Robotic-assisted radical prostatectomy (RARP)

When is this procedure indicated?

The procedure is indicated in cases of clinically significant prostate cancer, i.e. in all cases that would expose the patient to a risk of developing distant metastases should the decision be made not to operate but to carefully observe the clinical course of the disease (active surveillance). There are some contraindications to robotic surgery, and these are due to the clinical condition of the patient; for example, serious cardiovascular and respiratory diseases and some cases of severe glaucoma are contraindications.

Prostate cancer

How is it performed?

Robot-assisted radical prostatectomy surgery involves complete removal of the prostate gland and seminal vesicles and restoration of urinary tract continuity.

Step 1

The first phase of the intervention consists in the creation of the pneumoperitoneum with carbon dioxide for the positioning of the robotic ports. A 1-3 cm incision at the supra-umbilical level allows for direct vision and atraumatic positioning of the first robotic trocar through which the optics are inserted to allow the surgeon to visualize the abdominal cavity. Subsequently, the operating trocars are positioned, of which typically 3 are managed by the first operator and 2 by the assistant. The first operative time is represented by isolation of the seminal vesicles through a small puncture made in the parietal peritoneum that lines the Douglas cavity, above the rectal intestine. Once the isolation of the seminal vesicles is complete, access is gained to the pelvic space where the prostate and lymph nodes are located. If the risk of lymph node invasion calculated according to models based on clinical variables available before surgery is greater than 5%, according to the guidelines of the European Association of Urology, an extensive pelvic lymphadenectomy (removal of lymph nodes) of the external, internal, and obturator iliac stations bilaterally is performed. In selected cases of high-risk disease, lymphadenectomy can be extended to the common iliac and presacral stations. Pelvic lymph nodes may also be removed in patients with a less than 5% risk of lymph node invasion if lymphadenopathy (increased lymph node size) is found on preoperative imaging or during visual inspection during surgery.

Step 2

After the possible lymphadenectomy, we proceed to the section of the venous plexus of Santorini and its hemostatic suture with stitches placed under direct vision, paying the utmost attention to the preservation of the integrity of the external urethral sphincter, the muscle responsible for urinary continence. In some cases, section of the Santorini venous plexus may be performed after isolating the prostate.

Step 3

Removal of the prostate is therefore performed anterograde, starting from the bladder neck which is separated from the base of the prostate, taking care to preserve, where possible, the integrity of the muscle fibers that participate in the mechanism of urinary continence. Once this maneuver is completed, the previously isolated seminal vesicles are reached and the prostate detachment plan is identified starting at 6 o'clock. The technique provides the possibility to preserve bilaterally or on one side only those vascular-nervous bundles that are involved in the mechanism of erection. The possibility of preserving them depends on the oncological situation, i.e. on the preoperative characteristics of the disease (palpable disease at rectal examination, number of positive biopsies for cancer, aggressiveness of the tumor in biopsies, PSA values) and on anatomo-surgical factors, i.e. on the technical possibility of carrying out such a type of intervention. In particular, it is possible to identify an intrafascial plane (extremely adherent to the prostate capsule) or an interfascial plane (slightly more distant from the prostate capsule but always paying the utmost attention to safeguard the nerves surrounding the prostate). Prostate isolation is performed with great care to avoid the use of thermal energy in order to limit damage to the periprostatic nerve tissue. Hemostasis is achieved with the application of clips or micro sutures. In some patients, in whom the prostate tumor proves to involve the rich network of nerves responsible for the recovery of erectile function that surrounds the prostate gland, this must be sacrificed in part or totally to allow the complete removal of the tumor (extrafascial technique). In these cases, the recovery of penile erection can be very slowed down or a permanent erection damage can be created.

Step 4

The urethra is then dissected at the level of the prostatic apex. At this point, the surgical piece is placed inside a bag (endobag) and removed from the abdomen. In selected cases, an intraoperative histologic examination may be performed to assess the integrity of the surgical margins.

Step 5

The procedure proceeds with careful hemostasis care: every small source of bleeding is controlled with clips and stitches. Once optimal hemostasis is achieved, proceed with posterior reconstruction by bringing the bladder wall closer to the peri-urethral tissue using a continuous suture.

