Robotic- assisted (da Vinci ) laparoscopic radical prostatectomy: procedure specific information Introduction The aim of this leaflet is to help answer some of the questions that you may have about having a robotic- assisted laparoscopic prostatectomy. It explains the benefits, risks and alternatives to the procedure as well as what you can expect when you come into hospital. If you do have any questions and concerns, please do not hesitate to speak to your doctor or named nurse. What is the evidence base for this information? This publication includes advice from consensus panels, the British Association of Urological Surgeons, the Department of Health and evidence- based sources. It is, therefore, a reflection of best urological practice in the UK. It is intended to supplement any advice you may already have been given by your GP or other healthcare professionals. Where is my prostate and what does it do? Your prostate is a small walnut- sized gland that is situated at the base of your bladder. Its main function is to produce liquid, which is added to your ejaculate (sperm). The picture below indicates the location of the prostate in relation to other organs, including the bladder, rectum and urethra (water pipe). What is a robotic- assisted laparoscopic radical prostatectomy? A radical prostatectomy is an operation performed by surgeons to remove the prostate and seminal vesicles in men with a diagnosis of prostate cancer. In most men the aim of radical prostatectomy is to remove all of the cancer, thereby providing a cure. Traditionally, radical prostatectomy was performed by an open 1
approach using a 10-15 cm incision in the abdomen just above the pubic bone. More recently, surgeons have used a laparoscopic ( keyhole ) approach to perform radical prostatectomy, which can be associated with reduced complications and a shorter hospital stay. This method has been used at Nottingham University Hospitals NHS Trust for approximately the past five years. We now offer robotic- assisted radical prostatectomy using the da Vinci surgery machine to remove prostate cancer. In recent years, robotic prostatectomy has been shown to be safe and effective for prostate removal and it is now considered the method of choice in many cancer centres throughout the country and across the world. What are the benefits? Robotic- assisted laparoscopic radical prostatectomy has been associated with the following benefits when compared with traditional open surgery: Smaller scars 6 small incisions in the abdomen compared with one large incision above the pubic bone. Less pain usually managed by oral tablets alone. Less blood loss reducing the risk of needing a blood transfusion Shorter length of stay most patients go home 24-48 hours after surgery. Enhanced surgical 3D vision and dexterity of instruments giving surgeons a high level of control within the abdomen, minimising risk and contributing to cancer clearance. Rapid return to work most patients can return to work after 2-6 weeks. What are the risks? Most surgical procedures have a potential for side effects. Common, occasional, and rare side- effects/complications of surgery are listed below. Common (greater than 1 in 10) Temporary insertion of a bladder catheter. Temporary difficulties with urinary control after catheter removal. Inability to ejaculate or father children because the structures that produce seminal fluid have been removed (occurs in 100% of patients). Impairment of erections even if the nerves supplying the penis can be preserved (20-50% of men with previously good pre- operative sexual function). Discovery that cancer cells have already spread outside the prostate requiring further treatment. Occasional (between 1 in 10 and 1 in 50) Scarring at the bladder exit resulting in weakening of the urinary stream and a potential for further surgery (2-5%). Severe urinary incontinence (temporary or permanent) requiring pads or further surgery (2-5%). Blood loss requiring transfusion or further surgery. 2
Further cancer treatment at a later date, such as radiotherapy or hormone treatment. Lymph collection in the pelvis if lymph node sampling is performed. Some degree of constipation can occur; we will give you medication for this but, if you have a history of piles, you need to be especially careful to avoid constipation. Apparent shortening of the penis; this is due to removal of the prostate gland causing upward displacement of the urethra to allow it to be re- joined to the bladder neck. The reduction in blood flow to the penis also affects its length. Development of a hernia related to the site of the port insertion. Development of a hernia in the groin area after the operation. Scrotal swelling, inflammation or bruising (short- term). Rare (less than 1 in 50) Anaesthetic or cardiovascular problems possibly requiring intensive care admission (including chest infection, pulmonary embolus, stroke, deep vein thrombosis, heart attack and death). Pain, infection or hernia at incision sites. Rectal injury requiring a temporary colostomy. Hospital- acquired infection Colonisation with MRSA (0.9%) Clostridium difficile bowel infection (0.2%) MRSA bloodstream infection (0.08%) Failure to complete the operation using the robot, and conversion to standard open surgery. (Please note that if you are insistent that you would not agree to an open operation under any circumstances, we would be unable to proceed with the robotic operation. Please tell your urologist if this is the case.). What are the complications specific to having this surgery? Your surgeon will endeavour to perform a nerve- sparing operation if possible. This means avoiding removal of the nerves, which produce erections. Erectile problems Depending on your erectile function before the operation and whether it was possible or appropriate to save these nerves, problems with erection after the operation can occur. The risk of this problem varies: Very high (more than 80%; 8 out of 10 men), if the erections were not good beforehand or the characteristics of the tumour mean that it was not advisable to preserve the nerves. Moderately high (60%; 6 out of 10) if only one nerve could be saved Moderate (30-40%; 3-4 out of 10) if both nerve bundles were saved Erection problems can be helped by treatments ranging from tablets to injections. It is highly unlikely that you will lose your sex drive (libido) as a result of the operation. 3
