About Robotic Prostatectomy

What is a Robotic Prostatectomy?

The surgical removal of the entire prostate gland through the use of the daVinci Robotic Surgical System for the treatment of prostate cancer.

How is a Robotic Prostatectomy done?

The surgeon makes 6 keyhole incisions in your abdomen. Small plastic tubes (trocars) are placed inside the incisions to keep them open while a small camera (laparoscope) and the small robotic arms are inserted. The surgeon controls the laparoscope and robotic arms to remove the prostate gland.

What are the benefits of using the daVinci Surgical Robot?

  • The daVinci surgical robot allows surgeons to perform complex technical operations in a minimally invasive fashion through small key hole incisions
  • Smaller incisions produce less post operative pain and shorten the post operative recovery periods
  • The robot provides the surgeon with 3 dimensional vision magnified 10 times
  • The miniature robotic instruments articulate with small wristed joints providing an extremely dexterous means to perform minimally invasive surgery
  • The robot filters any tremor of the surgeon

What is the da Vinci Robotic Surgical System?

The da Vinci Robotic System is a master – slave robot. It does not perform anything in an autonomous fashion. It simply replicates the surgeon’s hand movements within the patient in a miniaturised dexterous fashion. The daVinci robot has 3 major components:

  1. The robot which holds the camera and robotic instruments
  2. The surgical console where the surgeon sits to view the surgical field and control the robotic arms and:
  3. The stack which displays the surgical view to the rest of the operating team The robot serves as an extension of the surgeon’s hands and eliminates the need for large incisions that are necessary in traditional open surgery.

Will I be asleep?

Yes: Robotic prostatectomy is performed under general anaesthetic. You are asleep for the entire operation with a breathing tube in.

What happens when the procedure is over?

At the end of robotic prostatectomy, the camera and robotic instruments are removed. The prostate is removed from within the abdomen in a plastic bag in one piece. The incisions are closed with absorbable sutures and surgical glue.

Will I experience pain?

Some discomfort is normal with robotic prostatectomy. This can usually be well controlled with the use of analgesic tablets

How long is the hospital stay?

Most patients are released from the hospital within 24-48 hours. What care will I require when I get home? Before leaving the hospital you will be instructed on what to expect and what you need to do. A urinary catheter will be present to drain your bladder usually for 7 days following surgery. top

How long will I need to be off of work?

Patients who don’t perform manual labour or jobs with lifting can usually return to work between 2-4 weeks following surgery. Work involving lifting and straining usually will require 4-6 weeks off.

General preparation

General measures when preparing for radical prostatectomy include weight loss. Many of us can afford to lose a few kilos. Weight loss improves your general fitness and makes your surgery easier to perform for your surgeon, enlisting the help of a personal training for an intensive regime prior to surgery is helpful for many men. Pelvic floor exercises should be taught to all men by a physiotherapist or continence advisor with an interest in men's health. Also stop smoking.

Preparing for Robotic Prostatectomy

General preparation

General measures when preparing for radical prostatectomy include weight loss. Many of us can afford to lose a few kilos. Weight loss improves your general fitness and makes your surgery easier to perform for your surgeon, enlisting the help of a personal training for an intensive regime prior to surgery is helpful for many men. Pelvic floor exercises should be taught to all men by a physiotherapist or continence advisor with an interest in men's health. Also stop smoking.

4 weeks before surgery

It is important to stop taking herbal medications before surgery as they may interfere with your anaesthetic or predispose you to bleeding. The following list contains SOME of the more frequent herbal medications, which should be ceased 4 weeks before the surgery.

  • Echinacea, Ginseng, Kava-kava, Liquorice, Saw Palmetto
  • St.John'sWort, Vitamin E, Garlic, Ginger,

Inform us if you are taking aspirin, plavix, anti-inflammatory drugs or warfarin.

On the day of your procedure

Take your regular medications (other than as above) as usual with a sip of water at 6:00 am.

DO NOT HAVE ANY OTHER FOOD OR DRINK BEFORE THE OPERATION

Having a Robotic Partial Nephrectomy

What is a partial nephrectomy?

A partial nephrectomy is an operation to treat small kidney cancers (cancer that has not spread outside the kidney). It involves removing just the tumour and not all the kidney. This surgery may also be suitable for people who have tumours in one or both kidneys, including people who only have one kidney. It is performed under a general anaesthetic and involves removing the kidney tumour and a small amount of surrounding normal kidney tissue. A small amount of healthy tissue is removed to help ensure that all the cancer cells are cut away. A general anaesthetic means that you will be asleep for the whole of the operation, so that you will not feel any pain. The anaesthetic is given through a small injection in the back of your hand.

Can a partial nephrectomy be done as a Robotic (keyhole) procedure?

Yes. A small number of surgeons perform this operation as a keyhole procedure. Dr Coughlin will discuss with you whether keyhole surgery is appropriate for you.

What are the benefits of using the daVinci Surgical Robot?

• The daVinci surgical robot allows surgeons to perform complex technical operations in a minimally invasive fashion through small key hole incisions • Smaller incisions produce less post operative pain and shorten the post operative recovery periods • The robot provides the surgeon with 3 dimensional vision magnified 10 times • The miniature robotic instruments articulate with small wristed joints providing an extremely dexterous means to perform minimally invasive surgery • The robot filters any tremor of the surgeon

What is the da Vinci Robotic Surgical System?

• The daVinci Robotic System is a master – slave robot. It does not perform anything in an autonomous fashion. It simply replicates the surgeon’s hand movements within the patient in a miniaturised dexterous fashion. • The daVinci robot has 3 major components: o The robot which holds the camera and robotic instruments o The surgical console where the surgeon sits to view the surgical field and control the robotic arms and: o The stack which displays the surgical view to the rest of the operating team • The robot serves as an extension of the surgeon’s hands and eliminates the need for large incisions that are necessary in traditional open surgery.

What are the alternatives to partial nephrectomy?

A partial nephrectomy is the only way we can treat and remove part of your kidney. Dr Coughlin and you should decide together whether this procedure is more suitable for you than removing one of your kidneys completely. Radiofrequency ablation is an alternative for some people with very small tumours in very specific circumstances.

What are the possible risks?

A partial nephrectomy is a major operation. Dr Coughlin will discuss the risks below with you in more detail, but please contact Dr Coughlin in writing if you require further clarification.

• Bleeding after the operation: There is approximately a one in 50 risk of bleeding after having a partial nephrectomy. This may mean that you need to have a further operation to stop this.

• Urine leak: Very rarely urine can leak from the cut surface of the kidney. This will generally stop naturally without the need for a further operation. A drain (small plastic tube) is inserted during the operation to drain any fluid from around the kidney. If there are signs of a urine leak, this may be left in until it has stopped.

• Need for dialysis: Dialysis means that a machine filters the blood and removes any waste products, which are normally removed as urine. Patients with two kidneys rarely need dialysis after the operation but a number of patients having a tumour removed from their only kidney may need to have temporary dialysis after the operation. The risk of needing dialysis is also increased if you have poor kidney function before the operation and especially if you have poor kidney function and only one kidney. The need for dialysis may be temporary (for a few days after the operation). For a very small number of patients this may be required for a longer period of time while your kidney function recovers. If Dr Coughlin feels that there may be a need for dialysis, he/she will discuss this with you and refer you to the renal (kidney) doctors.

• Complete nephrectomy: In a small number of patients the surgeon may need to remove the whole kidney. This is rare.

• Problems relating to the anaesthetic: Although rare, events such as the following may occur:

  • a chest infection;
  • a deep vein thrombosis (DVT)
;
  • a pulmonary embolus (blood clot in the lung);
  • stroke or heart attack can occur.

If you have any of these problems you may need to stay in the intensive care unit and your recovery will be delayed.

• Infection or hernia: As with all procedures there is a small risk of developing an 
infection or a hernia at the wound site. A hernia is when an internal part of the body, 
such as an organ, pushes through a weakness in the muscle or surrounding tissue wall.

• Blood loss: If the bleeding is severe, you may need a blood transfusion or another 
operation.

• Death: This is rare – approximately two in 150 of patients having this operation die from 
complications.

It is important to note that as this operation is to treat kidney cancer you may need further treatment after your operation. If we find that the cancer has spread outside of your kidney you will be referred to an oncologist (cancer specialist doctor) who will discuss further treatments options with you.

