treatment aspect of the operation. In order to provide the best cancer treatment, Dr. Gorbatiy may need to remove one or both neurovascular bundles.

Injury to the Rectum

The rectum is another important structure located very close to the prostate.

Injury to the rectum is unusual, occurring in <1% of patients.

Certain conditions such as prior surgery, hormone therapy, radiation treatment, infections and other causes of scarring to the area can increase this risk.

If an injury does occur and the rectum has been properly cleaned before surgery, it can usually be repaired at the time of surgery without significantly changing your recovery. However, if the rectum has not been properly cleaned, and the area of injury becomes soiled by stool, then a temporary colostomy may have to be performed. This is why it is very important to follow instructions for cleansing your rectum before surgery with an enema.

Lymph Node Removal

Dr. Gorbatiy may remove pelvic lymph nodes during your surgery. These small glands are located near the prostate and can be the first place prostate cancer spreads. This procedure adds an additional 20 to 30 minutes to your operation, with minimal added risk. Risks include damage to blood vessels to the leg and damage to a nerve that controls one of the groin muscles. Injury to either is very rare.

Positive Margins

We often get asked: “When you remove the prostate, can you tell if you got it all?” For the most part, the prostate cancer is invisible, and blends in with the normal gland. Thus, our goal is to remove the prostate and to avoid the surrounding structures. The final pathology is what matters the most.

Some patients may have microscopic spread of the cancer outside the gland that was not detected before or during surgery. This may result in a 'positive margin', which is identified after your surgery when the pathologist reviews the specimen. The risk of positive margins increases with presence of advanced and aggressive prostate cancer. Unfortunately, our current imaging or blood tests don’t provide the best prediction of microscopic extension of prostate cancer outside the prostate capsule.

After the prostate gland has been removed, the pathologist covers the outer aspect of the specimen with different colors of ink. Under the microscope, if there are any cancer cells touching the ink, than this is described as a 'positive surgical margin’. Having a positive surgical margin may mean that there are cancer cells left behind; this is often, but not always the case. Additional treatment after surgery may be necessary depending on the stage of disease, the aggressive nature of the cancer cells, the presence of cancer in the seminal vesicles or lymph nodes, if a positive margin is present or other findings.

If this occurs in your case, your Dr. Gorbatiy will discuss additional treatment options with you when you follow up after surgery.

Surgery Risks

Although robotic-assisted laparoscopic radical prostatectomy is a minimally-invasive procedure, it is a major operation that carries the same risks seen with any major procedure. These include:

Risks associated specifically with Robotic-Assisted Laparoscopic Radical Prostatectomy

  • Infection
  • Urinary infection
  • Wound infection
  • Bladder or ureteral (tubes draining kidney) injury that may require additional procedures or surgeries to correct, <1% risk
  • Internal urinary leakage from the connection between penis and bladder (<10% risk) may occur which may require leaving the drain in place longer and also wearing the catheter for a longer period of time. For most cases involving internal urinary leakage, no additional procedures are necessary, as the body will heal itself when proper drainage with the drain and catheter is provided.
  • Scarring in the urethra at the connection between penis and bladder, sometimes requiring surgical cutting of the scar tissue (<5% risk)
  • Permanent incontinence - the inability to control urine. This complication is rare, occurring in less than 2% of all patients (see discussion above)
  • Erectile dysfunction (see discussion above)
  • Rectal injury, rarely requiring a temporary colostomy, <1% risk
  • Conversion to open surgery, <2% reported risk
  • Robotic system failure, <5% risk
  • Inguinal Hernia (bulge in the groin that may require surgical correction in the future)
  • Temporary bruising of the scrotum and foreskin
  • Temporary swelling of the face and eyes from positioning. This is a result of the typical position during surgery to access the pelvic region and have the bowel “fall away” from the pelvic region, you are lay on the operative table with the table tilted in a way so that your legs up and upper torso down.
  • We secure your body to the operative table to avoid slipping. The positioning sometimes places pressure on the shoulders and thus may result in some shoulder pains or temporary numbness.

Risks associated with the Lymph Node Dissection

  • Lymph nodes are located on top of and next to major blood vessels that provide blood flow to your legs. Also, they are located next to a nerve that allows you to cross your legs. Injury of the nerve or those blood vessels are very rare.
  • Lymph nodes filter fluid that is not in arteries or veins of your body. When they are removed, the fluid may occasionally accumulate in areas of the operation. With open surgery, this was a very common problem, requiring drainage of this fluid until the body managed to absorb it on its own. With the robotic approach, this is rarely seen.

