Laparoscopic Radical Prostatectomy

Laparoscopic Radical Prostatectomy

APRIL 2002, VOL 75, NO 4 Home Study Program IAPAROSCOPIC RADICAL PROSTATECIUMY he article “Laparoscopic radical prostatectomy” is the basis for this...

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APRIL 2002, VOL 75, NO 4

Home Study Program IAPAROSCOPIC RADICAL PROSTATECIUMY

he article “Laparoscopic radical prostatectomy” is the basis for this AORN Journal independent study. The behavioral objectives and examination for this program were prepared by Rebecca Holm, RN, MSN, CNOR, clinical editor, with consultation from Susan Bakewell, RN, MS, education program professional, Center for Perioperative Education. A minimum score of 70% on the multiple-choice examination is necessary to earn 2.5 contact hours for this independent study. Participants receive feedback on incorrect answers. Each applicant who successfdly completes this study will receive a certificate of completion. The deadline for submitting this study is April 30,2005. Send the completed application form,multiple-choice examination, learner evaluation, and appropriate fee to AORN Customer Service c/o Home Study Program 2170 S Parker Rd, Suite 300 Denver, CO 8023 1-571 1 or fax the information with a credit card number to (303) 750-3212.

BEHAVIORAL OBJECTIVES

After reading and studying the article on laparoscopic radical prostatectomy (LRP), the nurse will be able to (1) identify the anatomy of the male reproductive system, (2) discuss the preoperative assessment and care of the patient undergoing LRP, (3) explain the perioperative nursing care of the patient undergoing LRP, (4) describe the surgical steps of the LRP procedure, and (5) discuss the postoperative course of the patient recovering from LRP. This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements.

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Laparoscopic Radical Prostatectomy

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rostate cancer is the most common type of cancer diagnosed in men, accounting for 11% of cancer deaths. It is the second leading cause of cancer death among men in the United States, after lung cancer.' Although there are a variety of treatment modalities available, surgical excision of the prostate gland remains the course of choice for many men with localized disease. Traditionally, a major open abdominal procedure (ie, radical prostatectomy) was the only option, and it required an extended hospital stay and recovery time. Patients often required blood transhsions and were at risk for both incisional infection and secondary infection from the long-term indwelling Foley catheter. Impotence and urinary incontinence were the two most common side effects of the surgery.' Surgical techniques have evolved (eg, nerve-sparing surgery in the 1980s), but the development of laparoscopic radical prostatectomy (LRP) has been one of the most significant changes in surgical treatment of this disease. As with any new procedure, training is required for surgeons and perioperative nursing staff

members on an ongoing basis as modifications continue to be made. Clinical outcomes need to be monitored continuously, and, to date, the procedure demonstrates good results and higher patient satisfaction than traditional open surgery. ANATOMY AND PHYSIOLOGY

The prostate gland, which is part of the male reproductive anatomy, is located below the bladder and surrounds the urethra (Figure 1). The front wall of the rectum lies just beneath the prostate. A normal gland is approximately 4 cm in diameter and weighs roughly 20 g, which is comparable to a small walnut. It is made up of fibromuscular tissue that contains alveoli and tubular ducts.' The prostate is composed of right and left sides and lobes. Conical in shape, the tip farthest from the bladder is called the apex and the wider portion is the base. The base adheres to the bladder and the apex adheres to the fascia and muscle tissue forming the urogenital diaphragm. The prostate gland is enclosed in a prostatic capsule and surrounded by extraperitoneal connective tissue. Denonvilliers' fascia comprises two layers of endopelvic fascia, A B S T R A C T Prostate cancer is the second leading cause of cancer deaths which separates the prostate from among men, after lung cancer. Traditionally, the traumatic open rad- the rectum.' If the capsule has ical PrOStateCtOmy procedure was the only treatment option avail- been penetrated by disease, there able. Although nerve-sparing techniques have evolved, the develop- is a greater likelihood that the ment of IaparOSCOpiC radical prOStateCtOmy (LRP) has been one of disease has or will spread.' the most significant changes in surgical treatment of the disease. The gland is divided into Like many minimally invasive abdominal procedures, LRP reduces three zones (ie, peripheral, centrauma, resulting in less postoperative pain, reduced length of hospi- tral, transition). The largest is the tal Stay, and more rapid return to normal activity when compared to peripheral zone. which makes up open radical PrOStateCtOmy. This article describes the preoperative, two-thirds of the prostate gland. intraOperatiVe, and postoperative care of a patient undergoing LRP. It The peripheral zone encompasses is anticipated that LRP will be the future standard for treatment of the anterior and posterior portions prostate cancer that requires radical surgery. AORN J 7 5 (April 2002) of the prostate, from apex to base. 762-782. The central zone is the second 0 E N IS E K I ('h' E R 1'. R N : I) E K 0R.4 Ii

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the prostate gland, the vas deferens continue as the ejaculatory ducts, which empty sperm into the urethra. The testicles produce the male hormone testosterone and make sperm.'' During ejaculation, the prostate uses rhythmic contractual movements to secrete prostatic fluid into the urethra. This fluid is an alkaline pH, milky, thin substance that helps protect the sperm as it travels in the acidic female reproductive tract. ' ? Enlargement of the prostate causes a narrowing of the urinary passageway. This narrowing makes it increasingly difficult for the male to maintain a constant flow of urine. Clinical symptoms include urinary frequency, hesitancy, slow urinary stream, retention, nocturia, and dysuria. I' Figure 1 Male reproductive anatomy. (Mustrution by Murk Katnik, Denver)

PROSTATE CANCER

largest zone. It is cone shaped and incorporates most of the base of the prostate. The transition zone, the smallest zone, is the location where benign prostate hypertrophy (BPH) occurs; therefore, it often is called the BPH zone.' Neurovascular fibers or bundles are located on each side of the prostate. These fibers contain the blood and nerve supply critical to erectile function; therefore, maintaining their integrity during surgery, when possible, is important.' The dorsal venous complex is contained in the retroperitoneal connective tissue that covers the prostate.* The prostatic pedicles are groupings of connective tissue found on either side of the vas deferens and seminal vesicle. These pedicles help stabilize the prostate. The bladder is located just above the prostate and posterior to the seminal vesicles, vas deferens, ureters, and r e c t ~ m .The ~ urethra leads from the bladder through the prostate, past the urinary sphincter, and out the penis. The urinary sphincter is a group of circuIar muscle fibers located just below the prostate that prevent leakage of urine during physical activity and coughing. A loss of control of this sphincter leads to incontinence.I0 There are two vas deferens in the male anatomy located on the lateral sides of the prostate gland. The vas deferens are tubelike structures that allow sperm to travel from the testicle to the urethra. In