Preparing for your surgery

You will attend a pre-admission clinic before your surgery. This is a mandatory requirement. The hospital will carry out a number of tests to make sure that your heart, lungs and kidneys are working properly. You may have a chest X-ray, ECG or electrocardiogram (which records the electrical activity of your heart) and some bloods taken.

If you do not attend, we may have to cancel your surgery.

If you smoke, you may be asked to stop smoking, as this increases the risk of developing a chest infection or DVT (already defined above). Smoking can also delay wound healing because it reduces the amount of oxygen that reaches the tissues in your body.

You will be given special advice if you take Warfarin, Aspirin, Clopidigrel, or any other medication that might thin your blood. Do not make any changes to your usual medicines, whatever they are for, without consulting your specialist first. Please bring all of the medicines that you currently take or use with you, including anything that you get from your doctor on prescription, medicines that you have bought yourself over the counter, and any alternative medicines, such as herbal remedies. For more information about Medications please see page 3 in your theatre pack.

Before Your Partial Nephrectomy

4 WEEKS BEFORE SURGERY: It is important to stop taking herbal medications before surgery as they may interfere with your anaesthetic or predispose you to bleeding. The following list contains SOME of the more frequent herbal medications, which should be ceased 4 weeks before the surgery.

• Echinacea • Ginseng • Goldenseal • Kava-kava • Liquorice • Saw Palmetto • St. John's Wort • Valerian • Vitamin E • Ephedra • Feverfew • Garlic • GBL, BD and GHB • Ginger • Ginkgo bilob

Inform us if you are taking Aspirin, Plavix, anti-inflammatory medications or Warfarin.

ON THE DAY OF YOUR PROCEDURE: Take your regular medications (other than as above) as usual with a sip of water at 6:00 am. DO NOT HAVE ANY OTHER FOOD OR DRINK BEFORE THE OPERATION

What can I expect after my surgery?

After the surgery is finished, you will be taken to the recovery room and remain there until you come around from the anaesthetic.

You will wake up with the following: • A catheter: this is a hollow tube inserted into the bladder. This will collect your urine 
so you will not need to leave your bed to pass urine. This also allows nurses to 
carefully monitor your urine output. This will stay in place one to two days. • Dressings and wound glue: a dressing will be placed over the wound site. This will be checked by your 
nurse for signs of bleeding and changed as needed. • Wounds: the keyhole incisions are closed with either absorbable sutures (stitches). • Drains: you will have a small tube placed around the wound site to drain any remaining 
fluid that can collect after your operation. A small bag will be attached to it, which the nurses will empty as needed. This will be removed one to two days after your operation or when there is minimal fluid in the bag. • a drip: this delivers fluids into one of your arm veins or a larger neck vein to prevent you getting dehydrated. It is usually removed one to two days after your surgery when you are able to drink freely.

You will be encouraged to move around as soon as possible and take fluids and food as soon as you are able. 
The average hospital stay is five to six nights. 


What can I expect when I get home? 


You will be discharged from hospital when:
• you can move around freely • your pain is well controlled with painkillers taken by mouth (orally).

The most common complaint after surgery is tiredness. It is important to remember that you have had major surgery and that you need to rest at home. It may take up to eight weeks before you start to regain your normal energy levels.

You may feel bloated and your clothes may feel tighter than usual. Wear loose clothing and try to walk around the house as this may help you to pass wind. It can be uncomfortable if you have not had a bowel movement for a few days. Exercise such as walking can help get your bowels moving again after the operation. If this continues to be a problem talk to you nurse or doctor for advice.

You will need to: • eat a light diet until your bowel movements are back to normal; • take it easy. Do not lift anything heavy or do anything too energetic for example, 
shopping, vacuuming, mowing the lawn, lifting weights or running for at least two to four weeks after your surgery. Doing these things may put too much strain on your stitches and may make your recovery take longer. • give yourself a couple of weeks rest before returning to work. If your work involves heavy lifting or exercise, please speak to your consultant. • start driving again when you are able to perform an emergency stop without feeling hesitant. Check with your insurance company to make sure you are covered to start driving again. 


When can I have sex again? 


You may begin sexual activity again two weeks after your operation, as long as you feel comfortable.


Follow up 


You will be seen by Dr Coughlin 8 weeks after your surgery to check the outcome your operation and your recovery. You will find a request form for bloods to be done a few days prior to this appointment inside your theatre pack. If this has not been included please contact our office.

Having a robotic simple prostatectomy

What is a simple prostatectomy?

This procedure aims to remove the central obstructing lobes of the prostate and preserves the outer shell and capsule of the prostate. It is also called an enucleative prostatectomy. It is traditionally performed when the prostate is too large to be treated via a cystoscopy and TURP (telescope through the penis/urethra).

Our aims in men with a large obstructing prostate gland are:

  • to remove the obstructing lobes of the prostate;
  • to allow you to pass urine with a stronger flow;
  • to reduce as many of your urinary symptoms as possible;
  • to preserve your continence; and
  • to preserve the erection nerves to your penis.

It is performed under a general anaesthetic. A general anaesthetic means that you will be asleep for the whole of the operation, so that you will not feel any pain. The anaesthetic is given through a small injection in the back of your hand. For more information, read the enclosed Queensland Health document: ‘Consent Information - Patient Copy - About Your Anaesthetic ‘ please tell us if you don’t have a copy.

Can a simple prostatectomy be done as a Robotic (keyhole) procedure?

Yes. A small number of surgeons perform this operation as a keyhole procedure. Dr Coughlin specializes in this treatment for benign prostatic hyperplasia.

What are the benefits of using the daVinci Surgical Robot?

  • The daVinci surgical robot allows surgeons to perform complex technical operations in a minimally invasive fashion through small key hole incisions
  • Smaller incisions produce less post operative pain and shorten the post operative recovery periods
  • The robot provides the surgeon with 3 dimensional vision magnified 10 times
  • The miniature robotic instruments articulate with small wristed joints providing an extremely dexterous means to perform minimally invasive surgery
  • The robot filters any tremor of the surgeon

What is the da Vinci Robotic Surgical System?

  • The da Vinci Robotic System is a master – slave robot. It does not perform anything in an autonomous fashion. It simply replicates the surgeon’s hand movements within the patient in a miniaturised dexterous fashion.
  • The daVinci robot has 3 major components:
  • The robot which holds the camera and robotic instruments
  • The surgical console where the surgeon sits to view the surgical field and control the robotic arms and:
  • The stack which displays the surgical view to the rest of the operating team
  • The robot serves as an extension of the surgeon’s hands and eliminates the need for large incisions that are necessary in traditional open surgery.

What are the alternatives to robotic simple prostatectomy for large obstructing prostates?

You and Dr Coughlin should decide together whether this procedure is the most suitable for you.

  • Medications – tablets that shrink or relax the prostate to help you pass urine
  • Long-term catheter – to drain your bladder permanently (this needs a change of catheter every 6 to 12 weeks
  • Holmium laser enucleation of the prostate (HoLEP) - using a laser fibre passed along a telescope through your urethra (water pipe)
  • Transurethral resection of the prostate (TURP) - coring out your prostate gland to improve the flow of urine. TURP is the most commonly performed prostate procedure most men get good relief of their symptoms. Large prostates are not always suitable for TURP
  • Green light laser (PVP) - creating a hole in the central part of the prostate using a laser that melts tissue away.
  • Embolisation of the prostatic arteries - blocking the arteries to the prostate under local anaesthetic using particles that cause the prostate to shrink

Preparing for your surgery

You will attend a pre-admission clinic before your surgery. This is a mandatory requirement. The hospital will carry out a number of tests to make sure that your heart, lungs and kidneys are working properly. You may have a chest X-ray, ECG or electrocardiogram (which records the electrical activity of your heart) and some bloods taken.

If you do not attend, we may have to cancel your surgery.

If you smoke, you may be asked to stop smoking, as this increases the risk of developing a chest infection or DVT (already defined above). Smoking can also delay wound healing because it reduces the amount of oxygen that reaches the tissues in your body.

