What is Robotic surgery?

Robotic surgery is based on the premise of a Master – Slave system wherein the latest generation 4 arm High definition da Vinci Si robot is used to perform complex advanced surgical procedures such as radical prostatectomy(removal of the prostate gland usually for cancer), partial nephrectomy ( removal of the diseased part of kidney involved by cancer) and pyeloplasty (reconstructing ureteropelvic junction – the drainage system from the kidney). In robotic surgery the surgeon sits behind a console and controls the robot that is docked to the instruments entering the patients body through key holes as in laparoscopy.

This technology relies on the advanced endowrist dexterity of the robotic instruments with 7 degrees of freedom of movement as well as 3-dimensional depth perception for the operating surgeon over & above the laparoscopic benefits. Consequently, robot has significantly decreased the learning curve for these advanced technically demanding surgeries.

 

Robotic Radical prostatectomy

Robotic Radical Prostatectomy (RRP) is a minimally invasive surgery for removal of the prostate in those diagnosed with organ-confined prostate cancer. In patients with organ confined prostate cancer the likelihood of a complete recovery from prostate cancer without long-term side effects is, for most patients, better than it has ever been.

 

The Preoperative Preparation

Medications to Avoid Prior to Surgery

•  Aspirin, Ibuprofen, other blood thinners like clopidogrel and some arthritis medications which can cause bleeding and should be avoided 5-7 days prior to the date of surgery

•  Please contact your Urosurgeon if you are unsure about which medications to stop prior to surgery.

•  Do not stop any medication without contacting the prescribing doctor to get their approval.

Bowel Preparation and Clear Liquid Diet

•  Do not eat or drink anything after midnight the night before the surgery and drink one bottle of Peglec the evening before your surgery(case specific) . The dinner on the night before the surgery may preferably be kept light.

 

Robot Assisted Radical Prostatectomy – The Surgery

The robot is docked to the endowristed instruments inserted through 5-6 small incisions across the mid-abdomen.

The camera inserted throughthe midport provides a magnified 3-D view of the delicate nerves and muscle surrounding the prostate, thus allowing optimal management of these important structures. The cancerous prostate gland is resected alongwith seminal vesicles and the bladder and urethra are stitched together. If indicated alymphadenectomy (standard/ extended) is performed alongside. The prostate is removed intact through one of the small incisions. These small incisions are closed with glue or absorbable suture. A Foley catheter is placed through the penis to drain the bladder and allow healing of the bladder-urethra connection for 5 -7 days. In addition, a small drain is placed in the abdomen exiting one of the keyhole incisions. This usually is removed in 1-3 days. The surgical duration can vary from patient to patient (1 – 3.5 hrs.) depending on patient specific factors. Estimated blood loss during RRP can vary from 200 – 500 ml. Transfusions are rarely required. Blood is arranged prior to surgery as a precautionary mearure; however donation is requested only if patient is transfused blood.

 

Robotic prostatectomy – the benefits

Unmatched precision and control

5-6 small incisions

Less pain and scarring

Better magnification &less blood loss

Fewer complications

Shorter hospital stay

Faster return to normal daily activities

While RRP is considered safe and effective, this procedures may not be appropriate for every individual. Your doctor in consultation with the patient would educate you about all treatment options, as well as their risks and benefits.

 

Potential Risks and Complications

As in any surgical procedure there are risks and potential complications.Potential risks include:

Bleeding: Blood loss during RRP is relatively low compared to open surgery, a transfusion may still be required (in <1% of patients) if deemed necessary.

Infection: Intravenous antibiotics decrease the chance of infection from occurring within the urinary tract or at the incision sites, however an occasional patient may be infected requiring additional antibiotics.

Adjacent Tissue / Organ Injury: Although uncommon, possible injury to bowel & vascular structures have been reported & may require further procedures. Transient injury to nerves or muscles related to patient positioning during the surgery have been reported too.

Hernia: Hernias at incision sites have been rarely reported. The larger keyhole incisions are closed under direct camera view.

Conversion to Open Surgery: Excess scarring or bleeding may require conversion to the standard open operation. This results in a standard open incision and possibly a longer recovery but is a rare occurrence.

Urinary Incontinence: As in open or laparoscopic surgery, urinary incontinence can occur following RRP, but improves with passage of time & regular Kegel exercises, which help strengthen the urinary sphincter muscle.

Erectile Dysfunction: Similar to laparoscopic surgery, a nerve-sparing technique is attempted during robotic dissection of the prostate gland unless there is obvious involvement of the nerve tissue by tumor wherin a wide resection is performed keeping in mind the oncological principles. The return of erectile function following RRP is a function of the age, preoperative sexual function, technical precision of the nerve-sparing technique and time.

Urethrovesical Anastomotic Leakage: Temporary small urinary leakages can occur at the anastomosis between the bladder and urethra following RRP and usually resolves with conservative management within a few days to up to a week. The urinary catheter remains in place until the leakage has stopped.

