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Prostate Cancer

Robot-assisted laparoscopic radical prostatectomy

Robot-assisted laparoscopic radical prostatectomy is a modern technique for treating localised prostate cancer. Few centres in the UK offer this procedure but many are training to do so. 

Laparoscopic surgery; also known as keyhole surgery, uses instruments inserted through narrow hollow tubes ('ports') rather than through a larger incision, as in traditional surgery. This type of surgery has the potential for shorter hospitalisation and convalescence, less bleeding and post-operative pain, and fewer wound complications, but randomised trials are still needed to assess outcomes.

The first robotic-assisted radical prostatectomy was performed in 2000. In 2007 we talked to a 48-year-old man, Mike, three months after he had had this treatment in the National Health Service and in 2010 we talked to another man, John, a year after he had this type of surgery.

 

Explains that the robotic device helps to eliminate the surgeon's hand tremor and allows great...

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Age at interview: 48
Sex: Male
Age at diagnosis: 48
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It's a robot-assisted laparoscopic radical prostatectomy. The robot-assisted part of that title is a bit of a misnomer because it does not involve a true robot in the sense of a machine that has volition and programming of its own. It's a so-called master/slave system. So if you can picture it, essentially what it entails is a surgeon sitting at a computer console a little like a very expensive child's computer game console but worth a few more million quid than an average child's game. Other assisting surgeons will make small incisions, in total 6, sorry 5 incisions are involved for a variety of ports to be inserted with implements or in effect binoculars attached to them. 

Those ports are manually inserted by the assisting surgeons and once inserted, the principal surgeon takes over. The principal surgeon is in the operating theatre although in theory given the wonders of modern technology the surgeon could be on a different land mass or a different continent operating on somebody. But in practice of course the surgeon is in the same operating theatre and what he or she would be looking at is a 3-D image on screen of what the robot ports inside the patient's abdomen are seeing. 

And the surgeon is able to manipulate the various robotic ports that have been inserted into the patient and is able to do so having scaled up or down his or her movement relative to the robot's movements. So in effect put, put simply you can task the robot to say let every two millimetres of my hand's movement equal 0.2 mm of the robotic arm's movement so that you can thus get extreme precision of movement guided by a 3-D image that the surgeon is seeing on screen. What the robotic device will also do is eliminate any manual tremor that might otherwise be there for a surgeon. And this of course is part of why I was drawn to this procedure in the first place. If you're tinkering around crucial nerve bundles that are responsible for amongst other things, erectile function, I was very drawn to the idea of great precision of movement with no tremor. So essentially it's a master/slave robot system, manually assisted insertion of the robotic ports and then the principal surgeon takes over on the computer console.

Between 2005 and 2006 Mike had had some urinary symptoms, had a raised PSA (about 12 ng per ml.), was referred to a consultant and had a prostate biopsy. During the biopsy and other investigations his privacy and dignity were not always respected (see 'Biopsy for prostate cancer').

Having been given the diagnosis of prostate cancer he found out about different treatment options and decided which would suit him best.  After having urinary symptoms for some time John was also diagnosed with prostate cancer. He explained why he decided to have a robot assisted laparoscopic radical prostatectomy and not brachytherapy or any other type of treatment.

 

Explains that the robotic device helps to eliminate the surgeon's hand tremor and allows great...

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Age at interview: 48
Sex: Male
Age at diagnosis: 48
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It's a robot-assisted laparoscopic radical prostatectomy. The robot-assisted part of that title is a bit of a misnomer because it does not involve a true robot in the sense of a machine that has volition and programming of its own. It's a so-called master/slave system. So if you can picture it, essentially what it entails is a surgeon sitting at a computer console a little like a very expensive child's computer game console but worth a few more million quid than an average child's game. Other assisting surgeons will make small incisions, in total 6, sorry 5 incisions are involved for a variety of ports to be inserted with implements or in effect binoculars attached to them. 

Those ports are manually inserted by the assisting surgeons and once inserted, the principal surgeon takes over. The principal surgeon is in the operating theatre although in theory given the wonders of modern technology the surgeon could be on a different land mass or a different continent operating on somebody. But in practice of course the surgeon is in the same operating theatre and what he or she would be looking at is a 3-D image on screen of what the robot ports inside the patient's abdomen are seeing. 

