About Keyhole Nephrectomy

 
About keyhole Radical Prostatectomy
 
About keyhole Radical Cystectomy

PROSTATE CANCER

Laparoscopic Radical Prostatectomy

Laparoscopic radical prostatectomy is an operation that removes your whole prostate. It also removes some healthy tissue around it, including the seminal vesicles, two small glands that (like the prostate) produce the fluid that comes out with your sperm when you ejaculate.

What does the operation involve?

 

Schematic diagram to explain the steps of radical prostatectomy

The operation involves the surgeon placing a narrow telescope (called a laparoscope) and other metal instruments through small tubes (ports) inserted into the abdomen through four or five1cm incisions. You will be given a general anaesthetic to put you to sleep. The operation lasts between 3 and 5 hours. This operation removes the entire prostate gland following which the water tube (urethra) is rejoined to the bladder. Please ask Mr Puri if you want further details.

Advantages of Laparoscopy

Open Radical Prostatectomy Laparoscopic Radical Prostatectomy

Incision Incisions

As there is no large incision this result is shorter hospitalisation and convalescence, less bleeding and post-operative pain and fewer wound complications.

Although laparoscopy is a type of keyhole surgery, the view obtained is much better than looking through a keyhole. Modern equipment produces a wide, bright, clear and magnified view of the operation. The gas used to distend the abdomen during laparoscopy also greatly reduces bleeding during surgery.

ALL PATIENTS OFFERED LAPAROSCOPIC SURGERY HAVE TO UNDERSTAND THAT IN CASE OF ANY DIFFICULTY IN CARRYING OUT THE PROCEDURE LAPAROSCOPICALLY I WILL CONVERT TO AN OPEN PROCEDURE

What are the advantages of surgery

  • The true extent (stage) and aggressiveness (grade) of prostate cancer can be determined.
  • If the cancer is confined to the prostate and completely removed the operation should be curative
  • PSA value should decrease to <0.1 six weeks after the operation
  • This operation also relieves the obstruction caused by enlargement of the prostate gland and relieves symptoms as poor flow and getting up at night to pass water.
  • If cancer recurs PSA rise will detect this 4-5 years before symptoms so the radiotherapy can be given.

 

Disadvantages of surgery

  • Wound discomfort- The wounds heal within 10 days and most patients are able to resume normal activity like driving within 2-3 weeks. The discomfort is easily controlled by painkillers. Wound complications are rare Serious complications are unusual but are rapidly recognised and dealt with.

Common

  • Erectile dysfunction (problems getting an erection)
  • Incontinence (problems controlling your flow of urine)

Occasional

  • Chest infection
  • Bleeding
  • Blood Clot formation

Rare

  • Bowel problems. It is possible for your rectum to become damaged during surgery, although this is not common.
  • There is a very small (less than 1 percent) chance that you may die from your surgery. As operation involves a general anaesthetic and this can lead to complications such as heart problems and breathing problems.

Despite your surgeon's attempt to remove the entire tumour, you may not be cancer-free. Even if your test results indicate your cancer is only in your prostate, it's still possible that it has spread to other parts of your body but can not be detected. It is essential that you have regular follow up for 5 years after operation.

What happens before the operation?

Approximately weeks before your admission date you will be requested to attend the pre-admission clinic to have blood tests and examinations performed to ensure you are fit for the operation. On admission to the ward, you will be welcomed and shown to your bed. You should plan to be in hospital for 3-4 days. The nursing staff will discuss your discharge from hospital with you.

You will be seen by the Surgeon who will explain the operation again to you and ask you to sign the consent for surgery. If you are unsure about any aspect of the operation, please ask for more details from the medical or nursing staff. You will be advised of the approximate time of your operation.

You will be seen by an anaesthetist who will discuss the anaesthetic you will be given. They will be interested in chest troubles, dental treatment and any previous anaesthetics you have had. The anaesthetist will discuss with you the different methods of controlling pain after the operation. The most common method a special pump that delivers pain-killing medication when you press a button, this is known as ‘Patient Controlled Analgesia (PCA).

The nurses will advise you as to when you need to stop eating and drinking before surgery. This allows a period for your stomach to empty preventing vomiting during the operation.

You will be asked to wear stockings to prevent blood clots and aid circulation and a cotton gown. You will also be asked to remove or secure with tape all jewellery.

You will be accompanied to theatre by a ward nurse. Your details will be checked several times before your anaesthetic begins.

What happens after the operation?

Although you will be conscious a minute or two after the operation ends, you are unlikely to remember anything until you are back in your bed. You will have a tube (called a ‘catheter’) coming from your penis. This tube drains the urine from your bladder and is connected to a collecting bag. It is quite normal for your urine to be bloodstained initially. Some men experience slight discomfort around the catheter. You will also have one wound drain.

