Prostate removal is an effective and safe option for the treatment of prostate cancer. Although many methods of removal exist today, the goals are always the same – remove the entire prostate while leaving the surrounding important structures as undisturbed as possible. The prostate serves only to produce the seminal fluid expelled during ejaculation. The ability to achieve orgasm (and the associated sensation) is not directly affected by removal of the prostate. However, the delicate structures surrounding the prostate are responsible for urinary, erectile, and some bowel function.
Robotic technology enhances the expertise of the surgeon during prostate removal. By more precisely separating the prostate from the surrounding tissues, our ultimate goal of cancer cure while maintaining urinary and erectile function can be more readily achieved. Of course the daVinci robotic system is only a tool; like any instrument, it is only as good as the surgeon behind it. Early in 2000, Scott D. Miller, MD performed the first laparoscopic radical prostatectomy in the state of Georgia. After several years developing this technique and achieving results clearly superior to open surgery, Dr. Scott Miller applied this expertise to the first robotic prostatectomy in Georgia in 2003. He since developed a unique method for nerve preservation (the SPECIAL™ technique) which also enhances other portions of the procedure. Using the SPECIAL™ technique now since 2005, functional results have reached a new level. By combining the experience of more than 2,500 major laparoscopic surgeries since 1995 with almost 2,000 laparoscopic and robotic prostate removals, state-of-the-art technology meets the ultimate in technique. Currently he performs approximately 200 robotic procedures yearly, in addition to 50-100 laparoscopic surgeries for other urologic disorders.
Robotic prostatectomy is a laparoscopic procedure, only with an added layer of technology. As with other laparoscopic procedures, the surgeon makes a button-size incision in the abdominal cavity for the insertion of a telescope (in this case near the belly button). After expanding the abdominal cavity with carbon dioxide gas, five additional small incisions are made to place narrow tubes used for interchangeable instruments. The robotic device is then wheeled up to the patient and the robotic arms are attached to the telescope and three of the instruments. The surgeon then sits at the control console a few feet from the patient, leaving the surgical assistant and scrub nurse at the patient’s side.
The surgeon then views a highly magnified, three-dimensional image of the patient’s interior structures. All movements of the camera and robotic instruments are precisely performed in real-time by the surgeon with ergonomic finger controls. The tips of these instruments can make any wrist-like turn that the surgeon so desires. The prostate is carefully separated from the delicate surrounding structures using tweezers and scissors the size of a fingernail (although these scissors appear to be the size of hedge clippers to the surgeon). The prostate is placed in a small plastic bag, later to be removed in one piece through the initial small incision. The urethra (urinary tube) is meticulously reconnected to the bladder opening and a urinary drainage catheter is placed through this natural passage. The skin openings are closed with shower-resistant glue as a substitute for both stitches and bandages.
Just like the human face, different prostates share common features, but no two are alike. Prostate removal is very unforgiving. Therefore, strict adherence to the anatomical roadmap is essential in order to achieve cancer control along with preservation of urinary and sexual function. Dr. Scott Miller optimizes robotic prostatectomy by incorporating several high-level techniques and innovative philosophies.
Results & More
Robotic prostatectomy facilitates quicker recovery, less pain, decreased urinary catheter time, and less blood loss as compared to the typical open-incision radical prostate removal. However, these are only minor considerations when compared to the benefits resulting from the high level of surgical precision inside the body. Obviously, the primary goal is cancer cure. Experience, continual technical modifications, and judicious self-evaluation (outcomes analysis) are essential to assure complete removal of all prostate tissue. After the prostate is removed, the PSA should remain undetectable in blood tests. A detectable level of PSA in the blood is the earliest indicator of cancer recurrence. As our laparoscopic and robotic prostatectomy experience rapidly approaches the 2,000th patient mark (some of whom have been followed for greater than seven years), our PSA recurrence data has either matched or surpassed any other published series for open-incision prostatectomy. When looking at our pathology results (microscopic examination of the entire prostate), if the cancer is truly confined to the prostate, our positive margin rate (cancer at the edge of the prostate) is less than 10%. Even if the cancer is beyond the borders of the prostate, more than two-thirds of our patients will still have clear margins.