And the surgeon is able to manipulate the various robotic ports that have been inserted into the patient and is able to do so having scaled up or down his or her movement relative to the robot's movements. So in effect put, put simply you can task the robot to say let every two millimetres of my hand's movement equal 0.2 mm of the robotic arm's movement so that you can thus get extreme precision of movement guided by a 3-D image that the surgeon is seeing on screen. What the robotic device will also do is eliminate any manual tremor that might otherwise be there for a surgeon. And this of course is part of why I was drawn to this procedure in the first place. If you're tinkering around crucial nerve bundles that are responsible for amongst other things, erectile function, I was very drawn to the idea of great precision of movement with no tremor. So essentially it's a master/slave robot system, manually assisted insertion of the robotic ports and then the principal surgeon takes over on the computer console.

 

John recalls what it was like to have a trans-perineal biopsy and why he decided to have a robot...

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Age at interview: 57
Sex: Male
Age at diagnosis: 54
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At the new hospital, the biopsy was a trans-perineal, I think it’s called, biopsy, which takes twenty four samples instead of twelve, and it was quite a painful experience, and there was a lot of blood and the outcome of it was that it revealed what the first biopsy hadn’t revealed, which was that the cancer was right in the centre of the prostate and it was fairly advanced, so as a result I was told that brachytherapy would have been the very worst possible treatment for me because it wouldn’t have been possible to have surgery after the brachytherapy, because of the amount of scar tissue created by the brachytherapy, so there was only one option which was a prostatectomy. The hospital I was at now, it was able to offer robotic laparoscopic prostatectomy, so I was, referred for an operation and so it had been quite a long process from seeing the GP at the, where I was originally living in August 2008 to being operated on in April 2009.

 

Mike and John both talked about pre-operative care, their operations, post-operative recovery and the side effects of surgery.

 

The pre-operative assessment took place two weeks before the operation.

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Age at interview: 48
Sex: Male
Age at diagnosis: 48
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I was sent for a pre-operative assessment in late March so just a couple of weeks before admission for height, weight, blood pressure, assorted blood work and other analysis to be done to make sure that there was nothing that would stand as an obstacle to my admission for surgery. That was all fine, so the admission went ahead.

I was admitted on the Thursday the 12th of April 2007, the day before surgery. I was, I underwent surgery then on the rather inauspicious date of Friday the 13th of April but of course I don't believe in superstition because I think it brings you bad luck. 

Mike was in hospital for three days. On the first day he had more investigations and was seen by various doctors, including the anaesthetist, and by a specialist urology nurse. He had prepared for the procedure by doing pelvic floor exercises for 2-3 weeks pre-operatively.

 
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The specialist urology nurse made sure Mike knew how to do pelvic floor exercised correctly.

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Age at interview: 48
Sex: Male
Age at diagnosis: 48
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My hospital stay was a 3-day stay. So there was a pre-operative day, an operative day and one post-operative day and then I was discharged on that first post-operative day. So the day after surgery I was discharged.

In terms of the process the pre-operative day I guess was relatively standard for any surgical procedure. It was about being clerked in, having assorted bloods and other investigations done, signing various pieces of paper, being visited by your anaesthetist, being visited by the surgeon, being visited by assorted other doctors and nurses. So, for example, I was seen by the specialist urology nurse. I was seen by the specialist continence nurse to make sure that I had an accurate grasp of how to do pelvic floor exercises correctly and appropriately and at the appropriate frequency and so on. So that first pre-operative day was just a blur of a steady succession of people wanting me to sign things or wanting to tell me things or wanting to investigate or analyse or stick needles in me or whatever. And it was all perfectly straightforward other than the usual doldrums of hospital food. 

 
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The operation went smoothly and Mike had no pain when he woke up from the anaesthetic.

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Age at interview: 48
Sex: Male
Age at diagnosis: 48
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On the operative day I was starved from the preceding midnight or nil-by-mouth from midnight. I was taken down to theatre at about 10'00, 10'30 in the morning. I was not given a premed. I didn't need a pre-med. I believe premeds are still used for patients who are more agitated or anxious about their surgical process but I was fairly relaxed about it so I went down unpremedicated to theatre. Spent a short time in the anaesthetic room where all the documentation was checked. My identity was checked. All that was fine. A venflon [plastic tube] was put in my hand, I think only on one side and I was put to sleep so to speak. 

