The Radical Perineal Prostatectomy (RPP)
technique is offered by Dr Jamie Wright at the Brady Urological
Institute at Johns Hopkins.
To make an appointment for consultation
please call 410-550-1700.
NOTE: Patients must
remember to bring all pathology reports, PSA values, and
glass pathology slides to their consultation appointment.
The pathology slides will be submitted for review at Johns
For directions to Johns Hopkins Bayview Medical Center
PRIOR TO THE SURGERY
What to expect prior to the surgery
Since insurance companies
will not permit patients to be admitted to the hospital the
day before surgery to have tests completed, you must make
an appointment to have pre-operative testing done at your
primary care physician's office within 1 month prior to the
date of surgery. Once your surgical date is secured, you will
receive a form along with a letter of explanation to take
to your primary care physician or family doctor in order to
have the following pre-operative testing done prior to your
Once your surgical date
is secured, you will receive a form along with a letter of
explanation to take to your primary care physician or family
doctor in order to have the following pre-operative testing
done prior to your surgery.
- Physical examination
- EKG (electrocardiogram)
- CBC (complete blood count)
- PT / PTT (blood work)
- Comprehensive Metabolic Panel (blood work)
These results need to be
faxed by your doctor's office to the Pre-operative Evaluation
Center at 410-614-0102
or 410-614-3230 two weeks prior to
your surgery. Please call The Documentation Center at 410-955-9453
two weeks before your surgery date to confirm that
this information was received.
Drink only clear fluids for a 24-hour
period prior to the date of your surgery
Remember not to eat or drink anything after
midnight the evening before your surgery.
Clear liquids are liquids that you are able to see through.
Please follow the diet below.
- Clear Broths (no cream soups, meat,
- Juices (no orange juice or tomato
- Apple juice or apple cider
- Grape juice
- Cranberry juice
- Hawaiian punch
- Kool Aid
- Gator Aid
- Tea (you may add sweetener, but no cream
- Coffee (you may add sweetener, but no
cream or milk)
- Clear Jello (without fruit)
- Popsicles (without fruit or cream)
- Italian ices or snowball (no marshmallow)
A bowel preparation called a Fleet Prep
Kit #1 must be purchased at your local pharmacy (this is an
over the counter item). You must start the preparation the
day before surgery and follow the instructions included in
Do not eat or drink anything after midnight
the night before the surgery. Aspirin, Motrin, Ibuprofen,
Advil, Alka Seltzer, Vitamin E, Ticlid, Coumadin, Lovenox,
Celebrex, Voltaren, Vioxx, Plavix and some other arthritis
medications can cause bleeding and should be avoided 1 week
prior to the date of surgery (Please contact your surgeon’s
office if you are unsure about which medications to stop prior
to surgery. Do not stop any medication without contacting
the prescribing doctor to get their approval).
If you wish you may donate blood to minimize
the need for a transfusion from another individual.
As compared to open radical prostatectomy
where a lower midline abdominal incision is required for dissection
and removal of the prostate gland, perineal prostatectomy
is performed by making a small (2 inch) incision between the
rectum and the scrotum. (see Figure 1). Results from multiple
centers specializing in perineal prostatectomy have acceptable
blood loss and similar potency and oncologic results as compared
to traditional open surgery. Potency can be reserved but may
be in lower percentage than the open surgery.
The perineal prostatectomy
is performed by making an incision between the scotum and
the rectum. Instrumentation is inserted to dissect the prostate
gland and seminal vesicles from the urethra and bladder. With
the use of a high-powered telescopic lens attached to a camera
device, excellent visualization of the prostate gland and
the surrounding neurovascular structures is achieved. Once
the prostate gland is dissected free from the bladder, rectum,
and urethra it is removed and sent for pathological evaluation.
The bladder is sewn back to the urethra to create an anastamosis.
A Foley catheter is placed to drain the bladder prior to closure
of the anastamosis. In addition, a small drain is placed around
the surgical site, exiting the incision. It is usually removed
the first post operative day. Typically, the length of the
operation is 4 hours.
