For Patients

Prostate Cancer

Prostate cancer is a common problem, and Newcastle Urology is one of the leading tertiary centres in the country providing treatment for men with all stages of this disease. Brachytherapy is not performed at any other hospital in the region and we undertake the highest number of robotic prostatectomies in the North of England.

Brachytherapy treatment for prostate cancer

What does the procedure involve?

This involves the insertion of radioactive seeds into the prostate gland with needles placed through the skin beneath the scrotum. This procedure may require a telescopic examination of the bladder as well.

What are the alternatives to this procedure?

Active monitoring (watchful waiting), external beam radiotherapy, surgery (radical/robotic prostatectomy)

What should I expect before the procedure?

We normally perform this as a 2 stage procedure. The first stage consists of a day case admission to perform a detailed ultrasound scan of the prostate gland under general anaesthetic, which will help us plan the position of the seeds and assess the exact volume (size) of the prostate gland. The second stage (3 weeks later) involves the implantation of the radioactive seeds. You will usually be admitted on the same day as your surgery and given an enema to clear your bowels before the procedure. After admission, you will be seen by members of the medical team which may include the Consultant, Specialist Registrar, and your named nurse. You will be asked not to eat or drink for 6 hours before the procedure.

What happens during the procedure?

Normally, a full general anaesthetic will be used and you will be asleep throughout the procedure. In some patients, the anaesthetist may also use an epidural anaesthetic which improves or minimises pain post-operatively. You will usually be given injectable antibiotics before the procedure, after checking for any allergies.

The procedure takes approximately 1½ hours. A catheter is passed into the bladder via the urethra (water pipe) and left in place until the following morning. An ultrasound probe is then inserted in the rectum and 15-30 needles are directed into the prostate through the skin between the anus and the scrotum (the perineum). The radioactive seeds, usually 60-90 in number, are then inserted along the needles into the prostate itself and remain in place permanently.

What happens immediately after the procedure?

A dressing will be placed between your legs, to reduce the swelling caused by penetration of the needles, and held in place by some elasticated pants. The catheter will be removed the day after insertion of the seeds. The average hospital stay is 2 days.

Are there any side-effects?

Most procedures have a potential for side-effects. You should be reassured that, although all these complications are well-recognised, the majority of patients do not suffer any problems after a urological procedure.

Up to 15% men will experience difficulty passing urine after brachytherapy and may need to self-catheterise temporarily whilst the swelling of the prostate settles. Impotence due to unavoidable nerve damage from the seeds will occur in up to 40%.

More rarely, the patient can develop narrowing or strictures in the urine pipe which may require surgery. If the tumour does not respond completely, other treatment including surgery and/or hormonal treatment may be recommended. Some men can experience rectal discomfort with discharge of blood or mucus from the anus.

A minority of men can develop urinary incontinence which may be temporary or permanent. There is an occasional need for surgery to the prostate if there is persistent difficulty in passing urine.

Rarely (less than 1 in 100), rectal damage may occur, requiring further surgery with a temporary colostomy.

What should I expect when I get home?

When you leave hospital, you will be given a “draft” discharge summary of your admission. This holds important information about your inpatient stay and your operation. If, in the first few weeks after your discharge, you need to call your GP for any reason or to attend another hospital, please take this summary with you to allow the doctors to see details of your treatment. This is particularly important if you need to consult another doctor within a few days of your discharge.

You will be discharged with mild painkillers and a 7-day course of antibiotics (Ciprofloxacin 500mg twice daily). Tablets to ease the flow of urine (alpha-blockers) will also be prescribed and usually need to be continued for a period of 3-6 months.

What else should I look out for?

If you develop a fever, severe pain on passing urine, inability to pass urine or worsening bleeding, you should contact your GP immediately.

Are there any other important points?

Women who are or may be pregnant should not sit close to you or on your lap for 3 months after seed implantation. The same precautions apply to children. During the first few weeks after seed implantation, condoms should be used during sexual intercourse and disposed by double-wrapping them in aluminium foil and placing them in your dustbin. Seeds may, occasionally, be passed in the urine. If you see a seed in the toilet, try to retrieve it with a spoon or a pair of tweezers and dispose of it as above.

Robotic Radical Prostatectomy

Introduction

What is a Robotic Radical Prostatectomy?

A robotic prostatectomy is a minimally invasive surgical procedure for removing the prostate gland with the surgeon using the DaVinci robot to perform the operation.

Why is it necessary?