And the next thing I knew I was waking up in recovery. I'm told that on waking up and I can't imagine why this would have happened because it seems quite out of character for me but I'm told that on waking up my first words were that I wanted a chicken chow mein and a bottle of Budweiser [laugh] which I wouldn't normally want as soon as I'd woken up but there we are that's patients recovering from anaesthesia for you. I do have a recollection that in the recovery room after surgery I was entirely pain free, probably still slightly euphoric hence the chicken chow mein and Budweiser reference but I was entirely pain free and I felt lucid whether or not I was lucid I think is very doubtful but I felt lucid. 

I do have a recollection of seeing other patients also in the recovery room. Some who were fully screened but one of whom, a rather large West Indian lady was not adequately screened and some quite intimate things were being done which frankly I ought not to have seen. So there's that privacy and dignity thing I still think probably doesn't feature as prominently in the mindset of some clinicians as it ought in hospital.

Anyway the recovery from anaesthesia was uneventful and relatively swift. I was taken up to the ward at about 3'00 in the afternoon. So left the ward at 10'30. I was back on the ward at about 3'00 in the afternoon where I spent a couple of hours asleep and then was quite awake and alert by about 6'00 pm, slightly nauseous but no more than I would expect after surgery. I treated food and fluid with extreme caution on that first day. I started out with small sips of fluid gradually escalating to a cup of tea. I don't think I actually ate anything on that first day. I could have done. There was no reason from the nurses' or doctors' point of view why I shouldn't have done but I've had an anaesthetic once before in my life and recall eating a little too swiftly after anaesthesia and regretting it almost immediately as did the cleaners.

A catheter was inserted during the operation, and a drain attached to a tube on one side of the abdomen. On the first post-operative day Mike got out of bed unaided and could go home that afternoon.

 
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Mike got out of bed the next day and went home with a supply of two different types of catheter bag.

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Age at interview: 48
Sex: Male
Age at diagnosis: 48
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On the first post-operative day I got out of bed unaided because I didn't need help. I'd been encouraged to get out of bed. Initially just sat in a chair beside the bed feeling mildly sorry for myself because by that time I was getting some discomfort, more related to movement. It was still the case that at rest I was completely comfortable but when I moved there was, there was pain but I had six small incision sites including the drains so pain was no great surprise.

I was discharged from hospital with a small supply of two different types of catheter bag, one being a day bag which is strapped to the leg with a sort of elasticated Velcro strap and it has a capacity of I think 750 ml or thereabouts. And that has a little valve at the bottom to allow you to drain the bag in a toilet whenever you need to. And I was also equipped with night time bags which have a capacity of I think about a litre and a half or two litres. So unless you have an excessive fluid consumption in the hour or two before you go to bed that's more than adequate for an average night time. 

What I was not equipped with and I don't even know whether such things exist was any kind of a catheter bag stand or rack or something to actually put the thing on. They had these things on the ward, little racks that they can then hang on a chair or on the side of a hospital bed but I wasn't equipped with anything like that to go home with. So I needed to rig up a sort of a Heath-Robinson arrangement at home particularly at night time of course with a night time bag to make sure that the basic hydrodynamics of things were properly managed because you can't expect water to flow uphill as it were. So you need to arrange things. And it took me a couple of nights to get the hydrodynamics right with that. 

 
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Mike recovered quickly and was able to go outside for a short walk two days after returning home....

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Age at interview: 48
Sex: Male
Age at diagnosis: 48
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I confined myself to my own home and garden for the first two days at home, simply because movement was uncomfortable and also because maybe this is a male psychology thing but even though I knew nobody could see the catheter bag when I was out walking around outside of my own home just getting used to the idea of having a catheter bag strapped to my leg when I'm walking past neighbouring houses. It took me two days to get to that point where I was willing to take the plunge and take a stroll. But from Day 3 really onwards I walked further and further and probably by Day 5 I was walking maybe a mile a day pretty slowly but nevertheless a mile a day. And the only reason it wasn't more was that I would need to get back to drain the catheter bag. Sometimes you can take advantage of a handy tree somewhere but it's actually not that quick a procedure to drain a catheter bag. 

And do you want to say anything else about recovery?

