LAPAROSCOPIC RADICAL PROSTATECTOMY AN INFORMATION LEAFLET Written by: Department of Urology June 2011 Stockport: 0161 419 5698 Website: www.stockport.nhs.uk Tameside: 0161 922 6696/6698 Website: www.tameside.nhs.uk Macclesfield: 01625 661517 Laparoscopic Radical Prostatectomy 1 of 11
What Is a Laparoscopic Radical Prostatectomy? The prostate gland lies just below the bladder and surrounds part of the urethra (the tube through which you pass urine, leading from the bladder to the tip of the penis). It sits on top of the sphincter muscle (the muscle that keeps a squeeze on the urethra to prevent urinary leakage / incontinence). The prostate is part of the male reproductive system and its main function is to make most of the fluid that carries the sperm. A radical prostatectomy is the term used for the removal of the whole prostate gland and the seminal vesicles (small glands located immediately behind the prostate that produce semen). A small amount of tissue may also be removed from the lymph nodes (part of the immune system) situated next to the prostate. Laparoscopic means the use of telescopic instruments and is often referred to as keyhole surgery. The Surgeon will make four small incisions (cuts) of about 0.5cm to 1cm in length in your abdomen (see diagram). These incisions are called entry sites or ports. The laparoscopic instruments are inserted into the ports and are then used to cut out the prostate. The operation is carried out under a general anaesthetic (when you are put completely to sleep). Why is the Operation Performed? Your prostate biopsies have shown that there are cancer cells within your prostate. A radical prostatectomy is one of the treatment options for early prostate cancer which means that the cancer is localised or confined to the prostate (not spread to other parts of the body). You will have had blood tests (PSA) and possibly x-rays which have led the Urology doctors to believe that you have early prostate cancer. The operation is not suitable on every patient with prostate cancer. It is usually carried out on otherwise healthy men who are expected to live for at least another 12 years. What Are The Benefits? Laparoscopic Radical Prostatectomy 2 of 11
The aim of the operation is to cure your prostate cancer and prevent spread of the disease to other parts of the body (metastases). Laparoscopic surgery usually means less blood loss during the operation and also reduces recovery time as it usually causes less pain than an open (large incision) procedure. This means that you should be able to mobilise earlier and resume your normal life in a shorter period of time. What Are The Alternatives? Active surveillance - in some cases prostate cancer can be slow growing and may not need treating, although there is no guaranteed way of predicting this. If this method of management is chosen, you will have regular PSA blood tests to monitor the cancer so that treatment can be offered if appropriate. Radiotherapy this treatment is given at the Christie Hospital. What Preparations are needed prior to Surgery? Pre-operative checks which may include blood, heart and lung tests will usually be performed a couple of weeks before the operation. A letter will be sent to you by your Consultant s secretary at Stepping Hill, informing you of the date and time of your admission to hospital. You will be given information on when you should stop eating and drinking before your operation. What Happens To Me When I Arrive At The Ward? You will usually come into hospital on the day of your operation. You will meet the nursing staff who will be looking after you and an anaesthetist, who will discuss your options for pain relief following the operation and also talk to you about the anaesthetic you will have. On the Day of the Procedure: You will have nothing to eat or drink for several hours before the operation. If you would normally take tablets during this time, you will be informed at the pre-operative assessment clinic which you should continue to take. You may be given some tablets as part of the preparation for your anaesthetic, known as a premed. These will help you feel more relaxed. Before going to the operating theatre, you may be asked to take a bath or shower and change into a theatre gown. Any jewellery (except your wedding ring), dentures and contact lenses must be removed. Laparoscopic Radical Prostatectomy 3 of 11
What Happens during the Operation? The operation usually takes approximately 3 hours. You will lie on your back for all of the operation with a breathing tube through your mouth. The surgeon will make four ports (see previous diagram) and insert a laparoscopic camera and instruments through them to see inside the abdomen. A steady, low pressure flow of CO2 gas is pumped into the abdomen to help visibility. Once the prostate has been removed, the bladder is then joined back up (using stitches) to the urethra. This is called an anastomosis. These stitches dissolve over the next 6 weeks. The prostate is then scooped up in a small bag inserted through one of the incisions and the bag, with the prostate in, is then removed through that wound which is made slightly larger to allow the prostate to be removed intact. The prostate is then sent for analysis and examination under the microscope in the laboratory. The skin incisions will be closed with dissolving stitches inside and small metal clips to the skin on the outside. What Happens after the Operation? After the operation you will be taken to a recovery ward and then transferred to a normal ward. If you require close monitoring, you may be nursed in the High Dependency Unit (HDU) until you are ready to return to the main ward. The ward staff will give you painkillers to control any pain you may have. You will have a catheter in your bladder (a soft, plastic, hollow tube up the penis which drains the urine from the bladder into a bag). The catheter is kept in place by a small balloon inside the bladder which stops the catheter falling out and allows you to move around more freely. The urine draining into the bag will look blood-stained to begin with and then becomes clearer. The catheter usually stays in place for about 1 or 2 weeks after the operation. You will have a drain (hollow, plastic tube) coming out from the abdomen, attached to your skin with a small stitch. It is connected to a bag that collects blood-stained fluid drained from inside the abdomen. This usually causes little discomfort and is removed after about 1 or 2 days following the operation or when there is no longer any fluid draining through the tube. You may notice the scrotum is swollen after the operation or that the skin around the face and eyes is puffy or swollen. This is temporary and is due to the gas used during the operation. It usually settles within a few hours and is not painful. You will have a drip or I.V.I. (fine, plastic tube inserted into a vein in your arm) which allows fluids to go into your veins to prevent dehydration. You will usually be able to eat and drink as normal 2 days after the operation. You may feel sick for the first 24 hours after the operation, but this can usually be resolved by medication. You may have an oxygen mask over your nose and mouth, and very occasionally a naso-gastric tube coming out of your nose will be present to allow drainage of wind from your stomach. You will be encouraged to breath deeply after your operation and move your legs in bed. The Laparoscopic Radical Prostatectomy 4 of 11
nursing staff will help you to get out of bed on the first and second day after the operation and help you start walking soon after this. You are normally up and about independently about two to three days after surgery. The area around the wound can be washed as soon as the dressing has been removed and you can shower 2 days following surgery, even-though the various tubes will still be in place. It is quite normal for bowels not to be open for a number of days after surgery. Passing wind usually takes 2 to 3 days and passing a formed stool may be longer than this. If you feel uncomfortable laxatives can be given, but discharge from hospital is not usually delayed by the need to have your bowels open. How Long Will I Be In Hospital For? Patients can usually go home about 3 days after this type of surgery, but it depends on how well you progress following your operation. Are There Any Risks Involved? Conversion to the standard open operation - There is a one in a hundred chance (1 %) that the surgeon would have to convert to the standard open procedure during the operation if access to the prostate is difficult or if the operation is not progressing as planned. This open procedure involves making a larger cut in the lower abdomen from the belt button to the pubic bone. The recovery period and stay in hospital may be longer following an open procedure. Pain The Ward staff will give you painkillers to control any pain you may have. This may be in the form of a device that you use to control the pain yourself which is known as patient controlled analgesia (PCA). This is given by a small drip in your arm which allows you to increase the amount of painkiller as required. It is controlled so that it is not possible to insert too much and you will be shown exactly how to use the device. Pain relief may also be administered by an epidural (needle and small tube inserted in your back before the operation). You will have time to discuss your preferences for pain relief with the anaesthetist before your surgery takes place. Bleeding - A blood transfusion may be needed to replace blood lost during the operation. Very occasionally (0.5% chance) there may be internal bleeding after the operation making further surgery necessary. Bowel perforation there is a 1% risk of a hole being made in the bowel during the operation. If this is small then it should heal but will mean that the catheter has to stay in for up to 2 months. If it is a large hole, a further operation may be required to repair it. There is a 4% risk that the new join between the bladder and urethra may become narrowed and cause a blockage to the urinary stream. This would usually occur in the first 2 months after your surgery and is treated by a small operation under anaesthetic which involves Laparoscopic Radical Prostatectomy 5 of 11