Adenocarcinoma of the prostate is the most common form of cancer in American males. The American Cancer Society estimated that approximately 198,000 men were newly diagnosed with prostate cancer in 2001. More than 3 1,000 men were likely to die from the disease in the same year.I4 During their lifetime, one in six men will be diagnosed with prostate cancer, but only one in 30 is likely to die of the disease. The incidence is higher in African American men than in Caucasian or Asian males.15 Like breast cancer, prostate cancer is familial. The risk of developing prostate cancer depends on the level of closeness and the number of affected relatives. Men with a first-degree relative, such as a brother or father who is affected, are twice as likely to develop prostate cancer. If a man's grandfather or uncle (ie, second-degree relatives) had prostate cancer, the risk is less, but it still is higher than it is for males with no evidence of prostate cancer in family members. If there are two first-degree relatives with prostate cancer, a man's risk is five times higher. Three first-degree relatives (eg, father and two brothers) increases the risk to 11 times the norm. The highest risk factor occurs if a first-degree relative had an onset of clinically recognized disease at age 53 or younger. Risk is minimized considerably if the disease is not diagnosed until after age 65.16 Many men will die with, rather than from, prostate cancer. Unsuspected carcinoma often 764

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appears in autopsy specimens in men older than age likely to spread (Table I). A tissue biopsy is per50. After prostatectomy for BPH, 10% to 20% of the formed, and on microscopic examination, the tissue prostate tissue examined demonstrates incidental car- is assigned two numbers between one and five. Two cinoma. By age 90, prostate cancer is evident on values are allocated because tumors usually demonstrate variation. The two most common types of tisautopsy in 67% of patients.” Recent American Cancer Society statistics sue are given numbers, and the combination of these demonstrate that approximately 93% of men diag- two numbers equals the score. The first number is nosed with prostate cancer survive at least five reflective of the most common type of tumor identiyears. Ten-year survival rates are 72%. The best sur- fied on biopsy, and the second assigned number repvival rates (ie, 100% relative survival rate) occur resents the next most common type of cell.” A Gleason score of two to four indicates a wellwhen the prostate cancer is localized to the gland. In 12% of patients, the cancer has spread to tissues differentiated or nonaggressive tumor. Moderatelyadjacent to the prostate by the time of diagnosis. differentiated and aggressive tumors are given a With regional spread, the survival rate is approxi- score of five to seven. The highest score range of mately 94%. Only 9% of men diagnosed with eight to 10 indicates poorly differentiated cells and prostate cancer have metastases to distant parts of highly aggressive tumor growth. There is a 2.1% the body, at which point the survival rate is 33% at probability that a tumor in a patient with a score of five years. When prostate cancer has been diag- two to four will spread beyond the prostate within nosed, treatment modalities are based on grading one year if not treated. At 20 years, the chance of and staging scores. spread is 40% to 45%. The moderate tumor scored Prostate specific antigen (PSA).The PSA at five to seven has a 5.4% chance of spread in one blood test measures the enzyme produced by both year, and statistically, at 20 years, 100% of these normal and cancerous prostate cells. Many physi- tumors will have spread beyond the gland. The most cians recommend the test be performed annually on aggressive tumor type, eight to 10, demonstrates all men older than age 50, in conjunction with a dig- growth beyond the prostate in 13.5% of procedures ital rectal exam.lXIt is normal for a small amount of within the first year. By 10 years, 100% of the PSA to be released constantly in the bloodstream, tumors have spread. Research has demonstrated that but if the prostate is irritated or damaged, more PSA the Gleason scores themselves do not change with is released; therefore, an elevated PSA level reflects time. The tumor spreads, but the makeup of the abnormalities of the prostate, including inflamma- tumor itself or the type of cells remain the same.” tion, infection, BPH, or recent prostatic biopsy. Patients who have undergone LRP at Valleycare Although an elevated PSA level indicates there is an Health System have had Gleason scores ranging increased possibility of having cancer, a very high from four to seven. PSA level is very suggestive of prostate cancer.’” Treatment plans and prognosis also are based on The normal range of PSA is 0.0 to 4.0 ng per the tumor’s stage or extent of growth. There are two mL. Most men diagnosed with prostate cancer have staging systems, the Whitmore-Jewett, which uses PSA levels between 10 to 30 ng per mL, but the the letters A, B, C, and D, and the newer TNM (ie, results can be much higher in patients with advanced tumor, nodes, metastases) staging scale. Both staging disease.’n Grading and staging scores. Prostate cancer, like other forms of Table 1 carcinoma, is graded after diagnoGLEASON GRADE sis. The grade is one of the most Low-grade intermediate High-grade important factors in predicting the 3 4 5 6 7 8 9 10 patient’s long-term results, re- 2 sponse to treatment, and potential Well differentiated Moderately differentiated Poorly differentiated for survival.” Can grow slowly or aggressively Grows aggressively The Gleason score is the Slow growing most commonly used method for Most like normal cells Somewhere between normal Least like normal grading prostate cancer by preappearing cells and abnormal cells dicting how fast the cancer is cells 765 AORN JOURNAL

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Grading is based on cell pathology, whereas staging is determined by clinical examination or testing.

systems combine letters with numerals to indicate the degree of spread or tumor size in each classification. In the Whitmore-Jewett system, the letter A indicates a previously undiagnosed localized tumor that is discovered because of an elevated PSA level or during a procedure unrelated to the cancer. A score of A3 represents a cancer detected from an elevated PSA level, and A2 indicates unsuspected cancer removed during a transurethral resection of the prostate for BPH that occupies more than 5% of the gland. A score of Al describes an unsuspected cancer found incidentally on prostate removal for BPH that occupies less than 5% of the gland. A localized tumor found via a diagnostic tool, such as digital rectal examination (DRE), is assigned the letter B. The number assigned in conjunction with the letter B reflects the size and location of the tumor in the gland. A B 1 classification indicates a palpable mass located on one side of the prostate, and a B2 classification indicates a mass that occupies both sides of the gland. The letter C indicates a tumor that is growing in the immediate area outside the prostate capsule, and D means the tumor has spread to lymph nodes or, in some cases, other organs of the body. A C2 classification reflects seminal vesicle involvement, and the highest classification, D2, indicates the cancer has spread beyond the pelvis to bones, lungs, or other organs.:4 The TNM staging method is more specific with regard to cancer location. The letter T stands for tumor. A number from one to three and a lower case letter. a, b, or c, are combined with the T to indicate the tumor stage. For example, T2a represents a cancer that can be palpated and occupies 50% or less of one side of the prostate. A tumor that has spread beyond the capsule to surrounding tissue is classified as T4b. The letter N represents lymph nodes. Positive nodes are classified as N+, and NO repre-

sents no lymph node involvement. If positive lymph nodes are present, a number also is matched with the N+ symbol to demonstrate the severity of node involvement. For example, N3 (n+) has spread to one or more lymph nodes, and the tumor is 5 cm or larger. The final class is M for metastasis. A plus sign or zero indicates whether the tumor has metastasized. The significant difference between Gleason grading and the TNM and Whitmore-Jewett staging methods is that grading is based on cell pathology, whereas staging is determined by clinical examination or te~ting.'~ The type of surgical intervention performed or oncological treatment prescribed is based on a combination of the scores. TREATMENT MODALITIES

Treatment options for prostate cancer range from conservative management in the form of hormonal therapy to aggressive therapy, such as radiation or surgical intervention. The choice of which intervention to use is based on the patient's age and the degree to which the cancer has spread. Hormonal therapy is prescribed more commonly for patients who have widespread metastatic disease. Localized or regional tumors are most commonly treated with radiation or radical prostatectomy. The long-term side effects of radiation and surgery are similar. Both can result in incontinence or urinary frequency, sexual impotence, and diarrhea. Radiotherapy versus radical prostatectomy. A National Cancer Institute (NCI) study examined the incidence of side effects of cancer treatment in men 55 to 74 years of age. Urinary incontinence was higher in patients undergoing radical prostatectomy, with 9.6% reporting frequent leaking or lack of control. By comparison, 2.6% of the radiotherapy patients reported these symptoms. Both treatment modalities resulted in high incidences of impotence, with 79.6% of surgical patients and 61.5% of radiotherapy patients reporting inability to sustain an erection sufficient for intercourse 24 months after treatment. The severity of impotence was dependent on both age and sexual potency before diagnosis. Bowel dysfunction, such as diarrhea or bowel urgency, was twice as common in radiotherapy patients. Surgical intervention, in the form of radical prostatectomy, was more common in younger patients (ie, less than 65 years of age) The majority of patients older than age 70 were treated with radiotherapy." Evolution of surgical techniques. Radical prostatectomy has been the surgical procedure of 766

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The main contraindication

for LRP is morbid obesity, previous pelvic surgery, or previous radiation.

choice for localized prostate cancer. Improved techniques that spare the neurovascular bundles when possible have reduced the long-term side effects previously described. Comparisons made at 18 months or more after surgery demonstrate that only 56% of patients undergoing a bilateral nervesparing procedure reported impotence compared to 65.6% of patients with non-nerve sparing procedures.” Developed primarily in France in 1998, the most recent development in prostate cancer surgery is LRP. Like many minimally invasive abdominal procedures, LRP reduces trauma, resulting in less postoperative pain, reduced length of hospital stay, and more rapid return to normal activity. The laparoscopic approach provides better visualization of the surgical site and surrounding areas, allowing for more precise dissection. The need for blood transfusion is reduced, and the duration of the postoperative indwelling Foley catheter is abbreviated.Ix Bertrand Guillonneau, MD, Amon Krongrad, MD, and Guy Vallancien, MD, from the Institut Mutualiste Montsouris in Paris are credited with the development of this new technique. Urologist Mark Avon, MD, and general surgeon Carlos Gracia, MD, from Valleycare Health System traveled to France to observe and learn the new procedure. On their return, Drs Avon and Gracia oriented perioperative staff members at Valleycare Health System to the new procedure. At this point, 30 LRPs have been completed successfi~lly.All procedures were completed laparoscopically, with no conversions to open procedures. KAPAROSCOPIC RADICAL PROSTATECTOMY

Men with localized prostate cancer are considered candidates for LRP, providing they have not had previous pelvic surgery or radiation. Morbid obesity is the other main contraindication. A patient

is scheduled for a lymph node biopsy in addition to LRP if there is a 4+4 or higher Gleason Score, four or more positive biopsies, or a PSA level greater than or equal to 15. A chest x-ray is taken as part of routine preoperative screening, and a bone scan is performed on patients with a PSA level greater than 10. These screening examinations help rule out distant metastases. Preoperative care. Preoperative teaching begins in the physician’s ofice. The surgeon discusses the need for surgery with the patient and describes what the procedure will accomplish. The surgeon explains the risks, benefits, and alternatives to the procedure. The risks of surgery include infection, bleeding, the possible need for a blood transfusion, and potential anesthetic complications, including pneumonia, cardiac arrest, and death. The nurse provides the patient with written information, discusses the risk of blood transfusion, and offers the patient the opportunity to donate autologous blood. Additionally, the surgeon explains the advantages of the laparoscopic approach, which include less blood loss, easier recovery, and faster return to the workplace or normal activities of daily living. The surgeon then explains the disadvantages to this approach, specifically explaining that the procedure is relatively new so it takes longer to perform than the more traditional radical open procedure. As with the open prostatectomy procedure, there is a risk of urinary incontinence and impotence; there is no longterm data available to state whether the laparoscopic approach improves these outcomes. The surgeon provides the patient with information about alternative treatment options, including the open surgical approach, radiation therapy, cryosurgery, and observation. The surgeon provides the patient with written information regarding prostate cancer and treatment. Valleycare Health System has two resources available to patients. The first is Pacific Advanced Center for Medical Education Development (PACMED). Located on the hospital campus, the center has audiotape and videotape links to the advanced laparoscopic OR and workstations where patients can access online information. An RN is available at PACMED to answer further questions for patients. The second source is the Valleycare Health Library and Ryan Comer Cancer Research Center. The library provides written materials, videotapes, models, and other learning aids, as well as on-line

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health information. The library is staffed with a medical librarian, an RN, and volunteers to help patients search for information. If patients have further questions that cannot be answered by the PACMED or library staff members, they are referred back to their primary physicians or surgeons. Routine preoperative screening includes a complete blood count (CBC), chemistry panel, re;p,at PSA, electrocardiogram (EKG), chest x-ray, and possible bone scan. A blood type and crossmatch is drawn for two units of packed red blood cells. The surgeon orders a two-day bowel prep to reduce the risk of rectal injury. The patient undergoes a mechanical prep, taking magnesium citrate, neomycin, and erythromycin base. The patient is then instructed to remain on a clear liquid diet for two days before surgery. When the patient is scheduled for surgery, the preadmission nurse contacts him to set up an appointment. Generally, all laboratory work is coordinated on the same day. The patient preregisters in the admitting department and then is directed to the preadmission area, where he meets with a perioperative nurse. Blood is drawn, and an EKG is performed in the preadmission area. If it is required, the patient is escorted to the radiology department for chest xrays. The preadmission nurse obtains a preliminary nursing history and reviews general surgical instructions with the patient. If the patient has been admitted to the hospital before, the preadmission nurse reviews the patient’s previous chart as well. The patient is asked to complete a preoperative questionnaire. which includes previous surgical and medical history, allergies, and any anesthesia history. The preadmission nurse then reviews the history with the patient, confirming the information provided. The nurse provides additional patient teaching to support the information the patient received in the physician’s office. The nurse confirms that the patient understands the procedure. He or she reviews the necessary steps of the bowel prep to include remaining on a clear liquid diet for two days before surgery. The nurse explains that the patient will take a combination of neomycin 1 g and erythromycin base 1 g at 10 AM and again at noon the day before the procedure. The nurse also instructs the patient to take 8 oz of magnesium citrate at noon the day before the procedure. He or she reminds the patient about his NPO status and the time to arrive at the hospital. The nurse also identifies which medications should be taken the morning of surgery, if

By signing the informed consent, the patient agrees to laparoscopic, andpossibZy open, radical prostatectomy.