In the first couple of weeks I was still taking quite powerful antibiotics. Doubtless they were doing their job from an antibacterial point of view but they had a powerful gastro-intestinal affect. I was eating and drinking normally but very definite signs of intestinal hurry that left me actually feeling a little bit debilitated and uncomfortable.

So diarrhoea sometimes?

Just so, yes. Compounded by the fact that the surgeon had been quite insistent that whether I thought I needed it or not I should persist with taking lactulose. So there was I taking powerful antibiotics and having some relatively acute diarrhoea also taking lactulose. Anyway it lasted for about 10 days and then subsided pretty quickly and it was bearable. It was an inconvenience at worst no more.

 

The operation went well but John thought that the hospital environment and organisation was ...

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Age at interview: 57
Sex: Male
Age at diagnosis: 54
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The operation was a great success, it was, I thought the surgeon was fantastic, everything was really great, my PSA since then has been, undetectable, the hospital treatment wasn’t great, the ward was, chaotic, it was very difficult to tell who was what, the cleaners wore the same uniform as the surgeons, but you know, you’re there to be treated and you go through it and it was just great to know that it was out of my system, it was a really good feeling,

 

 

 

 

John had a catheter for about 10 days after his surgery. Once that was removed he progressed...

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Age at interview: 57
Sex: Male
Age at diagnosis: 54
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Post operation I had a catheter for about ten days, again that was a little bit chaotically organised, I know other people who’ve been through the same experience and they’ve come home with pads, and catheters and a stand to put the catheter on at night, and I had none of that, and nobody really seemed that bothered about helping out, so I had to kind of sort it out for myself, the catheter I hated, it was very uncomfortable, very difficult walking around, I was able to walk, reasonably, the day after I got home, I went out for a short walk, walking very very slowly, quite unsteady, but things improved fairly rapidly and once the catheter was removed then I progressed fairly quickly.

 

 

 

“Some men have problems with urinary incontinence. This can range from leaking small drips of urine, to leaking larger amounts. However, for most men, this usually clears up within three to six months of the operation. About two in every 10 men have long-term problems requiring the use of pads.” (NHS Choices 2016).​ Mike had his catheter removed after 10 days. He stayed one night in hospital after the catheter had been removed and was pleased to find that he was not incontinent. He was glad that he had done the pelvic floor exercises before his operation. 

 
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Mike was delighted to find that he was not incontinent after the catheter had been removed. He...

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Age at interview: 48
Sex: Male
Age at diagnosis: 48
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They elected to keep me in or rather they invited me to stay in for one night after catheter removal so that I could have in the safe surroundings of the hospital the experience of going through a full night without a catheter and with bladder filling up overnight so to speak. And then they particularly wanted to check that I could void, empty my bladder properly in the morning. So that was fine. One extra night in hospital, pleasant enough. No big deal. The following morning up bright and early, quite mobile and to my great surprise my first post-catheter removal night had been an entirely dry night. I'd not been led to expect that. I'd been led to expect the near certainty of torrential urinary incontinence for quite some time after catheter removal or after surgery more generally. But my first post-catheter night was a dry night and indeed every night since with only two slight exceptions have been also dry. So I was discharged the following morning after I had demonstrated that I could void my bladder ok and that I was pain free and comfortable. Back home and I've just gone from strength to strength ever since.

And how many weeks did you say you were off work?

I was off work in total for four weeks. So that was 10 days during which I had the catheter and then roughly three weeks after that point. I, I could probably have resumed work earlier than that. Indeed to a degree I did resume work earlier than that because I dabbled at E-mails and odd bits and pieces from home.

Men who suffer from incontinence have various options, including special pelvic floor exercises, pads, catheters, medical therapies and surgical intervention. Surgery includes the ‘male sling’ and the artificial urinary sphincter. Surgical intervention is usually considered 1-2 years after prostatectomy (also see our summary 'Urinary incontinence').  
 
 

After surgery John experienced some incontinence. Two years later he still had problems so had a...

