Understanding Surgery for Prostate Cancer

‘ My diagnosis was very quick. I had a very aggressive form of cancer and everything happened very quickly… quickly into surgery and then follow-up after that. But obviously the most critical time was after the initial diagnosis of my cancer. I wanted more information.’

WHAT IS THE PROSTATE?

The prostate is a small gland below the bladder and in front of the rectum in men. It surrounds the urethra, the passage in the penis through which urine and semen pass. The prostate is often described as the size of a walnut and it is normal for it to get bigger as men age.

The prostate is part of the male reproductive system (see diagram). It produces most of the fluid that makes up semen, which enriches and protects sperm. The prostate needs the male hormone testosterone to grow and develop. Testosterone is made by the testicles.

THE MALE REPRODUCTIVE SYSTEM
(where the prostate gland is)

WHAT IS PROSTATE CANCER?

Prostate cancer occurs when abnormal cells develop in the prostate, forming a malignant tumour (cancerous growth). These cells have the potential to multiply in an uncontrolled way, and possibly spread outside the prostate into nearby or distant parts of the body.

Prostate cancer is generally a slowgrowing disease, and the majority of men with prostate cancer live for many years or decades without painful symptoms, and without it spreading and becoming lifethreatening.

STAGES OF PROSTATE CANCER

The stage of prostate cancer depends on whether the cancer has spread outside of the prostate or not.

When the cancer is found only in the prostate gland, this is known as localised prostate cancer or early prostate cancer.

For some men, their prostate cancer may grow slowly. But in other men, their prostate cancer may grow more quickly and may also spread to other parts of the body – this is called advanced prostate cancer.

There are different stages of advanced prostate cancer:

• Locally advanced prostate cancer: the cancer has extended beyond the prostate and may include seminal vesicles (the glands that produce semen) or other surrounding organs such as the bladder or rectum
• Metastatic prostate cancer: the cancer has spread to distant parts of the body such as lymph nodes and bone.

WHO CAN HAVE PROSTATE CANCER SURGERY?

The decision about surgery for prostate cancer is made in consultation with your urologist and healthcare team. Surgery is generally used as a treatment option for men with localised prostate cancer. It may also be considered for locally advanced prostate cancer, depending on how far the cancer has spread outside the prostate gland.

Surgery can be considered a good option when:

• you are medically fit for surgery, for example, you do not have health conditions that may put you at significant risk during or after surgery
• you are expected to live for 10 years or longer
• you have not previously received radiotherapy treatment for your prostate cancer
• your prostate cancer is considered to be at risk of progressing to threaten your health.

Listed below are some questions you may want to ask your urologist or members of your healthcare team about prostate cancer surgery.

• What does surgery involve?
• What are the benefits and how likely are they?
• What are the possible side effects and how likely are they to occur?
• How will surgery affect my quality of life?
• How will surgery affect my sexual function or sex life?
• Will surgery make me incontinent?
• What are the costs involved with surgery?
• How may surgery affect other health conditions I may have?
• If I want children, what are my options? Is there anything I need to do before surgery?
• What are my options if I don’t have surgery?

WHAT IS A RADICAL PROSTATECTOMY?

Surgery to remove the prostate gland and some of the surrounding tissue is called a radical prostatectomy. The aim of surgery is to remove all of the cancer.

Different approaches to radical prostatectomy

The way the urologist gains access to the area to be operated on is referred to as the surgical approach. There are three types of surgical approaches the urologist may take to remove your prostate – Open radical prostatectomy, Laparoscopic radical prostatectomy and Robotic-assisted radical prostatectomy.

• Open radical prostatectomy is an operation whereby an incision, approximately 10cm in length, is made in the lower abdomen (from below the belly button to the top of the pubic hair line or across the top of the pubic hair line).

OPEN RADICAL PROSTATECTOMY

• Laparoscopic radical prostatectomy involves the urologist inserting a small camera and instruments (surgical tools) through several small incisions in your abdomen to look inside your body and perform the operation. Your abdomen is filled with carbon dioxide so the prostate and surrounding area can be clearly seen.

LAPAROSCOPIC RADICAL PROSTATECTOMY

• Robotic-assisted radical prostatectomy is laparoscopic surgery performed with the assistance of equipment that helps with dexterity and 3-D vision. The surgeon performs the operation by controlling the surgical tools remotely with the aid of the computer. Small incisions in your abdomen are required. Robotic surgery isn’t available in all hospitals in Australia and currently can be financially costly.