You will be given special advice if you take warfarin, aspirin, clopidigrel, or any other medication that might thin your blood. Do not make any changes to your usual medicines, whatever they are for, without consulting your specialist first. Please bring all of the medicines that you currently take or use with you, including anything that you get from your doctor on prescription, medicines that you have bought yourself over the counter, and any alternative medicines, such as herbal remedies.

Before Your Robotic Simple Prostatectomy

4 WEEKS BEFORE SURGERY It is important to stop taking herbal medications before surgery as they may interfere with your anaesthetic or predispose you to bleeding. The following list contains SOME of the more frequent herbal medications, which should be ceased 4 weeks before the surgery.

  • Echinacea
  • Ginseng
  • Goldenseal
  • Kava-kava
  • Liquorice
  • Saw Palmetto
  • St.John'sWort
  • Valerian
  • Vitamin E
  • Ephedra
  • Feverfew
  • Garlic
  • GBL, BD and GHB
  • Ginger
  • Ginkgo bilob

Inform us if you are taking aspirin, plavix, anti-inflammatory drugs or warfarin.

ON THE DAY OF YOUR PROCEDURE take your regular medications (other than as above) as usual with a sip of water at 6:00 am.

DO NOT HAVE ANY OTHER FOOD OR DRINK BEFORE THE OPERATION You will be admitted to the hospital the day of your procedure. Dr Coughlin and the Anaesthetist will see you before your surgery. We may provide you with a pair of TED stockings to wear, and we may give you a heparin injection to thin your blood. These help to prevent blood clots from developing and passing into your lungs.

Details of the procedure The procedure is performed under a general anaesthetic (with you asleep). We will give you an injection of antibiotics before the procedure, after carefully checking for any allergies

  • Dr Coughlin makes 6 keyhole incisions in your abdomen
  • He cuts into the outer shell of your prostate gland and removes the central part
  • A bladder catheter is inserted; this stays in for about a week to allow the prostate capsule heal 

  • A drain is inserted to stop any fluid collecting around your prostate; this is normally removed the following day 

  • Absorbable stitches are used in your skin which do not require removal, and normally disappear within two to three weeks 


What can I expect after my surgery?

After the surgery is finished, you will be taken to the recovery room and remain there until you come around from the anaesthetic.

You will wake up with the following:

  • A catheter: this is a hollow tube inserted into the bladder. This will collect your urine so you will not need to leave your bed to pass urine. This also allows nurses to carefully monitor your urine output. This will stay in place seven days.
  • Dressings and wound glue: a dressing will be placed over the wound site. This will be checked by your nurse for signs of bleeding and changed as needed.
  • Wounds: the keyhole incisions are closed with either absorbable sutures (stitches).
  • Drains: you will have a small tube placed around the wound site to drain any remaining fluid that can collect after your operation. A small bag will be attached to it which the nurses will empty as needed. This will be removed one to two days after your operation or when there is minimal fluid in the bag.
  • A drip: this delivers fluids into one of your arm veins or a larger neck vein to prevent you getting dehydrated. It is usually removed one to two days after your surgery when you are able to drink freely.

You will be encouraged to move around as soon as possible and take fluids and food as soon as you are able. The average hospital stay is one night.

Are there any after-effects/risks?

The possible after-effects and your risk of getting them are shown below. Some are self-limiting or reversible, but others are not. We have not listed very rare after-effects (occurring in less than 1 in 250 patients) individually. The impact of these after-effects can vary a lot from patient to patient; you should ask Dr Coughlin’s advice about the risks and their impact on you as an individual:

  • No semen is produced during orgasm, effectively making you infertile – this happens to all patients.
  • Persisting symptoms of urgency, frequency by day & getting up at night to pass urine – this happens to most patients
  • Inability to pass urine after the catheter is removed needing intermittent catheterisation or a permanent catheter – this is rare 1-5% risk
  • Erectile dysfunction (impotence) if nerve damage is unavoidable, together with some shortening of your penis – effecting between 1 in 50 and 1 in 250 patients
  • Because the outer layer of the prostate remains intact, you can develop prostate cancer in the future; you should discuss PSA testing with Dr Coughlin and your GP – between 1 in 10 and 1 in 50 patients
  • Pathology tests may show unexpected cancer in the prostate tissue removed requiring observation, investigations &/or possible further treatment - between 1 in 10 and 1 in 50 patients
  • Bleeding requiring transfusion or further surgery - between 1 in 50 and 1 in 250
  • Scarring of the bladder neck or urethra requiring stretching or further treatment - between 1 in 50 and 1 in 250 patients
  • Anaesthetic or cardiovascular problems possibly requiring intensive care admission (including chest infection, pulmonary embolus, stroke, deep vein thrombosis, compartment syndrome, heart attack) - between 1 in 50 and 1 in 250 patients

Urinary incontinence which be temporary and require pads; this may need further surgery if it lasts for more than a year (with an artificial urinary sphincter or a synthetic male sling) between 1 in 50 and 1 in 250 patients

What can I expect when I get home?

You will be discharged from hospital when:

  • you can move around freely
  • your pain is well controlled with painkillers taken by mouth (orally).

The most common complaint after surgery is tiredness. It is important to remember that you have had major surgery and that you need to rest at home. It may take up to eight weeks before you start to regain your normal energy levels.

You will have some bleeding from the prostate area into your urine after the operation but the urine usually clears after 48 hours.

At first following catheter removal, you may get pain when passing urine and it may come more frequently than normal. Tablets can relieve any discomfort and the frequent passage usually improves within a few days.

You may feel bloated and your clothes may feel tighter than usual. Wear loose clothing and try to walk around the house as this may help you to pass wind. It can be uncomfortable if you have not had a bowel movement for a few days. Exercise such as walking can help get your bowels moving again after the operation. If this continues to be a problem talk to you nurse or doctor for advice.

You will need to:

  • eat a light diet until your bowel movements are back to normal;
  • take it easy. Do not lift anything heavy or do anything too energetic for example, 
shopping, vacuuming, mowing the lawn, lifting weights or running for at least two to four weeks after your surgery. Doing these things may put too much strain on your stitches and may make your recovery take longer.
  • give yourself a couple of weeks rest before returning to work. If your work involves heavy lifting or exercise, please speak to Dr Coughlin.
  • start driving again when you are able to perform an emergency stop without feeling hesitant. Check with your insurance company to make sure you are covered to start driving again.

When can I have sex again?

You may begin sexual activity again two weeks after your operation, as long as you feel comfortable.

Having a Robotic Nephrectomy

Key Points

  • The aim of robotic nephrectomy is to remove a kidney (usually because it has a tumour in it), using a robotic (keyhole) technique through several small incisions in your abdomen
  • In some patients, the adrenal gland and nearby lymph nodes are also removed
  • One of the keyhole incision needs to be enlarged to remove your kidney intact within a bag
  • The procedure is normally well-tolerated with an average length of stay of one – two days
  • Recovery normally takes four to six weeks but it can be longer 

  • Regular, long-term follow-up with scans is required after removal of a kidney tumour

What is a robotic nephrectomy?

Removal of your kidney through three or four keyhole incisions, using a surgical robot and robotic operating instruments put into your abdominal (stomach) cavity. One incision will need to be enlarged to remove the kidney.

It is performed under a general anaesthetic. A general anaesthetic means that you will be asleep for the whole of the operation, so that you will not feel any pain. The anaesthetic is given through a small injection in the back of your hand. For more information, read the enclosed Queensland Health document: ‘Consent Information - Patient Copy - About Your Anaesthetic ‘ please tell us if you don’t have a copy.

Can a nephrectomy be done as a Robotic (keyhole) procedure?

Yes. Dr Coughlin specializes in this treatment for kidney removal.

What are the benefits of using the daVinci Surgical Robot?

  • The daVinci surgical robot allows surgeons to perform complex technical operations in a minimally invasive fashion through small key hole incisions
  • Smaller incisions produce less post operative pain and shorten the post operative recovery periods
  • The robot provides the surgeon with 3 dimensional vision magnified 10 times
  • The miniature robotic instruments articulate with small wristed joints providing an extremely dexterous means to perform minimally invasive surgery
  • The robot filters any tremor of the surgeon

What is the da Vinci Robotic Surgical System?

