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1. Preparation

WHAT IS A PROSTATECTOMY?

Prostatectomy is an operation to remove all or part of the prostate gland. It may also include the removal of the seminal vesicles [1] , surrounding tissues and the nerve bundles on either side of the prostate that are responsible for erections. The prostate gland is a walnut-sized gland that produces and secretes the fluid in male semen. It is located at the base of the urinary bladder and wraps around the urethra [2] .

WHY IS IT DONE?

Because the prostate gland almost encircles the upper end of the urethra, any enlargement and tumour in the prostate gland can restrict the normal flow, causing symptoms such as difficult, painful or frequent urination. The two main conditions for prostatectomy are benign prostatic hyperplasia (BPH) and cancer of the prostate.

Benign prostatic hyperplasia (BPH) is a non-cancerous condition where the prostate grows larger due to benign growth of cells within the prostate gland. It commonly occurs in men older than 60 years of age due to hormonal changes. Its main symptoms are urinary obstruction and inability to empty the bladder completely.

Carcinoma of the prostate is a malignant tumour of the prostate gland. This cancer commonly occurs in men older than 50 years of age.

HOW DO I CHOOSE A SPECIALIST?

Your GP, or the doctor you first consult, will be able to recommend and refer you to a Urologist who can perform the procedure.

You may be happy to accept the advice of your GP with regard to a specialist, or you may like to investigate your choices; either option is safe and valid. In Australia each medical speciality has a governing body to which the consultants belong. You can access the Urological Society of Australia via their website www.urosoc.org.au. This is a very informative website.

The list of questions below may help you better understand your treatment, and if necessary decide on a particular doctor. Practical issues you may also like to consider are what hospital a particular doctor operates from, and what their fees are. (If you need more information about fee setting and gap arrangements, please refer to our brochure “what you should know before going into hospital”, which is also available on the HCF website).

To access a list of Urologists who participate in HCF’s Medicover no gap arrangement:

Please note: Participation in HCF’s no gap initiatives is at the doctor’s discretion. HCF does not guarantee that every medical service provided by these doctors will be a no gap service. Some doctors who participate in the HCF Medicover No Gap arrangement have chosen not to be listed on the HCF website. Patients are encouraged to confirm with their doctor whether they will support HCF’s no gap initiatives for their treatment.

WHAT SHOULD I ASK MY SPECIALIST?

Do not be afraid to ask your doctor questions about the procedure and any side effects which can occur. It is your right to know all the relevant information, as this is part of informed clinical and financial consent. Your doctor will ask you to sign a consent form.

In addition to what the procedure involves, you should also ask about:

• Preparation
• Follow up appointments, jot down any questions or concerns you may have so that you can ask your doctor at your next appointment
• Aftercare

Most medication should be continued as usual, but some may interfere with the surgery. Your doctor will inform you of the medication you should stop. As a guide, the following medication may require special instruction:

• Aspirin (or any related products),
• Blood thinners (Warfarin, heparin.),
• Arthritis medication,
• Pain medication,
• Anti-inflammatory medication,
• Insulin.

Don't forget to mention any homeopathic or herbal remedies you are taking as these can have interactions and side effects too.

WHERE IS IT DONE?

A Prostatectomy is done in a hospital. The anticipated length of stay for a trans-urethral prostatectomy is 3-4 days, for a radical prostatectomy it can be 5-10 days.

HOW LONG IS THE PROCEDURE?

The surgery time for a Prostatectomy depends on the type of procedure performed.

WHO IS INVOLVED?

The people involved in the procedure are:

• The Urologist, your Specialist doctor
• There may be an assistant surgeon
• Anaesthetist: they give you medication that makes you relaxed and sleepy and look after you whilst the procedure is being carried out
• Nurses for the procedure and recovery
• Pathologist for blood tests and/or specimen samples

HOW DO I PREPARE FOR A PROSTATECTOMY?

