Simple Robotic Prostatectomy

Hello Alan:

My shy bladder has gone away after the SRP because I am now able to "push" my bladder and push out my urine, regardless of who is around me . Before the operation, I never really pushed and had to relax and let it flow. My prostate was so large that it was pushing up into my bladder. How I was peeing at all is a mystery to me. I even use to try my best to not hit the water because I thought others could hear how weak my stream was (weird, I know), or how long I stood at the urinal to finish. Now it is all about making noise (hitting the water with a great force) and finishing before most other men (wondering if they are having troubles). I am now actually able to completely void, where before I do not think I ever completely emptied my bladder.

Dave

Tommy Sorry to hear you are not doing so well. Are you having the same surgery as Dave or are you having the radical. I wish you the best. And I hope you heal just as fast. But I have to ask you a question. You said that you could do a close watch because you ARE AT 6 You may not have a problem for 5 or 10 years but your doctor voted to do the surgery. If your doctor told you that you should wait would you wait. You know the surgery is really your choice. Good luck Ken

Hello Tommy:

Best to you. They say robotics is more accurate (precession and magnification). If you are having the same procedure as me, look to being a little sore in the abdomen area. First 4-days post-op are the most tender, then it starts getting better each day thereafter. I never took more than Tylenol and Motrin to manage pain. As soon as I could, I stopped both (I like staying in touch with my pain and recovery). Walking around is important after surgery, but at the same time, respect your recovery time.

You will probably be on a catheter for 10-14 days after surgery. Mine was a large diameter catheter hose. Take a stool softener so having a bowel movement is not causing you to strain too much. You will feel an emptiness in your groin area because of the removal. Even farting causes you to feel a different sensation in the pelvic area. The body has to recover from the removal and if having the SRP like me, the prostate capsules are empty and need to heal (yes there is internal scabbing).

Once the catheter comes out, you will be peeing like a young man (almost over shot the toilet the first time). I swear it looks like my stream is as big around as my little finger. Before, it was just trickle, if at all (retention). Because the prostate is healing, you will have more of a frequency to pee after surgery, but to me, I considered it fantastic because I could do it on my own without a catheter. I did not mind waking up during the night because I was peeing with a vengeance on my own. I knew it was healing and things would get better. Now 10-weeks afterwards, I am only getting up once at night during 8-hours of sleeping and my bladder capacity is getting better. I am able to hold more as the bladder is healing. Everyday it keeps getting better and I gain more and more confidence.

One more thing. When urinating after surgery, and after the catheter is removed, for awhile you will see pink in your pee. The bladder is still healing and the prostate is also. At about 8-weeks is when I noticed it was going away. The prostate bleeds a little at the very end of peeing when you are trying to completely void your bladder and you are working the pelvic floor muscles to get it all out. This also stops. Lastly, as your new garden hose is pushing out all that pee, you will experience a funny feeling at the end when the bladder empties. Do not worry. Your body is healing and getting better.

Before you know it, your quality of life will improve, at least it has for me.

Dave

HI Dave

Thanks so much for sharing everything.

I am pretty set on also getting a SRP.

My question is what did you do before the surgery? Did you get in great shape or were you just in pretty good shape? Did you have sex more often or just the same?

I have a 200 gm prostate and do ok with herbal medications- go 1 to 6 times at night- seems to have something to do with my diet (too much sugar sometimes brings on the 6 times a night) and usually have to go once an hour during the day- more if I drink alot of water. I am 62 years old and my BMI is just below obese in the normal range. I am in ok shape walk 15,000 to 20,000 steps a day and some calisthenics and stretch.

I really think you were not just lucky but were prepared for the surgery and did the right things afterwards. So I am asking for you guidance.

Oh also how many SRP's had your doctor done? I have a couple of doctors who I might use for the procedure.

warm regards

Steve

Hi Steve:

As for the number of times my doctor performed a SRP, I do not know. To be honest, I ask had he done it before. That's all, and he proceeded to explain (and draw) exactly how he was going to do it. He also said I will make you a garden hose. My confidence in his confidence said I want to work with you. I was also at a medical learning center/facility. Their were residents everywhere and learning and applying technology and techniques was all over. Plus, the facility is one of the top 2% in the nation with a recent NCI award. Saying I was fortunate is an understatement.

