By the time you have decided that you wish to proceed with surgery as treatment for your prostate cancer, you should feel that you have been informed of the treatment options available to you. You will have completed a series of investigations including a biopsy, a CT scan, a Bone scan and sometimes an MRI. These tests will have indicated that there is no evidence of cancer spread beyond the prostate and that the disease is potentially curable by surgery.
Radical prostatectomy is an operation that removes the entire prostate gland, both seminal vesicles (small glands behind the bladder that produce most of the contents of semen), a portion of both vas deferens (tubes that transport sperm from the testicles to the urethra) and sometimes the lymph glands within the pelvis, to which prostate cancer may spread.
Radical prostatectomy is most often accomplished through a “retropubic” approach in which a short incision is made from below the navel down to the pubic region. The “perineal” approach involves removing the prostate through an incision in the perineum (the area behind the scrotal sac and in front of the anal region). Lastly, radical prostatectomy may also now be done through a “laparoscopic” or even robot-assisted approach (multiple small incisions with placement of only a camera and small instruments, and not the surgeon’s hands in the pelvic cavity). These latter procedures rob the surgeon of tactile sensation. As yet, neither the cancer control rates nor the postoperative continence or potency rates achieved by the open approach have been surpassed. In contrast, recent evidence suggests that continence in particular remains superior with the open approach and that cancer control rates in the learning phase at least are markedly poorer for the robotic approach.
Radical prostatectomy is an involved operation. Depending on your general health, you may be referred for a cardiology assessment before the procedure. This is precautionary and for your own protection.
The procedure will not be performed if you are currently taking, or have recently taken any medication that may interfere with your ability to clot your blood. These include Aspirin, Warfarin or Plavix. Please refer to information provided by the rooms. If you have any questions, contact us as soon as possible.
We will ask you to clear out your bowels on the day before the operation using special treatments obtained from the chemist. All instructions will be sent to you and are also available from this website.
The duration of the operation is different for every patient mostly reflecting difference in each patient’s anatomy. The general range is about 2.5 ñ 4 hours. After the incision is made, the pelvic lymph nodes may be removed. If there is an immediate suspicion that cancer has spread to these structures, we will send them for immediate analysis (called a frozen section). If there is definite evidence that cancer has in fact reached the nodes, the operation may be terminated before removal of the prostate.
Next, the prostate as well as the seminal vesicles and part of the vas deferens are separated from surrounding tissue and removed. Because the prostate is the first part of the male urethra (urinary tube inside the penis), it is necessary to re-attach the bladder to the remaining urethra. This is a crucial part of the operation. A catheter is placed across this re-attachment and will remain in place for several days to a few weeks depending on your anatomy. In this regard, your urine drains through this tube into a bag.
Another part of the operation is the “nerve sparing procedure”. This refers to the nerves that control your ability to get erections. These consist of very fine, microscopic fibres that lie alongside and often intimately attached to the prostate. It is usually technically feasible to separate these fibres from the prostate. However, in doing so, there is a potential to also leave cancer behind, especially if there is high-grade disease on that side (Gleason sum 7 or higher). A final decision as to the feasibility and wisdom of sparing these fibres can only be made during the operation.
You should realise that very often, a nerve sparing procedure does NOT guarantee that you will be able to achieve adequate erections without the assistance of medications. It is sometimes wiser to sacrifice some of the nerve fibres on one or both sides of the prostate in order to ensure complete removal of the cancer.
After the procedure, you will be in the recovery room until you are ready to be moved to the ward. As mentioned, you will have a urethral catheter draining your urine, and this catheter may give you a constant sensation that you need to urinate. This sensation typically disappears in a few days. The urine may be crystal clear or appear bloodstained for a few days. Both are normal findings. There may also be a small tube in your abdominal wall that is called a drain. These will be removed within a few days.
A typical hospital stay for radical prostatectomy is four to six nights. It is important to get out of bed on the first day and spend time in the chair. With assistance from a nurse or family member, you may usually walk on the first day.
Upon discharge, you may have no dressing (bandage) on your incision and your catheter will be attached to a small bag that straps to one of your legs. It is easily concealed under your clothing and nobody knows it is there. You will get instructions while in the hospital on how to empty the bag and switch to a larger bag for overnight use when you are sleeping.
Before you are discharged, arrangements will be made for your return to hospital to have the catheter removed. The catheter is removed between 10-14 days after the operation. Before the catheter is removed, we must be sure that the join between the bladder and the urethra has healed. In this regard, a special X-Ray called a cystogram is performed. Contrast fluid is instilled through the catheter into your bladder. The radiologist will then be able to determine if healing is complete. If so, the catheter will be removed by a nurse. If healing is not complete, I will be notified and the catheter will be left in place a while longer. DO NOT WORRY. Having the catheter in place for a week or two more will not make a difference in the long term.