  • The da Vinci Robotic System is a master – slave robot. It does not perform anything in an autonomous fashion. It simply replicates the surgeon’s hand movements within the patient in a miniaturised dexterous fashion.
  • The daVinci robot has 3 major components:
  • The robot which holds the camera and robotic instruments
  • The surgical console where the surgeon sits to view the surgical field and control the robotic arms and:
  • The stack which displays the surgical view to the rest of the operating team
  • The robot serves as an extension of the surgeon’s hands and eliminates the need for large incisions that are necessary in traditional open surgery.

What are the alternatives to robotic nephrectomy for a kidney tumour?

Dr Coughlin and you should decide together whether this procedure is the most suitable for you.

  • Observation alone – leaving the tumour in your kidney and observing it carefully for any signs of enlargement may be an option for very small tumours
  • Open radical nephrectomy – removing the whole kidney and its surrounding tissues through an abdominal or loin incision 

  • Robotic partial nephrectomy – removing only the part of the kidney containing the tumour, through a keyhole operation 


What are the possible risks?

A nephrectomy is a major operation. Dr Coughlin will discuss the risks below with you in more detail, but please ask questions if you are uncertain. The possible after-effects and your risk of getting them are shown below. Some are self-limiting or reversible, but others are not. We have not listed very rare after-effects (occurring in less than 1 in 250 patients) individually. The impact of these after-effects can vary a lot from patient to patient; you should ask Dr Coughlin advice about the risks and their impact on you as an individual:

  • Pain or discomfort at the incision site – almost all patients
  • Shoulder tip pain due to irritation of your diaphragm by the carbon dioxide gas – between 1 in 2 and 1 in 10 patients
  • Temporary abdominal bloating (gaseous distension) – between 1 in 2 and 1 in 10 patients

  • Bleeding, infection, pain or hernia at the incision site requiring further treatment - 1 in 33 patients (3%)

  • Recognised (or unrecognised) injury to organs/blood vessels requiring further surgery - between 1 in 50 and 1 in 250 patients

  • Bleeding requiring transfusion - between 1 in 50 and 1 in 250 patients
  • Entry into your lung cavity requiring insertion of a temporary drainage tube - between 1 in 50 and 1 in 250 patients
  • Anaesthetic or cardiovascular problems possibly requiring intensive care (including chest infection, pulmonary embolus, stroke, deep vein thrombosis, heart attack and death) - between 1 in 50 and 1 in 250 patients
  • Involvement or injury to nearby local structures (blood vessels, spleen, liver, lung, pancreas & bowel) requiring more extensive surgery - between 1 in 50 and 1 in 250 patients
  • The abnormality in the kidney may turn out not to be cancer
  • Dialysis may be required to stabilise your kidney function if your other kidney does not function well - between 1 in 50 and 1 in 250 patients

Preparing for your surgery

You will attend a pre-admission clinic before your surgery. This is a mandatory requirement. The hospital will carry out a number of tests to make sure that your heart, lungs and kidneys are working properly. You may have a chest X-ray, ECG or electrocardiogram (which records the electrical activity of your heart) and some bloods taken.

If you do not attend, we may have to cancel your surgery.

If you smoke, you may be asked to stop smoking, as this increases the risk of developing a chest infection or DVT (already defined above). Smoking can also delay wound healing because it reduces the amount of oxygen that reaches the tissues in your body.

You will be given special advice if you take warfarin, aspirin, clopidigrel, or any other medication that might thin your blood. Do not make any changes to your usual medicines, whatever they are for, without consulting your specialist first. Please bring all of the medicines that you currently take or use with you, including anything that you get from your doctor on prescription, medicines that you have bought yourself over the counter, and any alternative medicines, such as herbal remedies.

Before Your Robotic Nephrectomy

4 WEEKS BEFORE SURGERY It is important to stop taking herbal medications before surgery as they may interfere with your anaesthetic or predispose you to bleeding. The following list contains SOME of the more frequent herbal medications, which should be ceased 4 weeks before the surgery.

  • Echinacea
  • Ginseng
  • Goldenseal
  • Kava-kava
  • Liquorice
  • Saw Palmetto
  • St.John'sWort
  • Valerian
  • Vitamin E
  • Ephedra
  • Feverfew
  • Garlic
  • GBL, BD and GHB
  • Ginger
  • Ginkgo bilob

Inform us if you are taking aspirin, plavix, anti-inflammatory drugs or warfarin.

ON THE DAY OF YOUR PROCEDURE

Take your regular medications (other than as above) as usual with a sip of water at 6:00 am.

DO NOT HAVE ANY OTHER FOOD OR DRINK BEFORE THE OPERATION

You will be admitted to the hospital the day of your procedure. Dr Coughlin and the Anaesthetist will see you before your surgery. We may provide you with a pair of TED stockings to wear, and we may give you a heparin injection to thin your blood. These help to prevent blood clots from developing and passing into your lungs.

Details of the procedure

The procedure is performed under a general anaesthetic (with you asleep). We will give you an injection of antibiotics 
before the procedure, after carefully checking for any allergies 


  • Dr Coughlin performs the procedure under a general anaesthetic and you will be asleep throughout
  • You may be given an injection of antibiotics before the procedure, after you have been checked for any allergies
  • Dr Coughlin distends (inflates) your abdominal (tummy) cavity by injecting carbon dioxide gas using a special needle / port
  • Several keyhole incisions (ports) are made and robotic operating instruments are inserted through them
  • Your kidney and its surrounding fat is dissected using these instruments, and the kidney is extracted from your abdomen by enlarging one of the port incisions
  • The wounds are closed with absorbable stitches or glue which normally disappear within two to three weeks and local anaesthetic is injected into the wounds for pain relief
  • A catheter is placed in your bladder to monitor your urine output; this is removed as soon as you are mobile
  • A drain is placed down to the area where the kidney was removed, to prevent fluid accumulation; this is removed when it stops draining usually the following day
  • The procedure takes from one to three hours to complete, depending on complexity
  • You can expect to be in hospital for one to two days

What can I expect after my surgery?

After the surgery is finished, you will be taken to the recovery room and remain there until you come around from the anaesthetic.

You will wake up with the following

  • A catheter: this is a hollow tube inserted into the bladder. This will collect your urine so you will not need to leave your bed to pass urine. This also allows nurses to carefully monitor your urine output. This will stay in place one to two days
  • Dressings and wound glue: a dressing will be placed over the wound site. This will be checked by your nurse for signs of bleeding and changed as needed.
  • Wounds: the keyhole incisions are closed with either absorbable sutures (stitches) or glue.
  • Drains: you will have a small tube placed around the wound site to drain any remaining fluid that can collect after your operation. A small bag will be attached to it that the nurses will empty as needed. This will be removed one to two days after your operation or when there is minimal fluid in the bag.
  • A drip: this delivers fluids into one of your arm veins or a larger neck vein to prevent you getting dehydrated. It is usually removed one to two days after your surgery when you are able to drink freely.

You will be encouraged to move around as soon as possible and take fluids and food as soon as you are able. The average hospital stay is one to two nights.

What can I expect when I get home?

You will be discharged from hospital when

  • you can move around freely
  • your pain is well-controlled with painkillers taken by mouth (orally).

The most common complaint after surgery is tiredness. It is important to remember that you have had major surgery and that you need to rest at home. It may take up to eight weeks before you start to regain your normal energy levels.

You may feel bloated and your clothes may feel tighter than usual. Wear loose clothing and try to walk around the house as this may help you to pass wind. It can be uncomfortable if you have not had a bowel movement for a few days. Exercise such as walking can help get your bowels moving again after the operation. If this continues to be a problem talk to you nurse or doctor for advice.

You will need to:

  • eat a light diet until your bowel movements are back to normal;
  • take it easy. Do not lift anything heavy or do anything too energetic for example, shopping, vacuuming, mowing the lawn, lifting weights or running for at least two to four weeks after your surgery. Doing these things may put too much strain on your stitches and may make your recovery take longer.
  • give yourself a couple of weeks rest before returning to work. If your work involves heavy lifting or exercise, please speak to Dr Coughlin.
  • start driving again when you are able to perform an emergency stop without feeling hesitant. Check with your insurance company to make sure you are covered to start driving again.

Having a robotic cystectomy and ileal conduit

What is a Radical Cystectomy?

Removal of the bladder, the pelvic lymph nodes and some surrounding tissue – see diagram below. In men, the prostate gland and seminal vesicles are also removed. In women, the uterus, ovaries and top of the vaginal wall may be removed, depending on where the cancer is.