Removing the entire prostate without injuring the surrounding structures can be a challenging endeavor. Meticulous separation of the prostate from both the bladder and the urethra (urinary tube) facilitates the return of urinary control after prostate removal. All surgical maneuvers are based on the anatomy at hand. Arbitrary decisions to cut “wide” in an attempt to improve the cure rate can cause the surgeon to stray away from the normal anatomic roadmap. As a result, prostate tissue can be left behind. Our method of carefully protecting and reconstructing the urinary control mechanism has resulted in greater than 95% of our patients being dry once fully healed.
The Holy Grail of prostate cancer treatment is preservation of erectile function. The nerves that supply this function lie intimately along the undersurface of the gland adjacent to the blood supply entering the prostate. These blood vessels must be controlled without “controlling” the nerves. In order to perform a true nerve-sparing prostatectomy, we must avoid not only cutting, clipping, tying, or burning the nerves, but also causing any disturbance to these delicate structures. To this date, the most common methods for performing this portion of the procedure involve either heat or clips. However, Dr. Scott Miller developed the SPECIAL™ technique in order to avoid pitfalls common with other methods of nerve preservation. As a result, 90% of patients with normal pre-operative erectile function will be able to consistently complete intercourse within 12 months of surgery, although some will require the use of oral medication. Thirty percent will achieve this success as early as six weeks, and greater than 50 % will reach this goal at 4 months.
Using Barbed Suture to Facilitate Nerve Sparing During Robotic Prostatectomy
This “set-up” is the key to subsequent suture placement. In fact, this technique can facilitate other methods of vascular pedicle control (Hem-o-lock clips, for example).
Here is the novel suture placement. See the original SPECIAL technique video to learn the finer points of how to pass this needle.
This clip demonstrates the nerve dissection following vascular control. Note that the previously placed suture is held in place to eliminate the need for direct nerve bundle manipulation or traction.
This clip demonstrates two methods for controlling bleeding vessels after nerve dissection. Note that no coagulation (heat) was applied.
This unedited clip demonstrates how both vascular pedicles can typically be secured by V-loc sutures in less than 5 minutes. Note that the clip includes instrument changes at both the beginning and end of the video.
Q: How long do I need to wait after my biopsy to undergo a robotic prostatectomy? A: Dr. Scott Miller recommends a minimum waiting period of 8 weeks following biopsy prior to proceeding with robotic prostatectomy. Significant inflammation occurs after a prostate biopsy resulting in temporary distortion of the anatomy (particularly when operating under such extreme magnification). Since prostate cancer is such a slow growing disease, this relatively short wait does not impose an appreciable risk.
Q: Will I have full control of my bladder once the urinary drainage tube is removed following the procedure? A: Temporary loss of some urinary control is not unusual immediately following catheter removal. Urinary leakage can occur in varying amounts for a variable period of time, depending on the individual. The muscles that control urination become lazy over time from having a prostate partially blocking the urinary flow. Once the prostate is removed, these muscles need to work a little harder. Return of urinary control almost always returns, especially for patients in their fifties and younger. Once this control has returned, the function of these muscles will remain unless a new problem arises. In patients that are approaching age 70 at the time of diagnosis, the risk of urinary leakage is somewhat higher.
Q: Will I be able to have sexual intercourse immediately after my urinary drainage tube is removed following the procedure? A: Patients with normal erectile function prior to surgery have approximately a 90% chance of regaining most of this function following bilateral nerve-sparing robotic prostatectomy by Dr. Scott Miller (using the SPECIAL™ technique). Since this recovery can take some time, less than one third of patients will have a full erection within a month. Although surgical precision is the most important factor for recovery, diligent erectile rehabilitation on the patient’s part is essential for the highest level of success. Patients requiring removal of one nerve, or those with compromised pre-operative erectile function, will have a lower likelihood of return to previous function.
