About the Procedure
Physicians of Pensacola Urology perform robotic laparoscopic Prostatectomy. Dr. Davinder Sekhon, Dr. Frank Greskovich, III and Dr. Brett Parra are available and provide the surgery at Baptist Hospital in Pensacola, Florida.

With the state-of-art da Vinci system, the surgeon uses a three-dimensional computer vision system to manipulate robotic arms. These robotic arms hold special surgical instruments that are inserted into the abdomen though small incisions. A laparoscope, lighted telescope is inserted through one incision and is connected to the computer monitor that will allow the surgeon to view inside the body.

The three-dimension view helps the surgeon easily find the nerves and muscles around the prostate. The robotic arms can rotate a full 360 degrees, allowing the surgeon to manipulate surgical instruments with flexibility. The surgeon can perform the same nerve-sparing procedure as done in a conventional laparoscopic prostatectomy. The prostate, lymph nodes, seminal vesicles and surrounding tissue are removed through the small incisions, which are later closed with small stitches.

With the robotic procedure the recovery period is more rapid and most patients can go home with 24 hours and can return to normal activities within one to two weeks following surgery. Patients have stated very little pain and are able to walk the evening of surgery.

Patients have told us they are most concerned about several factors when making their decision on what type of prostate cancer treatment they choose.

• Cancer Removal
• Potency
• Continence
• Blood Loss
• Pain
• Safety

Cancer Removal
Surgeons measure their success in eliminating cancer from the body by looking at the surgical margins -or the edges of tissue on the removed prostate. A pathologist will look at the removed prostate under a microscope, and if he sees cancer on the edge, this is called a positive margin. Whether a cancer can be removed completely depends on two factors, the skill of the physician and how bad the cancer is. No matter how good a surgeon is,he will not be successful in removing all the cancer if it is aggressive. Pathologist relate the aggressiveness of prostate cancer to tumor volume (how much cancer there is) and to tumor grade (how abnormal the cancer looks under the microscope)

If the cancer is completely removed, the PSA should be 0.

Continence at Six Months:
When the prostate is completely removed, one of two muscles the bladder neck smooth muscle that control urination is removed as this muscle lives in the prostate. The second muscle is able to control the urination in most cases. This will take time.

For patients having the robotic prostatectomy 89% are not wearing pads at six months.

First Appointment & Scheduling Information:
If you have been diagnosed with prostate cancer, our robotic surgeons are available for consultation.

You can call 850.444.4707 to make an appointment. It is requested at the time of consultation that you have the following information available:

• PSA level prior to biopsy
• Pathology report
• Updated medical history
• Current medications
• Any additional tests obtained after biopsy such as Cat scan or bone scans

Pre-Op Instructions:
You must get medical clearance from your primary care physician or cardiologist prior to surgery. Please have your physician fax medical clearance to the robotic schedule coordinator at fax number 850.432.2532.

TWO WEEKS PRIOR TO SURGERY:
Stop all medications listed below (check with your doctor before stopping these medications):

Please do not take PLAVIX at least three weeks prior to surgery.

• Lab work cannot be done more than 14 days prior to your surgery date.
• Be sure and notify your surgeon if you are on any types of blood thinning medications (Coumadin, aspirin or Plavix).
• Stop all multivitamins or herbal supplements two weeks prior to the procedure.

INSTRUCTIONS FOR THE DAY PRIOR TO SURGERY:

1. Clear liquids all day, no solid foods (clear liquids also includes popsickles, jello and chicken broth)
2. Take all of your normal medicines except those containing aspirin, Coumadin, vitamin or other blood thinners.
3. Bowel preparation: (see below - these can be purchased at your local pharmacy)
   • 10:00 a.m. - A.M. take 1 bottle of magnesium citrate
   • 6:00 p.m. - take 1 Fleet's enema

For any questions please call 850.444.4707.

Post-Op Instructions:
Questions and answers about post-op:

Q: How long can I plan on being in the hospital after the procedure?

A: On the normal 98% of the patients are able to go home the day after the surgery.

Q: After the surgery will I be able to resume my normal activities?

A: The major advantage of the robotic procedure is decreased bleeding and decreased pain, which results in easier recuperation period. Most patients undergoing this procedure will be able to resume normal activity within one to two weeks. However, each individual heals differently.

Q: After the surgery, when will I have complete urinary control?

A: With convention surgery 50 percent of patients will have full urinary control within 3 to 6 months following surgery. Ninety-five percent will achieve this within one year. The difference with robotics is how quickly urinary control comes back and not in ultimate urinary control, which is excellent with conventional surgery.

Q: After the surgery will I be able to have normal sexual relations immediately following surgery?

A: Usually not. Even when the nerves are spared it takes time for them to heal and begin to function.

Q: How long can I expect to be off work?

A: Long term disability is not usually necessary following this procedure. Additional disability will be given as determined on a medically necessary basis.

Why Choose Robotics?:
Studies of several thousand patients show that laparoscopic surgery is as effective as standard prostatectomy . Laparoscopic prostatectomy is generally associated with less postoperative pain, few complications, shorter hospital stay and a faster recovery. Compared to open surgery, robotic laparoscopic radical prostatectomy offer:

• Less Pain
• Fewer Complications
• Shorter Hospital Stay
• Faster Recovery
• Earlier return of urinary control
• Improved sexual function
• Less internal scarring

Robotic Technology:
With the state-of-the-art Da Vinci system, the surgeon uses a three-dimensional computer vision system to manipulate robotic arms. These robotic arms hold special surgical instruments that are inserted into the abdomen though small incisions. A laparoscope, lighted telescope is inserted through one incision and the connected to the computer monitor that will allow the surgeon to inside the body.

