Radical prostatectomy, the surgical removal of the prostate, is one treatment option for fit men between the ages of 45 to 75 years who are diagnosed with significant localised prostate cancer.
Over the last decade, there was a transition from open/laparoscopic prostatectomy to robotic-assisted surgical system due to better vision, surgical access, shorter hospital stays, faster recovery to normal activity and earlier attainment of urinary continence.
The procedure involves going to hospital on the day of the surgery, being administered a general anaesthetic (one will be put to sleep completely) in the theatre, six small incisions (circa one centimetre) are done across the abdomen (tummy) and the robot is docked. The surgeon usually sits two metres away and controls the robotic arms remotely. The surgery takes anything between two to three hours.
The prostate is detached from its neighbouring structures: bladder, pelvic floor muscles, large bowel and urethra (water pipe). The bladder is then joined to the urethra. A catheter (tube) is introduced through the urethra to allow the joint to heal.
Ninety-nine per cent of the patients stay one night and the following day they can go home. In some centres nowadays, this is being done as a day case procedure.
The patient will continue their recovery at home. The catheter is removed within seven to 10 days. Typically, it takes six to eight weeks to get back to normal life. One is given laxatives, simple pain relief, leg stockings and a blood thinner (typically for four weeks) to minimise risk of blood clots.
It is imperative that one walks on a daily basis starting with short distances and building one’s strength week after week. No heavy lifting and no straining for at least eight weeks to minimise the risk of hernias (ftuq).
Surgeon experience is key for success
For the patient to get the best chance of cancer clearance, gaining back their urinary continence and achieving good sexual outcomes, the surgeon’s experience is one of the most important factors.
It is the patient’s right to ask their surgeon how long they have been performing the surgery, how many they perform per year (the number should be more than 50 per year; surgeons with over 100 robotic procedures per year have the best results) and ask about their continence rates (meaning how many of their patients are dry) as it bears a great impact on one’s life.
Investing in oneself
If one opts for surgery, then it is like preparing for a sport event. If you buy the most advanced technological running shoes but you do not train religiously, what are your chances to win/ finish the race?
Stop smoking and cut down your alcohol intake (this decreases anaesthetic complications and improves recovery). Increase physical activity no matter what level you are at. Eat healthier. Lose weight. Patients who are over 100kg have been found to be at an increased risk of complications from the surgery (like wound infections/chest infections/clots in deep veins) and poorer outcomes (like incontinence, etc). Shed those extra kilos. It does make a big difference.
Urinary leakage
One should be referred to a physiotherapist that specialises in teaching how to perform pelvic floor exercises. Start them weeks before the surgery. Once you have the surgery, stop until the catheter is taken out, then restart them again and never stop performing them. If you go to the gym and bulk up but then stop your training, the muscles will shrink; the pelvic floor muscles are no different. Your physiotherapist will guide you.
Erectile function and sexuality
The erectile concerns are typically swiped underneath the carpet as the priority is given to removal of the cancer. However, most men do enquire about them after they recover from their surgery.
When the prostate is removed, the surgeon may or may not spare the nerves for erection called neurovascular bundles. If the erectile nerves are spared, the chances of you gaining your erections are 50 to 70 per cent.
Men less than 64 years of age who have good erections before the surgery and in whom the erectile nerves can be spared have the highest chance of achieving their erections back. If one gains the erections they may not be as strong or last as long as before.
There are numerous treatments available that address erectile problems. There is nothing to be ashamed about; ask your surgeon or GP.
Other unmet needs
It is not uncommon that patients experience a myriad of symptoms/changes post-cancer treatment. Tiredness, weight gain, change in bowel habit, alternation in sleeping habit, itching, rashes and mood swings are commonly reported.
If you feel they are impacting your quality of life speak to your GP/ surgeon/ cancer nurse. Remember: there is always help.
Edward Calleja has been working as a consultant in pelvic robotic surgery and general urology since 2019 in Eastbourne hospital, Sussex, the UK. He is the first person from Malta to become a fully trained robotic surgeon.