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Classical prostate cancer surgery
What does this procedure entail?
Removal of the entire prostate gland, seminal vesicles and sometimes regional lymph nodes in prostate cancer; access is acquired via a longitudinal incision in the lower abdomen.
What are the alternatives to this procedure?
- active follow-up
- radiotherapy with external or internal irradiation (IMRT, brachytherapy)
- perineal or laparoscopic approach
- robotic surgery (Da Vinci)
What should I expect before this procedure?
If you regularly use Anopyrin, Clopidogrel, Warfarin, etc., you must tell your doctor. These medications can be associated with increased risk of bleeding during and after the surgery if they are not stopped in time. In some cases, it is necessary to replace these drugs with injection preparations. It is necessary to consult your general practitioner or cardiologist about this approach.
At the request of the referring physician, you will have to schedule preoperative examinations to assess your overall condition, including laboratory and instrumental tests. If the report does not preclude the indicated procedure, you will be admitted to the hospital. If you don’t undergo a preoperative examination or it is incomplete, you will not be able to have the surgery as scheduled. You will be admitted by a nurse and a member of the medical team will complete your examination and assess your fitness for the surgery.
Remember to inform your physician about the following possible facts before the surgery:
- artificial heart valve
- coronary artery stent
- artificial joint
- artificial vascular graft
- neurosurgical bypass
- other implanted foreign body
- use of the following prescription drugs: Acylpyrin, Anopyrin, Aspirin, Godasal, Clopidogrel, Plavix, Kardegic, Aspegic, Micristin, Ibustrin,Ticlid, Tagren, Ipaton Apo-Tic, Plavix, Persantin, Curantyl, Anturan, Aggrenox, Vessel due F.
- drug and other allergies
- any abnormalities or eventualities
It is NECESSARY to inform the physician about your use of drugs affecting blood clotting before your admission for the procedure.
You will be asked not to eat or drink for at least 6 hours before the surgery!
In the evening before the surgery, you will receive medication from an anaesthesiologist to calm you down so that you sleep well.
What will happen during the surgery?
You will normally receive an injection or oral antibiotics before the procedure, but any allergies must be checked first.
The procedure is performed under general anaesthesia.
The entire prostate gland, including the seminal vesicles, is completely removed in this surgery via an incision in the lower abdomen. The bladder is then reconnected to the urethra (so-called anastomosis – a place very prone to scarring or urine leakage). Under certain circumstances, a sample of lymph nodes may be collected from the area around the prostate and drainage vessels at the beginning of the surgery.
The surgery will take 2 to 3 hours.
What will happen immediately after the procedure?
You will wake up at the intensive care unit equipped for the continued monitoring of patients immediately after the procedure. The surgeon will inform you about the course of the procedure. You will still have high levels of anaesthetics in your blood at that time, so you may not remember this conversation.
Patients usually have an infusion access point into a vein in their arm; if necessary, a monitoring/infusion port (a tube inserted into the vein to monitor blood pressure or administer drugs and nutrition) will be inserted into a vein (jugular vein) in the superclavicular region (the area between the collarbone and neck).
Nutrition is provided in an intravenous manner shortly after the surgery. You will receive a liquid and mushy diet for the next 2 to 3 days. This procedure is necessary for the proper restoration of gastrointestinal function. Non-compliance of the patient is usually associated with severe abdominal pain, vomiting with the risk of suffocation and may require surgical revision (further surgery in case of complications).
Physical rehabilitation is very important to prevent complications in the postoperative period. You will first exercise on the bed. As soon as your medical condition allows, you will be allowed to sit down and then stand up. After that, you will be able to walk slowly and carefully around the room, initially accompanied by medical staff. Pay close attention to eventual dizziness, uncontrollable weakness, and to gait stability. Otherwise immediately inform medical personnel or anyone in the vicinity.
Once you are fully conscious, you should:
- ask if the planned outcome was achieved
- inform the medical staff about any problems
- ask what you can and cannot do
- ask all the questions you have for the healthcare professionals and members of the medical team.
- remember (and understand) why the surgery was performed, how it turned out, and what will follow
After this procedure, you will have temporary drains (usually 2) from your abdomen, which will drain the secretion and blood from the surgical wound. Drains are usually removed after 48-72 hours. You will also have a catheter and an epicystostomy catheter (plastic tubes to drain urine) in your bladder. The epicystostomy catheter is usually removed on day 6 after the surgery, the urethral catheter on the day before discharge – but an X-ray scan is performed to see whether the anastomosis is leaking (instead of reconnecting the bladder and urethra).
