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Info » Radical Prostatectomy

Radical Prostatectomy

Introduction

It is important you read this information carefully before the operation so that you fully understand the operation and effect it will have on you.

If you have any questions or concerns about the procedure you can contact the Urology Nurse Specialist, Urology Registrar or Consultant by calling the Hospital. The specialist nurse is there to help you through the whole process.

Why do I need radical prostatectomy?

You have been diagnosed with early stage prostate cancer. This means that the cancer is confined to the prostate and there is no evidence that it has spread to other parts of your body.  You have several treatment options which should have been discussed with you. The cancer usually can be cured at this stage with surgery or radiation treatment. In some patients if the cancer is very small and is unlikely to spread observation is appropriate as well.

What is radical prostatectomy?

A radical prostatectomy aims to cure patients with early prostate cancer by removing the entire prostate gland and surrounding tissue. This operation is only performed if there is no evidence of spread of cancer outside the prostate gland.

Radical prostatectomy can be performed using different approaches. Traditionally it is done through an incision in the lower part of the abdomen. It also can be performed using minimally invasive techniques such as laparoscopy through several much smaller incisions (keyhole incisions). Laparoscopy can also be assisted by robotic systems. The main advantage of laparoscopic approach is improved vision due to magnification, decreased blood loss and need for blood transfusions, faster recovery and return to normal activities. However, most studies comparing different approaches to prostatectomy (open, laparoscopic or robotic-laparoscopic) find no difference in rates of cure from cancer or functional results such as continence and sexual function.

What is nerve sparing?

The nerves that run along the prostate are responsible for controlling erections. If the tumour is too close to the nerves or the biopsy specimen shows high grade cancer (meaning more aggressive cancer and therefore more likely to get outside of prostate where nerves are) the tissue surrounding prostate including the nerves is removed to increase the probability of cure from cancer.  In some patients it might be possible to attempt to preserve the nerves on one or both sides if that does not compromise probability of curing cancer. This is called nerve sparing and will increase the probability of recovery of erections after the operation.

Complications of laparoscopic radical prostatectomy

Incontinence

Most men find initially that they have little warning that they want to pass urine, and are incontinent, especially when the catheter is first removed. This generally improves rapidly with time and it is important that you perform pelvic floor exercises regularly to improve control.

It is rare that patient needs to wear any protective pads long term. About 1-2% of patients after this operation will have severe incontinence where continual protection is needed (or further surgery to improve continence). About 10% will have mild or moderate incontinence, i.e. a few drops of urine leak on coughing, laughing or sneezing. It can take 3-6 months before full bladder control has been achieved although most men find they have complete control before that time.

Impotence

(Inability to achieve or maintain an erection sufficient for satisfactory sexual intercourse)

The nerves that control erections run along the outside of the prostate and are inevitably damaged during the operation. Even with nerve sparing technique initially almost every patient reports problems with erections and it can take up to 24 months for this to recover. There are multiple factors that influence the probability of recovery including age, potency before operation and degree of nerve sparing.

If you want to recover sexual function after the operation there are several medications such as Viagra or Cialis that can help. Injections are more effective then tablets and can be used as a second line option.

Sexual activity after radical prostatectomy will result in normal orgasm but no (or “dry”) ejaculation. This is because the prostate is removed with part of the vas (tube that brings sperm from testicles to prostate) and seminal vesicles (organs producing most of ejaculate).

Bladder neck stricture (internal scarring)

Some patients (about 2-5%) will have problems emptying the bladder due to scar formation at the join between the bladder and urethra (water pipe). If this occurs (usually some time after surgery) you will notice that your flow becomes poor and you having difficulties emptying bladder. This problem can usually be fixed relatively easy with an endoscopic procedure (using a telescope).

Anastomotic leak

After prostate is removed the bladder joined with the urethra (water pipe that brings urine out). The join is called anastomosis. The bladder is sutured to urethra but sometimes there is problem with healing of tissues at the site of the join and urine might leak through the join. This will result in urine leaking through the drain and will require the drain to stay longer. Almost always this will eventually heal without any further specific treatment provided the drain is effectively draining the leak.

Bowel injury

Prostate is very closely related to rectum and rarely (about 1%) rectum can be damaged. If this is noted during operation usually rectum can be repaired at the same time but might require conversion to an open operation. If the injury is not noted further surgery might be required later.

