The Robotic Prostatectomy

The Radical Version!

Radical ProstatectomyEver since 2002, Dr. Bevan-Thomas has been performing the robotic prostatectomy -- removing the entire prostate laparoscopically -- with the assistance of the daVinci robot. Since that time, the procedure has been referred to as “the robotic prostatectomy.”

Back in 2002, there were only a few surgeons in the country doing robotic surgery. The daVinci robot has transformed how many surgeries are performed in the United States. Now, more than 95% of all robotic radical prostatectomy surgeries are done with the assistance of the daVinci robot.

SO THIS IS NOT THE SIMPLE/PARTIAL PROSTATECTOMY?

No. The robotic radical prostatectomy is different from the robotic simple/partial prostatectomy. Dr Bevan-Thomas performs both the robotic radical and the simple/partial prostatectomies every week but for different reasons.

For men with larger prostates (BPH) greater than 100 grams, Dr. B-T uses the robotic simple/partial prostatectomy. The simple prostatectomy removes only the inner part of the prostate. (See link here to the robotic simple section.)

To put this into perspective, the average prostate is roughly 40 grams, 100 grams is over twice the size of the average prostate. Doc B-T performs this procedure because it provides better symptom relief for men with larger prostates who aren’t candidates for any of the less-invasive procedures.

The radical prostatectomy, on the other hand, removes the entire prostate. Dr. B-T performs this procedure for prostate cancer. Think of the prostate as an orange with the peel around it. While the simple prostatectomy removes the inner part of the orange, the radical prostatectomy removes the entire orange. This is necessary for two reasons.

First, roughly 80% of prostate cancer starts in the peripheral (orange peel) part of the prostate, so leaving that part of the prostate behind would not cure the cancer.

Second, in order to ensure that the prostate cancer is gone, the entire prostate should be removed. The PSA [internal link here?] after this surgery should be undetectable -- less than 0.1. Just as importantly, if any of the prostate is left behind, it could harbor a small focus of cancer that could grow later. This would require further treatment.

WHAT ABOUT THE NERVES FOR ERECTIONS?

The prostate is in a very busy part of the pelvis. The nerves responsible for erections are located alongside and slightly underneath the prostate. Dr. B-T compares the nerves (neurovascular bundles) to a hammock that the prostate sits on.

These erection nerves come from the spinal cord and travel (like a hammock) on the underside of the prostate. These nerve bundles have only one function -- they conduct an impulse down to the penis to cause an erection.

The nerves are extremely small and fragile, so the challenge is to peel the prostate away from the nerves and cause as little damage as possible to those nerves. The precision of the daVinci robotic instruments make this delicate part of the procedure safer and more effective.

Luckily, the neurovascular bundles are not involved with any sensation impulses, and they are not responsible for the orgasm response. Those nerves are located elsewhere.

GLAD TO HEAR THAT! SO HOW DOES ROBOTIC SURGERY WORK?

Robotic surgery is simply a more precise way to perform laparoscopic surgery. With laparoscopic surgery, small keyhole incisions are made in the belly, and instruments are introduced through those incisions. Laparoscopic surgery is like operating with chopsticks, and robotic surgery simply adds little hands to the end of the chopsticks.

Dr. B-T will use these specialized robotic instruments to delicately remove the prostate and spare the erection nerves. Remember though, it’s Dr. Bevan-Thomas at the controls, not a robot. The robot is simply a tool in Doc B-T’s hands.

While many surgeries can be performed laparoscopically, the robot is especially good at peeling the prostate away from the delicate nerves responsible for erections. It is no wonder that it has become so popular over the last 20 years!

Fortunately, Dr. Bevan-Thomas has been performing robotic surgery for 18 years and has perfected his technique in that time. This really is one of those surgeries that you need an experienced robotic surgeon to perform your surgery!

TELL ME ABOUT THE ROBOTIC PROSTATECTOMY SURGERY

Instead of a step-by-step process of the surgery, you just need to understand what happens during the surgery. Through those tiny keyhole incisions, Dr. Bevan-Thomas will inflate carbon dioxide into the abdomen to create space to work. Think of it as inflating a balloon so you can see inside.

Dr. B-T will place those tiny instruments through the incisions to get down to the prostate. He will gently remove the prostate from the surrounding tissue like the muscles in the pelvis and the erection nerves.

After he removes the prostate, he will place it in a small sac and remove it through one of the keyholes. He usually has to open the incision a little bit more to create enough room to remove the prostate in the bag. He may also remove some lymph nodes in the pelvis as well.

The prostate sits between the bladder and the urethra, so next he will reattach these areas with sutures.

At the end of your surgery, the prostate and lymph nodes go to a pathologist (a doctor who specializes in looking at cells under a microscope).

Most patients will have a tube in the lower belly -- a suprapubic tube. You will also have a tube in the penis called a Foley catheter. This suprapubic tube is far more comfortable for patients and makes it easier for them to move around. Trust us when we say that you will be happier with a tube in the belly and not in the penis for several days after the procedure.

Fortunately, the tube in the penis is removed the following day in the hospital, leaving only the suprapubic tube.

Your sutures will take five to seven days to heal. At that time, you will plug the tube and try to urinate on your own. If you can urinate, you will come to the office so the nurse can remove the tube. (But don’t worry -- this should not hurt!)

When the pathology results come back -- also in five to seven days -- Dr. B-T will go over them with you at a postop appointment in his office.

WHAT ARE THE MAJOR RISKS OF THE SURGERY?

Like all surgical procedures, the radical prostatectomy has risks. The major risks of this procedure are:

  • Incontinence (losing urine with lifting, coughing, and sneezing)
  • Erectile dysfunction
  • The possibility of the cancer coming back after surgery
  • There are other, less-common risks that Dr. B-T will go over with you before we schedule surgery. Bleeding is a very low risk -- less than 1% -- that requires a blood transfusion.

WHAT HAPPES AFTER THE SURGERY?

Most men regain their ability to urinate on their own within the first several weeks to months after the surgery. Dr. Bevan-Thomas works closely with a local physical therapist, who helps his patients regain their pelvic muscle strength early in the process.

In terms of erectile dysfunction, most men can expect some ED after the surgery, but it should be a temporary issue depending on the number of nerves spared during the surgery.

Men with higher-volume and higher-grade disease will likely have more challenges than men with lower-volume disease, where more nerves can be spared. This also depends upon the patient’s erectile function prior to surgery. Dr. Bevan-Thomas recommends using Cialis, Viagra, or Levitra after the surgery to help regain erections sooner.

WHY CHOOSE DR. BEVAN-THOMAS?

Dr. Bevan-Thomas has been performing robotic surgery consistently since its inception in 2002. He has the experience and knowledge to get the best results for you. He has fine-tuned his techniques to maximize erectile function and minimize incontinence.

Most importantly, not everyone needs surgery. Dr. B-T also performs cryoablation and has a radiation oncologist as a partner in his group at Urology Partners of North Texas.

If you are a candidate for a robotic prostatectomy, Dr. Bevan-Thomas is your best pick. He will take the time to discuss your options with you so you can make the best decision for your cancer.

Urologist Dr. Richard Bevan-Thomas of Urology Partners
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