What is an Ileal Conduit?

A means of draining urine out of the body when the bladder has been removed - see diagram above and “What does the operation involve”.

What is the benefit of this operation?

The aim is to cure bladder cancer

What happens before the operation?

1-2 weeks before your operation you will be asked to attend the Pre-Admission Clinic. This is to check that you are fit for your operation. You will be asked questions about your general health. You will have some or all of the following tests: blood tests, chest x-ray and ECG (heart tracing). These are routine tests before an operation. It also gives you a chance to ask any questions that you may have. You will be referred to the Stoma Nurse who specialises in looking after patients having this type of operation. They will decide where your stoma should be placed (see “What does the operation involve”). A mark will be made on your abdomen (tummy) after you have discussed this. The stoma will be on the right side of your abdomen, just below the waist. You will usually be admitted onto the ward 1 day before your operation.

The day of your operation

You will be asked not to eat or drink from 12 midnight. If you are an insulin dependent diabetic, you will need special instruction, please discuss this with Dr Coughlin. The anaesthetist will give you a general anaesthetic.

What does the operation involve?

Dr Coughlin makes 6 or 7 keyhole incisions in your abdomen. Small plastic tubes (trocars) are placed inside the incisions to keep them open while a small camera (laparoscope) and the small robotic arms are inserted. The surgeon controls the laparoscope and robotic arms to perform the operation. A small incision is made to remove the bladder.

What does a cystectomy involve?

A cystectomy involves removing the bladder and often other organs, such as the prostate gland in men and the uterus (womb), ovaries and part of the vagina in women.

Once the bladder is removed Dr Coughlin needs to create
another way for your urine to drain from the body; this is done by forming a stoma. Other names you may hear stomas being called are ileal conduit or urostomy.

To form an ileal conduit/stoma, a small piece of your bowel (intestine) is normally used. The doctor will cut out a small piece of your bowel (removing this should not affect how your bowel works). The ureters (tubes which drain urine from the kidneys) are then stitched into one end of the small piece of bowel which was removed, urine can then drain into it. The other end comes out through a small opening on your abdomen to make the stoma. Urine can then drain from the ureters, through the piece of bowel and out through the stoma into a special bag fitted around your stoma. The bag is held in position by a sticky patch attached to the bag.

The operation will take about 5-7 hours. After the operation, you will routinely be transferred to the intensive care unit. You will be drowsy when you return to the ward and may want to arrange that only a close relative visit on the first day, so that you can have some quiet time to recover. Other relatives/friends can telephone the ward to find out how you are.

What are the risks?

Common

Infection due to insertion of temporary drains, stents following surgery Bleeding requiring the need for blood transfusion

(Women)

Pain or difficulty with sexual intercourse due to narrowing or shortening of vagina. Menopause may occur if ovaries removed

(Men)

High risk of impotence (inability to have erections) Dry orgasm. Retrograde ejaculation: no semen is produced causing infertility

Occasional

Blood loss requiring further surgery Cancer may not be cured

(Men)

Need to remove the urethra (water pipe) as part of the operation or at a later date

Rare

Infection or hernia of incision requiring further treatment Anaesthetic or heart problems possibly requiring admission to intensive care (including chest infection, clot in the lung or leg, stroke, heart attack and death) Decrease in kidney function over time

Very rare

Diarrhoea due to shortened bowel/vitamin deficiency requiring treatment Bowel and urine leakage from anastamosis (join) requiring further surgery

Scarring to the bowel or ureters requiring further surgery in the future Scarring, narrowing or hernia formation around the stoma opening requiring further surgery

Damage to the bowel during surgery resulting in the need for a colostomy

Are there any alternatives?

Radiation treatment to the bladder, continent urinary diversion (these options, if suitable, will have been discussed with you)

What will happen after the operation?

You will usually go to intensive care following the operation for 1 or 2 days.

The nurses will make regular checks of your blood pressure, pulse, breathing, stoma, wound, pain and urine output. As you get better, these checks will be done less often.

The tubes and drains you may return to the ward with are listed below. Do not worry about them, they are there to give you fluids or drain fluids away and are there for your safety. They will gradually be removed, as you get better.

  • Oxygen - You may be given oxygen for a short time after your operation until you are more alert and awake.
  • Intravenous infusion – (IVI or drip) – When the bowel is handled during your operation it stops working. It normally takes 2-3 days before it starts to work again. Until this happens you will not be allowed to eat or drink. A cannula will have been put into a vein in your arm and/or your neck and fluid will be given through the cannula to make sure you do not get dehydrated. This can also be used to give you intravenous antibiotics, blood etc. When you are drinking and do not feel sick they will be removed, normally 2-4 days after surgery.
  • Nasogastric or Gastrostomy tube - This is a small tube which drains fluid out of your stomach into a small bag attached at the end of the tube. When your bowel is not working, fluid collects in your stomach and can make you feel sick. The tube is inserted either through your nose or small opening on your tummy into your stomach, this will help reduce the feeling of sickness. You will gradually take fluids by mouth starting wilt sips of water and increasing slowly over the next few days until you are taking a light diet. The tube is normally removed 2-3 days after your operation unless you continue to feel sick. If you feel sick you should let the nurses know and they can give you medication to help with this.
  • Drains - You will have 1 or 2 drains (tubes) coming out of your lower abdomen (stomach). They drain away blood or fluid, which can collect after your bladder is taken out. They will normally be removed after 2-3 days. If they are still draining large amounts, they will be left in a little longer.
  • Stoma - You will have 2 small tubes (stents) coming out of your stoma. They come down the ureters (tubes from the kidney) and out through the stoma. They allow the joins where the ureters are stitched into the stoma to heal. The tubes are normally removed after about 10days.
  • Wound - you will have a dressing over the wound for a few days after the operation. The wound will heal and over time the scar will fade.
  • PCA (Patient Controlled Analgesia to control your pain. These will have been discussed with you before the operation. When you are eating and drinking and can take painkillers by mouth, the PCA/Epidural can be removed. It is important that your pain is controlled, if not, you should let the nurse know.

You will be encouraged to get up and about as soon as possible. This is to avoid complications such as chest infections, pressure sores, a clot in the leg (Deep Vein Thrombosis - DVT). You will be taught deep breathing and coughing exercises by the physiotherapist, who will see you before and after your operation.

When will I be able to go home?

After about 10-14 days when both you and the stoma nurse are happy you are able to look after your stoma.

What follow up will I have?

An outpatient appointment will be made for you to come back to the rooms 6-8 weeks after you are discharged home.

Discharge Information

Care of your stoma

You will be discharged when both you and the stoma nurse are happy that you can care for your stoma. Make sure you have enough stoma bags and supplies before you go home and have the stoma nurse’s telephone number in case you need to contact him/her.

Medicines to take home

You may be given painkillers to take home, you should use them as you need to but no more than the recommended dose. Your nurse will discuss this with you before you go home. You should continue to take your normal medicines unless advised otherwise.

Washing

You can bath or shower once you are home. Gently pat dry the area, rather than rubbing.

Driving

You should wait at least 4 weeks and be able to carry out an emergency stop without finding this painful. Avoid long journeys during this time. Check with your Insurance Company, some companies have guidelines on when you should drive again.

Sex

You will be able to resume sexual activity when you feel comfortable to do so but you may wish to wait 6-8 weeks before sexual intercourse to allow healing. Women may experience pain or difficulty with sexual intercourse due to the narrowing or shortening of the vagina after surgery. You may need to try different ways and positions in order to find what is easier for you. Many men are unable to achieve an erection after surgery due to nerves necessary for erections being damaged or cut. Treatments are available to help overcome this. If you are having problems you can discuss them with your doctor or nurse.

Work

You can normally return to work after about 4-8 weeks depending what you do. Manual work or work involving heavy lifting, will need at least 6-8 weeks off. You should discuss this with your doctor before you leave hospital. Ward nurses can give you a sick certificate, you should ask them for this if you need one.

General advice

You will be able to eat and drink normally. Take it easy for about
6 weeks but take gentle exercise like walking gradually increasing what you do, as you feel able. Avoid strenuous exercise for 6-8 weeks. Avoid lifting heavy objects for 6-8 weeks.

