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A cohort study investigating patient expectations and satisfaction outcomes in men undergoing robotic assisted radical prostatectomy

  • Urology – Original Paper
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Abstract

Introduction

Robotic assisted radical prostatectomy (RARP) is gaining widespread acceptance for the management of localized prostate cancer. However, data regarding patient expectations and satisfaction outcomes after RARP are scarce.

Methods

We developed a structured program for preoperative education and evidence-based counseling using a multi-disciplinary team approach and measured its impact on patient satisfaction in a cohort of 377 consecutive patients who underwent RARP at our institution. Responses regarding overall, sexual, and continence satisfaction were assessed.

Results

Fifty percent of our patient cohort replied to the questionnaire assessments. Ninety-three percent of responding patients expressed overall satisfaction after RARP with only 0.5% expressing regret at having had the operation. Biochemical recurrence and lack of continence correlated significantly with low levels of satisfaction, though sexual function was not significantly different among those satisfied and those not. Most patients (97%) valued oncologic outcome as their top priority, with regaining of urinary control being the commonest second priority (60%).

Conclusions

RARP appears to be associated with a high degree of patient satisfaction in a cohort of patients subjected to a structured preoperative education and counseling program. Oncologic outcomes are most important to these patients and have the largest influence on satisfaction scores.

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Acknowledgments

No external funding was obtained for this study.

Conflict of interest

The authors declare no conflict of interest.

Author information

Authors and Affiliations

  1. Lefrak Robotic Institute, Weill Cornell Medical College, New York, 525 East 68th Street, Box 94, New York, NY, 10065, USA

    Youssef El Douaihy, Prasanna Sooriakumaran, Mayank Agarwal, Abhishek Srivastava, Sonal Grover, Kumaran Mudaliar, Sivaram Rajan, Amanda Lawlor, Robert Leung & Ashutosh Tewari

  2. Organization institute of medical education and research, Chandigarh, 160012, India

    Mayank Agarwal

Authors
  1. Youssef El Douaihy
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  2. Prasanna Sooriakumaran
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  3. Mayank Agarwal
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  4. Abhishek Srivastava
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  5. Sonal Grover
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  6. Kumaran Mudaliar
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  7. Sivaram Rajan
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  8. Amanda Lawlor
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  9. Robert Leung
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  10. Ashutosh Tewari
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Corresponding author

Correspondence to Youssef El Douaihy.

Appendices

Appendix 1: Patients education protocol

We follow a structured preoperative education and counseling program. This program involves two preoperative sessions with nurses, physician assistants, nurse practitioners, fellows, surgeons, or surgical coordinators. In the first session, patients undergo multi-step counseling comprising a thorough explanation about the disease, as well as discussion of different treatment modalities and their possible outcomes. The second session focuses on preoperative, perioperative, and postoperative surgical issues. An effort is made to match clinical outcomes discussion with the patient’s unique demographic, oncological and medical data. For example, we highlight that obese patients can have a more challenging recovery and higher grades, and stages of cancer can negatively impact longer-term functional recovery.

Preoperative preparations

The preoperative issues include discontinuation of known and potential blood thinners, weight loss, an exercise protocol, as well as preoperative medical and cardiac consults in appropriate patients. High-risk patients are also encouraged to meet the anesthesiologist preoperatively. A list of possible complications such as bleeding, fever, port site hernias, bowel injury, urinary leakage, pain expectations, cardiac and thrombogenic complications are mentioned, and measures to minimize these events such as exercise and weight loss are also discussed [19–22]. Patients with a BMI >30 are counseled for their greater risk of anesthesia-related, perioperative, and surgical complications. This includes thrombo-embolic disease, anesthesia side-effects, incontinence, and sexual dysfunction following surgery [23–25]. We therefore institute a weight loss program for these patients and monitor them regularly. Once adequate progress is noted, a surgical date is finalized. Non-compliant patients are either referred to a weight loss specialist for more intensive programs or even recommended alternative treatments such as radiation ± hormonal therapy.

Postoperative expectations

Physical activity expectations

We highlight the value of ambulation following surgery. Patients who are sedentary prior to surgery are encouraged to follow a cardio and resistance training program following clearance from their internist. We motivate patients to start walking on their first postoperative day. They continue on a walking program of 2–3 miles/day for the first 6–12 weeks, and are encouraged to continue moderate exercise, other co-morbidities permitting, in the long term. We ask patients to refrain from strenuous exercise so as to protect the port site sutures. We also warn against cycling in the early postoperative period as this can be painful. Patients are given written materials regarding the above issues.

Return to work expectations

Our own data suggests that the average time to return to work is around 17 days. Naturally, the suggested resting time before return to work depends on the type of job. Desk jobs require less time (circa 2 weeks) than jobs that require strenuous physical activity (circa 3–4 weeks). We advise that return to work should be gradual with rests in the afternoon and no heavy lifting.

