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International Journal of Nursing Studies 46 (2009) 442449 www.elsevier.com/ijns

Patient outcomes in the acute recovery phase following robotic-assisted prostate surgery: A prospective study
Rosemary Watts a,*, Mari Botti a, Elizabeth Beale b, Helen Crowe c, A.J. Costello c
a

Centre for Clinical Nursing Research, Epworth Hospital/Deakin University, 89 Bridge Road, Melbourne, Vic. 3121, Australia b Epworth Hospital, Melbourne, Victoria, Australia c Department of Urology, University of Melbourne, Melbourne, Victoria, Australia Received 22 August 2006; received in revised form 20 March 2007; accepted 4 July 2007

Abstract Background: Robotic-assisted minimally invasive urologic surgery was developed to minimise surgical trauma resulting in quicker recovery. It has many potential benets for patients with localised prostate cancer over traditional surgical techniques without taking a risk with the oncological result. Objectives: To report the specic surgical outcomes for the rst Australian cohort of patients with localised prostate cancer that had undergone robotic-assisted radical prostatectomy (RARP) surgery. The outcomes represent the acute (in-hospital) recovery phase and include pain, length of stay (LOS), urinary catheter management and wound management. Methods: Prospective descriptive survey of 214 consecutive patients admitted to a large metropolitan private hospital in Melbourne, Australia between December 2003 and June 2005. Patients had undergone RARP surgery for localised prostate cancer. Data were collected from the medical records and through interview at the time of discharge. Descriptive statistics were used to describe the frequency and proportion of outcomes. Patient characteristics were tabulated using cross tabulation frequency distribution and measures of central tendency. Results: The ndings from this study are highly encouraging when compared to outcomes associated with traditional surgical techniques. Transurethral catheter duration (median 7 days (IQ range 2)) and LOS (median 3 days (IQ range 2)) were considerably reduced. While operation time (median 3.30 h (IQ range 1.07)) was marginally reduced we would expect a further reduction as the surgical team becomes more skilled. Conclusion: The ndings from this study contribute to building a comprehensive picture of patient outcomes in the acute (inhospital) recovery phase for a cohort of Australian patients who have undergone RARP surgery for localised prostate cancer. As such, these ndings will provide valuable information with which to plan care for patients who undergo robotic-assisted surgery. # 2007 Elsevier Ltd. All rights reserved.
Keywords: Prostatectomy; Nursing care; Outcomes research; Robotics; Surgery urologic male

What is already known about the topic?  There will be an increase in the surgical application of minimally invasive technologies.  The reported patient benets of robotic technology include reduced length of patient stay, reduced posto-

* Corresponding author. Tel.: +61 3 9426 6565/9576 0004; fax: +61 3 9429 5037. E-mail address: rosemary.watts@deakin.edu.au (R. Watts).

0020-7489/$ see front matter # 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijnurstu.2007.07.010

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perative pain, reduced bladder catheterisation time and improved functional ability. What this paper adds  Reports on specic patient outcomes following roboticassisted prostate surgery in the acute (in-hospital) recovery phase to:  commence building a comprehensive picture of the trajectory of recovery, and  allow hospitals to adapt their care and management protocols for this new patient group. 1. Introduction The evolution of robots into the surgical arena has been due largely to the progression and subsequent difculties associated with the use of minimally invasive (MIV) surgical techniques. The rst robotic-assisted laparoscopic urologic surgical procedure reported in the literature was in 1995 (Abbou et al., 2001). The rst totally endoscopic telerobotic radical prostatectomy surgery was rst reported as being preformed in 2000 (Binder et al., 2004). This new technology driven procedure has spread rapidly over the last four years. Binder et al. reported that by 2004, 5200 radical prostatectomies (RPs) had been performed worldwide, making RPs the most frequent single surgical procedure performed with robotic assistance. Our institution, one of the busiest network of hospitals in Australia, with 1000 beds and a staff of over 2000 across ve campuses, was the rst Australian hospital to implement robotic-assisted surgery using the da Vinci Robot for urology patients. In 2004, the rst year that the hospital employed the use of the robot, 120 patients underwent robotic-assisted surgery for open radical prostatectomy for localised cancer. Robotic-assisted urologic surgery has many potential benets. The system provides the surgeon with restoration of handeye coordination that was lost with MIV surgery. The instruments are easier to manipulate from an upright position at the console. The three-dimensional vision allows for depth and perception and high resolution video magnication thus improving precision (Kernstine, 2004; Lanfranco et al., 2004). The computer software of the robotic system allows elimination of hand tremors (Lanfranco et al., 2004; Mohr et al., 2001). The potential benets for patients with localised prostate cancer include preservation of continence and sexual potency without comprising the oncological result. It is expected that the number of patients who undergo robotic urologic surgery will increase rapidly as surgeons become more procient in using this new technology and patients become more aware of the potential postoperative benets offered. There are two forms of surgery for localised prostate cancer; open radical retropubic prostatectomy (RRP) and MIV, although RRP has been considered the gold standard in the management of prostate cancer. With the advancement of

