Robotic Radical Prostatectomy (RALP)

The first stage of the operation consists in the creation of the pneumoperitoneum: the abdominal cavity must be filled with carbon dioxide to create a working chamber for the robotic surgical instruments.

An incision of about 2 cm at the supra-umbilical level allows the first robotic trocar to be positioned under direct vision and in a completely atraumatic way through which the optics that will allow the surgeon to perform the operation are inserted.

Subsequently, another 5 operative trocars are inserted into the peritoneal cavity, typically 3 of which are managed by the first operator and 2 by the assistant.

Although this is an extremely rare occurrence, it is possible that due to numerous and tenacious intestinal adhesions it is not possible to position the robotic trocars and it is therefore necessary to convert the operation to an “open” method.

The premise to consider before describing the intervention in detail is that the robotic technique allows you to operate with a visual magnification of up to about 20 times and with a 3-dimensional vision. This allows the surgeon to appreciate the depth of field, which is not possible, for example, with the classic laparoscopic technique. The robotic intraoperative vision allows to recognize even the smallest anatomical details and to perform the operation with a significantly higher accuracy than what is possible to obtain with open surgery or with classic laparoscopic surgery.

The first operative step is represented by the isolation of the seminal vesicles through a small incision made in the parietal peritoneum that covers the Douglas fissure, above the rectum. This approach allows perfect visualization of the seminal vesicles and, in particular, of the blood vessels and nerves that surround them. These latter structures are preserved and care is taken to never use thermal energy in order not to damage the rich peri-vesicular nerve plexus where nerve branches pass through to the corpora cavernosa of the penis and are responsible for penile erection.

Once the isolation of the seminal vesicles is completed, the pelvic space is accessed from the peritoneal cavity where the prostate is located.

In the event that it is oncologically necessary – that is, when the pre-operative parameters advise it – we proceed to the removal of the pelvic lymph nodes (lymphadenectomy), to which the lymph produced by the prostate belongs, bilaterally. Lymph nodes are small organelles that filter fluids and proteins from throughout the body. When an organ becomes ill with a tumor it is possible that some tumor cells leave its borders and are captured by the nearest lymph nodes. For this reason, in some patients with prostate cancer, lymph node removal is performed in order to obtain a more precise staging of the disease and also because the removal of any diseased lymph nodes can have a curative effect. The robotic technique makes it possible to perform, when necessary, extremely extensive and accurate lymphadenectomies and therefore lends itself to being used successfully even in patients with advanced prostate cancer.

The removal of the prostate takes place anterograde, i.e. starting from the bladder neck which is separated from the base of the prostate, taking care to preserve as much as possible the integrity of the muscle fibers of the bladder neck itself which participate in the mechanism of urinary continence.

Once this maneuver is completed, the previously isolated seminal vesicles are reached and the plane of prostatic detachment is identified, starting at 6 o’clock.

Depending on the characteristics of the disease (disease palpable or not on rectal examination, percentage of biopsies positive for tumor, aggressiveness of the tumor detected in the biopsies – Gleason score, preoperative PSA, magnetic resonance imaging results), an intrafascial (extremely adherent to the prostatic capsule) or interfascial (slightly more distant from the prostatic capsule) plane is identified, always paying the utmost attention to safeguard the nerves that surround the prostate) and we proceed with the antegrade isolation of the prostate.

Isolation of the prostate is performed paying the utmost attention to avoiding the use of any thermal energy in order to avoid damage to the periprostatic nervous tissue. Hemostasis is obtained with the application of titanium microclips (2 mm) or with very small sutures.

In some patients in whom the prostate tumor demonstrates pre- or intraoperatively that it also involves the rich web of nerves that surrounds the prostate gland, this must necessarily be partially or totally sacrificed to allow radical removal of the tumor and reduce the risk of positive margins on histological examination. In these cases the recovery of penile erection can be greatly slowed down or permanent damage to the erection can be created.

