• Robotic Surgery

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    Robotic Surgery is

    Assisted robotic prostatectomy is a way of doing surgery for prostate cancer. It is a type of keyhole (laparoscopic) surgery. It is also called da Vinci surgery. A surgeon does the surgery but uses a special machine (robot) to help. It is not available at all cancer hospitals in the UK. We don't yet know whether this type of surgery is better than other types of surgery for prostate cancer or whether it is cost effective. You have assisted robotic surgery in an operating theatre under a general anaesthetic. Robotic Surgery of prostate cancer in India is now done at 5 to 6 cities. Dr. Ramani perform his Robotic Surgeries in Asian Heart Institute. He also performs Robotic Surgery of Kidney & Robotic Surgery of Renal Cell Carcinoma. He is one of Top uro-oncologist in Mumbai & amongst Ten Top Uro-Oncologist in India.

    Dr. Ramani performed his first Robotic Prostatectomy in the year 2002. Doctors need to have special training before they can carry out this type of surgery. It involves two machines

    Dr. Anup Ramani performing Robotic Surgery

    The patient unit

    You lie on the operating table and the patient unit is beside you. The unit has 4 arms. One holds the camera and the others hold the surgical instruments. The surgeon makes 5 small cuts in your abdomen. The camera and instruments are put in through the cuts to do the surgery. The patient unit is controlled by the control unit.

    The control unit

    The control unit is where the surgeon sits. It is in the operating theatre with you but is separate from the patient unit. The surgeon can see the operating area on a screen. This gives the surgeon a 3D view that they can magnify up to 10 to 12 times.

    Below the screen are the controls. The surgeon uses these master controls to move the instruments on the patient unit. This turns any movements the surgeon makes into much smaller movements of the machine. It also reduces any shaking, allowing the surgeon to make very tiny, accurate movements.


    Research into Robotic Surgery

    Surgeons only started using these machines in 2000. A systematic review in early 2007 found that it was as good at removing the cancer as other types of surgery. But we don’t yet know how well these men do long term, compared to men having regular surgery.

    In the review, robotic surgery had the same advantages as laparoscopic prostate surgery when compared to radical prostatectomy. There was

    • Less bleeding
    • Less scarring
    • A shorter stay in hospital
    • Quicker recovery

    The review also found that if the surgeon was experienced, the operation appears to be as good as the standard radical prostatectomy in removing cancer with a border of healthy tissue around it. Doctors call this a clear margin.

    Some studies in the review found that men were more likely to get their bladder control back quickly and were able to get an erection again sooner after this type of surgery. But the studies were small and weren’t randomised, so we don't yet know for certain if it is better than standard surgery at reducing the number of men who have side effects.

    The usual way of having your prostate removed is either through

    • A cut in your abdomen (retropubic prostatectomy)
    • Keyhole surgery (laparoscopic)
    • A cut between your testicles and your back passage (perianal prostatectomy)

    There is more information about surgery for prostate cancer in our treating prostate cancer section.


    What a Radical Prostatectomy is

    A radical prostatectomy is a common operation for treating prostate cancer. It used to be called total prostatectomy. This means using surgery to remove all of the prostate gland through a cut in your abdomen or the area between the testicles and the back passage (perineum). The aim of this type of surgery is to cure the cancer.

    Your surgeon may suggest radical prostatectomy if

    • Your cancer has not spread outside your prostate
    • Keyhole surgery (laparoscopic)
    • You are younger, rather than older, and have a high grade tumour

    Who has radical prostatectomy?

    Radical prostatectomy is done more often in younger men because they are more likely to

    • Be fit enough for such major surgery
    • Have a faster growing tumour that needs radical treatment
    • Die from their cancer rather than other health conditions if it is not successfully treated

    Radical prostatectomy is major surgery with many possible side effects. If you are an older man with a slowly growing prostate cancer, this type of surgery may not be necessary for you. This is because your cancer may be so slow growing that you are more likely to die of old age or other causes than from the prostate cancer. In many cases, it isn't worth putting you through the side effects if the treatment will not lengthen your life span.

    There is detailed information about choices of treatment for prostate cancer in this section. There is also general information about the side effects of surgery.


    How radical prostatectomy is done

    A radical prostatectomy is carried out by specialist surgeons. They take out the whole prostate gland with the aim of getting rid of all the cancer. The surgeon makes a cut in the abdomen (retropubic) or between the testicles and the back passage (perineal). This operation is called open prostatectomy. As well as the prostate gland, the surgeon also removes the surrounding tissues and the tubes that carry semen (seminal vesicles). They then close the wound.


    Laparoscopic prostatectomy (keyhole surgery)

    Often, a radical prostatectomy is done using keyhole (laparoscopic) surgery. The surgeon uses a tube with a light and eyepiece to look inside the body. They fill the abdomen with carbon dioxide gas so they can see the prostate clearly. A tiny video camera gives a magnified view of the prostate gland on a video screen. The surgeon cuts away the prostate gland from the surrounding tissues and puts it in a small bag before removing it through one of the cuts in the abdomen. The main difference with this surgery is that you won't have a big wound in your abdomen afterwards. Instead you have several small cuts.

