John J. Bauer, M.D. www.flinturology.com Urology Services, Inc. G-1121 West Hill Rd. Flint, Michigan 48507 Tel: 810.232.8888 Fax: 810.232.9190 Email: jbauer@flinturology.com [map]

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Contents
General information
Pre-operative instructions
Risks and Complications
Detailed Surgery Description
Family waiting instructions
Post-operative instructions

Printing tip: If you want to print only one portion of this entire document, you should be able to do this depending on your software. To print a selection, highlight the section you want to print using your mouse, then click on print, and then in the print menu, choose "selection."

Terminology tip: If you come across words you don't understand, look them up in the On-Line Medical Dictionary.

This procedure is performed to eradicate localized prostate cancer. It is performed through an incision through the midline abdomen from below the belly button to the top of the pubis bone. This procedure is suitable for any size prostate and the lymph nodes can be removed through the same incision. If you have a small prostate or the lymph nodes are unlikely to be involved then you could choose to do a less morbid procedure called the radical perineal prostatectomy. This perineal approach removes the prostate from an incision made between the anus and the scrotum. The perineal operation requires less hospital stay, less catheter time and has less blood loss

Your pre-operative appointments

Before your surgery, you will be seen by the physician and the anesthesiologist, and when applicable, there is a pre-admission appointment with the hospital. Click here to read more details about these appointments, referred to as the Pre-Operative Work-Up.

Change In Health Status

Notify your surgeon if you experience any significant change in your health status: develop a cold, influenza, a bladder infection, diarrhea, or other infection, before your surgery.

Pre-Operative Medication Instructions

Unless specifically instructed otherwise by your surgeon or anesthesiologist, please observe the following guidelines for taking your medicines before surgery:

1. One Week Prior to Surgery:
   - STOP all aspirin and all aspirin-containing medicines (e.g., Anacin, Excedrin, Pepto-Bismol). Check any cold or pain medication bottles to make certain aspirin is not contained. See additional list at Blood Thinners.

2. Two Days Prior to Surgery:
   - STOP all nonsteroidal anti-inflammatory medications (e.g., etodolac [Lodine], fenoprofen [Nalfon], ibuprofen [Advil, Motrin, Nuprin], ketorolac [Toradol], maproxen [Aleve], meclofenarnate [Meclomen], mefenamic acid [Ponstel], naproxen [Anaprox, Naprosyn].

3. Day Before Your Surgery:
   Start the pre-operative Bowel Prep (cleansing procedure) appropriate for this surgery, as described below.

   Your operation occurs near the bowels so your preparation involves an intermediate-level bowel prep, as follows.

   • 2-Bottles of Magnesium Citrate
   • 2-Fleets Enemas or Neomycin Enemas
     • Night before
     • Morning of the surgery

4. On the Morning of your Surgery:
   • DO NOT TAKE digitalis medicines (e.g., Crystodigin, Digoxin, Lanoxin).
   • DO NOT TAKE oral antidiabetes medicines (e.g., chlorpropamide [Diabinese], glyburide [DiaBeta, Glynase, Micronase], glypizide [Glucotrol], tolazamide [Tolinase], tolbutamide [Orinase].
   • DO TAKE one-half of your usual morning. INSULIN dose. DO NOT TAKE your morning INSULIN dose if you are driving a great distance the morning of surgery or if your surgery is scheduled for the afternoon.
   • DO TAKE, with a small sip of water, ALL of your other usual morning doses of regularly prescribed medicines. Use your asthma inhalers and bring them with you to the hospital.

Pre-Operative Diet Instructions

Unless specifically instructed otherwise by your surgeon or anesthesiologist, patients of all ages must observe the following diet restrictions before surgery:

1. Eight hours before the Scheduled Start of your Surgery:
   DO NOT EAT any solid foods, including juices with pulp (e.g., orange juice, nectars), lozenges, candy, chewing gum, and mints. DO NOT DRINK full liquid, such as milk, cream, and jello. You may continue to drink up to eight ounces of clear liquids until SIX hours before the scheduled start of your surgery. Clear liquids include Water, clear juices (e.g., apple, grape), black tea and black coffee.
2. Six hours before the Scheduled Start of your Surgery:
   DO NOT TAKE anything by mouth except for your usual medicines; follow the Preoperative medication instructions above.
3. Exceptions:
   DO NOT TAKE anything by mouth for eight hours, except for your usual medicines, if you are pregnant, morbidly obese, or are diagnosed with diabetes, renal failure, or stomach acid reflux with heartburn.