The section of the venous plexus of Santorini and its subsequent hemostatic suture with stitches placed under direct vision is carried out with the utmost attention to preserving the integrity of the external urethral sphincter, the main muscle responsible for urinary continence.

The urethra is then sectioned at the level of the prostatic apex and at this point the prostatic surgical piece, completely freed, is extracted from the abdomen through an operating port. When necessary, an intraoperative frozen histological examination is performed to evaluate the integrity of the prostatic surgical margins.

The operation proceeds with the careful treatment of haemostasis: any possible small source of bleeding is always controlled and as far as possible with mini clips and mini stitches.

The urethral-bladder anastomosis is performed with a continuous suture which guarantees an excellent seal and rapid recovery of urinary continence. A bladder catheter is placed and anastomosis leak test is performed.

A small drainage tube is placed in the pelvic cavity which allows monitoring of any loss of blood, urine or lymph.

The technique provides for the possibility of preserving the neuro-vascular bundles involved in the mechanism of erection on one side or bilaterally. The possibility of preserving them depends on the local anatomical situation of the patient, on the oncological situation, i.e. on the possible extension of the prostate disease, and on anatomical-surgical factors, i.e. on the technical possibility of carrying out this type of operation.

As early as six hours after the end of the operation, the patient can usually resume drinking and eating progressively. The patient is made to get out of bed already in the evening or on the first postoperative day  and, compatibly with the natural recovery of his energies, he is mobilized to an ever greater extent. It is advisable for the patient, as soon as he feels able, to take walks in the corridor, favoring the resumption of normal circulation, to avoid the formation of thrombi in the veins of the lower limbs and to facilitate the resumption of intestinal activity. In fact, it should be considered that the resumption of walking is the best natural laxative.

The bladder catheter, which is positioned during the operation, is kept in place for a period usually ranging from 10 to 15 days, depending on the local intra-operative conditions and the post-operative course. On rare occasions it may be necessary to keep the bladder catheter in place for longer, but usually no longer than 3 weeks.

The patient who is discharged from the hospital with indwelling bladder drainage or catheters receives an appointment to return to our clinics after a few days to remove them.

On the basis of the definitive histological examination and the first PSA performed three months after the operation, the patient can be kept under observation, because it is believed that he has recovered with the surgery, or a cycle of radiotherapy on the prostate cavity and lymph nodes can be suggested. The use of radiation therapy is usually considered in patients with extensive and very aggressive prostate cancer. Some patients in whom radiation therapy is given postoperatively may also require a period of androgen deprivation drug therapy to increase radiation efficacy.

In most cases, no therapy is needed immediately after surgery and follow-up is based on the evaluation of PSA values, a molecule produced almost exclusively by the prostate gland and easily measurable with a blood test. After radical prostatectomy, PSA typically reaches values below 0.01 ng/ml. This indicates the complete removal of the tissue of prostatic origin. However, the presence of aggressive disease not confined to the prostate may cause PSA values to rise during follow-up.

The finding of two or more consecutive PSA values ≥0.2 ng/ml is defined as biochemical recurrence. While 90% of subjects with low PSA values at diagnosis and mildly aggressive disease are recurrence-free at 5 years, this percentage drops to 65% when patients with high PSA values at diagnosis (>20 ng/ml), aggressive (Gleason grade 8-10) or locally advanced disease are considered. These results are superimposable if not superior to what observed with open surgical therapy and in line with what is reported by the most numerous international case studies.

The identification of patients with biochemical recurrence is essential for the possible administration of rescue therapies such as radiotherapy or systemic therapies aimed at reducing the risk of distant recurrence. These therapies are associated with excellent long-term results. For example, radiotherapy is able to reset the PSA values in about 80% of patients treated early after finding a biochemical recurrence.

