The Benefits of Robotic Prostatectomy

Robotic assistance has revolutionized prostate removal. It's a far better option than removing the gland through a large incision, which can cause significant blood loss and often leaves patients suffering from incontinence and erectile dysfunction. It's even an improvement over laparoscopic prostatectomy, a challenging procedure that demands masterful technique to remove the prostate from deep within the pelvic cavity.

With a robot, surgeons are able to remove the prostate through a few small incisions or even a single incision. Robotic prostatectomy has evolved into the preferred method for both surgeons — who prefer the precision and ease of operating robotically — and patients, who recover sooner and with fewer complications.

"About 90% of all prostatectomies in the country are done robotically," says Ryan Dobbs, MD, a robotics fellow at the University of Pennsylvania Medical Group in Philadelphia. He says the increasing numbers of robotic prostatectomies are helping to shift more cases to outpatient facilities.

"It would be unimaginable to safely discharge patients on the day of surgery without the robot," explains Dr. Dobbs. "We can after robotic procedures because patients lose less blood and, because we're making smaller incisions, they have less pain. These factors make the procedure safer and feasible in outpatient ORs."

Jihad Kaouk, MD, says the robot is also more effective for operating on patients who are obese, have had previous abdominal surgery or present with a complex or enlarged prostate.

Learning to use the robot is fairly straightforward, according to Dr. Kaouk, a professor of surgery and director of the Center for Robotic and Image Guided Surgery at the Cleveland Clinic. "The short learning curve is why the vast majority of urologists now perform the procedure robotically," he says.

It would be unimaginable to safely discharge patients on the day of surgery without the robot.
— Ryan Dobbs, MD

Surgeon experience still matters, however. "The robot is a tool — there's nothing magical about performing the procedure with a robot and complications can still happen," says Dr. Kaouk. "The robot is a machine and its performance depends on the skill of the surgeon."

Educating patients about the benefits of robotic prostatectomy and preparing them for same-day discharge are keys to performing the procedures in the outpatient setting.

"We have a very good system, in part because we have two full-time physician assistants who talk to patients ahead of surgery and give them the roadmap that outlines the course of their care," says Dr. Dobbs. "That way, patients know what to expect leading up to surgery and also know what potential post-op complications would necessitate giving us a call for follow-up care."

Many patients still approach surgery with the mindset of having to stay a couple of days in the hospital, according to Dr. Kaouk. He says it's important to reset their expectations at the first clinic visit and reinforce the message multiple times leading up to surgery. "When I meet with patients scheduled for prostatectomies, I make sure they understand the procedure is now commonly done in outpatient settings," he says. "They're told the robot operates through a single small incision, the procedure is not overly painful, and they'll be more comfortable recovering at home."

Optimizing fluid management and limiting the use of intraoperative opioids are important factors in transitioning procedures to outpatient facilities, points out Dr. Kaouk. Surgically, he limits dissection to the immediate area around the prostate.

"We adopted a single-port technique and shifted from an intraabdominal to an extraperitoneal approach," he says. "I operate outside the abdominal cavity, away from the bowel, which is not touched or retracted, allowing for a quick return of bowel function after surgery."

Post-operative pain management involves giving patients nonsteroidal anti-inflammatories such as ibuprofen instead of Percocet. Administering a local anesthetic at the incision site helps to limit the pain patients experience immediately after surgery, says Dr. Kaouk.

Working hard in the PACU to prepare patients for same-day discharge is just as important as the education you provide them before their procedures. "We have a nursing unit that takes care of outpatients on a different track than inpatients," says Dr. Kaouk. "The nurses manage patients' pain, monitor their vital signs and talk to them and their family members to make sure they're ready for discharge and can go home safely."

The robot's $2 million price tag — plus the added expense of the disposable instruments used during each case — makes the technology cost-prohibitive for some facilities. "Although the robot is an expensive piece of equipment, it lets surgeons operate in a safe, less invasive way and achieve excellent outcomes," says Dr. Kaouk.

For facilities that can afford to add robotic assistance, improved patient care is certainly a worthwhile investment. OSM