• Typically a patients will begin by being referred to the Urologist who then performs the ultrasound and biopsy and then pending results will opt for a “watch and wait” approach or advocate for a radical prostatectomy where the Gleason warrants it as aforementioned.
• In the case of BPH the Urologist can prescribe medications such as tamsulosin or dutasteride or a combination to manage symptoms or they can perform a transurethral resection of the prostate (TURP). This surgery utilises a combined visual and surgical instrument (resectoscope) which is inserted through the tip of the penis and into the urethra and it is basically a rebore or the prostate which relieves some of the pressure the prostate places on the urethra allowing normal flow. It is worth knowing that once a male is 50 there is a 50% chance they will have some BPH, and for every year after 50 their percentage risk of having BPH is the same as their age - ie at age 90 there is a 90% chance of BPH.
• Once the Urologist diagnoses prostate cancer and a radical prostatectomy is decided upon, a patient would generally be operated on within a small number of weeks. Da Vinci Robotic surgery is the gold standard for prostate removal and sees the patient have 5 small incisions made across their abdomen. This technology is preferred because it is less traumatic and minimally invasive; it certainly enables surgeons to overcome many of the shortcomings of both open prostatectomy (big incision) and laparoscopic (smaller incision) prostatectomy. The short comings of open and laproscopic prostatectomy included reduced patient activity/mobility/increased hospital stay and often resulted in a loss of bladder control and sexual function due to severance of the delicate plexus of nerves around the prostate.
 
• All forms of prostate surgery are quite expensive (approx $14,000-$20,000) and private health do not give much back leaving patients significantly out of pocket. Given the often urgent need for surgical intervention most patients rely on private health and will avoid the public system with possible waiting lists.
• Once the surgery is complete this hospital stay is brief; with the Da Vinci robot it is well less than a week (may even be 1-2 days). It is interesting to note that robotic surgery takes only 2-3 hours which is very quick compared to the other traditional removal options, hence some of the improved recovery times. It is worth noting that all patient will be catheterised for their surgery - the catheter would usually remain in for 7-10 days and then be removed without complication by the Urologist or their registrar.
• After this the patient will return home and begin their rehabilitation. This has historically been a physiotherapist advising on pelvic floor exercises to correct incontinence but today we are pushing to treat more than continence.

• It is suggested that patients present for rehabilitation 2-8 weeks post surgery - it is worth noting 2 weeks post surgery there is still considerable post surgery inflammation and there can be discomfort. For this reason it would be suggested to either wait until more comfortable or go very gently with any form of rehabilitation.
• Most patient’s will have follow up PSA tests around 8 weeks post operatively; at this stage the PSA should be undetectable given the prostate has been removed unless the cancer has metastasised in which case there will be a PSA reading and the patient will need either a repeat PSA check and/or investigation for metastatic prostate cancer. When the prostate is removed the Urologist can check the margins of the prostate and if they are intact the patient may be somewhat more optimistic; conversely if the margins are not intact there would be more reason for concern. Most patients will have this information given to them before being discharged postoperatively

SHOP

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e) Post-operative expectations/fears

There are a number of ‘big ticket’ outcomes patients want to see postoperatively. These include:

• Complete removal of an 'intack' prostate (cancer cells insuti)
• Recovery of continence
• Recovery of sexual function
• Preservation of penis length; if no rehabilitation is performed atrophy of the penis can occur rendering it difficult to simply urinate (especially noting that postoperatively the penis appears upward of 2.5cm shorter immediately)
• whilst the return of the the above are not guaranteed there are exercises/activities patients can undertake to ensure best outcomes result

Beyond these patients can report the following concerns:

• Abdominal distention, constipation or bloating - ensure regularity with softners such as coloxyl - no stimulant laxatives
• Bladder spasms - should resolve and are often secondary to urination
• Bloody drainage around the catheter or in the urine - can be a sign of not resting and will subside with rest. If it does not resolve with rest seek advice from specialist
• Bruising around the port sites - not uncommon - will resolve with time. Hirudoid cream may be an option
• Lower legs/ankle swelling - not uncommon - will resolve with time. Try and elevate legs and wear stockings if need be
• Perineal discomfort - may last for several weeks post surgery. It may help to elevate the feet on a small stool when passing a bowel movement, applying hemorrhoid ointment (Proctosedyl), and to increase the fiber and water intake in the patient’s diet
• Scrotal/penis swelling and bruising - not uncommon and is not a cause for serious concern. The patient might notice scrotal/penile swelling anywhere from immediately after surgery to 5 days later. It should go away on its own in a week or two. It may be worth elevating the scrotum on a small rolled up towel when sitting or lying down to reduce swelling. It is also advisable to wearing supportive underwear (briefs, not boxer shorts) or if still problematic employ the use of a medical scrotal support

BPH

Benign prostatic hyperplasia (BPH) relates to enlargement of the prostate gland caused by a benign (non harmful) overgrowth of usually glandular prostate tissue which usually presents as variable urine flow. This variable, and often poor urinary flow, is caused by constriction of the urethra and can be corrected by having what is known as a TURP (transurethral resection of the prostate).

Typically BPH occurs in men over 50 years old; at which point the liklihood of a male having BPH is approximately 50%; the risk/liklihood increasing by 1%/year. Ie at age 70 there is a 70% liklihood; at age 85 there is an 85% likelihood.

BPH is not a direct indicator of prostate cancer, however males experiencing BPH should speak to their GP about management strageties and ensure that they have regular checkups incase of changes.

• Estimated 16665 males diagnosed in 2017 (3rd to breast then bowel cancer)
• This accounted for 23.1% of all new cancer diagnosis in males
• Estimated 3452 males died of prostate cancer in 2017 (3rd behind lung and bowel)
• This accounted for 12.7% of all male cancer deaths
• The chance of 5 year survival was 95%
• At the end of 2012 there were 94114 living with prostate cancer that were diagnosed in the preceeding 5 years

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