Thyer Urology

Your treating team

Isaac Thyer

Isaac is a urologist specialising in prostate cancer and will look after you from diagnosis through to long term follow up. If you have decided to have surgical intervention for prostate cancer, Isaac will perform Robotic Assisted Radical Prostatectomy. If you choose to undergo radiotherapy for prostate cancer, Isaac will perform urological procedures in preparation for radiotherapy such as inserting fiducial markers into the prostate.

Francesca Rogers

Francesca is a Urology Nurse Practitioner specialising in prostate cancer, bladder dysfunction and sexual dysfunction. Francesca will be there to support you from diagnosis to long term surveillance. Francesca will monitor you long term and manage any side effects of treatment such as bladder and erectile dysfunction, implementing and changing treatment as needed.

Our Admin Team

Our dedicated administration team Jade, Julie and Hayley are available via the office phone or email to assist you with any administration queries.

Prior to the operation

MRI

• If your cancer was diagnosed by Isaac, you will most likely have undergone MRI prior to the biopsy. If you have been referred from another urologist you may require prostate MRI to ensure the cancer is able to be treated successfully with surgery

Staging

• To ensure the prostate cancer is contained within the prostate a PSMA PET scan is sometimes required
• No scan is required for low grade disease, particularly if the PSA is very low
• PSMA PET can be expensive, so a bone scan and CT are a cheaper option although not considered to be as accurate as PSMA PET

Discussion about options for treatment

• Generally low risk prostate cancer can be observed and does not require treatment
• Surgery and radiotherapy have roughly equivalent rate of cure for prostate cancer
• Surgery for prostate cancer is favoured for younger men with prostate confined cancer
• Radiotherapy is favoured for older men particularly if the prostate cancer looks to be growing outside of the prostate on MRI
• Hormone therapy is recommended for older men where the cancer has spread to lymph nodes, other organs or bone
• Men with high risk prostate cancer will likely require a combination of surgery, radiotherapy and possibly hormonal therapy for cure

Waiting for surgery

• After prostate biopsy the inflammation around the prostate will take about 6-8 weeks to settle. For safety reasons surgery to remove the prostate needs to wait until this period has elapsed.
• After prostate biopsy it is common to see blood in the ejaculation for weeks, this will initially be bright red before diminishing to a brown tinge. Blood in the urine after biopsy should only last a few days.

Risks of radical prostatectomy

(these are the main risks and this is not an exhaustive list):

• Incontinence (leakage of urine in particular with exertion such as coughing/ sneezing)
• Erectile dysfunction (inability to achieve and maintain an erection without aid)
• Bleeding
• Conversion to an open operation
• Infertility
• Anejaculation (loss of ejaculation)
• Climacturia (leakage of urine with orgasm)
• Cancer recurrence
• Positive surgical margin (cancer at the margin of resection)
• Rectal injury (injury to the bowel)
• Ureteric injury (injury to the tubes from the kidneys to the bladder)
• Urine leak from the anastomosis (the join between the urethra and the bladder)
• Heart attack
• Stroke
• Lung infection
• Bladder infection
• Venous thrombo-embolism (blood clot)
• Very small risk of death

Prostate Cancer Specialist Nurse (PCSN)

(Affiliated with the Prostate Cancer Foundation of Australia- PCFA)

• You will need to have contact with a PCSN at first diagnosis
• PCSN’s will provide you with information and support throughout treatment for prostate cancer
• Francesca is a Urology Nurse Practitioner and PCFA affiliated PCSN who works out of our rooms at Hollywood and you will have the opportunity to speak with her each time you see Isaac.
• Lisa Ferri, Lucy Lyons and Francesca are based a Hollywood Hospital and will see you when you are in hospital.
• There are also now PCSN’s at other sites across WA and a telehealth service available.

Physiotherapy

• Pelvic floor exercises prior to surgery optimises recovery of bladder control
• All men will need to see a specialist pelvic floor physiotherapist at least a few weeks prior to the operation to ensure you understand how to contract the pelvic floor. This will assist with recovery of continence post operatively
• Those who are experiencing incontinence after the operation will need follow up with the physiotherapist to help regain control. Francesca will prompt return to physiotherapy as needed during your recovery.
• We will recommend a specialist pelvic floor physiotherapist near to you. You can also refer to our website for a list of preferred physiotherapists, or email Francesca

Flexible cystoscopy

• Every man’s anatomy around the prostate is slightly different. Isaac will perform a flexible cystoscopy (look in the bladder via the penis) with a small telescope prior to the operation to check on your anatomy. This is a quick day procedure.
• Flexible cystoscopy may have already been performed at the time of biopsy if you had your biopsy with Isaac, you will therefore not require another one prior to surgery.

Weight loss

• Some men are asked to lose weight prior to surgery to optimise their outcomes, and safety.
• Weight loss
  • Improves vision at the time of the operation
  • Shortens the length of procedure
  • Improves recovery of continence post operatively
  • Improves prognosis of erectile function recovery
  • Reduces per-operative risk

Pre-operative blood and urine tests

• These tests need to be performed at least 10 days prior to the operation with any Western Diagnostic Pathology branch.
• If there is a urine infection you will need to take a course of antibiotics prior to the operation

Blood thinning medication

• If you take any blood thinning medication including aspirin or fish/krill oil, please let our admin team know at least 3 weeks prior to the scheduled surgery date

The operation

• Radical prostatectomy is removal of the whole prostate
• Radical prostatectomy is performed by Isaac with robotic technique
• Robotic prostatectomy involves 5 small incisions in the abdomen with a slightly larger incision above the umbilicus (belly button) to remove the prostate once the procedure is finished
• You will have a drainage tube (catheter) in the bladder via the penis which will stay for 5-10 days. You may also have a drain left in situ which is removed the day after surgery.

After the operation

In hospital

• Most people stay 1-2 nights after the operation
• You will need to move around your hospital room, sit out of bed for meals and walk around the ward as early as possible after the operation in order to limit the chance of lung infection, bowel issues and blood clots
• Isaac will see you the day following the operation to check on progress
• The Prostate Cancer Nurses, Lisa, Francesca or Lucy will see you on the ward post procedure.
• The ward nurses are urology nurses who are experienced with prostatectomy patients and will provide education about your catheter care.
• The Continence Advisor will see you while you are in hospital to make an appointment for catheter removal which will take place at Hollywood Hospital 5-10 days post op.

When you go home

Activities

• Stay mobile – walk freely, balance rest with walks.
• Do not drive until you can drive to your usual safe standard which is generally 2 weeks post operatively. Any issues or questions about driving please email Francesca.
• No heavy lifting or strenuous activities for 4-8 weeks. Returning to activities will also depend on your continence recovery so please discuss this with us.
• Most men do not have erections initially after surgery, you can still achieve orgasm. Avoid vigorous sexual activity for the first few weeks – please discuss this with Francesca as needed.
• Return to work varies from patient to patient and depends on many factors, some men who are office based / can work from home return after 2 weeks, some men who have very physical jobs or work long hours have 8 weeks off. Please discuss your individual situation with us.

Catheter Management

• Drink plenty of water to keep your urine clear
• Urinary bypass, discharge and bleeding around the catheter is to be expected
• Ensure your catheter and bag are secured and positioned as shown in the hospital
• Supportive underwear help reduce movement of the tube which makes you more comfortable.
• If you have penile tip pain, you can get ‘lignocaine gel’ from the pharmacy which helps to lubricate and numb the penile tip.

Bowel Management

• You will need to take Movicol (over the counter medication)1-2 sachets twice a day until your bowels are soft and regular
• If your bowels are not open 3 days post operatively take Lactulose 20ml, twice a day, in addition to the Movicol or contact Francesca to discuss using suppositories

Wound Management

• Wounds are usually glued; the glue will come away over the few weeks post op.
• If you have any dressings, they can be removed 3-7 days post op.
• You may shower as normal, pat the wounds dry after the shower, do not rub them
• Any wound issues or questions, you an email a photo to Francesca

Catheter removal

• This will take place at Hollywood Hospital with Continence Nurse Lesley or Niamh 5-10 days after the operation, this appointment will be scheduled while you are in hospital, if your surgery is a Friday, they will phone you the following Monday to arrange the removal.
• Antibiotics will be given to you when leaving hospital. These need to start 2 days prior to catheter removal and continue until complete.

