What are urodynamics?

Urodynamics are tests designed to assess bladder function and the bladder outlet. It helps in making a diagnosis about the cause of your bladder problems, and can help guide treatment decisions.

For example:

• In men, it can sometimes be difficult to know if urine symptoms are caused by a bladder or a prostate problem.
• In women with mixed incontinence (both stress and urgency incontinence), it is sometimes helpful to know which of the two is the main problem, and how much each problem contributes to overall symptoms.

How is the test performed?

The test is conducted on a day case basis in my clinic rooms, and only takes approximately 30-40 minutes. It is not painful. You will be asked to empty your bladder in private, into a special toilet, and the flow rate will be measured.

Soft, thin tubes will be inserted into your bladder and back passage to record pressure readings during the test. A small amount of local anaesthetic jelly is used to help insert the urine catheter.

Your bladder is filled with sterile water until you feel the need to urinate. You will be asked to cough at various stages during the test. At the end of the test, you will be asked to empty your bladder again, and the catheters will be removed.

After the test

Analysing the results takes some time, so it is usual for me to arrange a follow up appointment in my clinic rooms in order to discuss your results in detail with you. The test will help pinpoint the cause of your urine problems, and assist in deciding the right treatment for you.

What are the risks of this procedure?

All procedures have the potential for side effects. Although these complications are well recognised, the majority of patients do not have problems after a procedure.

Common risks:

• Some mild discomfort when passing urine for a couple of days

Occasional:

• Some mild bleeding in the urine

Rare risks:

• Infection in the urine

Very rare

• More serious infection (sepsis) requiring hospital admission and intravenous antibiotics

If you develop a fever, severe pain on passing urine, inability to pass urine or worsening bleeding, you should contact me immediately. If out of hours, please go to your nearest emergency department.

What is the prostate?

The prostate gland is a small but important gland in the male reproductive system. Its main function is to produce secretions that make up part of the semen protecting and enriching the sperm. The prostate gland sits just beneath the bladder and surrounds the neck of the bladder and the start of the urethra (the tube through which you pass urine).

About the procedure

A radical prostatectomy is an operation for men with prostate cancer. A small incision is made in the lower abdomen. The pelvis and lymph nodes are carefully evaluated for the presence of disease. The entire prostate gland and seminal vesicles are removed. The bladder neck is then joined to the urethra. A catheter is left in place to drain urine from the bladder to allow the join between the bladder neck and the urethra to heal. Two small drains are left in the pelvis for 24-48 hours.

The aim of the surgery is to remove all prostate cancer as well as maintain urinary control and sexual function.

In order to maintain urinary control, as much bladder neck and urethra is preserved as possible. Return of sexual function after radical prostatectomy depends upon preservation of the nerves that travel alongside the prostate down to the penis. It relies on very careful separation of the nerve containing tissue (neurovascular bundle) from the prostate. In the setting of more aggressive disease, nerve sparing may not be advised as it could increase the risk of leaving disease behind.

The pelvic lymph nodes are located on the side wall of the pelvis. Prostate cancer can spread to these lymph nodes particularly if the cancer is aggressive or advanced. If there is a risk of the lymph nodes being involved, then I will remove these nodes.

Preparation for a Radical Prostatectomy

Preparation for the procedure includes learning about the pelvic floor and pelvic floor exercises. This usually involves an appointment with a physiotherapist who specialises in pelvic floor training. A pre-operative appointment will usually be made to meet with your anaesthetist and pre-operative blood and urine tests will be arranged.

What to expect afterwards

After the operation you will return to the ward and you will be monitored closely by nursing staff. I usually place a local anaesthetic pump underneath the wound which release local anaesthetic into the wound this is generally very effective. Initially you will receive fluids through a drip. You will be able to recommence a diet over the next 1-2 days.

You should to do deep breathing and leg exercises. Mobility is encouraged and you will get out of bed with assistance usually the next day.

The chance of developing a deep vein thrombosis (DVT) is low, and we do everything possible to minimise that risk. You will be fitted with firm stockings which you should wear during your stay in the Hospital and you will be given a daily injection of Clexane which is a blood thinner.

The wound sutures are absorbable and therefore do not need to be removed. If you notice any increasing redness, swelling or ooze please let me know.

Catheter care

The nursing staff will fit a urine drainage bag that attaches to your leg. This allows for easier mobility. The catheter can be uncomfortable and cause irritation of the penile tip. By irritating the bladder it can sometimes give you a sense of needing to pass urine or bladder spasm.

You will be given instructions on how to look after the catheter before your discharge. You will also be given instructions on how to self-administer the Clexane at home.

Complications of surgery

The main longer term risks of prostate surgery are the potential for incontinence and erectile dysfunction.

Surgical risks include the following:

Bleeding Significant bleeding is uncommon now and the chance of requiring a blood transfusion is <10%.

Wound infection The chance of this is low, around 5% or less.

Urine infection The chance of a urine infection is around 10%. Antibiotics given around the time of surgery usually controls this.

Deep vein thrombosis (DVT) / Pulmonary Embolus The risk is small but real, around 1%. All precautions are taken to minimise this risk.

Rectal or ureteric injury Both structures are very close to the prostate and are therefore at risk with surgery. The risk though is very low, less than 1%.

Bladder neck stenosis Narrowing of the join between the urethra and bladder is possible, but again the risk is low, around 2%.

Overall, most men do very well at the time of surgery and the risk of complications at the time of surgery is low.

After discharge from hospital

Catheter - You will have a leg bag and a night bag for the time that the catheter remains in place. The catheter will usually remain for 14 days. Do not do pelvic muscles exercises while the catheter is in place.

Clexane - You will be given a supply of Clexane to complete.

Pain relief - You will be given appropriate pain relief to take home with you. I advise taking regular pain relief to allow easier mobility.

Cystogram - Arrangements will be made for you to have a follow up scan to ensure that the join between the bladder and urethra is secure and following this the catheter can be removed.

Wound care - The wound will gradually heal over 4-6 weeks. You should avoid heavy lifting and straining during this time. You will be comfortable enough to drive again in 2-3 weeks. Shower in the usual way, but keep the wound clean and dry in between. You may need a dry dressing if there is a slight ooze. If you have any abdominal creases where your wound may remain moist, it is important to place a dressing between the creases to separate the skin and keep the area dry.

Diet - Avoid becoming constipated by keeping up a good fluid intake and eating fruits and foods high in fibre. If you have problems with constipation you may require a laxative.

Contact my clinic rooms if you have any concerns. If the wound becomes red, hot, swollen, painful or continues to ooze it may indicate a wound infection. If the urine becomes cloudy or offensive smelling it may indicate a urine infection.

If the catheter stops flowing then it may be blocked. This could lead to a full and painful bladder. You should either contact my clinic rooms or present to the Emergency Department for assessment and flushing of the catheter. Do NOT allow your catheter to be removed/replaced.

Driving

Legally you should not drive for 24 hours after having sedation/ general anaesthetic. I would advise you not to drive for 2-3 weeks at least.

Follow up

I will arrange to review you with your first post-operative PSA blood test 6 weeks after your surgery.