Having a robotic cystectomy and neobladder formation

How is a Robotic Cystectomy done?

Dr Coughlin makes 6 or 7 keyhole incisions in your abdomen. Small plastic tubes (trocars) are placed inside the incisions to keep them open while a small camera (laparoscope) and the small robotic arms are inserted. The surgeon controls the laparoscope and robotic arms to perform the operation. A small incision is made to remove the bladder.

What does a cystectomy involve?

A cystectomy involves removing the bladder and often other organs, such as the prostate gland in men and the uterus (womb), ovaries and part of the vagina in women.

What is a neo-bladder?

A neo-bladder is a replacement for your original bladder and is created from a section of your bowel and reconnected to your urethra (water pipe), with the aim of collecting urine in an internal reservoir.

What are the benefits of having a neo-bladder?

It allows you to pass urine in much the same way as you would with a normal bladder, so it can improve the quality of your life by avoiding the need for an external device to collect your urine after your cystectomy. However, not everyone needing a cystectomy is suitable for this surgery. This is especially the case if you have had radiotherapy to your pelvis or a history of bowel abnormalities, or if cancer extends to the water pipe.

What happens during a bladder reconstruction?

This operation can be carried out in several ways. The different types of reconstruction are usually named after the surgeon who developed them. The most common technique I use is called a Hautmann W ileal pouch reconstruction. This involves using a 60cm section of the small bowel. This piece of bowel is used to make the new reservoir or pouch that replaces your existing bladder. The ureters (tubes linking the kidneys and bladder) are implanted into this new reservoir, which is then sewn onto the urethra. A catheter is placed into the new bladder through the urethra and left in place for three weeks, while the new joins heal. The catheter is then removed after this.

What are the alternatives?

If you decide not to have a neo-bladder, or are not suitable for the surgery, then you will need to have a stoma created at the same time that your bladder is removed.

A stoma, or urostomy, is an artificial opening on your abdomen that can be used to collect waste from your bladder or bowel. As you are having your bladder removed, it will be used to collect urine. If you have a stoma, the tubes connecting your kidneys and bladder (the ureters), are disconnected from your bladder. They are then connected to a segment of your bowel that’s been isolated from your intestine. This segment is then brought to the skin surface, usually on the right hand side of your abdomen. Your urine then empties through this stoma into a small bag.

Limitations of surgery

Sometimes during the surgery, it may not be possible to create a neo-bladder because of the length of your bowel or urethra. It is then necessary to create a stoma. The stoma nurse will see you before your surgery to mark a site on your abdomen where your stoma should be. If your surgeon has to create a stoma, this mark shows him where to put it.

How will this surgery affect me?

This surgery permanently changes your body in several ways. It can affect:

  • how you pass urine
  • how you have sex
  • your ability to have children
  • your bowel function.

Dr Coughlin will discuss with you in more detail how your operation will affect you. Please ask questions if you are uncertain.

Passing urine

After the operation, your kidneys will produce urine in the normal way and the ureters will drain urine into your new bladder. Your new bladder will store urine until you decide to empty it. However, your bladder will not feel full in the same way as it used to. Some people say that they get a sensation of fullness in the abdomen; others say that it feels a bit like having "wind". If you are unsure about when your bladder is full, keep an eye on the time and empty your bladder at regular intervals of three to four hours.

Many people who have had this operation will need to relax their pelvis and use some abdominal pressure or strain to empty their new bladder. At first, the amount of urine the new bladder can hold will be less than a normal bladder. This will increase over time. You will need to empty your bladder every one to three hours at first until your bladder reaches its full capacity. After about three to six months, it should hold around 500-6oo mls of urine (similar to the capacity of a normal bladder).

At night we recommend that you get up at least once or twice to empty your new bladder before it becomes full. This is important, as control may be difficult when you are asleep if your bladder is full. Most patients will experience leakage at night over the first couple of months. However, with pelvic floor exercises and bladder training, this should improve over time. Also, as the new bladder stretches it will be able to hold more urine, so you will not need to empty it as often.

Pelvic floor exercises will help to restore tone to the muscles in the pelvis. These muscles help you to control leakage. A pyhsiotherapist will teach you how to do these exercises before your surgery. For more information, please ask for a copy of our leaflet called Pelvic floor exercises for men/women. We will teach you how to pass a catheter into your new bladder. We will do this because you may occasionally need to use a catheter after you have emptied your bladder to make sure no urine has been left behind. If a large amount of urine is left behind in your bladder, it could cause infection, difficulty controlling urine leakage and problems with your kidneys.

How often you need to pass a catheter depends on how often and how much urine you are passing. Your consultant or specialist nurse will tell you what to do. About 30-40 per cent of people having this type of operation will need to insert a catheter once or twice a day in the long term.

If you do need to use a catheter to help empty your bladder, don't worry. Learning to pass a catheter is not as difficult as it sounds and it doesn't take long to become an expert. It is a safe procedure as long as it is done under clean conditions and can be carried out almost anywhere, with very little fuss.

Having sex and the ability to have children

The aim of the cystectomy is to remove all of your bladder cancer cells. This means other tissues that touch or lie close to your bladder are usually removed during the operation. These other organs and tissues affect your sexual function.

In men – the prostate, which sits directly below the bladder, is removed during the operation. The nerves responsible for achieving an erection touch the prostate gland and may be damaged or may need to be removed also. In some cases, it may be possible to preserve the nerves on one side or both sides of your prostate, to increase the chances of restoring your erectile function (the ability to get an erection) with the use of tablets and/or injections. We will discuss this in more detail at your follow-up appointment.

In women – there is an area of tissue between a section of the bladder and the vagina that has shared blood supply. This means that when this tissue is removed, a strip of the front wall of the vagina is also taken away. The result of this means that there may be some shortening of your vagina and full intercourse may not be possible for some patients. You should wait several weeks after your surgery before attempting to have intercourse and we advise you to use a lubricant such as KY jelly® to help. Your uterus (womb) is usually removed.

Bowel function

After this operation, some people notice a change in their bowel habit. You may go to the toilet more frequently or notice that your bowel movements are more "loose" than before. This is because removing a section to make your new bladder has shortened your bowel. This should improve within the first couple of months after your surgery. If it doesn’t, medicines are available to bulk up your stool. This can be discussed with you in more detail if it applies to you.

We want to involve you in all the decisions about your care and treatment. If you decide to go ahead with the surgery, you will be asked to sign a consent form that says you have agreed to the treatment and that you understand the benefits, risks and alternatives. If there is anything you don’t understand or you need more time to think about it, please tell the staff caring for you.

Remember, it is your decision. You can change your mind at any time, even if you have signed the consent form. Let staff know immediately if you change your mind. Your wishes will be respected at all times.

4 WEEKS BEFORE SURGERY:

It is important to stop taking herbal medications before surgery as they may interfere with your anaesthetic or predispose you to bleeding. The following list contains SOME of the more frequent herbal medications, which should be ceased 4 weeks before the surgery.

  • Echinacea
  • Ginseng
  • Goldenseal
  • Kava-kava
  • Licorice
  • Saw Palmetto
  • St.John'sWort
  • Valerian
  • Vitamin E
  • Ephedra
  • Feverfew
  • Garlic
  • GBL, BD and GHB
  • Ginger
  • Ginkgo bilob

Inform us if you are taking aspirin, plavix, anti-inflammatory drugs or warfarin

Coming to hospital

The day you come to hospital

  • You will come into on the day of your operation and should expect to stay about 10-14days;
  • You will meet the nursing and medical staff who will be looking after you on one of our urology wards.

The day of the operation

  • You cannot drink anything for six hours before you go to theatre. Usually you will fast from midnight the night before your surgery. If you have prescription medicines, you can take these with a small sip of water.

After your operation

After you come out of theatre, we will transfer you to the intensive care unit where you will stay overnight for close monitoring. You will return to the ward the following day. Staying in the intensive care unit will allow us to monitor your blood pressure, heart rate and fluid levels using very accurate equipment. To reduce the pain in your abdomen after the operation we will give you painkillers.

You will also have:

  • A drip running into a vein in your neck to give you fluids until you are able to drink normally (about a day or two after your operation). You will be allowed to start eating again a day or two later.
  • A catheter in your new bladder. This will drain your urine, so that the new bladder does not fill until it has had time to heal. It will be removed about three or four weeks after your surgery;
  • A small plastic tube from your abdomen that will stay in place for about seven days to drain any excess fluid surrounding the reconstruction.