Risks associated with ANY surgery

  • Anesthesia-related complications
  • Sore throat from intubation (breathing tube)
  • Bleeding that may require blood transfusions (<10% risk)
  • Prolonged intubation (keeping the breathing tube longer after surgery if you can’t breathe on your own too easily) Usually this risk is greater in patients who are active smokers, have a history of emphysema (COPD), other lung diseases, sleep apnea, and obesity.
  • Blood clots in the veins (especially in the legs or lungs). These can be life-threatening and usually require treatment with a prolonged course of blood thinners. (<1% risk)
  • Rhabdomyolysis (muscle breakdown from a prolonged surgery)
  • Pressure sores
  • Heart attack during or after surgery
  • Air embolus - an extremely rare condition seen with laparoscopic surgery of air getting into the bloodstream and into the heart that may be life threatening
  • Stroke
  • Pneumonia
  • Pain
  • Numbness of skin around incisions or in the arms and legs. This is often temporary and may be a result of pressure on nerves from positioning.
  • Incisional Hernia (a tear in the tissue where cuts were made causing a bulge underneath the skin, sometimes requiring surgical correction) This may be caused by lifting heavy objects prior to full healing of the incisions is is more common in patients with poor healing or poor nutrition. (<5% risk)
  • Bowel Obstruction (partial or complete obstruction of intestines that often resolves with time, a temporary nose-stomach tube, or rarely a surgical exploration to untwist or cut any scar tissue that is causing obstruction)
  • Ileus (bowel takes a long time to wake up and start passing gas) is among the most common problems seen with any abdominal surgery
  • Bowel adhesions (scarring) is commonly seen in patients undergoing any abdominal surgery. Rarely these adhesions may cause bowel obstruction.
  • Allergic reaction to drugs and/or equipment.
  • Electrolyte (salt) imbalances may occur.

What if I am overweight?

The robotic camera and instruments can access the pelvis very well in most men, even up to 350 pounds, so this procedure may be an advantage in this circumstance. We do see, however, a greater chance of complications in patients who are obese. These complications include an increased risk of bleeding, breathing problems, urinary incontinence, blood clots, and pressure ulcers.

Rarely, a very obese patient cannot tolerate our positioning during the surgery (head down, legs up) because his own weight doesn’t allow the lungs to expand fully. Thus, in this rare scenario we don’t even start the surgery if we see that the patient cannot be ventilated properly at the beginning of the case.

What about prior surgery?

In most cases, laparoscopic instruments can mobilize prior scar tissue and proceed with the case. However, this often increases the length of surgery and does increase the risk of bowel and blood vessel injury and at times may increase the length of recovery.

Equipment Problems

Occasionally, mechanical difficulties occur with the robotic machine. The system has multiple built-in safety features to prevent using the machine when a problem is present, In many of these cases, our team can troubleshoot these mechanical issues and proceed as planned. In some cases, however, the machine cannot be used until an engineer arrives to address the problem. If mechanical difficulties are identified before you are put to sleep, your surgical team will discuss with you how to best proceed. In circumstances such as these, your procedure may need to be rescheduled, possibly resulting in additional expense and inconvenience. Sometimes mechanical difficulties are identified after the patient is asleep and surgery has started. Our goal as surgeons is to always keep the surgery as safe as possible. Mechanical failure may be outside of our control, and can greatly affect surgical efficiency and/or our ability to perform RALP. While very rare, if an irreversible mechanical difficulty is encountered after the surgery has started, we will use our best judgment as to how to proceed; in some patients it may be necessary to disconnect the robot, and make a traditional incision and complete the surgery in an open manner.

Reducing Risk

Your surgical and anesthesia teams will take measures to reduce the risk of complications by giving you antibiotics during surgery and other measures meant to reduce the risk of certain known complications.

But, as with any operation, risk cannot be totally eliminated. There is a chance that complications could result in the need for a larger incision (open surgery). Your surgeon and surgical team will try to identify and respond to any problems that occur as early as possible. There may be unforeseen and unexpected complications that require additional treatment. Fortunately, most complications are reversible, readily treatable and do not require additional major procedures.

What to Expect - Brief Overview

The usual course experienced by patients undergoing robotic prostatectomy is as follows. The patient arrives in the hospital the day of the procedure. The procedure is then performed and typically takes between 2 and 4 hours. The patient then spends the first night in the hospital and is given a regular diet and is encouraged to walk the night of the procedure. Discharge is planned for the next morning and instructions are given on general postoperative and catheter care.

Patients are sent home with a prescription for a narcotic oral medication. Patients should walk as much as possible immediately. Stair climbing is acceptable. Some patients do experience constipation, which can be remedied by stool softeners or milk of magnesia.

The urinary catheter is removed in the office in one week. Patients are allowed to drive after catheter removal. The patient then may return to work within 2-3 weeks and then can go back to unrestricted activity in 3-4 weeks.