What is robotic assisted prostatectomy?
Since 2003, City of Hope has been performing prostatectomy using the da Vinci surgical system (DVP), allowing our physicians to take a giant leap forward in the treatment of prostate cancer. The robotic technique provides unparalleled surgical accuracy to significantly reduce blood loss and improve postoperative recovery. City of Hope performs more robotic assisted prostatectomies than any other medical center in the Western U.S and is second in the nation.
How does robotic assisted prostatectomy work?
With the state-of-the-art da Vinci computer-enhanced minimally invasive surgery system, City of Hope surgeons perform the same procedure done in conventional laparoscopic prostatectomy, but are aided by a three-dimensional computer vision system to manipulate four robotic arms. A pencil-size video camera held by one of the arms is inserted through an incision to provide magnified, 3D images of the surgical site. The 3D view helps the surgeon more easily identify the delicate nerves and muscles surrounding the prostate. The robotic arms can rotate a full 360 degrees, allowing the surgeon to manipulate surgical instruments with greater precision, flexibility and range of motion.
To view informational video on robotic assisted prostatectomy click here
What are the benefits of robotic assisted prostatectomy?
Patients experience significantly less pain and less blood loss than those undergoing conventional open incision procedures. In addition, patients tend to enjoy quicker recovery time.
A traditional, open radical prostatectomy requires two days hospitalization and recovery lasting about 2-3 months. With robotic assisted surgery the recovery time is as little as two weeks - a greater than 50 percent reduction in recovery time.
How experienced is City of Hope at the robotic assisted prostatectomy procedure?
City of Hope was one of the first cancer centers in the United States to begin performing the robotic assisted laparoscopic radical prostatectomy. Since October 2003, our physicians have performed over 3100 cases, more than any other site in the Western U.S and second in the entire U.S.
What are City of Hope's outcomes?
The department of Urologic Oncology at City of Hope specializes in the diagnosis and treatment of prostate cancer, bladder cancer, kidney cancer, and other urologic malignancies, providing therapies for patients that not only treat the disease but also attempt to achieve the best quality of life. Since 2000, we have been using state-of-the-art minimally invasive techniques for the treatment of urologic malignancies. Both the institution and the department were recently named as America's Best Hospitals in cancer and urology by U.S. News and World Report. We were the first regional cancer center to implement and subsequently advance the use of standard laparoscopic techniques for the treatment of prostate and bladder cancers.
In 2003, after an initial experience with over 500 laparoscopic radical prostatectomies we implemented the use of the da Vinci surgical system into our practice. Since then, we have become the busiest minimally invasive and surgical robotics program worldwide and have performed over 3,100 robotic prostatectomies. In 2007, we performed approximately 721 robotic prostatectomies.
The robotic program at City of Hope includes robotic and oncology fellowship trained surgeons, fellows, a dedicated operating room team, nurse practitioners, physician assistants, and research coordinators. We currently have four new generation, four-arm robotic systems, including the da Vinici S High Definition platform. All of our procedures are performed in minimally invasive operating theatres, utilizing Karl-Storz OR1 integrated and automated suites.
The operation typically takes 2 to 3 hours, and is performed under general anesthesia. Most patients have an estimated blood loss of 300 milliliters, and therefore less than 3% of patients are expected to need a blood transfusion). Most patients typically spend one night in the hospital, and can expect to get discharged the following afternoon if their laboratory tests are acceptable, pain is controlled with oral medications, and they are able to tolerated oral liquids. Patients are discharged with an indwelling foley catheter which will be removed in the clinic 5-7 days after the operation. Patients who do not reside in the local vicinity, can sometimes have their catheters removed by their community urologist. At the first post-operative visit, we review and discuss pathology results, and potential need for any adjuvant therapies if indicated. Most patients have a convalescence period of 2-3 weeks, and can expect to return to their normal activity 4 weeks after surgery.
The primary concern for patients with localized prostate cancer who undergo prostatectomy is recurrence, or a return of their cancer. Biochemical recurrence, indicated with elevated levels of prostate-specific antigen, or PSA, affects an estimated 12% of our patients three years following robotic radical prostatectomy, and an estimated 17% of patients at five years.
