Prostate Cancer: Minimally Invasive Surgery
Guest: Dr. Jonathan Picard – Urology Services, MUSC
Host: Dr. Linda Austin – Psychiatrist, MUSC
Dr. Linda Austin: Dr. Jonathan Picard is Assistant Professor if Urology, and is very active in the treatment of prostate cancer at MUSC’s Hollings Cancer Center. Dr. Picard, in a previous podcast, we talked about the diagnosis, and the whole process of somebody getting diagnosed with prostate cancer, and how that is then discussed at Tumor Board. Sometimes, the decision from Tumor Board is for a so-called robotic, like a robot, or minimally invasive procedure, which is where you come in. Now, let’s first talk about who is a good candidate for that procedure.
Dr. Jonathan Picard: Really, this is something that we go through at the tumor board. We essentially decide whether or not surgery would be a good option for someone. What we like to do is go ahead and have a patient who is, generally, younger than 70 years of age. We also like to have someone with a good status who, frequently, is active and has good general health.
Dr. Linda Austin: Now, explain that. Why is that?
Dr. Jonathan Picard: Well, surgery, even though we do it through small incisions, is still surgery, and it’s still a stress on the body. We like to make sure the patient can endure the surgery without having any poor side effects.
Dr. Linda Austin: But, I would think that the minimally invasive approach would actually be less stressful for the body. I’m a little surprised to hear that you actually try to pick out healthier, younger, men for this procedure.
Dr. Jonathan Picard: Well, really, even though it’s less invasive, I try to remind patients that just because they’re small incisions, it doesn’t mean that the surgery on the inside is really a whole lot different. You’re still removing the prostate, and there’s still a lot suturing there. There’s still going to be a stress and a time of healing and recovery. So, although it’s quicker, roughly about half the time of an open procedure, it still requires some time to recover. There will still be some fatigue, and there’s a stress on the body.
Dr. Linda Austin: So, are you saying, then, that if a patient is over 70, or if they’re not in good physical condition, they’re more likely to be referred for a traditional surgical procedure?
Dr. Jonathan Picard: Actually, they’re more likely to be referred for other therapies, such as radiation. In that situation, patients have a slightly smaller risk of having side effects.
Dr. Linda Austin: I see. Okay. Let’s talk about the procedure itself. I think for those folks who’ve never seen the robot, you think of C3P0 or R2D2, or something like that. Of course, it’s not like that at all. Can you kind of paint a picture for us of what the robot itself is like, and what the room where this happens looks like?
Dr. Jonathan Picard: What the robot really entails is two main parts. One part is what we call a bedside cart. Essentially, this is just a large machine that, essentially, has very tiny laparoscopic instruments attached to it, and allows you to move those instruments very precisely. The second part is actually kind of a control console. This is where the surgeon will actually be sitting. He get’s a 3D view of the field. He gets about a 10x magnification of the field. All this allows him to take the movements and the sites that he’s seeing and work in a much more detailed manner on the patient.
Dr. Linda Austin: So, in a way, it’s not unlike some of the video games that the kids have now where you may be swinging a tennis racquet standing in your living room, but it’s projected onto a screen and then the computer does the work of translating what’s going on in real space into something somewhere else. In this case, however, it’s manipulating those instruments that are actually penetrating through to the patient. Do I have that right?
Dr. Jonathan Picard: Well, I like to think of it more as the robot, really, does nothing on its own. Everything is done just from the doctor to the patient, and it’s just translated using these smaller instruments more precisely.
Dr. Linda Austin: I see. The instruments themselves look something like big chopsticks, right? They’re long.
Dr. Jonathan Picard: They do. They’re long thin instruments. The actual working part of each instrument is probably about a centimeter in length at the very tip of them.
Dr. Linda Austin: And, the incision sites are, how big?
Dr. Jonathan Picard: The incision sites, generally, are about 8 to 10 millimeters in size.
Dr. Linda Austin: Which is, what? That’s about half an inch?
Dr. Jonathan Picard: That’s about a little smaller than half an inch.
Dr. Linda Austin: And, where on the body are they?
Dr. Jonathan Picard: We make them in the lower belly, just below the belly button. We generally use about six of these. The largest incision is usually just large enough to fit the prostate out. That one, sometimes, can be about an inch or inch and a half in length.
Dr. Linda Austin: And, the instruments, when you said there are six incisions, what are each of the instruments doing?
Dr. Jonathan Picard: We have multiple instruments that the robot is actually controlling. In addition to that, we also have a surgeon who’s at the patient’s bedside, who’s also kind of helping do things such as passing suture, maybe also helping to keep the field clean, those sorts of things that the robot doesn’t do very well.
Dr. Linda Austin: Now, if I’m correct about this, doesn’t one of the incision sites have a fiber-optic instrument that goes in and actually has a little light, a little camera, and that’s how you see what’s going on?
Dr. Jonathan Picard: That’s right. Actually, we have a camera that’s designed to go through one of these small incision sites. The camera is one large tube, but it’s really made up of two very small cameras on the inside of it, and that’s what gives you the ability to really see depth and make good precise movements.
Dr. Linda Austin: So you can see 3D, as you’re going along?
