Clinical Programs / Nerve Sparing Prostatectomy
Nerve-Sparing Radical Prostatectomy - UCLA Department Of Urology
Information For Patients - Radical Prostatectomy
Background
Prostate cancer affects the prostate gland which is located just below the urinary bladder and surrounds the urethra. This prostate gland provides fluid for semen. Prostate cancer develops in approximately 10% of men, increasing in likelihood after age 60 with African-American men having the highest incidence of prostate cancer in the world.
The Hospital Stay
A radical prostatectomy is the most common operation performed to remove the prostate cancer. This surgery involves removal of the prostate gland, seminal vesicles and pelvic lymph nodes. It also allows the surgeon to thoroughly examine the surrounding area for any cancer spread. The operation can performed through an incision or in a minimally invasive manner using robotic assistance (the da Vinci prostatectomy). The usual hospital stay is 1-2 days.
The Operation
To perform the open operation the surgeon makes an incision in the lower abdomen and examines the area around the prostate, particularly the lymph nodes. The lymph nodes may or may not be removed at the time of surgery depending on the surgeon’s preference and/or the risk that the lymph nodes may be involved by cancer. In order to take out all of the prostate a portion of the urethra is removed along with the prostate gland. The remaining urethra is then reconnected to the bladder. A thin catheter is inserted through the penis into the bladder to drain urine and allow the connection to heal. The catheter remains in place 7-14 days or until the new connection of bladder to urethra has completely healed. The operation usually takes 2 to 31/2 hours.
To perform the robotic operation, the surgeon makes 5-6 small incisions through which the robotic instruments are placed. The prostate specimen is removed in a small bag and removed through the middle incision above the umbilicus. Following removal of the prostate, the bladder is reconnected to the urethra and a thin foley catheter placed across the connection until it is healed. The catheter is removed 7-14 days after surgery, or when the surgeon is assured that the connection of bladder to urethra has healed. Lymph nodes may be removed at the time of surgery if the surgeon believed there is a significant (>5%) chance that they could be involved with cancer. In general, the lymph nodes are removed in order to determine the extent of the cancer and subsequent treatment following surgery. The surgery generally takes 3-41/2 hours to complete.
After completion of surgery, patients are taken to the recovery room and remain there until they are fully awake from the anesthesia. This may take several hours. They will then return to their hospital rooms.
On the day of surgery, friends and family members can wait in the surgical waiting area on the first floor of the hospital. The surgeon will contact them there after completing the surgery. They may see the patient when he is transferred to his hospital room.
Post Operative Care
Most patients will be given Toradol for pain relief the first 24 hours (few days) after surgery. Toradol is a new pain medication that is given intravenously. It is very effective and has few side effects. Narcotics and other pain medications will be prescribed if needed.
You will be given clear liquids the night of surgery and then a regular diet thereafter. Sometimes the surgeon may elect to delay feeding depending on whether the abdomen is very distended or if you complain of nausea or vomiting. This is uncommon.
You may not have a bowel movement for several days after surgery. Request a laxative if you have not had a bowel movement before you go home. Stool softeners are useful but may not be strong enough to stimulate a bowel movement. If you have not had a bowel movement or passed flatus by 3 days after surgery, you should contact your surgeon, who may prescribe milk of magnesia or a stronger laxative.
You will have a small soft latex drainage tube inserted into your lower abdomen immediately after surgery to drain excess fluid that tends to accumulate in this area after the lymph nodes are removed. The drain is removed when its output decreases to a low level. This can occur at the time of discharge (1-2 days after surgery, most commonly) or after discharge from the hospital. A gauze dressing is used to cover the drain site and needs to be changed every day until there is no longer any drainage.
After the drain is removed you can take a shower.
Discharge Medications
Oral pain medications, antibiotics, and stool softeners will be given to you at the time of discharge and should be taken as prescribed.
Antibiotics are usually prescribed as long as the catheter is in place.
Most men find that taking Metamucil or any of the bulk laxatives every day is necessary for the first few weeks after surgery to regulate their bowel movements. It is extremely important not to get constipated during this time. Constipation can cause severe abdominal discomfort due to gas pains. If you are taking any narcotic medication you must be particularly careful to avoid this. Stool softeners are useful but may not be strong enough to cause a bowel movement. Milk of Magnesia and Dulcolax are very good laxatives and may be needed. The rectal area is fragile and thin immediately after surgery. Gradually scar tissue will form and this area will become thicker. Until this occurs do not put anything in your rectum and do not use any rectal suppositories or enemas for at least six weeks after surgery.