robotic-assisted surgery, there has been and will continue to be an increase in MIV surgery. It has been demonstrated that robotic-assisted radical prostatectomy (RARP) surgery can signicantly reduce patient length of stay (LOS), this change has implications for planning in-hospital care and discharge planning in order to prepare patients for both the intermediate and long-term phases of recovery.

2. Literature review Prostate cancer, a disease that most often occurs in the older male (Crowe and Costello, 2003) is the second most common cause of cancer related deaths in men and is a major health concern worldwide (Humphreys et al., 2004). It is the most common form of cancer among men over 55 years of age (Jemal et al., 2002). In Australia, prostate cancer is the most commonly diagnosed cancer in males and is the leading site of new cancer in Victoria in 2003. In 2003, prostate cancer was diagnosed in 3441 men in Victoria (Anti-Cancer Council of Victoria, 2005). In light of the ageing of the Australian population the incidence of prostate cancer will rise. Deciding the best treatment for prostate cancer is a challenge for the consumer as there is a range of treatment modalities available including surgery, radiotherapy and hormone therapy. Radical prostatectomy surgery (major surgery removing the entire prostate gland plus some surrounding tissue) is generally performed and considered effective when cancer is conned to the prostate gland (Prostate Cancer Institute, 2005). Traditionally, radical prostatectomy surgery was routinely performed using the standard open retropubic technique approach (prostate gland is removed through an incision in the lower abdomen). Generally, radical prostatectomy is recommended only for men in good health who have a life expectancy of 10 years or more. Studies of men with localised prostate cancer, typically treated by prostatectomy, indicate that post surgery specic problems in particular, urinary incontinence and impotence persist following the surgery (Litwin et al., 1995; Stanford et al., 2000). Urinary incontinence after open radical prostatectomy, which may be serious enough to have a substantial impact on quality of life, occurs as a result of damage to the urinary sphincter at the time of surgery. Because the external sphincter tends to be less efcient in older males the rate of incontinence is higher in patients over 70 years of age (Burnett and Mostwin, 1998; Eastam et al., 1996). According to Grise and Thurman (2001) post prostatectomy urinary incontinence is reported in the literature as occurring in 25 70% of cases. Donnellan et al. (1997) prospectively studied the rate and degree of incontinence after radical prostatectomy found signicant incontinence occurred in as many as 10% of patients. Similarly, impotence following open radical prostatectomy has been found to have a substantial impact on this

