Radical Prostatectomy

The operation to remove prostate cancer is called a “radical” prostatectomy, or, more properly, a total prostatectomy. This article is written to provide you with answers to the questions many patients and their families ask about the operation.  The answers we are presenting are the best we have today, but our understanding of prostate cancer and its treatment is constantly improving.

Radical prostatectomy means removal of the entire prostate and seminal vesicles (the pouches attached to the prostate that store the seminal fluid) and the tissue immediately surrounding them. Because prostate cancer is scattered throughout the prostate gland in an unpredictable way, removal of any part of the prostate would leave cancer cells behind.  The pelvic lymph nodes that filter the lymphatic fluid from the prostate are usually the first site of any spread of the cancer beyond the prostate gland.  Normally, these lymph nodes are also removed during the operation.  Fortunately, you have many other lymph nodes, so your body will not miss these few.

Preparations

Blood Donation. Donation of your own blood is not necessary. A blood transfusion with this operation is extremely rare.

Medications. You should stop taking aspirin and other anti-inflammatory drugs 2 weeks before the operation.  These medicines are mild blood thinners and slow the clotting of your blood.

Anaesthetists review. You may come to see the anaesthetist before the operation. Normally, we will obtain routine blood and urine tests, and ECG prior to or on the day of surgery.  A stress test is sometimes performed for men over 60 years of age.  Bring the results from your doctor if these same tests were performed recently.

Diet and Exercise. Maintain a regular diet and exercise program until the day before the operation. Take nothing by mouth after midnight the night before.  Pelvic floor exercises should be performed prior to surgery and instructions are provided for you in this booklet and.  Please discuss this with our practice nurse if any further tuition on this important aspect of pre-operative care is required.

Anaesthesia. You will come to the hospital the day of the operation (we will give you exact instructions). Pain control for a day or two after the operation is with a longer acting pain tablet taken by mouth which allows a constant level of pain control with the ability to ask for an extra dose as required for activity and so forth. You will be able to obtain a dose of a fast acting tablet simply by asking the nursing staff.

Family. Your family and friends can stay with you until you are moved to the operating theatre.  They will then be directed to the waiting area.  When the operation is completed, your surgeon will talk with your family about the operation and answer their questions. They can visit you once you are awake.

The Operation

Although the operation takes about 2-3 hours, you will be in the operating theatre for 1-2 hours longer because of the anaesthesia and preoperative measures. The primary purpose of the operation is to cure the cancer by removing it completely, while preserving your normal bodily functions as much as possible.

For open surgery the operation is performed through a small 8cm, up-and-down incision made from below your belly button to your pubic bone. First, we will remove the lymph nodes in the pelvis that are usually the first site of spread of the cancer. Unless there is extensive cancer in these nodes, we will proceed with removal of the prostate itself. Relying on all the information obtained before the operation and the look and feel of the tissues during the operation, we decide how much tissue must be removed around the prostate to completely excise the cancer while preserving normal sexual and urinary functions as much as possible.

It is critically important to ensure all of the cancer is removed and that the “margins” of the prostate are negative. A recent independent audit of our results indicated that our positive margin rate was below 4% indicating that the vast majority of patients are cured. This low margin rate is amongst the lowest reported in the literature indicating that the primary goal of curing the cancer has been achieved in the largest number of patients possible.

Once the prostate and seminal vesicles are removed, the nerves responsible from erections are inspected. If one or both nerves have to be resected, they may be replaced by a nerve graft taken from your foot or from a nerve within the open pelvis. A nerve graft remains a new technique which we are investigating and your surgeon will discuss this with you prior to the operation if you are suitable. Finally, the urinary tract is sutured back together over a specially coated catheter. One or two additional suction drains are left beside the bladder deep in the cavity to drain any fluid that accumulates. The drains decrease the risk of infection and pressure from any fluid that might accumulate in the operative bed.

For robotic assisted surgery, the same procedure is performed in a minimally invasive fashion utilising tiny instruments inserted through tiny incisions above and beside the belly button. The urinary tract is reconstructed and the prostate removed through the belly button incision leading to less pain, faster recovery and faster return to normal activities. Robotic surgery is discussed further below.

Recovery

Length of Stay

Our length of hospital stay is 3 days on average for open surgery and 2 days for robotic assisted but you may elect to stay longer if you wish. Currently time to return to normal activities is 9 days, to driving is 2 weeks and to full activities is 4 weeks regardless of the approach.

A recent study from the USA has shown no difference in these key parameters of recovery regardless of whether patients have had surgery via the open or robotic approach.

The Catheter

When you leave the hospital, you may still have the urinary catheter in place. Prior to discharge, you will be told how to care for the catheter when you are home. Generally, the catheter, which is held in place by a water-filled balloon on its tip, is left in about 1-2 weeks after the operation, but a few days more or less will not matter. This gives the anastomosis, or union between the bladder and the urethra (the urinary channel), time to heal completely. We now offer to remove the catheter in some patients prior to discharge from hospital if you wish. An x-ray will be performed prior to removal of the catheter if you are suitable. 90% of patients have their catheters removed within 7 days of surgery usually as an outpatient.

You can wear a urinary leg bag during the day, but at night a larger bedside bag is better. It will not overfill and allow the urine to back up into the bladder while you are asleep. Some leakage of urine or blood-stained fluid around the catheter is not unusual. It is also not unusual to notice a pink or red tinge to the urine after you have been walking or after you have had a bowel movement. Avoid being alarmed, simply increase your fluid intake and rest until the urine becomes clear again. You may also experience “bladder spasms,” a sudden and, at times, intense cramping pain in the lower abdomen and penis with an urgent need to urinate.

These spasms usually lessen with time, but if they are bothersome, they can be treated with a bladder relaxant medication such as Ditropan or Vesicare pills. These pills often cause a dry mouth and some other minor side effects.

You may develop some swelling of the scrotum and penis after surgery, which will resolve in time. You can hasten reduction of the swelling by elevating the scrotum on a rolled towel while sitting down and by wearing briefs, as opposed to boxer shorts, while walking.

The Incision and Your Activity

One drainage tube is inserted during the operation, this is situated next to your incision this drain is designed to remove all the wound fluid that accumulates beside the bladder after the operation. Normally, the drain is removed 1 or 2 days after the operation, but it may be left in longer, depending on the amount of drainage. While in hospital the dressing to your wound will be left intact and changed as necessary.  It will be removed on the day of discharge.

Clean the incision itself with soap and water. You may shower at any time. Usually, the main incision and the small drain sites on each side are dry and require no dressing. It takes 4 weeks for the abdominal incision to heal completely, so you should avoid heavy lifting (over 10 kilos) or straining during that time. Daily exercises such as walking, climbing stairs, or swimming will help you recover faster, but wait 4 weeks before beginning heavy exercise such as jogging, weight lifting, or golf with a full swing. Your perineum (the area between the scrotum and anus) may be tender for several weeks or months, so avoid sitting on anything hard or pointed like a bicycle seat, and do not ride a motorcycle or a horse until the tenderness is gone. Some men feel fullness or tenderness in the rectum, as though they have to have a bowel movement. The prostate gland lies just above the rectum, so this sensation is to be expected and usually will go away with time.

You may return home in a car or aeroplane, but you should preferably not drive for 2 weeks or as long as you have any pain or you are taking pain medications stronger than paracetamol, aspirin or panadeine. Avoid sitting with your feet on the floor for more than 15 minutes at a time. Get up and walk, stretch your legs, or keep your feet propped on a stool as much as possible. If you return home by plane, walk in the cabin area every half hour. Avoid standing still for more than a few minutes at a time. Sitting and standing still slow the circulation in your legs and predispose you to a blood clot. Notify the hospital immediately if you notice swelling in your feet or ankles or tenderness in your calves or thighs or if you become short of breathe or cough up blood.