General risks

Any surgery puts your body under stress and there is always increased risk of problems such as heart attack, stroke, deep vein thrombosis etc. Anaesthetists assess that risk before the operation and we will do everything possible to minimize that risk. Unfortunately it is not possible to avoid this risk completely and inevitably some of these complications will happen in a small proportion of patients.

Before the operation

You will be seen in the pre-admission clinic by the member of surgical team and your anaesthetist. We will go through the details of the operation and anaesthesia again and you will have an opportunity to ask any questions. You will be admitted to hospital on the day of your operation and again will have another chance to speak to the surgeon and ask any questions.

After the operation

When you return to the ward you will be under close observation. The nursing staff will record your blood pressure and pulse at regular intervals. You will be attached to a drip (intravenous infusion) to provide you with fluids. You will experience some discomfort after the operation and will be given pain relief. Most patients after laparoscopic surgery require minimal pain relief in form of tablets.

You will have a urinary catheter which is a tube draining the bladder so the bladder can rest and heal. The catheter will need to remain in place for at least one week. You also will have a wound drain which is a small plastic tube placed at the time of surgery in the wound. This will usually be removed after 24-48 hrs.

Most patients will be able to drink clear fluids a few hours after the operation. In some cases nausea can be experienced after general anaesthetic in which case it might be necessary to wait longer before you can drink.  You should be able to eat and drink normally by the next morning. As soon as you able to eat and drink the drip will be removed.

In the morning after your surgery you will be encouraged to get out of bed and walk around the word. This will help prevent clots forming in your legs and keep your circulation moving.

Usually patients are discharged 2-3 days after surgery. If you have good family support it may be possible to go home the day after surgery.

Your Catheter

The urinary catheter is placed at the time of operation to drain the urine from bladder and allow the join between the bladder and urethra to heal properly. It is very important that the catheter is not removed for at least a week after the operation. The catheter, tubing and drainage bag should be safely secured to your leg so they cannot be incidentally pulled. There should be no kinks in the tubing. The catheter bag should be lower than the bladder at all times. You can shower and wash the area around the catheter with soap and water and dry it with towel. Some patients do experience a little discharge around the catheter which then can dry and crust on the outside. This is nothing to be alarmed about and is caused by the catheter. You need to wash this area more frequently if that happens.

It is normal to see small amounts of blood and clots in the bag. You should try and drink plenty to keep the catheter draining and prevent blockages.

It is essential that the catheter does not get blocked. If the catheter stops draining please contact the urology department of the hospital or present to the emergency department after hours. Do not let anyone remove or change the catheter other than urology registrar or consultant. On call urologist should be contacted even in the middle of the night if there is a problem with catheter after radical prostatectomy.

Occasionally the balloon that holds the catheter in position bursts. This is very rare occurrence but can cause the catheter to fall out. If this happens please present to the emergency department of the hospital. Urology registrar or consultant must be contacted to replace the catheter using flexible camera, placing catheter blindly will result in damage to the join between the bladder and urethra.

Sometimes while the catheter is fitted you will experience normal sensation of wanting to pass urine. This is nothing to be concern about so long as the catheter is draining well. When you feel the urge to pass urine try to relax and let the catheter do the work for you. Do not push or try to pass urine. These involuntary contractions of the bladder muscles can sometimes cause the catheter to leak. If this becomes persistent problem we can give you medications to ease this.

What can I do after my operation?

  • Avoid heavy lifting for 8 weeks
  • Avoid driving a car until you completely recover (at least 2-3 weeks)
  • Take exercise gently, gradually increase the distance you walk
  • Eat normal healthy diet
  • Avoid playing sports for 4-6 weeks after surgery and then introduce it gradually
  • Avoid constipation
  • Avoid travelling abroad for 6 weeks after surgery
  • Drink plenty of fluid while the catheter is in position. When the catheter is removed drink normal of fluids
  • Do pelvic floor exercises regularly

Follow up

Once you recover and discharged from hospital we will arrange for you to come back to have the catheter removed. We usually would be able to discuss the results of the pathological examination of the prostate with you either when you have the catheter removed or on the phone. We will see you in outpatient clinic in about 3 months after the operation with PSA test and will be seeing you on a regular basis for several years.

© 2017 Otago Urology

Mr Serge Luke
MBChB MD FRACS
Consultant Urologist

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ROYAL AUSTRALASIAN
COLLEGE OF SURGEONS

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Mr Alastair J. Hepburn
MBChB FRACS
Consultant Urologist