In regards to my shape, I am a bulky ex-powerlifter. I do not compete anymore, but I still train heavy and do cardio. I was just doing heavy squats last Saturday. I am active and love the outdoors. I am fortunate that good DNA is on my side because I have never had to manage my life through meds. I do not take anything. My blood pressure has always been good and I have never smoked. I drank as a young airman in the Air Force, but I grew out of that. My preparation was just the way I live and good health. Plus, I have always healed fast. I knew if the doctor could get me to the other side, I would take over from there. Here I sit 10-weeks later and loving life, and peeing like a race horse.

Dave

Hi Steve:

I missed answering your sex question. We have always been sexually active and that has not changed since the SRP. Arousal and feeling are still there. More precum during foreplay, but that is probably because I am more open now than before. Nothing comes out during the orgasm, but I can squeeze out fluid afterwards when cleaning up. As shared with a friend recently, I am not looking to throw baseballs anymore.

Dave

Dave. I did read and look at some of the picture. There are more nerves then we know in that area on the prostate. The pictures that I have see there are a lot more nerves attached to the prostate then we know.

What I was saying before The doctor would not be able to touch or reach the nerves trough the urethra. When I come back from my test I'm going to look at the meds' that he was taking to see if all of them combined would do something.

.

Have a good day Ken

Dave is correct that there are two nerve bundles and they control erection.

Found this article which could explaini why SRP does not give its patients erectile dysfunction, presumably these two nerve bundles are not injured.

From UC Irvine:

“Sexual Function or Potency

After Robot Assisted Radical Prostatectomy”

"Anatomy of Sexual Function

A major factor in your ability to achieve an erection is your “electrical hardware” - the nerves that carry signals that control the flow of blood into the penis, and control theretention of the erectile state. The erectile nerves are in reality an interwoven set of nerves and blood vessels, called neurovascular bundles (NVB), which can be thought of as a bundle of wires in an electrical circuit. The two neurovascular bundles run along the surface of each side of the prostate are intimately contained within a delicate layer of tissue called fascia.

Depending on the pathologic features from your prostate biopsy, which may indicate an increased risk of whether cancer has likely spread outside the prostate (extraprostatic extension), your surgeon may recommend removing these nerves on one or both sides (i.e. wide excision) to maximize the chance of removing all of the cancer. If there is a no cancer outside the prostate, or a small amount of cancer on one or both sides, the surgeon may recommend “sparing” the nerves, which means that one or both bundles will be carefully separated from the prostate, so that they are left intact and not removed with the prostate. The amount of trauma endured by the neurovascular bundles during the nerve-sparing step is one factor which will determine the time required for the nerve to recover its erection-supporting electrical function.

Nerve-sparing Technique

A “nerve-sparing” procedure involves dissecting the nerve bundle off of the side of the prostate. This is one of the most delicate steps of your surgery. What once was a nebulous and difficult part of the procedure is now technically feasible and less traumatizing with the robot. While robotic-assistance does offer enhanced visualization of the neurovascular bundles and increased surgical precision, it does not make up for sloppy technique. Even with perfect technique, moving the nerves from their natural location on the side of the prostate will likely cause some nerve dysfunction or damage which can range from mild to severe. Our research has led us to several key findings to help minimize nerve injury: 1) thermal energy (cautery, heat) should be avoided or at least minimized, 2) nerve traction (stretching) should be avoided, and 3) dissection of the nerves causes inflammation which can be reduced with hypothermia (cooling) (Finley et al Urology, 2009; also for more detail, see Chapter 10 - Latest Advances).