Patients undergoing operative or diagnostic procedures involving sedation are required to refrain from eating, drinking or taking anything by mouth for a stated period prior to their surgery or procedure. The reason for this is to prevent complications caused by nausea or vomiting while you are unconscious. Should you vomit while in the unconscious state, the risk exists that the vomit may enter into your lungs causing serious complications such as pneumonia. These complications may result in an extension of your hospitalization following your surgical procedure. It is for this reason patients are often instructed to have nothing by mouth after midnight the night prior to your operation unless otherwise instructed by an anesthetist.

Pre-Operative Cleaning Instructions (bathing and showering instructions)

Pre-operative showers are to be taken the night before and the morning of surgery just prior to your arrival. All adults are required to take a shower using either a Betadine or Hibiclens Surgical Scrub antibacterial soap. The reason is to remove as much bacteria from your skin as possible prior to your surgery. If you are allergic to these products please notify your physician or nurse. Perform your shower as follows:

1. Generously lather your body, scrub well, and rinse. Give particular attention to the area were the incision will be made for your procedure.
2. Following the morning shower, do not apply creams, body oils, lotions, perfumes, deodorants, makeup, lipstick, nail polish or any other cosmetic product to the skin or nails.
3. Do not use Hibiclens on your face. You may use any other antibacterial soap for the face.
4. Children under 5 years of age are to be given a bath using an over the counter antibacterial soap.

On The Day Of Surgery

• Take your medicines as instructed above.
• You may brush your teeth; rinse your mouth, but do not swallow the water.
• Leave all jewelry (including wedding and all other rings) and valuables (including money and credit cards) at home.
• If you wear contact lenses, glasses or hearing aids, please bring a case or container, and solution for contacts, to protect them while you are in surgery.
• Wear a minimum amount of makeup, and no mascara. Please remove the nail polish from both index fingers.
• Please bring a copy of your current medical problem list from you primary care physician (family medicine/internist).
• Minors (anyone less than 18 years old) must be accompanied by a parent or legal guardian to sign the operative consent fount

The anesthesiologist will discuss with you the anesthetic most appropriate for your medical condition and procedure prior to surgery.

After your surgery you must be escorted/driven home by a responsible adult. You may take a taxi car or shuttle if accompanied by a responsible adult who can stay with you after the driver departs.

Time To Arrive For Your Surgery

During your Pre-Admission Interview, our Registered Nurse will provide you with the correct time to arrive for check-in prior to your surgery.

ARRIVAL TIME:
WHERE TO ARRIVE:

The risks and complications for this surgery are described in the "Counseling and Pre-Op Note" that you will need to sign before the surgery. The main content of that note is listed below.

Indications:

Patient is a male with a diagnosis of prostate cancer determined with needle biopsy of the prostate performed for an abnormal digital rectal exam and/or an elevated PSA blood test. The pathology report showed the cancer to have a Gleason sum of X + X = X. If the PSA was above 10.0 or the Gleason sum was greater than or equal to 8 the metastatic evaluation of CXR, bone scan and/or CT of the pelvis was without evidence of distant spread.

Alternatives:

Alternatives include watchful waiting, radiation therapy (external beam and radioactive seed placement), cyrotherapy, and hormonal therapy. Surgical options are retropubic or perineal prostatectomy.

Risks/Complications:

The risks and complications of the procedure where extensively discussed with the patient. The general risks of this procedure include, but are not limited to bleeding, transfusion, infection, wound infection/dehiscence, pain, scaring of tissues, failure of the procedure, potential injury to other surrounding structures, deep venous thrombosis, pulmonary embolus, myocardial infarction, heart failure, stroke, death or a long-term stay in the Intensive Care Unit (ICU). Additionally, mentioned were the possible serious complications of the anesthesia to include cracked teeth, airway damage, aspiration, pneumonia, spinal head-ache, nerve damage, spinal canal bleeding and malignant hyperthermia. Your anesthesiologist will discuss the risks and complications in more depth separately. Additional procedures may be necessary.

The specific risks of this procedure include, but are not limited to: impotence, incontinence, urinary tract infection, bladder neck contracture, rectal injury which may be severe enough to require a fecal diversion procedure with a colostomy and then future reattachment of the colon, fecal incontinence, loss of ejaculatory function, change in the character or loss of orgasm, chronic pain of the epididymus or testicle, additional procedures may be required in 30% of patients for incontinence that include: urethral bulking agents; male sling; or artificial urinary sphincter placement, 50-80% for impotence to include: oral agents; vacuum tumescence devices; penile injection therapy; intraurethral agents; and or penile prosthesis placement, 10-15% for bladder neck contracture to include: bladder neck incision; dilation therapy and laser ablation of the stricture, positive surgical margins or seminal vesicle invasion potentially requiring adjuvant radiation therapy or hormonal therapy. If palpable lymph nodes are detected during the procedure and confirmed to contain prostate cancer on the frozen section the procedure will be halted at the patients request (pre-operative decision). Patient also needs to realize that frozen section diagnosis could have significant error. The addition of PLND could cause a lymphoceole, which may require prolonged percutaneous drainage, lymph edema of the lower extremities, injury to the obturator nerve which will cause inability to move legs to midline and cause a gait disturbance.