You will be discharged with instructions for follow-up in our office. Other than your regular medications, we may give you an antibiotic, a pain medication, and a stool softener so that you do not strain to have a bowel movement. Other medications are rarely necessary but depend on your particular needs.
Expectations of Outcome
It is normal to feel a bit tired for four to six weeks. We typically tell patients that they will be out of work for four to six weeks and that it may take several weeks more before you truly feel like yourself.
Possible Side Effects of the Procedure
- Impotence (Erectile Dysfunction)
One side effect common to all treatments for prostate cancer (surgery, radiotherapy or hormone treatment) is an impact on your ability to gain a natural erection. Even if all of the nerves are carefully preserved, erectile function may be impaired or completely absent. Your outcome will depend on your pre-operative erectile function, your anatomy, and whether one or both nerves are indeed successfully spared. After radical prostatectomy, the majority of men will need help with erections. This may consist of oral medications such as Viagra, injections placed directly into the penis, or the insertion of an inflatable penile prosthesis. Many patients will also notice that the penis is shorter after radical prostatectomy. Sparing nerves does mean cutting closer to the prostate. This may risk leaving cancer behind. A final decision to spare nerves can only be made at the time of surgery.
- Incontinence (Involuntary Loss of Urine)
The type of incontinence most often associated with radical prostatectomy is termed stress incontinence; defined as the loss of urine with stress (coughing, sneezing, lifting a heavy object, swinging a golf club, etc…). The good news is that in the vast majority of cases, men will regain good continence after radical prostatectomy and few will need to wear pads in the long term. Some men are dry immediately, some will need pads for a month or so, some for a few months but almost all will be pad free eventually. Even fewer will require a second procedure to correct incontinence
Possible Complications of the Procedure
All surgical procedures, regardless of complexity or time, can be associated with unforeseen problems. They may be immediate or even quite delayed in presentation.
- Blood Loss/Transfusion
The prostate is surrounded by a complex network of veins. Some blood loss is expected. In some instances, blood loss is more severe and necessitates a transfusion. The risk of this is less than 5%.
- Wound Infection
As with any incision, an infection can occur. This would present with unusual redness, swelling, and/or drainage (white to yellow thick fluid) from the incision site. Usually, these are managed with antibiotics and local wound care. In some instances, a small area of the superficial (upper layer) incision needs to be opened for adequate drainage.
- Bladder Neck Contracture
As mentioned, the bladder is reattached (anastomosis) to the remaining urethra. This is done in such a manner to preserve urinary continence while maintaining a permanently open channel. Sometimes, the area of the repair can scar down (weeks to months later) and restrict proper urine flow. Often, this scar can be opened up with a small scope (minimally invasive) procedure. Unfortunately, this problem could recur and could eventually jeopardise urinary continence.
- Deep Vein Thrombosis (DVT) / Pulmonary Embolus (PE)
In any operation (especially longer operations), you can develop a clot in a vein of your leg (DVT). Typically, this presents 2-7 days (or longer) after the procedure as pain, swelling, and tenderness to touch in the lower leg (calf). Your ankle and foot can become swollen. If you notice these signs, you should go directly to an emergency room and also call our office. Although less likely, this blood clot can move through the veins and block off part of the lung (PE). This would present as shortness of breath and possibly chest pain. We may sometimes ask the medical doctors to be involved with the management of either of these problems.
A lymphocele is a collection of lymphatic fluid (fluid that drains through the lymph nodes) that can very rarely accumulate in patients that undergo removal of lymph nodes. These collections form in the pelvis. Typically, the first sign of a pelvic lymphocele is slight pelvic discomfort. More rarely, ankle and foot swelling on the side of the lymphocele may occur. Treatment ranges from observation (most often a self-limiting process) to a minimally invasive drainage procedure. The need for an open procedure is uncommon.
- Injury to the Rectum
The back of the prostate lies against the front of the rectum. Local extension of the cancer or inflammation from prior operations or biopsy may make it difficult to separate the two. Rectal injuries may very rarely occur and can usually be repaired quite easily and quickly. It is even less common to need a major procedure such as a temporary colostomy (bag for stool). Sometimes, a general surgeon would be asked to assist with this procedure. Extremely rarely, a small area of weakness in the rectal wall can form a connection between the rectum and bladder. This is called a fistula. This is a very serious problem and requires surgical correction including a colostomy. Colostomy may be required for 6-12 months and even longer. Whilst serious, this is an extremely rare complication and occurs in <0.5% of cases.
The incidence of death during or shortly after the operation is less than 1%. It is usually a result of an unexpected cardiac (heart) event or a pulmonary (lung) event.
Please contact the office within 3 days of discharge. You should make an appointment to see Dr Sved as directed in the hospital. You may see him in his offices at RPA, Bankstown or Strathfield Private Hospital. Do not hesitate to call at any time if you have any concerns. In the long term, regular follow-up PSA measurements will be required to look for any sign of cancer recurrence.