THE RADICAL PROSTATECTOMY PAGE

Yana Member Jim Jauchem produced this page which normal resides on his site. Due to an "upgrade" foisted on him by his ISP, his website has been wiped out. He has kindly agreed to allow me to put this on the Yana site until he gets his site back

This page was designed for men who have decided to undergo radical prostatectomy as a treatment for prostate cancer. This page should not be of interest to anyone else (and will not be very "pleasant" to read!)

An early radical prostatectomy to treat prostate cancer was performed at Johns Hopkins Hospital in 1904.  So this is nothing new and lots of men have been through this.

A web site from the University of Pittsburgh Cancer Institute covers the retropubic, perineal, and laparoscopic procedures.  A group in China actually performs a "combined retropubo-perineal prostatectomy" to achieve a better connection between the bladder and urethra (I've never heard of this in the U.S.).  Although I've tried to answer the questions below specifically for the retropubic approach, some of the information is pertinent to the other surgeries.

Questions and Answers on Radical RetropubicProstatectomy:

Q: Do I need to give blood and have it blood-banked before surgery?
A: It used to be common practice to have a patient donate several units of blood prior to surgery.  Many centers are now abandoning this practice.  I did not donate any blood before surgery. Even though I was told that I lost a lot of blood during surgery, it wasn't quite to the point of requiring any transfusions.

Q: Will I have to drink some nasty stuff the day before surgery to clear out my bowels?
A: Since the risk of rectal puncture during surgery is really low, some surgeons have eliminated that requirement.  But I believe most would still want it.  I had to drink "GoLYTELY" the day before.

Q: Will I be completely "out" (anesthetized) during the surgery?
A: A surgeon at Weiss Memorial Hospital at the University of Chicago has stated, "Pain is more effectively controlled by epidural rather than general anesthesia. We believe that if the patient is conscious he can effectively help us to monitor pain."  They also add methadone, and claim that this procedure results in less blood loss, a more rapid return of normal bowel function, and minimizes blood clots and respiratory suppression.  Their patients do appear to be released from the hospital faster (see interview on "drive-through" radical prostatectomy).  But would YOU want to be awake during the surgery (mine took three-and-a-half hours)?  I think not...

Q: Will my lymph nodes be sampled and analyzed before the rest of the surgery proceeds?
A: Some surgeons believe that lymph-node sectioning just extends the time of surgery and increases the chance of complications while waiting for the analysis of the frozen sections.  Depending on your PSA, Gleason grade, and clinical stage, lymph node dissection may be omitted, and the surgeon may simply do a gross inspection of the lymph nodes before proceeding.

Q: How big will my incision be?
A: The incision, in the lower abdomen, generally runs from the pubic bone up close to the navel. Here's a photo of my incision a few weeks afterwards (the dark "bruise-like" area on my far right is where the drain [see next Q&A] was).

Q: Will I have a bunch of tubes coming out of me when I wake up?
A: The surgical area must be drained of excess fluids, such as blood and urine.  While this used to mean several drains from the abdomen (known as "Jackson Pratt" or "penrose" drains), most surgeons now use just ONE drain.  It will be left in place for about three days, or until minimal fluid flows through it.

Some doctors now question the need for pelvic drains after the retropubic procedure, if the bladder neck was preserved.  In my case, however, it seemed like there was still a lot of drainage.

Q: Will I wake up with tight stockings or something on my legs to keep blood clots from forming?
A: One surgical group claims there's no evidence suggesting that "compression devices" lower the risk of clots, so "we decided to eliminate their use."  But it still seems like a good idea; I had a pneumatic-pump device that went to cuffs on both legs (the commonly-used technical term is "intermittent pneumatic compression stockings").  The cuff of the system that I had looks like this:

Q: What if I'm in pain when I wake up?
A: They should let you have morphine.  The easiest way to get this is via "patient-controlled anesthesia".  You can push a button when you want more, and a machine like the one pictured here will give you another dose.  Since morphine can cause nausea and vomiting, they will also periodically give you something like phenergan to decrease that likelihood.

 Q: How long will I be in the hospital?
A: They usually say about two to three days (I was in for three).  But "every patient is different" (and see interview on "drive-through" radical prostatectomy, above).

Q: What determines when I can go home?
A: At the bare minimum (according to most medical professionals), you must: be walking, have pain under control, have a normal temperature, and eat some solid food.  I actually had a bowel movement while still in the hospital (amazing what makes one proud at these times...)

Q: How long do I have to have the Foley catheter in?
A: While two to three weeks used to be standard, some centers are dropping down to ten days (like I had).  Since the urethra will have been re-attached to the bladder at the end of surgery, they want the catheter to stay in place for awhile to allow the new connection to heal.  One of the most recent studies suggests that only seven days is enough.  The fear in "early" catheter removal is that, without it in place as a kind of rigid "stent", a stricture could form (or there could be immediate post-decatheterization urinary retention).  During surgery, they may be able to determine that the anastomosis procedure went well (meaning less of a need for longer catheterization).