Step 6

Urethro-bladder anastomosis is then performed with a continuous suture that provides an excellent seal in most cases. A bladder catheter is then placed and anastomosis leak test is performed to verify the absence of spillage and the goodness of the suture itself. At the end of the procedure, a drainage tube may be placed to allow monitoring of any blood, urine, or lymph leaks.

Recovery

Recovery is usually rapid, usually from the first day after surgery the patient can resume walking and eating, thus promoting bowel movement and circulation. Discharge from the hospital occurs after about 2 days of hospitalization, the patient will return after about 7-10 days to the outpatient clinic for a check of the surgical wound and removal of the bladder catheter. Recovery of continence is variable, usually requiring the use of 1-2 diapers per day for the first 3-4 months, with progressive weaning. The recovery of erectile function is variable and has times between 3 months and a year. After about three months after the surgery, it is necessary to repeat the PSA blood test, which is usually repeated every six months for the first years, then annually.

Short-term complications

The percentage of patients who develop complications within the first 90 days after surgery reported in the literature varies from 5 to 30% and depends on individual characteristics (age, comorbidities, previous surgery), the aggressiveness of the tumor and therefore the need to be more radical surgically.

Post-operative complications are prospectively collected at our center and listed below are the most frequent complications observed in the first 90 days after surgery in our case series:

Fever requiring antibiotic treatment (8%);
Urinary fistula with dehiscence of vesicourethral anastomosis with the need for prolonged bladder catheter maintenance (7%);
Prolonged lymphocele or lymphorrhea that may possibly require placement of a percutaneous drain (6%);
Anemia with the need for transfusions (3%);
Acute retention of urine with the need to reposition the bladder catheter (3%);
Pelvic/abdominal hematoma that may require surgical treatment (2%);
Inguinal hernia that may require surgical treatment (1.5%);
Neuropraxia (altered sensation in the limbs) or nerve injury that may affect transient or, rarely, permanent sensory or motor changes (1.3%);
Lymphedema (accumulation of lymph and swelling in the tissues) in the lower limbs and pubis transient or, in rare cases, permanent (1.3%);
Re-surgery vs. embolization for acute hemorrhage or hematoma (1%);
Transient or, rarely, permanent chronic pelvic-perineal pain syndrome (1%);
Incisional hernia or laparocele that may require surgical treatment (0.7%);
Sclerosis of the urethral-bladder anastomosis that may require endoscopic treatment (0.4%);
Intraoperative vascular injury (0.4%);
Intestinal injury during trocar placement (0.3%);
Deep vein thrombosis and/or pulmonary thromboembolism (0.2%);
Re-intervention for intestinal occlusion/perforation (0.1%);
Transient or, rarely, permanent pelvic and lower extremity pain of neuropathic origin requiring medical therapy (<0.1%);
Rectal injury with possible surgical repair vs. colostomy packing (<0.1%).

Finally, robotic-assisted radical prostatectomy surgery is characterized by a risk of mortality in the first 3 months after surgery of about 1 in 1000 patients according to the reports of large multicenter case series. This value is in line with what has been observed in our case series.

Long-term complications

Le sequele più tipiche dopo l’intervento chirurgico di prostatectomia radicale sono rappresentate dall’incontinenza urinaria e dalla disfunzione erettile. Nella nostra esperienza la continenza urinaria viene recuperata da più del 90% dei pazienti durante i primi 12 mesi postoperatori. In questo periodo può essere necessario che il paziente utilizzi pannolini protettivi. E’ a nostro parere necessario eseguire una fisioterapia e/o un programma riabilitativo specifico per ottimizzare la ripresa della continenza. Nella nostra esperienza meno del 2% dei pazienti necessita di eseguire procedure chirurgiche addizionali per migliorare la continenza, come il posizionamento di uno sling uretrale, di piccoli dispositivi regolabili peri-uretrali o di uno sfintere artificiale.

