The months that follow the robot-assisted laparoscopic prostatectomy

What happens after the laparoscopic robot- assisted prostatectomy (RALP) ?

The patient usually leaves the clinic 4 days after the procedure with a vesical catheter in place.
Given to the patient upon his leaving, are his prescriptions and several explanatory documents on:

  • The possible incidents when he will have returned to his home and the measures to be taken for each instance;
  • The schedule of all post operative consultations;
  • Simple recommandations to facilitate the daily care of the vesical catheter whilst at home;
  • A description of the protection models and the channels through which they can be purchased to compensate for the inconvenience caused by urinary leakage if they exist after the removal of the urinary catheter.

The removal of the vesical catheter is usually carried out 7 days after the operation.

The catheter can be removed by a nurse in the patients home.

We usually prefer that the removal takes place at the radiology office, in the morning, by the radiologist that will first check that the suture between the bladder and the urethra (vesico-urethral anastomosis) is well cicatrised and tight by injecting a contrast product.

We rarely report on this radiography the existence of a urinary leak around the anastomosis, in general moderate importance but the catheter is then left in place for an additional week.

On removal of the catheter, the situation is variable from one patient to another without possibility to predict in advance the condition.

A lot of patients are perfectly continent or almost from this moment onwards and go back to normal and comfortable urination (or mictions) from natural means.

In contrast, other patients suffer from urinary incontinence with variable and considerable leaks, but rarely total incontinence.

The patient is seen in consultation one month after the procedure.

The quality of urination is considered, as well as the eventual existence of urinary leaks and their volume.

The operative report and the anatomo-pathologic exam report are explained and given to the patient. It is essential to make sure after this last report that the prostate tumor excision was complete and that the margins of this Da Vinci prostatectomy are healthy and free of tumors.If a lymph node dissection was carried out, we equally insure the absence of ganglionic metatasis.

The absence of invasion of the margins is essential to evaluate the chances of recovery and the absence of subsequent development of local recurrence.
Finally, the rate of PSA performed one month after surgery is also an essential prognosis criteria: it must have collapsed and be indosable.

The PSA is controlled for at 3 and 6 months after the robot assisted prostatectomy and then annually when they stay collapsed.

Persistantly low PSA rates, stabilse in time, may correspond to residual non cancerous prostate lobules. It is the absence of progressive elevation of these rates with time that indicate that simple monitoring is sufficiant.

In cases of progressive elevation of rates post- operation of the marker (rising PSA), complementary treatments must be envisaged and can be put into place rapidly due to the sensitivity of PSA.

What happens during the recuperation of urinary incontinence ?

When they exist after the removal of the bladder catheter, the urine leaks, however debilitating they are, to a large extent usually regress in the weeks following the laparoscopic robot-assisted radical prostatectomy (RALP).

During the first postoperative month, we do not start urinary re-education to any patient apart from perineal gymnastic movements that they will have learned before the procedure.

In cases where the patient suffers from persistant urinary leaks, he is then addressed by the kinesitherapist that he will have consulted with before the procedure.

A first series of 20 sessions of urethral sphinter electrostimulations and perineal muscles are undertaken.
Perfect continence may take a few weeks or even a few months to re-establish. We have had patients recuperate normal continence up until one year after the procedure.

Definitively, the number of patients that experience disabling leaks or total incontinence is thankfully very low, but in absence of recovery, a severe correctional surgical procedure of this handicap must be considered.

What kind of sex life after a robot assisted laparoscopic prostatectomy ?

A recovery of sexual function is possible when the vasculo nervous bundles of the erection have been conserved during the procedure.

This recovery is a progressive one. After 6 months after the operation, 30% of patients recover erections in cases of preservation of 2 bundles, and after 2 years, the rate of recovery is close to 60%. In cases where only one bundle has been conserved (on the opposite side of the tumor) the rate of recovery is less.

The sudden onset of sexual dysfunction after surgery and delayed recovery opposes the development of the plan of many irradiated patients who, having just after radiotherapy no erection problems will lose their sexual potency when the surgical patients recover theirs.

However, to obtain this delayed recovery, treatment early in the postoperative period must be implemented.

IThe first step consists of taking regular oral medication that facilitates the erection. Then intracavernous injections of prostaglandin are implemented, that the patient learns to make himself and that allows him to obtain solid erections authorizing the resumption of conjugal relations.

Progressively in favourable cases, spontaneous erections reappear under the effect of sexual stimulation adapted and allows the patient to pursue their sex life without medical help.

This sexual recovery means the return of solid erections. Sexual desire is not affected by this procedure. Penetrative sex can be concluded with orgasmic pleasure.

However, the ejaculations are removed by this surgery. The patient is therefore permanently sterile, which has little effect on the normal onset age of prostate cancer. The orgasms are “dry”, usually without affecting the sexual satisfaction of both partners.