Secondary outcomes of concern to patients include regaining continence and potency. Among our patients who were continent prior to undergoing prostatectomy, 63% regained continence within the first four months following surgery. By 12 months, we found that 87% of patients had regained continence. The average time to return to continence is 1.8 months.
Return to potency takes considerably longer for prostatectomy patients. At 12 months following prostatectomy, 46% of our patients had returned to desired potency levels. The number edges higher when we consider a 24 month follow-up period (63%), and the average time to return to potency is 14 months for our patients overall. Age, however, is a notable factor in these estimates. Among younger patients who were under the age of 65 at the time of surgery, the average time to return to potency was under 12 months, and 69% of these patients were said to have regained potency at 2 years.
It is important to keep in mind that these results represent outcomes since robotic prostatectomy was started at City of Hope in 2003. Since that time, with growing experience, positive margin rates have declined and individual surgeon results have improved. The operation we do now is considered to be leading edge and state of the art.
Who is a candidate for robotic assisted prostatectomy?
Anyone diagnosed with localized prostate cancer may benefit from robotic-assisted prostatectomy. However, the decision to have prostate cancer treated surgically revolves around numerous considerations. Variables that enter into preoperative evaluation include age, pre-biopsy PSA, biopsy findings, previous prostate cancer treatments and other illnesses. Robotic prostatectomy can be done for men of all sizes and shapes. The surgery can be done in men who have had other operations: appendectomy, laparoscopic hernia repair, repair of abdominal trauma, transurethral prostatectomy (TURP), and in some men who have been treated with previous pelvic radiation.
Does robotic assisted prostatectomy remove the whole prostate?
Yes. This surgery removes the prostate, seminal vesicles, ends of the vas deferens, and, depending on oncological considerations, nerve bundles and/or lymph nodes.
Why is there less blood loss with robotic assisted prostatectomy?
The reduction in blood loss reflects the improved view of the operative field, especially behind the pubic bone, home of the venous plexus of Santorini. The improvement in view comes from using a lens that tracks directly into the operative field where the remote human eye has a hard time going. The robotic surgery also uses magnification and bright illumination. Overall, this improved view permits a more precise and gentle dissection, which means better control of potential sources of bleeding.
Does robotic assisted prostatectomy require general anesthesia?
Yes. Robotic assisted prostatectomy is considered major surgery and thus requires general anesthesia.
Does prostate size matter?
As a practical matter, prostate size is not much of an issue. We routinely remove prostates ranging from 10 to 100 ccs in size.
Can lymph nodes be removed with robotic assisted prostatectomy?
Yes. Lymph nodes, to which prostate cancer may spread, can be removed.
What are the risks of robotic assisted prostatectomy?
This is major surgery, done under general anesthesia and carries the same risks of any major operation, including heart attack, stroke, and death. Robotic-assisted prostatectomy is also associated with the specific risks of impotence and incontinence.
Can the neurovascular bundles be preserved?
Yes. The neurovascular bundles whose preservation is associated with the likelihood of maintaining erections can be preserved. Nerve preservation does not guarantee satisfactory erections after surgery.
Does it make sense to preserve the neurovascular bundles?
Not in all cases. The issue here relates to the physical proximity of the bundles to areas of malignancy, which can microscopically extend beyond the prostate and into the bundles. The decision to preserve one or both neurovascular bundle depends on an individual analysis.
When will the ability to have an erection be regained following surgery?
Return of potency depends on many physical and psychological factors including preoperative erectile function and type of surgery (such as unilateral or bilateral; nerve-sparing or non-nerve sparing). Function may return spontaneously as early as one week after surgery, or with the aid of medications (Viagra, Muse). Potency rehabilitation can be discussed at the one-month visit. Factors that can interfere with erectile function include hypertension, diabetes, obesity, atherosclerosis, history of smoking, and anxiety, among others.
Are venous compression devices used in this surgery?
Yes. As a precaution against developing blood clots each patient has venous compression devices placed prior to surgery. These are removed when the patient becomes ambulatory.
Does robotic assisted prostatectomy require a catheter, drain, dressings, or stitches?