Pain Management

• Most people are uncomfortable rather than in pain and find that regular paracetamol is adequate.
• You may be sent home with stronger medication which are used ‘as directed, as required’ please see the instructions on the box, you do not need to take stronger medication unless you experience moderate pain as stronger medication cause nausea and constipation.
• You will be given written instruction from the hospital on your discharge medications.

Pad Use / Continence

• Until continence recovers you will need to wear a men’s continence pad, they look like a padded cricket box. Francesca will show you an example of continence pads and guide you what pads to purchase.
• Generally, we recommend disposable pads, Tena Men’s pads – level 2 or 3 tend to be the most appropriate. These can be purchased from your local pharmacy. Please see our information sheet ‘Continence Recovery’ for more detailed information.
• Please talk to Francesca about our expectations for your continence recovery, our outcomes are published on our website.

Erectile Function

• Erections are important not only for sexual activity but for maintaining penile length and health. We recommend and offer a penile rehabilitation program to all of our patients, regardless of whether or not you are sexually active.
• Penile rehabilitation / treatment for erectile dysfunction is incorporated into your regular PSA follow up.
• Please see our document ‘Erectile Dysfunction’ for more information. You can also request additional consultations with Francesca pre op as desired.

First post-operative visit (3 weeks)

• To see Francesca and Isaac with pathology result from the prostate specimen from surgery, check progress and check wounds.
• Depending on the pathology result you may need further treatment to ensure maximum chance of curing the cancer.
• DO NOT have a PSA test performed prior to this visit
• Francesca will also talk to you about recovery of sexual function and continence.

Second post-operative visit (8 weeks)

• To see Francesca our rooms with first PSA check
• The PSA request form will be given to you at the 3 week review.
• Francesca will also talk to you about penile rehabilitation. An individualised treatment plan will be implemented to promote penile health and aid sexual function recovery. Any ongoing continence issues will be discussed at this visit.

Ongoing surveillance

• PSA checks will be conducted with Francesca Rogers from Mr Thyer’s rooms every 3 months initially then less frequently with time. PSA checks will continue indefinitely at widening intervals. If your PSA becomes detectable in future, then you will be seen by Mr Thyer and discussion on further treatment options will be had.
• PSA follow ups will generally be done over the phone
• Ongoing management of sexual function recovery is carried out during these follow up phone calls.

Regional Patients

• If you live more than 100km outside of Perth, you are eligible for patient assisted travel schemes to help with the cost of travel.
• Accommodation through the cancer council is available for regional patients, Crawford lodge is on Monash avenue walking distance from our rooms and the hospital.
• This can be booked for any appointments and for surgery. They can be contacted on: 131120.

WHEN SHOULD I MAKE CONTACT?

• IF your catheter suddenly stops draining or falls out
• IF you have a fever of 38 or higher
• IF a wound looks infected (pus / heat / spreading redness around the wound)
• IF you have another urgent issue.

In hours call the office: 08 6323 5750

Do not allow anyone to remove or replace your catheter other than Isaac, Francesca or the Continence Nurses Lesley and Niamh at Hollywood Hospital.

AFTER HOURS EMERGENCY MANAGEMENT

Call Hollywood Private Hospital
08 9346 6000 – ask for the after-hours manager – readmission can be arranged

Attend Hollywood EMERGENCY department
Entrance 3, Monash Avenue, Nedlands – access in person of via ambulance

Attend your local EMERGENCY department

Please note, attending Hollywood Emergency Department attracts a fee of $200, this fee is to see the Emergency Consultant.

Useful Contact Details

Urology Nurse Practitioner
Francesca Rogers
e: francesca@thyerurology.com.au
p: 08 6323 5750

Prostate Cancer Specialist Nursing Service – Hollywood Private Hospital
Lisa Ferri & Francesca Rogers & Lucy Lyons
e: prostatecarenurse@ramsayhealth.com.au
p: 08 9346 6961