Radical Prostatectomy

 

Description of Procedure

A radical prostatectomy is a surgery used to remove the entire prostate gland including its capsule. The goals of radical prostatectomy are to cure prostate cancer and preserve urinary and sexual function.

 

Radical prostatectomy is a very different surgery then a simple or transurethral resection of the prostate, both of which are indicated to relieve outflow obstruction by partial removal of the central part of the prostate. The capsule remains. While transurethral resection of the prostate is sometimes used in men with prostate cancer, the intent is not to cure prostate cancer.

 

There are several different approaches to radical prostatectomy which include:

  1. Retropubic: A small vertical incision is made above the pubic area, typically about halfway to the umbilicus.
  2. Perineal: an incision is made between the scrotum and anus. This is very rarely done and currently there are only a few surgeons in North America using this approach.
  3. Laparoscopic: This approach uses multiple smaller incisions and long instruments to remove the prostate. This is sometimes done with the assistance of a robot in which case it is known as robotic-assisted laparoscopic prostatectomy (RALP).

 

WHEN IT COMES TO DELIVERING THE BEST OUTCOME IN ANY PARTICULAR SITUATION, IT ULTIMATELY COMES DOWN TO THE INDIVIDUAL SURGEON.

 

While the surgical approach (retropubic vs. perineal vs. laparoscopic) can play a role in your outcome, the over-riding factor by a very large margin is the surgeon performing the procedure. Your particular situation also plays a major role. The effect of surgical skill in determining the outcome is such that it is impossible to compare the different approaches to removing the prostate without generalizing to the point where the comparison becomes irrelevant to you. It is impossible to predict how an individual might perform following a treatment, but a surgeon's track record in different scenarios will be a good guide as to what you can expect.

 

Things to ask your surgeon:

  1. How are you measuring your outcomes? Are the measures you use standardized and generally accepted?
  2. How do your outcomes compare to the benchmarks set by the 'best cancer centers' in the world?
  3. If you are not measuring your outcomes, how do you know if you are performing good surgery or identifying areas for improvement?
  4. How many of these do you do per year?*
  5. What can I expect given my particular situation?

 

*Surgical volume is an important measure to guage competency, slightly more so than the approach (e.g. open vs. laparoscopic), but measured outcomes are even more important.  Each of the surgeons at Richmond Hospital would be considered 'very high volume' as defined in the medical literature - usually defined as over 30 radical prostatectomy surgeries per year.

 

Radical Prostatectomy at Richmond Hospital

 

Because of the large variation in how this surgery is performed, you may read or hear many different things. Radical retropubic prostatectomy at Richmond Hospital:

  • Two Urologists with extensive experience will conduct your procedure.
  • Surgery takes between 1 1/2 - 2 1/2 hours
  • Optical magnification with loupes to maximize preservation of erections and urinary continence
  • The chances of requiring a blood transfusion are approximately 1 in 20
  • Most patients are able to go home the day after surgery
  • The average length of the incision is 10-15 cm (3-5 inches) - less than halfway from the base of the penis to the umbilicus
  • The most common complaint immediately post-operatively has to do with catheter discomfort, not incisional pain. The catheter usually comes out 7-10 days after surgery.

 

After Procedure

If you have questions that are not answered here, please contact us.

 

In the Hospital

Duration

Surgery: usually takes about 2 hours. General anesthetic (you are completely asleep)

At your request, will talk to your family directly or contact them by phone to let them know how you are doing. 1 hour in recovery room.

Hospital stay: usually 1-2 days. Most patients go home the day after surgery.

Activity & Diet Mobilization the night of surgery, often with a regular dinner.
Tubes

Urethral Catheter: not to be removed except by the surgeon 1-3 weeks after surgery

Drainage tube: removed before discharge

 

On Leaving the Hospital

Prescription Pain medications: you only need to take this if you are having pain. Often advil/ibuprofen and plain tylenol will be adequate. A prescription for stronger pain medication will be provided just in case.

