da Vinci Robot (centre) with the surgeon's console on the right
Robotic-assisted laparoscopic prostatectomy (RALP) is the surgical removal of the prostate to treat prostate cancer. The robot is a state-of-the-art surgical interface system. It includes fine instruments that a urologist uses to remove the prostate gland through several small incisions (keyhole surgery).
Due to magnified 3D-visualisation of the anatomy, very precise surgery is possible. This results in less blood loss and faster recovery after surgery compared to conventional open surgery. Some studies show that there is a better outcome with regards to post-operative continence and sexual function.
The robot is completely controlled by the surgeon at all times and cannot operate independently.
Before your operation
The operation and outcomes will be explained to you by your surgeon. When you feel comfortable that you understand what is to be done and have had all your questions answered you will be asked to sign a consent form.
This consent form should be signed by both yourself and your surgeon and forwarded to the hospital a few days prior to your admission.
A blood test will need to be performed and a urine sample may need to be taken 4-5 days prior to surgery. Your surgeon will give you a form to take to the laboratory to have these tests done.
If you are over 60 or have other medical conditions you may have an electrocardiogram (ECG) to check the health of your heart prior to surgery.
It is important to avoid constipation. Try to establish and maintain a regular, soft bowel habit leading up to your operation. Identify the foods that can help you maintain a regular bowel habit for your post-op period.
Operation day
RALP is an operation performed by making several small cuts in the abdomen between your navel and pubic bone.
Laparoscopic ports are placed into these cuts and the robotic camera and instruments are introduced into the abdomen via these ports. The prostate will be removed. The cut at the navel will be enlarged slightly to remove the prostate. The bladder is joined back into the urethra (outflow pipe) and a catheter is placed to drain the urine.
The procedure takes about 2 hours.
Recovery
You will probably be in hospital 1 or 2 nights following this type of surgery.
When the operation is completed, you will go to the recovery room for a short while where you will be cared for until you are ready to be transferred to your room. When you wake up it is common to feel an urgent desire to pass urine. This is due to the catheter in your bladder.
Pain control
Pain control is managed in conjunction with your anaesthetist. For pain relief it is likely you will have a PCA (Patient Controlled Analgesic) pump attached to your intravenous line. You will be able to control the amount of pain relief by pressing a button connected to the pump.
Our aim is to keep you as comfortable as possible: it is important to let your nurse know when the pain or discomfort starts. At all times your nurse is there to help you. Please ring your bell if you need assistance and your nurse is not nearby.
Catheter
Your nurse will monitor your catheter drainage which is likely to be blood stained for the first 24 hours. Your catheter usually is left in place for 1-2 weeks after surgery. You will therefore go home with a catheter in.
Our continence advisor will contact you to organise a date to have your catheter removed at Urology Associates. The catheter is removed by deflating the balloon holding it in place. Once the balloon is deflated, the catheter slides out easily causing little discomfort.
Once the catheter comes out you may at first have a burning sensation when passing urine. If the burning sensation lasts for longer than 3 days, or there is sign of infection or obstruction, it is important to contact your surgeon or GP.
Bladder control
Initially, you will probably have to wear pads to control varying amounts of urinary leakage. At the appointment for catheter removal, pelvic floor exercises will be taught to help you regain control of your bladder. You will probably not require pads after 3-6 months.
Wound and drain tube
You will have six small wounds on your abdomen. The sutures are dissolvable and do not need to be removed.
You may have a drain tube coming from your abdomen. This will be removed after 1-2 days.
Expected symptoms
After surgery, you may or may not experience some of the following symptoms:
A stinging or burning sensation at the tip of the penis where the catheter enters. This is generally due to irritation and may be relieved by increasing fluid intake or ensuring the catheter is well supported.
A feeling of having a full bladder and low to nil drainage of urine through the catheter. This can be caused by blockage of the catheter tube either by a blood clot or by accidental kinking of the tube. Catheter blockages are easily cleared by the nurse.
Bladder spasms (short, sharp, grabbing pains) due to the bladder trying to expel the catheter because of irritation. These are easily treated with medication.
After discharge
You will receive two follow up appointments after your surgery. The first is for the removal of your catheter with the continence nurse and the second with your surgeon six weeks after the operation.
You can do most activities after your operation except heavy lifting, straining, intercourse or strenuous activity which should be avoided for 2-3 weeks after surgery. You will be able to continue with your normal daily routines as you feel able.
Generally when you feel that you could perform an emergency stop without being concerned about abdominal pain (at about 3 weeks), then you can resume driving.
You will be asked to drink extra fluids after your surgery and for the next few weeks after your discharge. This helps to keep the catheter draining.
It is normal to have some leakage or discharge at the end of your penis/catheter. The discharge may be urine, blood or brown coloured. You should wash the area with soap and water to remove this discharge and reduce any irritation. It is also normal to see blood occasionally in the catheter bag.
Some patients experience bladder spasm. Symptoms may include:
leakage of urine around the catheter
a feeling of wanting to pass urine
lower abdominal pain
Medication can be prescribed to relieve the spasm.
Complications
Bleeding
Bleeding severe enough to bring you back to the hospital is rare. This risk disappears when healing is complete, 6-8 weeks after surgery. If you notice an increase in bleeding or are unable to pass urine, contact your GP.
Incontinence
Urgency is common. Incontinence, or leakage of urine without control, may occur temporarily. Only very few patients have incontinence which lasts beyond the first few months.
If you have any incontinence after your operation, you will be given information and instructions about exercises that you can do to strengthen the pelvic floor muscles. Your surgeon or nurse can also provide you with information about the management of leakages.
Urethral stricture
In a small number of cases tightness may develop in the urethra. This may occur either near the tip of the penis or further up the urethra, several months after the operation.
You may notice your urinary stream, which was better after the operation, slows down again. Please mention this problem to your doctor. If detected early and treated with gentle stretching under local anaesthetic most strictures resolve. An operation to cut open the tight area may be appropriate.
Sexual function
A RALP can cause impotence – the inability to have an erection. The likelihood of this occurring depends on a number of factors.
At best only 35% of men retain normal erections which may take a year to return after surgery. This does not mean that you cannot continue to have a satisfactory sexual life. With some creativity, men can have orgasms without having an erection. There are also a number of treatments available to help bring back erections. Talk to your urologist about this if you are experiencing difficulties in this area.
Prostate Surgery
Booklet with more information about the Robotic Assisted Laparoscopic Prostatectomy (RALP)