You understand the procedure, general and specific risks as discussed and agree to proceed with the procedure. You also understand that not every possible complication can be listed in this counseling note and additional risks are possible, although unlikely.

To view the actual printable form for this surgery, click here: Counseling Note for Radical Retropubic Prostatectomy. To print the document, simply select print after you have opened the page. You can use that copy to sign before your surgery.

Terminology tip: If you come across words you don't understand, look them up in the On-Line Medical Dictionary?.

Indications: Male with clinically localized prostate cancer

Sample Procedure Dictation:

Patient was given a continuous epidural anesthetic with supplemental general anesthesia. He was placed in the supine position and then was prepped and draped in the usual standard sterile fashion. A 24 French Foley catheter was placed per urethra with good return of urine; balloon was inflated to 30 cc with sterile saline. A midline incision was made from the umbilicus to the symphysis pubis coagulating all bleeders as the where encountered. The rectus fascia was divided the length of the incision and the space of Retsius was developed bluntly to expose the bladder, prostate, and obturator fossa. The obturator lymph nodes were palpated to rule out any characteristics of metastatic spread. All nodes were normal in character. A standard obturator lymph node dissection was performed bilaterally taking care not to injury the iliac artery/vein and the obturator nerve. All vascular tributaries and lymphatics were clipped to remove the packets. These were then sent for permanent pathological review. The pre-prostatic fat was removed from the anterior prostate with bovie coagulation; a 0-chromic figure eight suture was placed around the superficial dorsal veins at the level of the bladder neck to control back bleeding. The endopelvic fascia was then entered bilaterally to expose the puboprostatic ligaments. The dorsal vein complex was then isolated with the mixter clamp and #2-vicryl was used to tie the deep dorsal vein complex without division of the puboprostatic ligaments. The complex was then bovied and divided over the mixter clamp. Bleeding was controlled with a figure eight suture just above the urethra and below the pubis.

A tonsil clamp was then used to isolate the neurovascular bundles unilaterally/ bilaterally.

A generous urethral stump was left after sharp division of the urethra over a mixter clamp. The rectourethralis muscles were then divided and dissection of the prostate off the rectum proceeded without difficulty, the pedicles were clipped and divided exposing the posterior bladder neck and Deonvielles fascia.

A nerve sparing technique was accomplished unilaterally/bilaterally as this dissection of the prostate proceeded.

The fascia was divided and the ampulla of the vas was isolated, clipped and divided. The seminal vesicles were then isolated, clipped at the apex and divided. The remaining portions of the pedicles were then clipped and divided exposing the posterior bladder neck. We proceeded with a bladder neck sparing procedure. The urethra was then divided sharply after the Foley catheter was removed and the specimen handed off the table after inspection for completeness of resection. The bladder neck was inspected and tapered to a 20 French Foley size. A Greenwald sound was then passed through the urethra to expose the distal urethral stump and five 0-chromic sutures where placed in a radial fashion. A 20 French Foley was inserted through the urethra and then into the bladder neck and the five 0-chromic sutures were placed in the bladder neck, taking care to get good mucosa to mucosa apposition. The sutures were then tied over gentle Foley traction. A 15mm Jackson-Pratt drain was placed through a separate stab incision in the pelvis. The operative site was inspected for possible bleeders, which were clipped if found. The fascia was then closed in a running fashion with #2-vicryl suture. The subcutaneous tissue was irrigated with saline and the skin was closed with staples. Xerofoam gauze was placed over the incision and bandaged. The JP drain was secured and the Foley was tapped with gentle traction. Patient was then awaken from anesthesia without complications and transferred to the Recovery Room (RR) with the epidural used for pain control. The patient arrived to the RR in stable condition and without complications.

To the family and friends of patients undergoing surgery.

SCHEDULED STARTING TIME OF SURGERY:

ESTIMATED LENGTH OF SURGERY:

You should plan to check in at the waiting area information desk as soon as your family member or friend has left for the Operating Room. This is the only way we can talk to you afterwards, or on occasion; reach you to give you updates on the operation's progress. If the surgery is scheduled for many hours, you can leave to eat or do other things, but you should let the information desk know that you are going to leave the area, where you are going, and how long you might be gone so that we might reach you if need be. You should be in the area before the elected time of the end of the operation.

