Robotic Prostatectomy to Treat Prostate Cancer
A robotic prostatectomy involves the removal of the entire (radical prostatectomy) or part of (partial prostatectomy) the prostate gland in men due to prostate cancer or enlarged prostate or BPH. Dr. Engel most often performs prostatectomies robotically.
A robotic prostatectomy has now become a very routine procedure for Dr. Engel. He performs this surgery at George Washington University Hospital as this is where his surgical team is. They have together performed over 1000 prostatectomies together as a complete team (the majority), and Dr. Engel considers his team vital to achieving not only speed and accuracy, but also to the minimization of complications and the maximization of outcomes. With this level of experience, the overall complication rate is less than 1% in cases where other co-morbidities are absent.
Since 2004, when less than 5% of prostatectomies in America were performed robotically, Dr. Engel has seen this figure grow to well over 90%. As a pioneer in the field, it has been gratifying to Dr. Engel to be a part of this transition. Now, the robotic approach has become standard for Dr. Engel in nearly all of his abdominal surgeries such as partial nephrectomy, pyeloplasty, cystectomy for bladder cancer and distal ureteral surgery such as repair of ureteral injury, strictures and ureteral implantation.
How The Robotic Prostatectomy is Performed
This video represents an actual Robotic Prostatectomy
Warning, Content is graphic
On the actual day of surgery, patients will be asked to arrive early to GW Hospital, and will eventually come to the pre-operative area where they will meet representatives of all the teams associated with their surgery. This will include the pre-op staff, the anesthesiologist, the operating room nursing team, and Dr. Engel. Several consent forms will be signed, an IV will be started, and once all questions are answered the patient will typically receive medicine to relax them. From this point onward, there will commonly be little memory of the surgery. Loved ones will wait for Dr. Engel to meet them after the surgery, and the patient will ultimately wake up in the recovery room. In Dr. Engel and his team’s hands, this surgery typically will be performed in less than 90 minutes such that the patient will be in and out of the operating room in 2 to 2.5 hours. Dr. Engel will speak to the family at this point regarding how the operation went. Although of course the family will hope to hear news regarding the prostate cancer, there will typically be no information to share with them other than what to expect regarding recovery. In most cases cancer is not seen visually, and we must wait for the pathology report and more importantly their PSA three months later to determine if they are cured.
Since 2004, when less than 5% of prostatectomies in America were performed robotically, Dr. Engel has seen this figure grow to well over 90%. As a pioneer in the field, it has been gratifying to Dr. Engel to be a part of this transition.
Potential Complications of a Robotic Prostatectomy
All of Dr. Engel’s patients will have been fully briefed on all possible complications, but we will discuss the most common of them below. One of the most worrisome, and fortunately one of the rarest, would be an inadvertent injury to abdominal contents such as the intestines. This is the reason that all patients will undergo a formal bowel regimen beforehand. The risk of bowel injury is increased somewhat if a patient has had previous abdominal surgery, but in experienced hands this does not preclude the ability to perform robotic prostatectomy. Another possible complication of course is bleeding as is the case with all surgeries. In this case, it will almost always be slow bleeding and occurs in the recovery room. Very rarely, a transfusion, or even a trip back to the operating room is necessary. Other rarer complications are blood clots, scarring at the site of the surgery, lymph collections or events somewhat unrelated to the surgery such as cardiac events. For this reason, all patients will be asked to have a formal physical examination by their internist so as to minimize risk during surgery.
Recovery After a Robotic Prostatectomy
The patient will wake up in the recovery room with little pain, with a catheter in the bladder and a drain coming out of the abdomen. He will have been given a non-narcotic pain medicine already called Toradol, and will typically feel as if he must urinate. Once fully awake, this feeling dissipates.
After being in the recovery room for an hour or two, the patient will be moved to the surgery floor where all rooms are private and a loved one may stay in the room if they wish. That same evening, the patient will already sit in a chair and walk the first night, and will go home without the drain the next day. He will receive Toradol via the IV automatically, but few narcotics. This is to avoid constipation and speed recovery. The nurses will go over the care of the catheter at home which is a very simple affair. The patient will be given a prescription for a weak pain killer which is taken only by fifty percent of patients, and an antibiotic to be taken around the time of catheter removal.