Pain expectations

Preoperatively, patients are told that pain might be experienced during the first postoperative week; it usually peaks in the first 24–48 h and declines thereafter. Our own data suggests that by the end of the first postoperative week, pain is usually limited to the incision sites and managed with non-steroidals. Narcotic use is very rarely required. The other common source of pain is the laparoscopy-related insufflations which usually peaks on postoperative days 2–3 and gets better once the patient starts passing flatus. Mobilization usually helps in expulsion of flatus and is encouraged. The catheter can be a source of penile pain and is managed by intraurethral lidocaine 2%. Upon catheter removal acute urinary retention can rarely occur, and patients are warned to inform the team and head immediately to the nearest emergency room if it does happen.

Cancer control expectations

We discuss our own series’ outcomes regarding margin rates and PSA recurrence. We highlight their individual risk of extraprostatic extension (EPE), contralateral involvement, and PSMs. We also warn patients with higher Gleason grades that their functional outcomes might be compromised in an attempt to afford them the best chance of cure. We tell patients that oncologic outcomes are program-dependent and always counsel based on our own results. We also discuss adjuvant and salvage therapy in the event of EPE, PSM, or biochemical recurrence. We also have a discussion about the possibility of lymph nodal positivity and the management options if that should occur. High-risk patients with Gleasons 8–10, clinical T3 disease, and multiple positive biopsy cores are counseled about the need for adjuvant therapies, and consults with the medical oncologist and the radiation therapist are set up preoperatively.

Expectations of return of urinary continence

Urinary incontinence has a significant negative impact on most patients’ QOL. We tell patients that immediately after the catheter is removed, they will usually experience some degree of leakage, although in most cases this is relatively mild. However, the vast majority of patients become continent with time in our series. The small percent that remain incontinent are counseled about Kegel exercises, biofeedback, sling procedures, and artificial urinary sphincters.

We provide the patients with our own results such that they go into the surgery with realistic expectations [17]. High-risk scenarios for incontinence or delayed continence include high BMI, large prostatic volume, non-nerve-sparing surgery, short urethral stump, previous urethral/prostatic surgery, and any idiopathic or neurologic condition affecting bladder storage.

Expectations of sexual function recovery

This is one of the most sensitive (for the patient) and challenging (for both surgeon and patient) aspect of prostate cancer surgery. Recovery of the sexual function following RARP depends on a vast list of oncologic [26], demographic [27, 28], medical, social [29], technical [30–33], and surgical experience [34, 35] related factors. Since most of the published data reports best case scenarios, patients often have very high expectations for sexual recovery [6]. This often becomes a source of lasting regret. We thus spend a lot of our preoperative education and counseling time discussing this aspect of the trifecta and use our own results to explain likely recovery times based on individual patient risk factors.

We highlight challenges of nerve preservation in the context of competing goals for nerve-sparing and complete eradication of cancer [36]. We use anatomic diagrams and cartoons to supplement patients’ understanding. MRI images and biopsy maps are generated to further aid the discussions. We ensure that by the end of our structured education and counseling program prospective surgical candidates have a clear idea of the extent and rationale for the proposed nerve sparing.

Appendix 2: Patient questionnaire

  1. 1.

    Please rank the following in order of your PRE-OPERATIVE priorities for treatment: (1= most important, 3= least important). Each number may be used only once.

    • Preservation of sexual function

    • Post operative urinary continence (no urine leakage)

    • Oncologic clearance (cancer-free)

  2. 2.

    Considering your current level of urine control ONLY, how satisfied are you with your decision to have had robotic surgery (select one)?

    • Regret having operation (0)

    • Extremely dissatisfied (1)

    • Dissatisfied (2)

    • Neutral (3)

    • Satisfied (4)

    • Extremely satisfied (5)

  3. 3.

    Considering your current level of sexual function ONLY, how satisfied are you with your decision to have had robotic surgery (select one)?

    • Regret having operation (0)

    • Extremely dissatisfied (1)

    • Dissatisfied (2)

    • Neutral (3)

    • Satisfied (4)

    • Extremely satisfied (5)

  4. 4.

    Overall, how satisfied are you with the treatment you received for your prostate cancer (select one)?

    • Regret having operation (0)

    • Extremely dissatisfied (1)

    • Dissatisfied (2)

    • Neutral (3)

    • Satisfied (4)

    • Extremely satisfied (5)

  5. 5.

    Given your treatment experience, would you recommend robotic surgery to your friends/family (select one)?

—Yes—No

  1. 6.

    If you would not recommend robotic surgery, please place an “X” on the line next to the SINGLE most influential factor in your dissatisfaction (a,b) and the specific reason (i–iii) if any.

  2. a.

    Unrealized expectations of robotic surgery—

  3. b.

    Poor clinical care (hospital staff, operating rooms, outpatient, etc.)—

  4. i.

    Disappointing postoperative functional outcomes, specifically urine control or return of sexual function—

  5. ii.

    Disappointing cancer control (i.e. biochemical recurrence)—

  6. iii.

    Greater than expected degree of pain or time away from work—

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Douaihy, Y.E., Sooriakumaran, P., Agarwal, M. et al. A cohort study investigating patient expectations and satisfaction outcomes in men undergoing robotic assisted radical prostatectomy. Int Urol Nephrol 43, 405–415 (2011). https://doi.org/10.1007/s11255-010-9817-5

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