The three-dimension view helps the surgeon easily find the nerves and muscles around the prostate. The robotic arms can rotate a full 360 degrees, allowing the surgeon to manipulate surgical instruments with flexibility. The surgeon can perform the same nerve-sparing procedure as done in a conventional laparoscopic prostatectomy. The prostate, lymph nodes, seminal vesicles and surrounding tissue are removed through the small incisions, which are later closed with small stitches.

With the robotic procedure the recovery period is more rapid and most patients can go home with 24 hours and can return to normal activities within one to two weeks following surgery. Patients have stated very little pain and are able to walk the evening of surgery.

Oncology

• Positive margin rates of 10.5% for the first 200, 7.7% for the first 350, and slightly less than 5% positive margin rates for the last 100 patients using intraoperative frozen section techniques.
• Excellent tumor control with 95% having an undetectable PSA in one year.

• 27% with immediate continence requiring no pads; 47% in one month, 82% in three months, 89% in six months, and 98% in one year of continence without pads.
• Potency data is pending but when nerve-sparing procedures are performed, the results have been very promising.
• Back to normal activities in 9-10 days per third party questionnaire.

Incontinence
Some patients have normal urinary control immediately upon removal of the catheter one week after the surgery. We wish that all patients would do so well; however, some will not. Part of the reason why some patients are not totally continent after the surgery is basically that their pelvis muscles are weak and their bladder has changes from being blocked by a large prostate. We request that you be very diligent about doing your Kegel exercises and keep up with the diaries as to how your continence is progressing. This will be in your brochure and will be a way you can monitor your progress.

Please note that it may take a number of months to become totally continent. Most patients do extremely well in two to three months, but Kegel exercises are very important initially in helping to get you to a stable point.

Erectile Disfunction
When most patients undergo the robotic prostatectomy, a specific type of nerve sparing procedure is performed. It should be expected that many patients will resume a fairly normal or stable erectile function level. Some patient’s erectile function returns in as long as four years. All the treatments that we do, including pills, vacuum device, penile injections, etc. are used in order to prevent damage to the penile tissue and help the time frame diminish. Instead of being one year, it might return in several months. Erectile function varies with each person, basically according to the function prior to the surgery and the amount of dissection needed because of the cancer that you might have. Therefore, this may be a rather slow process for some and it may be rather rapid for others.

Even if your erectile function returns on its own with time, there is no need to wait for the return. Use of oral medications, the vacuum device or injection therapy can provide interval help and speed the process. Then when erectile functions return on their own, you can put aside these aids.

We realize that the frustration level can be fairly high when it comes to sexual function. However, patience and proper usage of all things we have available hopefully will prevent the frustrations and bring function back to a satisfactory level within one year. Please continue to keep up with your diary that is part of your patient brochure.

Kegel Exercises
Pelvic muscle exercises strengthen the group of muscles called the pelvis floor muscles. These muscles relax and contract under your command to control the opening and closing of the bladder. When these muscles are weak, urine leakage may result. However, you can exercise these muscles and many times, regain your bladder control.

For best results with these exercises, imagine yourself as in training. You need to build strength in your muscles. THIS REQUIRES REGULAR EXERCISING.

Begin by locating the muscles to be exercised:

1. Once you start urinating, try to stop or slow the urine without tensing the muscles of your legs, buttocks, or abdomen. This is very important. Using other muscles will defeat the purpose.
2. When you are able to stop or slow the stream of urine, you know that you have located the correct muscles. Feel the sensation of the muscles puling inward and upward.

TIPS:

1. You may squeeze the area of the rectum to tighten the anus as if trying not to pass gas. This helps locate the correct muscles.
2. Remember NOT to tense the abdominal, buttock, or thigh muscles.

Now you are ready to start these exercises:

1. After you have located the correct muscles, set aside time each day for three exercise sessions (morning, midday, evening). It is important to do these exercises in different positions (laying, sittings, standing)
2. Squeeze your muscles to the slow count of five. Then, relax the muscle completely to the slow count of five. The five second contraction and five second relaxation make one "set". You should try to complete 20-30 "sets" with each session.

TIPS:

When your pelvic floor muscles are very weak, you should begin by contracting the muscles for only two to three seconds. Begin doing these on a regular basis. In a few weeks, you should be able to increase the amount of time you are able to hold the contraction and the number of exercise sets you are able to do. Your goal is to hold each set for five seconds, relax for five seconds and to complete 20 - 30 in each of the three exercise sessions per day.

In the beginning, check yourself by looking in the mirror and placing a hand on your abdomen and buttocks to ensure that you do not feel your belly, thigh or buttock muscles move. If there is movement, continue to experiment until you have found the muscles for the pelvic floor only.

If you are unsure that you are contracting the correct muscles, at your next visit ask your physician or his nurse to help you identify the proper muscle contraction.

Your bladder control should begin to improve in three to four weeks. If you keep a record of your urine leakage each day, you should begin to notice fewer instances.

Pelvic muscle exercises also improve orgasmic function. Whether you are doing pelvic muscle exercise to improve or maintain bladder control or control orgasmic function, or both, they must be done on a regular basis.

Use daily activities such as eating meals, watching television and walking as times to do a few pelvic muscle exercises.