Recovery time may be quicker with laparoscopic or robotic prostate surgery, compared to open surgery, but all three forms of radical prostatectomy have similar rates of side effects. The choice of surgery is largely dependent on the particular technique your urologist has expertise in. At this time, there is no high level evidence that one technique is better than the other.

WHAT HAPPENS DURING YOUR SURGERY?

You will require a general anaesthetic, which means you will be fully asleep during the surgery. The surgery can take 2-4 hours depending on the approach.

In some cases, the urologist may remove a small amount of tissue near your prostate that contains lymph nodes. This will provide information on whether the cancer has spread. One of the first places prostate cancer may spread to is the lymph nodes. Your urologist will discuss this with you before surgery.

BEFORE SURGERY

AFTER SURGERY

The prostate gland is then removed along with the seminal vesicles (glands that produce some of the fluid in semen) and vas deferens (a duct which carries semen). The urethra is then reconnected to the bladder.

The prostate gland, surrounding tissues and lymph nodes (if removed) will then be sent to a pathologist who will examine them and provide information on the stage and grade of the cancer. Your urologist will inform you about the results of this.

NERVE-SPARING SURGERY

There are nerve bundles that run either side of the prostate that affect your ability to have an erection. Depending on the extent of your cancer, these nerves will either be left intact or removed. Sometimes the urologist is able to leave the nerves on one side of the prostate only.

‘They did tell me that I’d possibly have a problem with erections after the operation, depending on whether they were able to spare the nerves or not.’

URINARY CATHETER AFTER SURGERY

The urethra is the thin tube that travels from the bladder through the penis, and carries urine and semen out of the body. The urethra runs through the middle of the prostate gland so it needs to be cut above and below the prostate. The urethra is then reattached to the bladder later in the operation – this reattachment is called an anastamosis.

To help this area to heal, a urinary catheter is used. A urinary catheter is a thin tube which runs from your bladder through your penis and drains urine into a bag on the outside of your body. The catheter is held in place by a balloon inflated inside your bladder. Generally a catheter is left in place for 1 to 2 weeks following your surgery. This may vary depending on your individual situation.

CATHETER IN PLACE

ADVANTAGES AND DISADVANTAGES OF SURGERY

The advantages and disadvantages of all types of surgery can depend on the stage of your cancer, your age, and your overall general health.

Advantages

• The aim is to remove all the cancer.
• Surgery provides detailed knowledge about the pathology of the cancer, for example, whether it has spread or if it has been contained within the prostate gland.
• Surgery is psychologically beneficial to some men, who take comfort knowing that the cancer has been removed.
• Treatment is completed in a shorter time period compared to other treatment options such as radiotherapy.
• It results in an immediate, rapid fall in prostate-specific antigen (PSA).
• It is associated with less chance of bowel problems compared to radiotherapy.

Disadvantages

• There is a risk of temporary or long term erectile dysfunction (impotence).
• After surgery there will be no ejaculation at orgasm (dry orgasm).
• Surgery will result in infertility.
• Surgery is associated with a risk of temporary or long term urinary incontinence.
• Penile shortening may occur after surgery.
• There is a small risk of bowel injury.
• Some men may need further treatment.

Possible complications

Even though your hospital stay may be short, you should be aware that this operation is still considered major surgery. As with all major operations, there is a risk of side effects or complications. Your urologist and anaesthetist will discuss possible complications with you before your surgery.

It is often helpful to break the surgical journey into smaller steps or stages. This strategy can also be helpful as you approach your surgery. It will help you cope with one thing at a time, from preparing for surgery through to your recovery at home. The following pages contain useful information on what to expect at each step of your surgical journey. You can use this information as a guide to further discussions with your doctor and healthcare team about your situation.

BEFORE SURGERY

Your physical wellbeing

There are a variety of ways that you can prepare yourself before your surgery:

• Consult with your general practitioner (GP), urologist and anaesthetist about any health issues that should be managed prior to your surgery. Further tests or examinations may be needed to assess your health before surgery.
• Visit your hospital’s cancer care nurse, urology nurse, continence advisor or physiotherapist for further information, advice and support.
• There are certain medications that you may need to stop taking temporarily before surgery, for example, anticoagulants (blood thinning medications) and anti-inflammatories. Discuss this with your healthcare team.
• Lose weight if required. Consult with your GP or a dietitian if a specific diet is required. Obesity is a risk factor for surgery complications.
• Quit smoking. Smoking can reduce the amount of oxygen being delivered to the tissues of your body and slow the healing process. Quitting may help with recovery and reduce the chance of developing chest and circulatory problems after your surgery. There are benefits in stopping smoking even 24 hours before your surgery. If you need help to quit smoking, talk with your GP or a member of your healthcare team.
• Constipation can be a problem after surgery as a result of reduced activity, medications that you may receive for pain, and a change in your food and fluid intake. It may be recommended that you have regular bowel movements, and your motions are soft prior to surgery. A good bowel movement prior to your surgery may assist in the prevention of constipation following surgery. Your urologist may advise you to take medication to ensure regular bowel motions before surgery.
• Discuss with your urologist about the need for a blood transfusion during surgery. You may be able to donate your own blood in the weeks before surgery to be used if required. However, it is quite rare to need a blood transfusion.
• Talk with your healthcare team about pelvic floor exercises and start strengthening your pelvic floor before surgery. For more information on pelvic floor exercise, please see the section on ‘Possible side effects of surgery’.
• Talk with your urologist about sexual function side effects. Discuss penile rehabilitation programs if erectile function is important to you. For further information on sexual function, please see the section on ‘Possible sexual function related side effects’.
• Infertility will occur after surgery. If you are planning to have children or more children following treatment, discuss this with your healthcare team. There may be options available to you, such as storage of semen in a sperm bank.

Your personal wellbeing

Practical tips:

• You will need time off work, usually 4 to 8 weeks. Discuss with your urologist when you can expect to return to work.
• Expect to be in hospital for 1 to 6 nights. This may vary based on your individual situation and the type of surgery you had. Members of your healthcare team will discuss with you about what to expect.
• Ensure that you have arranged transport to and from the hospital as you will be unable to drive for a period of time following your surgery. Ask your urologist about when you can expect to return to driving.
• If you are from a country area, consider accommodation requirements close to the hospital. You may have to return to hospital 1 to 2 weeks later for your catheter to be removed and therefore may need to make accommodation arrangements for this, or you may choose to remain close to your treatment centre until your catheter is removed.
• You may be informed by members of your healthcare team as to what you need to bring with you to the hospital. For example, personal belongings and medications.
• Consider support or assistance you may need when you first come home from hospital. You may wish to organise meals or house cleaning. For example, stock up on pre-cooked or frozen meals. If you do not have a support person to assist with cleaning, you may wish to organise a cleaning service for a short period. Social workers can give you information on community services such as cleaning services, meal services and financial assistance. They can also assist you with accommodation advice and arrangements. Social workers are members of most hospitals’ healthcare team. If your treating hospital does not have a social worker, discuss with your GP or your healthcare team.

Your emotional wellbeing

You may find yourself dealing with a range of feelings and emotions following your diagnosis and preparation for your surgery. Feelings such as anger, fear and frustration are common and can occur at any time. These feeling are normal reactions to what is a highly stressful situation.

You may not realise it, but you probably already have your own ways of coping with difficult situations or decisions. For some men, talking through problems with their partner helps them to cope, for others distracting themselves from an unpleasant thought or situation can be beneficial. Understanding the ways in which you usually cope or have coped in the past can help you deal with the challenges of a cancer diagnosis.

Sometimes your usual coping strategies may not provide all the ways you need to cope with the challenges of cancer. If you feel that your usual coping strategies are not helping, talk to your GP or another member of your healthcare team. They can provide support and information and refer you to other healthcare team members where required.

It is important to remember you are not alone; there are established prostate cancer support groups all around Australia. Support and advice can be received from men who have been in the same position as you. This support can provide a powerful way of coping.

YOUR HOSPITAL STAY

The following information is a guide only as to what you may expect. Your treating hospital and healthcare team will provide you with information specific to your individual situation.

Before admission to hospital

Your healthcare team and treating hospital will inform you about important details regarding your hospital stay.

Hospital admission:

• You may be required to attend a preadmission clinic.
• You may receive a phone call to discuss your health history.
• You may be required to complete your health history online.
• You may be admitted the night prior, or the day of your surgery.
• Admission to hospital (date and time) will be given to you.
• The hospital will inform you what personal belongings to bring with you.

Preparing for surgery:

The hospital will provide you with details of:

• fasting time (when to stop eating and drinking before your surgery)
• medication, X-rays, scans that you are required to bring with you
• medications you should stop temporarily before surgery, for example, anti-coagulants, anti-inflammatories, herbal or complementary supplements. If in doubt, discuss with your healthcare team
• appointment time with your anaesthetist either before your hospital stay or on the day of your surgery.

Admission to hospital

You may be admitted directly to a hospital ward or to a pre-surgery area. Following your preparation (see below) you will be taken to the operating theatre for your surgery.

The following lists what preparation for your surgery may include:

• Hospital admission paperwork will be completed with nursing staff.
• It may be necessary for the nurse to clip or shave the hair from you abdominal and genital area.
• You may be fitted with anti-embolic (compression) stockings that assist with blood circulation and help prevent the formation of blood clots in your legs.
• You will be asked to shower and change into the attire for your surgery, for example, a surgical gown.
• You may be given medication to help you relax, if prescribed by your anaesthetist.
• Your anaesthetist will visit and discuss your anaesthetic and the type of pain relief you will receive following your surgery.

WHAT TO EXPECT FOLLOWING SURGERY

‘After the surgery we didn’t get told a lot because it was all such a rush.’

Information and understanding about what to expect in your pathway to recovery following surgery can help you feel less anxious and more in control.

Pain relief following surgery

Due to tissue injury in the body, pain is often a consequence of surgery. A good level of pain relief is important for your comfort and wellbeing and will help your recovery. To prevent complications, within the first day following surgery you will be required to perform activities such as deep breathing and coughing. These activities can cause discomfort and you will need pain relief so you can perform them effectively.

The level of pain following radical prostatectomy is different for every man. You are the expert on how much pain you feel. It is important to talk with the nursing staff and your healthcare team about your level of pain to allow them to adjust your pain relief medication to your needs. Commonly, you may be asked to score your level of pain using pain score tools. For example, a number scale may be used where you rate your pain from 0 to 10, 0 being no pain and 10 being the worst pain imaginable. The healthcare team at your treating hospital will discuss their pain tool with you.

The type of pain relief and possible side effects will be discussed with you by your anaesthetist and members of the healthcare team.

Pain relief can be given in a variety of forms:

• tablets
• injections
• epidural infusion: pain medication is continuously delivered into the space near your spinal cord in your back. Sometimes this can be patient controlled, whereby you press a button to deliver the medication as you require it.
• PCA (Patient Controlled Analgesia): pain medication is delivered from a pump into a needle in your vein, whereby you press a button to deliver the medication as you require it.

Generally you will need more pain relief in the first 24 hours following your surgery, and will gradually require less and milder forms of pain relief in the following days.

You may need a tablet form of pain relief for the first few weeks at home following surgery. Discuss your pain relief at home and any possible side effects with your healthcare team.

Medical equipment, what to expect

Some men are quite alarmed at the amount of equipment in place when they wake up from surgery. The following is a guide to the equipment you can expect to find. Not all of this will be relevant to you and your individual situation.

PREVENTING COMPLICATIONS AFTER YOUR SURGERY

Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE)

Following any surgery, your risk of having a blood clot in your leg (DVT) or lung (PE) is higher than usual. You are more at risk if you have had a clot previously.

A blood clot that forms in a deep vein of the leg is called a deep vein thrombosis (DVT). A clot can partly or totally block blood flow. Most blood clots form in the calf muscle of your leg. Time spent lying in bed following surgery can prevent healthy blood flow and can increase your risk of developing blood clots in your legs.

A clot in your lung is called a pulmonary embolism (PE) and is generally the result of a clot that has formed in the leg (DVT). A clot can break away and travel through your blood stream to your lungs.

Preventative strategies for DVT or PE will be discussed with you by your healthcare team, taking into account your individual needs. Some strategies that may be used include:

• Your urologist may prescribe medication called an anti-coagulant (prevents clot formation), which is generally given as an injection following your surgery.
• You may be given anti-embolic (compression) stockings to wear just before and after surgery.
• You may be asked to walk short distances every hour (except when sleeping).
• You may be asked to perform leg exercises while resting in bed or a chair, as advised by your healthcare team.

DVT and PE – Signs and Symptoms

DVT signs and symptoms: occur in the affected leg if a clot obstructs or blocks the blood flow. You may experience redness, heat, pain or swelling in your leg.

PE sign and symptoms: You may experience difficulty breathing or feeling short of breath, faintness, coughing up blood, pain in your lungs or chest and a feeling of anxiety.

Inform your urologist or a member of your healthcare team immediately if you experience any of these signs or symptoms. They can occur at any stage following your surgery, and you can remain at a high risk of developing a DVT or PE up to 3 months after your surgery.

Preventing constipation

Constipation is the inability to pass or difficulty in passing a bowel motion because it is dry or hardened.

Following surgery, you are more likely to experience constipation due to the effect of the surgery on your bowel, side effects of pain relief medications, a change in your usual diet and fluid intake, or a reduction in your usual activity levels such as walking.

If you experience constipation you are more likely to strain or bear down when attempting to have a bowel motion. It is important to avoid this straining as it can affect the surgical sites, including the joint between the bladder and urethra. The pressure from straining can cause urine to leak through this join and may delay the healing process. Urine can also flow out around the catheter and cause leakage from the urethra when straining.

The following tips will help prevent constipation and achieve regular soft bowel motions.

• Eat a well-balanced diet including adequate amounts of fruit, vegetables and high fibre foods.
• Drink at least 1-2 litres of fluid per day, mainly water.
• Maintain regular activity as per your hospital healthcare team’s advice.
• You may be prescribed laxative medications by your urologist to maintain regular soft bowel actions in the short term following your surgery.
• Ask your healthcare team before going home from hospital for information on what to do if constipation occurs.

MANAGING AT HOME

Your treating hospital and healthcare team will provide you with specific information to follow upon your discharge from hospital until you visit your urologist for a follow up appointment.

WHAT TO EXPECT

Activity levels:

• A gradual return to normal activity is recommended.
• Short periods of activity such as gentle walking each day.
• Rest between activities. If you feel tired increase your rest periods.
• No heavy lifting, no activities that involve straining, no driving or physical exercise as advised by your urologist and healthcare team.

Eating and drinking:

• Continue with a healthy, nutritious diet.
• Fluids, particularly water, are important to help with clearing your catheter and preventing constipation. (For more information, please see the next section on ‘Managing your urinary catheter at home’.)

Pain relief:

• Follow instructions from your hospital healthcare team; ask questions about your pain relief medication if you are unsure.
• As you recover you will find you can reduce the amount of pain relief tablets you require. It is important however to have an adequate amount of pain

relief to allow you to perform normal daily activities comfortably such as showering yourself, dressing yourself, taking gentle walks.

Wound care:

• Nursing staff from your treating hospital will explain how to care for your wound. Ensure you have been given these instructions and understand them. Ask questions if you are unsure.
• You may either have dressings still in place or have no dressings when you go home. Usually wound dressings will be completely removed within 1 week following your discharge from hospital.
• Expect to have swelling and bruising of your scrotal area, which will resolve in the weeks following surgery. Wearing supportive underwear can assist with comfort.
• Look at your wound or the area around your wound dressing for signs of a wound infection. These can include redness of the surrounding skin, the area may be hot to touch or swollen, the wound may have a smelly odour, or there may be leakage of pus or fluid from the wound. Contact your healthcare team immediately if you have any signs of wound infection.

MANAGING YOUR URINARY CATHETER AT HOME

You will go home with a urinary catheter for a short period of time, usually between 1 to 2 weeks. If you are from a regional area, you may wish to consider staying close to your treatment centre until you have had your catheter removed.

Information and education on how to manage your urinary catheter at home will be given by members of your healthcare team, who may include a continence advisor, urology nurse or ward nurse. This advice will include:

• catheter bag care, including care of a leg bag and how to attach a night bag, how to remove and clean a night bag, how to change a bag if required, your hygiene needs with a catheter, how your catheter should be secured to prevent pulling
• what to do if catheter problems occur (further tips below)
• who to contact and what to do if an emergency occurs with your catheter (further tips below)
• where and when your catheter is due for removal
• information and advice on what to expect when your catheter is removed.

Tips to assist in your catheter care

• Drink: Preferably water. You should aim to drink enough fluids to keep your urine a pale yellow colour to prevent infection and possible blockage of the catheter.

• Regular bowel motions: Aim for regular bowel motions [for more information on constipation, please see the section on ‘Preventing complications after your surgery’]. Straining while having a bowel motion can cause problems such as urinary bleeding. Prevent straining by maintaining regular soft bowel motions.
• Hygiene: Wash your hands with soap and water before and after any catheter care. Continue to shower as usual, wash around the head of the penis and under your foreskin (if uncircumcised) in a downward action at least daily.
• Check equipment: Ensure there are no kinks in the catheter or drainage bag. Keep the drainage bag below the level of your bladder to allow for correct drainage of urine and to prevent backwards pressure into the bladder.
• Prevent pulling of catheter: Ensure your catheter is strapped or taped to your leg, as advised by your healthcare team. This prevents pulling of the catheter, which can cause pressure to the internal surgical area. Empty your catheter bag when half to three quarters full to prevent dragging on the catheter.

Tips on managing catheter problems

• Bleeding around the catheter: It is normal to experience small amounts of bleeding around the catheter (from the tip of the penis). This can commonly occur if you have strained, for example, when having a bowel action or when heavy lifting. If you are concerned with the amount of bleeding, contact your healthcare team.
• Discharge around your catheter: It is normal to experience small amounts of discharge (secretions) from around the catheter (from the tip of the penis). The discharge can be clear/milky and becomes brown when dry. Remove this discharge from around the catheter when showering. If you are concerned with the amount of discharge, contact your healthcare team.
• Bladder spasms: You may experience occasional spasms in your bladder, which can feel like you need to urinate. This is not uncommon. They can cause leakage of urine around the catheter - rather than urine coming out through the catheter, it bypasses the catheter. If this leakage becomes a problem for you, it can be managed by wearing a small continence pad. If you are experiencing discomfort or pain with the bladder spasms, talk with your urologist about medications to assist.
• Leaking of urine: Occasional leaking of urine around the catheter can occur. It can occur due to bladder spasms (see above), as a result of the healing process, if you have strained with a bowel action, or with strenuous activity. If the leakage becomes a problem it can be managed by wearing a small continence pad in your underwear. If you are concerned with the leakage, talk with a member of your healthcare team.
• Blocked catheter: If you are experiencing pain in the bladder area or your catheter stops draining urine, check that there are no kinks in the catheter or catheter bag tubing. Ensure the leg bag is well positioned on your leg and not pulling or dragging. Keep drinking water and walk around. If urine is still not draining, or if you are experiencing pain, contact your healthcare team immediately for further advice.

• Your catheter falls out: If your catheter falls out, contact your urologist, a member of your healthcare team or your treating hospital immediately.

• Urinary infection: A urinary catheter puts you at risk of developing a urinary infection. To prevent this, ensure you drink enough water to keep your urine a pale yellow colour (unless you have been advised otherwise by your healthcare team), and keep the area where the catheter goes into your penis clean. Signs of a urinary infection include: cloudy, coloured or smelly urine,you have a temperature, you feel unwell, you are experiencing pain in the bladder, urethra or kidney area (lower back or flank area). Contact your urologist or healthcare team for further advice.

WHAT TO EXPECT WHEN YOUR URINARY CATHETER IS REMOVED

You need an appointment either with your urologist or at the hospital to have your catheter removed. Make sure you have the date and time for this before you are discharged from hospital.

Sometimes you are required to have a small procedure called a cystogram prior to your catheter removal. A cystogram is an X-ray procedure that uses dye to show the bladder and surrounding area. This can be used to check if the area where your bladder and urethra have been joined is healing.

Your treating hospital and urologist will advise you what is required on the day when your catheter is removed.

It is common to experience urinary problems and urinary incontinence such as leakage of urine or accidental leaking of urine at this early stage (for more information, please see the following section on ‘Possible side effects from surgery’). How you urinate will be assessed and monitored after the catheter is removed.

Be prepared for urinary incontinence on the day when your catheter is removed. It is important to have continence pads with you on the day. If you have not been given continence pads by your treating hospital, they can be purchased from a supermarket or chemist. A men’s shield pad is recommended at this stage.

Sometimes urinary incontinence can be significant in the early weeks after the catheter has been removed, with some men experiencing leakage all the time early after the catheter is removed.

Listed below are some questions you may want to ask members of your healthcare team about what to expect.

• When can I commence pelvic floor exercises?
• What urinary problems or urinary incontinence can I expect?
• How long can these problems be expected to continue?
• How can I manage the problems or incontinence?

All prostate cancer treatments, including surgery, come with some side effects. Generally, the type of side effects can be predicted but how severe they are can be different between men. The important thing is for you to find out as much as you can about your treatment and the side effects before you start, so that you can be better prepared.

WHAT IS A SIDE EFFECT?

It is important to not confuse side effects with cancer symptoms. Side effects are unwanted and unpleasant symptoms or reactions caused by the treatment, not by the disease itself.

Side effects can be managed through additional treatments (e.g. medications or psychological interventions). Because people can react differently to the same treatment, their experiences of side effects can also be different.

• Some side effects are minor and can be managed, while others may be more difficult.
• Some side effects can be uncomfortable.
• Some side effects can be serious health conditions that require more medical treatments.
• Most side effects are reversible when treatments stop, but some are permanent.
• Some people don’t experience any side effects from treatments, while some people experience many.
• Always talk to your healthcare team about side effects because there may be ways of managing them.

POSSIBLE URINARY SIDE EFFECTS

Urinary side effects are problems that can be caused by prostate cancer surgery. Following surgery, some men don’t experience urinary problems or they are quickly resolved. For other men, the urinary problem can be more difficult, requiring further support and help from their urologist and healthcare team members who specialise in prostate cancer and urinary problems.

To understand possible urinary problems following surgery, it is important to know how the prostate and bladder are connected, and how your prostate cancer surgery affects them both.

How is urine function controlled?

• Urination is controlled by two urinary sphincters, which are muscles acting like valves. The internal sphincter is located where the bladder and urethra join, called the bladder neck. The external sphincter sits below the prostate near the pelvic floor.
• These two sphincter muscles act together, and control urine by opening and closing around the bladder neck and urethra. When they get permission from the brain, the sphincters relax to allow the bladder to empty. At the same time, the bladder muscles contract and squeeze urine out of the bladder. When you have finished urinating, the sphincter muscles contract and close while the bladder relaxes.

The pelvic floor muscles also play a part in bladder control. The floor of the pelvis is made up of muscle layers and tissues. The layers stretch like a hammock from the tailbone at the back to the pubic bone in front. Your pelvic floor muscles support your bladder and bowel. The urethra (urine tube) and rectum (anus) pass through the pelvic floor muscles.

When your prostate gland is removed entirely during surgery, two things occur that can cause urinary problems:

• A gap is created between the bladder and urethra, which is then surgically reattached. The bladder neck (where the bladder and urethra join) can be affected and this can cause urinary problems.
• Also, the external sphincter may be weakened, or very rarely, damaged during surgery, and this can cause urinary problems as well. This is why pelvic floor exercises (which can strengthen the external sphincter) before your surgery, and after removal of your catheter, can help with managing possible urinary problems after surgery.

INSIDE VIEW OF A PENIS

Within the first 6 weeks following surgery, you should be returning to more of your usual activities.

FOLLOW-UP APPOINTMENTS

As part of your ongoing care, follow-up appointments will be offered to make sure you are recovering or have recovered from surgery.

You may have a follow up appointment with your urologist within the first 4 to 6 weeks following surgery.

Discussions with your urologist may include:

• how you are recovering from the surgery
• what urinary problems you may be experiencing
• erectile function and ongoing management based on your individual situation
• pathology information from the operation and a recent PSA level.

After the surgery, the prostate gland and surrounding tissue will have been sent to a pathologist. The pathologist examines the prostate gland and tissue and provides information on the grade and stage of the cancer and if the cancer had spread to the edges of the prostate.

Your urologist will use this information along with your PSA level to decide on your ongoing care.

Your PSA should drop to an undetectable level and will be checked at regular intervals following your surgery. Your healthcare team will provide advice and support about your ongoing follow-up care.

MANAGING THE COST OF TREATMENT

The Australian Government subsidises the cost of listed prescription medicine to all residents and eligible overseas visitors through the Pharmaceutical Benefits Scheme (www.pbs.gov.au/info/about-the-pbs). Not everything relating to your cancer treatment may be covered by the scheme so check with your doctor when they prescribe a medication or refer you to a service. If you have private health insurance, check what your policy will cover so that you are prepared for any possible financial outlays.

Talk to a member of your healthcare team (e.g. social worker) about what financial and practical support services are available. Talk to your local Medicare office about the ‘Pharmaceutical Benefits Scheme Safety Net’ and the ‘Medicare Safety Net’ on costs of medications and medical bills (www.humanservices.gov.au/customer/services/medicare/pbs-safety-net and www.humanservices.gov.au/customer/services/medicare/medicare-safety-net).

ORGANISATIONS AND SERVICES

Listed below are some of the leading organisations and services that can provide you with accurate information and support about issues following prostate cancer treatment.

