BRYN MAWR UROLOGY GROUP Da Vinci Minimally Invasive Robotic Laparoscopic |
Rosemont Business Campus Building One Suite 300 919 Conestoga Road Rosemont, Pa 19010 Office [P] 610.525.6580 Fax [F] 610.525.3664 |
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BRYN MAWR UROLOGY GROUP Da Vinci Minimally Invasive Robotic Laparoscopic |
Rosemont Business Campus Building One Suite 300 919 Conestoga Road Rosemont, Pa 19010 Office [P] 610.525.6580 Fax [F] 610.525.3664 |
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Q. Why should I choose robotic prostatectomy instead of traditional open surgery?
A. If your doctor recommends surgery to treat your prostate cancer, you may be a candidate for robotic prostatectomy. This new, less-invasive surgical procedure utilizes a state-of-the-art surgical system that helps your surgeon see vital anatomical structures more clearly and to perform a more precise surgical procedure.
For most patients, robotic prostatectomy offers numerous potential benefits over open prostatectomy, including:
As with any surgical procedure, these benefits cannot be guaranteed, as surgery is both patient- and procedure-specific.
Q. What is robotic surgery?
A. Robotic surgery is a laparoscopic approach to the treatment of prostate cancer. The da Vinci robot is used to assist in surgical removal of the prostate by providing three-dimensional vision, magnification and an articulating robotic wrist.
Q. Does the robot perform surgery by itself?
A. No. The robot has no independent thought. It just recreates the actions performed by the surgeon at the console in a more precise manner.
Q. Is the procedure performed in the same manner as the open surgery?
A. Yes. The prostate is removed entirely, along with the seminal vesicles.
Q. Can lymph nodes also be removed during the robotic procedure?
A. Yes.
Q. How long does robotic prostatectomy surgery take?
A. The actual procedure normally takes 1 ½ to 2 hours, although unusual circumstances could increase the time required.
Q. Does the robotic prostatectomy surgery require general anesthesia?
A. Yes, general anesthesia is required. Robotic prostatectomy offers many advantages compared to conventional surgery, but it is nevertheless a major operation.
Q. Will I need to donate blood to have available during my robotic prostatectomy?
A. One benefit of this procedure is minimal loss of blood, so you will not have to donate your own blood to have on hand for transfusion.
Q. What if the robotic equipment fails during the surgery?
A. This is a very remote possibility, but if the robot mechanically fails during surgery, the procedure would be completed with either conventional laparoscopic or open surgery.
Q. How long will I have to stay in the hospital after surgery?
A. Most robotic prostatectomy patients are able to go home within 24 hours after surgery.
Q. How soon can I resume normal activities?
A. Every patient is different, and healing time depends on your particular circumstances. Most patients, however, are able to resume normal activities about 7 days after surgery.
Q. Will I have a urinary catheter after the surgery?
A. Yes. A urinary catheter is required to ensure adequate bladder drainage and facilitate healing.
Q. How soon can I bathe after the surgery?
A. You may shower after you get home, but bathing in the tub is not recommended for the first two weeks. Treat the incision sites carefully and dry them by patting, rather than rubbing.
Q. Will I have normal urinary control after this procedure?
A. Most patients experience some incontinence immediately following catheter removal, but urinary control generally returns with time.
Q. Will I be sterile (unable to father children) after this procedure?
A. Yes. All patients who have a radical prostatectomy, regardless of the type of surgery used, will be sterile.
Q. Will I be able to resume normal sexual relations after this procedure?
A. Not immediately, although erectile function returns for most patients within 9 to12 months. Some patients are able to resume sexual intercourse within a shorter time.
Q: What Are the Benefits for Patients?
A: Benefits of robot assisted prostatectomy include:
Q: How Do Patient Outcomes Compare for Robotic Prostatectomy?
A: Results of studies on robotic prostatectomy indicate that the success rate in controlling prostate cancer with robotic prostatectomy in patients with localized disease is as good as, or better than, open or laparoscopic prostatectomy. Some studies suggest that robot assisted prostatectomy may allow for earlier return of continence and potency.
Q: How safe is the da Vinci Surgical System for radical prostatectomy?
A: The system is FDA approved for radical prostatectomies. Each da Vinci system is rigorously maintained, tested, and upgraded as necessary by Intuitive Surgical. The robot at the University of Maryland Medical Center is the newest model available, representing state-of-the-art, computer-assisted robotic technology.
Q: What happens if there is a malfunction in the da Vinci System?
A: Recent studies show that the rate of robot malfunction is low, about 1%-4% of the time. In the unlikely event of malfunction, or if the surgeon feels that it is not safe to continue with the robot, the da Vinci system will be withdrawn and the surgery can proceed either via standard laparoscopy or via traditional open radical prostatectomy. The instruments and supplies necessary are kept on hand such that conversion, if necessary, can occur seamlessly.
Q: What are the side effects of this procedure? What can I expect?
A: There are several possible side effects after prostatectomy, and many of them will depend on a patient's individual characteristics. The most common side effects are incontinence, impotence, and discomfort. A bladder catheter will be placed at the time of surgery and is generally removed one week later. Incontinence (leakage of urine) of varying degrees will be initially experienced by most patients, but should improve over time. The majority will be continent within 3-6 months. Impotence (inability to get an erection) can also occur. Risk factors for impotence include age and pre-operative erectile dysfunction. Some patients will be potent within a few weeks after surgery, while others will take up to 2 years to recover potency. Probably the number one complaint after this surgery is pain in the perineum (the area just below the testicles), which can occur in about 10% of patients. This can last for a month or so, but usually responds well to Ibuprofen.