Potential Risks and Complications
Although laparoscopic prostatectomy
has proven to be very safe, as in any surgical procedure there
are risks and potential complications. Potential risks include:
- Bleeding: Although blood loss during this procedure
is low compared to the retropubic approach, a transfusion
may still be required if deemed necessary by your surgeon
either during the operation or afterwards during the Postoperative
period. It is advised to donate 2 units of autologous blood
(donating your own blood) prior to surgery. If you are interested
in autologous blood transfusion you must make your surgeon
aware. When the packet of information is mailed to you regarding
your surgery, you will receive an authorization form for
you to take to the Red Cross in your area. The Red Cross
will draw your blood and have it sent to Johns Hopkins Hospital
for your surgery.
- Infection:All patients are treated with intravenous
antibiotics prior to starting surgery to decrease the chance
of infection from occurring in the urine or in the incision
after surgery. If you develop any signs or symptoms of infection
after the surgery ( fever, drainage from incision, urinary
frequency/discomfort, pain or anything that you may be concerned
about) please contact us at once. Rarely will a bowel injury
occur that may require creation of a colostomy to allow
the rectal injury to heal.
- Adjacent Tissue / Organ Injury: Although uncommon,
possible injury to surrounding tissue and organs including
bowel, vascular structures, pelvic musculature, and nerves
could require further procedures. Transient injury to nerves
or muscles can also occur related to patient positioning
during the operation.
- Hernia: Hernias at incision sites rarely occur.
- Urinary Incontinence: As in any prostatic surgery,
urinary incontinence can occur following prostatectomy but
often improves over time. About 75% of men will gain control
by 3 months and most by 1 year. About 3 % of men will have
permanent incontinence requiring additional surgery for
- Erectile Dysfunction: A nerve-sparing technique
is used during perineal dissection of the prostate gland
unless there is obvious involvement of the nerve tissue
by tumor. The return of erectile function following prostatectomy
is a function of the age of the patient, degree of preoperative
sexual function, technical precision of the nerve-sparing
technique, and time.
- Urethrovesical Anastomotic Leakage: Transient
small anastamotic leaks can occur following prostatectomy
and often resolve without further intervention within a
few days to a week. If this occurs,, the pelvic drain and
urinary catheter is left until the leak is sealed to prevent
a buildup of urine (called a urinoma) from occurring within
- Rectal Incontinence: Rectal incontinence is rare
but urgency of bowel movements and seepage may occur shortly
after the surgery. This should resolve over time.
WHAT TO EXPECT AFTER
What to expect after discharge from
the surgery you will be taken to the recovery room, then transferred
to your hospital room once you are fully awake and your vital
signs are stable.
- Postoperative Pain:Pain medication can be controlled
and delivered by the patient via an intravenous catheter
or by injection (pain shot) administered by the nursing
staff You may experience some minor transient shoulder pain
(1 -2 days) related to the carbon dioxide gas used to inflate
your abdomen during the laparoscopic surgery. Occasionally
patients will have incisional pain which can last several
- Nausea:You may experience transient nausea during
the first 24 hours following surgery, which can be related
to the anesthesia. Medication is available to treat persistent
- Urinary Catheter: You can expect to have a urinary
catheter (Foley) draining your bladder (which is placed
in the operating room under anesthesia) for approximately
1 weeks after the surgery. If the urethra is not healed
it may stay in longer.
- Pelvic Drain: The wound drain is placed in the
operating room. This drain is usually removed the morning
after surgery, but may be kept in as long as a week if a
leak at the anastamosis occurs.
- Diet: You can expect to have an intravenous catheter
(IV) in overnight. (An I'V is a small tube placed into your
vein so that you can receive necessary fluids and stay well
hydrated; in addition it provides a way to receive medication.)
Most patients are able to tolerate ice chips and liquids
the day of surgery and clear liquids the first day after
surgery. Once on a regular diet, pain medication will be
administered by mouth instead of by IV or shot.
- Fatigue: Fatigue is common and should start to
subside in a few weeks.