In a recently published article, we analyzed the return of potency after robotic prostatectomy with unilateral wide excision of one neurovascular bundle compared with preservation of both neurovascular bundles (Finley BJU Int 2009). To study this issue we selected a cohort of men who were < 65 years and had “normal” preoperative sexual function. As shown in the following figure, for men who underwent unilateral nerve-sparing surgery (UNS), 80% regained potency at 24 months. For men who underwent bilateral nerve-sparing surgery (BNS), 93% regained potency at 24 months. It is evident from these curves that about half of these men regained potency between 9 and 15 months. These curves tend to shift downward with increasing age and impaired preoperative erectile function. This information serves to guide your expectation and understanding of how you may fare after surgery, keeping in mind the importance of other variables, such as prostate weight, that will affect the outcome.

It seems that Simple Robotic Prostatectomy could not escape the fate of retrograde ejaculation and may have more serious complications than HoLEP. See below.

From Penn State Hershey Medical Center:

Simple prostatectomy

Definition

Simple prostate removal is a procedure to remove the inside part of the prostate gland to treat an enlarged prostate. It is done through a surgical cut in your lower belly.

Risks

Risks for any surgery are:

Blood clots in the legs that may travel to the lungs

Blood loss

Breathing problems

Heart attack or stroke during surgery

Infection, including in the surgical wound, lungs (pneumonia), or bladder or kidney

Reactions to medicines

Other risks are:

Damage to internal organs

Erection problems (impotence)

Loss of sperm fertility (infertility)

Passing semen back up into the bladder instead of out through the urethra (retrograde ejaculation)

Problems with bowel movement control (bowel incontinence)

Problems with urine control (incontinence)

Tightening of the urinary outlet from scar tissue (urethral stricture)

hello ken,

the question is how do these nerve bundles NVB will impact the result of urolift and PAE in terms of erectile dysfunction and retrograde ejaculation.

i have done all i could and the situation is still murky.

perhaps u could make it clear using ur knowledge.

ken,

u need to catch up with ur sleep instead of staying up all night writing posts.

i am not dave!

in urolift if one of the metal tab of the implants happen to accidentally clamped on a nerve and in PAE if the blood vessel supply blood to a nerve is starved, this may slowly and eventually cause the nerve to die. nerve normally does not regenerate, this could be a problem.

Apology and correction.

In a previous post, I said that SRP may have more serious complications than HoLEP. This statement is wrong. In fact, the complications between the two are similar. They have similar functional outcomes and safety. The advantage HoLEP has is in having shorter hospital stay and shorter catheter time and less blood transfusion wheres SRP has shorter operating time. In the US, shorter hospital stay translates into significant cost saving.

Two published studies given below compare SRP To HoLEP in details.

(I) Holmium laser enucleation versus simple prostatectomy for treating large prostates: Results of a systematic review and meta-analysis

Patrick Jones, Laith Alzweri, ..., and Omar M. Aboumarzouk

Results

In all, 310 articles were identified and after screening abstracts (114) and full manuscripts (14), three randomised studies (263 patients) were included, which met our pre-defined inclusion criteria. All these compared HoLEP with OP. The mean transrectal ultrasonography (TRUS) volume was 113.9 mL in the HoLEP group and 119.4 mL in the OP group. There was no statistically significant difference in Qmax, PVR, IPSS and QoL at 12 and 24 months between the two interventions. OP was associated with a significantly shorter operative time (P = 0.01) and greater tissue retrieved (P < 0.001). However, with HoLEP there was significantly less blood loss (P < 0.001), patients had a shorter hospital stay (P = 0.03), and were catheterised for significantly fewer hours (P = 0.01). There were no significant differences in the total number of complications recorded amongst HoLEP and OP (P = 0.80).

Complications

There were no significant differences in the total number of complications recorded amongst HoLEP and OP (P = 0.80). The commonest Clavien–Dindo Grade I complication in the HoLEP group was dysuria (27.7%) and in the OP group it was transitory urge incontinence (23.2%) (Table 4). In the sub-analysis of complications according to Clavien–Dindo Grade, the only statistically significant difference was seen amongst Grade II complications, where the results of the meta-analysis favoured HoLEP (P = 0.02; WMD 0.35, 95% CI 0.15–0.82). For Grade I complications, the results favoured OP; however, this was not statistically significant. For Grade III, IV and V complications, the trend in results favoured HoLEP, but again this superiority was not statistically significant. There was one death in the OP group, with none in the HoLEP group.