Q: Does robotic prostatectomy affect bowel function? A: Typically robotic prostatectomy has very little long-term effect on bowel function.
Q: Can the surgeon see the cancer when performing a robotic prostatectomy? A: Microscopic examination by the pathologist is required to visualize cancer cells. The high level of magnification used during robotic surgery helps ensure complete removal of the prostate by revealing subtle anatomic details.
Q: How does prostate removal affect fertility? A: Following prostate removal, fathering a child is not possible through natural means. However, sperm can be withdrawn directly from the testicle for use with in vitro fertilization. A patient can also bank sperm prior to surgery.
Q: How much pain can I expect after the procedure?
A: Pain is typically less with laparoscopic procedures when compared to open-incision surgery. Some abdominal cramps and shoulder discomfort can occur from the carbon dioxide gas used during surgery. This type of pain is best treated with anti-inflammatories rather than narcotics. Bladder irritation (spasm) from the catheter can occasionally cause an uncomfortable urge to urinate. This symptom can be confused with pain but is best treated with anti-spasmodics. Although everyone is different, post-operative discomfort is usually easily managed and short-lived.
Q: How long does the surgery take Dr. Scott Miller to perform? A: Although many variables can affect the time necessary for Dr. Scott Miller to meticulously perform the surgery, he usually completes the procedure in two hours. However, the time away from family members also includes preparation (30-40 minutes), anesthetic reversal (15-20 minutes), and recovery room stay (2 or more hours). Dr. Scott Miller asks patients to arrive two hours prior to this process, during which time family members can remain present. Occasional updates are given to the family by the operating room nurse. Dr. Scott Miller will come to the waiting area when the patient is ready for transfer to the recovery room.
Q: How long do I stay in the hospital following surgery? A: Most patients are ready for discharge on the day following surgery.
Q: How long will I need a bladder drainage tube (Foley catheter) following surgery? A: Most patients require a catheter for only 5-7 days. The planned day for removal is determined at the time of surgery (based on each patient’s individual anatomy).
Q: What happens if the robot experiences mechanical failure? A: Dr. Scott Miller will disconnect the robotic arms and complete the procedure laparoscopically through the same narrow tubes. Unlike most robotic surgeons, Dr. Scott Miller acquired a vast experience with laparoscopic prostate removal prior to the availability of robotic technology.
Q: What happens if I have an erection while the urinary drainage tube is still in place? A: In such cases, no damage will occur. If it becomes uncomfortable, a cold compress can help reverse the process.
Q: Is “bruising” normal after a laparoscopic procedure? A: When a narrow tube is placed through a button-size skin incision, a small blood vessel just below the skin can break. However, since the snug fit of this tube will compress the blood vessel during surgery, bleeding will often not occur. If this blood vessel were to re-open at a later time, a small amount of blood could track over a large surrounding area (including the genitalia). This is not a true bruise but will have the same appearance. Most important, this finding is not an indication of internal problems.
Q: Does the robot perform the surgery? A: No. Dr. Scott Miller performs all robotic instrument and camera movements in real time with the controls at the surgeon’s console. By no means is the robotic device programmed to execute any maneuver on its own.
Q: What is the function of the neurovascular bundles referenced when speaking of a nerve-sparing prostate removal? A: This delicate nerve tissue is necessary for initiating an erection. These nerves have no direct role in penile sensation or sexual climax.
Q: When can I return to work or other normal activities following my surgical procedure? A: Dr. Scott Miller recommends at least two weeks away from work. Very few jobs would require more than four weeks of leave. In many cases, a small amount of light work-related duties are acceptable during the first two weeks. All patients should move around frequently from the time of surgery and resume light exercise at one week (gradually increasing to a normal routine by four weeks). Driving a car is often reasonable in approximately one week if reaction time is good. Of course, Dr. Scott Miller will provide guidance for each individual situation.