Dr. Jonathan: Absolutely. That’s right. It’s a three-dimensional view.
Dr. Linda Austin: And then, the apparatus itself, actually, can steady your hands, so if the surgeon has the minutest little tremor, that’s evened out. It’s a very cool thing.
Dr. Jonathan Picard: Oh, it’s fascinating. You can go ahead and remove any potential tremors that are there to make it, absolutely, as precise as possible.
Dr. Linda Austin: So, let’s go through a typical procedure then. The patient will come in. Do they come in the day of surgery?
Dr. Jonathan Picard: That’s right. We usually bring them in the day of surgery. We will bring them in early in the morning. The procedure usually lasts about four hours. I usually tell patients that it takes a little bit longer because there’s some setup time and time waking up from the anesthetic. But, in general, the procedure will last about four hours. The patient will be in the recovery room for about an hour. They’ll wake up with a small drain coming out of one of the small incisions on the side. They’ll also have a catheter, and that stays in for about seven days.
Dr. Linda Austin: Now, they will have been evaluated by an anesthesiologist before this, correct?
Dr. Jonathan Picard: Oh, absolutely. We usually have a time when they come in on a regular clinic visit to see an anesthesiologist, and just generally make sure that they’ll do well with the surgery?
Dr. Linda Austin: So that they’re really checked up very thoroughly?
Dr. Jonathan Picard: Absolutely.
Dr. Linda Austin: So it takes about four hours. What happens after that? The patient wakes up?
Dr. Jonathan Picard: Correct. The patient wakes up. They usually have some things that they can drink that evening. They’ll spend an evening in their hospital room where we’ll closely monitor them. The next morning, if they’re doing well, we’ll give them some regular food, make sure that they can walk around safely, and just generally continue to monitor their vital signs: blood pressures and heart rates. If they look good and they’re doing well, we frequently will let them go home in the afternoon.
Dr. Linda Austin: Hmm. So it’s really just what, 30 hours or so, start to finish, of being in the hospital? You arrive in the morning, and go home the next day, in the afternoon?
Dr. Jonathan Picard: That’s right.
Dr. Linda Austin: Dr. Picard, let’s talk about the postoperative time, the period of days and weeks after the surgery. What can a patient expect?
Dr. Jonathan: Generally, what I like to make sure is that patients understand that they’ll stay in the hospital for about 24 hours or so. They’ll go home with a catheter in place. That catheter will stay in for about a week. At that first visit, I generally make sure all the incisions look good. I make sure that they’re able to urinate after the catheter is removed and that, in general, their pain is being well-managed and they feel well. If they’re doing well, we’ll see them back about six weeks after that.
This time is an opportunity for us to discuss how their urinary control is. It’s also an opportunity to discuss if they have any other side effects. Our first blood check for PSA is usually at three months and, generally, will occur every three months after that.
Dr. Linda Austin: Now, I would think that what most men are most concerned about after surgery are two things. One: his ability to urinate and be continent. And, second: sexual function after surgery. Can you comment on those two things?
Dr. Jonathan Picard: Sure. You know, I always like to let patients know what my priorities are in the surgery because that’s very important to establish that early. I always say my number one priority is to get rid of the cancer, second to that is to make sure that they have good urinary control. Now, I usually let patients know that there’s about a three to five percent risk that they may have incontinence after the surgery at one year. What this means is that patients initially, after having the catheter removed, will expect to have some amount of leakage, and I tell them to bring a pad with them and expect to have that for some time. What we find is that their incontinence improves quicker after this procedure, as compared to the open procedures. I would expect them to have pretty good control over their urine stream within about three to six months.
Dr. Linda Austin: And, how about sexual function?
Dr. Jonathan Picard: Sexual function, also, is something that I think is important to understand. What I like is to do a process called penile rehabilitation. What we do is provide medication shortly after the surgery and continue for about six months. Initially after surgery, what we’ve found is that the nerves have been stretched and don’t work very well. If you don’t provide this medication, we think there’s probably some increased risk of forming scar tissue, and that after the nerves recover, the scar tissue then prevents them from good getting erections. If you can keep the tissue healthy during the time of recovery, the erections will recover. Now, that may take some time. What we usually expect to do is provide medication for six months, and then I’d expect them to have some recovery of erectile function within about six to nine months. Frequently, the recovery phase does not reach a stable level until after 12 months.
Dr. Linda Austin: I would imagine that patients sometimes get not only this procedure but, perhaps, radiation treatment, or chemotherapy, as well. Am I correct about that?
Dr. Jonathan Picard: Occasionally. What I like to do is let them know that those may be options we have to use. Frequently, surgery may be the only thing they need. They may, in general, receive only one treatment. In some events, there might need to be additional therapies, such a radiation; most frequently, and later, in the future, maybe even chemotherapies. In general, I let patients know that managing this cancer, as well as any other cancer, is really a journey. There are going to be steps along the way as to how we’re going to manage this and keep control over it, and those are all tools we can use for the control.
Dr. Linda Austin: Dr. Picard, thank you so much for talking with us today.
Dr. Jonathan Picard: Thank you for having me.
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