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group of patients. Emberton et al. (1996) conducted a prospective, cohort study in the United Kingdom recruiting 5276 patients undergoing prostatectomy. They found 31% of participants experienced some erectile impotence following surgery. An Australian cross-sectional study of 140 participants post radical prostatectomy found impotence was frequently (40%) reported as the treatment related problem most affecting life (Heathcote et al., 2004). It is postulated that renement in surgical technique using advances in technology should result in improvement in these specic patient outcomes following radical prostatectomy. The surgical management of prostate cancer has been an evolving process that now incorporates the principles of MIV surgery (Humphreys et al., 2004). Proponents of laparoscopic surgery, which utilises the principles of MIV, argue that the laparoscopic approach is based on the same anatomical principles as the traditional approach but that structure preservation is realised through improved visualisation, magnication and haemostatic control (Humphreys et al., 2004). Because laparoscopic techniques are relatively new in urological surgery no long-term patient outcome studies have been reported. Guillonneau and Vallancien (2000) reported on the surgical experience and outcomes of 240 patients who had undergone laparoscopic radical prostatectomy. They reported that the patient transfusion rate was 1%, postoperative pain was minimal and analgesics were not required by postoperative day 2. Guillonneau and Vallancien attributed patients discharged home without urethral catheterisation by day 3 postoperatively to the accuracy of dissection and suture placement associated with the technique allowed. Overall, the authors concluded these results were very favourable in comparison to traditional open approaches. While MIV surgery has many advantages, substantial difculties associated with the procedure such as poor touch feedback, loss of three-dimensional vision and poor ergonomics of the tools have been reported (Camarillo et al., 2004; Hemal and Menon, 2004) making it a difcult technique for the operator to master (Menon et al., 2002, 2003). To overcome this, the clinical introduction of robotic systems, such as the teleoperated da Vinci system, has opened up a new era of MIV surgery with the potential to eliminate many of these obstacles. Although robots have been used in industrial elds for several decades the application of this technology to surgery is relatively new. The literature pertaining to robotic surgery has traditionally focused strongly on the techniques of abdominal, cardiac and urological surgery. Robotic urologic surgery has a number of benets over traditional surgery, for both the surgeon and patient. Surgery performed through the utilisation of a robot allows the surgeon to have a view of the operative site that is three dimensional and magnied 10 times allowing rened microsurgical preparation, excellent endoscopic vision and suturing ability. The potential benets for patients include decreased length of hospital stay, decreased blood loss

(Ahlering et al., 2003) and hence, a reduced need for blood transfusion. Other benets reported include less postoperative pain (Tewari et al., 2003), reduced bladder catheter time and improved continence rates (Abbou et al., 2001; Ahlering et al., 2003). The ability to preserve the delicate structural integrity of the pelvic oor with robotic-assisted surgery results in an overall improved functional ability. The focus of this paper is to report the specic surgical outcomes in the acute transition of recovery (in-hospital stay) of the rst Australian cohort of patients who have undergone RARP surgery. The ndings of this paper will inform knowledge related to the specic care and discharge needs of patients who undergo MIV surgery using new, advanced technologies.

3. Method Prospective descriptive survey of the acute transition of recovery (in-hospital stay) of patients who have undergone RARP surgery for localised prostate cancer, admitted to a large metropolitan private hospital in Melbourne, Australia between December 2003 and June 2005. This 17-month timeframe reects the introduction of robotic surgery for this patient group at this hospital. Descriptive statistics were used to describe the frequency and proportion of outcomes. Patient characteristics were tabulated using cross tabulation frequency distribution and measures of central tendency. The distributions of continuous variables were examined for normality and homogeneity of variance. Where appropriate means and SD, frequency counts and percentages have been used. 3.1. Sample As part of the hospitals quality assurance process data were collected from 214 consecutive patients who underwent RARP surgery. The data were collected from the patients medical records and through interview. Approval was granted from the hospitals Human Research and Ethics Committee to report this data.

