Radical = removal of an entire organ and surrounding tissue
Prostate = the organ in the male that produces part of the ejaculate
Ectomy = removal of
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) and a portion of both vas deferens (tubes that transport sperm from the testicles to the urethra).
In certain instances (that we discussed in your prior consultation) it may be necessary to remove lymph nodes from one or both sides of the pelvis. Lymph nodes are small glands associated with virtually every organ in your body. Their role is to filter infectious cells or cancer from the organ with which they are associated. If there is a high likelihood that the cancer has already spread to these glands, then removing lymph nodes at the very beginning of the operation, and finding out that they contain cancer, may stop a surgeon from removing the prostate. In other words, removing the prostate at that point may not likely result in a cure. There are instances in which we would continue the operation with positive (cancer containing) lymph nodes, and this has been discussed in your surgical consultation.
Radical prostatectomy may be accomplished through a "retropubic" approach in which a short incision is made from just 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" approach (multiple small incisions with placement of only a camera and small instruments, and not the surgeon's hands, in the pelvic cavity). If this is the case, you will receive a supplement to this educational piece fully describing laparoscopic surgery. There are advantages and disadvantages to each approach, and the decision will reflect a combination of your thoughts combined with the preference and experience of the surgeon.
The reason we perform this operation is to cure the patient of prostate cancer. In other words, when we do this operation, we make the assumption that the cancer is still in the prostate and has not traveled out beyond the walls of the prostate or to distant areas in the body. Despite all modern technology, there is no way to guarantee this before the operation. Our decision to proceed is based on a combination of any of the following depending on your particular circumstances.
- The prostate specific antigen or PSA value (prostate blood test) and the way the prostate feels on digital rectal examination (DRE)
- The grade of the cancer: This is a scoring system (called the Gleason score) that pathologists (doctors who examine the biopsy specimens) use to determine how aggressive a specific tumor may be
- A bone scan (special nuclear x-ray of the entire skeleton) if it is indicated
- A CT scan (computerized tomography) or MRI (magnetic resonance imaging) when they are indicated. Neither of these sophisticated tests are very accurate in helping to stage (determine if cancer is localized or spread) prostate cancer.
There are instances when we may suggest radical prostatectomy even when we know that there is a high likelihood that the cancer has already begun to spread beyond the prostate. Although not curative, it would be to try to achieve "local control" of the tumor. Your surgeon will have discussed the uncommon circumstance with you.
Radical prostatectomy is an involved operation. Because anesthesia time can be prolonged, we may send you for an updated general physical and note of "medical clearance" from your primary physician. This is precautionary and for your own protection.
As with any procedure in which anesthesia is administered, you will be asked not to eat or drink anything after midnight on the evening prior to your surgery. You may brush your teeth in the morning but not swallow the water. If you are on medications that must be taken, you will have discussed this with us and/or the anesthesiologist and instructions will have been given to you. 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 ("blood thinners, aspirin, anti-inflammatory medicines, etc."). The most common of these medications are aspirin and all related pain relievers or anti-inflammatory compounds (whether prescription or over-the-counter). Please refer to the attached list and tell us if you took any of these within the past 10 days. If your new medication is not on the list, alert us immediately so that we may ensure optimal procedure safety. We will have reviewed all of your current medications with you during the pre-operative/pre-procedure consultation. You are obligated to inform us if anything has changed (medication or otherwise) since your previous visit.
We may ask you to clean out your colon the night before. You should plan a very light lunch and light, early dinner (perhaps around 5:00-6:00 p.m.) the evening prior and avoid vegetables or other foods that typically cause gas. Approximately two hours before bed, you will give yourself an enema and repeat a second enema approximately one hour before bed. Colon cleansing has many variations and your surgeon will choose the agents and the time of administration.
The duration of the operation is different for every patient, mostly reflecting difference in each patient's anatomy. The general range is less than three hours (but longer is possible). Surgical time is often longer when the procedure is done laparoscopically.
Your position on the table will depend on the approach, but most patients will be lying supine(flat on their back). In the perineal approach, your legs will be elevated in stirrups (much like the position for an exam at the gynecologist). The type of anesthesia used will reflect the suggestion of the anesthesiologist as well as contributions from your preferences as well as that of your surgeon. General anesthesia (complete sleep) is typically used, but a spinal is acceptable in many circumstances.
If your operation is being done through an abdominal incision, the first part involves inspecting (by vision and touch) the lymph nodes in the pelvis that drain the prostate. In most circumstances, we will have told you whether or not we intended to remove the nodes. If our suspicion changes for any reason, we may decide to remove the nodes even though we previously may have told you we didn't believe we would need to. Our decision to proceed with the remainder of the surgery may depend on an immediate report from the pathologist (a quick interpretation of tissue called a frozen section) as well as on our discussion in the preoperative consultation. 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 reattach the bladder to the remaining urethra. This is a crucial part of the operation. A catheter is placed across this reattachment and will remain in place for several days to a few weeks depending on your anatomy and the preference of the surgeon in your case. In this regard, your urine drains through this tube into a bag.
Another part of the operation that is always discussed is the "nerve sparing procedure." We are referring to the nerves that control your ability to get erections. While carefully sparing the nerves is appropriate in many patients, in others, it could compromise the dissection of the cancer. As we discussed in your consultation, we may attempt to spare nerves on both sides, one side, or not at all. You should realize that very often, a nerve sparing procedure does NOT guarantee that you will be able to achieve adequate erections.
