Robotic Surgery

Dr Jay YewDespite it's superiority to the open operation and it's minimally-invasive reputation, DVP (Da Vinci robotic laparoscopic Prostatectomy) is still a major surgical endeavor with potential for real problems and complications.

Frequently asked questions:
Specific Patient Scenarios

What are the advantages of DVP?

DVP (DaVinci robotic laparoscopic Prostatectomy) has all of the advantages of LRP (laparoscopic prostatectomy). The abdomen is inflated with inert gas, which creates a larger space for the surgeon to operate in. The gas also creates pressure, which compresses tissues and results in much less bleeding compared to open surgery. Blood transfusions are usually not needed during or after surgery, and DVP patients do not need to donate blood before surgery. DVP patients usually recover quickly and begin drinking clear liquids right after surgery. Pain is usually minimal and controlled with mild pain pills like motrin or vicodin. Many patients are eating, walking, and are able to go home the day after surgery. Once at home, full recovery is quick. Patients do not have any significant activity or food restrictions and can usually return to work or full daily activities shortly after removal of their urinary catheter.

During DVP there is very little bleeding to obscure the prostate anatomy, and the computer-enhanced 3-dimensional vision system provides a remarkably crisp, clear, view of the intricate anatomy around the prostate. This, in conjunction with the fine flexible operating robotic arms, allows more accurate visualization and meticulous dissection of the nerves and blood vessels (NeuroVascular Bundle, NVB) alongside the prostate. Sparing these vital NVBs increase the chances that patients will recover sexual functioning (potency) sooner.
In addition to precise surgical nerve-sparing technique, potency recovery following any prostate treatment is largely dependent on: (1) a patient's age and (2) his pre-treatment sexual functioning.

The advantages of the robotic technology also allow the surgeon to do an excellent job of preserving a small normal-sized bladder neck opening. Removing excess bladder neck tissue while detaching the prostate from the bladder can lead to a large bladder opening. This large bladder opening can be more difficult to reconnect to the much smaller urinary opening in the urethra. By meticulously preserving a smaller, normal-sized bladder neck opening, a "water-tight" seal is possible when reconnecting the bladder to the urethra. This may help with faster time to removal of the urinary catheter (5-8 days vs. 2-3 weeks) and faster return of total urinary control.


In many cases, men with prostate enlargement will have simultaneous bothersome urination (e.g. slow flow due to BPH) which will improve dramatically after DVP. While this is a distant priority behind treating prostate cancer, it is an important and welcome added benefit of the DVP operation. Conversely, irritative or slow urination symptoms may get worse after treatments such as radiation. Occasionally, a man's prostate will be too large for effective radiation treatments, such as brachytherapy (seeds).↑ top

 

What is Total Urinary Control?

Total Urinary Control is when a patient has total control of urination, and is comfortable engaging in normal daily activities without the worry of inadvertent urine leakage. In the days of open RRP (Radical Retropubic Prostatectomy) surgery, many patients experienced considerable urine leakage after surgery. This improved considerably after surgeons began doing a more anatomically meticulous operation (Walsh's Anatomic RRP). At this point, many urologists considered it a success if patients only had to wear 1 pad per day to control urine leakage.

More recent Quality-of-Life studies clearly indicate that even 1 pad-per-day urine leakage can lead to significant despair and disruption of a man's daily routine and self-esteem. Dr. Yew strives for a zero pads-per-day level of urinary control for his patients. The DVP technique makes this routinely possible for a majority of patients. Other important factors in recovery of urinary control include: (1) the patient's age and (2) any pre-existing urinary or bladder problems (overactive bladder, urinary retention, BPH, nocturia, or urinary urgency-frequency syndromes).↑ top

 

Is DVP as good as open radical prostatectomy (RRP) surgery for treating cancer?