4. Findings 4.1. Demographic characteristics The age range of patients admitted for RARP surgery was 4673 years, mean age of 60.8 years SD 6:0. Table 1 provides a breakdown of the patients age groups showing that 46.7% n 100 were in the 5160 year age group and 44.9% n 96 were in the 6170 year age group. The mean body mass index (BMI) of patients was 27.03 SD 3:09. A total of ve surgeons conducted the surgery; however, two surgeons (surgeon A and surgeon B) conducted the majority (91%, n 195) of the procedures. Just over half the

R. Watts et al. / International Journal of Nursing Studies 46 (2009) 442449 Table 1 Age groups 4050 5160 6170 7180 Total Frequency 10 100 96 8 214 Percent 4.7 46.7 44.9 3.7 100.0 Cumulative percent 4.7 51.4 96.3 100.0

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participants were admitted to hospital on the morning of the scheduled surgery (52.3%, n 112) with the remainder admitted the night prior (46.3%, n 99). Interestingly, surgeon A admitted the majority of patients (57.1%) the night prior to surgery while surgeon B admitted the majority of patients (64%) the morning of the scheduled surgery. There was a signicant association between surgeon (surgeons A and B) and timing of admission prior to the scheduled surgery x2 1 8:39, p 0:0004 p < 0:05. The majority of patients (77.4%, n 164) who underwent RARP surgery at this institution lived in the state of Victoria. With the exception of three patients who were residents of overseas countries, the remaining patients travelled to Victoria for the surgery from other Australian states. 4.2. Postoperative outcomes The median operating time for this cohort of patients was 3.30 h (IQ range 1.07). The median LOS was 3.00 days (IQ range 2), as shown in Table 2. Of the patients n 59 who
Table 2

had a LOS greater than 3 days the majority (n 32, 54%) were in the 6170 year age group. There are no barriers to mobilisation in the postoperative period. Some patients mobilised the evening of surgery while others were up the next morning. All patients were able to perform basic activities of daily living at the time of discharge. The primary incision, approximately 5 cm long is at the umbilical region. It is through this incision that the prostate gland is removed in a ne mesh bag. In addition to the primary incision there are four (4) incision or port sites. The wound and incision or port sites are covered with OpSiteTM dressings in theatre. These dressings remained intact during the in-hospital stay. Prior to the patients discharge the dressing was removed and OpSiteTM spray was the dressing of choice for each site. Postoperatively, patients returned to the ward with one (1) Yeates drain tube in situ, which is located to the left of the main incision. The drain tube was removed when the output had decreased to a minimal amount. The median time patients drain tubes were removed was 2 days (IQ range 1) postoperatively. Intravenous infusions were removed day 1 post surgery. It is our practice to remove the intravenous infusion once the patient is tolerating uids. The transurethral catheter remained in situ for a median of 7 days (IQ range 2), as shown in Table 3. It is the practice of the surgeons to review the patients postoperatively on day 7. Catheters were not removed if there was evidence of an anastomotic leak. In some instances, there may have been a delay in removing the catheter postoperatively due to the

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patients geographical location and the scheduling of the surgeon to visit the area. It is the practice of the surgeons to advise patients to see a physiotherapist preoperatively to learn pelvic oor exercises. Patients are advised to practice these exercises prior to surgery. This preoperative period is highly variable. During the in-hospital stay, a physiotherapist routinely visits the patients to provide education on the conduct of exercises following the removal of the urinary catheter. Data related to the presence of bladder spasms in the postoperative period was obtained from 184 (86%) consecutive patients. A substantial number (n 54, 30%) reported at least one episode of bladder spasm in the immediate postoperative period. Other areas of discomfort reported by patients included the presence of wind pain (n 14, 7%), shoulder tip pain (n 40, 22%) and a disruption to normal bowel pattern (n 51, 27%). While the overwhelming majority of patients (n 191, 94%) received analgesic medications in the postoperative period, a small number of patients (n 12, 6%) did not receive any analgesic medications in the postoperative period. The majority of patients received oral analgesic; paracetamol or paracetamol and codeine in the immediate postoperative period. The most frequently administered oral analgesic for pain management in the postoperative period was Panadeine1 , which was received by 67% of patients n 138. Less than a quarter of patients (21.8%, n 45) received Panadol1 . Approximately, 14% of the patients n 29 required the administration of oral analgesia only once or twice in the postoperative period. Almost a third of patients received oral Tramadol Ultram1 (n 64, 31%) during the postoperative period.
Table 3

Approximately, 35% of patients received an intravenous opiate analgesic: 27.5% n 57 of patients were administered morphine and 7.2% n 15 of patients administered pethidine. Pain and discomfort scores were collected at the time of discharge (approximately day 3). At the time of discharge the median pain score for the 192 patients who responded to this question was 3 (IQ range 4) and the median discomfort score was 4 (IQ range 3:25).