If all operated patients are considered, regardless of the operator, complete recovery of urinary continence without the need to use diapers was observed 3, 6 and 12 months after surgery in approximately 60%, 80% and 95% of patients. These percentages depend significantly on three factors:

1. Surgeon performing the surgery;
2. Age of the patient and general physical conditions (in particular the presence or absence of urinary disorders before surgery and level of body overweight);
3. Prostate disease stage.

Complete recovery of penile erection in patients with perfect sexual function before surgery was observed at 3, 6 and 12 months after surgery in approximately 30%, 50% and 70% of patients. These percentages depend significantly on three factors:

1. Surgeon performing the surgery;
2. Age of the patient;
3. Any risk factors for erectile dysfunction present before surgery (e.g. high blood pressure, obesity, diabetes mellitus, cigarette smoking).

ADVICE ON DISCHARGE

Power supply

• The patient can resume his usual diet gradually and progressively;
• In the first month after the operation it is important to drink at least 1 and a half liters of water a day and a moderate consumption of alcohol is acceptable;
• To resume normal intestinal function it is particularly important to vary the diet by enriching it with fresh fruit such as kiwi, cooked fruit and vegetables (at least twice a day), in order to avoid constipation. It is very useful to drink 1 tablespoon of extra virgin olive oil with main meals. As a goal, the patient should try to have a bowel movement once a day, in order to avoid particularly hard stools which could cause difficulty in defecation with consequent excessive abdominal thrusts – potentially harmful after prostate surgery. If this does not happen, the patient can try taking vaseline oil. It is advisable not to use enemas or bulbs during the first month following surgery; in fact, in this period the walls of the rectum are very thin and therefore you could cause damage.

Physical activity

After discharge from the hospital, the patient can gradually and with common sense resume his physical activity. He can walk, go up and down stairs. Car driving can generally be resumed 2 weeks after surgery.

Excessive efforts, such as lifting heavy objects or performing strenuous exercises (gym, golf, tennis, running), should be avoided during the first 3 weeks following the operation. It is also important to avoid the use of a bicycle or moped/motorcycle during the same period of time. In fact, this is the time required for adequate scar tissue to develop in the areas affected by the surgery. If you undertake strenuous physical activities before you should, you could damage the delicate structure that connects the bladder to the urethra; this could lead to long-term problems related to continence or even cause a hernia at the site of the wound.

For the first 4 weeks, try not to sit in a hard, straight-backed chair for more than an hour. Prefer comfortable chairs with more inclined backrests (for example reclining chairs, sofas or armchairs with footrests).

This behavior is useful for 2 reasons:

1. allows you to lift your legs, thus promoting venous return to the heart (reducing the risk of deep thrombosis, see below);
2. allows you to avoid placing all your weight on the areas of the perineum affected by the operation (between the testicles and the rectum).

4 weeks after the operation, he can resume all the activities  carried out before the operation.

Abdominal pain. Abdominal pain is frequent but mild and present especially the day after surgery. It is generally due to the air in the intestine and/or the resumption of intestinal peristalsis (movement): it passes quickly with the restoration of normal intestinal activity and therefore in this phase analgesics are useless, if not counterproductive.

In rare cases, typically in the first 24-48 hours after removal of the bladder catheter, acute abdominal pain localized particularly in the lower abdomen may develop and typically begins at the end of urination. Often this so strong and sudden pain depends on an incomplete seal of the urethro-bladder anastomosis with consequent leakage of urine that irritates the intestine and produces pain. The pain typically resolves as the bladder catheter is repositioned.

The wound. The stitches of small skin wounds can be absorbable or non-absorbable (stitches or metal clips). In the first case they must not be removed as they are absorbed by the skin, in the second case they will be removed approximately 2 weeks after the operation. In any case, the shower can be taken about 15 days after the operation, after removing any non-absorbable stitches.

A small proportion of patients may develop wound infection. This is manifested by the leakage from the wound of clear material (serum) or blood mixed with pus. Adequate dressing of the wound and possible antibiotic therapy can in most cases resolve the complication.