 

Post operative management

During your hospitalization

Immediately after RRP you will be taken to the recovery room & observed for a few hours before being transferred to your hospital room.

Hospital Stay: Usual Expected hospital stay is 3-5 days.

Diet: Clear liquids are started by the evening and a soft diet the following day getting back to the normal diet usually by third day post RRP.

Post Operative Pain: With RRP & advanced pain control modalities becoming the routine patient-controlled analgesia (PCA) pumps handled by the patient himself on demand or by injection administered by the nursing staff, pain is usually not a major botheration. Minor transient shoulder pain (1-2 days) related to the carbon dioxide gas used during RRP may occur but has no clinical significance.

Bladder Spasms: Bladder Spasms may happen occasionally due to catheter after prostatectomy & are experienced as a moderate cramping sensation in the lower abdomen.They are transient and decrease over time. If severe they can be controlled or reduced in severity by medications.

Nausea: Transient nausea related to anesthesia may occur during the first 24 hours. Persistent nausea is treated by medication.

Urinary Catheter: Urinary catheter post RRP is kept for 5 – 7 days. Blood tinged urine may be expected post RRP for 7 – 10 days.

Pelvic Drain: A drain is kept in the abdomen to drain the pelvic space. It is removed in 2-3 days when the drainage is minimal.

Fatigue: Post surgical stress fatigue is common and subsides in a few weeks.

Incentive Spirometry: Respiratory exercises with incentive spirometer alongwith active coughing & deep breathing help prevent respiratory infections like pneumonia leading to early postoperative recovery.

Ambulation: On the day after surgery get out of bed and begin walking with the help of your nurse or family member to help prevent blood clots from forming in your legs. Tight white stockings on your legs help to prevent blood clots from forming in your legs while you are lying in bed.

Constipation/Gas Cramps: Slow bowel recovery for several days as a result of anesthesia maybe expected. Suppositories and stool softeners help overcome this problem. Narcotic pain medication if given can cause constipation and should be discontinued as soon after surgery as tolerated.

 

Discharge Instructions

Bathing:  You may bathe at home immediately after discharge. Your wound sites must be padded dry. You will have waterproof dressing across your incisions. They will either fall off themselves or can be removed in 5-7 days.

Incisions and suture:  Your incisions will be closed with absorbable sutures which will dissolve within 3 – 4 weeks.

Activity:  Daily walks are encouraged after discharge. Sedentary lifestyle should be avoided as it increases the risk of pneumonia & forming blood clots in the legs.Climbing stairs is allowed but one should not overexert. Driving should be avoided for at least 3 weeks after surgery. Full activity can be resumed in 4-5 weeks on a patient to patient basis. Heavy weight lifting or exercising should be avoided upto twelve weeks.

Medications:  Resume your usual medications after surgery with the exception of aspirin or other blood thinners like clopidogrel, which can increase the risk of bleeding. These should be stopped or restarted as advised by your prescribing physician.

Follow-up Appointment:  You will be appointed for OPD follow up for removal of your Foley catheter (5-10 days after the date of surgery). An Dye X-ray test of the bladder called a cystogram may be done to confirm complete healing if needed.

Pathology Results:  Pathology results are usually available approximately 7-8 days after surgery. These results will be reviewed with you by Dr Manav Suryavanshi in the office. If need be our Coordinator can provide you a copy of the report by e – mail.

Discharge Instructions

CATHETER CARE:

Your catheter is the lifeline for adequate healing post sugery. The catheter should drain continuously. Any pull on catheter suggests it needs to be fixed higher up on your leg. Your surgeon should be notified immediately if the catheter blocks or falls out.

The urine collection bag must always be positioned below the bladder for proper draining by gravity. Regularly draining the bag before it fills up is advisable. Although use of the larger urobag is advised, a smaller leg bag is available and can be worn under clothing. The larger bag is better at night as the smaller bags are likely to fill up too quickly. The larger bag also has longer tubing , so there is less risk of stretch on the penis. In case one is not into a very active lifestyle it is preferable to have a larger bag.

Irritation at the tip of the penis can happen sometimes. Local hygiene with plain soap & water is hence mandated daily. Urine leakages or blood tinged urethral secretions may occur around the catheter especially during bowel movements & should not be a cause of worry. If pericatheter leakages affect the quality of life then ask your urosurgeon to start medicines to suppress the symptoms. Mild redness in urine during walking should not be a cause for worry. Reduce your straining & drink more water for this redness to clear off.

DIET:

Usually normal diet is started from the evening of first postoperative day. Some patients may be asked to take soft diets as their intestines may take up to a week to recover. To keep your urine flowing freely, drink plenty of fluids during the day (8 – 10 glasses). Water, juices, coffee, tea, soda are all acceptable.