Blood thinner: you may be prescribed a prescription for low-molecular weight heparin (e.g. Fragmin/dalteparin) to help prevent blood clot formation in the legs

Activity

There are only a few limitations for the first 6 weeks - there are no restrictions after 6 weeks:

  1. No heavy lifting (approx. 30 lbs or more)
  2. No vigorous activity or exercise. Walking is fine, but avoid things which would cause you to tighten your abdomen excessively (e.g. sit-ups, squats, golfing) or place pressure on your saddle area (e.g. cycling

It is important to stay active and walk.You may start showering 24-36 hrs after surgery.
Please review catheter care instructions.
You may start Kegel exercises once the catheter is removed.

While you may be able to return to non-physically demanding work within a week or two of the surgery, we generally recommend that you plan on 4-6 weeks off of work. It is usually easier to go back to work sooner than expected than to ask for additional time.

Diet
No restrictions. Avoid constipatiing foods. Drink lots of fluids if the urine has any blood.
Tubes
You will be discharged home with the catheter - see below and instructions on catheter care.

 

Post-Operative Office Appointments


Our office will schedule all your follow-up appointments. Please call if you have not received a time for your appointment within 3 days of discharge from hospital.
Catheter removal
An appointment will be scheduled to remove the catheter; usually 7-10 days after surgery (sometimes up to 3 weeks). This is usually done by the Continence Nurse Advisor (NCA) in Ambulatory care. Bring a diaper to wear.
Pathology
The prostate (and lymph nodes, if applicable) are sent for analysis. It usually takes 5-10 business days for the report to become available. An appointment to review this important report will be made if not available when the catheter is removed. This usually occurs in the office just after the catheter is removed in hospital.
Long-Term

You will be seen on a long-term basis by your urologist to assess your progress. We want to ensure that you have optimal results in terms of:

 

  1. Cancer control
  2. Urinary control
  3. Sexual function

 

We are happy to assess you at any time outside of routine scheduled appointments to address your concerns.

 

Important Notices and Frequently Asked Questions

 

 

Catheter

DO NOT ALLOW ANYONE TO REMOVE OR REPLACE THE CATHETER EITHER DURING OR AFTER YOUR HOSPITAL STAY WITHOUT CONTACTING YOUR UROLOGIST FIRST.

 

You will be discharged home with the catheter - see below and instructions on catheter care. Call us if:

  1. The catheter is not draining urine - check for kinks first.
  2. If your catheter comes out before the planned day of removal.

 

A catheter allows for continuous drainage of urine from your bladder. You do not need to go to the washroom to urinate. It allows the anastomosis between the bladder and urethra to heal properly. Your urologist will make a plan for catheter removal. Do NOT remove the catheter on your own.  It is critical that the catheter stay in place for as long as directed by the urologist, usually between 1 and 3 weeks. If the catheter is removed prematurely or an attempt is made to replace the catheter, there is the potential for serious damage to the anastomosis which may result in contracture or incontinence. Under no circumstances should you or another health care provider make any attempt to remove or replace the catheter unless directed by your urologist.

 

What to expect with your your urinary catheter

 

  1. Some blood is normal. It is normal for there to be some blood in the drainage tubing and around the outside of the catheter ('bypassing') at the urethral meatus (at the tip of the penis or at the opening to the vagina).
  2. Some debris and/or clot is acceptable as long as the catheter is draining.
  3. Some urgency to urinate and discomfort at the tip of the penis is normal.
  4. Bladder spasms are common with a catheter and should be considered normal. Bladder spasms are when the bladder tries to expel the catheter and the wall pushes against the catheter balloon inside, giving rise to discomfort and/or blood or urine leakage around the catheter. This is usually transient. Tends to be more common when having a bowel movement.