Discussion

The results of the present meta-analysis suggest that HoLEP and OP possess similar overall efficacy profiles for both objective and subjective disease status outcome measures. The present review shows these improvements persist to at least the 24-month follow-up point. However, in the perioperative period, patients undergoing HoLEP spend significantly fewer hours in hospital and are catheterised for a significantly shorter period.

Efficacy and safety

While OP retrieves greater tissue volumes and carries the advantage of a shorter operative time, it is associated with a significantly greater drop in haemoglobin. Elshal et al. reported that 24.5% of patients had required a blood transfusion after OP in a retrospective analysis of 163 patients at their institution. Such are the haemostatic advantages associated with HoLEP, Tyson et al. [18] determined it to be a safe alternative to TURP for patients on oral anticoagulation therapy.

(II) Holmium laser enucleation versus open prostatectomy for large volume benign prostatic hyperplasia: a meta-analysis of the therapeutic effect and safety].

Article in Chinese

Chen H1, Tang P, Ou R, Deng X, Xie K.

OBJECTIVE:

To compare holmium laser enucleation (HoLEP) versus open prostatectomy (OP) for large volume benign prostatic hyperplasia.

METHODS:

The randomized controlled trials (RCTs) pertaining to HoLEP and OP for management of large volume benign prostatic hyperplasia were retrieved from Medline and Embase. Meta-analysis was performed using Review Manager 5.0 software.

RESULTS:

Three RCTs were included in the analysis. No significant differences were found in IPSS or Qmax between HoLEP and OP (P>0.05). Compared with OP, HoLEP was associated with significantly less blood loss, a shorter catheterization time and a shorter hospital stay, but a longer operating time. HoLEP and OP were similar in terms of urethral stricture, stress incontinence, transfusion requirement and the rate of reintervention.

CONCLUSION:

HoLEP and OP have similar therapeutic effects in the management of large volume benign prostatic hyperplasia. Although with a longer operating time and less resected tissue, HoLEP causes less blood loss and requires a shorter catheterization time and a shorter hospital stay. HoLEP has a comparable safety to OP in terms of the adverse events.

Sorry. I will try. Went to bed at 5 am. Just could not sleep. Doing to much thinking.

With Urolift I do not think the procedure will do anything to the nerves bundles. They are all around the outside of the prostate. Doctor are saying that this procedure is the only one that has 100% no erectile dysfunction and retrograde ejaculation.

But for PAE I'm not that sure. With them sending the little seeds or pellets into the vein and the artery's. How do we make sure they are only doing the right ones. There are so many veins on the prostate and they can hit the wrong ones.

With retro there are some men that have had it that end up with not much or nothing coming out. I remember one guy that had the PAE done. He said that the first time he had sex he had some of a ejaculation and the next time it was less and by 6 month's he was dry. Nothing. So who is right

Men did to do there research. It seam like we find more and more we are not being told by the doctor. Ken

