Robotic-Assisted Laparoscopic Radical Prostatectomy (RALP) Video Transcript


Part 1: Information for the Patient
Time: 17:21


Hello. You are watching this video because your doctor feels that you can benefit from robotic-assisted laparoscopic radical prostatectomy - also called RALP. The primary goal of this specialized surgery is cure of the cancer. This video will discuss the prostate gland, describe the surgery, its benefits, and some of the problems that may occur during and after surgery.

Feel free to pause this video to make a list of questions you have or information that is not clear to you. Your surgeon and health care team will spend time with you reviewing this information in greater detail and will answer any questions or concerns you may have. Please tell your doctor if there are recent changes in your health.

The prostate gland is part of a man's reproductive system. It is located in front of the rectum and under the bladder. It surrounds the urethra, the tube through which urine flows. The prostate, along with the seminal vesicles, produce most of the fluid that comes out when ejaculation occurs. During ejaculation, seminal fluid helps carry sperm out of the man's body as part of semen.

Substances produced by the prostate and seminal vesicles are important for reproduction.

Men who develop prostate cancer may choose to have a specialized surgery to remove the prostate. It's called robotic-assisted laparoscopic radical prostatectomy.

During the surgery, six - 1/4 inch to 3/4 inch punctures are made in the abdomen. A thin tube with a camera on the end is placed into one of the punctures to help the surgeon see inside the body. Long thin instruments are placed in the other punctures to help your surgeons manipulate organs and perform surgery.

The robotic machine has 4 arms, one for holding the camera and 3 which have instruments attached. The surgeon controls all of these arms. The robotic arms are placed through four punctures, and an assistant surgeon will work through the remaining two punctures.

The surgeon will separate the prostate from the bladder, remove the seminal vesicles and a portion of the sperm ducts, separate the prostate from the rectum, perform nerve-sparing in some men and divide the urine channel again at the tip, or apex, of the prostate.

After the prostate and seminal vesicles are disconnected, your surgeon will place the prostate inside a small plastic bag while it is still inside your body. The bag will be removed by enlarging one of the punctures.

The bladder will be reconnected to the urine channel by suturing the two together. A catheter - a small plastic tube that allows urine to drain - will be left in place to help this area heal.

The specimen will be sent to a pathologist who will carefully examine it. Your surgeon may decide to remove lymph nodes at the time of your surgery. If so, these will also be placed in the specimen bag for examination by the pathologist later.

A small plastic tube, called a drain, will be placed outside the bladder to collect fluid that can accumulate after surgery.

This drain is usually removed before you are discharged from the hospital, but in some cases it may need to stay in longer. If so, the nursing team will show you how to manage the drain, and your surgical team will give you follow up instructions for an appointment to remove the drain.

The following section will explain how several important structures near the prostate may be affected during surgery.

Urinary Control

The urethra, or urine channel, exits the bladder and runs directly through the prostate. After the urethra exits the prostate it goes through the pelvic diaphragm, which is the muscle that will help with urinary control after surgery. The urethra then enters the penis. After your surgeon has removed the prostate, the bladder is sutured to the urethra to restore the flow of urine. A catheter, or a small plastic tube, will be placed through the penis and into the bladder to allow urine to drain freely into a bag.

During the healing process you will wear the catheter to allow this area to heal. Your nursing team will teach you how to care for the catheter while you are in the hospital. The catheter is usually removed within one to two weeks. Ask your doctor how long you can expect the catheter to stay in.

After the catheter is removed you will be taught to do a special exercise, called a Kegel exercise, which may help speed the recovery of urinary control. We will talk more about the Kegel exercise in another section of the video. All men will have some loss of urinary control in the beginning. For most men, this improves quickly, within a few weeks. But, for others, improvement takes longer - a few months. By the end of the first year, 98% of men will have full control. Up to 30%, or 1 out of 3 men may have stress urinary incontinence. This means that some men may lose a small amount of urine during times of physical straining, such as sneezing, coughing or lifting heavy objects. These patients may need to wear a pad in their underwear for protection. Stress incontinence is permanent in some men.