Your recovery

The nursing staff will help you to get out of bed on the first or second day after your operation and help you to start walking soon after this. Patients are usually up and about independently around four to five days after their surgery.

The nurses on the ward may need to wash out your new bladder occasionally. The washout is done to help clear your bladder of mucus, which is produced by the bowel tissue that your new bladder is made from. When you are eating and drinking and we have removed the various drain tubes, you can begin to take care of yourself. This includes learning how to manage the bladder washouts, if necessary. This is essential, as you will go home with the catheter in and it is important that the catheter does not become blocked.

Your new bladder will take around three weeks to heal. During this time the catheter will remain in place to drain away your urine. We will arrange a discharge date for when you feel confident you will be able to cope by yourself. This is usually one to two weeks after your surgery.

Cather removal.

About three weeks after your surgery you will be admitted to hospital to have your catheter removed. You will stay in the hospital overnight to assess your voiding and neobaldder emptying. Immediately after the catheter is removed you will find you need to empty your bladder very frequently, but this will improve with pelvic floor exercises.

Getting back to normal

  • Recovery time after abdominal surgery varies but generally, you should feel improvements after four to six weeks;
  • Do not attempt to drive a car during the first six weeks after your surgery. Before you begin again, make sure you feel able to do an emergency stop and check with your insurance provider;
  • Do not attempt to lift or move heavy objects, start digging the garden or do housework for the first six weeks after your surgery. Build up your activities slowly after this and only do as much as you feel able to;

When you can return to work depends on the type of job you do. Please ask your surgeon if you are unsure.

What are the potential risks of this operation?

There are potential complications from your bladder reconstruction, which your surgeon will discuss with you in more detail before asking you to sign a consent form.

Possible early complications of a major operation Problems that can occur while you are in hospital recovering are similar to those for any major operation. These include:

  • A chest infection
  • Blood clots in your lower leg, which could pass to your lung
  • Wound infection
  • Bruising around your wound
  • Poor wound healing or weakness in the wound site
  • Bleeding and the need for a blood transfusion
  • Injury to nearby nerves or tissues.

Specific risks for a cystectomy include:

  • Leakage or narrowing of your intestine where the section of the bowel was removed causing obstruction which could require additional surgery;
  • There is about a five per cent risk that the junction between your ureters (tubes from the kidneys) and your new bladder will narrow. You may need an operation to correct this if it interferes with the function of your kidneys;
  • Urine leakage from your new bladder. This usually settles down as your bladder stretches, but in rare circumstances you may need further treatment for this;
  • Very occasionally, stones may occur in your new bladder and you may need treatment to remove them;
  • Damage to your rectum requiring surgical repair and/or colostomy formation (additional temporary stoma for bowel);
  • The operation may not remove all of your cancer (if this was the reason for your surgery);
  • Your sexual function may be affected;
  • There is a small risk of dying from this surgery (1-2 per cent).

Having a robotic pelvic lymph node dissection

What is a robotic pelvic lymph node dissection?

It is the removal of lymph nodes that are situated around the reproductive organs and blood vessels in the pelvis. Lymph nodes, sometimes called glands, act as a filter in your body and can be a collection site for tiny (microscopic) cancer cells. The procedure is carried out through keyhole incisions as a robotic operation.

It is performed under a general anaesthetic. A general anaesthetic means that you will be asleep for the whole of the operation, so that you will not feel any pain. The anaesthetic is given through a small injection in the back of your hand. For more information, read the enclosed Queensland Health document: ‘Consent Information - Patient Copy - About Your Anaesthetic ‘ please tell us if you don’t have a copy.

Can a pelvic lymph node dissection be done as a Robotic (keyhole) procedure?

Yes. Dr Coughlin specializes in this treatment for pelvic lymph node removal.

What are the benefits of using the daVinci Surgical Robot?

  • The daVinci surgical robot allows surgeons to perform complex technical operations in a minimally invasive fashion through small key hole incisions
  • Smaller incisions produce less post operative pain and shorten the post operative recovery periods
  • The robot provides the surgeon with 3 dimensional vision magnified 10 times
  • The miniature robotic instruments articulate with small wristed joints providing an extremely dexterous means to perform minimally invasive surgery
  • The robot filters any tremor of the surgeon

What is the da Vinci Robotic Surgical System?

  • The da Vinci Robotic System is a master – slave robot. It does not perform anything in an autonomous fashion. It simply replicates the surgeon’s hand movements within the patient in a miniaturised dexterous fashion.
  • The daVinci robot has 3 major components:
  • The robot which holds the camera and robotic instruments
  • The surgical console where the surgeon sits to view the surgical field and control the robotic arms and:
  • The stack which displays the surgical view to the rest of the operating team
  • The robot serves as an extension of the surgeon’s hands and eliminates the need for large incisions that are necessary in traditional open surgery.

What are the risks and consequences associated with this operation?

A pelvic lymphadenectomy is a major operation. Dr Coughlin will discuss the risks below with you in more detail, but please ask questions if you are uncertain. The possible after-effects and your risk of getting them are shown below. Some are self-limiting or reversible, but others are not.

Most operations are straightforward, however as with any surgical procedure there is a small chance of side effects or complications such as:

  • Pain or discomfort at the incision sites – almost all patients
  • Shoulder tip pain due to irritation of your diaphragm by the carbon dioxide gas – between 1 in 2 and 1 in 10 patients
  • Temporary abdominal bloating (gaseous distension) – between 1 in 2 and 1 in 10 patients

  • Excessive bleeding.

  • Recognised (or unrecognised) injury to organs/blood vessels requiring further surgery - between 1 in 50 and 1 in 250 patients
  • Bleeding requiring transfusion - between 1 in 50 and 1 in 250 patients
  • You may also have some pelvic nerve damage as a result of your operation, you may experience numbness to your abdomen or thighs.
  • Post operatively there is a 5% of risk of developing a lymphocele (a collection of lymphatic fluid in the pelvis) that will require drainage
  • 1-2% of people will get permanent swelling in a groin or leg know as lymphedema
  • for several weeks after the operation you may feel bloated and feel fluid inside your abdomen. Your clothes may be tighter. This is not uncommon and occurs until the lymphatic fluid finds new drainage pathways.
  • Anaesthetic or cardiovascular problems possibly requiring intensive care (including chest infection, pulmonary embolus, stroke, deep vein thrombosis, heart attack and death) - between 1 in 50 and 1 in 250 patients

  • To reduce the risk of developing an infection, you will be given antibiotics through a drip (intravenously) during the operation. If you are concerned about any of these risks, or have any further queries, please speak to Dr Coughlin.

Preparing for your surgery

You will attend a pre-admission clinic before your surgery. This is a mandatory requirement. The hospital will carry out a number of tests to make sure that your heart, lungs and kidneys are working properly. You may have a chest X-ray, ECG or electrocardiogram (which records the electrical activity of your heart) and some bloods taken.

If you do not attend, we may have to cancel your surgery.

If you smoke, you may be asked to stop smoking, as this increases the risk of developing a chest infection or DVT (already defined above). Smoking can also delay wound healing because it reduces the amount of oxygen that reaches the tissues in your body.

You will be given special advice if you take warfarin, aspirin, clopidigrel, or any other medication that might thin your blood. Do not make any changes to your usual medicines, whatever they are for, without consulting your specialist first. Please bring all of the medicines that you currently take or use with you, including anything that you get from your doctor on prescription, medicines that you have bought yourself over the counter, and any alternative medicines, such as herbal remedies.

Before Your Robotic Pelvic lymphadenectomy

4 WEEKS BEFORE SURGERY It is important to stop taking herbal medications before surgery as they may interfere with your anaesthetic or predispose you to bleeding. The following list contains SOME of the more frequent herbal medications, which should be ceased 4 weeks before the surgery.

  • Echinacea
  • Ginseng
  • Goldenseal
  • Kava-kava
  • Liquorice
  • Saw Palmetto
  • St.John'sWort
  • Valerian
  • Vitamin E
  • Ephedra
  • Feverfew
  • Garlic
  • GBL, BD and GHB
  • Ginger
  • Ginkgo bilob

Inform us if you are taking aspirin, plavix, anti-inflammatory drugs or warfarin.

