Radical Prostatectomy

A small vertical incision about 10 cm in size is made above the pubic area, typically about halfway to the umbilicus. This is what is offered by our team.

This approach uses multiple smaller incisions (usually adding up to about 8 cm) through the abdomen. Small cuts are required for insertion of a camera, multiple instruments and to remove the prostate. Long instruments are used to remove the prostate along with a camera. This is sometimes done with the assistance of a robot in which case it is known as robotic-assisted laparoscopic prostatectomy (RALP).

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.

A date for surgery will be provided as soon as possible. This date will be provided by our office. Scheduling of surgery takes into account the availability of operating room time and the acuity of the case. Many patients are understandably anxious about their diagnosis of cancer and once you have made a decision would like to move forward as quickly as possible. You should be reassured that every effort will be made to expedite your surgery.

• Every patient is automatically placed on a ‘cancellation list’.

• There is robust evidence that postponing or delay in surgery of 6-12 months does not appear to have a negative affect on the chances of cure, even in cases where high risk features are present.

• We will generally try and avoid surgery within the first 4-6 weeks after biopsy as the biopsy-related bleeding and swelling within and around the prostate can, in some patients, make the surgery more challenging and jeopardize outcomes.

• You will be informed of the day of surgery several weeks prior to surgery and contacted the day prior to surgery with the time you should come to hospital.

Radical prostatectomy is major surgery. While it is important that the cancer be addressed, it is vitally important that treatment (surgery and radiation) must be conducted with an acceptable margin of safety. For the vast majority of patients this means:

• Pre-operative assessment by the anesthesiologist.

• Pre-operative assessment by an internist.

• Input from any specialist physicians when it may have an impact on your care (e.g. your cardiologist).

Our office will make the request for these consultations. Appointments will be scheduled by the hospital, typically about 2 weeks prior to surgery. These may be by phone or in person. They will describe what to expect in regards to the type of anesthetic, risks of the anesthetic and post-operative pain management.

Some patients may require additional investigation to ensure that it is safe to conduct the surgery or to optimize your status. This may result in a delay in surgery.

You should anticipate the following and prepare appropriately:

• You will need a ride home to and from the hospital.

• You will not be able to drive for several days before to surgery.

• If you are coming from out of town, please plan for 3 days in town. You may be able to return home sooner.

Ensure you have read the instructions provided to you during your pre-operative consultation. It is critical that you do not eat or drink anything from midnight onwards prior to the surgery. More detailed instructions will be provided to you at the time of your pre-anesthetic consultation.

Your surgical date will be provided many weeks in advance. You will be told the time to arrive at hospital the day prior to surgery.

Nursing staff will admit you to the pre-operative area.

The anesthesiologist and surgeon will visit you address any last minute questions. The surgical site will be marked. You will be asked to complete the consent for surgery form it it has not already been signed.

The permissibility of having someone accompany you will be dependent on current hospital policy. Ask anesthesia for permission if you wish to have someone accompany you in the pre-operative area.

After the pre-operative process is completed you will be brought to the operating room.

Please be aware that if you arrive late your surgery may be postponed or cancelled.

Surgery takes 2-3 hours. You will be asleep so you will not be aware of the passage of time.

Surgery is done under a general anesthetic (you are completely asleep) and this will be augmented by liberal use of local anesthetic.

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

After surgery you will spend a couple of hours in recovery room until it is safe to send you to the ward. It is not practical or possible to have family in the recovery room. This is a busy critical care area and the staff will be looking after multiple patients who require their full and undivided attention.

Duration of hospital stay is variable and you will only be discharged once it is determined it is safe to do so. Discharge is contingent on you meeting discharge criteria. This entails an ability to tolerate a full diet, adequate mobility, pain controllable with oral medications and the absence of any health issues that require ongoing admission.

• Most patients go home the morning after surgery (about 90%).

• Some patients will stay 2 days (about 5%).

• Few patients will require 3 or more days (about 5%)

Mobilization the night of surgery, often with a regular dinner. Post operative pain is usually managed by the anesthesiologist. We commonly employ Patient Controlled Analgesia (PCA). You are shown how to self-administer pain medication via pump - all of this is done with supervision under controlled circumstances.

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

DO NOT, UNDER ANY CIRCUMSTANCE, PERMIT ANYONE BUT YOUR UROLOGIST TO EXCHANGE OR REPLACE YOUR URETHRAL CATHETER WITHIN 2 MONTHS OF YOUR SURGERY. IN SELECT CIRCUMSTANCES, AND ONLY AFTER DISCUSSION WITH THE ON CALL UROLOGIST, WE MAY REQUEST THAT THE EMERGENCY ROOM PHYSICIAN ATTEMPT A CATHETER EXCHANGE OR REPLACEMENT.

In circumstances where the urologist is not present to replace a catheter, please confirm that the emergency room physician has spoken with the urologist on call. Failure to follow these instructions may result in uncorrectable urinary leakage or blockage of the bladder require life-long diapers, urethral catheter or urinary diversion.

Urethral Catheter is not to be removed except by the surgeon or their designate (e.g. urology nurse), typically 7-14 days after surgery. All patients will be discharged with a urethral catheter.

In the rare circumstance that you have a pelvic drain and are discharged with that drain we will make arrangements to remove it.

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. We generally recommend regular dosing of tylenol and advil (so long as you do not have a contraindication) for the first few days to ensure the pain does not rise to a level where it is difficult to control.

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.

Erection medications: prescriptions for Viagra and Cialis may be provided. You are not expected to fill or take these medications. We will discuss erections at your first post-operative visit.

