Robotic removal of the prostate for Prostate Cancer
Dr. Nimeh is proud to offer the latest technology for management of prostate cancer with the da Vinci Laparoscopic Robotic Prostatectomy. Dr. Nimeh has helped diagnose and successfully treat men with prostate cancer from Alaska and beyond, to help men who have visited us to experience our unique approach to beat prostate cancer, while preserving erectile function and urinary continence.
Dr. Tony Nimeh has performed hundreds of robotic cases including robotic prostatectomy, robotic cystectomy (bladder removal) as well as advanced robotic cases involving kidney cancer (robotic partial nephrectomy) and robotic da Vinci pyeloplasty (reconstruction of the kidney to optimize drainage).
Dr. Nimeh is routinely recognized for friendly, patient-centered care, and this remains the reason that patients find us to be the doctor and facility of choice for treatment of their prostate cancer.
Dr. Nimeh's surgical technique optimizes prostate cancer control, nerve-sparing for preservation of potency, and maximizing urethral length and pelvic floor preservation to optimize urinary control.
Maximum results, minimal incisions
At Fairbanks Urology Center, our philosophy for diagnosis and treatment of prostate cancer with robotics is simple: personalized care using the latest technology. This results in 24-48 hour hospitalizations in the majority of our patients. Less pain, smaller incisions, and faster recovery. Dr. Nimeh makes it a priority to be personally involved in every step of the diagnosis, surgery and recovery to ensure a path to restoring health and wellness.
What is da Vinci robotic surgery?
Simply put, the reason why we used to make large incisions for major surgeries was so we could put our hands inside the body. With the advent of robotics, we perform the same surgery, arguably better, with smaller incisions, because instead of the surgeon’s hands, we only need to make a few small half-inch incisions to insert the robotic hands. From there, we use 3D vision, high-definition cameras, and the latest technology to translate the surgeon’s hand movements to the robotics. Think Wii for robotic surgeons! All this technology translates to more precise movements, vision that is magnified in 3D, and other benefits. This results in our patients rarely requiring blood transfusions, having less pain than with open surgery, and returning home in 24-48 hours. Several studies suggest that the technology may allow for more precise nerve-sparing surgery to preserve erectile function when indicated, and also allow for faster return of continence.
Dr. Nimeh utilizes a comprehensive prostate cancer program to ensure that their patients and family are well educated in laparoscopic robotic da Vinci prostatectomy care to ensure optimum expectations and outcomes.
What to know before getting da Vinci prostatectomy
Dr. Nimeh has spent years refining his da Vinci robotic prostatectomy technique, beginning in his time at Harvard University.
His highly evolved robotic prostatectomy has reduced surgical times to two hours in most cases, and the vast majority of patients are in the hospital for 24 hours or less. Studies show that reduced operative time and shorter hospital stays can lead to lower complications and faster recovery.
The da Vinci robotic system utilizes high-definition optics and three robotic arms, each no wider in dimension and not much longer than a ballpoint pen. Using these small incisions, the robotic arms replicate the doctor’s movements in a surgeon console about three feet away from the patient.
The benefits include smaller incisions that often lead to less pain, high-definition optics with 10-15 times magnification that allow for less blood loss, and precise incisions that assist with delicate nerve sparing and dissection that help to optimize outcomes of continence and potency after the surgery, while maintaining adequate margins around the prostate to ensure that we give the patient the best chance to be free of prostate cancer.
Traveling to FAIRBANKS for the da Vinci robotic prostatectomy
We will start with a consultation to review your case. This includes review of your prostate-specific antigen (PSA); your prostate biopsy results; family, medical and surgical history; and your continence and potency expectations.
If you are found to be a good surgical candidate, we will reserve you a surgical date, typically performed on Thursday or Friday. We may need to give you an MRI, which will assist us with intraoperative mapping of the prostate to optimize nerve sparing for preservation of continence, potence, and optimizing a cancer-free outcome.
We will also coordinate pelvic-floor biofeedback therapy, here in Fairbanks, to help identify and strengthen your pelvic floor musculature. Practicing these Kegels exercises preoperatively and postoperatively will help maximize postoperative urinary continence. We are proud to have over 95% continence within a couple of months of surgery with our patients.