Q: Why do I still need PSA blood tests following my procedure if I no longer have a prostate? A: Prostate-specific antigen, or PSA, is a protein made by any type of prostate cell. Some of this protein is released into the blood stream and can be measured with a simple blood sample. After successful robotic prostatectomy, this test should fall to an undetectable level. Since all normal prostate cells are removed with the surgery, even a very small reading of PSA raises the concern of residual prostate cancer cells somewhere in the body. As a result, PSA becomes a very sensitive test for post-surgical surveillance.
Q: Are lymph nodes removed during a robotic prostatectomy? A: In low risk patients, lymph node removal is often unnecessary unless they appear abnormal at the time of surgery. Removal of lymph nodes does not typically improve cancer cure rates. Although relatively safe, this procedure does carry some risk.
Q: Does prior hernia repair preclude me from being a candidate for robotic prostatectomy? A: Because Dr. Scott Miller has an extensive experience with complex laparoscopy, he is very comfortable performing robotic prostatectomy in patients who have had mesh placed in their pelvis.
Q: Why can the urinary drainage tube be removed so early after robotic prostatectomy when compared to open-incision radical prostate removal? A: With open-incision surgery, connecting the urethra to the bladder is performed in part by feel rather than sight. Consequently, small gaps can reside between sutures requiring more healing time. During robotic prostatectomy, Dr. Scott Miller meticulously reconstructs and water-tests the urinary tract under continuous direct visualization. As a result, scar tissue formation in this area is a rarity.
Q: How does cancer cure with robotic prostatectomy compare to open-incision prostate removal? A: Dr. Scott Miller’s oncologic (cancer-related) outcomes match nationally published data for open-incision surgery from the premier academic centers. Since Dr. Scott Miller performs a much higher volume of prostate removals than the average urologist, he is able to achieve these results.
Q: What advantages does robotic removal of the prostate have over laparoscopic removal? A: Prior to the availability of robotic technology, Dr. Scott Miller acquired a vast experience with laparoscopic prostate removal. Less than 1% of urologists have ever removed a prostate laparoscopically without the assistance of a robot. Most robotic surgeons have very little laparoscopic experience, but this technology shortens the learning curve by easing the movements of the instruments. Since Dr. Scott Miller has performed thousands of laparoscopic procedures, this benefit provides little advantage to him. Rather, his expertise is enhanced by his ability to maintain control of three instruments and the camera. As a result, he is able to visualize detailed anatomy and readily manage even the most subtle tissue characteristics.
Q: Should I donate blood prior to my procedure? A: Since the risk of needing a blood transfusion is less than 1%, blood donation is not necessary.
Q: When can I shower or bathe following my surgery? A: Since shower-resistant glue was used as a substitute for both stitches and bandages, showering is acceptable once discharged from the hospital. Although water will not harm the surgical areas, mechanical cleansing of the incisions should be avoided for the first week to prevent premature removal of the glue. Complete immersion such as bathing or swimming is allowed at two weeks.
Q: What long-term follow-up care will I need? A: Beyond the initial recovery period, the PSA should be checked 2-3 times per year for the first three years and then yearly.
Q: What other cancer treatments will I need after my surgery? A: As long as the PSA remains undetectable, further cancer treatments will not be necessary.
Q: Does prostate size influence whether I am a candidate for robotic prostatectomy? A: Dr. Scott Miller has removed prostate glands as little as 10 grams and as large as 250 grams. Larger glands can take a little longer to remove.
Q: How does prostate removal affect sexual climax? A: Prostate removal does not directly affect the ability to achieve sexual climax. Most patients report very similar or identical sensation at the time of climax. However, no fluid is expelled as a result.
Q: Would hormone therapy prior to prostate removal be helpful? A: Although hormone therapy can dramatically slow down and partially reverse the growth of prostate cancer, it will not cure the disease. This therapy has not proven to be useful in conjunction with surgical removal and in some cases can distort the surgeon’s view of the anatomy. Since hormone therapy will lower the PSA even months after withdrawal, an undetectable PSA level following prostate removal will have very little meaning during the early post-operative period.
Screening and early detection are the first steps toward the successful management of prostate cancer. However, obtaining enough information to make an informed treatment decision is essential. Below are some useful links.