What is the prostate

Radical prostatectomy is the most common surgical procedure for treating localized, low-risk, intermediate-risk or high-risk prostate cancer. It is a major surgery offered to men in good health.

A radical prostatectomy is the total removal of your prostate and the surrounding tissues. It is done as a potential cure for prostate cancer as it removes all cancerous cells. It can be combined with other treatments—for example, surgery followed by radiation therapy if needed.

Pelvic lymph node dissection

Sometimes prostate cancer with only microscopic spread to your lymph nodes can be cured with surgery. How do you know if your cancer has spread to your nodes? Thanks to modern investigative techniques, it is rare that we have to wait until the operation to realize that the cancer is too widespread to be able to perform a prostatectomy.

That being said, if your cancer is more aggressive and you choose to go with radical surgery, your surgeon will remove your major pelvic lymph node groups during the operation. It is not necessary to remove them if your cancer is at a low risk of progression.

Transurethral resection of the prostate

Unlike radical prostatectomies where your prostate and its capsule are removed, a transurethral resection of your prostate (TURP) consists of removing the internal lining of your prostate through your urethra while leaving your prostate capsule in place. This is the most common surgical procedure for benign prostatic hyperplasia (BPH or enlarged prostate).

In general, transurethral resection of the prostate (TURP) is usually given to relieve urinary problems caused by a prostate that has increased in size and is compressing the urethra. It is also used as a palliative treatment to relieve urinary obstructions in patients with advanced prostate cancer who are not healthy enough to undergo radical surgery.

Is it for you

You may opt for this surgery:

• if you have early stage cancer that has not spread outside the prostate (stage 1 or 2)
• if your cancer has spread locally outside the prostate (stage 3)
• if you have a life expectancy of at least 10 years
• if you are less than 75 years of age, will depend on the individual
• if you are healthy enough to undergo anesthesia and surgery

Reasons for choosing surgery

A radical prostatectomy is effective in the early stages of cancer when it is still confined to your prostate. Chances for recovery are excellent and it offers a high probability for long-term survival (more than ten years).

However, it is also the most aggressive of treatments and therefore has the greatest risk of side effects. Radical prostatectomy is a major surgery. The younger and healthier you are, the more successful your recovery is likely to be. When thinking about surgery, you must consider the effect it will have on your life and weigh the possible benefits against the possible risks.

Surgical techniques

Techniques to surgically remove the prostate include open surgery, hand-assisted laparoscopic surgery and robot-assisted laparoscopic surgery. To learn more about each of these techniques, click here

Advantages of radical surgery

• Completely removes your cancer if there has been no spread outside your prostate
• Provides precise knowledge of the nature and extent of your tumor post-surgery
• Easily assesses the success of surgery with your PSA level six to eight weeks after the operation
• Allows for recourse to radiotherapy or hormone therapy if your PSA level rises

Disadvantages of radical surgery

• There are risks of complications with surgery, as with any major operation
• You will need to stay in the hospital for 1 to 4 days or longer if there are complications
• Different types of radical prostatectomy require, on average, three to six weeks of recovery at home
• If the cancer has spread outside your prostate, the surgeon may not be able to remove it completely
• You will no longer ejaculate and will be unable to have children after surgery.

Risks and complications of surgery

A radical prostatectomy is a major operation, and like any major surgery, there are risks of short-, medium-, and long-term complications. However, they do not affect all men in the same way. It will depend on the type of surgery, the surgeon’s experience, and your overall health.

Short-term

Complications during the operation are rare, but may include:

• Bleeding that may require a blood transfusion
• Injury to the ureter requiring repair
• Trauma or injury to the rectum due to its proximity to the prostate and tumor: it is usually repaired immediately without consequences
• Blood clots in the leg that could travel to the lung

Postoperative

Postoperative complications, upon returning home, may include:

• Pain
• Nausea and vomiting
• Wound infection
• Urinary infection requiring antibiotic treatment
• Constipation due to pain medication
• Bladder spasm due to irritation from the catheter on the bladder walls
• Urinary incontinence and immediate erectile dysfunction in practically all men. These complications are temporary, and things gradually return to normal within the following year for many of them.

Medium to long term

The most common problems associated with radical prostatectomy are:

• Urinary incontinence
• Erectile dysfunction
• Narrowing of the urethra
• For more information on incontinence or erectile dysfunction, see the section on side effects.

Surgery success

The success of surgery and the risk of side effects will depend on the experience and skill of your surgeon. Your surgeon should be able to tell you how many operations he has performed, the success rate of his surgeries, and the rate of side effects in his patients.

The number of surgeries

Surgeons who are regularly in the operating room, e.g., 3 times a month, or who perform at least 20 radical prostatectomies each year, ideally more than 35 per year, have better results, including lower rates of side effects.

The surgeon’s experience

It should be noted that it is not only the number of patients operated on that matters, but also the surgeon’s experience. In this regard, ask him if he can put you in touch with one of his patients. There are also websites where patients give their opinion on doctors. Be careful, as you may be more confused about your surgeon’s skills, as opinions can vary greatly from one patient to another.