5. Discussion The ndings reported in this study related to this Australian cohort make an important contribution to our growing understanding of the recovery of patients following roboticassisted MIV surgery. Apart from referral to particular surgeons by the patients general practitioners it appears that some patients actively seek to have robotic-assisted surgery. This assertion is based on rst, the number of men who did not live in the State of Victoria meaning that they travelled some distance and left traditional support networks to have surgery using this technology and second, anecdotal comments. Robotic surgical techniques and related information is readily available from various internet sites and at various times new technology has been discussed in the media. There is, however, little information available about the expected recovery related to this technology for both patients and health professionals. However, despite the apparent self-selection of this patient cohort the age range of the Australian patient cohort appears to be within the normal range for patient cohorts

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undergoing radical prostatectomy surgery in Germany and Japan (Binder et al., 2001; Hisasue et al., 2004). This suggests that the recruitment of patients to undergo surgery using robotic technology at our institution has not been age selective. Binder et al. (2001) reported the mean age of patients in their study that evaluated the postoperative outcomes of 46 patients following laparoscopic RPs was 61 years (range 4573 years). Similarly, Hisasue et al. (2004) reported a median age of 66 years (range 5374 years) of prostate cancer patients who underwent radical prostatectomy. It is important to note that gures from studies such as these supports the notion that prostate cancer is a disease that predominately affects older men. According to the National Institute for Health (2006), a normal weight status is a BMI range of 18.524.9 The BMI range for the cohort reported in this study of 2529.9 indicates a weight status of overweight. It is important therefore for these patients to mobilise early in the postoperative period. Interestingly, the mean BMI of 27.03 SD 30:9 for our cohort of patients compares with the mean BMI of 28 reported by Menon and Tewari (2003). These results are also consistent with ndings of a recent study (Freedland et al., 2005) that showed that after taking into account the clinical characteristics that inuence the likelihood of nding an existent cancer, a higher BMI is positively associated with a diagnosis of prostate cancer. The median operating time reported for this cohort of 3.30 h (IQ range of 1.07) is comparable, although of longer duration, to those times reported in other studies. Menon and Tewari (2003) reported that over 350 robotic RPs had been performed at their institution, Michigan United States (US), over a two-year time frame. A single surgeon had performed 250 of these procedures. Menon and Tewari (2003) reported on the data from the rst 200 patients, presenting a mean operating time of 2.40 h. In an earlier paper by Menon et al. (2003) a prospective outcomes analysis of the rst 100 patients undergoing robotic radical prostatectomy by a single surgical team, a mean operating time of 1955min was reported. We would expect, in line with the experiences of other surgical teams, for our operating times to decrease further as the surgeons become more familiar with the robotic technology and perform more cases using the technology. The LOS of 3.00 days (IQ range 2) reported for the Australian cohort is greater than LOS times reported in other countries. Menon (2003) reported that over 95% of the US cohort of robotic-assisted prostatectomy patients were discharged within 24 h. For patients who have undergone standard radical retropubic prostatectomy surgery an average hospital stay of 3.5 days has been reported (Tewari et al., 2003), demonstrating robotic surgery has resulted in a reduced LOS for patients. It is important to note our institution is a private hospital and while LOS is an important consideration patient turnover may not be as critical as in other healthcare facilities. As the LOS decreases so to does the time available for nurses to provide specic education