• Prostate Cancer Foundation of Australia (PCFA):
  providing information, resources and a list of support groups across Australia.
  Tel:(02) 9438 7000 / 1800 22 00 99 (local call)
  Email: enquiries@pcfa.org.au
  Website: www.pcfa.org.au/contact-us/
  (PCFA state offices are listed on the website).
• Cancer Australia:
  providing national leadership in cancer control and improving outcomes for Australians affected by cancer
  Website: www.canceraustralia.gov.au
• Andrology Australia:
  providing information about prostate cancer and male reproductive health.
  Tel:1300 303 878
  Email: info@andrologyaustralia.org
  Website:www.andrologyaustralia.org
• Continence Foundation of Australia:
  providing information about bladder and bowel health and accessing support.
  Tel:(03) 9347 2522 or 1800 330 066
  (free helpline staffed by continence nurse advisors) Email: info@continence.org.au
  Website:www.continence.org.au
• Impotence Australia:
  providing information about impotence, treatments and accessing support.
  Tel:(02) 9280 0084 / 1800 800 614(local call)
  Email: admin@impotenceaustralia.com.au
  Website:www.impotenceaustralia.com.au
• Cancer Council Helpline:
  a free, confidential telephone information and support service run by Cancer Councils in each State and Territory.
  Tel:13 11 20
• Lifeline Australia:
  providing all Australians experiencing a personal crisis with access to 24 hour crisis support and suicide prevention services.
  Tel:13 11 14 (24 hour service)
• beyondblue:
  The National Depression Initiative – providing information about and support for anxiety and depression.
  Tel:1300 224 636
  Website:www.beyondblue.org.au
• Black Dog Institute:
  providing treatment and support for mood disorders such as depression.
  Tel:(02) 9382 4523
  Email: blackdog@blackdog.org.au
  Website:www.blackdoginstitute.org.au
• Relationships Australia:
  providing relationship support services for individuals, families and communities.
  Tel:1300 364 277
  Website:www.relationships.org.au
• Cancer Council Australia:
  reducing the impact of cancer in Australia through advocacy, research, education and support.
  Website:www.cancer.org.au
• Cancer Councils:
  providing practical and emotional support, financial and legal assistance, information services and more.

Cancer Councils:

• Cancer Council ACT
  Tel: (02) 6257 9999
  Email: reception@actcancer.org
  www.actcancer.org
• Cancer Council Northern Territory
  Tel: (08) 8927 4888
  Email: reception@actcancer.org
  www.actcancer.org
• Cancer Council NSW
  Tel: (02) 9334 1900
  Email: reception@actcancer.org
  www.actcancer.org
• Cancer Council Queensland
  Tel: (07) 3634 5100
  Email: info@cancerqld.org.au
  www.cancerqld.org.au
• Cancer Council South Australia
  Tel: (08) 8291 4111
  Email: tcc@cancersa.org.au
  www.cancersa.org.au
• Cancer Council Tasmania
  Tel: (03) 6212 5700
  Email: infotas@cancertas.org.au
  www.cancertas.org.au
• Cancer Council Victoria
  Tel: (03) 9514 6100
  Email: enquiries@cancervic.org.au
  www.cancervic.org.au
• Cancer Council Western Australia
  Tel: (08) 9212 4333
  Email: inquiries@cancerwa.asn.au
  www.cancerwa.asn.au

• Talk It Over:
  Men’s Line Australia – providing professional telephone and online support, information and referral service, helping men to deal with relationship problems in a practical and effective way.
  Tel: 1300 789 978
  Website: www.menslineaus.org.au
• Fertility Society of Australia:
  providing information about fertility issues and accessing services.
  Tel: (03) 3645 6359 Website: www.fertilitysociety.com.au

FURTHER READING

• Localised prostate cancer information pack:
  Prostate Cancer Foundation of Australia. (2013). (You can get a free copy of this pack by contacting PCFA.
  Tel: (02) 9438 7000 / 1800 220 099 (local call)
  Email: enquiries@pcfa.org.au
  Website: www.pcfa.org.au
• Advanced prostate cancer information pack:
  Prostate Cancer Foundation of Australia. (2014). (You can get a free copy of this pack by contacting PCFA.
  Tel: (02) 9438 7000 / 1800 220 099 (local call)
  Email: enquiries@pcfa.org.au
  Website: www.pcfa.org.au
• Facing the tiger:
  a guide for men with prostate cancer and the people who love them, Chambers, S. (2013). Toowong: Australian Academic Press.
• After prostate cancer:
  a what-comes- next guide to a safe and informed recovery, Melman, A. & Newnham, R. (2011). New York: Oxford University Press.

Other resources
For more information about prostate cancer and symptom management, PCFA has a number of resources.
Please visit PCFA website
or call: (02) 9438 7000/1800 220 099 (local call).

Please note: If calling from overseas, the country code for Australia is +61