If you have cancer of the prostate that has not spread to any other parts of the body, the aim of the operation is to remove the prostate gland and to prevent the risk of cancer spreading.

What to expect during your pre-operative consultation.

Your surgeon will:
• review your history
• review your medical records
• review your PSA test (blood result associated with the prostate gland to determine stage of prostate cancer)
• review X-rays previously carried out
You will undergo a full physical examination followed by a discussion of treatment options available to you.

Before your procedure

What preparation is needed?

It is important for you to understand how and why the operation is being done. You need to be ready for a three to four day stay in hospital, but this can vary depending on the individual.

You will be up and about a day or two after the operation. Allow a period of four to six weeks for convalescence at home before you get back to your usual activities.

If you are a smoker it is helpful if you can stop a few days before you come into hospital. Advice can be offered, e.g. smoking cessation or quit smoking helpline number – (0191) 219 5111.

A routine blood and urine test will be required and also possibly a heart tracing and chest x-ray to make sure that you are fit for the operation. These are normally done in the pre-admission clinic, prior to your operation.

You will usually come into hospital on the morning of your operation and be seen by the nursing and medical staff on the ward.

The anaesthetist will explain what will happen when you are put to sleep. Elasticated stockings will be provided to prevent clots forming in the veins of your legs. You will be given a daily injection to slightly thin your blood.

Before surgery you will be seen by a continence nurse, who will advise you on carrying out exercises to strengthen the urinary sphincter muscle. This is because following surgery urinary incontinence can occur. This often improves over time with regular exercises.

You will change into a hospital gown and be taken to the operating department on your bed or on a trolley. The anaesthetist will put you to sleep usually by an injection through a needle in your hand.

During your procedure

How is the operation done?

The first part of the operation is to give you an anaesthetic (put you to sleep) so that you will not be aware of anything whilst the operation is being performed. The operation can take up to 4 hours but can vary depending on the individual. Five very small cuts (approx. 0.5-1cm) are made into your stomach to perform the operation. Through these small cuts a telescope and instruments on the robotic arms are used to separate the prostate gland and vessels from the urethra (water pipe) and the bladder.

Once the prostate gland is free from the bladder, rectum and urine pipe (urethra), it is placed in a bag and removed through one of the cuts. The bladder is sewn back to the urethra to restore continuity of the urinary tract.

A tube (catheter) is placed into your bladder to allow urine to drain whilst you recover from your operation. The urine may have blood in it but this is normal and will clear in a day or two.

You may also have a wound drain in your stomach to drain away any blood. This will be removed when there is little or no fluid draining from it which is a minor procedure carried out on the ward by a member of the nursing staff.

You will wake up in the recovery area in your bed. When the nurses are happy with your condition a nurse from the ward will take you back to the ward.

After your procedure

For the next 24 hours, you will have a drip in the back of your hand. For the first few hours we can give you fluids through the drip until you are drinking. While you are recovering from the anaesthetic, you may feel sleepy or ‘groggy.’ There may be some pain. We will give you painkillers to help with this, either with tablets or through a drip as ‘patient controlled analgesia’ (PCA). As the name suggests, you can control the amount of pain relief you receive. A nurse will show you how to use this.

Minor shoulder or stomach pain can be experienced for up to two days following surgery. This is due to the gas used to inflate your stomach during surgery. Patients often describe this as a “wind like” pain. You may feel sickly following your operation but medication can be provided to help with this. Everyone recovers at there own rate. If you are comfortable and do not feel sickly you will be offered food and drink.

The tube (catheter) will remain in your bladder when you are discharged from hospital, normally 2-4 days after the operation. A small urinary leak can occur at the connection between the bladder and the urine pipe. This can take from a few days to a few weeks to heal. You will need to return to hospital in about four days. An X-ray will be performed to check for this leak. If there is no leak the catheter will be removed. However if a leak shows up you will return home and be re-admitted in a further two weeks at which time the catheter will be removed.

What problems can occur?

You may experience some pain and discomfort, this will settle and painkillers are available to help reduce this. If you are in good health there is only a small risk that the operation and anaesthetic will affect your health in any way (less than 1 in 1000). If you do have other health problems such as a bad chest or angina then the risks are slightly higher, but precautions will be taken.

Bladder spasms are commonly experienced as a moderate cramping sensation in the lower stomach or bladder. If this is severe, medication can be provided.

Erection problems will occur in the majority of men having this operation – just as it can with open surgery. A nerve sparing technique is attempted during surgery unless there is obvious involvement of the nerve tissue with the cancer. The return of erectile function following surgery is dependent on the age of the patient, the degree of pre-operative sexual function, technical precision of the nerve sparing technique and time.

Once the catheter is removed some patients may have difficulty in holding on to their urine. This is because of sphincter weakness which normally settles in about 3 – 6 months in the majority of patients. However, 5% of men will have ongoing incontinence and may require surgery to treat the problem.

The urologist performing your operation will tell you that there is a very small risk of having to perform open surgery if there are any difficulties.

Are there any alternatives to this surgery?

The alternatives are conventional open surgery, radiotherapy and brachytherapy. No data is available to show that one option is better than the other. There is no reliable data available as yet to suggest whether surgery or radiotherapy improve survival rates.

What can I do when I get home?

Take it easy and build up your strength gradually over four to six weeks. Start with short walks and gentle exercise until you are fully back to normal. Try to eat a healthy diet with plenty of fluids, fresh fruit and vegetables. These are important to keep your bowels regular as this operation can make your bowels “lazy” for a few days.

Avoid heavy lifting, strenuous exercise and heavy housework during this period. Once you feel that you are back to normal it is safe to do house hold tasks and to drive. If you work it depends on how you feel and the type of job that you do, but four to six weeks convalescence is recommended.

A review appointment for twelve weeks will be arranged to check on your recovery from the operation.

If you have any problems following your discharge from hospital you can contact your GP for advice. A letter will be given for your GP when you leave the ward. A district nurse will be asked to visit you at home to check that your stomach wounds are healing. The nurse will also continue giving you your blood thinning injections for up to 28 days following the date of your surgery.

Further information and advice

How can other questions be answered?

It is very important that you are happy to go ahead with your operation and the best place to ask questions is during your clinic visit with the surgeon. In the pre-admission clinic you can speak to a nurse or a doctor who will be happy to help. One of the urology nurse specialists will be your named ‘key worker’ and can be contacted by telephone if you have any queries. The consultant or a member of their team will see you when you come into hospital for surgery to answer any further questions.

Final word

Most peoples’ stay in hospital is straightforward. We hope that this gives you the information that you need. Do not hesitate to talk to a nurse or doctor if you have any questions or worries by contacting Ward 1 on (0191) 213 7001.

 

My Prostate Cancer - A Patient's Perspective

The Start

On a visit to my local doctors’ surgery in February 2014 to arrange a blood sugar test, I asked about having a test to check my prostate (PSA – Prostate Specific Antigen test ) as the last one I had was an internal examination four years previous. This was arranged and formed part of the blood sugar and PSA blood test where a sample of blood was taken. Two days later the surgery phoned me to tell me an appointment had been made for the next day to discuss with the doctor the results of the PSA test – alarm bells started ringing. The following day the doctor told me that my PSA reading was higher than normal, the reading being 8.6, and stated that this needed further investigation to see if there were any signs of cancer or not, so with that, an appointment was made for the following week to visit Newcastle Urology at the Freeman hospital in Newcastle upon Tyne.

Advice: – Don’t panic, not all high readings are linked to cancer, the readings may indicate an enlarged prostate

The First Appointment (the initial investigation)

On that visit, more blood was taken and an internal examination took place. The doctor stated that the internal did not show any abnormal lumps or bumps although it was stated that the prostate was slightly enlarged, but a biopsy would give a more defined result as to whether there was any trace of cancer or not.

The Second Appointment (the biopsy)

On this visit the PSA result from the first appointment was 7.2 so another internal took place followed by a biopsy. The biopsy is not painful, just slightly uncomfortable as it is more of what you can hear as opposed to what you can feel. The biopsy consisted of taking five snips from the left and five from the right side of the prostate; you can hear each snip, but don’t worry. The whole experience takes about 15 to 20 minutes.

The Third Appointment (the results of the biopsy)

This took place between me and the specialist consultant, a nurse was also in attendance, as was my wife. The consultant confirmed that cancer had been found in the right hand side of the prostate, none in the left hand side. This was a shattering blow which literally took the wind out of my sails. I had to ask the consultant to stop talking so I could take in what had just been said, and after what seemed a lifetime, I asked him to continue. From this, he said the area needed to be scanned and a scan would be arranged. The next step involved going into another room with the nurse, who then gave me more information on the type of cancer I had and tried to put my mind at rest by stating this was one of the better cancers to have, if there is a better one.

Advice: – Whilst cancer is a dreaded word, this type of cancer is one of the most treatable and curable. You will be given literature that fully explains all about prostate cancer. My experience was that the appointment was handled in a very sympathetic manner, but with a positive outlook.

The Fourth Appointment (the scan)

The scan was arranged and the procedure consisted of getting kitted up, which included a jab to relax the area, then going feet first into the scanner but with just enough room that allowed the head to stick out, which was quite a relief. I was also given headphones with music playing. The whole scan took about 40 minutes which was done in various time stages.

The Fifth Appointment (results of the scan and pre-anaesthetic check)

This again took place with the specialist consultant, who informed me that the cancer had not spread but was contained in 30% of the right hand side of the prostate. Discussing the way forward it was agreed that surgery was the best option and that could be done within the next five days. I asked about radiotherapy and was informed this was a course done over 49 consecutive days. My decision was to undergo surgery. This would be carried out using robotic surgery – robotic radical prostatectomy (keyhole surgery).

The procedure and probability of success and recovery was then explained to me, again, it endorsed my thoughts that surgery was the best option. This was on the Tuesday, and I was informed that the operation could take place on the Saturday if I agreed, of which I did. After the meeting with the specialist consultant I then went to the pre-anaesthetic assessment room, this was to make sure I was fit enough for the operation which was going to take about 4 hours. First were the questions and answers about your health and history, don’t hide anything and tell the truth. After this has taken place, you are then taken to another room to have your heart and lungs checked; this couldn’t take place on the Tuesday as there were no slots for the rest of that day, and I would have to return on the Thursday.

The Sixth Appointment (the pre-anaesthetic check, continued – the bike test)

Thursday, two days later, the pre-anaesthetic check took place, first test is the lung function test followed by the bike test, and you will have electrodes fitted for monitoring purposes, nothing to be alarmed about. You will also have your blood pressure taken as well.

The Operation (Saturday 10th May, 2014 at the Freeman)

Arrived at the hospital at 7.00am for admission and was booked in to Ward 3. Later on in the morning I was prepared for the operation, the first thing to be done was an enema, no concerns. The anaesthetist also explained her procedure, and again no concerns. You are then taken down to the preparation room, you are prepared for theatre, given an injection and that is you out for the count after about 3 or 4 seconds. The next thing you know you are waking up in the recovery room. At this point I should stress that through all the appointments and tests, I had been treated with the utmost courtesy and respect. Once in the recovery room the aftercare kicks in, and as far as I am concerned, this surpasses all expectations, the recovery nurse was absolutely brilliant. I was then taken back to the ward where my wife and son were waiting. I felt drowsy, as expected, but also felt fine. After they had gone the nurses took over, and the pain management began. During the operation I had a catheter inserted to control my bladder movement, this would be taken out after a week. I also had elasticated stockings on each leg to prevent DVT (Deep Vein Thrombosis), and these would be kept on for the next 4 weeks. Throughout the night the nurses administered the pain killers and kept me comfortable.

The Recovery (Sunday 11th May 2014)

After a reasonably comfortable night and pain management, the amount of pain on a scale from 1 to 10 was no more than a 5, and all throughout the recovery period this was the same, the secret is to make sure you stick to the pain management and advice of the nurses, they were also absolutely wonderful. In the morning you are encouraged to get up and walk about, you will have the bag from the catheter attached to your leg, so don’t be too nervous and get up and move about. Carry on doing this as many times providing it feels comfortable, there may be some discomfort but that comes with the territory. You may or may not feel like eating but drink as much water as you can. Once the surgeon or one of his team has been to see you, you may be allowed to go home, I didn’t go home till the next day, Monday, as the drain into my stomach was still required on the Sunday.

On the day of your release you will be told how to look after yourself as you will have the catheter attached for a week, you will also be given literature, elastic stockings and new bags for the catheter. You will find walking easier on the second day as your confidence grows, the operation is not like a hip or knee replacement where you have to get used to walking again.

At Home (Monday 12th May 2014)

This is where I believe, the real recovery starts, the specialist, doctors and nurses have done what they can, your family and friends have given you all the support they can, so don’t let them down, prepare to help yourself with the recovery. Once at home, you will be visited by the district nurse for as many days per week as necessary, they are great. You will have to have an injection every day, for 28 days to stop the blood from clotting; the nurse will do this but I recommend that you get used to doing this yourself, it really is quite painless once the nurse shows you, don’t be nervous. Also keep the stockings on for the 28 days, only taking them off at nights after the catheter has been removed. The fluid from the catheter into the small bag will have to be emptied on a regular basis throughout the day, at night time this will be linked up to a larger bag so as not to disturb you too much through the night. Important, I strongly recommend that you keep the pain management going along with the pelvic floor exercises; if any of the recommended tablets make you feel nauseous, speak to the nurse.

