In radical
perineal prostatectomy, the prostate gland is removed through
an incision in the perineum, the area between the scrotum
and the anus.
This section
discusses what occurs
before,
during
and
after surgery;
follow-up
testing;
advantages and
disadvantages
of the perineal technique; surgical
risks and
complications; and
side effects of surgery.
Before surgery
- It
is important to tell your doctor if you have had any unusual
problems with bleeding in the past (from dental work, for
example).
- Aspirin
can cause excessive bleeding during surgery. If you regularly
take aspirin or a product containing aspirin, make sure
you stop taking it at least 10 days before surgery. If you
take aspirin for heart or blood problems, you need to get
permission from your doctor to stop taking aspirin. If you
are not sure about any of your medications, ask your doctor.
- Although
they don’t carry the same risk as aspirin, anti-inflammatory
medications should be avoided around the time of surgery.
If you are not sure about any of your medications, ask your
doctor.
- In
case you need a transfusion during surgery, the best blood
you can get is your own. If possible, donate one to two
units of your own blood within 30 days of your surgery.
- The
night before surgery, you may be given an enema and some
laxatives to clean out your colon.
- Your
doctor may put you on a liquid diet the day before surgery.
If you are not put on a liquid diet, eat a light meal the
night before surgery and do not eat anything after midnight
right before surgery.
During surgery
- The
patient lies on his back with his legs held in stirrups
designed to place the legs over and behind the body.
- The
surgeon makes an incision in the perineum.
- The
prostate gland is gradually separated from the rectum, bladder,
urethra and vas deferens.
- The
seminal vesicles are removed along with the prostate; the
vas deferens is divided and tied off.
- The
bladder is reconnected to the urethra. While the patient
is still under anesthesia, a Foley catheter, a hollow,
flexible tube to drain urine, is inserted into the penis
through the urethra and into the bladder. It is left in
place until the reconnection heals.
After surgery
What happens after the operation, while I'm in the hospital?
- The
surgical area must be drained of excess fluids, such as
blood and urine. Drains from the perineum will be left in
place for three to five days, until minimal fluid flows
through them.
- The
Foley catheter will remain in place for two to three weeks,
until the reconnection of the urethra to the bladder is
healed. The Foley catheter must remain in place. If it is
accidentally pulled out or removed too soon after surgery,
there is a risk of incontinence
(the inability to control urination voluntarily) or an inability
to urinate at all because scar tissue has closed the urethra.
- To
prevent constipation and strain on the rectum, you will
probably be given stool softeners or laxatives for several
days following surgery. The prostate gland sits right on
top of the rectum; after its removal, this part of the rectum
is thin, delicate and at risk for injury for the first three
months after surgery.
- You
will be encouraged to sit in certain positions and to walk
around almost immediately after surgery. This is very important
in lowering your risk of developing blood clots.
How
long will I be in the hospital after surgery?
You are
usually discharged once your bowels starting moving again
and you can eat a regular diet. A typical hospital stay for
a radical perineal prostatectomy is one to two days, including
the day of surgery.
What do I need to do after I come home from the hospital?
- Catheter
care: Your catheter should be securely taped to your thigh
and you should examine its mooring often. The site at the
opening of the penis should be cleaned with 1/2-strength
hydrogen peroxide (50% peroxide, 50% water) or an antibiotic
ointment. When you are home, keep the catheter connected
to a large drainage bag most of the time. Use the leg bag
only when you plan to go out. It doesn't hold as much urine
as the large bag and if it becomes full without your knowing
it, urine can "back up" into your bladder. Your doctor will
prescribe antibiotics to be taken around the time your catheter
is removed.
- Pain
management: Over-the-counter anti-inflammatory medications,
such as ibuprofen, may be used if recommended by your doctor.
Your doctor may also prescribe a stronger oral pain medication
in the early days after your surgery.
- Do
not have an enema or use a rectal thermometer any time soon,
because they can damage the rectum. The part of the rectum
closest to the surgery is now thin, delicate and at risk
for injury for the first three months after surgery.
- If
constipation continues to be a problem after you come home
from the hospital, use mineral oil or milk of magnesia.
Your doctor may also prescribe a stool softener.