Deep vein thrombosis. During the first 4-6 weeks after surgery, deep vein thrombosis affecting a lower limb may occur in about 1% of cases. The onset of deep vein thrombosis can produce pain in the calf, swelling of the ankle or leg and be associated with a red and warmer limb than the contralateral one. Sometimes fever may appear. Although very rarely, these thrombi can detach and reach the lung causing a very serious condition called pulmonary embolism. This manifests itself in chest pain (especially after taking a deep breath), shortness of breath, sudden onset of weakness and feeling faint. It is important to recognize these signs immediately and go accompanied immediately to the emergency room.

Urinary tract infections. They can happen when a bladder catheter has been held for a few days. They can manifest themselves in various ways (burning after urination, cloudy and foul-smelling urine, fever, chills, etc.). In these cases, a complete urinalysis and a urine culture with susceptibility testing allow the pathogen responsible for the infection to be identified. Treatment consists of the use of appropriate antibiotics.

Sediment in the urine. This can occur due to the leakage of old clots that were present in the bladder. Urine usually remains red or pinkish for at least 15 to 20 days after the catheter is removed. Abundant hydration (drinking at least 1.5-2 liters of water a day) can help make your urine clear.

Swelling. The scrotum and penis swell frequently because lymph can collect at this level. If this should happen, it is useful to lift the scrotum itself towards the abdomen, placing a rolled up towel underneath, between the legs. Genital swelling usually lasts a month and disappears spontaneously. An ice pack can sometimes relieve discomfort from this swelling. If the feet, legs or thighs swell, there may be lymphatic stasis (lymphoedema) or blockage of venous circulation (deep vein thrombosis, see above), which is why this complication requires an adequate diagnosis to establish the most suitable treatment.

Skin hematomas. In some cases, skin hematomas are observed, especially on the sides and genitals, due to surgical procedures, or in the subcutaneous injection sites of the anticoagulant. They disappear on their own in about 1 month.

Removing the bladder catheter. The catheter is generally removed 10 to 15 days after surgery. In rare cases it may be necessary to keep the catheter in place for longer. The patient is usually discharged with the catheter in place. It is important to always keep the catheter open, connected to the urine collection bag and never to the cap.

The patient can use the collection bag that attaches to the calf or thigh when they want to go for a walk. Care must be taken not to yank the catheter. If this should happen, it is probable that the urine turns red or that blood comes out next to the catheter itself.

In this case you have to drink a lot in order to clear the urine.

The bladder catheter is held in place by a balloon inflated in the bladder. Very rarely (1 in 200 patients) the catheter can accidentally dislodge due to balloon rupture. In this case it is important that you go to the nearest Emergency Department as it may be necessary for a urologist to place a new bladder catheter.

Resumption of urinary continence after removal of the bladder catheter occurs gradually and progressively.

The removal of the entire prostate gland is followed by the subsequent reconstruction of the urinary tract by means of anastomosis between the bladder and the residual urethral segment: this obviously guarantees the integrity of the channel which conveys urine to the outside, but does not allow adequate compensation for the loss of the closing mechanism guaranteed by the sphincter which is largely forcibly involved in surgical removal, in some cases giving rise to uncontrolled urine losses.

The anatomical structures that are usually not involved – unless they have undergone radiotherapy – are the muscles of the perineum (which is often called the “pelvic floor” precisely because it closes the abdominal cavity at the bottom) and which is the lozenge-shaped muscular area that is placed on the saddle when riding a bicycle and which supports the bladder and the last portion of the urethra.

Therefore, after surgery, continence is determined only by the function of the external sphincter with the support of the muscles of the perineal plane.

Rehabilitation treatment aims to strengthen the muscles of the perineal plane, improve their strength and their constant “holding” throughout the day, in relation to breathing and increases in intra-abdominal pressure, which occurs in the event of a cough, getting up from a chair, lifting a weight.