Yes. There is concern that since the surgeon cannot "feel" the prostate during DVP, the ability to detect hardness or possible extension of cancer is impaired with DVP. This has not been demonstrated in any study to date. At the City of Hope, one of the highest volume robotic prostatectomy centers in the world, the rate of positive margins among DVP patients has been as good, or better, than most open surgery patient series. (A significant number of these positive margin patients had high-risk prostate cancer) All the current evidence and experience suggest that DVP and open RRP are both equally excellent surgical options in regards to survival and prostate cancer control. However, DVP typically has a quicker recovery with much less blood loss and side-effects than open RRP.↑ top

 

How is DVP different than LRP (Laparoscopic Prostatectomy)?

Both DVP and LRP are excellent minimally-invasive operations for prostate cancer. The disadvantages of LRP are (1) lack of 3-D magnified vision, (2) lack of flexible, articulating dissecting instruments, and (3) poor ergonomics resulting in significant surgeon discomfort and potential surgical performance impairment over time. To see a demonstration of the flexible robotic dissecting instruments and standard laparoscopic instruments, please view this short video clip.↑ top

 

How is DVP performed?

To view short video clips of the DVP procedure, please go to Dr. Yew's Media Library.

**Warning!! This section may contain graphic photographs and video of real surgery that may not be suitable for viewing by non-healthcare professionals.

robotic surgery

Patients are not to eat or drink anything for at least 8 hours before DVP surgery. Antibiotics will be given before surgery. Once the patient is under anesthesia, he will be positioned with his arms tucked at his side and his legs slightly spread apart and bent at the knees with the table tilted.

A narrow urinary drainage catheter is inserted into the urethral opening of the penis to empty urine from the bladder. A spring-loaded, blunt-tip safety needle is carefully inserted into the abdomen above the umbilicus (belly-button). Inert carbon dioxide gas is pumped into the abdomen (not the intestines). Once the abdomen is filled and expanded, small operating robotic ports and a robotic camera port are placed through small puncture incisions about 1 cm each. At this point, the da Vinci robotic Surgical Cart is brought closer to the patient, between the legs, and carefully docked to the robotic ports.

surgeon's consoleDr. Yew will then go to the Surgeon's Console. Looking inside the stereoscopic viewfinders, Dr. Yew sees a very clear, computer-enhanced, 3-D image of the inside of the abdomen and pelvis. The bladder and prostate are dissected and exposed. Sometimes, it is useful to start at the deepest part of the pelvis, between the bladder and rectum, and enter behind the prostate to dissect the seminal vesicles beforehand. Once the prostate and bladder are defined, the endopelvic fascia on either side of the prostate is opened up to detach the pelvic floor muscles from the sides of the prostate. This further exposes the prostate. The bladder neck is then carefully dissected around the prostate until the urethra going through the prostate can be seen entering into the bladder neck. The urethra is then divided over the urinary catheter creating a small normal-size bladder neck opening. The prostate is now completely detached from the bladder. This smaller bladder neck opening may help with faster return of continence and shorter catheter times (5-8 days vs. 2-3 weeks).

 

At this point, the nerve-sparing procedure is performed. The nerves and blood vessels (NVBs) are located posteriorly along the right and left sides of the prostate. From the diagram, you can see how these vital nerves and blood vessels are squeezed between the prostate and the the rectum.

It is relatively safe to dissect anteriorly, and Dr. Yew starts here where there are no nerves. He will find a correct plane that will allow him to get safely between the capsule of the prostate and the NVB. Robotic technology allow the prostate to be peeled away from the nerves (instead of scraping the NVBs off the prostate). This may minimize stretching injury to these delicate NVBs. A small amount of gentle sweeping away of the NVBs is usually required. In this area, the NVBs are extremely close to the surface (capsule) of the prostate. If too aggressive, it is possible to cut into the capsule of the prostate, and this could result in a positive margin. The magnified 3-D vision and absence of bleeding are crucially helpful here in visualizing the NVBs alongside the prostate. Fine flexible dissecting instruments are used to carefully surgically sweep the NVBs safely away from the prostate capsule.