Don't know why I called you DAVE sorry Ken

You are right, Ken, there is no guarantee that the embolization won't touch wrong arteries. That's why it should be performed only by a very experience >10 years, IR doctor. They make a very detailed angiography of all pelvic arteries (could be very specific for each patient) and then during the procedure insetr the catheter with tine plastic pellets and alcohol(essentially glue) into the proper arteries supplying blood to the prostate. In PERfected PAE (like in my case ob one side, I believe left) they go even deeper into the internal prostate arteries supplying blood to the median lobe, yest, that's where most of the nerve bundle s may be outside that lobe, and plug them too. That procedure result is ischemia of the prostate (essentially lack of oxygen, not blood) which leads to infarction, like in heart, and eventual necrosis. Embolized arteries and healthy one are distinguished under continuum X-ray control through so called subtraction fluoroscopy, by comparing preop X-Ray angiogram with one seen in real time. That became possible only due to the high resolution CT scans with special contrast.A skilled and specifically trained IR can put the "glue" in the right arteries and smaller vessels of the prostae. I gave reference to the paper from IR from Barzil with detailed picture. I believe, but not totally sure, that my IR doc did only left side of my internal prostate embolization to avoid mistakes or impairing both nerve bundles around the prostate. There were no serious complications from PAE, at least in US. The few that resulted in bleeding from colon, some side effect were gone in 6-8 weeks because of the body self-healing and vessels regrowth. Only in two cases, when the necrosis of bladder was involved, additional surgery was performed to fix the problem. There were no deaths after PAE so far registered. Naturally, longevity of PAE is less that TURP or SRP (which is forever). Embolization is not a new procedure, it's used in varicose veins, fibroiod of uterus, lung bleeding, etc. It might be expensive because it's highly technical and requires expensive very narrow steel catheters.At our age, when BPH life changin even, our longevity and fears are limited as well. In my case, I tried and avoided to wind up in that 28% category with incontinence and impotence. I tried my luck and won. Complications are much more prevalent in the age group of 70+. Yes, RE or temporary aspermia could happen after PAE. Contrary to many who wrote on that site, and frequent comments that RE is a life changing disaster for most men, I don't think it's that important after age 50. Of course, if orgasmic function is preserved fully. Just less mess... Partner doesn't care. Having kids after age 60 is too late and BTW still possible with some help.

Any of the discussed methods, PAE including, which are designed to alleviate the bladder obstruction (and is teh only thing that matters in BPH cs PC) will somehow touch and shrink (or eviscerate thermally or mechanically) at least a part of the median lobe, which is obstructing the neck of the bladder. Any procedure will inevitably touch or disturb one way or another the neighboring nerve bundles, which are critical for erection and ejaculatory function. The rest depends mostly on the artful skills of the URO -surgeon/IR operator, stage of the BPH and personal anatomy.

Best of personal luck to everybody.

Gene

Gene that is very true. You need a good doctor for any procedure that you decide to have. I think I read that before they do the PAE procedure. They do a trail run on the computer to make sure they are going in the right spot

That is very good to do it that way. I am just stumped with Den problem with the Urolift giving him ED. I have talk to people and e-mail some. He was on a drug that will cause ED problem before the surgery and had no problem. But after it just will not work.

The Urolift did what it was suppose to do. Help him pee But I can't see it causeing ED. I'm going to send a e-mail to my doctor and see if he has any Idea's. He is a Urologist and a Fertility Doctor. Maybe he will know something.

Have a good day. And Gene that was a very good post. Thank you for doing that for us Ken

Thank you for kind words. The problem with UroLify , which is minimally invasive and probably least damaging, that it's certified and used only for a relatively small prostates, less than twice of the normal size. Most men will start to think about the surgery only when their prostate is much greater than cutoff size of 80 g, which is only 130% of normal size (cubic root of 2.5), speaking geometrically, but could nevertheless grow into the urethra and bladder neck area. So, only younger man with a modest BPH qualify. Nobody wanted to perform UroLift on my 135g prostate. Would teh procedure be available 5-10 years ago, it might be a different story for me. Back then I was offered only SRP, because it was most lucrative for my URO at my HMO. I didn't have a choice of doctors, only medicine, which I'm using since 2009 +recent PAE. Currently I feel better than at 40. Probably always has a lazy bladder and enlarged prostate due to high DHT. Also, from what I've read earlier, statistically UroLiftit lasts 4-5 years before prostate ingrowth back into urethra. Sometimes even less, 2 years. Didn't help some people, probably with bladder problems. It;s another story that many ageing males and females develop problems with controlling their bladder, size shrinks, wall thickens and became more sensitive even to a small amount of a residual urine in the bladder. Often BPH is the primary cause, but there are other natural changes over which we have very little control.

There are no simple questions with BPH and PC, it will always result in some impairment, to the lesser or greater extent, mostly dependent on the URO, which very few of us have access to the best. Most of them are outdated in their knowledge, arrogant with patients and more concerned with the length of their boat as somebody already noted on this site.

The informed decision is pretty much in our hands.

Gene

Hi Gene:

Right on, Brother! We have to defend ourselves and smarten up as much as we can. As I got smarter, my baseline of protection was don't disturb my nerve bundles, don't come up my urethra, don't mess with my sphincters, and don't mess with my bladder neck. And oh by the way, make it so I can pee on my own without the aide of anything but my own pleasure of pushing a stream so hard that the toilet water foams up.