There are only a few limitations for the first 6 weeks - there are no restrictions after 6 weeks. During the first 6 weeks the wound is rapidly gaining strength and while this occurs the wound is bound together by sutures. You do not want to jeopardize your recovery by having the wound come apart. The deep, strength layer is the critical layer and it is below the level of the skin and is not visible. If you see the skin incision opening slightly you should not be concerned that your abdominal contents will come our (i.e. evisceration). The time following surgery is not the time to undertake major home projects, to undertake a new exercise regime or to test the limits of the surgical repair.

Recovery is different for every patient. Here are some guidelines to help you make good decisions.

For the first 6 weeks after the date of your surgery.

Do not make any commitments that you are unable to or would not want to break (e.g. travel, meetings, work, family events). You are better off ‘opting in’ to activities if you recovery is going well than needing to ‘opt out’ if your recovery is not what you had hoped for.

Post-operative guidance and ‘permissibility’ for specific activities are not things that are to be negotiated with your surgeon - the guidance provided reflects the ability of the human body to heal in response to surgery and are based on based on human physiology and the insight derived from caring for many patients.

While most patients do very well following surgery, appreciate that this is major surgery.

Your ability to move about the house, bathe, cook, etc. will rapidly progress in the first week after surgery. You will not require someone to ‘wait on you’ full time. Some assistance with shopping any potentially doing household chores may be helpful but you can expect to do stairs, bathe and feed yourself.

You may resume driving as soon as you are able to control the car in a safe manner. Most importantly, you must be able to do hard braking or maneuvers to avoid an accident. Most patients can drive 5-7 days after surgery.

Walk as much as you please - you should avoid being sedentary following surgery as this increases the risk of blood clot development in your legs.

As a general rule for activities, if it really hurts, don’t do it - but also don’t assume the converse. If one of the types of ‘prohibited’ activities listed here doesn’t hurt you should not take it as permission to do that activity.

Use your common sense. Do not, under any circumstances, do anything that will or might cause you to over exert yourself and apply undue force to the lower abdominal muscles.

• No heavy lifting (nothing over 30 lbs).

• Do not return to your gym class or ride a bike. Same for hockey, golf, cross-fit, weight lifting, core exercises.

• Do not undertake major home projects or yard maintenance.

• Activities such as putting a golf ball do not qualify as exercise; mowing the lawn does. Again, use your common sense and if doubt, don’t do it.

If you feel a need to ask your surgeon if an activity is OK to do after surgery, this is usually a sign that you shouldn’t do it. Just let your body recover - it’s only 6 weeks.

You may return to cognitive tasks as soon as you feel fit.

Be aware that your surgery may affect your insurance coverage if you choose to travel abroad - check your insurance policy.

Avoid going to an area that has limited accessibility to emergency health care services.

Your ability to return to work will depend on your occupation, the nature of your work and how you recover from surgery.

It is recommended that patients take 6 weeks off whenever possible. This will be absolutely required for patients who perform physically intensive jobs. We appreciate that time off work is an imposition but rest after surgery is critical to a successful outcome.

You should appreciate that every patient will have post-operative pain and that after the catheter is removed they will be wearing a diaper because of incontinence. You are considered legally impaired for 24 hours after receiving a general anesthetic.

Cognitive only work/desk job. Plan for a minimum of 1-2 weeks off of work. Everyone is different.

Physical labor. Minimum 6 weeks. Graded return to full activity with an expectation that you will have an ability to return to full activity.

You may start Kegel exercises once the catheter is removed, however, benefit is limited in the first few months after surgery.

We would be happy to complete any disability or insurance forms for you. You may be charged a nominal fee for this service.

Generally no restrictions, but avoid constipating foods. Drink lots of fluids if the urine has any blood. A laxative is strongly recommended and may be purchased over the counter at a pharmacy.

We well schedule an appointment for you 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 hospital (in ambulatory care) though it may be done in the surgeons office. Bring a diaper.

Do not remove your own catheter.

Only allow the designated person to remove your catheter (urologist or nurse continence advisor).

DO NOT ALLOW ANYONE EXCEPT FOR A UROLOGIST REPLACE THE CATHETER WIHTIN 30 DAYS OF THE SURGERY.

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.

We may send you copies of the pathology report, operative report and an integrated risk assessment prior to your follow-up appointment.

ou 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 (if applicable)

You will need to do your first post-operative PSA 2-3 months after surgery (no sooner). Contact the office to book an appointment for review.

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

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.

• 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).

• Some debris and/or clot is acceptable as long as the catheter is draining.

• Some urgency to urinate and discomfort at the tip of the penis is normal.

• 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.

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.

• 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.

• Apply a lubricant such as vasaline, polysporin or KY-Jelly to catheter where it enters the body.

• 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.

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

• Mild 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.

Worsening symptoms or any symptoms described at the start of this section merit contacting your surgeon.

Take the pain medications as directed. Tylenol (acetaminophen) if often best taken regularly for the first several days. Add an anti-inflammatory (e.g. ibuprofen (Advil), diclofenac (Voltaren) or Celebrex) as needed. Take any of the opioid containing medications if you need them (Tylenol #3, Tramacet) but be aware that they are constipating and should be taken with a laxative.

You may resume any of the medications you were taking prior to surgery.

You should stop any medications you were taking for prostate problems. E.g. Flomax (tamsulosin), Proscar (finasteride), Avodart (dutasteride).

You may resume anticoagulants and antiplatelet medications on discharge from hospital unless otherwise directed by your surgeon.