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Background

Mr Bhanot is offering keyhole prostatectomy at the Spire Roding Hospital.

After 10 years of experience of open radical prostatectomy (see Publications section - ‘Radical Prostatectomy: Pathology findings in 1001 cases compared with other major series and over time’) ,he introduced this surgical technique in East London and Essex in May 2004 . Mr Bhanot has the credit of introducing and popularising the extra peritoneal method of Laparoscopic Radical Prostatectomy (see Publications section - ‘Leipzig Technique of Endoscopic Extra Peritoneal Radical Prostatectomy (EERPE): The Initial UK Experience’).

The extra peritoneal approach has allowed the surgeons to minimise the trauma of the surgery. Mr Bhanot and his dedicated team of doctors and nurses have worked together in setting up laparoscopic urological services in the region. Working jointly with other international experts in the field he has helped devise the modular method of surgical training (see Publications section - ‘Modular training for residents with no prior experience with open pelvic surgery in endoscopic extraperitoneal radical prostatectomy’ and ‘Modular Surgical Training for Endoscopic Extraperitoneal Radical Prostatectomy (EERPE)’. The principles of modular training are rapidly gaining popularity not only in Urology but in all surgical discplines.

Mr Bhanot is known to be the most experienced laparoscopic and open cancer surgeon in the region. He regularly audits all his surgical practice. The success rates and complication rates of various procedures quoted by Mr Bhanot during your consultation are based on his own practice.

The advantages of keyhole approach include reduced blood loss, less pain, quicker recovery and better chances of preservation of functions like potency and urinary incontinence.

What is the difference between open and keyhole prostatectomy?

Both the techniques are used to treat prostate cancer by removing the entire prostate gland and then attaching the urethra directly to the bladder.

The major difference as the name suggests lies in gaining the access to the prostate. Open prostatectomy requires a large incision whereas endoscopic operation requires tiny holes to pass the camera. A scope is passed through the hole that provides uniform lighting everywhere, including the far reaches of the narrow male pelvis. The scope used in laparoscopic prostatectomy transmits dynamic, magnified images to a monitor that can be simultaneously viewed by everyone involved in the operating theatre. A very precise and identical, well illuminated view of live surgery is presented to everyone, which promotes greater control of the anatomy and excellent coordination among team members.

Compared to open radical prostatectomy, laparoscopic prostatectomy is a controlled, coordinated, and elegant operation associated with less blood loss and less morbidity.

The benefits of Laparoscopic prostatectomy?

The magnified and illuminated view allows for a gentler and more precise dissection. As a result, the blood loss is very low, typically in the range of 100 to 400 ml.

Reductions in blood loss reduces the chance of transfusion, blood pressure fluctuations, and risks of post-operative complications such as heart attack. Patients without blood loss and without blood transfusion feel better.

Because it is performed through very small incisions, the laparoscopic operation is associated with very little surgical pain. Most patients recover without narcotic medication. The reduction of pain also permits most patients to be up and about fairly quickly.

Who are suitable for Laparoscopic surgery?

Anyone diagnosed with localized prostate cancer may benefit from the Laparoscopic approach, however, this decision to have a prostate cancer treated surgically revolves around numerous considerations, most importantly the severity of the prostate cancer and the severity of other illnesses. The following variables are taken into account for preoperative evaluation – age, pre biopsy PSA, previous prostate cancer treatments, height, weight, other illnesses, smoking history, previous surgery and current medications.

Laparoscopic Radical Prostatectomy can be done on men of all sizes and who have had other operations such as appendectomy, laparoscopic hernia repair, repair of abdominal trauma, transurethral prostatectomy (TURP) etc.

Preparing for the operation

You are advised to start doing regular pelvic floor exercises. These will strengthen your continence mechanism.

Try to keep yourself generally active prior to your operation.

You will have the standard blood and other tests and you will be given a laxative and an enema before your operation.

The operation

The operation will be performed under a general anaesthetic.

A cysto urethroscopy (examination of the urethra, prostate and bladder) is carried out before the operation while you are under the anaesthetic. If you have had previous prostatic surgery then you may require temporary stenting of tubes ( ureters) coming from your kidneys.

Depending upon your PSA test result, tumour stage and grade you may also need biopsies of your lymph glands at the time of your operation.

