Radical Prostatectomy

What is the prostate?

This is a small gland that lies just beneath the bladder in the male and surrounds the urethra through which urine is passed.

What does the operation involve?

Schematic diagram to explain the steps of radical prostatectomy

This operation removes the entire prostate glan, the water tube (urethra) is rejoined to the bladder. Please ask your Mr Puri if you want further details.

Why is this operation necessary for me?

Your consultant has performed investigations on your prostate gland, which have shown the presence of prostate cancer. The operation, which is described below, will remove all of the prostate gland.

Are there any alternatives?

For this kind of cancer, the alternatives to removal of the prostate gland are treatment of the prostate cancer with radiotherapy (a beam of special, focused x-rays) or brachytherapy (radioactive seed implantation into the prostate)

It is possible to do nothing for the time being – i.e. to watch and wait to see if problems develop. However for men like you, this is not recommended, as there is a significant chance of the cancer progressing if no treatment is given.

What are the advantages of surgery

• The true extent (stage) and aggressiveness (grade) of prostate cancer can be determined.
• If the cancer is confined to the prostate and completely removed the operation should be curative
• PSA value should decrease to <0.1 six weeks after the operation
• This operation also relieves the obstruction caused by enlargement of the prostate gland and relieves symptoms as poor flow and getting up at night to pass water.
• If cancer recurs PSA rise will detect this 4-5 years before symptoms so the radiotherapy can be given.

Disadvantages of surgery

• Wound discomfort- The wounds heal within 10 days and most patients are able to resume normal activity like driving within 2-3 weeks. The discomfort is easily controlled by painkillers. Wound complications are rare

Serious complications are unusual but are rapidly recognised and dealt with.

Common

• Erectile dysfunction (problems getting an erection)
• Incontinence (problems controlling your flow of urine)

Occasional

• Chest infection
• Bleeding
• Blood Clot formation

Rare

• Bowel problems. It is possible for your rectum to become damaged during surgery, although this is not common.
• There is a very small (less than 1 percent) chance that you may die from your surgery. As operation involves a general anaesthetic and this can lead to complications such as heart problems and breathing problems.

Despite your surgeon's attempt to remove the entire tumour, you may not be cancer-free. Even if your test results indicate your cancer is only in your prostate, it's still possible that it has spread to other parts of your body but can not be detected. It is essential that you have regular follow up for 5 years after operation

What happens before the operation?

You may be requested to attend the ward before your admission date to have blood tests and examinations performed to ensure you are fit for the operation. On admission to the ward, you will be welcomed and shown to your bed. You should plan to be in hospital for 3-4 days. The nursing staff will discuss your discharge with you.

You will be seen by the Surgeon who will explain the operation to you and ask you to sign the consent for surgery. If you are unsure about any aspect of the operation, please ask for more details from the medical or nursing staff. You will be advised of the approximate time of your operation

You will be seen by an anaesthetist who will discuss the type of anaesthetic you will be given. They will be interested in chest troubles, dental treatment and any previous anaesthetics you have had. The anaesthetist will discuss with you the different types of pain relief.

Very occasionally you may be nursed on the High Dependency Unit (HDU) after the operation. There are more nurses available so more attention can be given to you. If this is planned, you will be introduced to the nurses from HDU and shown around the unit the night before theatre.

You can have your usual diet until approximately 6 hours before surgery. This will let your stomach empty to prevent vomiting during operation. You will be advised at what time to stop drinking fluids.

You will be asked to wear stockings to prevent blood clots and aid circulation. You will be asked to wear a cotton gown and remove all jewellery.

You may be given a sedative about one hour before the operation to help relax you; if so you will be taken to theatre on a trolley. If no sedation has been prescribed, you may choose to walk to theatre, accompanied by a ward nurse. Your details will be checked again before your anaesthetic begins.

What happens after the operation?

Although you will be conscious a minute or two after the operation ends, you are unlikely to remember anything until you are back in your bed. You will have a tube (catheter) coming from your penis. This tube drains the urine from your bladder and is connected to a collecting bag. It is quite normal for your urine to be quite bloodstained initially. Some men experience slight discomfort around the catheter. Please inform the nursing staff who will be able to give you pain killers.

On the first day after your operation, you may begin to sip fluids. You will have in intravenous drip containing saline and this will make up for any fluids you are unable to drink. By the second day, you will probably be drinking quite freely again, and may be able to tolerate a light diet. Your bowels may stop working for 1-2 days after surgery. If you have not opened your bowels after 2 days, or are feeling comfortable, please ask the nursing staff for advice.

