“Robotic prostatectomy has superior or at least equal oncologic efficacy and complication rates compared to open prostatectomy,” writes Michael O. Koch, MD, from the Indiana University School of Medicine in Indianapolis. “I believe the most current literature supports that view and this debate should finally be put to rest.”
This is Medscape’s summary of an editorial that my mentor at Indiana, wrote comparing open and robotic surgery for prostate cancer. He has performed thousands of operations with both techniques and points out how robotic surgery does cost more, although only about $2000 more at high volume centers.
I first switched to robotic prostatectomy in 2004 and these conclusions were apparent to many surgeons that adopted and became proficient with robotic prostatectomy over a decade ago.
At six months, men who took a daily PDE5i had no SFPL loss, whereas those who did not take a PDE5i consistently had a significant mean 4.4 mm SFPL loss compared with baseline.“The present study is among the first to show preservation of SFPL in patients using daily PDE5i as compared with those patients not using regular PDE5i,” the authors wrote.
There have been reports of men having shorter penises after prostate cancer surgery for many years. This study looked at stretched flaccid penile length (SFPL) in men who were given phosphodiesterase inhibitors, like viagra, levitra, or cialis.
I have been recommending PDE5i for men for many years since the data shows that men who have good preoperative sexual function are more likely to have return of erectile function in assorter time if they take these medications after surgery. The same medication is used to have a full erection, but this use is more for penile rehabilitation after surgery.
This study shows taking PDE5i also helps prevent the shortening of the penis by 4.4 mm. This is about 1/5 of an inch.
This article describes that some men will have loss of urine during sexual intercourse. This usually happens during climax. The article refers to this problem as climacturia. I have seen men that recover normal erectile function, but have this problem of leaking urine during intercourse. It usually improves with time but not always. I have not kept accurate statistics on this problem, but have a feeling that it is less with robotic surgery for my patients.
Acting on anecdotal evidence, Dr. Nelson and his co-authors, Peter Scardino, MD, and John P. Mulhall, MD, assessed the erectile function of 250 men average age, 59±8 years pre- and post-radical prostatectomy. Of the men with baseline erectile function scores ≥24 mild to no dysfunction, about one-third 32% regained function; however, well over half 60% required medication to do so. Only 13% of men reporting mild to no dysfunction prior to prostatectomy reported returning to full baseline function at 24 months without medication.
This study from Memorial Sloan Kettering points out that it is important to explain to patients that the ability to achieve an erection is less after surgery. Many factors account for a patients ability to recover erectile function including, age, preoperative function, sexual activity, the type of nerve sparing that can be performed (based on the amount of cancer), skill of the surgeon, type of surgery (open vs. robotic), and other factors.
I try to give an estimate of the probability of the ability to get erections after surgery with and without PDE5 medicines (viagra, levitra, cialis) for each patient.
Eighteen patients with a prior LMH underwent RRP. Five of the 18 had bilateral LMH, with unilateral LMH in the remainder. Outcomes in this group were compared with 38 patients without prior LMH. There was no difference between the groups in terms of age, preoperative PSA, prostate size, preoperative Gleason score, or body mass index, and RRP was successfully performed in all 18 LMH patients. One of 18 patients had a postoperative complication (persistent JP drainage). Compared with the control group, differences in operative time and blood loss bordered on statistical significance.
Prior LMH is not a contraindication to RRP. While resulting in slightly longer operating times and higher blood loss, our experience suggests that RRP can be safely performed in these patients.
This study from the Medical College of Wisconsin showed how radical prostatectomy can be performed safely after laparoscopic hernia surgery with mesh. My experience with robotic surgery has been similar. Robotic prostatectomy after laparoscopic hernia surgery takes a little more time, but is not too much of a problem.
The first step where the bladder is moved out of the way is more complicated and performing a pelvic lymph node dissection is more complicated as well. Patients of mine who are at risk of developing prostate cancer sometimes develop inguinal hernias. If they are considering undergoing laparoscopic hernia surgery with mesh, I am comfortable with given them the OK.
I found an abstract about a way to manage urinary ascites that can rarely happen after dvP.
Conventional measures, including catheter traction, passive drainage, and needle vented Foley catheter suction, failed. On postoperative day 6 a unilateral nephroureteral stent was placed on intermittent suction.