inserting a camera up the penis and stretching the narrowing. Prolonged presence of wound drain there is a 4% risk that the drain tube needs to stay in longer than usual after the operation. Bruising there may be some bruising to the skin around your wound sites. This will gradually fade. Infection in the wounds an antibiotic injection is given at the time of the operation to prevent this, but if your wounds appear very reddened and/or have a discharge (pus), you may require some additional antibiotics. Urinary infection there is a small risk of infection occurring in the bladder requiring antibiotics. Failure to pass urine occasionally (1-2% chance) it is necessary to put the catheter back in temporarily because of difficulty passing urine. Blood clots in the leg (deep vein thrombosis/dvt) As you are not able to move around immediately after the operation, blood clots may form in your leg, which can occasionally lead to a clot in the lungs (pulmonary embolus/pe). Moving around as soon as possible after your operation can help to prevent this and you may be given special surgical stockings to wear, whilst you are in hospital and possibly injections to thin the blood. You may also be shown how to perform leg exercises, to help prevent blood clots occurring. Chest infection this is due to the effects of the anaesthetic and you may be taught deep breathing exercises by a physiotherapist, which you should do regularly after your operation, to help prevent a chest infection. Discharge Arrangements You will be required to arrange for a responsible adult to collect you from hospital. You will be given seven days supply of any medications you have been prescribed and a letter will be sent to your GP informing them of your treatment and progress. Day To Day Living at Home You will go home with the catheter still in place. It will be connected to a bag which can be strapped to your leg to allow you to walk around. You will be taught how to look after the catheter and bag. Occasionally, urine may leak between the outside of the catheter and the penis, and you may need to wear pads to manage this. You will be admitted to hospital again 1 to 2 weeks after the operation to have the catheter removed. This is not usually painful but may be a little uncomfortable and an antibiotic injection may be given prior to its removal to prevent infection. There may be some stinging on passing urine for the first few times after it is taken out and you may also see some blood in the urine. It may be necessary to stay in overnight or (very occasionally) the catheter may need to be temporarily re- Laparoscopic Radical Prostatectomy 6 of 11
inserted due to difficulty passing urine. You are likely to feel quite tired for a month following surgery but you will gradually improve during this time. Although you should be able to perform tasks that you did prior to surgery after a week without risk of damage to you or the wounds, you will find that these will tire you more than usual. Aches and twinges in the wound can be felt for a number of weeks after surgery. You will usually be able to drive a week after the operation or as soon as you can make an emergency stop without feeling discomfort in the wound. You may need to check that you are covered to drive this soon after this type of surgery with your insurance company. You will be able to exercise when you feel up to it although cycling, which presses on the sensitive area behind the scrotum, may cause discomfort and should be avoided to begin with. You will have an appointment made to see your surgeon approximately 4 to 6 weeks after the operation. The prostate removed during the surgery is examined under a microscope and the results of this will be explained to you during this appointment. A PSA blood test will be taken at this time as part of your follow up to check on the success of the operation. The level that the PSA goes down to and the examination of the prostate under the microscope will allow your doctor to assess the effect of the surgery on clearing your cancer. Specific Advice following Radical Prostatectomy Continence This is urine leakage from the end of the penis. All men can expect to have some problems once the catheter is removed although the amount of leakage and when it occurs varies between patients. The amount can range from a few drops per day to constant dribbling. The leakage is managed by using pads placed in the underwear. Some patients experience increased leakage when performing physical tasks. Some patients experience a frequent strong desire to pass urine and leak because they cannot reach the toilet in time. In the majority of patients the urinary control improves over weeks and months after surgery. Control normally occurs first at night and then during the day. The time taken to achieve urinary control is reduced if the patients perform regular pelvic floor strengthening exercises. You will be taught these and given instruction leaflets. Your doctor may prescribe medication for you to reduce bladder spasms to aid with your exercises. In total approximately 50% of men achieve full control by 3 months after surgery and 50% of the remainder only require 1 pad per day by this time. A year after surgery only 10% of men have not achieved full urinary control. Of these men most require 1 or 2 pads per day to look after urinary leakage. Approximately 2-3% of men who have this operation may need further surgery after 1 year due to their incontinence. This involves a small operation to insert a ring shaped plastic balloon at the base of the penis (an artificial urinary sphincter). Potency This is the ability to achieve erections suitable for penetration during sexual intercourse. The nerves Laparoscopic Radical Prostatectomy 7 of 11