You will be encouraged to get out of bed and start walking right from the first day. You will not do your wound any harm and it is important to start moving to avoid complications.

You will need to remain in hospital until you can walk freely without pain, and can manage by yourself. We will also ensure that you are eating normally before you are discharged home. Usually patients are discharged home 2

to 3 days after their operation

You will be sent home with your catheter in place. This catheter should remain in place for 5 to 12 days and must not be removed for any reason except on your surgeon’s instructions.

If any problems occur with the catheter please contact Ward 14 or Yorkshire Clinic Ward 1 immediately for advice.

Complications

Serious complications are unusual but are rapidly recognised and dealt with. If you think that all is not well, please ask the nursing or medical staff.

Chest infections can occur after anaesthetics, particularly in people who smoke. Exercises are taught to clear the air passages, and can prevent this condition. You should try not to smoke before surgery, and make every effort to give up smoking after your operation.

There is a risk that blood clots may form in the veins of the calf during surgery (known as "deep vein thrombosis") This may lead to a swollen, tender calf. Although this is easily treated, it can lead to further problems if the clots break away and float up into the lungs ("Pulmonary Embolus"). You will be given stockings to wear prior to surgery and you should keep these on during your stay on the ward. You will also be given a fresh pair to take home and you should wear these at home for a further 6 weeks. Your surgeon may also prescribe daily injections during your hospital stay to thin the blood slightly and reduce the risk of forming these clots.

Discharge advice

Diet

You can eat and drink whatever you wish. You may drink alcohol but it is not wise to overindulge. Try to avoid constipation by keeping to a diet that contains plenty of fruit and fibre. If you do become constipated, then ask your doctor for advice

Exercise

After you go home, you should avoid heavy lifting and vigorous exercise for 6 weeks, to let the scar tissue and wound heal. If you engage in strenuous activity before this time, you might cause damage to the join between the bladder and urethra (water pipe) and in the long term this could cause problems with incontinence.

For the first four weeks at home, do not sit upright in a firm chair for more than an hour at a time. Instead sit in a semi-reclining chair, on a sofa, or on a comfortable chair with a stool.

This achieves two aims:

• It raises your legs and improves the drainage from your leg veins reducing the risk of clots forming

• It avoids placing weight on the area of your surgery

You should take light exercise regularly. You can take off the elastic support stockings after 6 weeks at home and you can drive your car when you can operate the pedals without any discomfort at all.

Removal of the catheter

When you go home after the operation, you will have the original catheter draining urine from the bladder. Although it will be taped to your thigh immediately after your surgery (to prevent any pulling on the catheter), this tape will be removed when you go home. Avoid any situation where the catheter may be caught, or pulled on.

The catheter must remain in place for five to twelve days and should not be removed for ANY reason except on your surgeon’s instructions.

You will be given an appointment to come back into hospital five to twelve days after your operation for removal of catheter. The catheter will be removed on the ward. This is a painless procedure and is performed at the bedside. You will then be able to pass urine normally, we will observe you for a few hours but will usually allow you to go home on the same evening.

When the catheter is removed, you may find to begin with that you get little warning before needing to pass urine, and may leak a few drops of urine on movement. This is quite common and usually settles quickly. If it does not, please let the nursing staff know.

Rarely you may need a special x-ray to determine whether the internal stitches around the join between the urethra and the bladder have healed. This may mean that you have to stay overnight in the hospital.

Problems which may occur

Bleeding

It is common for there to be a slight discharge of blood around the catheter when you open your bowels. This will settle down by itself and is not a cause for concern. You may also see some blood in the catheter bag, particularly after exercise. If this happens, you should increase your fluid intake to help flush out the blood. This kind of bleeding usually settles by itself and does not require treatment in most cases.

Leaking around the catheter

Like bleeding, this is also common and does not require treatment. If the leakage is very severe, then it can be managed by absorbent pads that the community or hospital nursing staff will provide for you. The catheter should not be removed. Very rarely, the catheter may stop draining altogether. If this happens, lie down flat and drink plenty of fluids for an hour. If this does not result in drainage from the catheter, then come straight to Ward 14 / Yorkshire Clinic ward 1 for advice. Do not let anybody remove your catheter without discussion with your Consultant.