Your doctor will probably ask you to cease taking any aspirin and anti-inflammatory medication ten days prior to surgery to ensure they are out of your bloodstream. This allows for bleeding and clotting times to return to normal. If you are a smoker and you cannot give up completely, try to reduce smoking in the weeks leading up to your surgery; this may help to lower the risk of post-operative complications such as chest infection.

The night before the surgery, you may be given an enema or suppositories if your bowels have not opened. It is also important that you do not eat or drink anything from midnight prior to your morning surgery; if your operation is scheduled for the afternoon you shall be required to fast for at least 6 hours prior to surgery.

Please follow any instructions given to you by the hospital. Your doctor will have his/her own specific preparation requirements as well. These instructions should be strictly followed.

WHAT DO I TAKE WITH ME TO THE HOSPITAL?

• Do not bring any valuables with you
• Leave all jewellery at home, a wedding ring is acceptable
• Wear warm comfortable clothing
• Bring any medication that you would usually take during the day, under most circumstances you may still be able to take these
• Bring any relevant x-rays or scans
• You may also wish to bring something to read whilst you wait

2. Costs and Charges

WHAT IS IT GOING TO COST?

Ask your doctor whether he will participate in HCF’s no gap arrangement for your surgery so that you do not incur any out of pocket expense. If your doctor does not wish to participate, it is your doctor’s responsibility to fully inform you of your financial liability and any out of pocket expense prior to you consenting to the surgery.

For your information, the average charges for claims paid for Transurethral Resection of the Prostate (TURP) admissions for the financial year 06/07 are provided below:

Points to Note:

• Charges are based on HCF claims for a sample size of 670 overnight admissions with an average length of stay of 3.6 days in private participating hospitals (private hospitals that have an agreement with HCF for accommodation, theatre and hospital related services) – covered under Medicare item 37203.
• As a private patient in a non-participating hospital you may incur an out of pocket expense for the hospital component (accommodation, theatre and hospital related services).

¹ These medical services are in-patient services only.

² The medical charges are based on averages and each episode of care is different, i.e. you may not have all of these medical services, and/or you may also have other medical services not indicated here e.g. diagnostic procedures. Therefore, the total average medical service charge ($2,656) differs from the sum of the individual average charges as shown.

³ Doctors who do not use the HCF no-gap arrangement have a higher average out of pocket charge, as their charges are higher than those doctors who use the no-gap arrangement and incur nil out of pocket charges to the patient. Therefore, the sum of the average benefits plus the average out of pocket charge you pay will not equate to the charge as shown in the table.

⁴ Doctors’ charges vary so always ask your doctor whether he/she will participate in HCF’s No Gap Arrangements.

HCF Medicover Schedule of Benefits lists all services for extra benefit in excess of the Commonwealth Medicare Benefits Schedule (CMBS) fee, which providers, registered under the HCF Medicover No Gap arrangement will receive as full payment for services provided. This also applies to unregistered providers should they charge within the schedule of benefit listed. This arrangement ensures that our members incur no out of pocket expense.

⁵ This percentage indicates the total coverage of hospital and medical services for all transurethral resections of the prostate. The percentages shown for each type of medical service are much higher as they are calculated for those services only and not the entire admission, which includes all medical services and the hospital services. In an admission you may have one medical service with an out of pocket expense, which then excludes the whole admission from being fully covered. Hence the significant difference in percentage for individual types of medical services as compared to the total admission fully covered.

Radical Prostatectomy

For your information, the average charges for claims paid for all Radical Prostatectomy admissions for the financial year 06/07 are provided below:

Points to Note:

• Charges are based on HCF claims for a sample size of 402 overnight admissions with an average length of stay of 5.9 days in private participating hospitals (private hospitals that have an agreement with HCF for accommodation and hospital related services) - covered under Medicare items 37210 and 37211.
• As a private patient in a non-participating hospital you may incur an out of pocket expense for the hospital component (accommodation and hospital related services).

¹ These medical services are in-patient services only.