    Most studies have shown that laparoscopic surgery is as good at treating prostate cancer as open surgery. Men also lose less blood, have less pain, and spend less time in hospital. Most men also recover and go back to normal activities more quickly than with open radical prostatectomy surgery. Two of the most common side effects of prostatectomy are problems with control over when to pass urine (urinary incontinence) and inability to have an erection (impotence). There doesn’t seem to be any difference in the number of men who have these side effects after open prostatectomy or after laparoscopic prostatectomy.


    There can be risks with laparoscopic surgery though and these include heavy bleeding for some men and damage to healthy tissue close to the prostate. These complications are uncommon when the operation is carried out by a surgeon with specialist training and experience in laparoscopic techniques.

    The National Institute for Health and Clinical Excellence (NICE) issued guidance on radical laparoscopic prostatectomy in November 2006. They say that this procedure is safe and works well enough to use on the NHS. As with all operations, the surgeon should explain the risks and benefits to you fully beforehand. And only surgeons who have had special training and experience in this type of surgery should offer it. Your surgeon may need to refer you to another hospital to have it.


    Robot assisted prostatectomy

    Assisted robotic prostatectomy is a new type of keyhole (laparoscopic) surgery for prostate cancer. It is also called da Vinci surgery. A surgeon uses a special machine (robot) during the operation. Doctors need to have special training before they can carry out this type of surgery. It is only available in a few hospitals in the UK. We don't yet know whether this type of surgery is better than other types of surgery for prostate cancer or whether it is cost effective. You can read more about it on our page about robotic surgery for prostate cancer.


    Checking for clear margins

    After your operation, your surgeon will send the tissue they removed to the laboratory. The aim of the surgery is to get all the cancer out with a safety margin of cancer free tissue around it. This is called a clear margin. It helps to make sure that all the cancer is gone and that it won't come back.

    In the laboratory the pathologist looks very closely at the edges of the tissue to make sure there are no cancer cells there. If you do not have clear margins, there is a risk that some cancer cells have been left behind. You might then need to have radiotherapy or hormone therapy to try to get rid of any cancer cells that are still there. Your doctor will look at your prostate specific antigen (PSA) level to help decide whether or not you need more treatment.


    Nerve sparing surgery

    Surgeons have developed a technique to try to prevent erection difficulties after the operation. This is called a nerve sparing prostatectomy. Two bundles of nerves run alongside the prostate. These nerves help control erections. During nerve sparing prostatectomy, the surgeon cuts prostate tissue carefully away from the nerve bundles without damaging them. If the surgeon can remove the prostate without harming the nerves it is much more likely that you will still be able to have erections afterwards. But with nerve sparing surgery there is a higher risk of some cancer cells being left behind.

    Nerve sparing surgery is only suitable for men with very early prostate cancers. The cancer must be completely inside the prostate (as it is for all total prostatectomy operations). And it must be as far away from the bundles of nerves as possible. If your cancer is growing too close to, or into the nerve bundles, then they have to be removed. If the surgeon leaves them behind, the cancer will not be cured by the operation.

    If your biopsies show that the cancer is only on one side of your prostate gland, you may be able to have the nerve bundle on the other side left untouched. This may still cause some difficulty with erections but drugs like sildenafil (Viagra) can sometimes help.

    If you are interested in nerve sparing surgery, you can ask your surgeon if it is likely to be suitable for you.


    After radical prostatectomy

    After a radical prostatectomy you will have

    • A drip
    • A catheter
    • A wound
    • Painkillers
    • A few days in hospital

    A drip

    You will probably have a drip (intravenous infusion) to maintain your body fluids. It will be taken out as soon as you are drinking normally again. It is important to drink plenty of fluids.

    A catheter

    You will also have a tube (catheter) into your bladder to drain your urine into a collecting bag. After this surgery, it is quite normal to have blood clots forming in your urine. The blood in your urine will slowly clear and then the catheter can be taken out. This is normally about 1 or 2 weeks after your surgery. You must tell your nurse as soon as you pass urine after your catheter has been removed.

    Rarely, men cannot pass urine when their catheter first comes out. This may be because there is still swelling around the neck of the bladder and the prostate after your surgery. If you can't pass urine, you will probably need to have the catheter put back and you can try without it again in a day or so. Sometimes you need the catheter to stay in place for a while after you go home. Before you leave hospital your nurse will show you how to look after it.

    Your wound

    You will have a wound and perhaps a small drain to collect any fluid that is produced. Your nurse will take the drain out when it is no longer producing fluid.

    Painkillers

    You will almost certainly have some pain for the first few days after your operation. But you will have painkillers to control this. For the first couple of days, you may have a pump with a button that you can press to give yourself painkillers whenever you need them. You may need to plan your pain relief by giving yourself a boost before you are going to get up or before your physiotherapist comes to see you.