We typically remove the Foley catheter that is placed intraoperatively seven to 10 days after surgery. It is at that time that we review the pathology report, and do a postoperative check. The first PSA check should be performed four to six weeks after surgery.
We often recommend use of daily 5 mg Cialis or 40 mg Sildenafil postoperatively to help with accelerated recovery of the nerves for regaining erectile function.
Leaving the hospital
While robotic prostatectomy is performed routinely, it’s still a relatively major surgery that will take some time and effort to recover from, so stay positive. You can get through this.
All patients will be discharged from the hospital with a urinary catheter in place. This catheter is known as a Foley catheter and is held in place by a balloon inside the bladder. It allows continuous drainage of the bladder into a small external collection bag which is emptied as needed. Do not try to remove this catheter on your own. It must stay in place until you heal enough that it is no longer needed. Since you will not be cleared to drive yourself, you will need someone to drive you home.
- Please refrain from driving for one to two weeks after your surgery. After your catheter is removed, you can resume driving and most activities. Refrain from vigorous activity (running, golf, exercising, horseback riding, motorcycles, bicycling) however, for six weeks after surgery to give yourself time to heal.
- After six weeks, you may resume full activities using common sense.
- Avoid climbing stairs as a form of exercise.
- Avoid sitting still in one position for too long (more than 45 minutes).
- Avoid bathtubs, swimming pools, hot tubs, or otherwise submerging yourself in water for as long as the catheter is in place. Showering is fine as soon as you go home.
- When you may return to work depends on your occupation and how fast you recover. With most jobs, you may return to in two to four weeks. Use common sense.
- Most of our patients experience only minimal discomfort, and we recommend that you try ibuprofen or TylenolⓇ (acetaminophen) for pain first, as they usually suffice. Stronger, prescription painkillers tend to be extremely constipating, so it is better to avoid them if possible. However, if you still have significant pain despite MotrinⓇ or Tylenol, use a stronger pain medication, which will typically be VicodinⓇ or something similar.
- Upon discharge from the hospital, you will also be prescribed an oral antibiotic, which you will begin taking the day after discharge, until the prescription is finished.
- You may resume any of the usual daily medications you had taking before surgery for other medical conditions as soon as you are discharged. Aspirin or blood thinners can generally be restarted two to four weeks after surgery.
- We recommend that you take stool softener as needed to combat constipation once you get home.
- On occasion, you may develop bladder spasms while the catheter is still inserted. Bladder spasms are typically associated with a sudden onset of lower abdominal discomfort, a strong urge to urinate, or with sudden leakage of urine from around the catheter. Let us know if this is a significant issue.
- To make it easier on you immediately out of the hospital, you may initially want to stick to a bland diet. Some patients prefer a mostly liquid diet. Avoid carbonated beverages.
- Once you have had a bowel movement, you should move to a soft food diet of things like soups, scrambled eggs, toast, oatmeal, etc., and then work your way back to your normal diet as you feel comfortable.
- Avoid foods that cause gas such as flour, beans, and broccoli.
- For a few days after surgery, try to spread out eating throughout the day with snacks and small meals to avoid eating large meals at once.
Immediately after surgery, your abdomen will be slightly bloated, so you may have trouble fitting into your regular clothes. For comfort, wear loose-fitting clothing such as sweatpants or other pants with elastic (not button) waistbands. You will probably need to do so initially anyway to accommodate the catheter and collection bag.
You may start showering the day of your discharge. The catheter collection bag may be removed during showering. Gently pull the colored catheter straight off of the clear plastic tubing from the bag and allow urine to run into the shower. After showering, gently pad the suture sites (do not rub or otherwise irritate them) with a towel.
Sutures were used which will dissolve on their own, so there is no need to have them removed. Skin glue is often used, and should gradually flake off like a sunburn. A small amount of redness at the edges of the incision sites, as well as a small amount of clear or bloody leakage from the wound, is acceptable. Drainage of sufficient quantity to soak dressings, or redness greater than half an inch from the incision should be reported to the physician.
- You will be discharged from the hospital with a Foley catheter in place which continuously drains urine from your bladder. It must stay in place while the connection between the bladder and urethra heals. Do not attempt to remove this on your own. If it should accidentally fall out, you MUST IMMEDIATELY notify your urologist to have it replaced. Do NOT allow anyone else (even if they are a nurse or doctor) to replace it. The catheter was carefully placed by your urologist with specific regard to your prostatectomy and cannot be replaced by just anyone.