All that remains now is the prostate connection to the urethra. The urethra is divided over the urinary catheter. The prostate is now completely detached and free. The previously detached bladder neck opening (see above) is normal-sized and about the same size as the urethra. The bladder opening is now pulled down into the pelvis and reconnected to the opening of the urethra. This water-tight connection is then tested by filling the bladder with water.

Before reconnecting the bladder down to the urethra, the NVBs for potency and continence can be seen nicely intact on either side of the rectum (prostate removed).

If necessary, pelvic lymph nodes are then removed from the regions surrounding the major blood vessels supplying the lower torso and legs. A new catheter is inserted to make sure it passes easily past the area Dr. Yew just reconnected. A soft plastic drain is placed through one of the port incisions. This drain will usually be removed before the patient goes home.

The prostate is placed inside a laparoscopic specimen bag and brought out through the middle (belly-button) port. This incision usually needs to be widened a bit to allow the prostate to be removed. Skin incisions are closed with dissolving suture or skin glue.↑ top

 

Can the nerves and blood vessels be saved in DVP?

Yes. In fact, the magnified 3-D vision and minimal bleeding are crucial in visualizing and gently preserving the neurovascular bundles (NVB) by moving them away from the prostate. If necessary, Dr. Yew can spare the NVB on one side only, if there is high-risk cancer on the other side. In this prostate photo, the right side is smooth and shiny where the NVB was gently swept away from the prostate capsule. On the left side, if you look closely, you can see extra tissue (containing cut NVB fibers) where the prostate was cut wider to make sure all the cancer on that side was removed.

 

Is DVP safe? Will my surgeon ever lose control of the robot?

DVP and robotic surgery, in general, is very safe. There are numerous redundant safeguards built-in to the da Vinci Surgical System. Dr. Yew will always be in control of the robot and your operation. If there is any malfunction, the system will automatically go into a safe passive mode that allows the robotic arms to move freely and passively allowing safe removal of the robotic instruments.↑ top

 

Is it dangerous if the robot system malfunctions?

No. There are many safety features to the robot. The robotic arms will go limp and be removed harmlessly. The rare times this occurs, it is usually only a temporary sensor alert. Dr. Yew has extensive experience with many robotic cases and can usually troubleshoot the sensor alert and resume the DVP safely. In the exceedingly rare event that the robot cannot be used, Dr. Yew is capable of performing the operation using standard laparoscopic technique (LRP) or via an open technique (RRP).↑ top

 

What are some possible complications of DVP?

Complications of DVP are identical to the open RRP operation. This is not a complete list or comprehensive discussion of complications. For a more complete and thorough discussion, please arrange a consultation your urologist. These are a few of the complications of DVP: Significant bleeding; however, this is much less common in DVP; Injury to the rectum since the prostate lies on top of the anterior surface of the rectum. If this happens, it can usually be repaired robotically without any long-term adverse effects. There can be a small intestine or colon injury. All of these surgical complications are very rare, and can usually be addressed safely using advanced robotic techniques. In DVP, the small puncture incisions in the skin are less likely to get wound infections compared to the much larger open incision in RRP. There is a remote chance of developing a bowel hernia exiting the umbilical (middle) port incision. This incision is usually opened up more at the conclusion of the case to allow removal of the prostate within a specimen bag. If this occurs, it can be repaired easily. ↑ top

 

What are the side-effects of DVP?

Early side-effects of DVP may include nausea from moving the intestines around and from the general anesthesia. Shoulder pain after surgery is due to left over carbon dioxide gas in the abdomen (not in the intestines) irritating the diaphragm. This pain resolves on its own as the gas is reabsorbed naturally. Swelling or puffiness of the face, abdomen, scrotum, and penis are due to bruising or carbon dioxide gas leaking into the tissues under the skin in these areas. This also resolves on its own. Some bruising around some of the port incisions and the scrotum can occur. Longer-term side-effects include impotence and incontinence; however, these often resolve.↑ top

 

What can I expect after DVP?