La riduzione della funzione erettile è descritta nei pazienti che si sottopongono a intervento di prostatectomia radicale. Nel caso sia possibile eseguire la tecnica di conservazione dei nervi responsabili dell’erezione, circa il 70% dei pazienti riprende un’attività sessuale soddisfacente con l’aiuto di una terapia medica specifica dopo l’intervento. La ripresa della normale funzione erettile tuttavia dipende dalle condizioni generali del paziente ed è influenzato dalla presenza di un’alterazione pre-intervento della funzione erettile, dall’età, dal numero di comorbidità e dall’indice di massa corporea (BMI). Per questo, la tecnica “nerve sparing” pur correttamente eseguita, non garantisce totalmente la completa ripresa della funzione erettile. E’ a nostro parere necessario che il paziente segua una riabilitazione farmacologica per facilitare la ripresa delle erezioni.

The most typical sequelae after radical prostatectomy surgery are urinary incontinence and erectile dysfunction. In our experience, urinary continence is recovered by more than 90% of patients during the first 12 post-operative months. The patient may need to use protective diapers during this period. In our opinion, it is necessary to perform physiotherapy and/or a specific rehabilitation program to optimize the recovery of continence. In our experience, less than 2% of patients require additional surgical procedures to improve continence, such as placement of a urethral sling, small adjustable peri-urethral devices, or an artificial sphincter.

Reduced erectile function is described in patients undergoing radical prostatectomy surgery. If it is possible to perform the technique of preservation of the nerves responsible for erection, about 70% of patients resume satisfactory sexual activity with the help of specific medical therapy after surgery. Recovery of normal erectile function, however, depends on the patient's overall condition and is influenced by the presence of pre-intervention impairment of erectile function, age, number of comorbidities, and body mass index (BMI). For this reason, the "nerve sparing" technique, although correctly performed, does not totally guarantee the complete recovery of erectile function. In our opinion, it is necessary that the patient follows a pharmacological rehabilitation to facilitate the recovery of erections.

Following the surgery, ejaculation is completely and always missing (i.e. no more seminal fluid comes out at the time of orgasm), while the perception of orgasm is maintained almost always. This loss of ejaculation actually determines a condition of male infertility following surgery. In this sense, seminal fluid can be collected and frozen before the intervention, to be used eventually for a subsequent path of Medically Assisted Procreation (PMA).

In addition to erection and continence problems, other disorders of the sexual sphere can sometimes occur. After surgery, in fact, once sexual activity is resumed, the patient may complain of the following problems:

Reduced sexual desire (30%).
Lengthening of the stimulation time required to achieve an orgasm (40%).
Inability to reach orgasm (condition defined as anorgasmia) or decreased intensity of orgasm (30%); this condition is usually transient, rarely permanent.
Pain at the moment of orgasm, typically localized at the level of the penis, but also in other areas of the external genital district, pubic, pelvic and/or abdominal (7%); this condition is usually transitory, rarely permanent.
Climacturia, otherwise known as orgasm-associated urinary incontinence (consisting in the occasional loss of modest amounts of urine - usually drops - at the time of orgasm; 30%). This problem typically disappears in more than half of the cases in the months following the intervention.
Altered, more often decreased, penile sensitivity (25%).
Retraction of the penile shaft, resulting in a shortening, usually greater than or equal to 1 cm (45%).
Penile curvature during erection (35%).

Possible recovery problem that occurs infrequently is related to the occurrence of a subacute pelvic pain syndrome that may be related in some cases to a microscopic fistula at the level of the vesicourethral anastomosis that could cause osteitis or pubic osteomyelitis that is typically treated conservatively.

Finally, the most recent case reports show that 15-30% of patients treated with robotic surgery may have a tumor involving the surgical resection margins. The finding of a positive surgical margin is therefore an eventuality not to be excluded even in the presence of tumors with preoperative characteristics with good prognosis and should be considered as an intrinsic risk of the procedure itself. The clinical relevance and prognostic implications of a positive margin seem to be limited, and it is often sufficient to follow the patient without doing any additional treatment since surgery alone is resolving the problem. However, when a positive surgical margin is associated with the presence of an aggressive and extensive tumor, additional therapies such as radiotherapy and/or hormone therapy may be indicated immediately or as PSA values rise to reduce the risk of distant recurrences.