Dr. Geoff Coughlin

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.

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.

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

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.

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: