Comprehensive Urology

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The daVinci System

Delta Medix Patient General Information

Suprapubic or Simple Retropubic Prostatectomy

Definition

Suprapubic = above the pubic bone of the pelvis and through an opening in the bladder

Retropubic = lower than the pubic bone and not through an opening in the bladder

Simple = removal for benign disease process

Suprapubic or Simple Retropubic Prostatectomy (SPP and SRP) are operations that are performed to remove the enlarged center portion of the prostate (referred to as the transition zone). In contrast to the "radical" prostatectomy in which the entire prostate is removed for a diagnosis of cancer, these operations are performed on benign (not cancerous), very large prostates to improve urination.

As men grow older, their prostate gland often enlarges due to an overgrowth of benign tissue(BPH -benign prostatic hyperplasia). Consequently, the center of the prostate obstructs the flow of urine. Patients with bothersome symptoms may be placed on medications to help open the channel or reduce the prostate size. If medication fails over time, or if a patient does not tolerate the possible side effects of the medicine, then a surgical procedure may be the next step. There are minimally invasive office-based procedures (i.e. microwave or thermotherapy)that may be suitable for minimally or moderately enlarged glands. The gold-standard operation(often referred to as a "scraping") is called a TURP (transurethral resection of the prostate).This procedure requires anesthesia and a brief hospitalization. The TURP and the office procedures are done through special instruments (telescopes or special catheters) that are placed in the urethra (tube through which one urinates).

In some instances, it may be better to perform an open procedure through an incision in the lower abdomen. The first instance is when a prostate is so large that one of the other procedures would not work well to remove the obstruction. Another less common reason would be in a patient whose middle prostate lobe (termed the median lobe) is so large that it blocks proper view of the ureteral orifices (holes in the bladder where urine enters from the kidneys). If the surgeon cannot visualize them properly through a scope, they may be injured during a TURP. In addition, patients with large median lobes may also have less satisfactory results with minimally invasive office procedures. The presence of a large median lobe ,however, does not mean that a TURP or office-based procedure cannot be done. Often, they are successful.

Preparation

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. In a patient with no significant medical problems, this may not be necessary for this operation.

*It is definitely to your advantage not to strain to have a bowel movement in the week after the procedure.

We therefore recommend that for the entire week before the procedure, you avoid constipating foods such as rice, bananas and red meat. You should be eating lots of fruits and vegetables as well as oatmeal and cereals. If you have a known problem of constipation, you should consider taking an enema one hour before bed the night before your procedure. You should plan a light lunch and light, early dinner (perhaps around 5:00-6:00 p.m.) the evening prior.
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.

Procedure

The duration of the operation is different for every patient, mostly reflecting difference in each patient's anatomy, but is usually less than two hours.

For the operation, you will be lying supine (flat on your back). 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 often used, but a spinal is acceptable in many circumstances.

This operation is performed through an incision in the lower abdomen. It may be straight up and down in the lower middle of the abdomen or even lower from left to right, depending on the surgeon's preference. We then approach the surface of the bladder and prostate.

In the suprapubic (SPP) approach, the front wall of the bladder is opened and we remove the enlarged center of the prostate through this opening in the bladder. The outer portion of the prostate remains. The bladder is then closed as is the abdominal wall. Prior to closing, a catheter is placed in the bladder and brought out a small hole in the abdomen. A second catheter is already in the urethra and into the bladder from the onset of the procedure. Lastly, a small drain may be placed just outside the bladder and brought out through the skin. The purpose of the catheters is to create a well-drained bladder (continuous irrigation system) to keep small blood clots from accumulating in the bladder.
In the retropubic approach, the incision is made on the top of the prostate, and the enlarged center portion of the prostate is removed without opening the bladder. This procedure often requires only one catheter and may not need a continuous irrigation system. Because we do not open the bladder, we never visualize the ureteral orifices (see above). In patients that have a large, intravesical median lobe, the suprapubic approach is preferred so that we may effectively remove the tissue protruding into the bladder while minimizing risk of injury to the ureteral orifices.

