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A Patients’ Guide to Radical Prostatectomy
Department of Urology St Vincent’s University Hospital
Helen Forristal
Sinead Farrell
Urology Cancer Nurse Specialists
In association with Mr. David Quinlan mad Mr. David Mulvin
Consultant Urologists
Acknowledgements
I would like to thank Mr. David Quinlan and Mr. David Mulvin for encouraging me to write this booklet and foe their valuable input and continuing support.
To the many doctors and nurses who reviewed this booklet, your valuable comments were much appreciated and to the many prostate cancer patients who inspired me to write this booklet.
Date of preparation 2002
Review date Dec 2007-12-07
Contents
Acknowledgements
Introduction
Preparation for surgery
Hospital Admission
Day of Surgery
Discharge and Follow up
Possible complications Incontinence post surgery
Altered Sexual function
Bladder neck contracture
Blood Loss
Rectal injury
Conclusion
Useful Names/Numbers
Additional Contacts
Introduction
You and your medical team have decided that a Radical Prostatectomy is the most appropriate treatment for your prostate cancer.
This booklet is to help you understand what a radical Prostatectomy is entails. It describes what procedures are carried out prior to your surgery. Then it explains what happens in the operating theatre and during your hospital stay. Follow up care is discussed. Finally, the possible complications you may encounter from your surgery are explained.
What are the alternatives to Radical Prostatectomy?
Radiotherapy
Brachytherapy
Active surveillance
What is the prostate and where is it?
The prostate is a small firm gland only found in men. The size of the gland is in an average; male is roughly the size of a walnut.
The prostate lies next to the inner wall of the rectum, directly below the bladder, at the base of the penis. The gland surrounds the first part of the urethra; this tube carries urine from the bladder to the penis.
The prostates only function is that it produces a thick white fluid known as semen, which is used to carry sperm on ejaculation.
Preparation for Surgery
Medications
Please do not take medications such as Aspirin or Warfarin for ten days before surgery. These medications are blood-thinning agents and may cause bleeding during or after surgery if not stopped.
Please check with your doctor before stopping any medication.
Smoking
Try to stop smoking at least a few weeks prior to surgery, as this will help your breathing and reduce the risk of chest infections and other complications after surgery.
Alcohol
Limit your alcohol intake. If you have a high alcohol intake, please inform your doctor.
Kegel sphincter exercises
These are exercise to help strengthen the muscles, which control your bladder.
To do these exercises stop and start the flow of urine midstream. It will become clear as you read this booklet why these exercises are helpful.
Hospital Admission
You will be admitted to hospital 1-2 days prior to surgery
The following routine investigations will be carried out the day before your surgery.
Chest x-ray – in patients with a previous history of heart or lung problems.
Electro cardiograph
Blood tests – including cross matched in case you need a blood transfusion
Bowel Preparation
You will be given an enema the day before surgery
Physiotherapy
The physiotherapist will visit the day prior to your surgery and will instruct on deep breathing and coughing exercises. You will be taught to use a small breathing device called an incentive Spiro meter. The reason for this exercise is to reduce these risk of developing a chest infection.
The physiotherapist will also instruct on leg exercises. This is to reduce the chance of circulatory problems.
Anaesthetic review
The anaesthetist usually visits patients the evening before surgery to ensure that you are fit for anaesthetic. He/she may order a sedative for you to take before going to the operating theatre.
Deep Vein Thrombosis (DVT) Prophylaxis
May include
Thrombo Embolic Deterrent Stockings (TEDS)
Medication
Pneumatic compression boots (worn in theatre)
Day of Surgery
You will be asked to fast from food and drink from 12 midnight
Pre-medication may be given to relax you a few hours prior to the operation
Operation
The operation lasts one and a half to three hours. An incision is made in your lower abdomen, which is usually 6 –10 inches.
During your operation, the prostate, the prostatic urethra (the small section of the urethra that is surrounded by the prostate) and the seminal vesicles are removed. The bladder is then rejoined to the remaining urethra and external sphincter. A urethral catheter will be inserted into your bladder through the remaining urethra.
If your PSA (prostate specific antigen) is >15 mglml or the Gleason score of your cancer is greater than 8, the lymph nodes which drain your prostate will be removed.
The prostate specimen is then sent to the pathology department for further analysis.
After the Surgery
Following your surgery you will have the following
Dressing over your abdominal incision, which is usually 6-10 inches.
Drain in your lower abdomen. These are small drains that are removed 2-4 days after surgery.
Central venous line this is situated in your neck. Its function is to provide you with fluids. This will remain in situ until you can tolerate food and fluids by mouth.
Urinary catheter: this will remain in situ for at least three weeks after the operation – see follow up section for more details
Pain control
Pain is not usually an issue
Pain relief may take the form of
Patient Controlled Analgesia Pump (PCA)
A suppository
Injections
Tablets
The PCA pump is a small pump containing pain relief medication attached to an intravenous line.
There is a button that you may press when you need pain relief. You will be instructed on its use.
The goal during the first few days after surgery. Will be to prevent infection and circulatory problems. To reduce this risk of this happening, breathing exercises as instructed by the physiotherapist and nurse and early mobilisation are important.
