Not all patients can take advantage of the laparoscopic technique. It is not recommended in patients with increased intracranial pressure, also with a brain tumour and hydrocephalus, or in patients in whom a ventriculo-peritoneal (VP) shunt was inserted. Another contraindication for laparoscopic surgery is glaucoma due to the harmful effect of pneumocephalus and Trendelenburg position on intracranial pressure.
- Preparation for prostatectomy
- The course of the prostatectomy
- Urine control after the surgery
- Sexual functions after the surgery
- Benefits for the patient
Preparation for prostatectomy
Patients in the pre-, peri- and post-operative period are under the care of an interdisciplinary team consisting of a surgeon/da Vinci operator, an anaesthesiologist, a psychooncologist, physiotherapist and dietician as well as other specialty doctors depending on the overall health status. The necessary preparations include assessment of full blood count and blood smear and of kidney function as well as cross-matching.
Particular attention is given assessment made by anaesthesiologists and other specialist of patients with respiratory and respiratory diseases as well as those suffering from congestive heart failure and valvular insufficiency due to the increased risk of complications in their cases.
The anaesthesiologist starts perioperational antithrombotic therapy. Depending on the patient’s overall condition, they may also be assisted by other specialist in order to put in place the optimal pharmacological procedure.
The psychooncologist supports patients with cancers as well as their loved ones during the whole journey through the disease. They may also assist in minimising the adverse mental effects that the patient and his family experience in connection with the disease as well as in building a system of support to the patient, both internal (sense of worth, optimism, creativity and sense of humour) and external (family, significant others, friends and fellow workers). They also provides instruction on how to transform the attitude and thoughts that have a weakening effect on the patient and on reducing techniques, such as visualisations, relaxation or breathing exercises.
The physiotherapist works with the therapy and functional assessment of the pelvic floor and the overall condition of the patient. Physiotherapy used before and after the surgical intervention enables appropriate preparation for the procedure and maintaining its effects. Rehabilitated patients have a faster recovery rate with regard to the sexual function and urinary continence. Appropriate physiotherapy on the day of the procedure prevents complications in the form of pneumonia and venous thrombosis.
Of great importance for the recovery after cancerous diseases or extensive surgical interventions is correctly balanced nutrition. Therefore, the therapeutic team includes a dietician.
The course of the prostatectomy
At the start of the procedure, a camera and some instruments fitted in the arms of the robot are inserted through five incisions in the patient’s body. The surgeon working at the control console removes the lymph nodes within the lesser pelvis to an extent that depends on the degree of probability of the presence of metastases, calculated based on the preoperative parameters. Then, after cutting off the prostate gland from the urethra and the bladder neck, they remove the affected organ together with the seminal vesicles.
This part of the procedure requires exceptional precision in making incisions and preserving the neurovascular bundles that are responsible for erectile function and the contractile behaviour of the external urethral sphincter. The accuracy of this step in the procedure is determined by the robotic assistance and the fact that it is performed using a three-dimensional (3D) image of the inside of the human body at multiple magniﬁcation.
The method also allows to reduce bleeding. At the end of the procedure the urethra is reconnected to the bladder neck by suturing. A drain is left for 1-2 days after the operation in order to keep control of anastomotic leak. The catheter, which is inserted through the urethra into the bladder, is usually removed on the 3rd day after the surgery.
The surgery leaves small scars at the spots where the instruments were inserted.
The procedure is performed under general endotracheal anaesthesia. The resected lymph nodes and prostate are sent for histopathological examination. Based on the result, typically after about 2 weeks, the actual degree of local advancement of the cancer is assessed and a further course of treatment is determined.
Urine control after the surgery
Radical resection of the prostate (prostatectomy) causes total or partial damage to the internal urethral sphincter which is located within the urinary bladder neck. It is, however, not necessary to ensure urinary continence. Of crucial importance, on the other hand, is the external urethral sphincter which is located distal to the prostate apex and is innervated by autonomic branches from the pelvic plexus. The delicate handling of this region using the da Vinci system and leaving an appropriately long section of the urethra allows for a fast return to urinary continence.
After the surgery, symptoms of urinary incontinence are usually observed, initially in the form of total and then stress urinary incontinence (involuntary leakage of urine caused by coughing or bending down), which gradually disappear. In approx. 70% of patients full continence returns within the first 3 months after the surgery. After a year even 98% of them can hold urine. If the symptoms of urinary incontinence persist for a long time, implantation of an artificial urethral sphincter should be considered.
Sexual functions after the surgery
Penile erectile dysfunction is the effect of removing or damaging the penile nerves in the course of the surgery. On the lateral walls of the prostate gland there are so-called neurovascular bundles containing cavernous nerves which are responsible for inducing and erection. For patients with locally advanced cancer, it is recommended that these structures be removed during the surgery in order to ensure a good oncological outcome; hence, the chance to maintain erectile function does not exceed a few percent. For low-risk cancers, prostatectomy can be carried out in such manner as to preserve either one or both neurovascular bundles (unilateral or bilateral nerve sparing radical prostatectomy), which significantly increases the chance to maintain erectile function.
It should, however, be emphasised that the return to the function is slow and can even take 2 years following the surgery. Ultimately, return of spontaneous erections is reported in approx. 40% of patients with unilateral and 70% with bilateral nerve sparing radical prostatectomy. Erections are often weaker and of shorter duration than before the operation; then, it may be necessary to use additional assistance (oral medicines, penile injections or vacuum devices). It is also essential to prevent the development of erectile dysfunction through early pharmacological rehabilitation which should be commenced during the first 3 month following the prostatectomy. The treatment involves taking medicines or having erection-inducing injections on a regular basis. This procedure significantly reduces the risk of permanent erectile dysfunction.
Benefits for the patient
The da Vinci system is a better tool as compared with the classical or laparoscopic access, for dissecting and removing lymph nodes and providing protection of the autonomic nerves during oncological procedures. Robot-assisted surgery provides urologic oncologists with the possibility of performing minimally invasive, precise and complete procedures with good oncological clearance.
In comparison with procedures performed using the classical or partly laparoscopic methods, the use of a robot enables:
- over two-fold higher likelihood of retaining potency
- nearly two and a half times greater chance of returning to urinary continence
- lower probability of biochemical recurrence
- fewer number of complications
- reduction of postoperative pain
- reduced blood loss
- better cosmetic effect
- shorter stay at hospital
- faster return to the daily routine and professional life