- You can use a petroleum jelly or antibiotic cream such as NeosporinⓇ to lubricate the outside catheter where it enters the tip of your penis (the urethral meatus). Apply the ointment as needed.
- You will be provided with a “stat-lock,” a plastic clip or strap which will be placed on your thigh to hold the catheter.
- You will be provided with two urine collection bags of different sizes, a smaller bag to be worn under your pants during the day, and a larger bag to be used at night. The smaller bag usually lasts about three to four hours before needing to be emptied, but of course, this varies with how much liquid you consume. The larger bag should last you all night, so you do not need to wake up to empty it. Remove, empty, and exchange these two bags as needed.
- Alert the surgeon if the catheter does not drain well, or if you have any other serious problems with it.
- This catheter will stay in place until your scheduled a follow-up appointment, at which point pathology/results will be discussed and catheter removed.
Usually, Dr. Nimeh will communicate to you a desired follow-up time frame. Please call us the day after the procedure to verify a time to see us in the office.
Regaining urinary control
- Most men have difficulty with urinary control after catheter removal. You should bring an adult urinary pad, such as DependⓇ Guards, with you the day your catheter is removed. You should be prepared to wear these pads for a while because normal urinary control will take time to gradually return. Remember, everyone is different. Some men regain control in a week, some take six months. Don’t be discouraged! Also, remember you will typically leak more standing, moving, and straining, and less when lying down and sleeping.
- Remember to do your Kegel exercises regularly. The operation removed your prostate and affected your secondary urinary control mechanisms. Your external sphincter muscle must now take overall responsibility for control. It will take time and effort to strengthen this mechanism.
- Some men may continue to have mild incontinence with straining even several years after surgery. You can avoid a problem in these situations by wearing a small pad. Rarely, urinary control will be unsatisfactory even after a year. If so, something can still be done.
Regaining sexual function
- The operation will affect sexual function in several ways, but it should not prevent you from having a fulfilling sex life when you recover. There are three components to sexual function in men: sexual drive, sensation, erection and climax (orgasm). Although these normally occur together, they actually are separate functions. Losing one doesn’t necessarily mean you will lose the others.
- Erections occur due to a complex sequence of events involving stimulation of the cavernosal nerves and engorgement of the penis with blood. The cavernosal nerves run alongside the prostate, only millimeters away from where cancer often occurs. Prostate cancer also tends to spread along these nerves. For these reasons, although it may have been technically possible to spare the nerves, it may not have been done.
- Since the primary goal of the surgery was to rid you of cancer, one or both of these nerves may have been resected. There is a chance of recovering erections, but recovery may be slow. Nerves can heal, but very slowly. The average time to recovery for erections adequate for sexual intercourse is six to 18 months, but in some men it can be even longer. While you are waiting for erections to return, a number of approaches are available for achieving erections. Ask about these in our office. If these methods are unsuccessful, a prosthesis can be placed to restore sexual function.
- Climax will not be affected by the surgery, but ejaculation (the release of fluid during orgasm) will no longer occur. You will still have the same sensations of pleasure, but no fluid will be discharged and you will have a dry ejaculation. This is because the seminal vesicles, which store fluid for ejaculation, and the vas deferens, the tubes that carry sperm to the prostate, are removed and cut during the operation. This means you will be infertile and no longer able to father children.
Things you might encounter after surgery
- Abdominal distention, constipation or bloating: Make sure you are taking your stool softener as directed, and drinking prune juice or milk of magnesia. If you still haven’t had a bowel movement 48 hours after surgery, you may take an over the counter suppository such as DulcolaxⓇ.
- Bladder spasms: Bladder spasms are typically associated with a sudden onset of lower abdominal discomfort, a strong urge to urinate, or with sudden leakage of urine from around the catheter. If they are a big problem, contact the office, as we can prescribe a medication for you.
- Bloody drainage around the Foley catheter or in the urine: Under stress, such as during physical activity or bowel movement, this is not uncommon immediately after surgery. This should improve if you cease activity and rest for a short time. If it does not, or if you see clots in your urine, or have no urine output for two hours, contact your physician.
- Bruising around the port sites: This is not uncommon, and should not worry you. They will go away as you heal.