Robot Assisted Radical Prostatectomy

Robot assisted radical prostatectomy (RARP) is a surgical procedure for prostate cancer performed laparoscopically (by means of keyhole surgery) and with the assistance of the da Vinci Surgical Robot. It involves the removal of the entire prostate and seminal vesicles. Sometimes, depending on the parameters of the prostate cancer, the pelvic lymph nodes are also removed. RARP has become the standard in the surgical management world wide, and the majority of radical prostatectomies globally are performed this way. The goals, in order of importance, of RARP are:

  1. To remove the entire prostate including all cancer and to achieve a clear margin with no remaining cancer. If this is successful, there should be no need for additional treatment and the PSA level should decrease to less than 0.2 ng/mL.
  2. To preserve urinary continence.
  3. If appropriate, depending on the parameters of the prostate cancer, to preserve penile erectile function.

Description of the Procedure
RARP is performed under general anaesthesia. The procedure usually takes between two and four hours in theatre. Once asleep, the patient is positioned and the laparoscopic (keyhole) incisions are made in the abdomen. The abdomen is inflated with carbon dioxide and access ports are placed through the abdominal wall. The robot arms are coupled to the access ports and the robotic instruments are introduced into the abdomen.

The procedure is not performed by the robot, but with the assistance of the robot. The surgeon controls the robot at all times during the procedure.  The robot offers the advantage of mini-instruments which are extremely precise, and which mimic the surgeons hand movements within the patient’s abdomen.

The surgeon opens the space in front of the bladder and removes the entire prostate with the seminal vesicles.  Care is taken to preserve the nerves and muscle fibres of the external sphincter to improve continence. The nerves to the penis which are responsible for penile erection run closely adjacent to the prostate. If the prostate cancer is confined to the prostate and not high-risk of extra-prostatic extension, a nerve-sparing prostatectomy can be attempted, during which the surgeon attempts to spare the nerves to the penis. After removal of the prostate, the bladder is sutured to the urethra and a catheter is inserted. A drain into the abdomen may also be inserted. The pelvic lymph nodes may be removed, depending on the risk assessment of lymph node spread.

Video of the Procedure

Robot assisted radical prostatectomy (abridged) played at 4x speed.

Risks and Complications of the Procedure
All surgical procedures have inherent risks and complications. It is not possible to list every possible complication of a surgical procedure. Some of the common risks and complications of RARP are:

  1. Absence of semen production and infertility will occur in all patients.
  2. Damage to the nerves controlling penile erection occurs in most patients. The risk is reduced if a nerve sparing procedure is performed, but even so, there is a significant risk of loss of erectile function. If recovery occurs, it can be expected over 6 months to 1 year. Your team can assist you with options to continue enjoying a healthy sex life after the surgery.
  3. Urinary incontinence occurs in the majority of patients early on after the procedure. This tends to improve over the the first few months. By one year, approximately 90% of patients have achieved satisfactory continence. In a small number of patients, and additional procedure is required, such as a male sling or artificial sphincter, to assist with continence.
  4. Positive margins can occur if the cancer has spread beyond the prostate tissue which is removed. The risk of positive surgical margins increases with more aggressive cancers. If the surgical margins are positive, there is a high likelihood that additional treatment will be required.
  5. Later recurrence, indicated by a rising PSA level after the surgery, may occur if cancer recurs at the site of the prostatectomy, or at distant sites. If this occurs, there is a high likelihood that additional treatment will be required.
  6. Urine leak at the site of anastomosis between the urethra and bladder may result in prolonged admission or catheterisation.
  7. Bleeding at the time of surgery or after the procedure may require blood transfusion. Although rare, uncontrolled bleeding may require further surgery to manage.
  8. Injury to adjacent organs such as the rectum may occur. Although rare, bowel injury may require formation of a temporary colostomy to drain stool until the injury heals.
  9. Lymph fluid collection in the pelvis in the event of a lymph node dissection being performed. This may require drainage.
  10. Complications related to the port sites such as pain or hernia occur occasionally.
  11. Conversion to laparoscopic or open surgery may be required in the event of a technical failure with the robot, or of a complication which cannot be managed endoscopically.
  12. Complications related to surgery in general and anaesthesia such as deep vein thrombosis (DVT), pulmonary embolism, hospital acquired infection, pneumonia and heart attack can occur.

Requirements before the Procedure

  1. You may need a pre-operative assessment by a physician or anaesthetist if you have any medical problems which place you at additional risk for anaesthesia or surgery.
  2. You will be provided with a pair of TED stockings before or on the day of the procedure to improve blood flow in the legs and help prevent deep vein thrombosis.
  3. You will be asked to use a suppository or enema on the night before the surgery and the morning of surgery to empty your rectum prior to the surgery.
  4. You will be admitted on the day of the procedure, approximately two hours before surgery.
  5. You will be seen by the surgeon and anaesthetist prior to surgery.
  6. You must inform the surgeon at least 7 days in advance if you are on blood thinning medication or have a pacemaker or other implanted device.

Expectations after the Procedure

  1. You will be transferred to the high care unit for one night after surgery.
  2. You will have a catheter in your bladder when you wake up. You will not need to pass urine, it will drain spontaneously via the catheter.
  3. You will be given intravenous medication for pain and nausea.
  4. You will experience bloating of the stomach, and may have puffiness of the face from being in a ‘head-down’ position during the procedure.
  5. You will be allowed to start taking sips of water once you are awake from the procedure, and something small to eat if you are up to it.
  6. If everything goes according to plan, you will be discharged to the general ward on the first day and home on the second day after the procedure.
  7. You will be sent home with a catheter. The nursing team will explain to you how to use the catheter. You will return to have the catheter removed at the doctor’s rooms approximately 7-10 days after the procedure. You will be given a leg bag and a night bag for the catheter.
  8. You will be given pain killers, medication to relax the bladder and stool softeners after the procedure. If you are at high risk for DVT, you may be sent home with blood thinning medication.
  9. You should wear your TED stockings for as long as possible after the procedure.
  10. You will need to make a follow up appointment to remove the catheter, for the first post-operative visit and to discuss the histopathology results. You will also be given medication maintain blood flow to the penis (penile rehabilitation therapy) at this visit. You should bring continence pads with you, as you will most likely leak urine after removal of the catheter.
  11. If there is an emergency, you should attend the emergency department.
  12. Your first PSA test will be 6 weeks after the procedure.

Alternatives to the Procedure
Depending on the parameters of the patient and the prostate cancer, there may be alternative treatments to RARP. It is the responsibility of the treating doctor to discuss these with the patient. They include:

  1. Active Surveillance – a strategy which treatment is deferred in low risk prostate cancer until there is evidence of the cancer becoming more aggressive, at which time treatment such as surgery is implemented. It requires regular PSA checks, follow up MRI imaging and repeat biopsy.
  2. Radical Prostatectomy (open or laparoscopic) – the procedure of radical prostatectomy can be performed without the robot either by open or traditional laparoscopic (keyhole) surgery.
  3. Brachytherapy seed placement – radioactive seeds can be permanently implanted into the prostate to treat the prostate cancer without removing the prostate.
  4. External beam radiotherapy – prostate cancer can be treated using radiation directed at the prostate from outside the body.

This page is intended to provide information about the surgical procedure discussed. All diagnoses and treatment options should be discussed between the patient and his/her doctor. This page is not intended to replace that discussion in any way, or to provide advice in any specific circumstance. The information contained herein is evidence based, but the authors make no guarantees regarding the accuracy and completeness of the information. There may be errors or omissions in this information and the authors take no responsibility for decisions taken or not taken as a result of the information contained herein.