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   Chris Anderson
   P O Box 58534
   London
   SW13 9QQ

   Tel: 020 8735 6077
   Fax: 020 8741 0093

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  Robotic Prostatectomy

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  What is radical prostatectomy?

A Radical Prostatectomy is an operation to remove the prostate in men who have early stage prostate cancer. This operation is best suited to patients in whom the cancer is confined to the prostate prior to spreading outside it. The procedure may be performed as "open" or "laparoscopic" (keyhole technique).The latest innovation in the context of laparoscopic surgery is robotic assisted laparoscopic radical prostatectomy.

The prostate and seminal vesicles are removed to provide the best possible chance of removing the cancer. The urethra is then joined (sewn) onto the opening of the bladder.

Care is taken to preserve the nerves that control erections. These nerves are closely attached to the sides of the prostate and essentially have to be dissected free without leaving thin pieces of the prostate edge behind. If this occurs and there is cancer in the remaining tissue there is a chance of subsequent recurrence of the cancer. Therefore nerve sparing is not suitable for all cases and should be avoided in cancers that have an aggressive nature and also those cancers that are present in large volumes in the prostate. This information is known beforehand from the information gained from the trans rectal ultrasound and biopsy.

Care is also taken to achieve a good join between the bladder and urethra and in so doing ensure that the patient will be fully continent eventually .



  I have elected to have surgery: Are there any consequences?

Incontinence

After the surgery patients you will have a catheter in the bladder for a week. You will be taught to manage the catheter at home before its removal.

Most men have difficulty with urinary control initially after the catheter has been removed and will require a pad that fits inside the underwear. The degree of urinary control varies greatly but most men will have achieved reasonably good control within one to three months and require minimal protection, if any. Sometimes, the recovery of continence is slower, but rarely more than three to six months. About 2% have incontinence at one year and will require pads for protection.

The continence level can be improved by performing Pelvic Floor Exercises. Ideally you should learn these and start doing them before the operation to strengthen the pelvic floor muscles prior to surgery .These can then resume when the catheter comes out. There might be some ache /pain below the scrotum initially when doing these exercises: if so you should stop and recommence a day or two later. These exercises can be done for many months and certainly until full continence is achieved.

Erectile Dysfunction

Rehabilitation of erectile function is much like a sports injury. Proper conditioning and medical treatment promptly 6-8 weeks after surgery may potentially speed up recovery, but it is not guaranteed. If you see any fullness in your erections in the months after surgery, this is a positive sign that some of the nerves are working or re-growing.

It is important to remember that regaining erectile function takes time after prostate surgery. Nerve tissue, even when spared, takes time to recover from the inflammation and scarring that can occur after surgery. Factors affecting patient recovery include age (better recovery before the age of 65), how rigid the erection was prior to surgery, and whether one or both nerves are spared.

In order to improve your chances of reaching your desired outcome I recommend a three component rehabilitation program.

This programme consists of
  1. Preoperative counseling about expectations of sexual function after surgery. Where possible I encourage patients to have discussion with a colleague Lorraine Grover, a specialist in erectile dysfunction and psychosexual counseling (www.lorrainegrover.com)
  2. the use of Cialis( or Viagra/Levitra) and
  3. the use of the vacuum device(Osbon ErecAid® or Owen Mumford Rapport premier vacuum devices ).
This combined therapy has been specifically designed to take advantage of both active and passive rejuvenation of your erectile tissue.

The importance of preoperative counseling for the patient and spouse cannot be underestimated. Helping understand what to expect and how to cope with changes in your sex life equip you mentally and physically to deal with the mostly temporary constraints in your sexual welfare . You will be guided when to start medication and vacuum devices and also when to embark on sexual activity again.

The Cialis 20 mg (or Viagra/Levitra) should be taken three time a week 6 weeks post operation before bedtime. The reason for this is that during your sleep cycle your brain stimulates night time erections. Immediately after surgery it is unlikely that you will have rigid night time erections, however, taking cialis at night allows for improved blood flow to the penis during these stimulation periods.

The vacuum pump (manual or automatic) is used once a day.
This device has been proven to pump oxygenated blood into your erectile tissue and to prevent penile shrinkage that can occur after prostate cancer treatment. At your 6 week appointment full instructions on this programme will be given.

This improved blood flow has been shown to have some significant benefits to the recovery of your sexual function. Specifically, following this regimen for 6 months has been proven to reduce scarring in your erectile tissues and retain the smooth muscle necessary for erections to occur.

If you have an NHS GP, you are eligible to receive prescriptions for ED therapies at NHS expense. The regulations governing this are set out in Health Service Circular HSC1999/148, which can be found on the Department of Health's website. A written recommendation for this to your GP can be sent at your request.