There is scientific evidence that suggests that these exercises can contribute to the prevention and treatment of any urinary and sexual problems with the aim of having a positive impact on the quality of life.

Post-operative rehabilitation is therefore divided, according to the problems present, into the use of different techniques:

• voiding education, together with the sharing of suggestions relating to lifestyle and the way and amount of drink intake
• kinesitherapy for strengthening the perineal muscles is complete, focusing in particular on the anterior muscles (the one that surrounds the urethra, not the anus muscles, which are posterior and essentially useless for blocking the flow of urine); depending on the recovery obtained, the exercises can become increasingly demanding, up to being performed with the telemetric Biofeedback technique (with anal manometer probe) during the execution of more demanding physical activities (jumping and running on the spot)
• in particular situations, functional electrical stimulation is used, which has as its objective not only the strengthening of the muscles, but the awareness of the perineal plane and the possible inhibition action on the contraction and emptying of the bladder. In addition to the usual technique which involves the use of anal probes with ring electrodes, the more recent SANS technique is preferentially used, which involves the stimulation of the posterior tibial nerve of the lower limb in case of urge incontinence

A personalized pharmacological medical treatment can help address post-surgery problems and improve the quality of life in the first months after surgery, accelerating the recovery of bladder function.

It is recommended to use absorbent devices until adequate urinary continence is restored.

The fundamental requirement for the return of spontaneous erections is the preservation, during the operation, of the nerves responsible for the mechanism of erection.

the return of sexual function therefore depends on age, preoperative sexual potency and tumor extension which is the key parameter in determining the surgical technique.

After the operation, erotic erections will resume first, i.e. those stimulated by adequate sexual excitement, only then the “psychogenic” or “nocturnal” erections that every man is normally used to seeing: these can take up to 2 years to reappear.

It is therefore important that the patient “practices” with his sexual activity which must be considered as a real rehabilitation gymnastics. The first favorable sign during sexual activity is to see a lengthening and enlargement of the penis at the moment of maximum excitement, even in the absence of rigidity. In the first months after surgery, sex is typically non-penetrative, but all patients still manage to reach orgasm. It should be remembered that the removal of the prostate involves the disappearance of the ejaculation and that therefore after the surgery the patient becomes sterile. If the patient is interested in having children after surgery, it is important that cryopreservation of the semen is performed before admission to the hospital, so as to be able to proceed with any assisted fertilization later.

Some practical tips to resume sexual activity quickly and well:

1. Lubricating the penis and vagina before intercourse with any vaseline-based gel or oil helps a lot (such as Johnson and Johnson oil)
2. Kneeling or standing during intercourse improves erections
3. Once the erection is obtained, a normal rubber band can be placed at the base of the penis which facilitates the entrapment of blood inside the penis.
4. You don’t wait for “the perfect erection” before having sexual intercourse. Try to have intercourse even if the erection is partial. Sexual activity facilitates the recovery of one’s abilities.
5. It is important to note that initially the sex is not penetrative since the necessary penile rigidity returns in a few months. In the first period after surgery, sex is therefore masturbatory, but equally pleasant. It is important to masturbate frequently (at least 3 times a week) because this is the most effective form of penile rehabilitation gymnastics
6. The orgasm will not be followed by the emission of seminal fluid, as the seminal vesicles and the prostate were removed during the operation. A condition of permanent sterility has therefore been created.
7. It is always useful to completely empty the bladder before each sexual act to avoid the phenomenon of urinary incontinence at the moment of orgasm.

The achievement and maintenance of an erection can be facilitated or obtained by the use of drugs that improve blood circulation inside the penis or micro-injections that promote blood flow to the penis. The vacuum device can also help to obtain an early recovery of the erection and to avoid the possible shortening of the penis.

For the management of any post-operative erectile dysfunction, the patient can contact the Urologist of reference.