    Pain is likely to be less with keyhole (laparoscopic) surgery. If you are in pain it is important that you tell the nurse or doctor as soon as possible. With your help, they will be able to find the right type and dose of painkiller for you. Painkillers work best when you take them regularly.

    A few days in hospital

    You can usually go home about 3 to 7 days after an open prostatectomy and 1 or 2 days after keyhole surgery. If you think you might have problems at home, let your nurse or social worker know when you are admitted so that they can arrange help. They can also arrange for a district nurse to visit you.

    There is general information about the side effects of surgery in the Cancers in general section.


    Long term side effects

    Radical prostatectomy may cause erection problems (impotence) in up to 70% of men. Impotence means you can't have an erection. This is more likely to happen if you are older.

    The operation can also cause problems controlling the flow of urine (incontinence) because of swelling or damage to the muscle that holds urine in your bladder. With modern surgery techniques these problems are less common than they used to be. About 2 out of every 10 men (20%) will have minor problems with urinary incontinence.

    About 1 in 20 men (5%) will have more severe problems with urinary incontinence after this type of surgery. For many men the incontinence is temporary and does not last longer than 6 months.

    It is important to remember that doctors can't know for certain which men will have problems with getting an erection or incontinence after surgery. You must be very clear about these risks before your operation. Ask your doctor to discuss the operation with you in detail. You can also ask about the chance of having other types of treatment.


    Transurethral resection (TUR) of the prostate
    Why transurethral resection of the prostate is done

    Sometimes men need surgery to remove the part of a prostate cancer that is pressing on the tube that carries urine from the bladder (the urethra). If anything presses on the urethra this can make it difficult for you to empty your bladder properly. Your doctor may suggest an operation to take away some of the cancer so that you can pass urine more easily again. This operation does not cure the cancer. But it can relieve symptoms caused by the cancer pressing on your urethra.

    This operation is also often used for men who have a non cancerous (benign) swelling of the prostate gland called benign prostatic hypertrophy (BPH). Here we are just describing its use as a treatment for prostate cancer. This type of surgery is called a TUR or TURP, which stands for transurethral resection of the prostate.


    How a TURP is done

    A TURP is carried out by passing a thin tube up the urethra through your penis. The tube has a tiny camera and an eyepiece, so that the surgeon can see inside your urethra. They remove the blockage using an instrument attached to the tube that can cut away the abnormal areas. Afterwards you usually need to stay in hospital for about 2 or 3 nights.

    You usually have a TURP under a general anaesthetic, but for some men, it is done with a spinal anaesthetic. A spinal anaesthetic means you are awake, but can't feel anything below the level of the anaesthetic injection into your spine. Your doctor will suggest a spinal anaesthetic if there are reasons why you shouldn't have a general anaesthetic, for example if your lungs are not as healthy as they might be.


    After a TURP

    You recover more quickly if you can start moving around as soon as possible. You'll probably be up and about within 24 hours.

    You may have a drip (intravenous infusion) to maintain your body fluids. It will be taken out as soon as you are drinking normally again. It is important to drink plenty of fluids.

    You may also have a tube (catheter) into your bladder to drain your urine into a collecting bag. After this surgery, it is quite normal to have blood clots forming in your urine. To prevent the blood clots blocking this catheter, fluid is passed into your bladder and drained out through the catheter (bladder irrigation). The blood in your urine will slowly clear and then the catheter will be taken out. This is normally about 2 or 3 days after your surgery.

    You must tell your nurse as soon as you pass urine after your catheter has been removed. Sometimes, men can't pass urine when their catheter first comes out. This may be because there is still swelling around the neck of the bladder and the prostate after your surgery. If you can't pass urine, you will probably have the catheter put back in and you can try again without it in a day or so.

    Sometimes you may need to have the catheter in for a while after you go home. Before you leave hospital your nurse will show you how to look after your catheter. They can also arrange for a district nurse to visit you at home to help with any problems.

    There is general information about the side effects of surgery in the Cancers in general section.


    Going home

    Before you leave hospital your nurse will give you an appointment for the outpatient clinic for a check up. The appointment is a good time to discuss any problems you may have after your operation. It is usually 6 weeks after your surgery.

    Most men go home within 3 days or so of their TURP. If you think you might have problems coping at home, let your nurse or social worker know when you are first admitted so that they can arrange help.


    If you have pain

    You may have some pain or discomfort for a few days after your operation. But you will have painkillers to control it. Remember that if you still have pain, tell the doctor or nurse looking after you as soon as possible. Your painkillers can be changed, as different drugs suit different people.


    Laser surgery

    Recently, a type of laser surgery has been used to remove prostate tissue. This procedure uses a holmium laser or thulium laser. It seems to work as well as a traditional TURP, and appears to cause fewer complications. This is still quite a new technique, and is not available in all hospitals.