This is the alternate surgical management option for a localized prostate cancer. Widely used in the USA in the early 2000’s prior to robotic assisted surgery.

• Still a great technique to avoid a frozen abdomen due to multiple previous surgeries
• Transplanted kidney.
• Obesity
• Smaller than 50 cc prostates are better

Criteria include:

• PSA less than 10.
• Gleason 3,4 adenocarcinoma prostate.
• Higher grades with no extra-prostatic extension
• Staging negative, (bone scan negative, CT negative).
• 75 years and younger.

• It is the complete removal of the prostate, seminal vesicles and bladder neck.
• A nerve sparing procedure is attempted for those guys who have good erections and wish to maintain this.
• The procedure takes 2-3hours excluding the anesthetic time.

How is it done?

• • General anesthetic.
  • You will be placed in hyper-lithotomy.
  • Anus at eye-level.
  • The surgical filed is prepared.

• • A flexible cystoscopy is done to exclude any urethral strictures, bladder cancers and any other pathology.
  • An IDC is then placed.
  • A horseshoe incision is made around the anus.
  • The space in the front part of the rectum is entered and passed under the sphincteric muscle.
  • Dennon Villiers Fascia is cleared and opened in the midline, this brushing the erectile nerves laterally.
  • The urethra is encircled and cut just distal to the prostate sparing the sphincter.
  • The prostate is loosened anteriorly from the dorsal venous complex, thus sparing the complex and avoiding major blood loss (DVC).
  • The anterior bladder neck is opened.

• • The UO identified.
  • The posterior bladder neck cut.
  • The lateral pedicles are clipped.
  • The seminal vesicles and ampullae of the Vas Deferens, the SV are removed and the Vas clipped.
  • The prostate is loosened and removed.
  • The bladder mucosa is everted.
  • The bladder neck reconstructed.
  • The anastomosis with the urethra completed over an Indwelling Catheter.
  • A drain is left.

Complications

• Blood loss 200-400cc.
• Wound infections.
• Wound breakdown.
• Managed with Betadine sit baths.
• Stress incontinence which will improve over the next 12 months (12%).
• Complete incontinence at 12 months (2%).
• Erectile dysfunction (40-50%) where a nerve sparing procedure has been performed. It may take 12-18 months to recover.
• Anejaculation/ Infertility.
• Testicular pain similar to vasectomy for 2-3 day.

Post operative care:

• Sutures are dissolvable and will not be required to be removed.
• Normal diet.
• A salt water or Betadine Douche is required after every stool for the first week.
• Apical wound dehiscence can occur in 7% which requires extra care in the form of prolonged Salt water or Betadine Douches.
• Wounds generally heal in 7-10 days.

Post-operative review:

• Your catheter will remain for 10-14 days.
• Only after a cystogram (radiological investigations where radio-opaque contrast is placed in the bladder) confirms no leakages from the bladder-urethra-anastomosis, will the catheter be removed.
• Should there be any urine leakages on the cystogram, the catheter may remain another 7 days.
• Review PSA roughly 6 weeks after the surgery to assess post-operative Nadir.
• Review in rooms a week later.
• 3-6 monthly review depending on risk factors.
• If stable with good PSA outcomes, refer back to GP for 6 monthly PSA review.
• You will be referred to a Men’s Health Physician to assist with erectile function recovery – erections can take as long as 18 months to recover
• Continue your pelvic physiotherapy

PSA failure:

• PSA never dropping to undetectable with positive margins in histology.
• 3 consecutive PSA rises following RRP.

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Wes Prostatectomy Radical (Perineal)

Why is it done?

• This procedure is performed when the prostate gland is enlarged to such an extent that medication cannot relieve the urinary symptoms.
• Your prostate is larger than 120 cc
• Symptoms include: LUTS
  • a weak stream,
  • nightly urination,
  • frequent urination,
  • inability to urinate,
  • kidney failure due to the weak urination (obstruction),
  • bladder stones,
  • recurrent bladder infections.
• Medication such as Flomaxtra, Xatral Minipress etc. should always be given as a first resort.
• Step-up therapy should have been used for prostates larger than 35-50cc with either Duodart, Avodart or Proscar and can be used as a first line in these huge prostates.
• Conservative management with medication has failed
• Doing transurethral resection may take excessively long causing side-effects to your urethra as well as risk of irrigation fluid being reabsorbed in your vascular system leading to increased cardiac load
• You may be at risk for electrolyte disturbances with a transurethral resection of the prostate when Glycine is used
• You have BPH—benign prostate enlargement
• Prostate cancer has been ruled out by doing a PSA, and when indicated, with a 3T MRI scan of the prostate with an abnormal PSA with a possible prostate biopsy of any suspicious lesions.
• A staged-TURP can also be performed to dis-obstruct a huge prostate. Either Bipolar resection or Laser can be utilized.
• Patient informed decision is vital.
• It provides a quicker solution with more marked side-effects and risks.

How is it done?

• Patients will receive a general anesthesia, unless contra-indicated.
• Prophylactic anti-biotics is given.
• A Flexible cystoscopy is done to exclude any urethral strictures, bladder cancers and any other pathology
• An IDC is then placed
• A Camera port is placed above the Umbilicus
• 3 Additional ports for robotic arms in a horizontal line on the abdomen with 2 assistant ports on the right side of the abdomen
• The abdominal space is entered and the bladder dropped from the abdominal wall.
• Bladder opened at the dome as the prostate will be removed through the bladder
• Bladder neck opened
• Prostate adenoma enucleated
• Haemostasis
• Trigonalization of bladder, bladder pulled down into prostate cavity
• Catheter replaced
• Drain placed if required

What next?

• You will spend up to 5-7 nights in hospital.
• You will have a catheter for that time.
• A drain for 2-3 days.
• You will a trial without the catheter on the 5th day.
• You will be discharged as soon as you can completely empty your bladder.
• You may initially suffer from urge incontinence and dysuria (irritable voiding) and will improve within the next 6 weeks.
• Allow for 6 weeks for stabilization of symptoms.
• There may be some blood in your urine. You can remedy this by drinking plenty of fluids until it clears.
• A ward prescription will be issued on your discharge, for your own collection at any pharmacy.
• A follow-up appointment will be scheduled for 6 weeks. Remember there is no pathology due to vaporisation.
• Don’t hesitate to ask Jo if you have any queries.
• DON’T SUFFER IN SILENCE, OR YOU WILL SUFFER ALONE!

Side-effects

• Blood loss requiring blood transfusion.
• Infection.
• Prolonged hospital stays.
• Retrograde ejaculation in more than 90% of patients. Therefore, if you have not completed your family, this procedure is not for you unless absolutely necessary.
• Infertility as a result of the retrograde ejaculation.
• Stress incontinence especially in the elderly and the diabetic patients.
• Patients with Multiple Sclerosis, Strokes and Parkinsons have a higher risk of incontinence and risks should be discussed and accepted prior to surgery.
• Less chance of growth of prostate lobes usually within 3-5 years requiring a second procedure.
• NB! Each person is unique and for this reason symptoms vary!

Remember

You still have a peripheral zone of your prostate and regular PSA reviews are required up to the age of 75.

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Wes RA-Enucleation Prostatectomy BPH

• This is the surgical management option for a prostate cancer.
• This Surgery is done minimally invasive with the help of DaVinci Robotic System.

Indication:

• PSA less than 20.
• Gleason 3,4 to low volume Gleason 4,5 contained adenocarcinoma prostate.
• Higher grades may be considered with patients fully informed of the positive margins and the need for adjuvant radiation therapy.
• See D’Amico criteria in terminology.
• Staging negative, (PET PSMA).
• 75 years and younger.
• It is the complete removal of the prostate, seminal vesicles and bladder neck. It may include a bilateral pelvic lymphadenectomy. (Gleason 4,3 and higher).
• A nerve sparing procedure is attempted for those guys who have good erections with no tumour infiltrating the erectile nerves.
• A 24h post-operative High Care nursing may be required for patients with multiple risk factors.
• The procedure takes 2-3 hours excluding the anesthetic time.
• You will be given Deep-Vein-Thrombosis prophylaxis in the form of compression stockings, pneumatic compressions and Clexane 40-80mg subcutaneously daily. You will continue with the Clexane for 28 days. You are at risk for deep vein thrombosis due to the dynamics of any cancer in the body, which may lead to a pulmonary embolism with immediate death as result.

PSA failure

• PSA never dropping to undetectable with positive margins in histology.
• 3 consecutive PSA rises following RARP.

How is it done?

• General anesthetic.
• The surgical field is prepared.
• A flexible cystoscopy is done to exclude any urethral strictures, bladder cancers and any other pathology.
• An IDC is then placed.
• A camera port is placed above the Umbilicus.
• 3 Additional ports for robotic arms in a horizontal line on the abdomen with 2 assistant ports on the right side of the abdomen.
• The abdominal space is entered and the Retropubic space of Retzuis is entered.
• Endopelvic fascia is cleared and opened exposing the lateral sides of the prostate.
• An “ULTRA-HOOD’ed” technique has been adopted this sparing the neurovascular bundle and the anterior supporting structures of the prostate providing superior continence preservation
• The bladder neck is opened.
• The bladder is loosened from the prostate.
• Dennon Villiers fascia is opened to expose the Seminal Vesicles and ampullae of the Vas Deferens, the SV are dissected and the Vas clipped.
• The lateral vascular pedicles are clipped.
• The erectile nerves are now completed spared off the prostate.
• The Dorsal Venous Plexus is partially preserved.
• The urethra is cut.
• Prostate is removed.
• The anastomosis with the urethra is completed over an Indwelling Catheter.
• Obturator nodes may be removed depending on the D’Amico Risk category at the beginning of the procedure.