The operation is carried out through 5 keyholes below the level of the belly button. The whole of the prostate including its true capsule and both seminal vesicles are normally removed during the operation. The urethra is sutured (anastamosed) to the bladder to keep the continuity of urinary tract.

The operation normally takes about 3 hours to perform.

Does the operation require general anesthesia?

Yes. Laparoscopic Radical Prostatectomy is a major operation and would be unbearable without anesthesia.

What are the risks of this operation?

Laparoscopic Radical Prostatectomy carries the general risks of any major operation.

Laparoscopic Radical Prostatectomy may also be associated with the risks of infertility, injury, impotence, and incontinence.

Can the potency be preserved?

Yes. There is a strong chance of nerve sparing surgery but this depends on lots of other factors such as hypertension, diabetes, obesity, smoking history, anxiety etc.

Does Laparoscopic Radical Prostatectomy require a catheter, drain, dressings, or stitches?

Yes. Like any radical prostatectomy, LRP requires reconstruction of the bladder-urethra connection. A catheter is left in the urethra, connected to a drainage bag, and used to align the healing suture line and drain the bladder. In the immediate post-op period, LRP also requires a drain. The drain assures the collection of blood and urine that may accumulate immediately after surgery and is removed when the output drops, usually the morning after surgery. There are stitches, but these dissolve by themselves and require no special care. The surgical dressings for LRP are five band-aid dots used to cover the instrument entry sites. These dressings are generally removed 48 hours after surgery.

Can I bathe after LRP?

Yes. Most patients have showered within 24 hours of surgery.

How would I feel immediately after LRP?

Patients leave the operating room with an intravenous line, a urethral catheter, and a small rubber drain in their lower abdomen.

After recovering from anesthesia, almost all patients start to drink clear liquids. In the first few hours, depending on strength and motivation, most patients get out of bed and stretch their legs. Most have walked around the nurse's station by next morning. Patients are discharged with a catheter connected to a leg bag, which fits under their pants. Loose clothing and shoes that don't require tying seem easier to handle in the first few hours and days.

How long should the catheter stay in?

The Catheter is usually removed within a few days of the operation.

What can I expect after getting home?

The single most common complaint after hospital discharge seems to be sleep deprivation and fatigue. While relative to open surgery, the LRP is generally less demanding, the experience is still a major pelvic operation. Most patients are anxious going into surgery, get little sleep the night before surgery, arrive at the hospital very early on the morning of surgery, and get very little sleep the night after surgery. Accordingly, most patients seem most interested in a good, long nap and a shower after getting home.

The other major complaint seems to be a sense of bloating, with clothes fitting very tight. This bloating seems related to the effects of surgery, anesthesia, and bedrest on intestine function and responds well to walking, which helps the patient expel intestinal gas, which helps the patient regain his overall comfort and appetite.

What can I expect after the catheter comes out?

Almost all patients have some incontinence when the catheter comes out. Continence function returns with time. While recovering continence, it is wise to carefully consider one’s fluid intake, as a full bladder is much more likely to leak than an empty bladder.

What is the long-term followup after LRP?

Depending on the pathologist’s report of the LRP specimen, a patient may or may not consider additional cancer treatments. In most cases, but not all, the wise course of action is surveillance: periodic measurement of blood PSA, thought to be the most sensitive indicator of cancer recurrence.

Potential Complications

Every operation has certain associated complications and LRP is no different. These complications are similar to the complications associated with open operation but much less frequent.

Serious complications involving bowel injury with this technique are rare as this operation is performed through the extra peritoneal route.

1. Infection
2. Delayed wound and anastamosis healing
3. Bleeding and need for blood transfusion
4. Injury to big blood vessels
5. Injury to nerves; ilio-inguinal (nerve to groin area), obturator (nerve to inner side of thigh and knee) and cavernosal nerves( used for erectile function)
6. Injury to urinary sphincter causing urinary incontinence
7. Injury to ureter(tubes from kidneys)
8. Injury to rectum
9. Injury to other abdominal viscera
10. Tumour positive surgical margins
11. Scarring of bladder neck
12. Some shortening in length of penis
13. Lymphocoele formation (collection of tissue fluid)
14. Complications related to anaesthesia and positioning during operation
15. Conversion to open surgical operation