Throughout the first week you may have some discomfort with the catheter, but this will not stop you from having a shower or bath, but keep the area around the head of your penis as clean as possible. During the first week at home, walk around the house and garden as often as you can, and although you will get tired during the day, I found this normal for a couple of weeks. Once you feel a bit more confident, try walking further afield but don’t drive to get there, in fact don’t drive for 3 weeks, as I believe your insurance will not cover you during that period, you will need to check. Do not do any overstretching or lifting of objects during this time.

The Seventh Appointment (Monday 19th May 2014 – the removal of the catheter)

I had the catheter removed on this day. Regardless of what stories you have been told, the removal was not painful, it was actually a great relief. You will be kept there for a few hours until they are happy with your urine flow. If you cannot release much urine for a while, don’t worry, this is quite normal. You will also be given a pack to take home, this will consist of incontinence pads, and you will need these day and night to protect you and your clothing from urine and wet discomfort. This could last for a few months so get used to it, there is nothing to be embarrassed about or be ashamed of, and whilst the operation is common, it is also a major operation and incontinence is part of the recovery process.

At Home (continued)

As the days go by you may be feeling a lot more confident in your movements around the house and garden, just be careful. After one week I had a small scare, I couldn’t pass water, which at the time was slightly painful. I phoned the district nurse who, in turn spoke to a resident urologist and it was decided that I needed to go back to the hospital for assessment. Again, the aftercare was brilliant, once I was at the hospital my urine flow gradually came back, but very slightly. I was assessed over a couple of hours, and this included a temperature reading and blood sample, I was also informed that there were 3 options, re-insert the catheter, stay in overnight or go home and return the following morning, I chose the third option, the following day I was informed that it was a slight infection and was given a week’s supply of antibiotics. Since then, there were times when sitting was uncomfortable, so you have to move around and keep the pain management going, but things did start to return back to normal, with the exception of having to wear the pads, but as I said before, this will be the case for a few months.

Back to Work (6 weeks after the operation)

The company I work for were as supportive of me after my return as they were from day one of my diagnosis, so going back was not as daunting as I thought it might be. I went on a shorter working day so that I could leave earlier and miss the traffic. I was still wearing pads but my advice is to take a toiletry bag to work with a few pads and clean underwear, you may have a few minor mishaps, but that should ease after a couple of weeks, it is all about confidence.

The Eighth Appointment (8th July, eight weeks after the operation)

This was with the specialist consultant urologist that performed the operation. He will give you the feedback from the operation, and again, you are treated with the utmost courtesy and respect. In my case I was given the all clear, a blood sample was then taken to see what the PSA count was, the result followed a few days later, and this confirmed that the cancer had been overcome. When I had the cancer my PSA reading was 8.62, this blood sample had a PSA reading of 0.02. My next appointment with the specialist consultant is in 3 months.

At Home (continuing up to the 8th August)

Over the next few weeks I made good recovery and that has continued up to the present day. I am still wearing the pads, but at a reduced number per day, I also wear a one at night but it is completely dry in the morning, and my next paragraph will give you some details and advice about the pads.

The Pads (how to cope)

I feel that my story would not be complete without a short paragraph about the use of the pads. These can be looked upon as a form of inconvenience and embarrassment but believe me, your confidence and recovery cannot proceed without using them, so take all this in your stride. I found that in the early days after my operation and catheter removal, I was using up to 6 pads a day. When getting up after sitting on a seat I was releasing at quite a constant rate and drinking approximately 2 litres of water a day wasn’t helping, this eased after a few weeks, but again I keep stressing, I firmly believe this was down to the pelvic floor exercises, so keep them going, even up to today, I am still doing them, and will continue until full continence returns. After you have used up the allocated pads that you were given after the catheter was removed the District Nurse will supply more, although you may need to go on the short term incontinence programme in order for them to supply them. You may still have a few mishaps but this again is quite normal. You may find as time goes by you should get less leakage, but your time of needing to go to the toilet and actually getting there is in quite a short time frame. You may also find that alcohol and caffeine act as an irritant, again quite normal, but with all of this you will find you and your body will recover providing you use common sense.

Conclusion

My eternal thanks go to the specialist consultant and his medical team, the staff and nurses at the Freeman, and the District Nurses, these experts have given you another chance which some people do not have the good fortune to have.