Complications

• Wound infections.
• The first 6 weeks are the worst with frequency and urgency as a result.
• Stress incontinence may occur and will improve over the next 12 months (12%).
• Complete incontinence at 12 months (2%).
• Erectile dysfunction (30%) where a nerve sparing procedure has been performed yet may improve over the next 18 months.
• Bladder neck stenosis in up to 2 % requiring intermittent self-dilatation.
• Anejaculation / Infertility.
• Testicular pain similar to vasectomy for up to a week.
• Possibility of bowel injury.

Post operative care

• Sutures are subcutaneous and will be dissolved.
• You may have a drain in the wound for 24-48 hours until it drains less than 30ml / 24 hours.
• You may be discharge on the 2-3 days post operatively depending how soon your bowels open.
• Normal diet will be commenced.

Catheter care

• Your catheter will remain for 10-14 days.
• Only after a cystogram (radiological investigations where radio-opaque contrast is placed in the bladder) confirms no leakages from the bladder-urethra-anastomosis, will the catheter be removed.
• Remember you will leak initially, with gradual improvement up to 6 weeks post-operatively.
• Nursing staff will teach you catheter care.
• Your catheter should always be fixed to your leg with a catheter dressing.

Post-operative review

• Cystogram at 10 days post-operatively to assess complete healing of urethra bladder neck anastomosis to exclude any leakages.
• Should there be any leakages, the catheter may remain another 7 days.
• Review PSA roughly 6 weeks after the surgery to assess post-operative Nadir.
• Review in rooms a week later.
• 3-6 monthly review depending on risk factors.
• If stable with good PSA outcomes, refer back to GP for 6 monthly PSA review.
• You will be referred to a Men’s Health Physician to assist with erectile function recovery – erections can take as long as 18 months to recover
• Continue your pelvic physiotherapy

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Wes RA Radical Prostatectomy

• This procedure is performed when the prostate gland is causing LUTS and you want an alternative to medication without the complications of a permanent procedure.
• Ejaculation sparing
• Symptoms include:
  • a weak stream,
  • nightly urination,
  • frequent urination,
  • inability to urinate,
  • kidney failure due to the obstruction,
  • bladder stones,
  • recurrent bladder infections.
• Medication such as Flomaxtra, Urorec Minipress etc.  should always be given as a first resort.
• Duodart should not be prescribed for a man wishing to preserve sexual function.
• This is alternative to medication where ejaculatory function is to be preserved.
• Prostate cancer first needs to be ruled out by doing a PSA, and when indicated, with a 3T MRI scan of the prostate with an abnormal PSA with a possible prostate biopsy of any suspicious lesions.
• Prostate sizes up to 80-90 cc even midlobes are acceptable.

How is it done?

• Patients will receive a general anesthesia, unless contra-indicated.
• A cystoscopy is performed by placing a camera in the urethra with the help of a lubricant jelly and an irrigant (fluid).
• The inside of the bladder is viewed for pathology. If any suspicious lesions are seen, a biopsy will be taken.
• The device is placed through the cystoscopy sheath.
• A string will be left hanging out
• Prophylactic antibiotics will be given to prevent any infections.

Prophylaxis

• Prophylactic antibiotics.
• Cease all anti-coagulants i.e.: Warfarin and Aspirin 7-10 days prior to surgery.
• A script for Clexane 40mg daily subcutaneously will be provided to be commenced 7 days before biopsy when you Warfarin is ceased.

What to expect afterwards

• Any anesthesia has its risks, and the anesthetist will explain this to you.
• You may in extreme cases experience some blood loss.
• You will have a string hanging out from your urethra for 5-7 days
• Don’t pull on the string
• Lower abdominal discomfort for a few days
• Could have an inflammatory response requiring antibiotics.
• Discomfort in urination and frequency and urgency while the stent is in.
• You will be needed to return a week later for another day procedure under sedation for the removal of the stent
• A trial of void to confirm good urination
• Allow for 6 weeks for stabilization of symptoms thereafter.
• There may be some blood in your urine for up to 4 weeks post op. You can remedy this by drinking plenty of fluids until it clears.
• A follow-up appointment will be scheduled for 6 weeks.
• DON’T SUFFER IN SILENCE, OR YOU WILL SUFFER ALONE!

Complications

• Hematuria (blood in urine) 2-3days.
• Ejaculation will not be affected thus preserving sexual function
• Infertility should not be an issue as there is no retrograde ejaculation. Don’t do it if you still want children.
• No Stress incontinence especially in the elderly and the diabetic patients
• May experience a slower stream initially due to swelling
• Some urgency symptoms for 6 weeks
• Possible infection.
• Further enlargement of prostate lobes within 3-5 years requiring a repeat procedure.
• NB! Each person is unique and for this reason symptoms vary!

ANY FEVER OR RIGORS REQUIRES URGENT ATTENTION

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