- Do
not lift anything -- including children or pets -- over
10 pounds for six weeks from the day of surgery. In the
weeks following surgery and before scar tissue forms, the
incision is being held together only by sutures (stitches).
Heavy lifting can cause a hernia (bulge) to develop
in the incision. Even worse, heavy lifting can damage the
reconnection between your bladder and urethra and lead to
long-term problems with urinary control.
- Common
medications your doctor may prescribe after surgery include:
- iron
for low red blood cell count due to blood loss during
surgery, or to replenish the blood you donated prior
to surgery
- oxybutynin
chloride to help with bladder spasms which may occur as
the bladder tries to expel the catheter
- antibiotics
to be taken around the time your catheter is removed.
Follow-up testing after surgery
Follow-up
PSA testing is performed
six weeks after surgery. At this point, if the cancer was
completely removed, the blood should show no detectable PSA
levels.
Advantages of the perineal technique
The perineal
technique does not remove the vein system lying over the prostate,
so less bleeding occurs during surgery. If the odds of the
cancer having spread to the lymph nodes are very low, then
the perineal technique makes it unnecessary to cut through
the abdomen. The perineal operation typically takes less time
than a radical retropubic prostatectomy
and healing time is faster. The perineal operation is also
the appropriate choice for obese men, because the retropubic
approach of cutting through a large lower abdomen is extremely
difficult.
Disadvantages of the perineal technique
Pelvic
lymph nodes cannot be removed through the same incision, as
they can in the retropubic technique. Therefore, a laparoscopic lymph node dissection
would be necessary prior to the operation. The perineal technique
also makes it difficult to perform the nerve-sparing procedure,
because the surgeon cannot see and feel the nerves responsible
for erections.
Risks
and complications of radical prostatectomy
- Excessive
bleeding, the most common surgical complication, is
usually the result of a blood vessel being injured during
the operation.
- Bladder
neck contracture, usually the result of scar tissue
encircling and narrowing the bladder neck, causes a dribbling
urinary stream. In a recent study of over 1000 men who had
undergone radical prostatectomy, 2.8 percent reported persistent
difficulty with bladder neck contracture.1
Outpatient surgery performed with a cystoscope can relax
the contracture.
- Damage
to rectum or ureters is rare and can usually be repaired
during surgery.
- Blood
clots, due to sluggish blood flow in the legs, are another
rare occurrence with prostate surgery. During recovery,
compression stockings help maintain a continuous blood flow
in the legs. Walking after surgery is another important
way to pump blood from the legs to the heart.
- Death
is a risk of all surgery involving anesthesia, but an extremely
rare occurrence in radical prostatectomy.
Side effects of radical prostatectomy
The main
side effects which may occur with radical prostatectomy are
incontinence,
the inability to hold urine inside the bladder voluntarily
or prevent its leakage and erectile
dysfunction, the inability to achieve or maintain
an erection adequate for sexual intercourse. These side effects
are somewhat less common than in the past. In the hands of
a skilled surgeon, nerve-sparing surgery significantly increases
the likelihood that impotence and incontinence will be only
temporary.
After
radical prostatectomy, men experience dry orgasms in
which there is no ejaculation. The reason is that the two
structures responsible for most of the fluid in semen -- the
prostate and the seminal vesicles -- have been removed. The
vas deferens, the tube which transports sperm from the testicles,
has been shut off. This lack of fluid emission has no connection
to and does not interfere with, a man's ability to feel sexual
desire and arousal, or achieve orgasm.
1 Kao TC, Cruess DF, Garner
D, Foley J, Seay T, Friedrichs P, Thrasher JB, Mooneyhan RD,
McLeod DG, Moul JW. Multicenter patient self-reporting questionnaire
on impotence, incontinence and stricture after radical prostatectomy.
J Urol 2000;163(3):858-64.
The
Prostate Cancer pages of this Web site are part of the Comprehensive
Prostate Cancer Awareness Program (CPCAP), a major regional
effort to reduce the rates of death and illness caused by
prostate cancer in southwestern Pennsylvania. Funding for
CPCAP is provided by a grant from the Commonwealth of Pennsylvania.
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