Frequently Asked Questions
What is the prostate? Where is it located?
The prostate is a secondary sexual organ exclusive to males which secretes products such as a protein known as prostate-specific antigen (PSA). Though females do not have prostates, they do have similar organs which also produce this PSA protein. The prostate is typically the size of an apricot, and it is located beneath the bladder and surrounds the upper urethra. Its position in front of the rectum makes the prostate accessible to touch during rectal examination. The prostate functions in conjunction with another pair of secondary sexual organs known as seminal vesicles to produce the liquid portion of semen. Despite this inclusion in processes of intercourse, the role of the prostate in human fertility remains debatable. The position of the prostate deep within the pelvis makes surgical access difficult.
What else should I know about prostate-specific antigen (PSA)? Elevated levels of PSA are common in ejaculate, though the level of PSA which leaks from the prostate into the bloodstream is typically low. The level of PSA in the bloodstream is indicative of the probability for developing prostate cancer, and higher levels are associated with higher probability. Specific conditions such as infections or use of certain medications can affect the level of PSA without increasing the probability of prostate cancer. As such, each patient must be evaluated individually in order to interpret the credibility of a PSA level. Though PSA levels can be indicative of cancer, they are not a sure warning sign; this is why an additional test called a biopsy is required to diagnose prostate cancer.
What purpose does a biopsy serve?
During a biopsy, sample cores are taken from the prostate to be fixed in formaldehyde and stained to identify sections which represent different regions of the prostate. These cores are then examined through microscopy to identify cancer, infection, inflammation, or other distinguishable abnormalities. A biopsy core is only a sample of a prostate, and as such results are not always a definite representation of the condition of the prostate. While a biopsy which reveals cancer can be considered a definite source of diagnosis, absence of cancer in a biopsy does not always indicate absence of cancer in the prostate. Biopsy results are also subject to the interpretation of the biopsy cores, and for this reason communication between Dr. Gholami and your pathologist can ensure an accurate and impartial interpretation. The pathologist will prepare a report for Dr. Gholami which will explain the nature of cores sampled in the biopsy. If cancer is detected this report will include the grade of the cancer as well as the proportion of the core involved. This report should also describe any abnormalities visible in the biopsy cores. Even biopsies which are negative for prostate cancer should note these abnormalities, as they could lead to future cancer diagnoses.
Why are the classifications of prostate cancer important?
Prostate cancer is described by two separate classifications. The first classification, the grade of prostate cancer, pertains to the shape of cancer cells. Prostate cancer cells vary in shape when viewed under a microscope, and these shapes have been categorized and numbered by a Dr. Donald Gleason. The Gleason score of prostate cancer is the sum of two of the most common shapes of cancer cells. The least aggressive of these cells is labeled 2, while the most aggressive is labeled 10. The Gleason score of prostate cancer determines how aggressive the cancer appears to the pathologist, and it is important in allowing Dr. Gholami to pair his patient with the most effective therapy available. The second classification, or stage of prostate cancer, simply indicates the extent of growth of the cancer.
What is a Robotic Radical Prostatectomy (DVP)? What makes this an effective therapy for prostate cancer?
A Robotic Radical Prostatectomy (DVP) is a surgical procedure specialized for men with localized prostate cancer in which the prostate gland and the seminal vesicles are removed. Laparoscopy is a new technique whereby instruments are passed into the body through small incisions in order to perform surgery. Comparable to open radical prostatectomy, which requires an abdominal incision for surgery, the incisions required for an LRP are often less than five millimeters in length. These smaller incisions allow for faster recovery post-procedure to offer earlier relief and to allow patients to return to work after less recovery time. LRP is an effective therapy for men with localized prostate cancer because of the complete removal of the cancer in most cases. After the prostate has been removed it is possible to determine the extent of the prostate cancer in more definite terms. It is also easier in most cases to evaluate patients after LRP to ensure that their cancer is gone. Blood loss is also significantly decreased given the nature of the procedure, and most patients only lose 100 to 200 milliliters. This significantly reduces the need for transfusion. Patients are also commonly able to recover without narcotic medication, which eliminates complications such as fatigue or constipation. Some patients have returned to work 48 hours after surgery, and most experience levels of comfort completely unattainable through traditional open radical prostatectomy.
Am I a good candidate for DVP?
Patients who should consider DVP as therapy for prostate cancer should have very good health with a life expectancy exceeding 10 years. They should also have cancers which are localized to the prostate gland. Other variables to consider for patients considering LRP include PSA, biopsy results, previous treatments for prostate cancer, weight, smoking history, other illnesses, and current medication regimens.
What type of anesthesia is necessary for my procedure? Should I donate blood?
DVP is done under general anesthesia with the use of ketrolac, an anti-inflammatory medication, after surgery. General anesthesia is a technique in which the anesthesiologist administers medication which will induce sleep so that the patient will remain unconscious for the duration of a procedure. Donation of your own blood is available, though it is not necessary given the restricted blood loss associated with LRP. Blood loss is minimal in LRP, and as such blood transfusions are rarely given. If you prefer to donate blood prior to your procedure, 1 to 2 units of blood can be drawn and made available at the time of surgery.
What should I expect before surgery?
A number of tests such as blood tests, ultrasound, and prostate biopsy, should be performed prior to LRP to determine the extent of the prostate cancer. A physical examination should be performed a couple days before surgery; you anesthesiologist will call you the night before your procedure. You will be admitted to the hospital on the day of your surgery, and you should cleanse your colon the night before in preparation. To do this, purchase a Fleet Enema at your local drugstore to use the evening before surgery. You should not eat or drink anything after midnight the night before your surgery. Ask Dr. Gholami about any medications you are using to determine whether you should discontinue use at this time in preparation for the procedure.
What will occur during surgery?
During DVP the entire prostate gland and seminal vesicles are removed. Once they are removed, the bladder is reattached to the urethra. If cancer has spread to the lymph nodes close to the prostate, these may also be removed by laparoscopy during surgery. This lymph node dissection is not necessary and thus is only performed on patients at high risk for metastasis (spread) of prostate cancer. A catheter is left in the bladder while healing from the procedure takes place. A tube which drains accumulating fluids will be left in place to drain the bladder for one to two days.
What is a nerve-sparing procedure?
Neurovascular bundles are bundles of nerves which run along each side of the prostate and aid in achieving an erection. On or both of these bundles of nerves may be spared during LRP, thereby preserving the patient’s sexual function. Younger patients with a history of strong erections and frequent sexual activity benefit from a nerve-sparing procedure. Older men or men with limited erections see less benefit from such a procedure, and as such preservation of these bundles is frequently not recommended. Because of the proximity of these bundles to the prostate, is it possible that a nerve sparing procedure may risk leaving cancer behind. You should discuss the risks and benefits of a nerve sparing procedure with Dr. Gholami when choosing an ideal therapy.
What should I expect after surgery?
You will be hospitalized for 1 to 2 days after surgery. You will be allowed to drink fluids almost immediately after the procedure, and you will gradually be allowed to eat solid foods. Urinary continence is typically restored soon after surgery. Sexual function returns more gradually in patients who have undergone a nerve-sparing DVP. Use of Viagra or penile injections may facilitate the return of sexual function.
Your incisions will be closed with absorbable sutures and thus do not require you to return to the office for removal of sutures. The drains are usually removed in one to two days, and you will be discharged home with a catheter to drain urine from your bladder into a bag which is fitted to your leg and can be easily covered with loose-fitting clothing. Urine is commonly bloody for several days following surgery. The catheter will be removed here in the office three to ten days after you are discharged from the hospital.
It is normal to experience mild pain at the site of the penile hole incisions after surgery. Immediately following surgery, patients are given intravenous pain medication every two to three hours by their nurse. Pain may also be decreased with anti-inflammatory ketorolac, which may minimize pain and reduce the need for infusion of narcotics. Before being discharged from the hospital you will be given oral pain medication. You will also be given additional oral medications to take as needed to regulate residual pain. Please inform Dr. Gholami of any medications you are currently taking to ensure that they will not interfere with this pain medication. With exception to intravenous Toradol which is given every eight hours continuously for the first day, pain medications are administered on an “as needed” basis, so be sure to tell your nurse if you are in pain so that s/he may medicate you further. It is recommended to ask for additional pain relief before pain becomes severe to avoid unnecessary discomfort. Should you feel that your pain is not being treated adequately, please discuss this with your nurse or doctor. They may not be able to relieve all of your pain, but they are able to make you as comfortable as possible.
Patients undergoing DVP commonly experience anxiety which results in lack of sleep both before and after their procedure. For this reason, fatigue is one of the most common complaints to follow DVP. Another common complaint is a sense of bloating, which may make clothing tight and uncomfortable. Walking can help to alleviate this bloating by expelling intestinal gas, which will help to restore comfort and revive appetite.
Your nurse should assist you with a sponge bath the day after your surgery. Showers are permitted at home after two or three days have passed to allow incision sites time to heal partially. Do not scrub incisions. Let water run over your incisions and pat them dry. The steri-strips used to seal your incisions should peel off by themselves in seven to ten days. If they do not, you should remove them after ten days. Ask Dr. Gholami or your nurse when you should bathe again.
How can I help the healing process?
It is very important to walk, to use your voldyne(breathing exerciser), and to do your leg exercises soon after surgery to avoid complications such as pneumonia or blood clots. A nurse will be able to assist you in walking after your surgery, and support stockings may be made available to wear until you are discharged.
What should I expect when I return home?
Fatigue is normal for several weeks following your surgery, so be sure to arrange a ride home from the hospital when you are discharged and to get plenty of rest when you arrive home. Also be sure to eat well-balanced meals high in protein and iron, and exercise lightly every day with walking and stretching. Driving is typically permitted after the catheter has been removes, but your ability to drive also depends on your comfort level. Do not do any heavy lifting (15+ pounds) or exhaustive exercise for two weeks following surgery. After these two weeks have passed it is recommended that you gradually increase your light exercise, and activities such as golf or tennis should be postponed until two or three weeks after the procedure. Heavy exercise should be postponed for four weeks. Any painful activities should be avoided.
The five pencil-size holes in the area around your navel should be kept clean and dry. Showering once daily should be enough to maintain healthy incision sites. You should notify Dr. Gholami if you note increased tenderness, pus, swelling, redness, itching, or a moderate amount of drainage.
The catheter with which you will be discharged should be removed in the office within five to ten days after your procedure. The bag of drained fluid should always be placed lower you’re your bladder to allow for easy drainage. Leaking may occur, and should be managed by wearing incontinence pads. Keep the area where the catheter exits your penis clean using soap and water, and be sure to empty the bag frequently. Your urine may be cloudy during the weeks following surgery, and it is also common to note blood in the urine during this time. If large clots longer than one inch in length are noted, or if you catheter becomes plugged, you should contact Dr. Gholami. Bladder spasms may cause discomfort if the catheter irritates the bladder, and Dr. Gholami can prescribe medication to help with this pain if necessary. Removal of the catheter is relatively painless and does not require anesthesia.
After your catheter has been removed you should use exercises suggested by Dr. Gholami to decrease leaking of urine and increase bladder muscle strength. Your bladder control may be poor immediately after surgery, and leaking is normal, but this should improve significantly after a short time. Continence will return in stages, so while continence is achieved while lying down you may not yet have achieved continence while sitting or walking. Incontinence pads may be used to manage leaking, and are available at your local drugstore. Please bring one of these pads to the office on the day when Dr. Gholami will remove your catheter so that you may wear it home. Most patients regain excellent urinary control three months after their surgery. If you have not regained control at that time, please contact the office so that Dr. Gholami can discuss further management options. Also contact the office is you experience slow or decreased urinary stream, hesitancy, or painful urination. At times it is necessary to dilate the urethra after prostatectomy to treat scarring, and this is easily performed with local anesthesia.
Skin irritation often accompanies incontinence, and can be treated with Desitin cream or similar skin care products. Please notify the office if this irritation evolves into a rash.
Constipation is another symptom common among patients who have undergone DVP. Constipation can be treated with stool softeners, though dietary modifications are also sufficient for management of constipation. To avoid such complications, please be sure to increase your fluid intake to at least eight glasses of water each day and eat plenty of fruits, vegetables, and grains. Only use laxatives in cases of severe constipation.
Swelling of the scrotum and penis occasionally occurs after DVP. This should decrease after four to six days. Swelling after this time should be reported to Dr. Gholami, as should swelling of the legs or feet.
Some men have difficulty attaining an erection after DVP. The nerves on either side of the prostate which are involved erectile function can be left intact by way of a nerve-sparing procedure. Sometimes these bundles need to be removed in order to ensure that cancer is entirely removed from the area around the prostate. Feel free to discuss concerns about erectile function with Dr. Gholami, as he will be able to suggest effective methods for treating poor erectile function. Oftentimes the ability to maintain a successful erection after surgery is relative to a patient’s erectile function prior to surgery. This means that patients with excellent erectile function have greater chances for successful erections prior to surgery than patients who have decreased erectile function prior to surgery. Some of the options for treatment of poor erectile function or impotence post-DVP include Viagra (sildenafil), penile injections, vacuum pumps, and (on occasion) penile implants. Because the prostate has been removed by DVP, there will be no ejaculate released. However, even if an erection cannot be achieved, you should still be able to have an orgasm by stimulation of the penis. Dr. Gholami can also suggest a variety of resources which can provide information if you wish to learn about the influence of cancer treatments on sexual function. Even extensive treatment of prostate cancer does not entirely halt sexual activity for patients or their partners, and as such it is important to research treatments for impotence to regain your desired level of sexual gratification after your procedure.
What is a pathology report? How should I understand it?
After the prostate is removed it is dyed with ink to clarify certain structures and to allow your pathologist to examine it after surgery. This report is important because it is the summary of an extensive examination of the removed prostate, which at that point can offer insight into the prostate cancer which was unattainable before removal. Your pathologist should include three distinctions in your pathology report: cancer grade, cancer stage, and margin status.
Cancer grade: This is the appearance of cancer cells by microscopy. The cells are classified by size and shape and categorized using the Gleason grading system. The grade of prostate cancer is calculated by adding the grade of prominent non-aggressive cells to the grade of prominent aggressive cells. A score of two through six indicates low-grade cancer, while seven though ten indicates high-grade cancer. Low-grade cancers are usually more easily treated and have a lower risk of recurrence, while high-grade cancer has a higher likelihood of recurrence.
Cancer stage: This indicates the size of the tumor. T2 cancer is confined to the prostate; T3 cancer has grown beyond the prostate into the capsule of the prostate (T3a) or the seminal vesicles (T3b). Patients with T3 cancer are more likely to experience recurrence of prostate cancer than patients with T2 cancer. T4 cancer is quite rare and indicates cancer which has spread into proximal organs such as the bladder.
Margins: A positive margin indicated that cancer cells have reached the very edge of the prostate. Your pathologist should note the number and locations of such positive margins in your pathology report, as positive margins denote an increased risk of recurrence of prostate cancer. Post-operative radiation may be recommended to eliminate this risk of recurrence. Most patients with positive margins are cured through such management.
Should I follow up with Dr. Gholami?
Yes! You will need to schedule a follow-up appointment to have your catheter removed after surgery. It is also important to return so that Dr. Gholami can evaluate your recovery and ensure that urinary and sexual function return. Though further treatment is usually not required, it is advised that you obtain a repeat P.S.A. at three to six month intervals for the first three years after your procedure to ensure that your level has dropped back down to normal levels. A CT scan, bone scan, MRI, or blood tests might also be requested after your procedure to further ensure successful evaluation and recovery. Additional visits may be recommended for patients with higher risk for recurrence.
Is there anything else I should know before proceeding with LRP?
Diagnosis of prostate cancer can, understandably, be an emotional and difficult experience for many patients. Your fears, concerns, questions, and opinions are welcomed and valued as part of your treatment. Communication with Dr. Gholami and the office staff is recommended to maintain rapid recovery. Support groups may also prove helpful in dealing with frustrations and other feelings associated with cancer.
Determine if robotic prostate surgery is right for you.