ACTIVITY:

Restrict your physical activity especially during the first two weeks at home. Walking 6-8 short walks a day is preferable to prevent complications like blood clots in the legs or lung infections. Climbing stairs is permitted if necessary but should be taken slowly. Lifting heavy objects should be avoided (anything greater than 4-5 kgs) upto 6 weeks. Car driving should be avoided for 4 weeks post surgery.One should also avoid long car rides.

BOWELS:

Bowels return to normal after surgery over 4-5 days. Straining at bowel is to be avoided as this can cause bleeding in the urine. Use a mild laxative (e.g. liquid paraffin or cremaffin) for 20 days post RRP.

MEDICATION:

You should resume your pre surgery medication unless told not to. We recommend staying off aspirin or other blood thinners for 4-5 days post surgery. Antibiotics are prescribed routinely for 5-7 days post RRP.

HYGIENE:

Bathing is allowed 3 days after surgery. Dab your incision sites dry. Don’t use creams or ointments on your incisions. Keeping them dry and open to air is fine.

 

KEGEL EXERCISES

PELVIC MUSCLE EXERCISES TO IMPROVE BLADDER CONTROL (MALE)

It is recommended that you start doing Kegel exercises 7-10 days prior to surgery to acclimatize yourself.Begin by locating the muscles to be exercised:

1. As you begin urinating, try to stop or slow the urine WITHOUT tensing the muscles of your legs, buttocks, or abdomen. This is important as using other muscles will not serve the purpose.

2. When you are able to stop or slow the stream of urine, you know that you have located the correct muscles. Feel the sensation of the muscles pulling inward and upward.

3. You may squeeze the area of the rectum to tighten the anus as if trying not to pass gas and that will be using the correct muscles.

4. Remember NOT to tense the abdominal, buttock, or thigh muscles.

Squeeze your muscles to the slow count of ten. Then, relax the muscle completely to the slow count of ten. Make such repetitions ten times at a go. If feeling tired do as much you are comfortable with. Target 200 – 300 repetitions over a day.

It is important to know that full urinary control may take even up to one year following surgery. Most men experience improvement within 3-6 months. By 6 months, 70% of patients are pad-free and 90% are pad-free at one year.

Exercise your pelvic muscles regularly for a lifetime to improve and maintain bladder control. Use daily activities such as eating meals, watching the news, stopping at traffic lights, and waiting in lines as clues to do a few pelvic muscle exercises.

PROBLEMS YOU SHOULD REPORT TO US:

1. Fevers over 100°F with chills & rigors as this may be a sign of infection.

2. Thick clots in urine.

3. Calf or leg pain or swelling as this may be a sign of a blood clot.

4. Call immediately if your catheter stops draining completely or falls out.

 

FOLLOW-UP

The first postoperative appointment will be to remove the catheter, usually done at 5-7 days after surgery. Dr Manav Suryavanshi will decide on the timing of this and you shall be provided the date for the samein your discharge summary. Most people will have some difficulty initially with urinary control at the time the catheter is removed.Therefore, come to the office with a small supply of adult diapers. Post catheter removal avoid caffeine, alcohol and excessive fluid intake for 6-8 weeks as this can aggravate incontinence.

PATHOLOGY RESULTS:

Pathology results are usually available approximately 7 days following surgery. These results will be reviewed with you by Dr Manav Suryavanshi in his office.

Follow-up Protocol:

A prostate-specific antigen (PSA) test is done at 6 weeks following surgery. Patients are re-evaluated every 3 months. It is advisable that one should follow the same lab for repeated testing of PSA’s to prevent interlab variations in readings.

 

FAQS

1. Length of operation?

The length of these operations may vary. In general these cases can last anywhere between 2-5 hours.

2. How much pain will I have after surgery?

Patients often require a small amount of intravenous and/or oral pain medication during their hospital stay.

3. Will I need a transfusion and do I need to donate blood?

Transfusions are rare with RRP.

4. How long is the hospitalization?

Usually 3-5 days. Patients are able to walk the following day after RRP.

5. How long will I have to have the bladder catheter?

5-10 days

6. When can I return to normal activities?

Usually 3-4 weeks after surgery. However, urinary control and sexual function may take months and even up to a year or so to improve significantly.

7. What is my chance of urinary incontinence?

Most men experience at least some degree of stress urinary incontinence during sneezing or coughing. This generally improves with time and Kegel exercises. Approximately 70% of men are dry at 6 months and 95% at 12 months following RRP.

8. What is my chance of erectile dysfunction?

The return of erectile function is perhaps the most difficult outcome measure to predict. Factors involved include age, having an active sexual partner, whether one or both nerve bundles were spared, and time since surgery.

9. Will I need further treatment following surgery for my prostate cancer?

Adjuvant treatment such as radiation or hormonal therapy is decided upon the pathologic stage of the cancer as well as PSA trends following RRP. Patients if detected early by PSA screening are by and large curable with surgery. But treatment is still individualized.

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