There will be some post-operative discomfort. Despite the tiny skin incisions, a major operation was still performed on the inside. Pain usually improves quickly. A urinary catheter in the penis, draining the bladder, remains in place to allow healing of the area where the bladder was reconnected to the urethra. A small plastic drain tube will exit the abdomen and empty clear amber to light red fluid into a plastic ball. This is a drain and is usually removed prior to leaving the hospital. After surgery, patients can take a walk and drink liquids (water or juice). Within the next 24-48 hours, patients are usually walking on their own without pain and eating regular food.↑ top

 

What can I expect at home after DVP?

Almost all patients feel well enough to go home the day after, or 2 days after, DVP surgery. They are given mild pain pills, a stool softener, and a short course of antibiotics for when they return in 5-8 days to have their catheter removed. They can walk and do light exercise as tolerated. Patients can eat regular food, but oftentimes, they will start with light foods and gradually progress to heartier meals. Patients should avoid constipation and straining. They may use any oral laxative. Patients should not place anything in the anus or rectum like an enema or suppository due to the close proximity of the rectum to the area where Dr. Yew removed the prostate. Dr. Yew prefers that patients not drive until the catheter is removed (5-8 days) and patients are completely off any narcotic medications (eg. Vicodin, Tylenol #3).

All of Dr. Yew's patients will be given nurse teaching and written detailed home care instructions prior to leaving the hospital. Dr. Yew's DVP Instructions can also be downloaded here.

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How soon can my urinary catheter be removed?

Typically 5 to 8 days after surgery. On rare occasions, there may be some internal leakage from the area where the bladder and urethra were sewn together. If this occurs, patients will usually go home with the plastic abdominal drain to prevent this fluid from collecting. In these rare instances, a special x-ray called a cystogram will be obtained to make sure the area is completely healed before removing the catheter.↑ top

 

Will I leak urine after my catheter is removed?

Maybe. Do not get discouraged. Some patients will have immediate bladder control and not leak any urine. Some patients will have leakage of urine requiring a pad or liner. Usually this improves dramatically within the first 1 - 3 months after DVP. In many cases, patients do not wear any pads, or wear a single thin liner pad only for precautions. Eventually, most are comfortable and confident enough to go without any pad protection at all.↑ top

 

When can I expect to have return of potency and urinary control after DVP?

Erectile function recovery can be variable. Some patients start having return of some function fairly rapidly. Many will have a more prolonged recovery period. Meticulous nerve-sparing technique during DVP is very important; but it is also important to consider the patient age and his erectile function prior to surgery. Older patients or those who already have some pre-existing impotence will have a slower recovery, and may have some lasting worsening of impotence after any treatments for prostate cancer. Recovery of potency can continue for as long as 18-24 months following surgery. In younger men who had excellent erectile function prior to bilateral nerve-sparing DVP, a majority are able achieve satisfactory erection and engage in intercourse within a year following surgery. Some men may require some pharmacologic assistance with Viagra, Cialis, Levitra, MUSE, or injection therapy.

Urinary control recovers much quicker with DVP, when compared to the open operation. About 90% of men consider themselves mostly dry by 1-3 months and require zero or less than 1 pad per 24 hours to control urine leakage.↑ top

 

Is there anything I can do to help the recovery of potency and urinary control after DVP?

There is recent research recommending early use of PDE5-inhibitor drugs like Viagra following prostatectomy to speed the return of erectile function. This therapy will probably not result in immediate erections after surgery or even improved erections. The drug is believed to act behind-the-scenes to rehabilitate the nerves, blood vessels, and erectile tissues of the penis while the patient sleeps, even if there is no obvious external signs of tumescence. This Potency Rehabilitation regimen should only be started under the guidance of Dr. Yew or your own urologist, and only if you are healthy enough to take these medications.