relating to the postoperative period. This therefore places greater emphasis on the discharge planning process; the process must be clear to all members of the healthcare team caring for these patients. A reported patient outcome associated with RARP surgery is reduced urinary catheterisation time. The median duration of the transurethral catheter remained in situ reported in this study of 7 days (IQ range 2), compares pleasingly with duration times reported in other studies. Sim et al. (2004) presented the results of their early experience with robotic-assisted laparoscopic radical prostatectomy at Singapore General Hospital. They reported the mean duration of bladder catheterisation to be 9:86:1 days. In the US, Menon and Tewari (2003) reported catheterisation time of 7 days for robotic prostatectomy. Menon (2003) reported catheterisation time of 8 days for laparoscopic prostatectomy in comparison to 15 days for open prostatectomy. In comparison, in another study conducted in the US, Tewari et al. (2003) reported the duration of catheterisation after standard radical retropubic approach prostatectomy of 15.8 days. As highlighted by Starnes and Warren Sims (2006) and supported by the ndings of this study, acute care nurses need to be mindful that bladder spasms, related to urinary catheter irritation and the sensitivity of the trigone region of the internal urinary bladder, do occur in the in-hospital period of recovery following robotic-assisted prostatectomy surgery. No data could be found in the literature to allow comparison of duration of intravenous catheters or drain tubes. A reported benet of robotic-assisted surgery is that patients experience less pain in the postoperative period. The Australian cohort reported a median pain score on discharge of 3 and a median discomfort score of 4. It is difcult to make a comparison to standard prostatectomy surgery pain scores as the literature is not consistent in its reporting of pain scores. However, Tewari et al. (2003) provide a day 1 pain score of 7 for standard prostatectomy patients. According to the American Pain Society Quality of Care Committee (1995) scoring regime, a pain score in the range 13 is categorised as mild pain. It is not known how individualised the pain management protocol is for patients who have undergone robotic-assisted prostatectomy surgery. For example, did patients ask for a specic analgesic to be administered in response to their pain levels or were the analgesics received by the patient dependent on the personal preference of the nurse on duty or the care pathway used. Only further research mapping postoperative pain management and its overall effectiveness will answer this question. It would be reasonable to expect that day 3 post surgical prostatectomy patients would still be experiencing some pain and discomfort; however, such a nding places a greater emphasis on the need to ensure explicit patient discharge planning related to pain and comfort management in the home environment. Interestingly, the need for better pain management is perhaps highlighted by a nding from Davi-

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son et al. (2004) study of patient evaluation of a discharge program following a radical prostatectomy. Patients reported that a phone call at 48-h post discharge provided them with an opportunity to ask a number of questions about ongoing care issues including pain management. While a lack of subjective measures are available, apart from discharge pain and discomfort scores, we can conclude that our choice of analgesic usage predominately non-narcotic oral analgesia appears to be in line with other studies. Herrell and Smith (2005) reported on the rst year of their program with robotic-assisted laparoscopic prostatectomy in which over 250 robotic-assisted laparoscopic prostatectomy procedures were preformed. Herrell and Smith believe that overall postoperative pain in this patient group is minimal, the mean pain reported on a 10-point likert scale (1 as least and 10 as worst) was less than three. However, it is unclear at what point in the patients post-operative recovery this reading was taken. Because of the belief that pain is minimal epidural catheters and injections are not used and narcotic usage is minimised. 5.1. Limitations of the study It is acknowledged that the results of this study are limited to one surgical team at one institution. This study has looked at specic patient outcomes at one point in the trajectory of patient recovery, in the immediate postoperative period in the acute care setting. Patient recovery cannot be totally understood if patient outcomes are not explored at other key trajectory points of recovery, namely the intermediate and long-term phases of recovery. 5.2. Directions for future research A multi-centred comparative study exploring patient outcomes following open traditional and robotic-assisted techniques for radical prostatectomy surgery will provide a comprehensive understanding of patient recovery following surgery. Such a study will allow data to be gathered on a comprehensive range of patient outcomes at key times in the patients recovery thus allowing the mapping of the trajectory of recovery. This study is about to commence in late 2006.

patient and their signicant others for discharge. However, while operation time, catheter duration, length of stay and postoperative pain control are all variables that must be considered in the postoperative period; tumour control, continence and potency are considered primary outcomes. Only further research will provide the answers in relation to the use of robotic technology and these patient outcomes in the immediate and long-term phases of the patients recovery.