Wound problems

You will have a approximately 3 to 3.5 inch wound below the belly button

Most wounds are closed with self dissolving internal stitches and skin glue and so do not require removal. These stitches are not visible on the skin. Occasionally we use skin clips, these should be removed ten days after you option. If you have already gone home at this stage, we will arrange for the District Nurse to remove the clips for you. You can shower or bathe at home.

Some patients may develop a wound infection after they go home which shows as redness or swelling around the wound. If this happens, seek advice from your GP.

Clots in the leg (Deep Vein Thrombosis)

In the first six weeks after surgery, one of the most serious potential complications is the development of clots in the back of the calf. If you develop any of the symptoms described earlier, e.g. chest pain, shortness of breath, pain or swelling in your leg, then call your GP or contact your nearest Accident and Emergency Department if you are away from home. You should tell the doctor who sees you that you have had a radical prostatectomy, and are concerned about a possible blood clot.

Infection in the urine

Urinary tract infections are quite common in anyone who has a catheter in place. Unless you have symptoms, the infection may not require any treatment.

Symptoms of a urinary tract infection include

• Chills and fever
• Concentrated or cloudy urine
• General malaise

Sometimes there may be cloudiness in the urine, which does not necessarily signify an infection, but may represent sediment in the urine that is a normal occurrence.

Urinary control

In the discussion you had with your Consultant prior to surgery, the problem of urinary incontinence following surgery was discussed with you. The majority of men find that they experience a small amount of urinary leakage. However for a few men, the problem is more severe.

The return to normal control occurs in three phases, and you should try to be patient with the speed of your recovery. The first phase is that you will be dry when you are lying down at night. In phase two you will be dry when walking around, and finally in phase three you will be dry when you get up from a sitting position. The return to normal occurs at different speeds in different men and is impossible to predict accurately. Until you gain full control, you may find it useful to limit the amount of caffeine drinks (tea and coffee) and alcohol that you drink as these drinks act as a stimulant on the bladder.

Overall recovery of urinary control occurs in up to 95% of men who undergo this procedure although this can take up to 1 year.

Return of sexual function

Sexual function

After surgery, you may find it difficult to get or maintain an erection that is firm enough for intercourse.

Erectile dysfunction happens because the nerves and blood vessels that control erections lie close to the prostate and can become damaged during surgery. A technique called nerve-sparing surgery can protect the nerves from injury and where possible this will be done. However, nerve-sparing surgery is not possible for all men. Even when nerves are spared, it may not prevent erectile dysfunction. However, your erections may continue to improve over time. The nerves that are involved seem to be able to recover after surgery, but the older you are, the less likely you are to regain the ability to have an erection.

Although you may not be able to have penetrative sex, you may still experience the sensation of an orgasm, which may be achieved from either foreplay or masturbation. After your prostate is removed, you will no longer be able to ejaculate (release fluid from your penis when you orgasm). This is because you no longer have a prostate to produce this fluid. As you will be sterile you do not need to use any form of contraception.

There are treatments available for erectile dysfunction, so it's worth talking to your Consultant or Specialist Nurse about which one may be right for you at your regular follow up appointments. Current research suggests that early treatment is associated with greater success.

Potency (erection) rates differ amongst surgeons. Good potency rates would be 50% of patients, at 12 months after surgery.

Do not be afraid to attempt intercourse, but it is better to wait for at least 6 weeks after surgery, to make sure everything has healed. Do not be tempted to wait for a perfect erection before attempting intercourse

Follow up after surgery

6-8 weeks after the operation you will be seen by the Consultant in the outpatient clinic. You will have a card for a PSA test to be carried out at your GP surgery , BRI, SLH or the Yorkshire Clinic a week before your clinic appointment. This so is the results of the surgery can be discussed with you, and any other treatments planned.

Further follow up appointments will be given at regular intervals, although the time between visits may lengthen if there are no particular problems.

A final word

Please do not hesitate to contact us with any questions or concerns that you may have about your condition. We are here to help you.

Any questions?

If you have any questions please contact

Uro-oncology nurse specialists

BRI Yorkshire Clinic
Mr David Tyson 01274 382079 Mrs Lyn Taylor 01274 550600
Miss Zoe Scaife

Ward 14 Ward 1
Bradford Royal Infirmary Yorkshire Clinic
Tel (01274) 364383 Tel (01274) 560311

Secretary to Mr R. Puri
Bradford Royal Infirmary Yorkshire Clinic
Duckworth Lane Bradford Road
Bradford BD9 6RJ Bingley BD16 1TW
Tel (01274) 382655 Tel (01274) 564521