During the first week or so following discharge, you may notice a number of other common occurrences.
- Bladder spasm: Surgery and the catheter can irritate the bladder, leading to spontaneous contractions. These feel like a cramping sensation in the lower abdomen and are normal. If they are particularly uncomfortable, your surgeon can prescribe a bladder relaxant.
- Urine or blood around the catheter: You may notice blood or urine drainage around the catheter. This commonly occurs during bowel movements. Although scary, this is completely normal.
- Leakage around the drain site: This is quite common and is not worrisome unless it is increasing and you cannot keep the site dry with dressings. If so, call your surgeon.
Feel free to call your surgeon if you are concerned about a symptom or experience something not mentioned here.
Discharge Instructions
Call your physician if the catheter comes out or if any of the following symptoms develop:
- Pain or swelling in the legs
- Sudden chest pain
- Fever
- Nausea, vomiting
Care Of The Catheter
While the catheter is in place it is important to keep the tip of the penis clean. Clean with soap and water starting from the tip of the penis outward towards the catheter in the morning and before you go to bed. Use soap and water to wash the tip of your penis when you take a shower. If the penis is not cleaned every day crusts may form around the catheter causing irritation and redness. The tip of the penis may then become red, swollen and painful.
The nurses will teach you how to connect the catheter to a leg bag and a urine drainage system before you go home. You will also be given written discharge instructions .
One to two weeks after date of discharge you will need to see your physician in the Clark Center to remove your catheter. The catheter is held in place by a small balloon filled with water. The water is withdrawn from a valve on the side of the catheter and the balloon deflated. The catheter can then be removed easily and with no discomfort.
Regaining Urine Control
After the catheter is removed, you may have difficulty controlling your urine stream. You may be totally incontinent and unable to hold any urine in your bladder. This is temporary. Most men will regain a good portion of their control within the first 6 weeks after the catheter is removed, more by 3 months, and a majority by 6 months. In some men it may take longer to regain control, so remain optimistic. Our quality of life studies at UCLA have shown that 90% of our patients have regained complete or near complete control by 1 year and 95% by 2 years.
You will need to use absorbent pads or undergarment liners until you regain control of your urine. The pads can be obtained from most drug stores or surgical supply companies listed in the yellow pages of the phone book
Urine control can be regained in almost all cases with the help of exercises of the pelvic floor muscles and with time.
Returning To Normal Activity
It takes approximately four to six weeks for the surgical area to heal completely. Do not do any heavy lifting, strenuous exercises, or excessive stair climbing during this time. Most men are able to drive a car after 2-4 weeks. Do not drive if you are taking any narcotics for pain or do not feel well. However, light exercise, such as ellipticals, walking on treadmills, light swimming in golf is OK as soon as 2-4 weeks after surgery if you have no pain and feel well. Always err on the side of being conservative.
The length of time you stay home from work depends on the amount of physical effort your work requires. Following robotic and open surgery, most men can return to work within 2-6 weeks. If you need to file for short-term disability contact your physicians office.
Follow Up Care
Most men will see their physician three months after catheter removal and then every six months for two to three years and then once a year. At each visit a PSA blood test and a rectal exam will be performed.
Changes In Sexuality
The prostate and seminal vesicles (organs responsible for the production of semen), are removed during the operation. This means that following surgery you can have an orgasm but you will no longer ejaculate semen.
If possible, the nerves controlling penile erection will be left in place when the prostate is removed. Whether or not the nerves can be spared depends on the location and the size of the tumor. When the nerves are saved approximately 40 to 60 per cent of men will be able to have erections following surgery. The ability to have an erection may occur within one to two months or it may take as long as 12 to 18 months. During this time temporary methods may be used to obtain an erection. Please discuss this with your physician.
Peer Counseling And Education Groups
Talking with another patient who also has prostate cancer may be beneficial To obtain the name of another man to talk with please the American Cancer Society at (310) 670-2650 or (310) 390-8766 for the “One to One” peer support program.
The UCLA Prostate Cancer Support Group, an educational and emotional support group, was formed to provide a setting where ideas and concerns can be shared and discussed. Physicians and medical personnel provide up to date information on various topics of interest to the group at the monthly meetings. For more information please call the Prostate Program Office at (310) 825-5538
Men living outside of Los Angeles can call the “Prostate Cancer Support Group Network” at (800) 242-2383 to find location of groups near their homes.
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