Robotic Assisted Radical Prostatectomy (RARP)
Robotic assisted radical prostatectomy is a procedure involving surgical removal of the prostate and seminal vesicles. It is one of the treatment options for men diagnosed with prostate cancer. This is Dr Threadgate’s preferred surgical approach when patients elect surgical treatment for prostate cancer.
The procedure is done in hospital under a general anaesthetic. It takes two to four hours and patients stay in hospital for one to two nights. A catheter is placed in the bladder during the procedure and stays in for a minimum of one week. Patient are taught how to look after their catheter during their stay in hospital.
The diagnosis of prostate cancer can often come as a shock to men and their families. There are often many questions that come to mind about the disease itself and the various treatment available. Dr Threadgate encourages all his patients to take time to consider their treatment options and often refers to other specialists (radiation oncologists in particular) for further review and opinions. Men should not rush treatment decisions but take their time and choose the treatment that is best for them.
If the decision is to proceed with a robotic assisted radical prostatectomy then preparations and planning commence straight away. A date for surgery will be selected and the necessary pre-operative blood, urine and heart tests organised. Referral will be made to a dedicated pelvic floor physiotherapist who will see patients before and after their procedures for support and assistance in regaining bladder control. If a nerve sparing procedure is planned then treatment aimed at improving erectile function is started pre-operatively.
A booking form is completed for the appropriate hospital and patients should expect a call from the hospital pre-admission clinic pre-operatively. The hospital will provide the patient with fasting and admission times. The hospital may also give advice regarding nearby accommodation should family members wish to stay closer during the admission.
A written estimate of Dr Threadgate’s (and the surgical assistants) fee are provided ahead of surgery. Patients should contact the anaesthetist, pathology provider (Douglas Hanly Moir) and their private health fund to obtain an estimate of their fees.
A small incision is made near the umbilicus and a telescope inserted in to the abdominal cavity. Carbon dioxide gas is pumped in to the abdominal cavity to create space to work in. An additional five small incisions are made in order to insert three robotic instruments and two instruments for use by the bed side surgical assistant.
The da Vinci robot is then positioned between the legs and the instruments inserted. Dr Threadgate then leaves to sterile field and moves to the da Vinci control console where he controls all movements of the robotic instruments.
The procedural steps can be summarised as:
- The prostate is released from its attachments to the pelvic floor muscles
- The bladder is freed from the base of the prostate
- The vas deferens are cut close to their entry in to the prostate
- The seminal vesicles are freed
- The rectum is moved away from the prostate
- The nerve bundles are moved away from the prostate (if nerve sparing is intended)
- The arteries and veins to the prostate are ligated
- The urethra is divided as close to the prostate apex as possible
- The prostate along with the seminal vesicles are placed in a bag for removal
- The bladder is anastomosed (re-attached) to the urethra over a urethral catheter
- The pelvic lymph nodes are excised (if a lymph node dissection is intended)
- A drain is inserted through one of the small incisions and placed near the join between bladder and urethra. An additional drain is inserted if a lymph node dissections was undertaken
- The prostate, seminal vesicles and lymph nodes are removed via the umbilical incision
- The incisions are closed and local anaesthetic infiltrated
Post operative hospital stay
Patients wake up in recovery shortly after the procedure. When their condition is stable and pain under control they are transferred to the ward (normally 90 minutes). On the ward most patients will have a patient controlled analgesia (PCA) device, this allows the patient to press a button and have pain relief delivered via an intravenous drip when required. The PCA is usually not required the following morning and tablet pain relief used instead.
Whilst in bed patients are encouraged to complete breathing exercises and move their feet and legs. Compression stocking and or calf compression devices as well as blood thinning injections are used to reduce the risk of deep vein thrombosis (DVT). Early mobilisation is encouraged with patients sitting up out of bed on the evening of the procedure and walking around the ward the following morning.
Intake of fluids and light food is allowed after the procedure. Medication may be given to assist with nausea and constipation.
Patients and family carers are taught how to look after the urethral catheter the morning after the procedure. It is imperative that no one removes the catheter until Dr Threadgate himself authorises it.
Wound dressing stay on for three days. Dissolving sutures are used and do not require removal.
Recovery at home
Patients should avoid heavy lifting (more than 5kg) or vigorous activity for four weeks following their procedure. Activities should resume gradually and if exertion causes pain then rest and retry in a day or two. Normal bowel function will take a few weeks to return, laxatives, fibre and adequate hydration will assist during this time.
Even though the incisions are small it can take time for patients to return to full activities. Help at home and time off work for four weeks after this procedure is recommended. Dr Threadgate recommends no driving for at least two weeks and only return to driving if the patient is certain they can operate the vehicle in all situations.
Men will be seen one week post operatively for urinary catheter removal. It is imperative that no one removes the catheter until Dr Threadgate’s himself authorises it. Urinary leakage will occur once the urinary catheter is removed. It is important to commence pelvic floor exercises (as taught by the physiotherapist) once the catheter is removed. A small supply of male incontinence pads should be purchased ahead of time. The time taken to return to full urinary control is variable and ongoing reviews with the pelvic floor physiotherapist are essential.
Erection function takes time to improve and in almost all cases requires the addition of oral and or injectable medications. Dr Threadgate will discuss this pre-operatively and at each post operative visit.
Post operative appointments
The following is a summary of the usual post op appointments:
- One week urinary catheter removal
- Two weeks review with Dr Threadgate for histopathology results and wound check
- Two weeks review with pelvic floor physiotherapist
- Six weeks review with Dr Threadgate for post operative PSA blood test and assessment of bladder control and erectile function
- Six weeks review with pelvic floor physiotherapist (then as required from here)
- Twelve weeks review with Dr Threadgate with PSA blood test and assessment of bladder control and erectile function (then three monthly reviews until 12 months post op)
- After 12 months ongoing appointments six to twelve monthly as directed