Acknowledgement The authors wish to thank Mr Justin Peters, MBBS, FRACS for his assistance with patient recruitment.

References
Abbou, C.-C., Hoznek, A., Salomon, L., Olsson, L.E., Lobontiu, A., Saint, F., Cicco, A., Antiphon, P., Chopin, D., 2001. Laparoscopic radical prostatectomy with a remote controlled robot. The Journal of Urology 165, 19641966. Ahlering, T.E., Skarecky, D., Lee, D., Clayman, R., 2003. Successful transfer of open surgical skills to a laparoscopic environment using a robotic interface: initial experience with laparoscopic radical prostatectomy. The Journal of Urology 170 (5), 17381741. American Pain Society Quality of Care Committee, 1995. Quality improvement guidelines for the treatment of acute pain and cancer pain. Journal of the American Medical Association 274 (23), 18741880. Anti Cancer Council of Victoria, 2005. Cancer in Victoria. Cancer Epidemiology Centre, Melbourne. Binder, J., Bentas, W., Wolfram, M., Jones, J., Probst, M., Bickeboller, R., 2001. Remote-controlled laparoscopic radical prostatectomy using the da Vinci surgical system. Ospedali dItalia Chirurgia 7 (4), 15. Binder, J., Brautigam, R., Jonas, D., Bentas, W., 2004. Robotic surgery in urology: fact or fantasy? BJU International 94, 1183 1187. Burnett, A.L., Mostwin, J.L., 1998. In situ anatomical study of the male urethral sphincter complex: relevance to continence preservation following major pelvic surgery. Journal of Urology 160, 13011306. Camarillo, D.B., Krummel, T.M., Salisbury, J.K., 2004. Robotic surgery in surgery: past, present, and future. The American Journal of Surgery 188 (Suppl to October), 2S15S. Crowe, H., Costello, A.J., 2003. Prostate cancer: perspectives on quality of life and impact of treatment on patients and their partners. Urologic Nursing 23 (4), 279285. Davison, B.J., Moore, K.N., MacMillan, H., Bisaillon, A., Wiens, K., 2004. Patient evaluation of a discharge program following a radical prostatectomy. Urologic Nursing 24 (6), 483488. Donnellan, S., Duncan, H.J., MacGregor, R.J., Russell, J.M., 1997. Prospective assessment of incontinence after radical retropubic prostatectomy: objective and subjective analysis. Urology 49 (2), 225230. Eastam, J.A., Kaltam, M.W., Rogers, E., 1996. Risk factors for urinary incontinence after radical prostatectomy. Journal of Urology 156, 17071713.

6. Conclusion The ndings from this study report the patient outcomes in the acute recovery phase of an Australian cohort of patients who underwent RARP surgery for localised cancer. We have been able to commence building a comprehensive picture of the trajectory of recovery in acute care to inform practice. As more patients undergo robotic-assisted surgery worldwide these ndings will provide nurses, who are not experienced in caring for this patient group, with valuable information to plan in-hospital nursing care and prepare the