Generally, you can return to work about 2-4 weeks after the operation. If your work requires heavy physical activity, you may need a longer period of recovery until all the soreness disappears from the incision and the urinary control is satisfactory. You should be comfortable with desk or office work within 2 weeks — once the catheter is out and you feel confident with the urinary pads. After your return home, do not plan any long trips for 6 weeks after the operation to avoid prolonged sitting.

Diet and Intestinal Function

After the operation, you can have ice chips and water as soon as you are fully awake, progressing to a clear liquid diet that evening or the next morning.  You can try solid food 12-24 hours after the operation, when your intestinal activity begins to recover.  Most people do not pass flatus (intestinal gas) for 1-2 days and do not have a bowel movement for 4-5 days.

When you return home, you may resume your normal diet.  Since you will be a bit anaemic after the operation, it is a good idea to eat a lot of red meat, spinach, and other foods rich in iron for the first month or two.  Iron pills are usually not necessary and may cause troublesome constipation, but they are sometimes necessary if the anaemia is severe. Avoid constipation by taking a stool softener, such as Lactulose, twice a day. Drink plenty of fluids.  Metamucil is an excellent natural stool softener as well.  It is very important that you do not strain to have your bowels open as this will cause excessive blood in the urine and prolong your recovery.  You will be given Lactulose or Movichol to take home with you and use as required.

A major operation can predispose you to heartburn and indigestion from excess stomach acid.  Let our team know before the operation if you have a tendency to these problems and do not hesitate to take a medicine to control heartburn such as Zantac, Nexium or Losec or use an antacid such as Mylanta if you have these symptoms.

Urinary Control

Most men will have some urinary leakage for a few weeks after the catheter is removed.  You need to purchase Tena for Men Level 2 pads which may be obtained from your local supermarket or chemist.  If incontinent change the pads regularly.  In our experience many men regain control immediately, but the average man takes about 6 weeks to regain satisfactory urinary control to be free of any pads.  Try to keep your skin dry.

You will notice that during the night, when you are lying down and the effect of gravity on the urine in your bladder is less, your control will be better than when you are up and about during the day.   You will likely have more leakage with straining, coughing, or reaching down to lift something (stress incontinence).  The leakage will gradually decrease over time and almost always stops. By 6 weeks half of all men will have regained urinary control, by 6 months 8 of 10 will be essentially normal, and by 1 year 95% will have good control and not require pads at all!!.  Only about 1 in 100 men will have a serious problem with urinary leakage after 1 year. Excellent options are now available for patients who have persistent leakage and are bothered. Our unit has extensive experience in the male urethral sling (InVance or AdVance systems and the new Virtue Male Sling) which is highly effective with excellent patient satisfaction for these patients with this unfortunate side effect. The chance of recovering urinary control depends on your age, whether the nerves were preserved, and whether you develop a rare stricture (or narrowing) at the anastomosis (where the bladder is sewn to the urethra).

Some men notice frequent urination for the first few months after the operation.  The bladder takes time to fill out again after it has been kept empty by the catheter for 1 or 2 weeks.  As the bladder is able to hold more urine at lower pressure, your control will improve.  Sometimes a prescribed medicine helps the bladder relax and hold more urine.

Some men continue to have mild leakage (stress incontinence) when they exercise vigorously even several years after the operation, especially if the bladder is full, or they become tired, or they drink alcohol.  You may need to wear a small pad in these situations.

Rarely, urinary control will not become satisfactory even after a year.  If so, remember that something can be done.  Although seldom needed, placement of a male sling or artificial urinary sphincter will almost always restore satisfactory control.  In our experience which extends to several thousand patients we have not had to place an artificial urinary sphincter in any patient.