² The medical charges are based on averages and each episode of care is different, i.e. you may not have all of these medical services, and/or you may also have other medical services not indicated here e.g. specialist consultations. Therefore, the total average medical service charge ($6,988) differs from the sum of the individual average charges as shown.

³ Doctors who do not use the HCF no-gap arrangement have a higher average out of pocket charge, as their charges are higher than those doctors who use the no-gap arrangement and incur nil out of pocket charges to the patient. Therefore, the sum of the average benefits plus the average out of pocket charge you pay will not equate to the charge as shown in the table.

⁴ Doctors’ charges vary so always ask your doctor whether he/she will participate in HCF’s No Gap Arrangements.

HCF Medicover Schedule of Benefits lists all services for extra benefit in excess of the Commonwealth Medicare Benefits Schedule (CMBS) fee, which providers, registered under the HCF Medicover No Gap arrangement will receive as full payment for services provided. This also applies to unregistered providers should they charge within the schedule of benefit listed. This arrangement ensures that our members incur no out of pocket expense.

⁵ This percentage indicates the total coverage of hospital and medical services for all radical prostatectomies. The percentages shown for each type of medical service are much higher as they are calculated for those services only and not the entire admission, which includes all medical services and the hospital services. In an admission you may have one medical service with an out of pocket expense, which then excludes the whole admission from being fully covered. Hence the significant difference in percentage for individual types of medical services as compared to the total admission fully covered.

2. Day of procedure

WHAT HAPPENS TO ME AT THE HOSPITAL?

When you arrive at the hospital, the admissions clerk will attend to the paperwork associated with your stay.

On admission to the hospital a nurse will orientate you to your surroundings and request your medical history, current medication and any known allergies. The consent for the operation is attended to by the surgeon. An anaesthetist will visit you prior to your operation to discuss your anaesthetic options, and also the type of pain relief you will receive after the operation.

There are two types of anaesthetic that may be used:

▪ General – You are asleep throughout the procedure

▪ Epidural – Numbing usually from the waist down

An intravenous line will be put into the back of your hand so that you can be given sedation, antibiotics and fluid replacement.

WHAT CAN I EXPECT DURING A PROSTATECTOMY?

The removal of all or part of the prostate gland can be performed in a number of ways depending on the size of the prostate, the cause of the enlargement and the general health of the patient. The following are the most common types of prostatectomy:

Trans-urethral Resection of the Prostate (TURP) is the most common procedure for benign prostatic hyperplasia (BPH). It is less invasive than other types and performed on patients whose prostate is moderately enlarged. The obstructive glandular tissue is removed using a special endoscope and an electrical loop passed through the penis into the prostate gland. From inside the prostate, the wire loop is used to remove part or the entire prostate. This procedure takes about 30 to 60 minutes.

Radical Retropubic Prostatectomy is the removal of the prostate gland through an incision made in the abdomen and then into the fibrous capsule surrounding the prostate. This is the common treatment for prostate cancer where the lymph nodes in the area may also be removed for testing of cancerous spread. This is generally recommended only for men in good health who have a life expectancy of ten years or more. Before the prostate can be fully removed, the urethra must be cut both above and below the prostate. After removing the prostate, the urethra is stitched to the neck of the bladder so urine is able to flow. On average, this procedure takes about 2 to 3 hours. The most common side effects of this type of surgery are impotence and urinary incontinence.

Suprapubic Prostatectomy is similar to retropubic prostatectomy but with an incision through the bladder instead of the fibrous capsule surrounding the prostate.

Perineal Prostatectomy is the removal of the prostate from behind, through an incision between the rectum and the scrotum. The recovery type of this approach is shorter than the retropubic approach, but a separate incision must me made if removal of lymph nodes is required. On average, this procedure takes about 2 to 3 hours. This procedure is not performed as often these days.

Nerve-sparing Radical Prostatectomy is a modified technique where the nerves responsible for erections are preserved if they are cancer-free. This procedure is not suitable to everyone and can increase the risk of cancer recurring if left behind.