applicable. The preadmission nurse reviews the numeric pain scale with the patient, describing that zero is no pain and 10 is the worst possible pain. The nurse and patient clearly establish the patient’s pain goal. The nurse helps the patient understand what he can expect postoperatively, including the postanesthesia care unit (PACU) and hospital stay. The nurse instructs the patient on incentive spirometery and the importance of deep breathing and coughing along with early ambulation. The nurse reminds the patient that he will have a Foley catheter and an abdominal drain postoperatively and that he will be discharged home with the urethral catheter in place. Day ofsurgery. The patient arrives three hours before his scheduled surgery time. An admission staff member admits the patient to the preoperative admission area. A nurse obtains the patient’s baseline vital statistics after he has changed into hospital attire. This includes height, weight, blood pressure, pulse, respirations, oxygen saturation, and temperature. If not signed previously in the physician’s office, the nurse has the patient sign the informed consent form for laparoscopic, and possibly open, radical prostatectomy. The risk of dehydration exists, even though the patient has had a clear liquid diet for two days. The patient, therefore, is hydrated in the holding area with an IV solution of 5% dextrose and 0.45% normal saline at 125 mL per hour. The nurse reviews the patient’s laboratory reports and nursing and physician histories. He or she then discusses these reports with the patient to confirm that all information is current and correct and confirms the patient’s allergies and NPO status. The nurse reviews and verifies the consent with the patient, ensuring that he understands the procedure. If not done already, the nurse has the patient remove and give all jewelry to a family member. The nurse 769

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preoperative checklist, consent form, and physician’s orders. The circulating nurse has the patient confirm the consent, allergies, and NPO status. The nurse then assesses any other needs, such as skin rashes or joint disorders requiring special positioning consideration. The circulating nurse tells the patient what he will see as he enters the OR suite and explains that monitors, including EKG electrodes, pulse oximetry, and a blood pressure cuff, will be applied. Before proceeding to the OR, the circulating nurse allows the patient to express any concerns and ensures that all his questions have been answered. The circulating nurse uses all of this information to prepare a nursing care plan specifically for this patient. (Table 2)

then reinforces the teaching completed at the preadmission visit. He or she reviews the pain scale and confirms the patient’s pain goal. The nurse tells the patient’s family members where they can wait during the surgery. A prep, if ordered, is completed at this time. Prophylactic antibiotics are initiated preoperatively, so the preoperative nurse administers 1 g of cefazolin when notified that the OR is ready for the patient. Finally, the nurse places antiembolism stockings on the patient. The anesthesia care provider and circulating nurse assess the patient in the holding area, after which the anesthesia care provider usually orders preoperative sedation. The circulating nurse reviews the

Table 2 NURSING CARE PLAN FOR PATIENTS UNDERGOING IAPAROSCOPIC RADICAL PROSTATECTOMY

Nursing diannosis Risk for impaired skin integrity related to immobilization, positioning, pressure, shearing forces, and age-related skin changes

Interventions Identifies physical alterations that may affect procedure specific positioning. Positions the patient correctly.

Interim outcome statements

Outcome statements

The patient’s skin remains smooth, intact, nonreddened, nonirritated, and free from bruising other than at the surgical incision sites.

The patient is free from signs and symptoms of physical injury.

The patient will 0 maintain urine output greater than 50 mL per hour; maintain blood pressure, pulse, and oxygen saturation within expected ranges; maintain respiratory function; have laboratory values within the expected range; and have nonswollen extremities and dependent areas.

The patient’s fluid, electrolyte, and acid-base balance is consistent with or improved from baseline levels.

Implements protective measures to prevent tissue injury due to thermal, chemical, or mechanical sources. Evaluates for signs and symptoms of skin and tissue injury. Uses supplies and equipment within safe parameters. Evaluates for signs and symptoms of injury as a result of positioning.

Fluid volume deficit related to preoperative bowel prep, NPO status, and surgery

Recognizes and reports deviations in diagnostic study results. Identifies baseline tissue perfusion. Assesses preexisting conditions that predispose the patient to inadequate tissue perfusion. Collaborates in fluid management. Monitors physiological parameters. Evaluates postoperativetissue perfusion.

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The patient has wound and tissue perfusion consistent with or improved from baseline levels.

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Intraoperative care. The circulating nurse and scrub person set up the room for a typical laparoscopic procedure. They work cooperatively to place the electrosurgical unit, ultrasonic scalpel, camera, light source, and insufflator on the left side of the OR bed. The monitors will be placed on both sides of the OR bed and between the patient's legs after the patient is positioned, prepped, and draped. A surgical team member checks each piece of equipment to ensure that all are functioning correctly and places the robot base of the voice-controlled robotic arm, which is used to hold the camera during the procedure, near the right upper corner of the OR bed. At Valleycare Health System, laparoscopic

equipment and flat-screen monitors are mounted on booms. This allows greater versatility for monitor and equipment placement. The equipment is controlled from the field using a sterile-draped, flatscreen monitor. The procedure preference card can be displayed on one of the x-ray monitors in the room to help staff members accomplish a more rapid room setup (Table 3). A small table is stocked with sterile cystoscopy supplies and equipment, which are not opened unless required. Urethral dilators also are available but not opened. Surgical team members open a laparoscopy custom pack, the 5-mm laparoscopic instruments, and a backup major instrument

Table 2 NURSING CARE PIAN FOR PATIENTS UNDERGOING LAPAROSCOPIC RADICAL PROSTATECIOMY ( C O W

Nursing diagnosis Risk of anxiety related to knowledge deficit, stress of surgery, and altered physical status (eg, impotence, urinary incontinence)

Interim outcome statements

Interventions

The patient verbalizes or demonstrates decreased anxiety, Determines knowledge level, includan ability to cope, ing expected outcomes and risks understanding of the procedure of surgical side effects, such as and sequence of events, and impotence and urinary incontinence. understanding of expected outcomes. Assesses readiness to learn. The patient verbalizes concerns Includes significant other in periabout treatment decisions being operative teaching. discussed and participates in decision making. Explains sequence of events (eg, preoperative preparation at home, The patient's family member, signifiday of surgery, postoperative cant other, or spouse verbalizes conhospital course). cerns about decisions. Assesses coping mechanisms

Outcome statements The patient participates in decisions affecting his plan of care. The patient demonstrates knowledge of psychological response to procedure and possible side effects.

Provides resources for psychological support (eg, social service contact, prostate cancer support group). Evaluates patient's and family members' response to instruction. Risk for impaired home maintenance management (eg, indwelling foley catheter care)

Identifies expectations for home care. The patient, his family members, or Assesses environmentfar homecare, significant other will communicate concerns and goals related to the Assesses readiness to learn. surgical intervention, indwelling Provides instruction related to pharma- catheter care, and next visit with the cological and nonpharmacological health care provider in realistic pain management, wound healing, terms. prescription medication use and side effects, and indwelling catheter care. 77 1 AORN JOURNAL

The patient participates in the rehabilitation process.

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Table 3 PROCEDURE PREFERENCE CARD FOR IAPAROSCOPIC RADICAL PROSTATECTOMY

Supplies a Endoscopic custom pack Laparoscopic drape Antiembolism stockings Sequentiai-compression leggings Under-buttock drape Robotic orm drape 36-inch Penrose drain Electrosurgicol cord Lubricating jelly a 20-Fr and 22-Fr 5 mL Foley catheters a Urinary drainage bag Flat-screen monitor drape a Ultrasonic scalpel blade 5-mm ports (X 3) 10-mm ports (X 2) a Verres needle a 22-9 needle a 1 0-mm Endoscopic specimen bag a Endoscopic fascia closure device 15-Fr round drain and evacuator bulb a 60-mL catheter-tip syringe a Catheter plug Long teflon electrosurgical tip 1 1/2-inch ostomy pouch a 1 1/2-inch ostomy wafer a Ostomy pouch clamp Medications 0

0

0.5% Bupivacoine 1,000 mL hot sodium chloride to warm scope 1,000 mL warm sodium chloride for irrigation Ampule of indigo carmine for anesthesia care provider

Sutures and blades 2-0 braided nonabsorbable nylon suture on medium cutting needle (x 1) 2-0 braided absorbable polyglactin suture on small cutting needle (x 1) 2-0 braided absorbable polyglactin suture on urology needle (X 1) 0 braided absorbable polyglactin ties (x 1) 2-0 braided absorbable polyglactin suture on round, medium taper needle (x 2)

Suture and blades (continued) 4-0 braided absorbable polyglactin suture on medium cutting needle (x 2) 3-0 braided absorbable polyglactin suture on medium taper needle (x 8) 0 monofilament nonabsorbable polyolefin suture on small cutting needle (x 5)

Scrub person notes Place on Mayo tray at start of case 0 Skin marker and 2 towel clips Skin hooks and Verres needle Lubricating jelly Long bowel graspers (X 4) Dissector Metzenbaum scissors Debokey grasper 20-Fr Foley catheter Surgeon will suture in all trocars at start of cose with 2-0 monofilament nonabsorbable polyolefin suture On small cutting needle

15 blades (x 2) 12 blades (x 2) Backup cystoscopy set up (open PRN)

0

Small cystoscopy table Table cover Cystoscopy tubing Rubber tubing with stopcock 0 ' and 30" 19-mm and 25-mm cystoscopes with obturators Bridges (x 2) Light cord Thumb resectoscope Flexible ureteroscopy with lighi source Sterile IV tubing Pressure bag 1,000 mL sodium chloride Urethrotome Cold knife 1,000 mL sterile water

Equipment

0

0

Cut one 2-0 braided absorbable polyglactin suture on small cutting needle 8 inches long, and cut the rest of the sutures 6 inches long.

Do not test the catheter balloon

Circulator notes Patient remains in Trendelenburg's position most of the procedure in Allen stirrups with legs in slight abduction and upper leg parallel to the floor. Place kidney rest on left side of head of bed. Place the robotic arm at the right of the patient's head and use the physician's specific voice card to set the robotic arm. Place sequential-compression pump on the floor.

Padded shoulder rest (ie, kidney rest) Sequential-comPressionPump Temperature-regulating blanket Ultrasonic scalpel machine Place ultrasonic pedal to surgeon's Robotic arm right and monopolar electrosurgical Boot-type stirrups unit pedal to surgeon's left. Adult tubing circuit drain Smoke-evacuator suction adapter instruments Pitcher Major instrument set Laparoscopy instrument set robotic kidney rest 5-mm laparoscopy instrument arm Ultrasonic scalpel set Robotic arm collars Camera and light cord 0 ' 1 0-mm laparoscope / monopolar 30' 10-mm laparoscope pedal Rinse pan 0 Rectal bougie and depressed tip urethral sound with hole person Catheter guide monitor Cystoscopy dilators (open PRN) 772 AORN JOURNAL

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the OR bed and at the foot between the patient’s legs. set on the back table (Figure 2 ) . The scrub person prepares two #10 trocars and The scrub person positions the Mayo stand between three #5 trocars and the ultrasonic scalpel. He or she the patient’s legs. The scrub person connects the catheter to graviensures that the key instruments used during the procedure, including long bowel graspers (ie, platypus), ty drainage but does not test the catheter balloon by laparoscopic curved needle holders, and the curved inflating it unless requested to do so by the surgeon. ultrasonic scalpel, are available and working correct- The surgeons at Valleycare believe that testing the ly. He or she places the most commonly used laparo- balloon creates a slight bulge in the catheter because scopic instruments on the Mayo stand (Figure 3). The the balloon does not return to its original shape comscrub person precuts 3-0 braided absorbable pletely after being inflated. The surgeon inserts a 20polyglactin suture to the surgeon’s desired Iength and Fr Foley catheter in the patient’s bIadder and inflates makes sure that lubricant jelly and a Foley catheter the balloon with the manufacturer’s recommended are available on the field. The circulating nurse and amount of saline. The surgeon introduces a Verres anesthesia care provider transfer the patient to the OR needle at the umbilicus and insufflates the periand help him move onto the OR bed. The circulating toneum with carbon dioxide to a pressure of 12 mm nurse places sequential compression sleeves over Hg. The surgeon removes the Verres needle and antiembolism stockings on the patient’s legs, con- replaces it with a 10-mm trocar, inserts the laparonects them to the pump, and initiates compressions. scope, and connects it to the camera. The surgeon The circulating nurse then helps the anesthesia care inserts another 10-mm and three 5-mm ports and provider with induction of anesthesia and intubation, after which the patient is placed in a low lithotomy position. His legs, in slight abduction, are secured with straps in padded Allen stirrups. The circulating nurse tucks the patient’s arms at his sides and protects them with padding and positioning sleds. The circulating nurse attaches a padded shoulder rest (ie, kidney rest) to the head of the bed on the patient’s left side to prevent him from sliding when the OR bed is placed in the steep Trendelenburg’s position. The circulating nurse performs a final assessment to ensure that the patient is positioned safely and no risks of compression injury exist. He or she connects the robotic arm to the right side of the OR bed above Figure 2 Back table with instrumentation for a shoulder level. The anesthesia care provider then laparoscopic radical prostatectomy. adjusts the OR bed to an extended Trendelenburg’s position and places a temperature-regulating blanket across the patient’s chest and arms. The circulating nurse preps the patient’s abdomen, penis, scrotum, perianal area, and upper thighs with skin prep solution. The surgeon and scrub person place the sterile under-buttock drape and leggings on the patient and drape the robotic arm. They then drape the abdomen with four towels and a laparotomy sheet. The circulating nurse places the pedals for the electrosurgical unit and ultrasonic scalpel in position according to surgeon preference. The circulating nurse -then posi- Figure 3 Most commonly used laparoscopic instruments are placed on tions the monitors at either side of the draped Mayo stand. 773 AORN JOURNAL