Yes. Like any radical prostatectomy, robotic-assisted prostatectomy requires reconstruction of the bladder-urethra connection. A catheter is left in the urethra, connected to a drainage bag, and used to align the healing suture line and drain the bladder. In the immediate post-op period, the surgery also requires a drain that goes through the abdominal wall and left in the pelvis behind the pubic bone. The drain assures the collection of blood and urine that may accumulate immediately after surgery and is removes when the output drops, usually prior to leaving the hospital. There are stitches, but these dissolve by themselves and require no special care. The surgical dressings are five Band-Aid type dots used to cover the instrument entry sites. These dressings are generally removed 48 hours after surgery.
How long should the catheter stay in?
We routinely remove the catheter in five to seven days at the first follow-up visit.
What can I expect after the catheter comes out?
Almost all patients have some incontinence when the catheter comes out. Incontinence varies from person to person, but usually improves significantly or resolves by the one-month follow-up clinical visit. Continence function returns with time, and patience here is a real virtue.
How can I speed my continence recovery?
You will be given an instruction sheet for Kegel exercises and other suggestions that will help in the recovery of continence. In addition, a Continence Recovery Program is available through our Rehabilitation Services Department beginning 1 month after surgery. Ask your MD for a referral.
Can I bathe after robotic assisted prostatectomy?
Yes. Most patients may shower within 24 hours of surgery.
What can I expect immediately after robotic assisted prostatectomy?
Patients leave the operating room with an intravenous line, a urethral catheter, and a small rubber drain in their lower abdomen. In the first few hours, depending on strength and motivation, most patients get out of bed and stretch their legs, and begin walking by nightfall. Most leave the hospital within 48 hours. Most patients begin drinking fluids on the 1st day after the procedure. Patients are discharged with a catheter connected to a leg bag, which fits under their pants. Loose clothing and shoes that don't require tying seem easier to handle in the first few days.
What can I expect after getting home?
While relative to open surgery robotic assisted prostatectomy is generally less demanding, the experience is still demanding. The single most common complaint after hospital discharge seems to be sleep deprivation and fatigue. Most patients are anxious going into surgery, get little sleep the night before surgery, arrive at the hospital very early on the morning of surgery, and get very little sleep the night after surgery. Accordingly, most patients look forward to a good, long nap and a shower after getting home. The other major complaint seems to be a sense of bloating, with clothes fitting very tight. This bloating seems related to the effects of surgery, anesthesia, and bed rest on intestine function. Often this sensation responds well to walking, which helps the patient expel intestinal gas, which in turn helps the patient regain his overall comfort and appetite.
If I live far away, can I travel after surgery?
Many of our patients come from far away and we can help with numerous logistical issues related to travel, from finding a suitable hotel to arranging medical evaluations pre-operatively. After surgery, we have had patients leaving Duarte within two days, be it by car or plane to various destinations.
What happens to my medical records and who will take care of me when I get home?
We work with our patients to transmit any and all relevant medical data to their home physicians. For those who chose to stay a while, we provide all follow-up medical care.
Must I return for follow-up care?
We support our patients regardless of where their paths take them. In a practical sense, this means that once a patient has had a robotic assisted prostatectomy, we consider him a lifetime patient and are always available. In fact, most of our patients, having come to rely on us during a very trying time in their lives, stay in touch and regularly call and email to update us or ask for our help. While we deliver urological care to all our local patients, there may be no compelling reason for patients to make trips to Duarte for routine follow-up.
What is the long-term follow-up after robotic assisted prostatectomy?
Depending on the pathologist's report of the surgery specimen, a patient may or may not consider additional cancer treatments. In most cases, but not all, the wise course of action is surveillance: periodic measurement of blood PSA, thought to be the most sensitive indicator of cancer recurrence.
What is the Survivorship Clinic?
We are very excited to now offer a unique opportunity for eligible patients. If you are one year post treatment and free of disease, we believe that you would benefit from the Prostate Cancer Survivorship Clinic. Services provided in the Clinic include general health promotion, follow-up assessments, screening for other cancers, education and other support services.
For more information, please see the Prostate Cancer Survivorship Program.