After the urethra is reconnected to the bladder, a Foley catheter is inserted into the penis while the patient is still under anaesthesia. The catheter is an artificial tube to help drain the bladder after the surgery. In some cases a suprapubic catheter is inserted into the bladder through a small incision in the lower abdomen. This is often used in case the patient has difficulty passing urine when the urethral catheter is removed and provides another access for urine drainage.

3. Aftercare

WHAT HAPPENS AFTER A PROSTATECTOMY?

Following the surgery, you will be taken to recovery where you will be closely monitored by nursing staff. Your vital signs will be checked on a continual basis until you are fully conscious, when you will be returned to the ward.

Your intravenous drip will usually be removed as soon as you are drinking normally, but may stay in a few days longer if antibiotics need to be given.

A catheter with bladder irrigation attached is used to flush the bladder of old blood clots and debris from the operation. Following a trans-urethral resection (TURP), if your urine is not too heavily bloodstained, the irrigation is turned off and the catheter is removed on the second day after surgery.

Following a radical prostatectomy you are often required to keep the catheter in after being discharged, returning a couple of weeks later to have it removed. Sometimes dribbling and urgency occur which means you may not feel comfortable venturing too far from toilet facilities until this resolves.

At first your urine will be bloodstained but this gradually clears as you heal. You are encouraged to drink plenty of fluids each day. You will have pain and discomfort for a few days after surgery, which is usually controlled with a combination of strong tablets given regularly and an injection if required.

Usually you can start walking the day after surgery but will have tubes attached as previously mentioned. Early mobilisation is advised as it drastically reduces the risk of post-operative complications such as blood clots in the legs (Deep Vein Thrombosis, or DVT) and chest infection.

To prevent constipation and strain on the rectum, you will be given a high fibre diet or laxatives for several days following surgery. Straining may cause haemorrhage due to the rectum’s close proximity to the prostate shell.

Depending on the type of procedure, you will be in hospital for 3-7 days and will be ready for discharge once you are passing relatively clear urine.

Before discharge, you should be given specific advice about any self-care necessary over the next couple of months. Make sure you are clear on the following issues:

• Wound care
• Restrictions on your level of activity, including lifting
• Whether you are able to drive (it’s also a good idea to check with your car insurance company in case they have a restriction following surgery)
• Strategies to avoid and treat constipation (avoiding enemas)
• When you are able to resume sexual activity
• Any changes to your regular medication

1. Preparation

WHAT IS A PROSTATECTOMY?

Prostatectomy is an operation to remove all or part of the prostate gland. It may also include the removal of the seminal vesicles [1] , surrounding tissues and the nerve bundles on either side of the prostate that are responsible for erections. The prostate gland is a walnut-sized gland that produces and secretes the fluid in male semen. It is located at the base of the urinary bladder and wraps around the urethra [2] .

WHY IS IT DONE?

Because the prostate gland almost encircles the upper end of the urethra, any enlargement and tumour in the prostate gland can restrict the normal flow, causing symptoms such as difficult, painful or frequent urination. The two main conditions for prostatectomy are benign prostatic hyperplasia (BPH) and cancer of the prostate.

Benign prostatic hyperplasia (BPH) is a non-cancerous condition where the prostate grows larger due to benign growth of cells within the prostate gland. It commonly occurs in men older than 60 years of age due to hormonal changes. Its main symptoms are urinary obstruction and inability to empty the bladder completely.

Carcinoma of the prostate is a malignant tumour of the prostate gland. This cancer commonly occurs in men older than 50 years of age.

HOW DO I CHOOSE A SPECIALIST?

Your GP, or the doctor you first consult, will be able to recommend and refer you to a Urologist who can perform the procedure.

You may be happy to accept the advice of your GP with regard to a specialist, or you may like to investigate your choices; either option is safe and valid. In Australia each medical speciality has a governing body to which the consultants belong. You can access the Urological Society of Australia via their website http://www.urosoc.org.au/. This is a very informative website.