to the penis that cause the penis to become erect lie very close to the prostate gland on both sides. Depending on the extent of your cancer it may be possible to safely remove the prostate without removing any of the surrounding tissue. If this is done the nerves can be left intact on one or both sides and this is called nerve sparing surgery. Your surgeon will talk to you about whether this is appropriate in your case. Even if the nerves can be protected they will not function normally for a period of time after surgery and in most men a period of impotence (inability to achieve erections) can be expected. The erections will return in some men undergoing this surgery. The chance that the erections will return is increased if both the nerves are saved and if a man has no problems with erections prior to surgery. 2 out of 3 men will have regained erections in these cases 3 to 6 months after surgery. A further improvement in erection quality can be seen for up to 18 months after surgery. The chance of erections returning is less if a patient has had to have his nerves removed with the prostate or if the erection quality is weak prior to surgery. Preservation of the nerves or erections cannot be guaranteed for any man prior to the operation. The chance of erections returning is improved by technique of regular stimulation of the penis after surgery. Your surgeon will discuss this with you but it involves regular physical stimulation of the penis after the surgery to encourage the blood flow and nerve supply to this area. In order to strengthen the erection after surgery your doctor may prescribe for you various treatments including tablets (such as Viagra or similar). For those men who are incapable of getting erections either with or without tablets there are a number of other treatments that may prove successful. If there is a Problem If you have a problem following discharge from hospital, please contact your GP for advice. Other Useful Contacts or Information It is important that you have as much information as you would like before you agree to have this operation. You may also be feeling a wide range of emotions and for some people undergoing surgery can be a frightening and unsettling time. It may help you to talk about how you are feeling to someone who specialises in dealing with this condition, such as your Urologist or the Urology Specialist Nurse. They will listen, answer any questions you may have, or can put you in touch with other professionals or support agencies if you wish. Some useful contact numbers are listed below. Macmillan Cancer Support 89 Albert Embankment London SE1 7UQ 0808 808202 www.macmillan.org.uk (provides specialist advice through Macmillan nurses and doctors and financial grants for people with cancer and their families.) Laparoscopic Radical Prostatectomy 8 of 11
Cancer Backup Bath Place Rivington Street London EC2A 3JR 0808 8001234 (freephone information line, Monday to Friday, 9am to 7pm) www.cancerbackup.org.uk (provides information on all aspects of cancer and its treatment and on practical and emotional problems of living with cancer) Greater Manchester and Cheshire NHS Cancer Network website www.gmccn.nhs.uk (website with information about all aspects of cancer and details of support for people affected by cancer). NICE guidance on prostate cancer http://www.nice.org. uk/guidance/index.jsp?action=download&o=30685 Cancer Support agencies http://www.cancerhelp.org. uk/help/default.asp?page=2874 www. prostate-cancer.org. uk If you have any questions you want to ask, you can use this space below to make notes to remind you. Laparoscopic Radical Prostatectomy 9 of 11
Source In compiling this information leaflet, a number of recognised professional bodies have been used, including Greater Manchester and Cheshire Cancer Network and the British Association of Urological Surgeons. Accredited good practice guidelines have been used. If you have a visual impairment this leaflet can be made available in bigger print or on audiotape. If you require either of these options please contact the Health Information Centre on 0161 922 5332 If you would like any further information please telephone the Urology Nurse Specialists at your local Urology Department on: Stepping Hill 0161 419 5695 Tameside 0161 922 6698/6696 Macclesfield 01625 661517 Author: Division/Department: Date Created: Reference Number: Version: Greater Manchester and Cheshire Cancer Network / Urology Department Elective Services April 2010 Version 1.1 Laparoscopic Radical Prostatectomy 10 of 11