A team of anaesthetists and specialist nurses (known as the ‘Pain Team’) will see you to ensure that the pain is controlled with the epidural or PCA. This team will visit you daily in the first few days after your operation.

On the morning after your operation, you will usually be able to sip fluids and progress to tea or coffee later. By the end of the day you will probably be drinking quite freely, and should be able to tolerate a light diet. You will have an intravenous drip and this will make up for any fluids you are unable to drink in the early hours after the operation. There is also a small possibility that you may need to be in the High Dependency Unit overnight to monitor your progress after the operation.

Your bowels may stop working for a few days after surgery. If you have not opened your bowels after 2 days, or are feeling uncomfortable, please ask the nursing staff for advice. It is also normal to have some bruising and swelling of the scrotum after the operation. You will be given a special support to wear; this will help with the swelling and make you more comfortable. This swelling will usually settle within a week or two after surgery.

You will be encouraged to get out of bed and start walking from the first day. You will not do your wound any harm and it is important to start moving to avoid complications.

You will need to remain in hospital until you can walk freely without pain, and can manage by yourself. We will also ensure that you are eating normally, and that your bowels are working, before you are discharged home. The majority of patients will be discharged home between 2 and 3 days after their operation

The length of time that the catheter needs to remain in place will depend on a number of factors, including the surgical technique used and the ease or difficulty the surgeon encountered with particular aspects of your operation. It may be possible to remove the catheter quite early (around 7 days) but it is also possible that it may need to remain in for around two weeks. Very occasionally it may be necessary to leave a catheter in place for around two weeks while healing takes place and confirm that the join has healed by carrying our a special x-ray (cystogram). The catheter must not be removed for any reason except on your surgeon’s instructions.

Very rarely, the catheter may stop draining altogether. If this happens, drink plenty of fluids and then lie down flat for an hour. If this does not result in drainage from the catheter, then ring your ward for advice. It may be suggested that you return to the ward.

Bleeding

It is common for there to be a slight discharge of blood around the catheter when you open your bowels. This will settle down by itself and is not a cause for concern. You may also see some blood in the catheter bag, particularly after exercise. If this happens, you should increase your fluid intake to help flush out the blood. This kind of bleeding usually settles by itself and does not require treatment in most cases.

Leaking around the catheter

Like bleeding, this is also common and does not require treatment. If the leakage is very severe, then it can be managed by absorbent pads. The catheter should not be removed.

Wound

You can shower or bathe at home as normal, this will not affect the small wounds. You should observe for signs of infection such as redness or swelling. If this happens seek advice from your GP or Community Nurse.

Clots in the leg (Deep Vein Thrombosis)

There is a risk that blood clots may form in the veins of the calf during surgery (known as "Deep Vein Thrombosis"). This may lead to a swollen, tender calf. Although this is easily treated, it can lead to further problems if the clots break away and move up to the lungs (Pulmonary Embolus). The stockings you are given to wear prior to surgery should be kept on throughout your stay on the ward. You will be required to wear them at home for 2 weeks. Please ask the nurses on the ward and ensure that you obtain a spare pair so that they may be washed. Your surgeon may also prescribe daily injections during your hospital stay to thin the blood slightly and reduce the risk of forming these clots.

In the first six weeks after surgery blood clots are the most serious potential complications. If you develop any of the symptoms such as chest pain, shortness of breath, pain or swelling in your leg, then call your GP or contact your nearest Accident and Emergency Department if you are away from home. You should tell the doctor who sees you that you have had a Radical Prostatectomy, and are concerned about a possible blood clot.

Infection in the urine

Urinary tract infections are quite common in anyone who has a catheter in place. Unless you have symptoms, the infection will not require any treatment.

Symptoms of a urinary tract infection include

  • Chills and fever
  • Concentrated or cloudy urine
  • General feeling unwell

Sometimes there may be cloudiness in the urine, which does not necessarily signify an infection, but may represent sediment in the urine that is a normal occurrence. If you suspect that you have a urine infection please contact your G.P.

Urinary control

In the discussions you had with your Consultant and Specialist Nurse prior to surgery, the problem of urinary incontinence following surgery was discussed. The majority of men find that they experience some urinary leakage. However for a few men, the problem is more severe and can in rare cases last over 12 months, especially if they had problems with urinary urgency or frequency before the operation.

The return to normal control occurs in three phases, and you should try to be patient with the speed of your recovery.

  • The first phase is that you will be dry when you are lying down at night.
  • In phase two you will be dry when walking around.
  • Finally in phase three you will be dry when you get up from a sitting position, cough or sneeze.

The return to normal occurs at different speeds in different men and is impossible to predict accurately. Until you gain full control, you may find it useful to limit the amount of caffeine drinks (tea and coffee) and alcohol that you drink as these drinks act as a stimulant on the bladder.