Infertility

Patients will be infertile after the surgery for the reasons mentioned.

Men who wish to keep open the option of fathering children after surgery should consider storing frozen semen samples, collected before surgery. If you do not arrange to have semen samples stored before surgery, it might still be possible to collect sperm samples by needle aspiration from the testis after surgery, for use in an in vitro fertilization (IVF) procedure .

Stricture

After surgery there is a small risk of scar tissue in the urethra forming a band that is too tight to let urine pass freely from the bladder. This can even happen long after the operation.

If your flow starts to deteriorate at any time after the operation, you may need to have your urethra dilated; this is a simple procedure done in hospital. However, the robot-assisted procedure has led to a lower incidence of bladder neck stricture than open surgery and this complication is rare with this procedure.



  Preparing for your surgery

Anaesthetic - If possible, you should see your anaesthetist prior to your admission to hospital. He will help you to get as fit as possible and assess your suitability for undergoing general anaesthesia and surgery.

Tests - You will need blood tests, a urine culture and an ECG which is an electrical picture of your heartbeat.

Diet and Bowels - You will be asked to self-administer a dose of MILPAR, a mild laxative, on the evening before the operation. This is to help empty the lower bowel. It is important to keep your fluid intake high in the 24 hrs before surgery. You will not be allowed to eat 6 hours prior to your surgery. This is very important as during anaesthetic there is a risk of vomiting and the stomach contents can enter your lungs. You will, however, be encouraged to drink water up until two hours before the operation. You may also be given an intravenous drip overnight to ensure you are not dehydrated prior to surgery.

Medicines - Be sure to bring all medications that you are on with you to the hospital, including inhalers and sprays, in their labelled containers. Please ask which medicines you should take on the day of surgery as some need to be avoided. Let the surgeon or anaesthetist know if you are on Warfarin or Plavix, as these may need to be stopped in the days leading up to the surgery.

What to bring with you - Loose-fitting and comfortable pants/pyjamas with an elasticized waistband are recommended for after surgery. These will be helpful if your abdomen is bloated and button pants may not fit well. Leave non-essential valuables at home. If you wear contact lenses, glasses or dentures, bring a case so these can be stored during surgery.

Consent - Prior to your surgery you will need to sign a Consent Form. This gives the surgeon permission to operate on you. Before you sign this, please ensure that you fully understand the procedure you are about to undergo. If you do have any questions or concerns, please ask your consulting team to clarify them for you.

Preparation - After a shower, you will be given a surgical gown to wear and anti-thrombus compression stockings will be fitted. These can come off to shower during your hospital stay but must remain on at other times to reduce the risk of blood clots forming in the legs. They are removed when you are ready to be discharged from hospital. You need to be ready one hour prior to theatre.

When you are due to go to theatre, the nurses will complete a theatre checklist and escort you to the theatre. You will enter the theatre anaesthetic room where you will be once again check-listed by the theatre staff and anaesthetist. They will put a drip in your arm or neck to allow them intravenous access during the operation.

You will be anaesthetised and taken through to the operating theatre; you will not know that the operation is taking place.



  What can I expect after surgery?

You will be taken to Recovery after your operation. There are good systems in place to prevent you feeling any pain after the operation, though it is possible that you may have some pain. Please let your carers know so they can keep you comfortable. Do not hesitate to use your bell to alert your nurse if you have any concerns.

You will have a catheter in your bladder draining into a bag, and the amount of urine you pass will be measured over the first night to make sure you have adequate fluids. The urine is often blood-stained. Over the stay, the urine will clear to yellow but you may have some blood in the urine intermittently for weeks after the operation. The catheter stays in until the join between the bladder and urethra heals, usually around 7 days, and is worn with a slim bag, out of sight, strapped to your leg under your clothing. You will be taught how to look after the catheter before you go home.

You will have a wound drain that exits from the abdomen and this usually stays in for one or two days after the surgery. This prevents build-up of pressure from any wound ooze and avoids the body having to reabsorb excess fluids.

You will receive intravenous fluids until you are drinking adequately, usually the next day. You will also receive antibiotics through the drip to prevent any infection.

You will be able to go home once you are mobilising safely, you are able to care for your catheter, your bowels are functioning and your pain is well controlled on appropriate tablets taken by mouth.



  What can I expect after getting home?

You should not forget that although you may feel comfortable and have no large wounds, you have still had major surgery. You will need a period of time to recover before returning to normal activities. You should be active about your home and build up returning to your usual tasks. No cycling, motorcycling or horse riding for 4 weeks.

You can shower as you usually would. There will be dressings on your wounds that can get wet. If this happens, remove the dressings and dry with a towel to prevent moisture sitting on the wounds. Once your dressings are removed, it is not uncommon to have a small amount of drainage from a wound site. You can use a large plaster to cover these and change daily after showering as necessary. Any stitches or clips will be removed and your wounds will be checked when your catheter comes out.

Resume your medications as soon as you are discharged from the hospital. If a course of antibiotics is prescribed, please complete the course, even if you are feeling well.



  Things you may encounter after surgery

Bruising around the incision sites and abdomen - not uncommon and should not alarm you. This will resolve over time.

Leakage or ooze at a wound site or drain site - change dressings daily or as necessary if oozing. Wash the wound in the shower to clean, and dry with clean pad or towel before applying clean dressing.

Abdominal bloating or constipation - make sure you use your stool softener (Milpar) as directed. Any bloating should settle quickly after your bowels start returning to normal function. Your bowels may be loose initially when they first start to work after the operation. Increasing the fibre and water intake in your diet should help to keep stools soft.

Shoulder pain - this occurs as a result of the distention of the abdomen caused by the gases used during the operation.

Weight gain - this is temporary and due to shifts in gas and fluid. Your weight should be back to your pre-operative weight in approximately 5 - 7 days.

Scrotal and penile swelling and bruising - this may appear immediately after surgery or after 4 - 5 days. Any scrotal swelling will resolve in 7 -14 days. You can reduce the swelling if it occurs by elevating the scrotum on a small towel that you have rolled up when you are sitting or lying. It is recommended that you wear supportive underwear such as Jockeys, even with the catheter in place.

Bloody drainage around the catheter or in the urine - especially after increasing activity or following a bowel movement, this is not uncommon. Resting for a short period usually improves the colour of the urine. Sometimes there can be intermittent bleeding in the urine even after the catheter is removed. This should be pale red and fairly clear. If you have any concerns, ask your consulting team. Drink more fluids if there is blood in the urine to help keep it dilute.

Leaking around the catheter - this is fairly common, especially on straining. If this happens, you may need to wear a small pad inside your underwear for protection.

Bladder spasms - these present as mild to severe pain or cramping, the sudden need to urinate or a burning sensation when you urinate, caused by sudden, strong bladder contractions. These are infrequent but can be caused by irritation from the catheter against the bladder wall. Let your consulting team know if you have these troubles as mostly these can be relieved with tablets.

Perineal pain - pain between your scrotum and your rectum or in your testicles may last for several weeks after surgery, but it will resolve. Simple pain medications such as Paracetamol or Ibuprofen should relieve the discomfort. Please contact your consulting team if the pain medication does not alleviate this.

Lower leg or ankle swelling - this can occur in both legs and should resolve in around 7 - 14 days. Elevating your legs while sitting will help. If swelling in the legs is uneven and associated with redness or pain, please contact your consulting team quickly as this can be a symptom of a blood clot in the leg.



  Catheter home care instruction

The catheter is held in place by a balloon inside your bladder and allows continuous drainage of your urine into a collection bag. This prevents leakage of urine through the new join that has been created between your bladder and urethra.

During the day - you will use the smaller leg bag that is strapped to your thigh. It lets you move around more easily but it must be emptied every 3 hours or when needed as it gets full. This stays on the whole time your catheter is in. It should be fixed in place with a strap around the upper thigh to prevent it pulling down on the bladder and penis.

During the night - you will be shown how to connect the larger, 2 litre bag onto the end of the day bag. This does not need to be emptied as often and should last through the night when a lot of urine is produced. When you get into bed, be sure that the leg bag tap is ON and the night bag tap is OFF. You will need to arrange the tubing so it does not pull on the leg bag or kink.

To empty the collection bags - wash your hands first. You will be shown how to work the tap on the bag before you leave hospital. To disconnect the overnight bag, turn the leg bag tap to OFF, pull the night bag off the end of the leg bag and empty into toilet. Wash hands.

To care for your overnight collection bag - rinse through with warm, soapy (not hot) water. Leaving the drainage spout open, hang the collection bag to air-dry.

To change your collection bag - this is only required if you have your catheter in for longer than usual. Ask if you are not sure. Wash your hands. Prepare the new bag ready to be connected but without the tip of the bag tube touching anything. Empty the collection bag. Carefully, without pulling on the catheter, disconnect the catheter end from the bag drainage tube. Connect new bag to catheter. DO NOT TOUCH THE OPEN END OF THE CATHETER OR NEW DRAINAGE TUBE TIP. Hold the tube at the base of where it would connect to the catheter to push it firmly into place. Wash hands.