If a nerve- sparing procedure has been performed and it is appropriate to do so, we will ask your general practitioner to prescribe medication such as Viagra or Cialis when you return for your results after surgery. We would not expect this to result in erections immediately, but it is designed to maximise the blood flow into the penis, thereby providing the best possible opportunity for your erections to recover. Sometimes patients take as long as 18-24 months to recover erectile function. Additionally, vacuum devices may be used either alone or in conjunction with the above. If oral medication proves to be unsuccessful, we can arrange for you to be seen by an erectile dysfunction specialist to discuss other alternatives. Continence problems It is common to experience some temporary loss of control over the passage of urine. This tends to settle within 3-6 months but, during this period, you may need to wear absorbent pads. As discussed before your operation, a small minority of patients will experience severe incontinence after the procedure, which may require corrective surgery at a later date. What are the alternatives to this procedure? Your surgeon will have discussed all the suitable alternatives with you when you were deciding on which course of treatment to opt for. The full list of alternative treatments includes the following: Active monitoring Open radical prostatectomy Conventional laparoscopic (keyhole) surgery External beam radiotherapy Brachytherapy (radiotherapy seeds ) Hormonal therapy There are also a number of other alternatives, including high- intensity focused ultrasound (HIFU) and cryotherapy, which are sometimes used in prostate cancer. National recommendations currently support these options only in the context of clinical trials at present. What do I need to do to prepare for surgery? You will receive an appointment to attend our nurse- led prostatectomy clinic, where you will be given general information about your surgery. At this appointment you will receive instruction on how to perform pelvic floor exercises, how to make an appointment with the Continence Advisory Service after your surgery, and what to expect after the operation. Your nurse will also ask you to fill out a number of baseline questionnaires to assess your erectile and continence function. We will also do our best to give you a date for surgery at this appointment, although this cannot always be guaranteed. You will normally then receive an appointment to attend the pre- assessment clinic 7-14 days before your surgery date. The aim of pre- assessment is to assess your general fitness, to screen for MRSA and to perform some baseline investigations. 4
Please be sure to inform your pre- assessment nurse or Urologist in advance of your surgery if you have any of the following: An artificial heart valve A coronary artery stent A heart pacemaker or defibrillator An artificial joint An artificial blood vessel graft A neurosurgical shunt Any other implanted foreign body A prescription for warfarin, aspirin or clopidogrel (Plavix ) A previous or current MRSA infection A high risk of CJD (i.e. if you have received a neurosurgical dural transplant, have previously received injections of human- derived growth hormone or gonadotropins, if you have a family history of CJD, or if you have been told you are at risk of CJD.) Provided there are no problems you will be admitted to the Urology Department on the day of your surgery. Please ensure that you do not eat anything for 6 hours before your surgery. You may wish to have a shower on the morning of your surgery; special antiseptic soaps are not usually required and you do not need to shave any areas of your body. If shaving is required it will be done in the anaesthetic room once you are asleep. After admission, you will be seen by a senior member of the urology team who will confirm that you still wish to go ahead with the procedure. If you decide to proceed, by law we must ask you to sign a consent form. This confirms that you agree to have the procedure and understand what it involves. The staff member will explain all the risks, benefits and alternatives before they ask you to sign the consent form. Even after you have signed it, if you are unsure about any aspect of your proposed treatment, please do not hesitate to ask to speak to a senior member of the urology team again. Finally, you will also see the anaesthetic team prior to your surgery. You are encouraged to ask them questions at this stage about any concerns or issues you have regarding the anaesthetic. Immediately before your procedure, you will be asked to put on a gown and elasticated stockings. The stockings are required to reduce the chances of a thrombosis (blood clot) forming in your legs after surgery. What happens during the procedure? When it is time for surgery you will be taken to the anaesthetic room. Your doctors will put a drip into your arm to allow them access to your circulation during the operation. You may also receive a spinal injection to help with pain relief after the operation. You will then be anaesthetised and taken into the operating theatre. During the surgery you will also be given antibiotics by injection to help prevent infection. If you have any allergies, be sure to let the anaesthetist know. 5