 

Pelvic floor (or Kegel’s) exercises

  • To do these exercises effectively, you need to first relax your abdominal and buttock muscles.
  • To identify and correctly contract the pelvic floor muscles, imagine that you are trying to hold back bowel movements or from passing gas. During this action, you should feel a ‘lifting sensation’ inside and a tightening around your anus. You should not be tensing your thighs, buttocks or anus.
  • Tighten the muscles for 3-5 seconds and then relax for 6-10 seconds. Repeat this sequence 20-25 times.
  • Do the set of 20-25 contractions 3-4 times daily.

During the first week of the programme, perform the exercises whilst lying down, but later while sitting and standing. After the initial learning period, perform the exercises when you need them, i.e.  just before sneezing, coughing or straining.

Sexual function

After surgery, you may find it difficult to get or maintain an erection that is firm enough for intercourse.

Erectile dysfunction happens because the nerves and blood vessels that control erections lie close to the prostate and can become damaged during surgery. A technique called nerve-sparing surgery can protect the nerves from injury and where possible this will be done. However, nerve-sparing surgery is not possible for all men. Even when nerves are spared, it may not prevent erectile dysfunction. However, your erections may continue to improve over time. The nerves that are involved seem to be able to recover after surgery, but the older you are, the less likely you are to regain the ability to have an erection.

Although you may not be able to have penetrative sex, you may still experience the sensation of an orgasm, which may be achieved from either foreplay or masturbation. After your prostate is removed, you will no longer be able to ejaculate (release fluid from your penis when you orgasm). This is because you no longer have a prostate to produce this fluid. As you will be sterile you do not need to use any form of contraception.

There are treatments available for erectile dysfunction, so it's worth talking to your Consultant or Specialist Nurse about which one may be right for you at your regular follow up appointments. Current research suggests that early treatment is associated with greater success.

Potency (erection) rates differ amongst surgeons. Good potency rates would be 50% of patients, at 12 months after surgery.

Do not be afraid to attempt intercourse, but it is better to wait for at least 6 weeks after surgery, to make sure everything has healed. Do not be tempted to wait for a perfect erection before attempting intercourse

Discharge advice

Diet

You can eat and drink whatever you wish. Try to avoid constipation by keeping to a diet that contains plenty of fruit and fibre. If you do become constipated, then ask your doctor or nurse for advice.

Exercise

After you go home, you should avoid heavy lifting and vigorous exercise for 4 weeks, to allow the small wounds to heal.

For the first two weeks at home, try to avoid sitting upright in a firm chair for more than an hour at a time. Instead sit in a semi-reclining chair, on a sofa, or on a comfortable chair with a foot stool.

This achieves two aims:

  • It raises your legs and improves the drainage from your leg veins reducing the risk of clots forming

  • It avoids placing weight on the area of your surgery

Most men will be able to take light exercise with in two weeks. You should particularly exercise the calf muscles to reduce the risk of blood clot formation. You can drive your car when you can operate the pedals without any discomfort at all.

Removal of the catheter

You will be given an appointment to come back into hospital after your operation for removal of the catheter. Very occasionally a special x-ray is required to determine whether the internal stitches around the join between the urethra and the bladder have healed.

The catheter will be removed on the ward. This procedure is performed at the bedside. You will then be able to pass urine normally, although you may need to remain on the ward overnight so that we can ensure you are able to control your water sufficiently.

When the catheter is removed, you may find to begin with that you get little warning before needing to pass urine, and may leak urine on movement. This is quite common and usually settles quickly. If it does not, please let the nursing staff know. Absorbent pads can used to help manage this problem. Please ensure that you have a supply of pads when you leave the hospital after your catheter has been removed. Further supplies will be obtained via your community nurse.

Follow up after surgery

6-8 weeks after the operation you will be seen by the Consultant in the outpatient clinic. This is so the results of the surgery can be discussed with you, and any other treatments planned. A PSA test may be done either at the hospital or at your GPs practice, 7-10 days before the appointment date.

Further follow up appointments will be given at regular intervals. The time between visits will lengthen if there are no particular problems.

A final word

Please do not hesitate to contact us with any questions or concerns that you may have about your condition. We are here to help you.

Any questions?

If you have any questions please contact

Uro-oncology nurse specialists

BRI Yorkshire Clinic
Mr David Tyson 01274 382079 Mrs Lyn Taylor 01274 550600
Miss Zoe Scaife

Ward 14 Ward 1
Bradford Royal Infirmary Yorkshire Clinic
Tel (01274) 364383 Tel (01274) 560311

Secretary to Mr R. Puri
Bradford Royal Infirmary Yorkshire Clinic
Duckworth Lane Bradford Road
Bradford BD9 6RJ Bingley BD16 1TW
Tel (01274) 382655 Tel (01274) 564521

 


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