Trust

If your surgeon has taken the time to talk to you, answer your questions, and has instilled confidence in his skills, success rate, failures if applicable, and is regularly in the operating room, chances are you are in very good hands. And it is precisely the surgeon’s hands that will make the difference, regardless of whether the surgery is conventional (open) or robotic.

Your doctor has offered you radical surgery to treat your prostate cancer? This section describes this treatment and the precautions to be taken to ensure that everything goes as smoothly as possible.

The medical intervention

Your hospital stay

You will be hospitalized either on the day of or the day before your operation and will stay for anywhere from 24 hours to a few days, if there are no complications.

Duration of the surgery

Two to 4 hours. If your surgeon tells you that he or she can perform this procedure in less than two hours, get a second opinion.

The operation

You will be given general anesthesia or spinal anesthesia (or an epidural like those given to women in labour) so you won’t feel a thing. During the operation, the surgeon will remove your:

• prostate
• seminal vesicles
• area where the prostate meets the bladder (bladder neck)
• part of the urethra that passes through the prostate
• pelvic lymph nodes

Your urinary catheter

While you are still under anesthesia, a urinary catheter will be inserted through your penis to drain urine from your bladder during your healing process. Your catheter will remain in place for 1–2 weeks after your surgery. As urinary incontinence will begin as soon as the catheter is removed, make sure you have absorbent pads in your possession.

The size and nature of your tumour

In the days following your operation, your prostate, seminal vesicles, and removed tissues will be analyzed by a pathologist. This will allow your surgeon to identify the exact size and nature of your tumour.

Your PSA level

Your PSA level should drop to an undetectable level (0) once your prostate has been removed.

Preparation before surgery

Good preparation can make the recovery period after surgery less difficult than expected. Your preparation will play a crucial role in a quicker and less stressful recovery. Before your surgical procedure, you will be asked to come to the hospital for a preoperative visit. Additionally, you will need to sign a release of liability form for your surgeon and the hospital for the risks involved in surgery. This release is mandatory for all surgeries. By reading the following on this page, you will know what to expect and how to cope with it.

Your preoperative visit to the hospital and admission protocol

Before surgery, there are two important steps to follow. The first is your preoperative visit to the hospital, where you will discuss the details of the surgery with the medical team. Then, there is the admission protocol, where you will be prepared for your hospital stay. You will need to sign a release of liability form for your surgeon and the hospital for the risks involved in surgery. This release is mandatory for all surgeries.

The importance of understanding

The side effects related to your surgery

Make sure to have a thorough discussion with your urologist about what the surgery entails, its impact on your quality of life, your sexuality, and the tools available to cope with it. Do not hesitate to reconsider or discuss this option again if you are unsure.

Your prescriptions after your surgery

It will be important to understand the prescriptions you will receive from your urologist and take them when you return home. Your pharmacist can also advise you, but discuss it with your urologist first.

Your Kegel exercises after your surgery

Also, make sure you understand how to resume your Kegel exercises.

Your penile rehabilitation after your surgery

Finally, ask questions about your penile rehabilitation. This involves helping – notably through erection medications – the penis to regain erectile function. Note that this approach is not universally accepted due to the lack of studies on the subject. However, you can still discuss it with your doctor.

• It usually starts soon after your surgery, at a low dose and taken on a weekly basis (frequency may vary from one urologist to another) for several months if you tolerate it.
• Some urologists prescribe these medications (tadalafil, sildenafil, or vardenafil) right away, which you will find in your information envelope or pouch when you leave the hospital.
• Others prefer to wait for the post-surgery follow-up appointment to discuss it.

If your urologist does not address the topic with you during your preoperative visit or follow-up appointment, do not hesitate to bring it up.

A few days before

The hospital Admission service phone call

The day before your surgery, the Admission service will call you to let you know when to come to the hospital. You must arrive 2-3 hours before the scheduled time of your surgery. The surgery time is not definitive. Surgery may take place before or after the scheduled time.

Cancellation

If you are unwell, call your surgeon’s office as soon as possible. If you cannot reach the surgeon, call your hospital’s Admission service.

If your surgery is delayed or canceled due to an emergency, your surgeon will reschedule your surgery as soon as possible.