After 9-10 days, you will be discharged for home treatment. A post-operative appointment will be scheduled. Skin sutures are removed before discharge.
What are the postoperative risks or complications?
Common (10% of procedures of this type)
- Temporary insertion of catheters into the bladder and wound drainage
- High probability of impotence due to inevitable nerve damage (60-90%). This risk will depend on your previous ability to get an erection and also on whether your surgeon decided to remove one or both nerves due to the tumour growth there. This will be discussed with you in advance.
- Inability to ejaculate or sire children due to removal of seed-producing structures (in 100% of patients)
- Urinary incontinence (temporary or permanent) requiring urinary pads or another surgery (3-30%)
- Minor problems with urine leakage
Occasional (2-10% of procedures of this type)
- Scarring at the exit of the bladder leading to weaker urine flow, requiring further surgery (approximately 14%)
- Severe urinary incontinence (temporary or permanent) requiring urinary pads or another surgery (2-5%)
- Blood loss requiring transfusion or repeated surgery
- Cancer spread detected beyond the prostate, requiring follow-up or further treatment
- Apparent shortening of the penis; due to the removal of the prostate with the relevant part of the urethra. This in turn requires pulling the urethra toward the bladder to create a new junction.
- Other later treatment, if necessary, including radiotherapy or hormonal therapy
- Lymphatic collection in the pelvis in case of lymph node sampling
Rare (may occur in 2% of procedures of this type)
- Anaesthesia-related or cardiovascular problems that may require intensive care (including chest infection, pulmonary embolism, infarction, deep vein thrombosis, myocardial infarction and death)
- Pain, infection or hernia in the incision area
- Rectal injury that requires a temporary colostomy
- MRSA colonisation (0.9% – 1 of 110)
- Intestinal infection by clostridium difficile (0.01% – 1 of 10,000)
- MRSA blood infection (0.02% – 1 of 5,000)
Hospital infection rates may be higher in high-risk patients, such as in cases requiring long-term drainage, after a previous infection, after prolonged hospitalisation or after multiple hospitalisations.
What should I expect when I return home?
When you are discharged from the hospital, you should:
- get recommendations on recovery at home
- ask when you can return to normal activities such as work, exercise, driving, housework and sexual activities
- get a contact number for further questions after returning home or in case of trouble
- ask about the date of the following check-ups and the place where you should come (hospital or your attending physician)
- make sure you are aware of the reason, course and outcome of the surgery, the results of examinations or the removal of tissues or organs.
At your departure from the hospital (sometimes several days later), you will receive a hospitalisation report. The document contains important information about your hospital stay, your surgery and recommended follow-up. If you need to call your attending physician or visit the hospital for any reason, take this document with you so that the physician knows the details of your treatment. This is especially important if you need to consult another doctor or longer after discharge.
You will need 6 weeks of recovery after the surgery (usually). Patients usually feel tired and weak for several months.
What else should I watch out for?
In case of more problems occur, unusual bleeding, fever, etc., see your attending physician.
If you have a catheter and related problems (especially if it is falling out or clogging), ask your doctor to contact a urologist as soon as possible. If you cannot urinate after your catheter has fallen out, you should return to the hospital immediately to have the issue resolved.
In case of fever, redness, pulsation or secretion at the site of the surgical wound, contact your attending physician. Inform your attending physician of any other problems related to the procedure, do not underestimate any breathing difficulties.
After this procedure, there is about a 50% risk of losing erectile function (see above). Even if your erection is retained, you will lose the ability to ejaculate. Of course, you will not be able to have children.
Up to 30% of patients experience some small urine incontinence (often one or two drops when getting up with a full bladder). This may also happen when the patient coughs, in case of strain or during demanding activities. It is useful to strengthen the pelvic floor before the surgery to improve the control of urine leakage. We recommend to continue exercising after the discharge from the hospital. Urine leakage control will constantly improve in most patients during the first year after the surgery, but a small percentage of patients (3-5%) have persistent problems with urine incontinence.
The results of the histological examination are usually available within 2-3 weeks after the surgery. These findings may be decisive for your further treatment. The date of your check-up at our or referring urology site will be determined at discharge based on the course of the surgery and postoperative care (usually 6-8 weeks after the surgery).
There is usually additional follow-up at the urology or oncology outpatient office. Follow-up is provided at certain intervals – mainly based on the prostate blood test (PSA). Eventual PSA level increase may be associated with a relapse (return) of the cancer. This condition usually requires further treatment.