ON THE DAY OF YOUR PROCEDURE take your regular medications (other than as above) as usual with a sip of water at 6:00 am.

DO NOT HAVE ANY OTHER FOOD OR DRINK BEFORE THE OPERATION

You will be admitted to the hospital the day of your procedure. Dr Coughlin and the Anaesthetist will see you before your surgery. We may provide you with a pair of TED stockings to wear, and we may give you a heparin injection to thin your blood. These help to prevent blood clots from developing and passing into your lungs.

Details of the procedure

  • Dr Coughlin performs the procedure under a general anaesthetic and you will be asleep throughout
  • You may be given an injection of antibiotics before the procedure, after you have been checked for any allergies
  • Dr Coughlin distends (inflates) your abdominal (tummy) cavity by injecting carbon dioxide gas using a special needle / port
  • several keyhole incisions (ports) are made and robotic operating instruments are inserted through them
  • Using the surgical robot the lymph nodes in the pelvis are dissected free and placed in a specimen bag for removal from your abdomen.
  • the wounds are closed with absorbable stitches or glue which normally disappear within two to three weeks and local anaesthetic is injected into the wounds for pain relief
  • a catheter is placed in your bladder to monitor your urine output; this is removed as soon as you are mobile
  • a drain is placed down to the area where the surgery was performed; this is removed when it stops draining usually the following day
  • the procedure takes from one to three hours to complete, depending on complexity
  • you can expect to be in hospital for one night

What can I expect after my surgery?

After the surgery is finished, you will be taken to the recovery room and remain there until you come around from the anaesthetic.

You will wake up with the following

  • A catheter: this is a hollow tube inserted into the bladder. This will collect your urine so you will not need to leave your bed to pass urine. This also allows nurses to carefully monitor your urine output. This will stay in place one to two days
  • Dressings and wound glue: a dressing will be placed over the wound site. This will be checked by your nurse for signs of bleeding and changed as needed.
  • Wounds: the keyhole incisions are closed with either absorbable sutures (stitches) or glue.
  • Drains: you will have a small tube placed around the wound site to drain any remaining fluid that can collect after your operation. A small bag will be attached to it that the nurses will empty as needed. This will be removed one to two days after your operation or when there is minimal fluid in the bag.
  • A drip: this delivers fluids into one of your arm veins or a larger neck vein to prevent you getting dehydrated. It is usually removed one to two days after your surgery when you are able to drink freely.

You will be encouraged to move around as soon as possible and take fluids and food as soon as you are able. The average hospital stay is one night.

What can I expect when I get home?

You will be discharged from hospital when:

  • you can move around freely
  • your pain is well controlled with painkillers taken by mouth (orally).

The most common complaint after surgery is tiredness. It is important to remember that you have had major surgery and that you need to rest at home. It may take up to eight weeks before you start to regain your normal energy levels.

You may feel bloated and your clothes may feel tighter than usual. Wear loose clothing and try to walk around the house as this may help you to pass wind. It can be uncomfortable if you have not had a bowel movement for a few days. Exercise such as walking can help get your bowels moving again after the operation. If this continues to be a problem talk to you nurse or doctor for advice.

You will need to

  • eat a light diet until your bowel movements are back to normal;
  • take it easy. Do not lift anything heavy or do anything too energetic for example, shopping, vacuuming, mowing the lawn, lifting weights or running for at least two to four weeks after your surgery. Doing these things may put too much strain on your stitches and may make your recovery take longer.
  • give yourself a couple of weeks rest before returning to work. If your work involves heavy lifting or exercise, please speak to Dr Coughlin.
  • start driving again when you are able to perform an emergency stop without feeling hesitant. Check with your insurance company to make sure you are covered to start driving again.

About Transperineal ultrasound guided biopsies of the prostate

Key Points

  • Transperineal ultrasound-guided biopsy of your prostate is done to check for prostate cancer
  • There is, at present, no more reliable way than biopsies for checking your prostate
  • The commonest side effects are bleeding and reduced urinary flow, but infection is rare.

What does this procedure involve?

Putting an ultrasound probe into your rectum (back passage) to scan your prostate. Guided by ultrasound, biopsies are taken from your prostate through your perineum (the skin between your scrotum and rectum). We use a special grid to standardise the biopsies, and we take between 24 and 50 samples, depending on the size of your prostate.

What are the alternatives?

  • Observation with repeat blood tests – repeating your blood tests and only investigating further if the tumour marker levels rise
  • MRI scanning – using advanced multiparametric MRI scanning, it may be possible to detect tumour(s) in your prostate at an early stage
  • Transrectal ultrasound-guided prostatic biopsies – usually taken under local anaesthetic with a biopsy needle passed through the ultrasound probe.

What happens on the day of the procedure?

You will be seen by Dr Coughlin and your Anaesthetist.

We may provide you with a pair of TED stockings to wear. These help to prevent blood clots from developing and passing into your lungs. Your medical team will decide whether you need to continue these after you go home.

Details of the procedure

  • We carry out the procedure under a general anaesthetic (where you are asleep)
  • Before the procedure, we will give you either an antibiotic injection after we have checked carefully for any allergies
  • We position you in special supports which allow the surgeon to access the skin behind your scrotum
  • We normally examine your prostate first, by rectal examination, before inserting the ultrasound probe
  • The probe is as wide as a man’s thumb and approximately 10 cm (four inches) long
  • To take biopsies from the prostate, we use a special grid so that all areas of the prostate can be included
  • The biopsy needles are guided into position using the ultrasound scanner (pictured)
  • We may get additional biopsy guidance by superimposing multiparametric MRI images on the ultrasound scans
  • We take typically up to 24 biopsy samples, depending on the size of your prostate
  • We apply a firm dressing to your perineum which is held in place with a pair of disposable pants
  • The procedure takes 30 to 45 minutes to complete
  • The procedure is performed as day surgery

Are there any after-effects?

The possible after-effects and your risk of getting them are shown below. Some are self-limiting or reversible, but others are not. The impact of these after-effects can vary a lot from patient to patient; you should ask Dr Coughlin’s advice about the risks and their impact on you as an individual:

  • Blood in your urine for up to 10 days – occurs in almost all patients
  • Blood in your semen which can last up to six weeks (this poses no risk to you or your sexual partner) – occurs in almost all patients
  • Bruising in your perineal area – occurs to between 1 in 2 & 1 in 10 patients
  • Discomfort in your prostate caused by bruising from the biopsies – occurs to between 1 in 2 & 1 in 10 patients
  • Temporary problems with erections caused by bruising from the biopsies – occurs to 1 in 20 patients (5%)
  • Inability to pass urine (acute retention of urine) – occurs to 1 in 50 patients
  • Bleeding in your urine preventing you from passing urine (clot retention) – occurs to 1 in 50 patients
  • Failure to detect a significant cancer in your prostate – occurs to between 1 in 10 and 1 in 50 patients
  • Need for a repeat procedure if biopsies are inconclusive or your PSA level rises further – occurs to between 1 in 10 and 1 in 50 patients
  • Bleeding in your urine requiring emergency admission for treatment – occurs to 1 in 100 patients
  • Infection in your urine requiring antibiotics – occurs to 1 in 100 patients
  • Septicaemia (blood infection) requiring emergency admission for treatment – occurs to 1 in 1000 patients

What can I expect when I get home?

  • You will get some blood in your urine which may last several days, often with the occasional blood clot
  • We advise you to drink plenty of fluid to help stop this bleeding
  • You often see blood in your semen for up to six weeks
  • If you are unable to pass urine at all, you should go to your local Emergency Department
  • Dr Coughlin will see you or contact you with the biopsy results

General information about surgical procedures

Before your procedure Please tell a member of the medical team if you have:

  • A regular prescription for a blood thinning agent (warfarin, aspirin, clopidogrel, rivaroxaban or dabigatran);
  • A present or previous MRSA infection; or
  • A high risk of variant-CJD (e.g. if you have had a corneal transplant, a neurosurgical dural transplant or human growth hormone treatment).

Smoking and surgery Ideally, we would prefer you to stop smoking before any procedure. Smoking can worsen some urological conditions and makes complications more likely after surgery. For advice on stopping, we recommend you see your GP: