RADICAL PROSTATECTOMY

Radical prostatectomy - Indications :
- Localized prostate cancer

Anaesthesia :
General or regional

Post-operative care :
Mobilize as quickly as possible and continue subcutaneous heparin and AK-TEDS until discharge, to reduce the risk of DVT and PE. Remove the drains when drainage is minimal. If there is persistent leak of fluid from the drains, send a sample for urea and creatinine, and if it is urine, get a cystogram to determine the size of the leak at the vesicourethral junction. Urethral catheters are left in situ post radical prostatectomy for a variable time depending on the surgeon who performs the operation. Some surgeons leave a catheter for 3 weeks and others for just 1 week.

Common post-operative complications and their management :
- Haemorrhage
Managed in the usual way (transfusion; return to theatre where bleeding persists or where there is cardiovascular compromise).
- Ureteric obstruction
Usually results from oedema of the bladder, obstructing the ureteric orifices. Retrograde ureteric catheterization is rarely possible (this would require urethral catheter removal and it is difficult to see the ureteric orifices because of the oedema). Arrange placement of percutaneous nephrostomies.
- Lymphocele
Drain by radiologically assisted drain placement. If the lymphocele recurs after drain removal, create a window from the lymph collection into the peritoneal cavity so the lymph drains into the peritoneum from which it is absorbed.
- Displaced catheter post radical prostatectomy
If the catheter falls out a week after surgery, the patient may well void successfully, and in this situation no further action need be taken. If, however, the catheter inadvertently falls out the day after surgery, gently attempt to replace it with a 12Ch catheter which has been well lubricated. If this fails, pass a flexible cystoscope, under local anaesthetic, into the bulbar urethra and attempt to pass a guidewire into the bladder, over which a catheter can then safely be passed. If this is not possible, another option is to hope that the patient voids spontaneously and does not leak urine at the site of the anastomosis. An ascending urethrogram may provide reassurance that there is no leak of contrast and that the anastomosis is watertight. If there is a leak or the patient is unable to void, a suprapubic catheter can be placed (percutaneously or under general anaesthetic via an open cystostomy).