What is the prostate surgery called?
Surgery to remove prostate cancer is called a “radical prostatectomy.” Surgery can be performed in the traditional “open” way in which large incisions (cuts) have to be made to allow the surgeon to get to the prostate, which lies deep in the pelvis. This is called an “open radical prostatectomy.” Surgery can also be performed using smaller incisions in which special instruments and telescopes are used to perform the operation. This is “called minimally-invasive surgery.” Minimally-invasive surgery can be performed with the surgeon standing at the operating table holding the instruments and telescopes. This is called “laparoscopic radical prostatectomy.” At Roswell Park we also perform robot-assisted radical prostatectomy. This is a minimally invasive operation that takes advantage of robotic technology.
How should I prepare for my surgery?
When you come to Roswell Park for a consultation there is a lot of information we need to make sure we do the best job possible. The information can include an up-to-date list of your medications, previous surgeries, allergies, and current medical conditions.
Before surgery we require that you hold any aspirin or Plavix®, herbal supplements and vitamins (as long as your primary care doctor allows) for at least 1 week. 5 days prior to surgery: discontinue Coumadin® (warfarin). 3 days prior to surgery: discontinue all non-steroidal anti-inflammatory medicines such as ibuprofen. On the day before surgery we recommend drinking clear liquids. We then need you to not eat or drink anything after midnight on the day prior to surgery. You can take your morning medications the day of surgery with a sip of water.
How long is my surgery, and how long do I stay in the hospital?
The amount of time the surgery takes can varies between patients but is on average 3 hours. If lymph nodes need to be removed surgery can take longer. Below is a graph of the time on average the operation has taken over the past 6 years. Our operative times have been consistent for the past four years. In this graph “mean” is a mathematical way to say average. In a large series of patients having prostate surgery, those patients who had minimally-invasive radical prostatectomy were in the hospital for approximately 2 days. Patients who had an open prostatectomy were in the hospital for approximately 3 days. In our robotic experience, at Roswell Park, the majority (93%) of patients are discharged from the hospital the day after surgery.
What else is removed with my prostate?
Open or robot-assisted radical prostatectomy includes removing the prostate gland and the seminal vesicles. Sometimes, depending on how aggressive the cancer is, the lymph nodes near the prostate are removed as well. One consequence of removing the prostate and seminal vesicles is loss of ejaculatory fluid.
The nerves that cause the penis to become erect are adjacent to the prostate gland. Sometimes we leave the nerves behind (nerve sparing) and sometimes they are removed with the prostate (non-nerve sparing). Like most things in the body there is a right and left nerve. Depending on the aggressiveness and location of the cancer the surgeon may decide to leave one, both or no nerves behind. This can impact a patient’s ability to have an erection after surgery. Only 0.3%, (3 patients in 1000 per 100 person years) at Roswell Park had to undergo extra surgery for treatment of erectile dysfunction.
What do I go home with?
Catheter and urinary drainage bag
Urine empties from the bladder, passes through the prostate and continues through the urethra to the tip of the penis. When the surgeon removes the prostate and hence the part of the urethra that passes through the prostate, the remaining urethra is sutured (sewn) to the bladder. In order to let the tissues heal a catheter is placed in the urethra and into the bladder to allow urine to drain. This catheter will stay in until the follow-up visit with the surgeon, usually 9 -10 days after surgery. The catheter drains into a bag, which can be fastened to the leg. Urinary bags usually need to be emptied every 4-6 hours. Larger bags can be used while you sleep.
It’s unusual to require pain medicine when you leave the hospital, but we prescribe a small amount of pain medicine just in case.
Pain medicine, which contains narcotics (morphine is an example), can make you constipated. Stool softeners often help.
In order to prevent a urinary infection when the surgeon takes out the catheter, we prescribe an antibiotic for you to take the day before and the day of your first follow-up appointment.
When will I follow up with my doctor?
Upon discharge from the hospital a follow-up appointment is typically 9 to 10 days after surgery. At this appointment we discuss the results of the surgery. From this we can determine whether additional treatments may be needed and whether there were “positive margins.”
During this appointment we also remove the catheter that has been draining urine since the operation. Remember to take your antibiotic!
Are there any alternatives to surgery?
Treatment alternatives to open or robotic surgery include radiation therapy and cryotherapy. Radiation can either be delivered by a radiation machine (this is external and requires multiple consecutive visits as an outpatient) or by having radioactive seeds implanted into the prostate. Cryotherapy is a short surgical procedure in which the prostate is frozen with special probes. Another option specifically for low risk prostate cancers is to observe the prostate cancer, also known as “active surveillance.” Many prostate cancers are so slow growing that they never cause a problem.
If you choose to have surgery for your prostate cancer the surgeon (urologist) will discuss the different ways to perform the operation.
What will happen in the weeks after surgery?
At your first clinic visit, approximately 9 to 10 days after your surgery, you may have your catheter removed. After it is removed you will be asked to pass your urine and stop and start your stream. Your pathology report will be available and your urologist will review it will you.
It may take some time until you feel comfortable controlling your urine output and preventing leaks. Doing your Kegel exercises will help. You probably will need protective pads for your undergarments, at least for several weeks.
Complete control is the goal but it takes time. You will notice an improvement when you can walk without leaking, and then stand without leaking, and then do regular activities. The following tips will help.
- Drink most of your fluids during the day and stop drinking after dinner. Take sips until bedtime to keep hydrated to cut down on nighttime trips to the bathroom.
- Avoid alcohol, caffeine or any medicine that causes an increase in urine output.
- Pass urine every 3 hours during the day and always stand to urinate.
- When you pass urine, stop your stream 2 to 3 times.
- Continue your Kegel exercises.
- Small amounts of blood and small clots are usually passed for about 1 month after surgery.
- Some burning is common when you urinate for the first week after the catheter is removed. If this occurs with a fever, call your doctor.
Several visits will follow to test your urinary control, sexual function and PSA.
How do I know if my cancer has come back?
PSA. It is possible your doctor used a blood test called a PSA to help diagnose your cancer. PSA stands for prostate-specific antigen, a protein produced by the prostate gland. The PSA test measures the level of this substance in the blood. High levels of PSA can be caused by prostate cancer, prostate infection or just by having a large prostate.
The same test is used after treatment for prostate cancer to monitor for cancer recurrence. If you are cancer-free, the PSA levels should be low or even undetectable. PSA is checked regularly after surgery, typically every 6 months to 1 year for 5 or 10 years depending on your particular situation.