The information deck will overhead page you or the "family of" when they receive the recovery call to let you know that the surgery has been completed. The overhead page system works ONLY on the Surgical Waiting Area and not throughout the hospital or the cafeteria.

We will plan to see you in the surgical waiting area after we have safely completed the early phases of the post-anesthesia recovery in the "Recovery Room" or PAR (Post Anesthesia Recovery). This may take up to an hour after the initial call. Sometimes, especially if another case is ready to start, we will call and talk to you. If for some reason, we have not come or called within 30 minutes, please ask the information desk to page us.

Your family member will be in the Recovery Room for 1-2 hours. This is standard recovery time, although the times vary with each individual. For example, spinal anesthetics take longer to "wear off," local anesthetics are much shorter acting. Under no circumstances are family members or friends allowed in the recovery room. The information deck will inform you of the patient's return to the room as soon as they receive the information that the patient has left recovery. At that time, they will give you the room number and direct you to the correct wing and floor.

Activity

1. No heavy lifting (more than 15 lbs.) for 4 weeks (1 week for an implant).
2. No driving for 3 weeks (1 week for an implant). We also discourage riding in a car since the vibrations and movement may cause bleeding.
3. Use the stairs infrequently. Take one step at a time, and have assistance available.
4. No long trips for 3 weeks.
5. No cutting the lawn, shoveling snow, raking leaves, etc., for 4 weeks.
6. No sexual activity for 6 weeks after surgery.
7. No manipulation of the prosthesis
8. Showers after the bandages are removed (48 hrs) are okay. It is okay to wash the wound, do not rub the wound just pat dry it. Avoid tub baths or swimming in a pool for 1 week.
9. Regular light activity is encouraged several times daily. We encourage walking. Do not be a couch potato.
10. If discomfort returns then reduce activity, take it easy, and more gradually resume activities.

Diet

1. Drink plenty of fluids. We recommend 24-32 oz over your usual daily fluid intake. Limit fluids after 6 PM. Avoid tea, coffee (including decaf) and pop.
2. Resume a regular diet at home. Take high calorie supplements if appetite is poor.
3. If you have a special diet secondary to Diabetes, Renal Disease, Liver Disease, etc. you may resume eating when tolerated.

Medication

1. Please take the medications as prescribed by your doctor. Start them on day of discharge, and please complete the entire prescription. Take pain medication only as needed. Try Tylenol or Motrin for milder pain. You will typically be discharged with your old medications and new pain medication, antibiotics and stool softeners
2. Resume all medications you normally took before surgery, unless instructed otherwise. Do not take blood thinners or aspirin products for 1-2 weeks or as directed.
3. If there is a problem taking or getting the medication, call us.

Catheter and Wound Care

1. Do not remove the dressing from the wound unless instructed. If you are home with a bandage, it is usually removed after 48 hrs.
2. Your sutures will dissolve over time and do not need to be removed. Your steri-strips will fall off over a two-week period; please let them fall off on their own rather than removing them. You can trim the edges of the steri-strips that have rolled up onto themselves if they bother you.
3. You may cover the wound with gauze if there is mild drainage.
4. If the wound becomes red, inflamed, or has excessive drainage, please contact your doctor immediately.
5. If you notice pus coming from any wound, please call your physician.
6. Expect some spotting or bleeding from your incision for the next 1-week, if it progressively worsens then please call your physician.
7. If you have a catheter in place, wash around it gently with soap and water. Keep the catheter taped to your thigh or abdomen to avoid inadvertent jerking or pulling. Do not disconnect the catheter from the drainage bag unless directed by your doctor. You may apply Bacitracin ointment at the point the catheter enters your body.

Bowel Movements

1. Do not strain when having a bowel movement. Expect irregular bowel habits after surgery until fully recovered. Increase fiber in your diet.
2. You may need to use a stool softener or laxative. Try Colace (Docusate Sodium), Metamucil or Milk of Magnesia at your local pharmacy.

When to Contact your Doctor

1. Excessive bleeding or passage of large clots. Also if you feel your bladder is not draining or if you are unable to urinate.
2. Fevers greater than 101º F, excessive chills.
3. Nausea and vomiting or inability to keep down fluids.
4. If you have any questions or concerns that are not covered by this handout.
5. Significant tenderness or swelling in the legs, chest pain, shortness of breath.
6. If it is a serious emergency, go the Emergency Room or call 911.
7. Please call the office to arrange your follow-up appointment.

Contacting Your Physician

Dr. Bauer can be contacted by calling the number listed at the top of the page. You may also call the hospital to have them contact us. Please do not hesitate to call with any questions or concerns.

Frequently Asked Questions after surgery

This section is under construction.