Robotic Assisted Laparoscopic Prostatectomy (RALP)


        Pre-operative MRI scan                 Prostate after removal with 
              to plan surgery                           bi-lateral nerve spare


Christian performs robotic prostate surgery as part of The London Robotics Centre at The Wellington Hospital, London.

http://www.londonroboticscentre.com/Team-Surgeons-Urology.aspx#ref34


What is a robotic assisted laparoscopic radical prostatectomy (RALP)?

It is a minimally invasive (key hole) operation performed with the intent to cure a man of prostate cancer. It is performed under general anaesthetic and involves removing the entire prostate gland, seminal vesicles (glands that produce semen) and sometimes lymph glands within the pelvis. The bladder is then re-attached to the urethra (water pipe) with stitches. The prostate is analysed by a pathologist giving a precise understanding of the amount and type of cancer removed, and whether any additional treatments are required. This information cannot be obtained with transrectal ot transperineal core biopsies of the prostate.

RALP is endorsed by the National Institute for Clinical Excellence (NICE) http://www.nice.org.uk/guidance/IPG193


What are the advantages of Robotic / Laparoscopic surgery?

Due to improved vision with 3D and HD there is more accurate identification of important structures which leads to:

-        Shorter hospital stay. Most patients are discharged after a 1 or 2 night stay after the operation

-        Less blood loss. It is very rare to give patients a blood transfusion (<1%)

-        Less post operative pain. Smaller scars result in less pain with only tablet pain killers required and quicker return to normal activities. It is very uncommon to require morphine based analgesia resulting in less side effects such as drowsiness and constipation

Christian has personally performed over 350 laparoscopic / robotic radical prostatectomies, he trains other consultants in the technique and is part of a team at King's College and Guys Hospitals who collectively have performed near to 2000 cases.


What are the risks of having a robotic assisted laparoscopic radical prostatectomy?


General risks of having any operation and solutions to reduce risk

-        Infection (chest or wound), antibiotics are given during the operation

-        Bleeding (during or after the operation), laparoscopic procedures tend to bleed less

-        Thrombosis (blood clots), patients self-administer a small injection for 40 days after the procedure


Specific risks of having a robotic assisted laparoscopic radical prostatectomy and solutions to reduce risk

-        Urinary incontinence (involuntary leakage of urine). All men suffer incontinence of urine when the catheter is removed (7 – 10 days) after the operation and pads are necessary. Patients are taught to perform pelvic floor exercises which can be started before the operation to help regain continence which can take days, weeks or months depending on the patient. Laparoscopic surgery gives improved continence outcomes compared to traditional open surgery due to improved vision of the anatomy of the urethra and sphincter.

-         Erectile dysfunction. Depending on the amount and type of cancer it may be possible to attempt to protect or spare nerves and blood vessels that are involved in erections. This does not guarantee future erections and recovery can take up to 2 years. Men who have existing erectile problems will see a further decline and are the most difficult to treat. Patients may require addition help with for example tablets e.g. Viagra to obtain an erection. Men wishing to return to potency after the operation are encouraged to engage in penile rehabilitation. This may involve the use of daily tablets and penile pumps. It is however possible to experience a satisfactory orgasm / climax without an erection but there is no emission.



There is no single nerve which controls erections but a plexus or sheath which can be preserved in certain cases depending on the posiion and grade of the cancer.




-        Rectal injury. This is a rare (<1%) but serious complication and may require a temporary colostomy.

-        Bladder neck contracture. Excessive scar tissue where the bladder and water pipe have been re-connected occasionally needs to be released under anaesthetic as a day case.




What happens before the operation?

A week before the operation you will be invited to attend a pre-assessment clinic to assess fitness for surgery. This will involve blood and urine tests and a heart tracing called an ECG. Patients are admitted on the day of surgery. It is important that patients don’t have any food or drink on the day of surgery.


What happens after the operation?

There is no need for a high dependency unit (HDU) stay although if necessary expert facilities exist and are freely available.

Patients have a urinary catheter draining urine into a bag which can be strapped to the leg so trousers can be worn. A drain (small plastic tube) is also placed and is usually removed on the first day after the operation. Patients are encouraged to eat and drink normally on the night of the operation.

 Most patients will be discharged home after 1 or 2 nights after the operation. Some abdominal bloating is expected and bowels typically open after 2 to 3 days. Drinking 2 to 3 pints of water is essential to ensure a good urine output and prevent catheter blockages. Any post-operative problems can be dealt with easily and if necessary via the on-call urology service at King’s College Hospital.

Driving, lifting, gardening and any activity more than light walking should be avoided for 2 to 3 weeks after the operation to prevent damage to internal healing.

The catheter is removed typically after 5 days. Patients are seen at this time for discussion of their pathology specimen. Penile rehabilitation can if requested start at this time. Patients are then seen after 6 weeks to discuss continence recovery and the first PSA blood test. It is expected that the PSA will become unrecordable (<0.03). If radiation oncology input is required it can be arranged at this time.


Other information sources


Prostate Cancer UK http://prostatecanceruk.org/

Prostate U.K. Tel: 02088775840 or visit http://www.prostateuk.org

The Prostate Cancer Charity Tel: 0845 300 8383 or visit http://www.prostate-cancer.org.uk

The bladder and bowel foundation  Tel. 0845 345 0165 www.bladderandbowelfoundation.org



         
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