Q: How does robotic-assisted surgery work?
A: The computer-enhanced robotic surgical system consists of three components that provide:
Q: How long does this robotic surgery take?
A: Although this robotic surgery takes approximately 2-4 hours to perform, patients generally feel much better and have significantly fewer pain requirements in the early post-operative period. What are the advantages of this procedure?
This procedure is performed through small key-hole incisions that do not cut muscle. Laparoscopic and robotic prostatectomy offer surgeons unparalleled visualization of the area, thus permitting precise removal of the prostate. Patients also experience significantly less blood loss. Additionally, patients benefit from:
Q: What are the benefits to patients who have laparoscopic and robotic prostate cancer surgery?
A: The benefits are similar between robotic and laparoscopic prostate cancer surgery. Patients are usually able to go home the day after prostate surgery, and can return to daily living activities as early as 7-10 days after surgery. Patients undergoing open surgery generally have 4-6 weeks before they can resume routine daily living activities, generally experience less post-operative pain and discomfort and have a faster recovery. They also experience significantly less intraoperative bleeding. Robotic and laparoscopic prostatectomy uses small incisions and is highly precise; the risk of incontinence is low; and the surgical technique is continuously refined to improve potency.
Q: What sexual side effects are possible after robotic and laparoscopic prostate surgery?
A: Laparoscopic and robotic prostate surgery are highly precise in their ability to spare the nerve bundle responsible for erections.The degree of sexual function after radical prostatectomy is determined by many factors. These include the man's age, how sexually active he was before the procedure. Most men experience at least temporary erectile problems after a radical prostatectomy.
Q. How is laparoscopic radical prostatectomy (LRP) different from open radical prostatectomy?
A. In contrast to open radical prostatectomy, the surgery does not require an abdominal incision, and is thus a much less invasive procedure. Instead, the procedure relies on tiny entry sites or “ports,” most of which are no longer than five millimeters. surgeons then insert slender instruments through these small ports, including a computerized scope (the laparoscope), allowing them to view a powerfully magnified image in real time video. The surgeons utilize advanced technology to visualize and remove the cancerous prostate gland. The LRP and open radical prostatectomy both remove the entire prostate, and then attach the urethra directly to the bladder. In excision and reconstruction, therefore, the LRP and open radical prostatectomy are the same.
Q. How does robotic assisted laparoscopic prostatectomy work?
A. With the state-of-the-art da Vinci ® computer-enhanced minimally invasive surgery system, surgeons perform the same procedure done in conventional LRP, 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.
Q. What are the benefits of DVP?
A. 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.
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.
Based on our most recent data review, our pathological positive margin rate is below 20%. The average time to regain continence is about 40 days, with almost 96% of patients reporting continence at one year after surgery. Patients may be enrolled in a continence rehabilitation program to strengthen their pelvic muscles and accelerate their recovery. Furthermore, depending on age and pre-operative erectile function, approximately 70-80% of patients can expect to have return of potency with or without the use of oral medications.
Q. Who is a candidate for DVP?
A. Anyone diagnosed with localized prostate cancer may benefit from robotic-assisted LRP. 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. DVP can be done for men of all sizes and shapes. DVP 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.
Q. Does DVP remove the whole prostate?
A. Yes. DVP removes the prostate, seminal vesicles, ends of the vas deferens, and, depending on oncological considerations, nerve bundles and/or lymph nodes.
Q. Why is there less blood loss with DVP?
A. 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 DVP 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.
Q. Does DVP require general anesthesia?
A. Yes. Robotic assisted laparoscopic prostatectomy is considered major surgery and thus requires general anesthesia.
Q. Does prostate size matter?
A. As a practical matter, prostate size is not much of an issue. We routinely remove prostates ranging from 10 to 100 ccs in size.
Q. Can lymph nodes be removed with DVP?
A. Yes. Lymph nodes, to which prostate cancer may spread, can be removed.
Q. What are the risks of DVP?
A. DVP is major surgery, done under general anesthesia and carries the same risks of any major operation, including heart attack, stroke, and death. Robotic-assisted laparoscopic prostatectomy is also associated with the specific risks of impotence and incontinence.
Q. Can the neurovascular bundles be preserved?
A. 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.
Q. Does it make sense to preserve the neurovascular bundles?
A. 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.
Q. When will the ability to have an erection be regained following surgery?
A. 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.
Q. Are venous compression devices used in this surgery?
A. 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.
Q. Does DVP require a catheter, drain, dressings, or stitches?
A. Yes. Like any radical prostatectomy, robotic-assisted laparoscopic 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, DVP 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.
Q. How long should the catheter stay in?
A. We routinely remove the catheter in five to seven days at the first follow-up visit.
Q. What can I expect after the catheter comes out?
A. 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.
Q. How can I speed my continence recovery?
A. You will be given an instruction sheet for Kegel exercises and other suggestions that will help in the recovery of continence.
Q. Can I bath after DVP?
A. Yes. Most patients may shower within 24 hours of surgery.
Q. What can I expect immediately after DVP?
A. 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.
Q. What can I expect after getting home?
A. While relative to open surgery DVP 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.
Q. If I live far away, can I travel after surgery?
A. 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 Bryn Mawr within two days, be it by car or plane to various destinations.
Q. What happens to my medical records and who will take care of me when I get home?
A. 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.
Q. Must I return for follow-up care?
A. We support our patients regardless of where their paths take them. In a practical sense, this means that once a patient has had a DVP, 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 Bryn Mawr for routine follow-up.
Q. What is the long-term follow-up after DVP?
A. Depending on the pathologist’s report of the DVP 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
