Robotic Surgery

A minimally invasive treatment for prostate cancer

Today, medical advances allow to identify the management of prostate cancer. Treatment options go from active surveillance (delaying treatment) to radical surgery (removing the prostate and lymph).

Both focal and radical treatments are available in the management of prostate cancer. When the tumour in the prostate is extensive or aggressive, focal treatment (where only the diseased part of the tissue is treated and the healthy tissue is preserved) is no longer an option and the entire prostate needs to be removed.

Your doctor will inform you of the different treatments available. It is important to investigate all options and talk with your family about the different possibilities to make sure that you select the most appropriate for you and your lifestyle.

ROBOTIC TX . Minimally invasive treatment for Prostate Cancer

With the increasing use of PSA (Prostate Specific Antigen), many men are diagnosed in the early stages of prostate cancer. The localised tumour needs to be handled individually. The location of the tumour, tumour volume, the type of Gleason and total PSA determine the type of treatment that is needed.

You have just received a diagnosis of prostate cancer. Your urologist has suggested a treatment using Robotic Tx. Your prostate contains a tumour that needs to be removed using minimally invasive radical surgery.

Radical prostatectomy consists in removing the prostate and seminal vesicles. It is sometimes accompanied by a lymphadenectomy, which consists in removing the lymph nodes of the pelvis in the same procedure. Radical prostatectomy can be performed by means of open, laparoscopic or robot-assisted surgery. Thanks to the DaVinci robot, surgery can be performed more accurately with the intention of preserving nerves and anatomical structures associated with erection and urinary continence.

What is radical prostatectomy?

Radical prostatectomy is a surgery to treat localised prostate cancer (cancer that has not spread outside of the prostate gland). Surgery may also be performed increasingly for locally advanced prostate cancer (when the cancer has begun to spread outside the prostate, or has spread to the lymph nodes). It is performed under general anaesthesia, which means you are asleep throughout the procedure. “Radical” means that the entire prostate is removed, instead of only a part of it.

The surgery involves removing the prostate gland, seminal vesicles (glands that store semen) and possibly, the blood vessels, nerves, and fat around the prostate. The elimination of these structures will increase the likelihood to kill all of the cancer cells. The prostate is located outside the bladder, in continuity with the urethra. To remove the prostate, a crucial step of surgery is to reunite the bladder with the urethra by performing an anastomosis. Therefore, patients undergoing radical prostatectomy will need a bladder catheter during a few weeks after surgery.

What are the different types of prostatectomies?

When we refer to types of radical prostatectomies, we refer to the way in which we agree to remove the prostate. At present, there are 3 ways to perform radical prostatectomy: open, laparoscopic or robot-assisted surgery.

  • Open surgery consists in making an incision of 10-15cm below the navel through which we arrive to the pelvis in order to perform the surgery.
  • Laparoscopic surgery is carried out through various small incisions instead of one large incision. Air is introduced (pneumoperitoneum) to inflate the abdomen, creating a space where to be able to operate. With the help of an optical drive that we introduce, we can see the image of the interior on a monitor. This magnifies the image of your pelvis, so that your surgeon has a more detailed view. Each incision (between 5 and 6) is used to introduce the instruments used for the prostatectomy. Most of the incisions are 0.5-1 cm in length, but one is 3 cm to allow the removal of the samples.
  • Robot-assisted surgery is a laparoscopic technique that uses a robotic system console (DaVinci®) to help your surgeon during the operation. Your surgeon is in the same room, and controls the robotic arms to perform the operation from the console. It is important to understand that the robot is not performing surgery. The surgeon performs the procedure, but the console robotics allows increased control and precision in the movements of the robotic arms. The robot arms execute commands from the surgeon and are in contact with instruments introduced into the patient through a laparoscopic access. The robotic console has four arms; one has a 3D webcam with great magnifying power, and the three remaining arms are the “hands” of the surgeon that control the instruments.

What are the advantages of robot-assisted surgery, ROBOTIC Tx?

The DaVinci® system has been widely used in the United States and Europe for over 10 years. Robotic surgery is a remote-controlled operation, where the surgeon is located far away from the patient and the surgeon’s movements pass through sensitive fibres of the machine with greater precision until the tip of the instruments.

Robot-assisted surgery has a number of advantages over traditional open surgery that include:

  • Less blood loss. This translates into a lower risk of needing a blood transfusion with robot-assisted surgery.
  • Less pain in the postoperative period.
  • Shorter hospital stay. Most patients go home one or two nights after the robotic assistance, compared to the four nights with open surgery.
  • Shorter recovery time with an early incorporation to daily activities.
  • Smaller scars
  • A greater chance of preserving the nerves and blood vessels tied to the prostate.

What should I consider before surgery?

If you decide to undergo radical surgery, your surgeon will consider whether it is possible to preserve the nerves and blood vessels (“neurovascular bundle”) linked to the prostate. These contribute to erections. Although some form of erectile dysfunction is inevitable after prostate removal, this preservation will result in a higher probability of maintaining some erection after surgery. The majority of men (80%) discover that their erectile function improves over time and observe some improvement up to two years later.

Nerves can only be preserved if there is no risk that the tumour will touch the edges of the prostate, next to the neurovascular bundle. In general, preserving them increases the possibility of leaving the cancer. The quality of erection prior to surgery also conditions the results of a preservation.

What are the possible risks?

Your doctor will warn you that any medical procedure conveys risks. Your surgeon will discuss the possible risks of this operation in more detail. Possible complications include:

  • The need to move to traditional open surgery
  • Your sexual function (the ability to have an erection) can be affected
  • Urinary incontinence (inability to control urine output)

What should I expect after surgery?

You will be taken to the recovery room and will remain there until the doctors take a decision, normally within 24 hours. You will leave the operation room with a urinary catheter (which you will keep approximately 14 days) and a drain (removed before you leave the hospital). During the hospital stay, we will adjust the need for analgesics. The normal stay is two days.

At discharge, we will explain how to take care of your wounds, of the bladder catheter and how to inject heparin to prevent blood clots in the legs (deep vein thrombosis).

Will radical prostatectomy cure my prostate cancer?

If your doctor thinks that you are a candidate for ROBOTIC Tx prostatectomy, it is very likely that the procedure will cure your prostate cancer.

The effectiveness of anti-cancer therapies is measured in terms of number of years that patients are free of disease after treatment.

The graph shows the percentage of patients who are free of cancer a number of years after treatment.

ROBOTIC Tx radical prostatectomy is effective, providing patients a life free of disease. Given that treatments for prostate cancer have similar survival rates, side effects and quality of life are important considerations when choosing one or the other.

Open radical prostatectomy versus minimally invasive radical prostatectomy

In 2003, only 9.2% of the radical prostatectomies were performed using a minimally invasive procedure. Today, over 70% of prostatectomies are performed using minimally invasive approaches.

There are studies that compare the results between the different types by comparing the benefits and complications of open surgery versus minimally invasive surgery.

No differences were found in the mortality or the need for a second treatment for cancer control.

  • The average hospital stay was 2 days for minimally invasive surgery and 3 days for open surgery.
  • 2.7% of men undergoing laparoscopic surgery required a blood transfusion in comparison with 20.8% of men who underwent open surgery.
  • There is a greater risk of anastomotic stenosis (narrowing of the suture where the bladder joins the urethra) for open surgery (14%) than for minimally invasive surgery (5.8%).

The functional results of continence and erectile function are controversial and some data suggest early recovery of continence and erectile function in cases of robot-assisted techniques.