Once in the operating theatre you will be carefully positioned in a head down position on the operating table; this allows us gain access to your pelvis and prostate. Surgical ports will be inserted into the abdomen and carbon dioxide used to create a working space in which to perform the surgery. A robotic surgical cart is then placed beside you in the operating theatre. Attached to the cart are four robotic arms, three for instruments and one for a high- magnification 3- D camera to allow the surgeon to see inside your abdomen. The three robotic arms hold various instruments that allow the surgeon to carry out your operation. The instruments measure only 7mm in diameter, but have a greater range of movement than the human hand, allowing the surgeon to carry out the operation with high precision in a small space within the body cavity. The operating surgeon sits at a console in the same room but away from the operating table where he/she controls the robotic arms. The robot cannot work on its own. What happens immediately after the procedure? Once your surgery is complete, you will be taken to the recovery area. Although you have had minimally invasive surgery, it is still possible that you may have some pain and painkillers will be given accordingly. It is very important that whilst you are in the recovery/ward area you let the staff know if you feel any pain or become nauseous, so that they can give you the appropriate medication. You will wake up with a catheter in your bladder, a wound drain from your abdomen and 6 small incisions where the robotic port sites have been closed. Once the anaesthetic staff, surgeons and nursing staff have agreed that your condition is stable, you will be transferred back to the ward. Occasional symptoms in the first 24 hours after surgery are as follows: 6
Abdominal tenderness - the wounds themselves are very small (5-10mm) apart from the one by the umbilicus (belly button) as this is extended to remove the prostate at the end of the surgery. Since the surgery is performed through small incisions, most patients experience much less pain than with open surgery. In fact after one week, very few men feel any pain at all. Please be assured that we will give you painkillers to go home with after your surgery. Shoulder tip pain - Your abdomen is filled with gas during the procedure to create a space to operate in. This can cause the abdomen to feel stretched and bloated afterwards. All the gas is let out at the end of the operation but some people complain of pain in their shoulders due to diaphragm being stretched by the gas. This usually settles within 24-36 hours after surgery. Facial swelling - Some patients have a swelling of the face and eyes when they first wake up after surgery. This reduces quickly when they are nursed sitting upright. We would ask you not to rub your eyes when they are swollen, as this can cause accidental damage and pain. The recovery nurses will remind you about this. Sore throat - Occasionally people complain of a sore throat after surgery. This is due to the anaesthetic tube that helps you breathe during the operation, and will soon settle. Numbness - Very rarely patients suffer from numbness over the knee or in the fingers, but this settles completely in most patients. Scrotal bruising - It is not unusual to experience bruising across the lower abdomen and in the scrotum. The scrotum can occasionally become swollen and occasionally dark purple in colour. If the pain or swelling become more severe after discharge please contact your GP. Once back on the ward, you will be given clear fluids to drink and can start to eat as soon as you feel able to do so. You will be encouraged to sit out of bed in a chair as early as possible and begin gentle mobilisation as soon as possible. This will speed up your recovery. Ideally, we would expect you to be discharged home on the day after surgery. Typically the abdominal drain will be removed prior to discharge. Your catheter however will stay in place for 10-14 days to allow the new join between the bladder and urethra to heal. You will be taught how to look after your catheter prior to discharge. Please ensure that you have received an appointment to come back to the ward for catheter removal before leaving the ward. What should I expect when I get home? When you are discharged from the ward, you will need some comfortable, loose clothing as you may find that your abdomen is uncomfortable & swollen. You will also need someone at home with you for the first few days after you are discharged to help with daily tasks such as shopping and bathing etc. Your wounds are sealed with a surgical glue and do not need any special care or dressings. The glue will wear off over a period of 10 15 days. You may shower and bathe as normal. 7
It is important to stay active after your surgery as this minimises the risk of complications such as chest infection and deep vein thrombosis. A little gentle exercise each day is recommended walking is ideal. After 3-4 weeks gentle jogging and aerobic exercise is permitted, along with light lifting e.g. small bag of shopping. You can start to drive again when you are comfortable to do so (usually about 2 weeks after surgery) and when you feel able to make an emergency stop. You should, however, check with your insurance company before returning to driving. Please allow at least 2 weeks before returning to work. Everyone recovers at a different rate and some people may require longer but most people are able to return to work after 6 weeks. An appointment will be made to come back to the ward for catheter removal 10-14 days after surgery. When your catheter is removed you may experience some temporary loss of control over the passage of urine. This tends to settle within 3-6 months but, during this period, you may need to wear absorbent pads. To be prepared for your catheter removal and any potential temporary urine leakage, you should ensure that you have a supply of absorbent pads (e.g. those specially designed for male underwear) at home prior to attending the ward for catheter removal. Your continence advisor will order these for you. During this period you should also be performing regular pelvic floor exercises, as directed by your nurse and Continence Advisory Team. A description of how to do pelvic floor exercises is included at the back of this leaflet. When should I expect to receive a follow- up appointment? Your first appointment will usually be on the ward 10-14 days after surgery to remove the