R. Watts et al. / International Journal of Nursing Studies 46 (2009) 442449 Emberton, M., Neal, D.E., Black, N., Fordham, M., Harrison, M., McBrien, M.P., Williams, R.E., McPherson, K., Devlin, H.B., 1996. The effect of prostatectomy on symptom severity and quality of life. British Journal of Urology 77, 233 247. Freedland, S.J., Terris, M.K., Platz, E.A., Presti, J.C.J., 2005. Body mass index as a predictor of prostate cancer: development versus detection on biopsy. Urology 66, 108113. Grise, P., Thurman, S., 2001. Urinary incontinence following treatment of localized prostate cancer. Cancer Control 8 (6), 532539. Guillonneau, B., Vallancien, G., 2000. Laparoscopic radical prostatectomy: the Montsouris technique. The Journal of Urology 163 (6), 16431649. Heathcote, P.S., Mactaggart, P.N., Boston, R.J., James, A.J., Thompson, L.C., Nicol, D.L., 2004. Health-related quality of life in Australian men remaining disease-free after radical prostatectomy. Medical Journal of Australia 168, 483486. Hemal, A.K., Menon, M., 2004. Robotics in urology. Current Opinion in Urology 14, 8993. Herrell, S.D., Smith, J.A., 2005. Laparoscopic and robotic radical prostatectomy: What are the real advantages? BJU International 95, 39. Hisasue, S.-I., Takahashi, A., Kato, R., Shimizu, T., Masumori, N., Itoh, N., Tsukamoto, T., 2004. Early and late complications of radical retropubic prostatectomy: experience in a single institution. Japanese Journal of Clinical Oncology 34 (5), 274279. Humphreys, M.R., Gettman, M.T., Chow, G.K., Zincke, H., Blute, M.L., 2004. Minimally invasive radical prostatectomy. Mayo Clinic Proceedings 79 (9), 11691180. Jemal, A., Thomas, A., Murray, T., Thum, M., 2002. Cancer Statistics 2002. A Cancer Journal for Clinicians 52 (2345). Kernstine, K.H., 2004. Robotics in thoracic surgery. The American Journal of Surgery 188 (Suppl to October), 89S97S. Lanfranco, A.R., Castellanos, A.E., Desai, J.P., Meyers, W.C., 2004. Robotic surgery. Annals of Surgery 239 (1), 1421.

449

Litwin, M.S., Hays, R.D., Fint, A., Ganz, P.A., Leake, B., Leach, G.E., 1995. Quality of life outcomes in men treated for localised prostate cancer. JAMA 273, 129135. Menon, M., 2003. Robotic radical retropubic prostatectomy. BJU International 91, 175180. Menon, M., Tewari, A., 2003. Robotic radical prostatectomy and the Vattikuti urology institute techniques: an interim analysis of results and technical points. Urology 61, 1520. Menon, M., Shrivastava, A., Tewari, A., Sarle, R., Hemal, A.K., Peabody, J.O., Vallancien, G., 2002. Laparoscopic and robot assisted radical prostatectomy: establishment of a structured program and preliminary analysis of outcomes. The Journal of Urology 168, 945949. Menon, M., Shrivastava, A., Sarle, R., Hemal, A.K., Tewari, A., 2003. Vattikuti Institute Prostatectomy: a single-team experience of 100 cases. Journal of Endourology 17 (9), 785790. Mohr, F.W., Falk, V., Diegeler, A., Walther, T., Gummert, J.F., Bucerius, J., 2001. Computer-enhanced robotic cardiac surgery: experience in 148 patients. Journal of Thoracic and Cardiovascular Surgery 121, 842853. National Institute for Health, 2006. Calculate your body mass index. hwww.nhbisupport.comi, accessed 12.07.06. Prostate Cancer Institute, 2005. Prostate treatment. hwww.pros tatecancertreatmenti, accessed 1/06/2005. Sim, H.G., Yip, S.K.H., Lau, W.K.O., Tan, J.K., Cheng, C.W.S., 2004. Early experience with robot-assisted laparoscopic radical prostatectomy. Asian Journal of Surgery 27 (4), 321325. Stanford, J.L., Feng, Z., Hamilton, A.S., Gilliland, F.D., Stephenson, R.A., Eley, J.W., et al., 2000. Urinary and sexual function after radical prostatectomy for clinically localised prostate cancer. The prostate cancer outcomes study. JAMA 283 (354360). Starnes, D.N., Warren Sims, 2006. Care of the patient undergoing robotic-assisted prostatectomy. Urologic Nursing 26 (2), 129136. Tewari, A., Srivasatave, A., Menon, M., 2003. A prospective comparison of radical retropubic and robot-assisted prostatectomy: experience in one institution. BJU International 92, 205210.