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sutures them all into place (Figures 4 and 5 ) . The scrub person assists the surgeon in connecting the robotic arm to the laparoscope, which subsequently is controlled with voice activation by the surgeon. During the procedure, the surgeon performs the majority of tissue manipulation using the long bowel grasper and the majority of dissection using the ultrasonic scalpel. The surgeon incises the peritoneum and then isolates, dissects free, and transects the vas deferens. He or she dissects the seminal vesicles, located at the inferior portion of the vas, leaving them attached only at the base. The surgeon incises Denonvilliers’ fascia, identifies the rectum, and dissects the prostate off the rectum. In the past, surgeons used a rectal bougie to identify the rectum; however, this instrument no longer is used routinely. The surgeon dissects the bladder free to allow it to move posteriorly. The bladder also needs to be freed from its anterior attachments to allow the surgeon to complete a tension-free vesico-urethral anastomosis. The surgeon removes the Foley catheter and replaces it with a urethral sound. The anesthesia care provider injects indigo carmine intravenously. The dye moves through the patient’s systemic circulation and exits through the patient’s ureteral orifices. This helps the surgeon identify the ureteral orifices during bladder dissection and urethral bladder reanastomosis. The surgeon identifies the dorsal venous complex, ligates it with 2-0 braided absorbable polyglactin suture, and transects it using scissors and monopolar electrosurgery. The surgeon isolates the prostatic pedicles and then exposes them by grasping and pulling up the vas deferens and seminal

vesicle. The surgeon cauterizes vessels using the ultrasonic scalpel and transects the pedicles. He or she identifies and dissects the neurovascular bundles off the prostate. Although care is taken to preserve the neurovascular structures, the surgeon’s primary concern is to obtain clean margins. Nerve function will be sacrificed, if necessary, to ensure the removal of all tumor tissue. The surgeon retracts the dorsal vein complex anteriorly to expose the anterior urethral wall. He or she then incises the urethral wall, advances a urethral sound into the pelvis, and incises the back wall of the urethra. The scrub person applies traction to the prostate while the surgeon frees the final attachments. The surgeon places the prostate in an endoscopic specimen bag for removal. The vesico-urethral anastomosis is achieved using interrupted stitches of 3-0 braided absorbable polyglactin suture, and all knots are tied intracorporally. The urethral sound has a depressed tip at the end, which the surgeon uses to guide the needle into the lumen. When all sutures have been placed, the surgeon inserts a 22-Fr Foley catheter and inflates the balloon. The surgeon injects air into the rectum with a 60-mL catheter-tip syringe to check for injury; air bubbles would be noted if a rectal laceration was present. The surgeon irrigates the bladder to remove clots and to check for leaks at the anastomosis site. The surgeon lowers the abdominal pressure by releasing carbon dioxide to monitor for any possible bleeding. This is accomplished by venting one of the laparoscopic ports. The surgeon removes the prostate via the 1 0-mm port. He or she then removes all ports and closes the incisions with suture or self-adhesive wound approximating strips. The surgeon places a

Figure 5 Illustration of trocar port placement. (Illustration by Mark Katnik Denver)

Figure 4 Photograph of trocar port placement using one 10-mm and three 5-mm ports.

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15-Fr round drain in the abdomen via the right lower quadrant 5-mm port and connects it to an evacuator bulb. The surgeon then injects all port sites with 0.5% bupivacaine. The circulating nurse and scrub person perform closing sponge and sharps counts. The perioperative team members remove the drapes and move the patient from the lithotomy to the supine position. The circulating nurse checks the integrity of the skin and ensures that the drain and Foley catheter are patent and secured. The anesthesia care provider extubates the patient in the OR and transfers him with the assistance of the circulating nurse to the PACU by stretcher. Postoperative care. The circulating nurse provides the PACU nurse with a verbal report on arrival in the PACU, and the PACU nurse initiates a postoperative assessment of the patient to include assessing the patient’s airway for patency and observing frequency and pattern of respirations. The PACU nurse provides the patient with supplemental oxygen by nasal cannula or mask. The PACU nurse also obtains and monitors the patient’s vital signs every 15 minutes and as indicated thereafter. The IV fluid is continued at 125 mL per hour using a solution of 5% dextrose and 0.45% normal saline unless otherwise ordered by the surgeon or anesthesia care provider. The sequential-compression pump is continued and monitored. The nurse maintains the Foley catheter to gravity drainage, with strict instructions not to manipulate or irrigate the catheter. Manipulation of the balloon or catheter could threaten the anastomosis of the urethra and bladder neck. The PACU nurse monitors the compression-bulb drain from the abdominal cavity for the type and quantity of output. He or she obtains repeat laboratory work (eg, CBC, chemistry panel) and reports abnormalities to the surgeon and anesthesia care provider. When the patient is stable, PACU staff members transfer him by stretcher to a patient room on the surgical unit in the main hospital. The PACU nurse provides a verbal transfer report to the surgical unit nurse at the time of transfer. He or she monitors the patient’s vital signs (ie, blood pressure, pulse, respirations, temperature) every 30 minutes for the first hour and then every four hours. The sequential-compression pump is continued until discharge but is disconnected during ambulation and personal bathing. The patient remains NPO the first night after surgery. but the nurse may give the patient ice chips not to exceed 30 mL per hour. The IV fluid is maintained

at 125 mL per hour. The compression bulb drain is emptied at least every eight hours and usually can be removed before discharge. The nurse maintains the Foley catheter to gravity drainage with continued instructions not to irrigate the catheter but rather to notify the surgeon if he or she observes blood or clots draining from the patient’s catheter. The nurse routinely administers 1 g of cefazolin IV piggy back every eight hours. He or she may give the patient 650 mg of acetaminophen orally as needed for headache or temperature greater than 100.4” F (38” C). If the patient experiences bladder spasms, the nurse may administer 5 mg oxybutynin orally every eight hours. One advantage of the laparoscopic approach to radical prostatectomy is that patients require less pain medication to manage their pain adequately. Initially, 2 mg of morphine is administered by IV every two hours for pain as needed. Within six hours, meperidine 75 mg with hydroxyzine hydrochloride 25 mg intramuscular (IM) every three hours as needed is adequate for pain control. Typically, within 24 hours, the patient’s pain can be controlled with one tablet of hydrocodone bitartrate 5 mg with acetaminophen 500 mg every four hours. Most patients do not require pain medication 36 hours after surgery. Patients are restricted to bed rest the first postoperative night. Nursing staff members help the patient ambulate the morning after surgery. Activity then is progressively increased according to the patient’s tolerance. Repeat laboratory work is performed the morning after surgery, including a CBC and chemistry panel. Based on the results of the hemoglobin and hematocrit tests, a unit of blood may be transfked according to the surgeon’s orders. To date, no patient has required a transhion at Valleycare Health System. The patient is discharged with the Foley catheter in place. The staff nurse reviews catheter care and maintenance instructions with the patient. To ensure that the patient hlly understands how to care for his catheter, the nurse requires him to perform a return demonstration in catheter care and application of a leg bag. The Foley catheter is removed by the surgeon an average of I0 days postoperatively. A clinical pathway is used to quickly assess and monitor the patient’s progression along the continuum (Table 4). Areas of deficit are identified easily and, when indicated, appropriate interventions can be initiated in a timely manner. Variances are easily identified and tracked. The pathway provides a summation of