catheter. Following your operation, the histology results (microscopic examination of the removed prostate and surrounding tissue) will be reviewed by the Specialist Multi- Disciplinary Team (made up of surgeons, oncologists and specialist nurses) and an outpatient appointment will be made with your operating Consultant at 6-8 weeks to discuss the results. Your PSA will be checked at this appointment. Further appointments will be made in the nurse- led prostatectomy clinic at three monthly intervals for the first year, and six- monthly for the second year. You will need to have your PSA blood test checked at your GP surgery one week before your routine appointment in each case. At two years, provided there is no cause for concern, you will be discharged back to your GP for on- going monitoring. Please be assured that there are strict protocols in place for this to happen which will also be made available to you at the time of your discharge. 8
Pelvic Floor Exercises Pelvic floor muscles stretch below the bladder and the bowel, supporting the bladder and helping to control when you pass urine. These muscles can become weak following prostate surgery and can lead to urinary incontinence. Pelvic floor muscle exercises strengthen these muscles and are designed to give you more control over the passage of urine. Performing pelvic floor exercises prior to surgery and soon after a robotic prostatectomy has been shown to help men regain control of bladder function more quickly. You should therefore aim to start performing pelvic floor exercises at least two weeks before your surgery, then recommence after your catheter is removed following your operation. How to do the exercises Your continence advisor will check that you are performing pelvic floor exercises correctly; however following the steps below will help you. Finding the right muscles Your pelvic floor muscles stretch underneath your bladder and bowel. To find the right muscles you need to sit, stand or lie comfortably with the muscles of your thighs, buttocks and tummy relaxed. Tighten the ring of muscle around your back passage (anus) as if you are trying to control wind, and then relax it. Try not to squeeze your buttocks together or tighten your thighs or tummy muscles. Do not hold your breath. Now imagine you are passing urine, try to stop mid flow and then start again. There is no need to actually do this, but imagine that you are doing it. If you are tightening the right muscles, you should be able to feel a dip at the base of your penis and feel your scrotum move up slightly. It may help to do the exercises in front of a mirror so that you can see the base of your penis and your scrotum move. You can also check if you are using the correct muscles by placing your fingertips on the skin behind the scrotum. You will feel the muscles lift up away from your fingers when you are tightening the pelvic muscles correctly. The exercises Once you have found the correct muscles and you know what it feels like when you tense them you can do the following exercises. There are two sets of exercises. Do the slow exercises first. These exercises can be done in a lying, sitting or standing position. Slow pelvic floor muscle exercises Slowly tense the muscles as hard as you can so you feel a lifting sensation. Try to hold this lift for ten seconds, keep breathing normally. If you find that you cannot hold for ten seconds, hold for as long as possible and try to build up to ten seconds. Slowly relax the muscles and rest for ten seconds. Repeat the lift. You should aim to lift then relax up to ten times. 9
Fast pelvic floor exercises Repeat the same action as before but this time try tightening the muscles as quickly as possible. Hold the lift for one second and then let go. Try to do up to ten short fast lifts. Make sure that you are concentrating when you do these exercises; if you do not do them properly you will not feel the benefit. How often should I do the exercises? You should do a set of slow exercises followed by a set of fast exercises about three to six times each day. Try to make them part of your daily routine, it may be helpful for you to do them at regular times throughout the day. You should also practise doing the exercises when doing activities that may cause you to leak urine such as getting up from a chair, lifting or when you cough or sneeze, this may help prevent urine leaking. It may take three to six months before you begin to notice an improvement so it is important that you keep doing them. You will need to continue to do the exercises regularly to keep your pelvic floor muscles strong. What else can help? Reducing the amount of pressure on the pelvic floor muscles can also help. Try to maintain a healthy weight and level of fitness. Being overweight can put pressure on your pelvic floor muscles. Avoid constipation. Straining to go to the toilet will put extra pressure on your pelvic floor muscles. Eating a healthy diet that is high in fibre will help to avoid constipation. Coughing will make incontinence worse; if you smoke try to stop as it can cause coughing. If you develop a chest infection or worsening cough speak to your GP. Avoid heavy lifting. You will also have the contact details of your continence advisor for any additional support and information. 10
Who can I contact for more help or information? Urology Oncology Nurse Specialist Team Monday Friday (except bank holidays) 7am 5pm 0115 9691169 ext. 54082 Please note that you may need to leave a message on the answer phone. Messages are retrieved and answered twice daily. Harvey 2 Ward Out of hours 0115 9691169 ext. 55869 or 55872 Nottingham Continence Advisory Service Sherwood Rise Health Centre 29 Nottingham Road Sherwood Rise 0300 3003333 Please note that this number is only for patients within the Nottingham area. Patient Advocacy and Liaison Service (PALS) If you are concerned about any aspect of your care or have any comments and you would prefer to speak to someone outside of the Urology department please contact the Patient Advocacy and Liaison service. 0800 0521195 11