Q: Will the Foley "bother" me?
A. "Every patient is different..." I used loads of tape around my thigh to hold it in place.  That way, the one time I forgot that I had temporarily hooked the "bag" somewhere and wasn't holding it with me, when I walked away it didn't hurt.  About 20% of patients have bladder contractions due to the catheter (mine were very painful).  (The bladder's essentially trying to get rid of the catheter.)  These can be minimized by oxybutynin chloride (Ditropan) or belladonna & opium suppositories (wish I'd had some at the time...).

Q: How do I keep the catheter and penis clean?
A: They used to be pretty strict about this, requiring the site at the opening of the penis to be regularly cleaned with 50% peroxide or an antibiotic ointment.  Apparently, someone has studied this and surprisingly found that it doesn't really matter much whatever one does.  I don't have a reference from the medical literature that addresses this specifically, but one did find that the same degree of infection occurred with water vs chlorhexidine cleaning prior to catheter insertion.

Q: Does it hurt when they take out the catheter?
A: "Every patient is different..." (get the picture?).  Some say, "I didn't even know they had taken it out."  Then there are those of us that do NOT enjoy it (but it's over with quickly).

Q: Do you think you did the right thing by agreeing to have a prostatectomy?
A: Bottom line: Yes; at this point, I feel that it was right for me.

Q: Should I go with a surgeon in private practice or with one at a medical school?  What if I don't want residents "practicing" on me?
A: Studies have shown that the "whole team" in the hospital is as important as who has their hands on you the most during surgery.  When I went with a highly-regarded med. school urology department, I was willing to accept the fact that a resident could do a lot of the "hands-on" cutting.  Actually, you could be better off in a teaching hospital with surgery being overseen by a well-experienced surgeon, regardless of the participation of the residents.

Q: Should every patient count on having at least some incontinence for awhile after surgery?
A: I never had any incontinence.  Although I talk to more and more patients with the same experience, the norm would seem to be at least some incontinence, with gradual improvement.

Q: I've heard that some patients end up with "strictures" when the new connection between the urethra and the bladder essentially closes up.  How common are these?
A: In the past, at some centers about 10 to 20% of RP patients developed bladder neck contractures or strictures.  Some centers nowadays, on the other hand, have lower rates of stricture development (and see next Q&A).   Most of those happen within 3 or 4 months of surgery; some within a year of surgery; and a smaller percentage even later (source: British J. of Urology 81:823, 1998).

Q: What difference does it make if the bladder neck is "spared" during surgery?
A: There are data to support the theory that preserving the bladder neck (in addition to helping with continence) helps prevent strictures (e.g., the article listed above, another showing 3% incidence [vs 8% WITHOUT sparing], and one with only 0.5% [in patients without prior transurethral prostate resection]).  I don't think my surgeon has ever had any patients with this condition after sparing the bladder neck.  The article listed above also suggested that tension on the anastomosis from the catheter balloon should be avoided after surgery since it could decrease blood supply (and make tissue healing less than optimal, resulting in more chance of stricture).

Q: Will I be impotent after surgery?
A: Every patient is REALLY different here. In a 2000 paper, "Among men who were potent before surgery, the proportion of men reporting impotence at 18 or more months after surgery varied according to whether the procedure was nerve sparing (66% of non-nerve-sparing, 59% of unilateral, and 56% of bilateral nerve-sparing)."  Thus, although nerve-sparing is often touted as a really big deal, that particular study showed it didn't make a "huge" difference.  The data seem pretty surprising to me.  I've heard most guys (including me) say that after several months they start to see some action, with gradual improvement over time.

Q: Are there are new improvements to radical prostatectomy that I should ask for?
A: The University of Texas Health Science Center at San Antonio is looking at the possiblity of urethral-sparing radical prostatectomy.  This could improve continence (and maybe make stricture less likely, I'm guessing).  So far, it looks like prostate cancer isn't likely to be right alongside the urethra, but there is residual prostate adenoma (benign prostatic hyperplasia) in the length of urethra running through the prostate.  This could release enough PSA to still be detected (and could make follow-up PSA readings difficult to interpret).  But if they can learn more about how to deal with this, sparing the urethra could be a good thing.  (Guess it's a little too early to ask your urologist about this yet; but maybe some day.)

 

Q: What if I think I'm too fat to haveradical prostaectomy?
A: My surgeon was recently involved with a retropubic procedure on a guy over 300 lbs.  A perineal approach couldn't be used, but new techiques for the anastomosis allowed for the retropubic.