Robotically Assisted Laparoscopic Radical Prostatectomy (RALP)

The prostate gland is a small but important gland in the male reproductive system. Its main function is to produce secretions that make up part of the seminal fluid protecting and enriching the sperm. The prostate gland sits just beneath the bladder and surrounds the neck of the bladder and the start of the urethra (waterpipe).

This involves the precise removal of the whole prostate gland, seminal vesicles and sometimes the draining lymph glands as well as tying off the vasa deferentia (sperm carrying tubes). It is performed through several small keyhole incisions in your abdomen using robotic instruments.

Robotic surgery uses sophisticated instruments which are under the total control of the surgeon. The robot mirrors the surgeon’s movements, it does not do the operation. This technique is widely used given its high degree of surgical accuracy and because the recovery is quicker than it is with open surgery.

A RALP is performed under a general anaesthetic and at the start of the operation you will receive an intravenous injection of antibiotics. You will be wearing compression stocking and you will receive a blood thinning medication which is designed to thin your blood to prevent blood clots from forming.

Through five or six keyhole incisions I will use robotic instruments to free your prostate from your bladder and urethra so that it can be removed whilst sparing the muscles and nerves that control continence and trying to preserve your erection nerves. I then re-join your urethra to your bladder using absorbable stitches and a catheter is left in place to allow the join between the bladder and the urethra to heal. All the keyhole incisions are then closed with absorbable stitches.

Return of sexual function after a radical prostatectomy depends upon preservation of the nerves that travel alongside the prostate down to the penis. It relies on very careful separation of the nerve containing tissue (neurovascular bundle) from the prostate. In the setting of more aggressive disease, nerve sparing may not be advised as it could increase the risk of leaving disease behind.

After the operation you will return to the ward and you will be monitored closely by nursing staff. You will receive regular paracetamol for pain relief and if required you will also receive a stronger painkiller however this is not usually required. You will receive intravenous fluids through a drip on the day of the operation and you will be able to have something to eat and drink later on the same day of the operation.

You should do deep breathing and leg exercises. Mobility is encouraged and you will get out of bed the next day. The chance of developing a deep vein thrombosis (DVT) is low however we do everything possible to minimise that risk. You will be fitted with compression stockings which you should wear during your stay in the Hospital, and you will be given injections of a blood thinner.

The sutures used to close your keyhole incisions are absorbable and therefore do not need to be removed. If you notice any increasing redness, swelling or ooze please let me know.

The main longer-term risks of prostate surgery are the potential for incontinence and erectile dysfunction.

Surgical risks include the following:

• Bleeding - Significant bleeding is uncommon now and the chance of requiring a blood transfusion is <1%
• Wound infection - The chance of this is low, around 5% or less
• Urine infection - The chance of a urine infection is around 10%. Antibiotics given around the time of surgery usually controls this
• Deep vein thrombosis (DVT) / Pulmonary Embolus - The risk is small but real, around 1%. All precautions are taken to minimise this risk
• Rectal or ureteric injury - Both structures are very close to the prostate and are therefore at risk with surgery. The risk though is very low, less than 1%
• Bladder neck stenosis - Narrowing of the join between the urethra and bladder is possible, but again the risk is low, around 2%

Overall, most men do very well at the time of surgery and the risk of complications at the time of surgery is low.

Catheter - You will have a leg bag and a night bag for the time that the catheter remains in place. The catheter will usually remain for one week. Do not do pelvic floor exercises whilst the catheter is in place.

Cystogram - Arrangements will be made for you to have a follow up scan to ensure that the join between the bladder and urethra is secure and following this the catheter can then be removed.

Wound care - The keyhole incisions will heal over 4-6 weeks and you should avoid heavy lifting and straining during this time. Shower in the usual way and the dressings over the keyhole incisions can be removed after 2 weeks.

Diet - Avoid becoming constipated by keeping up a good fluid intake and eating fruits and foods high in fibre. If you have problems with constipation you may require a laxative.

Driving - Legally you should not drive for 24 hours after having sedation / general anaesthetic. I would advise you not to drive for 2 weeks at least.

Contact my clinic rooms if you have any concerns. If the keyhole incisions become red, hot, swollen, painful or continues to ooze it may indicate a wound infection. If the urine becomes cloudy or offensive smelling it may indicate a urine infection. If the catheter stops flowing then it may be blocked. This could lead to a full and painful bladder. You should either contact my clinic rooms or present to the Emergency Department for assessment and flushing of the catheter. Do NOT allow your catheter to be removed or replaced.

Follow up:

I will review you with your first post-operative PSA blood test 6 weeks after your surgery.