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Table 4 IAPAROSCOPIC RADICAL PROSTATECTOMY CLINICAL PATHWAY

Baseline General information Patient verbalizes basic understanding of the ype of surgery. Patient verbalizes understanding of preoperative preparations. Patient verbalizes understanding of pain management interventions and his role in pain management. Cardiopulmonary Patient will maintain adequate ventilation and oxygenation and will noi develop pulmonary embolism. Monitor vital signs (VS) every 4 hrs; call physician if VS not within normal limits. Assess lungs and respiratory status every shift and PRN. Teach patient cough and deep breathing exercises and how to use incentive spirometer 10 times every hr while awake and PRN. Administer antibiotics per physician order. Monitor sequential compression pump settings and leg wraps. Gastrointestinal and fluid management Patient will maintain hydration and have normal gastrointestinal function. Continue NPO status except ice chips; advance per physician orders, Assess abdomen for distention and bowel sounds. Monitor IV fluids and maintain strict intake and output. Maintain Foley catheter to gravity drainage and monitor every 2 hrs-Do not manipulate or irrigate. Monitor quality and quantity of drainage from suction-bulb drain. Review laboratory results and notify physician of abnormalities. Pain management Patient will achieve pain control to a level of patient's tolerance. Assess patient's pain every 2 hrs and PRN. Administer pain medication as directed. Reassess pain after administration of medication or implementation of other pain management modalities. Mobility Patient will be independent with activities of daily living. Continue bedrest through the first postoperative night. Begin ambulation in the morning and ambulate three times per day. Patient education and wellness Patient and significant other will demonstrate understanding of postoperative guide1ines. Describe signs and symptoms of infection. Define aiterations in type of drainage from foley catheter. Explain directions in scheduling follow-up appointment, Patient and significant other will demonstrate understanding of indwelling Foley catheter care. Verbalize signs and symptoms of urinary infection. Verbalize and return demonstrate steps to care for Foley catheter. Demonstrate the use of a leg bag.

Codes: VU=verbalized understanding; D=declined; NR=needs reinforcement; kvariance; F=further instructions needed; M=instructed and met outcome

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specific nursing interventions and their effect on the variance. It provides a source of immediate evaluation of interventions and allows for more rapid changes or modification to the care path. OUTCOMES M W U R E M E N T

A database is maintained on all patients who undergo LRP at Valleycare Health System. Preoperative information includes height, weight, and body mass index (BMI). On average, patients present with a BMI of 27. The highest BMI to have presented thus far is 32. The surgeons at Valleycare Health System generally use a maximum BMI of 30 as a guideline for candidate selection, but each patient is given individual consideration. Technically, it is more challenging to complete the procedure laparoscopically on obese patients. As the surgeons become more experienced in the technique, they may accept patients with a higher BMI. Intraoperative data is collected on conversion to open procedure rates, OR time, and estimated blood loss. To date, 40 LRP procedures have been performed, and none have converted to open procedures. Both surgical time and blood loss have decreased since the first procedures were performed. The average surgical time (ie, incision to closure) for the first 10 procedures was 310 minutes. The next 10 procedures averaged 226 minutes, demonstrating a reduction of 27%. The third set of 10 procedures had an average surgical time of 268 minutes. The average surgical time of the most recent 10 open procedures was 230 minutes. Blood loss for all procedures has ranged from 100 mL to 1,150 mL (ie, 357 mL average). Blood loss in the first 10 procedures averaged 305 mL. This decreased to 255 mL in the next 10 procedures, 380 mL for the third set of 10 procedures, and 490 mL for the last 10 procedures. The highest blood loss was experienced in these final 10 procedures, with two procedures experiencing a blood loss of 900 mL and one a blood loss of 1,150 mL. Interventions to establish hemostasis lengthened surgical time. No conversion to laparotomy was necessary, and the patients experienced no adverse sequela. Thirty-eight out of 40 patients required pain medication in the PACU. Postoperative day one, 24 patients received one to three doses of meperidine hydrochloride IM during the first 24-hour period. Nine other patients received morphine IV with an average 24-hour total of 9 mg. One patient took oral medication during the first postoperative day, and six patients declined pain medication altogether on postoperative day one. Most patients remained in the hospital one to two days, an average of 1.5 days for all 40 patients.

Patients stay in the hospital for the initial five procedures was a minimum of three days. The surgeons then began to write earlier discharge orders for the remainder of the procedures. Valleycare Medical Center statistics for LRP were compared to corresponding statistics on the last 14 patients undergoing an open retropubic radical prostatectomy (Table 5). Surgical time averaged 165 minutes for the open procedure, compared to 230 minutes for the laparoscopic procedure. Although the open procedure required less surgical time, it is far more traumatic for the patient, involving an open abdominal procedure with a vertical incision from just below the umbilicus to the pubis. Additionally, blood loss, postoperative pain, and return to daily activities were significantly greater in patients undergoing an open radical prostatectomy as compared to those undergoing the laparoscopic radical procedure. Surgical blood loss in the open procedures averaged 782 mL (ie, 200 mL minimum, 1,450 mL maximum). Two patients undergoing the open procedure required blood transfusions. The patient with the highest blood loss received two units intraoperatively and one unit of blood postoperatively, and the other patient received one unit of blood postoperatively. Blood loss in the laparoscopic procedures is significantly less (ie, 782 mL compared to 357 mL). Decreasing postoperative pain is one of the most significant improvements for patient care. Every patient who underwent open prostatectomy received pain medication in the PACU. Medication type varied according to the preference of the anesthesia care provider. Seven patients received IV fentanyl in total doses ranging from 50 pg to 200 pg. Four patients received meperidine, and four others received incremental morphine. All 14 patients used a morphine patient-controlled analgesia (PCA) pump the day of surgery through postoperative day one. Twelve patients continued their PCA through at least part of the second postoperative day. One patient continued on PCA through the fourth postoperative day, and his course was complicated by a postoperative ileus. In general, by postoperative day three, all but two patients achieved pain relief with oral medications, or stated pain was at an acceptable level that did not require medication. Length of stay between open and laparoscopic patients was compared. Ten patients who underwent open procedures were in the hospital for four days, three had a five-day length of stay, one remained six days, and one patient remained seven days. Of the two patients with the most prolonged length of stay, one had the aforementioned ileus and the other experienced a delayed return of bowel function. The 779

