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.
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.
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.
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:
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 UUANJ endeavors to ensure the reliability of information, such information is subject to change as new health information becomes available. UUANJ 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.