After the procedure, you will be in the recovery room until you are ready to be moved to a regular room. 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 bloody for a few days. Both are normal findings. You may also have boots on your legs that inflate and deflate (intermittent squeezing) to help prevent the formation of blood clots in your veins (deep vein thrombosis or DVT). There may also be small tube(s) in your abdominal wall that are called drains. These will be removed in the next few days depending on your surgeon's preference and your progress.
A typical hospital stay for radical prostatectomy is 2-3 nights. We have had rare instances of patients staying only one night as well as occasions when patients have stayed longer. It is important to get out of bed 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 it to a larger bag for overnight use when you are sleeping. It sounds complicated but is quite easy...we assure you.
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 bowel movements. Other medications are rarely necessary but depend on your particular needs.
Expectations of Outcome
It is normal to feel a bit tired or weak for 2-3 weeks. *Remember, you had a big operation. We typically tell patients that they will be out of work for 4-6 weeks (up to 12 weeks is possible if your occupation requires strenuous activity) and that it may take several weeks more before you truly feel like yourself. While we will be able to tell you about our findings during surgery, you must understand that the specimen will be evaluated by the pathologists. They carefully examine the entire specimen under the microscope. It may take a week before we have an official report to discuss with you. Of course you will be anxious, but we encourage you to be as patient as possible. use that week to concentrate on your recovery.
*Because of the organs removed, men will no longer be able to ejaculate any fluid if orgasm is achieved.
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. While we have discussed these and possibly others in your consultation, we would like you to have a list so that you may ask questions if you are still concerned. Aside from anesthesia complications, it is important that every patient be made aware of all possible outcomes which may include, but are not limited to:
- Blood Loss/Transfusion: The prostate is surrounded by a complex network of veins. Some blood loss expected. In some instances, blood loss is more severe and necessitates a transfusion.
- 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.). With a good operative result, the average patient has occasional and minimal stress incontinence. There are patients that are perfectly continent regardless of stress, but this is not the most common outcome. Regardless, the degree of stress incontinence is usually minor, and does not interfere with resumption of normal activities. Total incontinence (the constant dripping of urine) or urge incontinence (the loss of urine following uncontrolled bladder spasms) are less common following radical prostatectomy. The incidence of incontinence is greater in the rare occurrence of injury or disruption of the anastomosis (pulling apart of the surgical connection of the bladder to the urethra).
- Impotence (Erectile Dysfunction): You will have discussed with your surgeon whether or not a "nerve-sparing" surgery is going to be attempted on one side, both sides, or not at all. 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. This is not always possible. Although this has been discussed in greater detail in your consultation, we reiterate that following radical prostatectomy, most patients may need some form of therapy to assist with erectile function. Many patients will also notice that the penis is shorter after radical prostatectomy.
- Urinary Tract Infection or Urosepsis: Although we may give you antibiotics, it is still possible for you to get an infection. It may be a simple bladder infection that presents with symptoms of burning urination, urinary frequency and a strong urge to urinate. They will usually resolve with a few days of antibiotics. If the infection enters the bloodstream, you might feel very ill. This type of infection can present with both urinary symptoms and any combination of the following: fevers, shaking chills, weakness or dizziness, nausea and vomiting. You may require a short hospitalization for intravenous antibiotics, fluids, and observation. This problem is more common in diabetics, patients on long-term steroids, or patients with disorders of the immune system.
- Wound Infection: As with any incision, an infection
can occur. This would present with redness, swelling,
and/or drainage (white to yellow thick fluid) from
the incision site. Usually, these are easily managed
with antibiotics and local wound care. In some instances,
an area of the superficial (upper layer) incision
needs to be opened for adequate drainage.
*If you have symptoms suggesting any of the above after your discharge from the hospital, you must contact us immediately or go to the nearest emergency room.
- Bladder Neck Contracture: As mentioned, the bladder is reattached to the remaining urethra (anastomosis). 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 jeopardize 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.
- Lymphocele: 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 and may compress nerves (causing weakness in the leg) or blood vessels (increasing the risk of a deep veint hrombosis). Typically, the first sign of a pelvic lymphocele is ankle and foot swelling on the same side of the lymphocele. 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 occur and can usually be repaired quite easily and quickly. It is 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.
- Ureteral Injury: The ureters are the tubes that
connect the kidneys to the bladder. If the cancer
extends toward the bladder, or if the prostate is
quite large inside the bladder, the dissection can
be near the ureters.
An injury to the ureter can usually be fixed right there and usually has no long-term effects. Other procedures are less likely, but could be necessary in the future.
- Inability to Remove the Prostate: Although unusual, a patient's anatomy, excessive bleeding, local spread of the tumor, or scarring from prior procedures may prohibit the surgeon from safely removing the prostate.
- Chronic Pain: While quite unusual, any patient can develop chronic pain in an area that was subject to surgery. The cause is not always forthcoming. While this usually resolves with time, consultation with a pain specialist may be necessary.
- Obturator Nerve Injury: The obturator nerve is located in the same area as some of the lymph nodes that are removed in this operation. Injury to this nerve would present with a specific problem with leg motion on that side (specifically close your legs together).
- Death: 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.
We provide this literature for patients and family members. It is intended to be an educational supplement that highlights some of the important points of what we have previously discussed in the office. Alternative treatments, the purpose of the procedure/surgery, and the points in this handout have been covered in our face-to-face consultation(s).
The information contained in this document is intended solely to inform and educate and should not be used as a substitute for medical evaluation, advice, diagnosis or treatment by a physician or other healthcare professional. While Delta Medix endeavors to ensure the reliability of information, such information is subject to change as new health information becomes available. Delta Medix cannot and does not guaranty the accuracy or completeness of the information contained in this document, and assumes no liability for its content or for any errors or omissions. Please call your doctor if you have any questions.
Delta Medix, P.C.