To help prevent infection or discomfort -
  • always wash your hands before and after emptying your catheter
  • wash the area around the catheter at the tip of the penis at least twice a day. Debris and mucous will collect there. Use soapy water
  • keep the bag attached to the catheter at all times, even when showering keep your catheter strapped to your thigh for comfort; this prevents it pulling in the bladder
  • keep the drainage bags free of kinks and loops
  • always keep the drainage bag below the level of the bladder
  • drink at least 8 glasses or water a day to keep urine a clear, pale yellow colour
  • occasionally when the bag is emptied, an airlock may form. This is caused by all the air emptying out of the drainage system and can cause urine to stop draining, but is easily fixed. If the sides of the bag look sucked hard together and no urine has drained, just allow a small amount of air back into the system after emptying your bag by pulling the front and back of the bag slightly apart while the tap is open.




  Commonly asked questions

How much pain will I be in?
Since the surgery is done through small incisions, most patients experience much less pain than with open surgery. They tend to need much less pain medication. After one week, most are feeling no pain at all.

When can I exercise?
Light walking is encouraged right after the procedure. After just 2 weeks, jogging and aerobic exercise is permitted. After 4 weeks, heavy lifting can resume.

Can I shower or bathe?
Yes, the stitches in your wounds are dissolvable; we just ask that you rinse the soap thoroughly from your body as this may irritate sensitive skin. Also, pat yourself completely dry and dry into the belly button to minimize infection risk.

When can I drive?
When you are comfortable to do so, and you can twist to look behind you as necessary and make an emergency stop. Remember the seatbelt may pull tightly across your stomach if you do. Please also check with your insurance company before returning to drive.

When can I return to work?
Please allow a couple of weeks' recuperation before returning to work. If your work entails heavy lifting, please speak to your consultant prior to leaving hospital.



  Follow-up appointments

Trial without Catheter (TWOC) - You need to attend the London Clinic( or other arranged venue) about a week after your operation, to have your catheter removed. This can be uncomfortable but is generally well tolerated. Please bring supportive underwear with you as it will need to hold a pad in place once your catheter is removed. Allow around four hours for this visit as we like to gauge how well your bladder is emptying. It helps if you can drink 1 - 2 litres over the morning. Blood tests, a urine culture and flow tests with residual ultrasound might also be done.

One month after TWOC and every three months after that for the first year, (then six-monthly for the second year, and annually thereafter) you will continue your follow-up at Chris Anderson's rooms. You will need to get a PSA level taken prior to each appointment. A full assessment of your status will take place at each visit.



  Pelvic floor muscles exercises to improve continence

The pelvic floor is a strong sling or hammock of muscles that help to support the bladder and the bowel. The muscles stretch across the inside of the pelvis and are attached to the pubic bone at the front and the coccyx (tail bone) at the back. It has two openings:-
  1. for the urethra, the small tube that carries urine from the bladder
  2. for the bowel.
These muscles naturally relax when you pass urine, to let the flow of urine through, then tighten again at the end of the flow to prevent leakage. When these muscles are weak, urinary leakage may result. However, you can exercise them to make them stronger and help regain your bladder control.

How to do the exercises

To achieve best results when performing these exercises, imagine yourself as an athlete in training. You need to build strength and endurance of your muscles. THIS REQUIRES REGULAR EXERCISE.

It is recommended that you start doing pelvic floor muscle exercises up to 8 weeks prior to surgery. When you first start doing the exercises, find somewhere quiet and take time to concentrate so that you can locate the correct muscles.

Sit comfortably on a chair with your knees apart and your feet flat on the floor. Lean forward and rest your forearms on your thighs.
  1. Begin by drawing up in the back passage as if you are trying to stop yourself passing wind. Hold on to this while you
  2. Draw up around the front passage as if you are trying to stop yourself passing urine.
  3. Try holding while you count to 2 initially, gradually increasing to count to 10, as your muscles become stronger.
  4. Relax the pelvic floor then repeat for 5 sets, 3 or 4 times a day.

Remember:
- keep breathing normally
- do not push or bear down as if you were trying to pass wind
- try not to tighten your stomach, buttock or thigh muscles
- do not pull your knees together

Tip - As you begin urinating, try to stop or slow the flow of urine without tensing the muscles in your legs, abdomen or buttocks. This is very important. Using other muscles will defeat the purpose of the exercise. When you are able to slow or stop the flow of urine, you know that you have located the correct muscles. Feel the sensation of the muscles pulling inward and upward. Only do this to locate the muscle group, not as a regular occurrence.



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