Robot-Assisted Prostate Surgery: FAQs
Frequently Asked Questions
- What is the da Vinci® robot?
- Does the robot do the operation?
- What is nerve-sparing surgery?
- Can you perform nerve-sparing surgery using the robot?
- What advantages does robot-assisted prostatectomy provide?
- Are there disadvantages?
- How is the care different at Scott & White?
- How long does the surgery take?
- What can be expected following surgery?
- How long will I be in the hospital?
- How long will I have a Foley catheter?
- What follow-up is required?
- How long will it take for me to recover?
- How do you know if the cancer is gone?
- How is success measured?
- What are the side effects?
- What can be done to minimize incontinence?
- What can be done to minimize impotence?
- What are the odds of cure?
- What criteria are used to determine if I am a candidate?
What is the da Vinci® robot?
It is a surgical system manufactured by Intuitive Surgical in Sunnyvale, CA. It is the only FDA approved robotic platform and was approved for radical prostatectomy in 2001. It consists of a surgeon console and patient side cart. Watch a video overview of the da Vinci Surgical System.
The surgeon console consists of a 3-D video headset and hand controls which are moved by the surgeon's hands. The image is transmitted from a special dual-lens telescope with 10x magnification. The surgeon console removes tremor from the surgeon's movements and can scale hand movements to allow for more precise surgery.
The patient side cart consists of four robotic "arms" that connect to the patient through small incisions. One arm controls movement of the telescope and the other three arms control movement of the da Vinci® surgical instruments. The instruments are unique in that they are "wristed" or have the ability to move inside the patient's body with 7 degrees of freedom. This means that the instruments can replicate any movement of the surgeon's hand in all directions. This technology is different from standard laparoscopic instruments which only move with 4 degrees of freedom. The increased maneuverability makes it easier for the surgeon to perform the operation.
What is nerve-sparing surgery?
The cavernous neurovascular bundles are delicate nerves and blood vessels located on the left and right sides of the prostate, near the rectum. They play a key role in the complex physiology of erections. In most cases of clinically localized prostate cancer, these nerves can be separated from the prostate and "spared." This technique provides the best opportunity to recover sexual function after prostatectomy.
Can you perform nerve-sparing surgery using the robot?
Yes, the robot offers additional magnification and precise instrumentation. This allows for meticulous dissection during the nerve-sparing portion of the operation.
What advantages does robot-assisted prostatectomy provide?
Patients experience less pain with smaller incisions and tend to recover more quickly. The risk of major bleeding and blood transfusion is significantly decreased, as well. In addition, the time to achieve continence may be shorter than with open surgery.
Are there disadvantages?
The robotic system is very expensive for hospitals to acquire and maintain. As a result, it may not be available in every community hospital. Furthermore, there is a major commitment required for the surgeon and team to become trained. The learning curve for robot-assisted prostatectomy has not yet been established, but experienced surgeons tend to have better outcomes with radical prostatectomy in general.
How is the care different at Scott & White?
We have been doing da Vinci® prostatectomy since January 2005. We have a dedicated operating room and surgical team committed to providing consistent care for our patients. Drs. Kristofer Wagner and Patrick Lowry are both urologists with fellowship training in minimally invasive surgery and extensive experience in laparoscopy and robotic surgery. They currently perform the procedures together. There are very few centers with two fellowship-trained surgeons performing robotic prostatectomy as a team.
We have developed a perioperative care map protocol which provides consistent nursing care from the time patients check in until discharge. We strive for continuous quality improvement and routinely monitor patient outcomes including cancer control, incontinence, impotence and overall quality of life using validated questionnaires.
As a teaching hospital, we are committed to education and research. We are involved in urology resident teaching, present at national and interational meetings and have published work in major scientific journals and textbooks. Although we teach resident urologists, your surgery is performed by an experienced team.
How long does the surgery take?
The operation usually lasts between two to three hours. We will provide each patient with the best possible operation and take as much time as needed to do it safely and properly.
What can be expected following surgery?
Patients spend about an hour in the recovery room and then are moved to the Urology Department. Within a few hours after the surgery, patients are out of bed sitting up in a chair and may take a clear liquid diet.
How long will it take for me to recover?
Everyone's recovery is different, but in general you can expect to feel better each day after surgery. Patients get out of bed on the day of surgery and are walking and eating a regular diet within 24 hours.
The only restricted activity after surgery is heavy lifting (over 10 lbs.) for four weeks. Climbing stairs, walking, showering, and dressing yourself are not a problem.
Most patients are able to drive and perform light work within one to two weeks after the surgery (as long as you are not taking narcotics). Nearly all patients are able to return to full activity/work after four weeks.
How do you know if the cancer is gone?
The prostate specimen is sent to the lab and a report is available in one week. This is reviewed with your physician on the day of catheter removal. This report details the size and extent of the cancer and provides some information about prognosis.
The most important indicator of "cure" is your first PSA (blood test) which is obtained three months after surgery. The PSA should be "zero" or "undetectable" after removal of a cancerous prostate. Any detectable or measurable PSA after surgery may mean that cancer is still present or has recurred, but this is not always the case.
How is success measured?
The primary goal of radical prostatectomy via any approach is cancer control. How this is measured is explained above. In addition to cure, quality of life is important. We ask all our patients to fill out questionnaires that assess important bowel, bladder and sexual side effects. The combination of cancer control, continence and potency (or the "trifecta") is the goal.
What are the side effects?
- Stress urinary incontinence is defined as involuntary loss of urine that occurs with coughing, sneezing, heavy lifting, or other physical activity. It is usually due to weakness of pelvic floor and urinary sphincter muscles.
Most men experience some stress incontinence early after prostatectomy (when the catheter is removed). This often requires the use of an incontinence pad. Most men experience signficant improvement within weeks. Improvement continues up to two years after surgery and overall greater than 90 percent of men are dry or socially continent at one year.
- Impotence is defined as the inability to develop or maintain an erection of the penis. Most men experience impotence immediately after prostatectomy. This function may take several months, up to a year to return. Between 50-80 percent of men with normal erections will regain the ability to achieve erections adequate for intercourse at one year.
Younger men and healthier patients are more likely to experience return of erectile function.
Following surgery, your surgeon will explain Kegel exercises as part of a continence rehabilitation program. These exercises help to strengthen your pelvic floor muscles and regain urinary control. Pelvic floor physical therapy may be employed. Your surgeon can refer you for this additional treatment, if needed.
Emptying your bladder more frequently, avoiding caffeine and alcohol can also help to minimize incontinence.
Although uncommon, persistent severe incontinence that continues beyond six months after surgery can be effectively treated.
Surgical technique and nerve-sparing surgery are also important to preserve erectile function.
Following surgery, our patients are enrolled in a program of penile rehabilitation that includes daily use of medications like Viagra, intraurethral pellets and/or a vacuum erection device. Several studies have shown that these measures help optimize the likelihood that spontaneous erections return after surgery.
Several tools are available to review the statistical liklihood of cure. We routinely utilize the Kattan nomogram in preoperative patient counseling.
In some cases, morbidly obese (severely overweight) patients may not be candidates. At Scott & White, we do have extensive experience with very obese patients and this is not usually a problem. We also have experience with patients who have undergone previous abdominal and pelvic surgery.
While not usually a problem, some patients may not be candidates due to previous surgery.