Placement of one nephroureteral stent on suction device immediately stopped the urinary anastomotic leakage into the peritoneal cavity.
In case of a persistent urinary leak after RALP that fails conservative management, a nephroureteral stent on suction may aid to stop the anastomotic leak.
I have seen this problem a few times in the past 5 years. The best way to manage it, in my opinion, is to place a drain laparoscopically by the surgeon if one does not exist. I found that interventional radiology does not place as large a drain or in as good a place.
While I am placing the drain laparascopically, I also perform a cystoscopy to attempt to place 5 fr ureteral catheters for urinary diversion. I think the most important thing is to push the foley in away from the bladder neck. I think foley traction on the anastamosis is what keeps the opening open.
This is my first technique that I will be adding to a new section of the blog.
After watching many videos and trying different ways to approach an intravesical median lobe, I found a new way to take care of it.
The following video was uploaded to google video and shows the dissection of a median lobe.
In simple terms: The bladder holds the urine and then the urine passes through the prostate on its way out. The prostate needs to be removed completely in prostate cancer surgery. The prostate is separated from the bladder routinely during the operation.
The median lobe is the part of the prostate that sometimes pushes into the bladder. This is the main reason why some urologists elect to place scopes into peoples bladders prior to surgery. This is one of the most difficult parts of the operation for beginners and experienced surgeons. The video shows the prostate (yellow) being separated from the bladder (green). The stitch is placed into part of the prostate to lift it off of the bladder.
Instruments used: PK dissector (bipolar), hot shears (monopolar- setting coag only 30), 2 needle drivers
Suture: 2’0 vicryl on an SH needle. (I have used 0’vicryl on a CT-1 for larger median lobes)
Color scheme- Yellow- Prostate; Green bladder and bladder opening; Orange arrrow- foley
Genengnews.com: Robot Spurs Men’s Recovery After Surgery, Urologist Says at
NCCN Annual Conference
Even surgeons who once favored traditional ‘open’ methods of cutting and
suturing during prostate or bladder-cancer operations have learned to
love the joystick-operated robot, said Timothy G. Wilson, M.D., director
of the Prostate Cancer Program at City of Hope Cancer Center, at the
National Comprehensive Cancer Network’s 12th Annual Conference, March
Studies show that men undergoing radical prostatectomy go home sooner
and regain bladder control and sexual function weeks earlier when the
robot is employed, Wilson said.
‘If you can save somebody three months of diaper time, that’s
important,’ he said, noting that patients’ two top postoperative worries
are incontinence and impotence. Wilson predicted Food and Drug go-ahead
for other manufacturers’ robotic devices in the next few years, bringing
competition to a field now dominated by Intuitive Surgical’s da Vinci
device, approved in 2000 to perform advanced surgical techniques.
Surgeons are always trying to re-invent the wheel. This is a good, even
great thing. We try to make surgical techniques easier, quicker and less
This is a
study out of Miami claiming that pelvic drains are not required after
open prostate surgery.
There is a current debate in robotic surgery whether a drain is required
after a robotic prostatectomy. Personally, I think a drain is a safe and
easy way to manage a patient. It can prevent serious side effects such as
a urine leak. The drains are easy to remove and do not hurt when they come
out, typically the day after surgery.
I think JP drains can be a very useful thing to use. I know of robotic experts that still use them on every patient. If there are significant urine leaks, they are critical.
I routinely have stopped using them. My experience at Indiana for open prostatectomies was that they were not routinely used. I used them on my first 9 robotic patients and 17 of my first 27 patients.
The only downside of a drain is a small amount of discomfort as it is being removed.
The upside of not having a drain is that I allow my patients to shower the day after surgery if they do not have a drain. The incision I would normally put the drain through is closed with glue.
The risks of infection or a lymphocele from having a drain in place should be minimal as I haven’t seen any yet.
I have used them 9 times in my last 220 operations and have had 1 problem in not leaving it in. One man was doing well and went home after 36 hours and then returned to the hospital after 5 days with a urine leak in which he needed a drain put back in for. I also had one of my 9 patients that had a drain that was removed after 1 day and sent home return after 3 days with a urine leak. This leads me to conclude that drains are good to leave in if you think it will help, but also don’t hesitate to send a patient home with one if there is any concern about a possible urine leak.