Post Procedure

After the procedure, you will be in the recovery room until you are ready to be moved to a regular room. If you had an SPP, continuous irrigation may be running in through the catheter in your urethra, out through the catheter in the abdomen, and to a bag at the bedside. If you had the retropubic approach, there may be only one catheter in the urethra draining to a bedside bag. In either procedure, there may also be some type of small drain coming out of a separate small hole in the skin. With either procedure, you may have a sensation of urgency (feeling a need to urinate). This results from the catheter(s) causing bladder spasms. Typically, this feeling disappears over the next few days. If necessary, we can give you medication to help minimize these spasms. In either procedure, the drainage in the bags 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 to prevent the formation of blood clots in your veins (deep vein thrombosis or DVT).

A typical hospital stay for simple prostatectomy is less than one week (often shorter for the SRP). This may vary according to particular patient circumstances. It is important to get out of bed the first day and spend time in the chair.

In most instances you may walk the first day with assistance from a nurse or family member.

The timing and sequence for removal of the catheters varies according to the clarity of your urine and the preference of the surgeon. In many instances, a patient might be discharged with one catheter (either from the urethra in patients who had an SRP, or from either the urethra or abdomen in patients who had a SPP).

Upon discharge, you may have no dressing (bandage) on your incision and the catheter (if you have one) will be attached to a small bag that straps to one of your legs. In this regard, 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 a few weeks. Remember, you had a big operation. We typically tell patients that they will be out of work for 2-4 weeks (up to 6 weeks is possible if your occupation requires heavy lifting or straining) and that it may take several weeks more before you truly feel like yourself.

Most patients are very satisfied after the procedure. We typically hear phrases such as "I can urinate like a teenager again." The improvements that are typically noted immediately after the operation are:

  • Stronger force of stream
  • Decreased standing around waiting for the urination to commence
  • Decreased need to push
  • Loss of incontinence (i.e. where the flow used to start and stop and stop and start, etc.)
  • Loss of the sensation that you are "not really emptying your bladder"

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 supplied by a complex network of veins. There is always 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 simple prostatectomy is termed urge-type incontinence (the loss of urine following uncontrolled force). The bladder is a muscle, and like any other muscle, it thickens and gets stronger with more work. Now that the obstruction is gone, it can take weeks or longer for the bladder to readjust. In this period, you might occasionally lose some urine when the bladder suddenly squeezes forcefully against a now open channel. In extremely rare instances, this may never resolve fully. Total incontinence (the constant dripping of urine resulting from damage to the voluntary sphincter) or stress-type incontinence (the loss of urine following coughing, sneezing, lifting a heavy object, swinging a golf club, etc.) are less common following simple 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.
  • Urinary Retention: Sometimes, a bladder that has been severely obstructed for many years can lose its ability to contract (squeeze) properly. If prior testing of your bladder demonstrates reasonable muscle contractility, we may offer a simple prostatectomy as a last resort to get you to empty your bladder. It is possible, however, that even with an open channel the bladder is still unable to fully empty or even empty at all. Sometimes it improves over time, and occasionally never. Patients at greatest risk are those who presented originally with a severe blockage and huge volumes in the bladder, as well as diabetics in which the bladder may have already lost some ability to contract.
    Again, in cases that we are suspicious of this outcome, we may have performed a special test on your bladder (urodynamics) to help predict the outcome. If you remain in retention, you may need to live with a catheter or learn to catheterize yourself once to a few times per day.
  • 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.
  • Bladder Neck Contracture: Sometimes, the neck of the bladder can scar down (weeks to months later) and restrict proper urine flow. This scar can sometimes be opened up with a small scope (minimally invasive) procedure. Unfortunately, this problem could recur and could eventually jeopardize urinary continence.
  • Ureteral Injury: The ureters are the tubes that connect the kidneys to the bladder. 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 quite unusual, a patient's anatomy, excessive bleeding, or scarring from prior procedures may prohibit the surgeon from safely removing the enlarged portion of 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.
  • 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.