Erectile Function

The nerves that control erections may also be affected during surgeries such as RALP. These nerves control only the ability to obtain an erection of the penis, and do not affect sexual desire, frequency of intercourse, sensation in the penis, ability to experience climax or bladder control. Their sole function is creating a stiff erection.

In order to preserve the ability to have erections after surgery, some men may be candidates for a "nerve-sparing operation".

Along with large blood vessels, the microscopic nerves travel on both sides of the prostate and are located in structures called "neurovascular bundles".

The nerve sparing operation is a very delicate surgery that gently 'peels' the neurovascular bundle away from the surface of the prostate, allowing the prostate to be removed while minimizing the effect on erections.

Men under 60 years of age who had good erections before surgery and in whom both sides of the neurovascular bundles are spared have the best chances for recuperating erections after surgery. Men who do not have rigid erections before surgery, or who are unable to sustain an erection during intercourse, may not have satisfactory return of erections even when both neurovascular bundles are spared. Some men who have just one side spared and the other side removed may also recuperate erections, but usually to a lesser degree. Erectile dysfunction - the inability to have an erection - will occur if both nerves are removed. Treatments are available for erectile dysfunction.

It is important for you to remember that the full recuperation of erections can take up to 2 years. During this time your urologist can offer you a variety of treatments for penile rehabilitation, which may both improve the recovery of your erections and allow you to become sexually active during this active period of healing. While a nerve-sparing operation may be planned for both sides, it is important to remember that at the time of surgery your surgeon may encounter situations that will make nerve-sparing difficult on one or both sides or find that nerve-sparing may compromise the cancer treatment aspect of the operation. In order to provide the best cancer treatment, your surgeon may need to remove one or both neurovascular bundles. For more information, ask your surgeon abut your chances of this happening.

Injury to the Rectum

The rectum is another important structure located very close to the prostate.

Injury to the rectum is unusual, occurring in 1% or less of patients.

Certain conditions such as prior surgery, hormone therapy, radiation treatment, infections and other causes of scarring to the area can increase this risk.

If an injury does occur and the rectum has been properly cleaned before surgery, it can usually be repaired at the time of surgery without significantly changing your recovery. However, if the rectum has not been properly cleaned, and the area of injury becomes soiled by stool, then a temporary colostomy may have to be performed. This is why it is very important to follow your surgeon's instructions for cleansing your colon before surgery.

Lymph Node Removal

Your surgeon may remove some lymph nodes during surgery. These small glands are located near the prostate and can be the first place prostate cancer spreads.

This procedure adds an additional 20 to 30 minutes to your operation, with minimal added risk.

Risks include damage to blood vessels to the leg and damage to a nerve that controls one of the groin muscles.

Injury to either is very rare. If your surgeon identifies a large amount of cancer in the lymph nodes during surgery, he or she may choose to stop surgery and offer you alternative treatments. Ask your surgeon if your lymph nodes will be removed.

Some patients may have microscopic spread of the cancer outside the gland that was not detected before or during surgery. This may result in a 'positive margin', which is identified after your surgery when the pathologist reviews the specimen.

After the prostate gland has been removed, the pathologist covers the outer aspect of the specimen with different colors of ink. Under the microscope, if there are any cancer cells touching the ink, than this is described as a 'positive surgical margin'.

Having a positive surgical margin may mean that there are cancer cells left behind; this is often, but not always the case.

Additional treatment after surgery may be necessary depending on the stage of disease, the aggressive nature of the cancer cells, the presence of cancer in the seminal vesicles or lymph nodes, if a positive margin is present or other findings.

If this occurs in your case, your doctor will discuss additional treatment options with you when you follow up after surgery.

The following section will discuss the risks associated with surgery and possible problems that may occur.