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of the Institut Mutualiste Montsouris published a paper outlining the outcomes of their first 120 patients. They estimated their learning curve was 40 procedures per surgeon to develop and improve the technique but suggest that other surgeons will experience a lesser learning curve now that the procedure is better defined.” This assumption was found to be accurate at Valleycare Health System, though outcomes data is more limited to date. Like Table 5 the French surgeons noted, surgiOUTCOME MEASUREMENTS FOR VAUEYCARE HEALTH SYSTEM cal time and blood loss decreased Open radical Laparoscopic radical after the initial procedures were prostatectomy (n = 40) Data type prostatectomy (n = 14) performed when compared to the open procedure. Average surgical time 165 minutes 230 minutes The mean surgical time in Blood loss 782 rnL 357 m l the Paris study averaged 239 Average hospital stay 4.9 days 1.5 days minutes for all 120 patients. Time decreased from an average of 282 Pain medication in 95% (38/40) 1OOo/o (1 4/14) minutes for the first 40 patients to the postanesthesia 231 minutes for the final group. care unit Seven out of the first 80 proce1 00% (1 4/14) required 82.5% (33/40) Pain medication dures converted to open procerequired 1 to 3 on postoperative patient controlled dures; however, they were able to doses IV day one analgesia (PCA) complete the last 40 procedures 2.5% (1/40) laparoscopically.’” received oral (PO) The French surgeons also medication saw a reduction in intraoperative 15.0% (6/40) blood loss as their experience received no pain with the procedure increased. medication Average blood loss for each group Pain medication 86% (1 2/14) required Not applicable (NA) of 40 patients was 534 mL, 517 on postoperative PCA mL, and 277 mL for groups one, day two 14% (2/14) required two, and three respectively.“ Ten PO medication or percent of the patients received a received no pain mediblood transhsion, with the transcation fusion rate decreasing from 15% in the first 40 procedures to 2.5% Pain medication 14% (2/14) required NA in the last 40.” on postoperative PCA With more procedures comday three 86% (1 2/14) required pleted and a longer study period, PO medication or Dr Guilloneau and Dr Vallancien received no pain medihave been able to track both postcation operative urinary continence and NA Pain medication 7% (1 /14) required erectile function in their patients. on postoperative PCA Urinary continence statistics were day four 93% (1 3/14) required calculated based on a self-adminPO medication or istered questionnaire. Seventyreceived no pain meditwo percent of the first 57 patients cation were continent six months postop2 to 3 weeks Return to daily activities 6 to 8 weeks eratively. This trend was reflective

average length of stay for an open prostatectomy was 4.9 days. Follow-up in the surgeon’s oftice indicates that patients who undergo the laparoscopic procedure are able to return to normal daily activities within two to three weeks and patients undergoing the open procedure take six to eight weeks. Drs Bertrand Guillonneau and Guy Vallancien

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of continence rates of patients undergoing open retropubic surgery, in which the continence rate at 12 months was 73%.” Postoperative impotence was not evaluated in the French patients until the third group, as the surgeons were unable to preserve neurovascular bundles consistently until this point. Drs Guilloneau and Vallancien now perform a nervesparing procedure, when possible, using careful bipolar coagulation techniques. Twenty men in the third group were sexually active preoperatively, and nine (45%) of them reported spontaneous erection three months after the surgery. The physicians hope that erectile function will improve with time, as it has been demonstrated with open procedures.” CONCLUSION

Laparoscopic radical prostatectomy results in reduced blood loss and fewer transfusions, decreased length of stay, less pain, and a more rapid return to daily activities when compared to open radical prostatectomy. Although the population size and time frame of the Valleycare Health System study were inadeNOTES 1. J Y Gillenwater et al, eds Adult and Pediatric Urology, third ed (St Louis: Mosby. 1996) 1575. 2. J L Stanford et al, “Urinary and sexual function after radical prostatectomy for clinically localized prostate cancer: The Prostate Cancer Outcomes Study,” J A M 283 (Jan 19,2000) 354. 3. K L McCance, S E Huether, Pathoph.vsiology: The Biological Basis for Disease in Adults and Children, second ed (St Louis: Mosby-Year Book, 2000) 730. 4. E A Tanagho, J W McAninch, eds. Smith j. General Urology, 15th ed (East Nonvalk, Conn: Appleton & Lange, 2000) 8. 5. M A Moyad, K J Pienta, The ABCb of Advanced Prostate Cancer (Chelsea, Mich: Sleeping Bear Press, 2000) 33. 6. Ibid, 3 1-32. 7. S Marks, Prostate and Cancer: A Family Guide to Diagnosis, Peatment. and Survival (Tucson: Fisher Books, 1999) 37-38.

quate to assess long-term outcomes, statistics from the Montsouris study would indicate that continence and sexual potency improve more rapidly with this minimally invasive technique. Long-term data collection needs to be compiled to study survival rates, but oncological outcomes have been similar with the Montsouris study population to those of open procedures.”’ Follow-up with Valleycare patients indicates a high level of satisfaction. It is anticipated that LRP will be the future standard for treatment of prostate cancers that require radical surgery. A Denise Bickert, RN, MS, CNOR, is the director of surgical and marernal child services at Valleycare Health Svstem, Pleasanton, Callf. Deborah Frickel, RN,BSN, is the bariatric coordinator at Valleycare Health System, Pleasanton, Calif The authors wish to thank Mark Avon, MD, and Carlos Gracia, MD, for their assistance in the preparation of this manuscript.

8. Ibid, 38. 9. Tanagho, McAninch, Smith’s General Urology, 15th ed, 7. 10. Ibid. 4. 11. Ibid, 2. 12. McCance, Huether, Pathophysiology: The Biological Basisfor Disease in Adults and Children, 734. 13. Ibid, 779. 14. “Prostate cancer resource center,” American Cancer Society, http://www.cancer.org (accessed 3 Feb 2002). 15. Ibid. 16. Gillenwater et al, Adult and Pediatric Urology, third ed, 1576. 17. Ibid. 18. Marks, Prostate and Cancer: A Family Guide to Diagnosis. Treatment, and Survival. 39. 19. Ibid, 40. 20. Ibid. 21. Ibid, 78. 22. Moyad, Pienta, The ABCS of Advanced Prostate Cancer; 52-53. 23. Ibid. 52-53. 24. Ibid. 54-55.

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25. Ibid, 55-56. 26. A L Potosky et al, “Health outcomes after prostatectomy or radiotherapy for prostate cancer: Results from the Prostate Cancer Outcomes Study,” Journal ofthe National Cancer Institute 92 (Oct 4, 2000) 1586-1589. 27. Stanford et al, “Urinary and sexual function after radical prostatectomy for clinically localized prostate cancer: The Prostate Cancer Outcomes Study,” 354. 28. B Guillonneau, A Krongrad, G Vallancien, Laparoscopic Radical Prostatectomy (Santa Barbara, Calif: Computer Motion, 1999) 28. 29. B Guillonneau, G Vallancien, “Laparoscopic radical prostatectomy: The Montsouris experience,” The Journal of Urology 163 (February 2000) 422. 30. Ibid, 419. 3 1. Ibid. 32. Ibid. 33. Ibid, 422. 34. Ibid. 35. Ibid.