Prepup

The evening before surgery:

• Take a shower or bath
• Wash your body, starting from the neck down, including your belly button
• Use regular shampoo and soap for your face and hair
• Wear clean clothes to sleep

On the morning of surgery:

• Take a shower or bath
• Put on clean clothes
• Do not apply lotion, wear jewelry, or piercings
• Do not shave the area where you will be operated on

Items to bring to the hospital

• Your health insurance card and hospital card
• Any information related to your private insurance (if you have any)
• Your medications in their original containers
• 1 pack of your favorite chewing gum
• A bathrobe, slippers, loose and comfortable clothes
• Absorbent pads or Depends or Tena incontinence underwear
• Your toiletry kit: toothbrush, toothpaste, mouthwash, comb, deodorant, soap, shaving items, tissues, and earplugs if needed
• Your glasses, contact lenses, hearing aid, dentures with appropriate containers for storage and labeled with your name
• Your cane, crutches, walker labeled with your name
• If you’re tech-savvy, bring your headphones and your music

Note

Please leave all valuables, credit cards, and jewelry at home. The hospital is not responsible for lost or stolen items. Some hospitals will provide a locker for your belongings, but you will be responsible for bringing your lock. Inquire about amenities offered for your personal belongings.

Know that…

You won’t have time to read, as you will be prompted to move, eat, drink, move again, manage your pain, and adjust to this bodily shock. And ideally, if all goes well, you will be discharged from the hospital 1 to 4 days after your surgery.

Questions to my doctor

We invite you to consult our page Questions to ask to your doctor and your healthcare team regarding tests and diagnostic exams for prostate cancer. Asking questions will open up communication, provide information tailored to your situation, and reduce the stress associated with understanding the diagnosis of prostate cancer.

The day of the operation

Make sure you get to the Surgery Pre-Admission office on time

• The admitting attendant will have you sign an admissions form and will ask about your room preference. It is not always possible to get a private or semi-private room.
• The nurse will ask you to put on your hospital gown and will fill in a preoperative checklist with you. You should have been fasting since midnight so your intestines should be empty.
• In some hospitals, you may be asked to wear tight elastic socks to help with blood circulation and prevent blood clots. If this is the case, you should wear them until the nurse tells you to remove them.

The operating room

• An attendant will bring you to the operating room. You will meet your anesthesiologist, the doctor who puts you to sleep, and other members of your surgical team.
• At this stage, there is no point in stressing yourself out or being anxious. You have made the right choice and you are now ready for the next step. Your attitude is vital and will dictate the length of your recovery and facilitate your healing process.
• You will be asleep and feel no pain during surgery.

The waiting room

Your family and friends can wait for you in the room or in the cafeteria. ATMs are usually available in most hospital centres.

During the operation

Your IV

You will be given fluids intravenously until you are able to drink and eat normally. N.B.: When you walk, you will need to push the IV pole with the hand that is not connected to the IV.

Your Jackson-Pratt tube or other post-operative drain

A drain, such as a Jackson-Pratt tube, will be installed in you. The drain is a special tube that prevents blood and fluid from building up inside your abdomen. It consists of two major parts: a flexible tube and a collection bulb. Most patients do not return home with their drain but it is possible. If this is the case, you will be instructed on how to take care of it once you get home.

Your urinary catheter

You will come back from the operating room with a catheter, a tube inserted into your penis called a urinary catheter, which will drain urine from your bladder to a collection bag. You will leave the hospital with your catheter. It is possible for your urine to be tinged with blood—don’t worry.

Your oxygen dose

You might have small tubes in your nostrils to give you oxygen. You will have a small clip on your finger to measure your blood oxygen levels. This is called pulse oximetry. The nurse will adjust the amount of oxygen given to you based on the results and will stop giving you oxygen when you no longer need it.

In the recovery room

After your surgery, you will wake up in the post-anesthesia care unit, also known as the recovery room. This is a quiet place where patients are carefully monitored. You will stay in recovery for several hours.

You will have:

• an oxygen mask, if needed
• an IV line providing liquid
• a urinary catheter (tube) that drains urine from your bladder
• a Jackson-Pratt tube that collects liquid or blood in your abdomen

A nurse will:

• frequently check your pulse and blood pressure
• check your dressings
• make sure that everything is okay

When you are ready, you will be taken to your room. Visitors are not allowed in the recovery room, unless you stay overnight. Your family will be able to visit you when you are in your room.

Pain control

It is normal to feel pain after your surgery. It will feel like a burning or tightening sensation in the area around your incisions. The pain is stronger in the first 24–48 hours and will then gradually decrease.

It is important to control your pain because it will help you to:

• take deep breaths
• move more easily
• eat better
• sleep well
• recover more quickly
• do the things that are important to you

Your nurse may ask you to rate the level of your pain on a scale from 0 to 10. Level 0 means you feel no pain and 10 is the worst pain you can imagine. The staff will want to keep your pain under 4 out of 10. If you are in pain, you need to tell them.The most common possible side effects of pain medication are:

• Nausea and vomiting
• Drowsiness
• Itching
• Occasional headaches

If you experience any of these symptoms, tell your nurse and they will help you. Remember, it is very important that you not wait until the pain is intense to ask for sedatives. If you do, the medication will be less effective and will delay pain relief.

Your mobilization, your exercises, and the objectives to achieve

To prevent pneumonia, blood clots, and muscle mass loss, it will be essential to stay active both in and out of your bed. Click here  to discover the expectations of your healthcare team, from when you wake up until your discharge from the hospital, to ensure a safe recovery.