Surgery Risks

Although robotic-assisted laparoscopic radical prostatectomy is a minimally-invasive procedure, it is a major operation that carries the same risks seen with any major procedure, including infection, blood clots, bleeding that may require blood transfusions and death. Also, internal urinary leakage may occur which may require leaving the drain in place longer and also wearing the catheter for a longer period of time. For most cases involving internal urinary leakage, no additional procedures are necessary, as the body will heal itself when proper drainage with the drain and catheter is provided.

Other known risks seen following RALP include scarring in the urethra and permanent incontinence - the inability to control urine. This complication is rare, occurring in less than 2% of all patients undergoing RALP.

As mentioned previously, permanent erectile dysfunction - the inability to have erections - can also occur.

Equipment Problems

Occasionally, mechanical difficulties occur with the robotic machine.

The system has multiple built-in safety features to prevent using the machine when a problem is present, In many of these cases, our team can troubleshoot these mechanical issues and proceed as planned. In some cases, however, the machine cannot be used until an engineer arrives to address the problem.

If mechanical difficulties are identified before you are put to sleep, your surgical team will discuss with you how to best proceed. In circumstances such as these, your procedure may need to be rescheduled, possibly resulting in additional expense and inconvenience. Sometimes mechanical difficulties are identified after the patient is asleep and surgery has started. Please ask your surgeon what his or her strategy will be if this occurs. Performing surgery is somewhat similar to flying an airplane. Our goal as surgeons is to always keep the surgery as safe as possible. Mechanical failure may be outside of our control, and can greatly affect surgical efficiency and/or our ability to perform RALP. While very rare, if an irreversible mechanical difficulty is encountered after the surgery has started, we will use our best judgment as to how to proceed; in some patients it may be necessary to disconnect the robot, and make a traditional incision and complete the surgery in an open manner.

Reducing Risk

Your surgical and anesthesia teams will take measures to reduce the risk of complications by giving you antibiotics during surgery and other measures meant to reduce the risk of certain known complications.

But, as with any operation, risk cannot be totally eliminated. There is a chance that complications could result in the need for a larger incision. Ask your surgeon what the risk of this might be. Your surgeon and surgical team will try to identify and respond to any problems that occur as early as possible. There may be unforeseen and unexpected complications that require additional treatment. Fortunately, most complications are reversible, readily treatable and do not require additional major procedures.

Frequently Asked Questions

Not necessarily. As a man ages, his prostate may enlarge. Enlargement of the prostate may be caused by benign (non-cancerous) growth of the prostate (BPH) or by cancer. BPH can cause problems when urinating, while early stage prostate cancer does not usually cause symptoms. BPH is the most common cause of prostate enlargement. Some men have only BPH, some have only cancer, and some men may have both conditions at the same time. Having a very large prostate, however, can make any treatment more difficult, including robotic surgery.

After surgery, you will not need to take medications such as Proscar® , Avodart® , or Flomax®. If you are taking drugs such as Hytrin® or Cardura® - also called 'alpha-blockers' and which are sometimes used to control blood pressure - ask your surgeon or your family doctor if you should discontinue these.

Certain herbal supplements such as saw palmetto may have hormone-like actions and may affect aspects of your surgery. These substances can also lower PSA levels. Their effect on cancer is unclear, which could be misleading, as you and your health care team make decisions regarding your treatment based on PSA levels. Herbal and nutritional supplements may not be regulated by the U. S. Food and Drug Administration (FDA) in the same way that prescription medications are and may have highly variable or unknown interactions with prescribed medications and anesthetics. Tell your surgeon immediately, if you are taking herbal or nutritional supplements, homeopathic substances or if you utilize complementary or integrative medicine remedies.

A history of prostatitis, or infection of the prostate, can cause scarring in the area of the prostate. Tell your surgeon if you have had prostatitis in the past, or if you are prone to prostate infections. Active urinary or prostate infections should be treated before surgery.

Hormone therapy is sometimes used to try to slow the growth of cancer before surgery or to shrink a large prostate before additional treatment. Hormone therapy may cause scarring around the prostate and in some cases can make the nerve-sparing portion of the operation more difficult. In many cases, men who have been on hormone treatment for a long period of time are poor candidates for nerve-sparing.