This thought process (and defense) for BPH and retention problems quickly boils down to few options. I was talking with a friend lately just like me and he said we are fortunate (him and I) that our prostate was/is so big that our only option was removal. Kind of cuts to the chase and puts us right where we need to be in order to be a free man and rid us of what was/is controlling our lives.

Please excuse my evangelism.

Dave

Gene that is why I say a man has to do his research for any procedure that he feel that will help him. You have to wright down what he wants out of the procedure. I myself did not want any erection problems and I did not what to lose my ejaculation I was 58 when I had the Urolift done. My prostate was the size of a large lemon and it was closed tight. So my prostate was the problem.

Men have watch that if they have a bladder or kidney problem. Urolift or any other procedure is not going to help. At 63 I deal with all the other stuff men get. Just got done with Prostatitis and 28 days of Cispro. Been kinda over active in the sex departed. There have been days that I could not get anything out of my friend no matter what I tried nut lately 3 or 4 times a day. I try to not pay attention But thats life

At 63 I am happy that that I still have my ejaculation. It may be it own function but it goes with my orgasm. Well enough about sex. We are all different and we have to do our own research and talk with the doctor and may sure they have our concerns at heart. God bless Ken

You knew what you wanted and you had a very good doctor. That helps Ken

It is amazing that u have such admirably deep understanding pf PAE

Not familiar with PAE, so ask some ignorant questions and hope that u don't mind.

1. "28% category with incontinence and impotence"

   --- does it mean that there is a 28% chance of getting incontinence and impotence after PAE? If yes, this percentage is alarmingly high nearly 1 in 3 patients.

2. After reading ur post, I got the impression that PAE critically depends on the surgeon skill much more so than other techniques even holep. If the patient has an inexperienced surgeon, the consequence would be more serious. Not sure if I got it right.

Ken,

I truly appreciate that you're trying to help.

No one is more stumped than me. My urologist has ordered a pelvic CT scan for next Monday.

He is hoping that will help detect if there is a problem with the placement of the clips. I have 5 total.

He said that I may need to see a specialist if the CT scan doesn't produce any clues to what is going on. He mentioned perhaps sending me to the Mayo Clinic, but that sounds pricey.

And he wants to put me back on Rapaflo, which he called in a prescription for, but I refuse to take any more meds, especially after reading all the stuff on here. The entire situation has me exhausted, to be honest. I am beginning to think this will never be explained or resolved.

All the best,

Den

Den

It's no problem buddy. That is a good call on the Rapaflo. I hated it when I was on it.

I have been looking and reading everything on your case and I can't figure it out. I was up to 5 am this morning I could not sleep. It makes no cents. With the meds you were on you should have had a problem before but you didn't. Jalyn It has a possible side effect of 55 which is 50 to many...

Earlier today I sent my Urologist a e-mail with all the information I have on you with the meds and what you tried and nothing is happening. I don't know if it will help but my doctor is a urologist and he specializes in fertility.

I will let you know if he tells me something. It's worth a try.......

Try to relax and not stress. I know that does not help Ken

Good luck on next Monday! I sincerely hope that CT will review what is wrong with the implants.

Ken,

Thanks again. You're a good man. Sorry it's keeping you awake. I appreciate your concern, but don't lose sleep worrying about my problem.

Hopefully the CT scan on next Monday will point my urologist in the right direction.

I have been off the Jalyn for the last 2 weeks and as I said, I am not going to take the Rapaflo that he prescribed. One of the reasons I had the UroLift was to get off the meds.

It has been a long 8 years since this all began with a diagnosis of prostatitis when I was 46. I never thought that diagnosis would lead me down the rabbit hole that I now find myself in. Thankfully I have a very loving and supportive husband and a few close friends who help keep my spirits up.

Plus finding this forum has truly helped me by finding other men who can understand what I am/have been experiencing.

Den

Thanks DL, so do I. I truly appreciate your encouragement and support.

Den