Normal recovery means simply feeling better each day. If at any point one is not doing better each day, examples of which being increased pain, nausea and vomiting, abdominal distention, fevers, or leg swelling in one leg that does not go down with elevation (may be the sign of a blood clot),patients must go to the GW Emergency Room right away to be evaluated. A phone call will not typically suffice. In such a case, a patient must come to GW specifically so that Dr. Engel can manage the case personally. Conversely, things such as gas pains, bruising, swelling, or any other symptom or sign that is not making the patient feel worse overall is typically not a cause for concern.
Catheter Removal and Longer Term Recovery
By the time the patient comes in to have his catheter removed six days later on Tuesday, he will typically look very healthy. Patients will feel fully recovered by 10-14 days and may resume all activities at that point (other than driving which Dr. Engel advises to avoid for one month). Any activity that a patient feels he can do in this first two weeks is what he should do. By the same token, any food that is desired in this period is what should be eaten. Dr. Engel advises his patients that they should listen to their body and do what it tells one to do. It is nearly always right.
The catheter removal visit is used to teach pelvic floor exercises and to go over the pathology report. Regarding the pathology report, all that is truly pertinent will be the lymph node status. The presence of positive nodes means that the cancer has metastasized and the patient is not cured. Fortunately, this is rare. Virtually any other information on the report, which will state how much cancer was present, how aggressive it was, and whether the cancer was confined or not, will not tell us whether the patient is cured. For that, we must wait three months for the PSA, which should be zero at that point since the source of it, the prostate, has been removed. The main focus of this visit is to discuss incontinence. The act of removing the catheter is a chance to learn perfect pelvic floor exercises, so it is treated as a teaching point/lesson. The patient will be asked to demonstrate that they know how to squeeze the muscles they would normally use to stop their urine stream. Then, the bladder will be filled, and the catheter removed slowly. The patient will be asked to try to hold the water that had been put into the bladder. Then they will urinate and show that they can stop their stream just as they could before. Dr. Engel does not believe that formal Kegel exercises help. However, if one knows what movement will cause leakage, what should be done is simply to hold the urine during that action, and then relax when that action is over. An example is standing up or sitting down. If done religiously, a patient will have many opportunities to do this during the day. But never are they asked to do a “set” of 20 or so. What Dr. Engel’s approach does is lessen leakage, gives the patient a sense of control over the situation, and decreases but does not eliminate pad usage. For that, we must wait for the bladder to heal. That is a function of time, not exercise.
A more detailed discussion of post-prostatectomy incontinence is found here. The hope is that over the next three months the need for pads will resolve. First, one gets dry at night. Then, they are able to hold their urine to go to bathroom in the morning after sleeping. Then, they will stay dry until perhaps noon. The last thing to dry up is leakage in the afternoon, or after drinking alcohol. Patients return three months or so from catheter removal and will have their first post-operative PSA performed which should now be zero. At that time, most patients will be dry with their cancer cured. At this point, Dr. Engel will seek to formally address erections. Please see this discussed in detail here. However, Dr. Engel’s basic advice is to not expect return of erections with the aid of Viagra or another pill before 9-12 months. Dr. Engel was the senior author on the definitive American paper on whether the concept of penile rehabilitation, or giving medicines each day after prostatectomy for erections, is effective. View Dr. Engel’s bibliography here. Unfortunately, his study showed it was not, and has since been corroborated by an even more powerful European study. For this reason, Dr. Engel advises his patients that if early erections and sexual function are important to the patient and partner, he should strongly consider injections for erections at the three month point while he is waiting for his own function to return later on. The most motivated are taught injections by Dr. Engel personally. More commonly, patients choose to wait.
Outcomes of a Robotic Prostatectomy
Outcomes and the patient’s happiness are of the utmost importance to Dr. Engel. His pledge to all patients is to help them as much as they want to be helped for their erections. This holds true also for his commitment to seeing that none of his patients are forced to live with any degree of permanent incontinence if one is unlucky enough to have it, and roughly 5% of patients will have it. Such patients are offered minor procedures at one year after prostatectomy to eradicate their incontinence. Patients are seen every three months after surgery for the first year, and at each of these visits a PSA is performed, and a thorough discussion regarding any lingering incontinence, or progress with erections, are discussed.
Dr. Engel has always managed this aspect of prostatectomy personally for his patients, and insisted that patients follow up with him so they may be helped in this way. He feels that sharing his expertise regarding impotence and incontinence as equally important as his expertise in the operating room.