The Procedure

A prostatectomy necessitates an average hospital stay of two days and a minimum of three weeks' recuperation. It can be carried out under general anesthesia or with a local block (spinal or epidural) in which the patient is awake but feels nothing. When a local block is used, the patient is also given sedation and usually sleeps through the operation. Some surgeons and anesthesiologists have strong preferences regarding which form of anesthesia to use, whereas others let the patient decide.

Is Laparoscopic or Robotic Surgery Right for You?

Laparoscopic and robotic prostatectomies are new; thus few follow-up data are available. Advocates and critics make the following points:

• All agree that there is usually less blood loss, less pain, shorter hospitalization, quicker recovery, and smaller scars.

• Some claim the camera provides better vision. Others claim the surgeons cannot see the whole field and, because their fingers are not used in the operative field, they cannot feel cancerous tissue that is palpable but not visible in lymph nodes or surrounding tissues.

• Some claim the computerized system permits a more precise dissection of the nerves next to the prostate and thus improves the chances of retaining erections. Others doubt this. There is as yet no long-term follow-up to ascertain the facts.

• Some claim that preliminary studies with these methods have reported a higher rate of positive margins, meaning that some cancer may have been left behind. Others say this occurs only with inexperienced surgeons.

• All agree that the cost of surgery using the robotic system is extremely high and may not be fully covered by medical insurance.

• All agree that laparoscopic and robotic surgery is technically very demanding and difficult to learn. Men selecting this option should choose a surgeon who has performed at least thirty such surgeries. (The question is, on whom should those thirty surgeries be done?)

In most cases a vertical, abdominal incision is made, stretching from the umbilicus to just above the penis; this is the retropubic prostatectomy. A perineal approach, in which a small horizontal incision is made between the back of the scrotum and the anus, is also possible; it can be useful for men who are obese, but may present problems if the tumor is very large. A perineal prostatectomy is much less commonly performed now than it was in the past.

In the last decade, laparoscopic prostatectomies have been introduced in which the procedure is carried out with long instruments through multiple small abdominal incisions. This surgery is technically very demanding and is presently performed in only a few centers, but it is rapidly becoming more widely available. Proponents claim that it produces less blood loss, less postoperative pain, and quicker recovery. All the same, laparoscopic prostatectomies have been described by one surgeon as being like ''backing a tractor trailer around a curve by looking through the rearview mirror.''4

A variant of laparoscopic surgery is surgery performed by a robot, which the surgeon guides by using a computer. The surgeon may be seated several feet from the patient, or theoretically could even operate while sitting in the next room. Three computer-controlled robotic arms do the actual surgery: one holds a video camera, and the other two hold tiny tools for cutting, suturing, and so on. The robotic system most widely used is the da Vinci system developed by the U.S. military; the robot costs approximately $1.2 million.

Surgical removal of the prostate can be carried out in many cases via a nerve-sparing procedure. This approach, developed in 1982 by Patrick Walsh at Johns Hopkins University and Pieter Donker in the Netherlands, involves careful dissection of the nerves to the penis that run immediately next to the prostate gland. When the nerves are preserved, the chances of retaining erections after surgery are increased. In 10 to 20 percent of prostate cancer cases, it is not possible to preserve one or both nerves, because the cancer is immediately adjacent to them, and preserving the nerves would risk leaving cancer cells behind.

Most surgeons like to wait at least four weeks after the biopsy before doing surgery; this delay gives the rectal wall a chance to heal and decreases the likelihood of injuring the wall as the prostate is removed. In addition, it provides the man who has decided on surgery an opportunity to take care of necessary tasks.

All blood-thinning medications including warfarin (Coumadin), aspirin, and aspirin-containing over-the-counter medications should be stopped at least ten days prior to surgery. Many surgeons ask patients to donate two units of blood for use during surgery, since the average blood loss is between one and one and a half units. Some surgeons ask men to take iron pills to build up their blood before the surgery. Men should also discuss anesthesia with the surgeon and/or anesthesiologist.

One of the things I personally found helpful before surgery was planning how I would spend my "post-op" recuperation period. I went to a video store and made a list of old movies I wanted to see. My wife recommended comedies, but I selected mostly the tragedies of Ingmar Bergman; they seemed more in keeping with the occasion. I also did all the yard work I could, knowing that it would be depressing to sit on the porch during my recovery and look at the jobs not done.

Another presurgical task I found helpful was to visualize myself entering the hospital, taking off my clothes, putting on a surgical gown (it hardly warrants such a designation), and being wheeled into the operating room. It was also helpful to have visited the hospital for my presurgical procedures. Although I am a physician, my

Things to Do Prior to Surgery

• Check your insurance coverage.

• Draw up and sign a living will if you do not already have one.

• If you are employed, check your sick-leave policy and arrange coverage of your tasks for at least three weeks following the surgery.

• Stop warfarin (Coumadin), aspirin, and all medications containing aspirin (Anacin, Bufferin, and the like) at least ten days prior to surgery.

• Donate two units of blood for use during your surgery, and take iron pills if your surgeon recommends it.

• Discuss anesthesia options with your surgeon and/or an anesthesiologist.

• Plan for your initial weeks of recuperation.

• If you live alone, make arrangements to have someone stay with you for the first week after surgery.

• Visualize yourself going to the hospital and into surgery. The image will decrease your anxiety when you actually do so.

relationship with surgeons and hospitals was a distant one on the best of days. My only personal surgical experiences were having had my tonsils removed as a child under ether anesthesia (which I clearly recall produced a feeling of suffocation), and the surgical repair of a fracture under local nerve block anesthesia that did not really block the nerve. Thus, I could identify with General Schwarzkopf who, in discussing his own lack of enthusiasm for surgery, said, ''I go into a kung-fu attack position when I go through the door of a hospital.''5 Men who have previously undergone other major surgery are likely to have an easier time with prostate cancer surgery than those who have not.

On the day prior to surgery, you are restricted to a clear liquid diet, and the night before, you are instructed to give yourself a Fleet enema. Entering the hospital for the surgery proved to be less onerous than I had anticipated, thanks to having practiced visualizing it and to the support of my wife. Nevertheless, the temptation remained to suddenly declare that watchful waiting was the better treatment—and bolt. I was scheduled as the first case of the day, an arrangement I recommend so that you do not have to lie around waiting. My surgeon greeted me; I briefly contemplated asking him to replace my degenerating hip while he was working on my prostate, since it was anatomically close by. However, I decided that although I was certain about his surgical skills, I was uncertain about his sense of humor. In the operating room, I surveyed the operating room staff, reassured myself that they appeared alert, then suddenly was asleep.

I vaguely recall awakening in the recovery room and being asked questions. I do not recall feeling much pain, but I have a high pain threshold, so I may not be an accurate gauge. I apparently answered questions correctly, because I was wheeled to my room and my waiting spouse. I considered rolling my eyes up in my head and letting my tongue hang out the side of my mouth as a novel greeting but calculated—correctly, I was later told—that even a strong marriage might not withstand such a shock.

Despite being groggy from the anesthesia, I felt it necessary to reconnoiter my anatomy. I had an intravenous tube in one arm, and my legs were enveloped in pneumatic stockings that effectively tied my legs to the bottom of the bed. Every minute or so, the mechanized stockings slowly massaged my legs, a process described by one man as ''coiling upwards, squeezing you from ankle to thigh like two pet boas in estrus.''6 The stockings decrease the probability of blood clots in your legs. My lower abdomen was covered with a large dressing, and an adjacent smaller dressing covered the opening for the surgical drain. A urinary catheter exited my penis and ran to a bag attached to the bed. My penis and the surrounding tissues were partially black-and-blue. I was beginning to understand the meaning of the ''major'' in major surgery.

And then, with a shock, I noticed: my penis looked a little shorter! I recalled a passage in Dr. Patrick Walsh's Guide to Surviving Prostate Cancer:

Note that the gap between the bladder and urethra—where the prostate used to be—is now filled by the bladder. Some men worry that the penis will be shortened—that the surgeon will pull it up to meet the bladder. This doesn't happen; instead the bladder is mobile, and can easily be pulled down to meet the urethra.7

The book's reassurance notwithstanding, the visual evidence was compelling. Most men pay close attention to such details. My initial reaction was a mix of incredulity and amusement, and I wondered how many other things that I had read about prostate surgery were mistaken.

A few weeks later, I surveyed the medical literature regarding this phenomenon. Two studies reported that, when measured before prostate surgery and three months later, two thirds of men showed a decrease in penile length. In the majority of cases, the decrease was minimal, but in some men it was 15 percent or more. One man wrote that his genitals ''had shrunk and receded into [his] body to such an extent that they surely would have been safe from Lorena Bobbitt.''8 Over time, the decrease in penile length becomes less noticeable and does not seem to affect penile function. Some urologists have attributed the shortening to disuse or fibrosis of the penis, but this is obviously not the case, since the shortening is visible immediately post-op. A more likely explanation is that it is a reaction to the inevitable small-nerve damage during surgery. The bottom line is that nobody seems to know the cause, but denying that the decrease may occur is not helpful when the facts are otherwise.

On the day of surgery, I received intravenous ketoralac (Toradol) for pain and did not feel much discomfort. Toradol is a strong, nonsteroidal anti-inflammatory drug that should not be taken for more than five days because of its propensity for causing peptic ulcers or gastrointestinal bleeding. It can also generate nausea or diarrhea. It made me drowsy, so I slept much of the day and woke up at two in the morning. Fortunately, I had brought headphones and CDs with me and spent most of the night listening to classical music, pleased that I had survived the ordeal. My private room was well worth the extra expense and allowed my wife to spend the night there as well. The following morning, twenty-four hours after surgery, one of the urologists checked me and asked if I wanted to go home. This seemed extraordinary, but is typical of hospital stays in the era of managed care. I allowed that I thought I would stay for another day; if I had been living alone, I would have stayed longer. Nevertheless, because of the risk of hospital-acquired infections, hospitals are dangerous places to spend time unnecessarily and no one should stay longer than is absolutely essential. I spent the day walking the hall with my catheter bag, accompanied by other prostatectomy patients. In My Prostate and Me, William Martin describes a similar scene as ''the few, the humiliated, the Urine Corps'' and adds: ''One look at my new peer group moved me to suggest that it might be best if would-be visitors just sent a note or called. Men look better in power suits.''9

By day 2 after surgery, I was ready to go home but had two urgent questions for my urologist: What did the pathology report say about whether my cancer was confined to the prostate, and had he saved one or both nerves? The second question was quickly answered: one (as I had suspected would be the case from the size and position of the cancer). To answer the first question, my urologist went to the pathology department himself and reviewed the slides with the pathologist. The cancer had penetrated the capsule but had not gone through it and had a ''negative margin,'' meaning that the cancer appeared to have been confined to the tissue removed at surgery. There was also no spread to the seminal vesicles or lymph nodes. This was all positive news.

The first two weeks of recuperation were surprisingly pleasant. My wife and I read, took short walks, and watched movies each afternoon before having a drink. I was surprised at how easily I became fatigued and I took a nap each day. I also listened to a CD series on the history of science and sat in the sun. I was fortunate to have only occasional pain, such as when I sneezed and thereby increased the abdominal pressure; I used no pain medication after leaving the hospital. Some nurses recommend a firm ''laugh pillow'' to hold against your abdomen when you laugh, sneeze, or cough. It is also important to not become constipated, which can be caused by pain medications such as codeine, by iron pills, and by inactivity; constipation can be avoided by taking laxatives. (I elected not to take iron pills

Of Dogs and Catheters

Geoff Barnard of Flagstaff, Arizona, wrote the following account of his adventures with a catheter after having a radical prostatectomy for prostate cancer:

Several nights ago here at home I woke up to our smoke alarm going off. That scared the dog, Copper, who dove under the bed and in so doing got my catheter tube wrapped around her neck. So imagine my fun, grabbing the tube with a forty-five-pound terrified dog pulling in the other direction, screaming to Diane to hold the dog and get it unwrapped, with the smoke alarm going off all the while. It will be hard to top that with an encore!

after surgery, as had been recommended to build up my blood count, in order to avoid possible constipation.)

My main post-op problem was the catheter, which rubbed my penis and made it sore. Anchoring the catheter tube with safety pins to my pant leg seemed to help. Others have recommended putting K-Y jelly or antibiotic ointment around the opening of the penis to minimize irritation. You are given a small catheter bag that straps to your leg to use during the day; it allows you to take walks and move about freely. At night, you hook a large catheter bag to the side of the bed. Bert Gottlieb, writing of his experience in The Men's Club, said that he christened his small catheter bag ''Rover,'' because it followed him everywhere.10

My recuperative turning point came with the removal of the catheter and suture clips at ten days; contrary to what I had been told, the first did not hurt, but the second did, briefly. Some surgeons leave the catheter in for up to three weeks. Its removal meant that I was on my own to either recover urinary continence or not. My urologist had advised me to bring to the hospital what is essentially an adult diaper (see Chapter 10) to wear home, but even as I did so,

I felt as if I was getting well. I resumed driving, which also made me feel better.

Recovering urinary function after prostate surgery is an interesting experience. It is as if you have been living in an old house for many years and are familiar with the sounds of its plumbing. You know when someone downstairs flushes the toilet and when somebody upstairs is taking a shower. When your house is completely renovated with new plumbing, all the old familiar cues are gone and you have to learn new ones. I was fortunate that my external sphincter was up to the task. Continence returned quickly. I discarded the adult diaper the first day and thereafter used pads of varying sizes for three weeks. After that, I needed nothing, and in fact had less dribbling than I had had prior to surgery. Some men are not so fortunate; Michael Korda's account in Man to Man describes the problems that occur when continence does not return quickly.

After three weeks I returned to work but restricted my hours. Some men recover more slowly and take more time off. My strength gradually returned. At six weeks post-op, at which time my urologist said I could resume normal activities, my wife and I went on a planned vacation to Newfoundland to do some gentle sea kayaking. It was not until approximately three months after surgery, however, that I felt that my full strength had returned.

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