The list of questions below may help you better understand your treatment, and if necessary decide on a particular doctor. Practical issues you may also like to consider are what hospital a particular doctor operates from, and what their fees are. (If you need more information about fee setting and gap arrangements, please refer to our brochure “what you should know before going into hospital”, which is also available on the HCF website).

To access a list of Urologists who participate in HCF’s Medicover no gap arrangement:

• Call HCF Member Services on 13 13 34
• Visit one of HCF’s customer service branches
• Access HCF’s website at www.hcf.com.au/members/findahealthprofessional/findadoctor

Please note: Participation in HCF’s no gap initiatives is at the doctor’s discretion. HCF does not guarantee that every medical service provided by these doctors will be a no gap service. Some doctors who participate in the HCF Medicover No Gap arrangement have chosen not to be listed on the HCF website. Patients are encouraged to confirm with their doctor whether they will support HCF’s no gap initiatives for their treatment.

WHAT SHOULD I ASK MY SPECIALIST?

Do not be afraid to ask your doctor questions about the procedure and any side effects which can occur. It is your right to know all the relevant information, as this is part of informed clinical and financial consent. Your doctor will ask you to sign a consent form.

In addition to what the procedure involves, you should also ask about:

• Preparation
• Follow up appointments, jot down any questions or concerns you may have so that you can ask your doctor at your next appointment
• Aftercare

Most medication should be continued as usual, but some may interfere with the surgery. Your doctor will inform you of the medication you should stop. As a guide, the following medication may require special instruction:

• Aspirin (or any related products),
• Blood thinners (Warfarin, heparin.),
• Arthritis medication,
• Pain medication,
• Anti-inflammatory medication,
• Insulin.

Don't forget to mention any homeopathic or herbal remedies you are taking as these can have interactions and side effects too.

WHERE IS IT DONE?

A Prostatectomy is done in a hospital. The anticipated length of stay for a trans-urethral prostatectomy is 3-4 days, for a radical prostatectomy it can be 5-10 days.

HOW LONG IS THE PROCEDURE?

The surgery time for a Prostatectomy depends on the type of procedure performed.

WHO IS INVOLVED?

The people involved in the procedure are:

• The Urologist, your Specialist doctor
• There may be an assistant surgeon
• Anaesthetist: they give you medication that makes you relaxed and sleepy and look after you whilst the procedure is being carried out
• Nurses for the procedure and recovery
• Pathologist for blood tests and/or specimen samples

HOW DO I PREPARE FOR A PROSTATECTOMY?

Your doctor will probably ask you to cease taking any aspirin and anti-inflammatory medication ten days prior to surgery to ensure they are out of your bloodstream. This allows for bleeding and clotting times to return to normal. If you are a smoker and you cannot give up completely, try to reduce smoking in the weeks leading up to your surgery; this may help to lower the risk of post-operative complications such as chest infection.

The night before the surgery, you may be given an enema or suppositories if your bowels have not opened. It is also important that you do not eat or drink anything from midnight prior to your morning surgery; if your operation is scheduled for the afternoon you shall be required to fast for at least 6 hours prior to surgery.

Please follow any instructions given to you by the hospital. Your doctor will have his/her own specific preparation requirements as well. These instructions should be strictly followed.

WHAT DO I TAKE WITH ME TO THE HOSPITAL?

• Do not bring any valuables with you
• Leave all jewellery at home, a wedding ring is acceptable
• Wear warm comfortable clothing
• Bring any medication that you would usually take during the day, under most circumstances you may still be able to take these
• Bring any relevant x-rays or scans
• You may also wish to bring something to read whilst you wait

2. Costs and Charges

WHAT IS IT GOING TO COST?

Ask your doctor whether he will participate in HCF’s no gap arrangement for your surgery so that you do not incur any out of pocket expense. If your doctor does not wish to participate, it is your doctor’s responsibility to fully inform you of your financial liability and any out of pocket expense prior to you consenting to the surgery.

For your information, the average charges for claims paid for Transurethral Resection of the Prostate (TURP) admissions for the financial year 06/07 are provided below: