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Robotic radical prostatectomy (for cancer)

Dr Pokorny trained under Prof Alex Mottrie, a world-renowned robotic surgeon, to learn the operation of robot-assisted radical prostatectomy, in 2014 in Belgium. This technically challenging procedure, which until the mid-2000's was commonly performed via open surgery, has been revolutionized by the use of the Da Vinci® robot.

The goals of this surgery are as follows, in order of importance:

  1. Removal of the prostate gland and cancer therein
  2. Preserving the continence mechanism of the bladder and sphincter (i.e.. preventing men leaking afterwards)
  3. Preserving sexual function

By the late 2000's and early 2010's, robot assisted radical prostatectomy had replaced open surgery in most western countries. The reasons for this were obvious to surgeons - significantly improved vision while operating (with 10x magnification in HD as standard now) much better dexterity and tissue handling using the fine and versatile robotic instruments, less blood loss and faster postoperative recovery for patients. In addition, the surgeon has much greater precision when performing dissection and preservation of the delicate nerves for erectile function and the urethral sphincter for continence.

This procedure of robot-assisted radical prostatectomy (RARP) is a +/- 3 hour long operation to remove the prostate and join the bladder to the urethra (see Figure 1). The water pipe (urethra) runs from exit of the bladder, through the prostate and then into the penile urethra. In removing the prostate the continuity for urination is restored by performing a join between the tip of the bladder and the urethra. The surgery is keyhole surgery using 5 small incisions in the mid abdomen, with the largest typically about 4-5cm wide above the belly button, and the other 4 being 10mm incisions, two on either side (See Figure 2). The prostate is removed at the end through the larger incision above the belly button. Recovery is usually rapid, with a 2-night stay in hospital and normal diet the following day.

Dr Pokorny's patients often have the catheter removed on the second day after surgery (normally this is done at 7-14 days), owing to the specific techniques he learnt under Prof Mottrie. This allows patients to go home without a catheter and the inconvenience involved. A picture of the bladder (cystogram) is done on the second day after surgery to check there is no leak, and if clear, the catheter is removed.

All patients experience some urine leakage after surgery, this is completely normal, and our Prostate Cancer Nurse Specialists counsel all patients pre- and postoperatively about this and educate patients on supplies etc. Patients typically have to wear a pad in the underwear from 2 to 12 weeks postoperatively until there is no further leakage. A small number of patients may take longer to achieve complete continence, depending on age and other factors.

Recovery of erectile function is dependent on pre-existing erectile function, age, other illnesses, and how much of the nerves for erection on each side of the prostate were preserved during the surgery. Usually at least one nerve on one side can be fully preserved, depending on the size and location of the prostate cancer. This is fully discussed with all patients before surgery.

Patients are usually fully mobile and independent by the time of leaving hospital, but are asked to avoid heavy lifting or strenuous exercise for 6 weeks, and to avoid driving for 1-2 weeks postoperatively. Patients are sent home on a low dose of a blood thinning injection, Clexane, which is administered by the patient himself once a day. This is used to prevent blood clots in the legs (DVT), a particular risk after cancer surgery. Patients are educated on how to perform self-injection during their hospital stay.

The first follow-up visit is usually scheduled at 6 weeks postoperatively, with a PSA test repeated just prior. Patients are then seen every 3 months for the first 2 years, with a PSA test at each visit.