Regarding urinary control, the best scientifically proven way to help continence recovery is to start a regimen of pelvic floor exercises (a.k.a. Kegel exercises) before your surgery. This is true for any prostate cancer treatment you choose. These exercises should be continued after surgery once the catheter is removed. To do a proper Kegel squeeze, you need to first learn what muscle to squeeze. During urination, try to stop the flow of urine in the middle of the stream. Make a mental note of that muscle you used to stop the flow. Also, imagine you are in an elevator or public place and feel the urge to pass flatus (gas). The muscle you would squeeze to hold the gas in is also the correct pelvic floor muscle. Once you know it, you can squeeze and hold it for 2-10 seconds at anytime (not just while urinating). You can do them while sitting or standing, watching TV, standing in the grocery check-out line, etc. It can be dull and seem unrewarding, so it requires some discipline. It is helpful to establish a routine. For example, I suggest doing sets of 10-20 (or more) Kegel squeezes during every commercial break while watching TV, or at every stop light or stop sign while driving.

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What should I ask my urologist about my prostate cancer and DVP?

You should have a discussion with your urologist about all treatment options. Ask him about the specific features of your prostate cancer, like PSA, Gleason Score, and DRE (Digital Rectal Exam) findings (normal, abnormal, large, etc..). You should discuss with your urologist your overall health and ask if you are a good candidate for any surgical treatments for prostate cancer. You should be pro-active in obtaining as much information as possible, and ask your urologist for other sources of information or second opinions. These may be from a pathologist, radiation oncologist, medical oncologist, or even an outside urologist. You should ask your urologist if you are a good candidate for a minimally-invasive operation like LRP or DVP, and if he or she performs those operations. Regardless of the type of treatments your doctor offers (surgery or radiation), you should feel comfortable asking him or her about their experience and training. All operations, including radiation (brachytherapy), open RRP, LRP, and DVP, are challenging and require a skilled surgeon with appropriate training. Because of the very high learning curve for LRP and DVP, consider a consultation with a surgeon who has extensive formal fellowship training (beyond a weekend 2 or 5 day training course) at an accredited reputable center of excellence. You are the one having the operation, so you need to feel at ease and confident in your surgeon's professional demeanor, experience, and capabilities. Your caring competent physician should never be offended by your request and search for more information.↑ top

 

How do I find a surgeon who performs DVP?

Despite rapidly growing demand for the DVP operation, they are only being offered at relatively few hospitals around the country. In part, this is due to the relatively few number of highly-trained urologic surgeons capable of performing a high-quality DVP operation efficiently.

Here is a complete list of all surgeons in the United States who have completed the basic Intuitive Surgical robotic surgery training course.↑ top

 

Specific Patient Concerns

I have had previous abdominal surgery. Can I still have a DVP?

Probably yes. Previous surgery can create some scarring inside the abdomen, called "adhesions". This can cause intestines to be stuck together or even stuck up to the abdominal wall. There may be some added risks, such as a slower return of bowel function (nausea, vomiting, ileus) or a slight risk of bowel injury. Typically, a cautious, skilled surgeon will be able to free up the adhesions and proceed with DVP. Dr. Yew has taken care of DVP patients who have undergone prior ruptured appendectomy, cholecystectomies, colon and liver resections, aortic aneurysm repairs, and laparoscopic hernia repairs. Carefully dissecting these adhesions may add a few minutes to the overall operative time of DVP. ↑ top

 

I was told that I could not have an LRP because of my prior laparoscopic hernia repairs. Can I still have a DVP?