Pelvic Floor (Kegel) Exercises and Pelvic Floor Physiotherapy.  The operation removed your prostate and bladder neck, the main (internal) sphincter muscle responsible for holding in the urine.  Now the secondary (or external) sphincter muscle has to take over the job.  You might help this muscle by performing pelvic floor exercises.  Try to identify and control the muscle you tighten to stop the urinary stream and then relax to let the urine flow again.  Exercise this muscle over and over again. A/Prof Cozzi has a rigorous rehabilitation programme which includes referring you to an expert pelvic floor physiotherapist before surgery for biofeedback training to aid you with these exercises. We have an expert pelvic floor physiotherapist in Neutral Bay for our North Shore patients and at Sans Souci, conveniently for our St George and Sutherland Shire patients. There are detailed instructions provided for you to remind you of the correct technique. Develop a pattern, as you would for any other type of exercise, working this muscle regularly throughout the day.  These exercises alone will not bring about urinary control, but they will lessen the amount of leakage and hasten the day when your control returns to normal.  Younger men tend to regain control earlier than older men, but everyone is different. Be patient and don’t get discouraged!

Sexual Function

The operation will affect sexual function in several ways, but it does not prevent you from enjoying a rich sex life when you recover.  Sexual function in men has three components:  erection, ejaculation, and climax (orgasm).  Although these three normally occur together, they are separate and independent functions.

Seminal fluid expelled during ejaculation is made and stored in the prostate and seminal vesicles, therefore, removal of these organs means that a climax will be accompanied by a sensation of ejaculation but no fluid will come out (dry ejaculation).  The vas, which transports the sperm, is now divided so you will not be able to father children.  Some men notice a small amount of fluid from the glands within the urethra (urinary channel), and occasionally, more fluid is released from the bladder with ejaculation.  If this is troublesome, a condom can afford protection.

Erection of the penis occurs because of the stimulation through the cavernous nerves, which send signals to dilate the blood vessels in the penis allowing it to fill with blood and become rigid.  The two nerve bundles responsible for erection run along either side of the prostate, only a few millimetres away from the area where prostate cancer most commonly arises.  Unfortunately, cancer cells tend to migrate toward the main cavernous nerves along the branches that penetrate the prostate.  Although preserving these nerves at the time of surgery is always possible, it is not always wise.  The less tissue removed around the prostate, the greater the chance cancer cells will remain.  Since the primary goal of the operation is to remove all of the cancer, one or both of these nerves may have to be resected in some patients. Unless both nerves are resected, the chance of recovering erections definitely exists, but recovery may be slow. The average time until recovery of erections sufficient for intercourse is 4 months, but in some men it takes longer. Erections usually improve with time, for as long as 2-3 years after the operation, because nerve fibres grow slowly.  Of course, the operation will not make your erections better than they were before surgery, even if both nerves are spared!  Even with full recovery, most men find the erections a bit less firm and durable than before.  Younger men recover sooner than older men; those with stronger erections before the operation have a better chance of recovery than if the erections were weak.

Our independent questionnaire based follow up would indicate that over 80% of men will recover erectile function with good surgical technique and appropriate rehabilitation.

Our surgeons employ newer techniques to improve potency recovery including improvements in nerve sparing with optical loupe magnification for open surgery and the very latest technology for robotic assisted surgery to minimise injury to the nerve bundles particularly from thermal and traction injury.

Integral to both and supported by the literature is state of the art penile rehabilitation.

A/Prof Cozzi has developed, based on his training in New Yorkat Memorial Sloan Kettering Cancer Center, a very intensive rehabilitation programme for return of erections in patients after surgery. This approach, including the use of Viagra tablets before surgery with early post-operative use followed by penile injections if recovery does not occur has been shown to be superior to use of tablets alone.  The more effort we take to recover erections the more likely it is to be successful and we will guide you personally through this process.  We offer the services of a relationship counsellor and sex therapist and encourage you and your partner to visit with her to discuss these issues.

A/Prof Cozzi worked extensively with and has co-published scientific papers with Dr John Mulhall, a world leader in penile rehabilitation after surgery. We feel very strongly that only the surgeon has the knowledge and experience to optimise the rehabilitation of his patient and for that reason we do no not delegate this important responsibility to another doctor as occurs in other units.

You may try sexual activity as soon as the catheter is out and your urinary control is satisfactory.  Do not be afraid to experiment.  Sometimes different approaches work better after the operation than before.  For example, erections may now respond better to physical stimulation than to mental arousal.  You cannot hurt anything by trying.  Remember, cancer is not contagious and presents no danger to your partner.

Nerve Grafts.  The chance of recovering workable erections also depends on the amount of nerve tissue preserved.  If part or all of one nerve has to be removed, recovery will be slowed and full recovery less likely than with complete preservation of both nerves.  Consequently, we are studying the advantages and disadvantages of using a nerve graft to replace any nerves resected during the operation. Recent data with longer follow up suggests this approach may be beneficial.  The decision to use a nerve graft should only be made after careful consideration of all the pros and cons.

Treatment for Erectile Dysfunction. Several practical methods are available for assisting erections; the most popular and widely known is the pill, Viagra® (sildenafil).  Studies now recommend that you begin using one of these methods before and as soon after your operation as possible and particularly before continence has returned.  By stimulating erections in the early weeks after the operation, you are more likely to recover better erections sooner than if you simply wait for erections to return on their own.  Healthy functioning of the penis seems to require regular, frequent erections, which may be why men normally have erections off and on during sleep.  In addition to Viagra, Levitra and Cialis tablets, effective measures to aid erections include the injection of medications such as Caverject (alprostadil) or a mixture of drugs that dilate the blood vessels (Trimix), and the vacuum erection device (VED).

Generally, Viagra, Levitra and Cialis will not give you a full erection until you begin to have some fullness of the penis or partial erections on your own.  However, injections work in most patients regardless of any spontaneous partial erections you are having.

If none of these prove satisfactory, you can also try the vacuum erection device (VED), which can be ordered directly from the company.  If none of these conservative options prove satisfactory after a few years, a penile prosthesis can be used to restore erectile function with over 90% satisfaction to the patient and his partner.

A/Prof Cozzi’s Instructions for the use of Viagra, Levitra and Cialis

Pre-operative Viagra

Viagra is the only drug of the three with evidence for its use before surgery. Dr Cozzi’s “rule of 2’s” should apply ( we will give you a script and where possible free samples) –

2 weeks pre-op

2 Hours before dinner

½ a tablet (100mg dose)

Twice per week

Post-operative Viagra, Levitra and Cialis

Remember that all three drugs are similar and therefore have similar side effects- stuffy nose, headache, facial flushing, muscular ache and pains and reflux or heartburn.

The drugs differ in the amount of time in the blood stream- Cialis is active for up to 36 hours, Viagra 8 hours and Levitra 4 hours. Viagra and Levitra are preferably taken on an empty stomach with no alcohol.

Higher doses may be required in the initial post-operative period and intermittent use of injections is also encouraged. There is debate about daily dosing or “on demand” dosing and your surgeon will advise you as to the latest evidence in this area.

Future Checkups and Further Treatment

Arrangements will be made prior to you leaving the hospital for removal of the catheter. If this has not occurred, please call our office at 02 9570 5510 to make arrangements to have the catheter removed about 10 days after the operation.  We will send full details about your treatment to your GP or urologist.

In our practice we mandate a program of regular checkups for 5-10 years. One week before you return for a 6 week post-operative visit, you should have a blood sample drawn for a PSA test.  We expect the PSA level to be undetectable or “less than 0.1 ng/ml” if the cancer has been completely removed.  Please plan to have your PSA measured and to return here 6-8 weeks after the operation so we can discuss the final pathology report, review your PSA result, evaluate any problems with your recovery, and determine whether further therapy should be considered.

A/Prof Cozzi has a strict follow up protocol of check-ups at 3 months, then every 6 months for the first 2 years after the operation and annually until 5 years have gone by.  If the PSA is < 0.01 at 2 years almost all patients can be considered cured long term.

If your checkups will be performed by your own doctor, please ask that the PSA results and any other important information be sent to our office so we can keep your records up to date.  If possible, we would like you to return here each year for a check-up.  If not, our office will contact you each year for a progress report.

Please let us know if things are not going well.  The best way to reach us during the day is through our office on 02 9570 5510 or you may speak to our practice nurse.  After business hours please call the hospital at which you had your surgery and our nurses will contact your surgeon urgently.

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