Discharge
If you have an uneventful post surgery period you will be discharged home 7-10 days after your surgery.
Follow Up
As mentioned earlier, you will have a urinary catheter in place for approximately three weeks after the operation. On discharge from hospital you will be instructed on the use of the leg bag and night drainage bag.
While your catheter is in place you may experience bladder spasm, which may cause leakage of urine around your catheter. This is normal. The most common time this happens is when your bowels move. Medications may be prescribed if this becomes a problem.
You will be admitted for the removal of your urinary catheter. This entails a two-day stay in hospital. Removal of the catheter is a simple procedure that causes minimal discomfort.
Out patient appointment
This usually takes place about 6 weeks after discharge. During this consultation the following takes place
Pathology (specimen taken from prostate) result is discussed
Wound check
PSA level taken
Opportunity for you to discuss any problems with your doctor/nurse.
Follow up Out patient appointments
These will take place initially every three months, then six monthly and then annually after five years. During these visits your PSA level will be checked and again you can discuss any problems with your doctor/nurse.
With regard to resuming physical activities and returning to work, this varies from patient to patient. Generally we would advise patients to wait for a minimum of four weeks before returning to work and at least six weeks before carrying out any strenuous activity.
Possible Complications
As with all surgery there is potential for a lot of different complications. It is beyond the scope of this booklet to discuss all of these in detail.
The most common side effects following a Radical Prostatectomy are
Incontinence
Impotence
Infertility
Blood Loss
Rectal Injury
Bladder Neck Contracture (narrowing)
Incontinence
Following a Radical Prostatectomy leakage of urine occurs because the urethral sphincter is close to the area touched on during surgery.
The amount and duration of urine leakage may be hard to predict. The table below gives approximate guidelines to the duration of incontinence.
50% of patients are dry within three months
75% of patients are dry within six months
25%of patients may take up to one year for total dryness
2% of patients may have long-term leakage problems.
You may experience incontinence of varying degrees
Incontinence at rest
Incontinence whilst standing or walking
Stress incontinence; this is urine leakage associated with coughing, sneezing or laughing.
Advice
It is advisable to wear an incontinent pad when your catheter has been removed. Depending on the duration of incontinence will determine how long you need to wear pads. You will get a small supply of pads from the hospital on discharge. You can obtain additional pads from your local chemist/supermarket
Remember to continue your Kegel sphincter exercises as these should help improve your bladder control
Do not restrict fluids. This will make the problem worse and put you at risk of infection.
Avoid large quantities of caffeine and tea as these may act as a bladder irritant
If your leakage of urine continues over along period of time you may be referred to a physiotherapist for additional treatment.
Altered Sexual Function
Because of the location and the function of the prostate gland, a Radical Prostatectomy often leads to change sin physical sexual function. A high percentage of patients will become impotent (unable to have an erection) after surgery
Retention of sexual potency depends on extent of cancer
Patients age
Prior state of sexual potency
Level of interest in sexual activity
Whether nerve-sparing surgery is performed
Healing after a Radical Prostatectomy takes 2ix months to 2 years. Therefore it is not possible to determine immediately if the ability to have an erection has been lost. Impotence is caused by a reduction in blood supply to the penis and or by removing the nerves serving the penis. The surgeon may be able to carry out nerve sparing surgery, this depends on a lot of factors. Your surgeon can discuss these with you in more detail.
During a Radical Prostatectomy the entire prostate and seminal vesicles are removed, therefore you will be unable to produce semen following surgery.
Altered sexual function can cause a lot of emotional distress. It is important that you discuss any anxieties with your partner, doctors and nurses.
Treatment for impotence are available. These include
Oral medications
Injection therapy
Penile implants
Vacuum pumps
Infertility
Because the prostate and seminal vesicles are removed and the vas deferens tied off, natural fertility is not possible after a radical prostatectomy. If this is an issue for a patient and his spouse/partner assisted methods of reproduction may play a role and should be discussed further.
Bladder Neck Contracture (narrowing)
This is an uncommon complication where the newly fashioned junction between the bladder and the urethra becomes scarred and narrowed. Te patient may notice a gradual decrease in the power and calibre of his urinary flow. This problem responds very well to a minor telescope procedure. It is very rare for it to be a permanent problem.
Blood Loss
All surgery carries the risk of blood loss to varying degrees. There is a small risk that you may require blood transfusion either during or after the operation.
Rectal injury
This is a rare complication, due to the proximity of the bowel to the prostate, there is a 1% chance of damage to the bowel during a Radical Prostatectomy. Should this occur a temporary colostomy may be necessary. This will be explained to you further.
Conclusion
There have been a lot of advances in Radical Prostatectomy. These include
Reduction in risk of incontinence and impotence
Lower risk of blood transfusion
Shorter hospital stay
Increased patient satisfaction
The period immediately following surgery may be difficult for you and you r family. However within 2-4 months your body will heal. The staff here want to make the adjustment as easily as possible. We encourage you to contact us whenever you need assistance with any aspect of your illness, your treatment or your recovery.