See above. Laparoscopic hernia repairs are a unique situation. The space that is created to repair the hernia laparoscopically is immediately anterior to the bladder and prostate. Also, hernia repair usually involves tacking synthetic mesh to the area. This causes dense scarring of the area that traditionally has made it near-impossible to safely perform a traditional open RRP or an LRP. With the enhanced 3-D vision, fine robotic dissecting technology, and meticulous technique, the bladder and prostate can be exposed, and DVP can be performed safely without injury or damage to the prior hernia repair. There may be a small added risk of bladder or bowel injury. Dissecting this scarred area may add a few minutes to the overall operative time of DVP.↑ top

 

I was told that I need to have radiation or hormone therapy (or both) because of my high PSA and bad Gleason Score on my biopsy. Is DVP a reasonable treatment for me?

Possibly yes. DVP may be a reasonable initial treatment option for select patients with "high-risk" prostate cancer. If you have a high PSA, high Gleason prostate cancer, there is a high likelihood that you may need additional treatments later (a.k.a. multi-modal therapy) regardless of what you choose as your first (or primary) treatment. Most of the other treatments for prostate cancer are better-tolerated after surgical prostatectomy. This is controversial."Salvage prostatectomy" surgery following failed radiation is fraught with difficulty and a high incidence of incontinence and impotence due to poor tissue healing from the prior radiation. Conversely, radiation following DVP is fairly well-tolerated with much-improved preservation of urinary control and, possibly, potency.↑ top

 

My PSA is rising after I had prostate radiation therapy. Am I a candidate for a Salvage DVP? What are the risks of Salvage DVP?

Yes. Salvage prostatectomy can be performed using the da Vinci robotic technology. In some ways, it is much better than the traditional open salvage prostatectomy operation. The largest problems with this operation are due to the extensive scarring, tissue changes, and poor healing caused by radiation. The radiated tissues around the prostate include the bladder, rectum, pelvic floor muscles, urethra, and urinary sphincter muscles. These tissues are weakened and tend to heal much more slowly. Because of the scarring, there is a significantly higher risk of rectal injury. This is a dangerous, high-risk operation regardless of the approach used, and it is not frequently offered to most patients following radiation failure. Most of these patients will be advised to go immediately on hormonal or castration therapy for their rising PSA. While this may be a prudent option, Robotic Laparoscopic Salvage Prostatectomy may also be a viable option. Dr. Yew believes that the ability to put the computer-enhanced 3-D vision system's "eye" right down by the prostate and rectum, the prostate can be meticulously dissected away from the rectum under direct vision without injury. To facilitate this dangerous part of the operation, in some cases, the rectum may be dissected away from the prostate via a perineal incision beforehand. If a rectal injury occurs, poor tissue healing from radiation may increase the chances of requiring a colostomy. After a successful salvage DVP, patients often will still experience considerable urinary incontinence and erectile dysfunction. This appears to be equal or perhaps marginally better than the results of open salvage prostatectomy. Some patients after salvage DVP or salvage robotic cystoprostatectomy (removal of bladder and prostate) have a satisfactory cancer response as demonstrated by a declining PSA.↑ top

 

I am 72 years old, and my urologist says I'm too old for prostate surgery. Am I too old for DVP?

Possibly no. This depends on many factors. Are you medically fit for any type of treatment? There is a perception that men who are in their 7th decades (or beyond?) of life may die from something other than prostate cancer before their prostate cancer progresses to dangerous levels. This is based on an old premise that presumes at least a 10-year life expectancy before proceeding with potentially curative prostate surgery. Today, many men are living full, functional, meaningful lives well into their 8th and 9th decades. Also, the physiological impact of DVP surgery appears to be less than open RRP. This may be a reflection of much decreased blood loss. So, healthy elderly patients may much better tolerate DVP than traditional open RRP. Also, the adverse consequences of DVP, such as incontinence, are much less than the traditional open RRP. However, typically, elderly patients may have slower return of urinary control and experience some degree of incontinence due to age-related factors. Also, elderly patients are more likely to have a decline in erectile function following any prostate treatments (even if the neurovascular bundles are spared during DVP surgery).




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