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Age at interview: 57
Sex: Male
Age at diagnosis: 54
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The two principal side effects were firstly, incontinence I had to wear incontinence pads, I was wearing quite large pads, and getting through a couple a day, two or three a day to begin with,  things improved over the course of the first six months I suppose, I was doing pelvic floor exercise, perhaps not as consistently as I might have done but they helped, but then it’s, it reached a plateau, I was, after that point I was going back to the hospital every six months, for a check up which consisted of a PSA test and a chat about my condition generally, and after the first two or three perhaps of those assessments I had... the guy I saw had been trained and was operating on male slings which reduce incontinence and he thought that I was an ideal candidate for that, so I had a test for that, which was basically to see the capacity of my bladder and the amount of leakage, and they decided that because I wasn’t too severely incontinent that I was a good candidate for that so I was put forward for that second operation, which took place just about two years after my prostatectomy. I had the operation under, I had the choice of local anaesthetic or a general anaesthetic, and I chose a local because I don’t like anaesthetics very much, the operation was quite straightforward, quite quick, I went home the following day. It was incredibly uncomfortable, the operation is basically you’re, you’re cut open, right underneath, right underneath the bit you sit on, which made it very difficult, when I got home, very difficult to get comfortable, difficult at night, difficult when you are sitting down, and difficult walking, the first couple of weeks were pretty uncomfortable, it was, I would say it was, that the operation was worth doing because the incontinence was reduced, but I had rather hoped that I’d be completely free and in control of, that aspect and free of having to wear pads, but it wasn’t, things were a lot better, I wear one smaller pad now, and I don’t have to worry so much about it, I don’t have to worry about making sure that I’m within reach of a loo so I can change my pad when I go out in the evening or anything like that, so from that point of view it’s been very beneficial, not as good as I would have hoped.

 

 

John explains that his incontinence may still improve as his 'male sling' gets stronger. He finds...

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Age at interview: 57
Sex: Male
Age at diagnosis: 54
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And have you been told that that will get better, or will that be the level of incontinence?
 
It [urinary incontinence] may still get better, because the, the way the male sling works it’s, I believe it’s attached to the pelvic bone at either side, and then it just flops underneath the bladder, but in the course of putting it, or in the course of fitting it, there is scar, operation surgery damage which creates scar tissue and the scar tissue actually [lights go out] strengthens the sling so that over the course of time the sling actually gets stronger.
 
The sling gets stronger?
 
The sling gets stronger, so there is hope, I’ve been told that over, perhaps the first year, there, there is certainly a possibility that things will get better, and I’m trying to help myself a bit more now and doing pelvic floor exercises which definitely do help and I notice that if I go a day or two without doing the exercises, then things get worse. So I really should be doing them several times a day, and I should be drinking less coffee than I do, but I like coffee and like to have a pint sometimes in the evening, and one puts up with the consequences.

 

Some men may have problems getting an erection (erectile dysfunction) after the surgery. This can improve with time for some men, but around half will have long-term problems (NHS Choices 2016). 

 

After his robot-assisted laparoscopic prostatectomy John was impotent. He tried Cialis, and a...

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Age at interview: 57
Sex: Male
Age at diagnosis: 54
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The other side effect of my prostatectomy was loss of sexual function, and I think that, seemed to be more, more a problem for the people at the hospital than it was for me, I mean I’ve been married a long time, my wife and I have a very loving relationship, but I mean physically, we’re kind of not all that bothered, so neither of us felt it was a major problem, but the hospital tried me out with Cialis which is to try to increase the sexual function, and with a vacuum pump to encourage blood flow into the penis, and I was, to be honest, rather half-hearted about the whole thing and I’ve given up with all of that, now, and I think, that probably gets us up to pretty much where I am right now.

 
 

 

Mike was glad he had chosen this type of treatment. Three months after surgery his PSA reading was 0.1ng per ml. He will continue to have regular check-ups. John was also glad that he had had this operation. He believes that he had exactly the right treatment.

It is important to note that this is only based on two men's experiences of robot-assisted laparoscopic radical prostatectomy. 

Laparoscopic and robot-assisted prostatectomy are seen as more expensive then open surgery because of the expense of the equipment and it is normally only offered in specialised cancer centres with specially trained clinicians. National Institute for Health and Care Excellence (NICE) guidelines 2014 (CG175) states “Commissioners should ensure that robotic systems for the surgical treatment of localised prostate cancer are cost effective by basing them in centres that are expected to perform at least 150 robot-assisted laparoscopic radical prostatectomies per year".

Last reviewed July 2017.

Last updated July 2017.

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