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Robotic Prostatectomy

(Robotic-assisted laparoscopic prostatectomy)

Nerve-sparing robotic assisted radical prostatectomy is a well established procedure at Johns Hopkins and is performed with the assistance of an experienced and dedicated laparoscopic surgical team including nurses, anesthesiologists, operating room technicians, many of whom you will meet the day of surgery

Robotic prostatectomy is accomplished with the assistance of a experience and dedicated laparoscopic and robotic operating room staff including nurses,anesthesiologist, and technicians many of whom you will meet the day of surgery.

Robotic assisted radical prostatectomy is accomplished using the daVinci Surgical System, a sophisticated robotic device that uses a high quality three dimensional camera image to provide a superior view of the prostate gland and surrounding anatomy.

Diagram of the abdomen, showing five small incisions from the robotic procedure

Miniaturized robotic instruments are passed through 5 - 6 small 1-cm keyhole incisions across the mid abdomen (Figure 3) to allow the surgeon to dissect the prostate and sew the bladder to the urethra with great precision.

This is in contrast to the conventional open radical retropubic prostatectomy where a lower midline abdominal incision is required for dissection and removal of the prostate gland (Figure 4)

During robotic assisted radical prostatectomy, a telescopic lens is inserted into one of the keyhole incisions, providing a three dimensional and magnified view of delicate structures surrounding the prostate gland (e.g. nerves, blood vessels, muscles) thus allowing optimal preservation of these vital structures. The cancerous prostate gland is dissected free from the bladder and urethra, and the bladder and urethra are sewn together without the surgeon's hands ever entering into the patient's body. The prostate is eventually removed intact through one of the keyhole incisions located at the belly button by extending the incision to accommodate the prostate depending on its size (usually 3-5 cm). Results from multiple centers specializing in robotic surgery have indicated that patients undergoing robotic assisted radical prostatectomy have less blood loss than traditional open surgery. Results for cancer cure, urinary continence, and potency also appear similar to open surgery.

Diagram of the abdomen, showing a vertical incision from the open procedure

For most of the surgery, the surgeon is seated at a computer console and manipulates the robotic wristed instruments with joystick hand controls (Figure 5). The surgery is performed adhering to the same anatomic principles of open surgery, but without the surgeon's hands entering into the patient’s body cavity.

All surgical steps of nerve-sparing robotic assisted radical prostatectomy can be viewed in the Video Resources section of this site. Once the prostate gland is dissected free from the bladder, rectum, and urethra, it is placed in a small plastic bag and eventually removed by extending the incision at your belly button to accommodate the prostate. The bladder is sewn back to the urethra to restore continuity of the urinary tract using laparoscopic suturing techniques inside the body. A Foley catheter is placed through the penis to drain the bladder and allow healing of the bladder-urethra connection. In addition, a small drain is placed around the surgical site, exiting one of the keyhole incisions.

Dr. Pavlovich operating the robotic console in the operating room

The length of operative time for robotic assisted radical prostatectomy can vary greatly (generally 2-4 hours) from patient to patient depending on the size of the prostate gland, shape of the pelvis, weight of the patient, and presence of scarring or inflammation within the pelvis due to infection or prior abdominal/pelvic surgery. Blood loss during robotic-assisted radical prostatectomy is routinely less than 300 cc. Transfusions are very rarely required. Donation of blood prior to surgery for autologous blood transfusion can however be arranged if the patient desires.

Potential Risks and Complications

Although this procedure has proven to be very safe, as in any surgical procedure there are risks and potential complications. The safety and complication rates are similar when compared to the open surgery. Potential risks include:

  • Bleeding: Although blood loss during this procedure is relatively low compared to open surgery, a transfusion may still be required (in <1% of patients) if deemed necessary by your surgeon either during the operation or afterwards during the postoperative period. If you are interested in autologous blood transfusion (donating your own blood) prior to surgery, you must make your surgeon aware. An authorization form can be faxed to the Red Cross in your area.

  • Infection: All patients are treated with intravenous antibiotics, prior to the start of surgery to decrease the chance of infection from occurring within the urinary tract or at the incision sites.

  • Adjacent Tissue / Organ Injury: Although uncommon, possible injury to surrounding tissue and organs including bowel, vascular structures, pelvic musculature, and nerves could require further procedures. Transient injury to nerves or muscles can also occur related to patient positioning during the operation.

  • Hernia: Hernias at incision sites rarely occur since all keyhole incisions are closed under direct laparoscopic view.

  • Conversion to Open Surgery: The surgical procedure may require conversion to a pure laparoscopic procedure (performed without the robotic system) or even to the standard open operation if extreme difficulty is encountered during the robotic procedure (e.g. excess scarring or bleeding). This could result in a standard open incision and possibly a longer recuperation period.

  • Urinary Incontinence: As in open surgery, urinary incontinence can occur following robotic prostatectomy, but often improves over time with the use of Kegel exercises, which help strengthen the urinary sphincter muscle.

  • Erectile Dysfunction: Similar to open surgery, a nerve-sparing technique is attempted during robotic dissection of the prostate gland unless there is obvious involvement of the nerve tissue by tumor. The return of erectile function following prostatectomy is a function of the age of the patient, degree of preoperative sexual function, technical precision of the nerve-sparing technique, and time.

  • Urethrovesical Anastomotic Leakage: Transient small urinary leakage can occur at the connection between the bladder and urethra following both open and robotic prostatectomy and often resolves without further intervention within a few days to up to a week. The urinary catheter will remain in place until the leakage has stopped.

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