- Incentive Spirometry: You will be expected to
do some very simple breathing exercises to help prevent
respiratory infections by using an incentive spirometry
device (these exercises will be explained to you during
your hospital stay). Coughing and deep breathing is an important
part of your recuperation and helps prevent pneumonia and
other pulmonary complications.
- Ambulation: On the day after surgery it is very
important to get out of bed and begin walking with the supervision
of your nurse or family member to help prevent blood clots
from forming in your legs. You can expect to have SCD's
(sequential compression devices) along with tight white
stockings on your legs to prevent blood clots from forming
in your legs while you are lying in bed.
- Hospital Stay: The length of hospital stay for
most patients is approximately one day.
- Constipation: You may experience sluggish bowels
for several days to a week after surgery. Suppositories
and stool softeners are usually given to help with this
problem. Taking one teaspoon of mineral oil and milk of
magnesia at home will also help to prevent constipation.
- Wound Care: Some patients develop some drainage
from the incision after they go home. This can either be
clear fluid (seroma) or a mixture of blood and pus. You
should call your doctor and report the color and amount
What to expect
after the surgery
- Pain Control:You can expect
to have some pain that may require pain medication for a
few days and occasionally last for a few weeks after discharge,
and then in most cases Tylenol should be sufficient to control
- Urinary Catheter:You may
have some bloody discharge around the catheter during a
bowel movement, this is not uncommon and will subside. It
is not uncommon to feel some increased pressure in your
bladder during a bowel movement. If you see blood in your
urine (which is not uncommon) it will help to increase your
fluid intake. By increasing your intake your urine will
remain diluted, preventing blood clots from forming and
obstructing your catheter. Increasing your fluid intake
will also help to stop the bleeding. Bloody urine is usually
insignificant and resolves on its own. You may notice some
leaking around the catheter when you are walking around.
This can be managed through the use of depends or absorbent
materials. If you notice that your catheter stops draining
completely, lie flat and drink a lot of water. If your catheter
is still not draining after 1 hour you may have to have
your catheter irrigated. You must notify the urology office,
call the urology resident on call (see contacts) or visit
your local emergency room. Please have the doctor at the
emergency room call prior to removing the catheter.
- Urinary Tract Infection:
You may develop a urinary tract infection related to the
urinary catheter (usually due to placement and catheter
removal). It is important to check the clarity of your urine
before the catheter is removed as well as drainage around
the catheter. If you notice any urinary frequency or burning
after the catheter is removed you may have an infection.
It is important to call your doctor with any of these symptoms.
Your doctor may prescribe an antibiotic to prevent such
- Showering: You may shower
at home. Your wound sites can get wet, but must be padded
dry. Tub baths can soak your incisions and therefore are
not recommended in the first 2 weeks after surgery. Sutures
underneath the skin will dissolve in 4-6 weeks.
- Activity: Taking walks
is advised. Prolonged sitting or lying in bed should be
avoided and can increase your risk for forming blood clots
in the legs as well as pneumonia. If you notice any pain
or swelling in your leg, chest pain, especially when deep
breathing, shortness of breath, sudden onset of weakness
or fainting, and or bloody sputum, please notify us immediately
or go to your local emergency room. Climbing stairs is possible
but should be limited. Driving should be avoided for at
least I week after surgery. Absolutely no heavy lifting
(greater than 20 pounds) or exercising jogging, swimming,
treadmill, biking) until instructed by your doctor. Most
patients return to full activity on an average of 3 weeks
after surgery. It is common for patients to feel fatigue
or weak for a while. The length of time it takes to recover
- Diet: No restrictions.
Drink plenty of fluids.
- Follow-up Appointment:
You will need to call soon after your discharge (unless
arrangements were made before discharge) to schedule a follow
up visit for a cystogram, voiding trial and catheter removal
to be done one week after your surgery. The foley catheter
will only be removed if your cystogram is negative. For
this appointment please call The Johns Hopkins Out Patient
Center at 410-955-6101.
- Long-Term Follow-up: A
PSA test is drawn at 3 months following surgery and at regular