 

What to do about blood in the catheter


The amount of blood loss around or through the catheter is usually minimal. The major issue is if a blood clot blocks off the tubing and urine cannot drain from the bladder. You can minimize the chances of problems by:

  1. Increasing your intake of fluid, especially water, until the urine clears. Drink as much fluid as is necessary to keep the urine relatively clear (color of fruit punch or better).
  2. Limit physical activity if increased bleeding is noted.
  3. Ensuring catheter movement is reduced by attaching the catheter to your leg with tape. Normally you will have been sent home with the catheter fixed to your leg. If the catheter comes free, you may use any tape to attach the tubing to your leg. Allow enough slack so that movement does not tug on the catheter.
  4. Avoiding constipation. Drink fluids, try laxatives.
  5. Apply a lubricant such as Polysporin ointment to where the catheter exits the body - the urethral meatus. Wash the area with a gentle soap while in the shower.

 

Tips to decrease catheter discomfort

 

  1. Keep the outside of the catheter clean where it meets the meatus (opening of the urethra on the head of the penis). You may shower and wash with gentle soap and water.
  2. Apply a lubricant such as vasaline, polysporin or KY-Jelly to catheter where it enters the body.
  3. Minimize movement of the catheter by attaching the catheter to the leg with tape. Most patients are sent home with a catheter fixation device. Make sure there is enough slack so that leg movement does not pull on the catheter.

 

Call us

Call us if you notice any of the following

  • Catheter comes out or is not draining
  • Redness, foul-smelling drainage or separation of incision site.
  • Fever over 38.5 C.
  • Severe pain unrelieved by medication.
  • Leg pain or swelling.
Don't Worry

Do not be alarmed if you notice any of the following:

  • Swelling and bruising of the penis or scrotum.
  • Pain or discomfort around incision site especially with coughing or sitting up. Take pain medication.
  • Bladder spasms which are associated with an intense sensation of needing to urinate and occasionally passage of urine or blood around the catheter (‘bypassing’) of pass blood or debris through the catheter.
  • Blood or clot in the catheter drainage bag - as long as the catheter is draining.  Please see catheter care instructions in the General Post-Op care info page.
  • You may feel tired and need to nap during the day.

 

Your care doesn't end once you are through your surgery. Your urologist will want to see you periodically for several years to monitor for prostate cancer and ensure that your recovery is the best it can be.

 

Cautions

 

 

 

Medications

Take antibiotics as per prescription (most patients will NOT have a prescription for antibiotics).
Use prescription pain medication and bladder spasm pills as needed.
Do not apply ointments or creams to incisions until the steristrips have been removed. You may then apply polysporin or other antibiotic ointment 2-3 times per day until healed. 
Take a stool softener (obtain over the counter at local pharmacy) starting the night of your surgery.  Stop taking stool softeners once having soft bowel movements.  Do not take stool softeners if diarrhea occurs.
If you have not had a bowel movement by the 3rd day after your surgery, take a laxative (obtain at your local pharmacy over the counter).  Do not use suppositories.
You may begin your regular medications when you leave the hospital unless instructed otherwise.
If you take bloodthinners (ASA, plavix, warfarin), your doctor will advise when you can start them again.

 

On the Web

General Prostate Cancer Web-Resources

Memorial Sloan-Kettering Cancer Center in New York is an excellent resource for information on prostate cancer. Balanced, unbiased discussions of the disease, including discussion regarding some of the controversies in prostate cancer.

General Information on Cancer

UNDERSTANDING CANCER - Metrovan Urology info on the principles of diagnosis, staging, prognosis and more.

American Cancer Society

BC Cancer Agency: Good general website from the British Columbia Cancer Agency. Has contact information on locations.

National Cancer Institute: Excellent source of understandable and mainly unbiased information. Several very good brochures on every stage of prostate cancer.

National Comprehensive Cancer Network: peer-reviewed expert content/prostate cancer guidance on evidence-based cancer diagnosis and management. Best for Prostate and Kidney Cancer. The most in-depth information is located in the physician section and requires registration.