Robotic Prostate Surgery

ROBOTIC PROSTATE SURGERY

Overview

Robotic assisted laparoscopic radical prostatectomy, a form of robotic prostate surgery, is a minimally invasive surgery to remove the prostate. This robotic prostate surgery operation is performed as a local treatment for men with prostate cancer.

Robotic laser surgery is performed through several small incisions in the front of the abdominal wall. This allows access to the prostate which is located deep in the pelvis, below the bladder and on top of the pelvic floor. Through these small incisions ports (or thin tubes) are inserted through which specialised instruments are placed. These instruments are then controlled in a delicate fashion by the surgeon who sits at a consol adjacent to the operating table.

A total of 6 small incisions are used. At any one time the primary surgeon has control of four instruments which include the camera. In contrast to this, in standard keyhole or laparoscopic surgery the primary surgeon controls two instruments at any one time.

Another difference between robotic assisted laparoscopic surgery and laparoscopic surgery is in the approach to the prostate. In robotic prostate surgery we use only 5 ports and approach the prostate in an extraperitoneal fashion, meaning that the instruments pass out-with the abdominal cavity. With RARLP a total of six ports are used and the instruments travel through the abdominal cavity. The bladder is then mobilised to allow access to the prostate.

There are some subtle differences in the instruments used for robotic laser surgery and standard keyhole surgery. In robotics we use wristed instruments which facilitate a wide range of motion improving access in certain circumstances.

In my opinion, one of the significant advantages to both robotic assisted keyhole and standard keyhole surgery lies within how the anastomosis or join between bladder and urethra (bladder outlet pipe) is created. In open surgery an interrupted anastomsis is created. This entails separate stitches, usually between 6-8, being used. Data, from the surgical literature demonstrates that the likelihood of problems with this technique is in the order of 8%. Problems that can occur include leaks and strictures (or scar tissue).

In both robotics and standard keyhole techniques I perform a continuous anastomosis. This involves a three layered join. The back wall is first reinforced before using a single continuous suture to secure the urethra (or outlet pipe of bladder) to the bladder. A further layer is then created on the front of the bladder which reinforces the anterior aspect of this join. Since making these refinements, the incidence of anastomotic problems has been significantly reduced and are rarely encountered today.

These advantages of robotic prostate surgery are in addition to shorter hospitalisation, less post operative pain, reduced convalescence and a quicker return to normal activity. Currently the majority of patients undergoing RALP are in hospital overnight and discharged the next day usually by lunchtime.

Patients are discharged with a catheter (a small plastic tube) in place which is usually removed on day 6 after surgery. The aim of the catheter is to splint the anastomosis (or join) in the immediate post operative period. A dye test is then performed usually on day 6 or 7 post surgery. This is called a cystogram; the purpose of this test is to confirm that the join has had knitted together before removing the catheter.

Following catheter removal the rehabilitation phase of treatment begins. This involves rehabilitation of urinary control and sexual function. In my practice, all patients commence pelvic floor training with our practice nurse and dedicated prostate cancer support nurse David Hughes before surgery. This should be carried out for a few weeks prior to robotic prostate surgery, discontinued during the period of catheterisation and then recommenced after a successful trial of void on day 6 after surgery.