Prostrated by My Prostate

This account is about the life-threatening complications that I had after undergoing prostate surgery (at age 69 years), which resulted in a return to the hospital for an additional 5-day stay after being home for 3 days after the surgery.

Diagnosis and Surgery

Prior to surgery, my doctor had sent off a blood sample from my yearly wellness checkup, and a few days later, I received a call from his office informing me that my PSA level had increased from 3.5 to 4.0 over the past year, and I should have a prostate biopsy to check for cancer. The biopsy report came back with a diagnosis of cancer. After investigating all the treatment options, I decided to have a Radical Prostatectomy (complete removal of the prostate, including seminal vessels and lymph nodes associated with the prostate).

My surgeon recommended laproscopic surgery, which is a robotic procedure, and requires a few small incisions in the abdomen. The surgeon manipulates miniaturized instruments on the end of robotic arms from a remote console - he does not even stand over the patient. The open, or traditional prostatectomy requires one large incision, usually from the pubis to the bellybutton and usually has a longer recovery period, so I chose laproscopic surgery.

The surgery was the first one of the day and my wife and I arrived at the hospital at about 6:30 am. Changed into one of those hated hospital open-back gowns, had my blood drawn, and other vital signs taken; then off to the operating theater, where my surgeon greeted me, introduced the anesthesiologist, and the next thing I remember was being shaken on the shoulder by a nurse telling me to wake up.

After the operation, my surgeon reported that that the operation went well, and he did not damage or have to remove any nerves related to sexual function and incontinence. The post-operative biopsy showed no signs of cancer in the excised seminal vessels and lymph nodes, and it appeared that all the cancer cells had been removed. Blood tests and a chest X-ray also indicated no metastasis. I spent the night in the hospital, and then went home with a catheter in my bladder - the catheter drained through my urethra into a urine bag strapped to my leg, and the bag was periodically drained.

Gastroesophageal Reflux Disease

When you undergo a radical prostatectomy, the operating table is usually tilted so that your head is lower than your feet. This allows more operating space and a better view of the prostate, as the intestines are pulled by gravity away from the pelvic organs. In addition, Carbon Dioxide gas is pumped ("insufflation" is the medical term) into your abdomen to distend it, creating even more room for the surgeon to operate. These procedures, however, aggravated my GERD, (Gastroesophageal Reflux Disease) because all the abdominal organs were pushed up against my stomach, which in turn put pressure on the stomach valve that prevents the stomach contents from entering the esophagus.

After the surgery, I had severe GERD and nausea, and it felt like the top part of my stomach had been pushed up into my esophagus. After the anesthetic wore off my diaphragm area was sore and I was nauseous. So nauseous that I simply could not eat. I tried to eat my first breakfast the day after the surgery, and managed to get some scrambled eggs and toast down. This made me even more nauseas and I completely stopped eating solid food from then on, including my 3 day stay at home before being re-admitted to the hospital.

In the hospital, I had an electrolyte and glucose drip which prevented dehydration, and at home, I drank electrolyte liquids. The nausea was treated with anti-nausea medication, and the pain with various pain-medications, which I was taking anyway for the pain from the incisions and the abdominal distension. I spent one night in the hospital and was discharged the next day.

Return to the Hospital

The post-operative instructions had warned that I might have bladder spasms and I did have moderate intermittent pain after getting home. However, in the late evening of the third day at home, my lower abdomen in the pubic area became very painful. At first, I thought that this was just another spasm and took my pain medication. However, 3 hours later, the pain returned at a much higher level and the painkillers were ineffective. It was becoming obvious that this was not a spasm, but something more serious. My wife called the surgeon and he told her to take me to the hospital emergency room (he called the ER to let them know I was on the way).

Because of the catheter and the pain, it would have been too difficult and risky for me to get in and out of the car, with only my wife to help me, and so we decided to call an ambulance.

The fire station is about 3 miles from our house and the paramedics were there within 5 minutes. I was put on a stretcher and loaded into the ambulance. Now, I expected a relatively smooth ride to the hospital, but this was not the case. The ambulance appeared to have no shock absorbers and I bounced and rattled all the way to the hospital - not a very pleasant experience.

We almost had to drive by as the ER was on caution status. This meant going to another hospital, which was not on our insurance plan. Luckily, they did accept me and I was transferred onto a gurney and taken to one of the ER rooms, where the triage nurse (with the OK of my surgeon) administered morphine. The time was about 3:00 am and I had to wait until a CT scan and cystogram that were done at about 7:00 am. During this period, the morphine wore off and I was given a longer- lasting painkiller. My blood pressure was dropping and was getting dangerously low - and nobody knew why.

Diagnosis

The CT scan of my lower abdomen showed a mass near my bladder, which was diagnosed as either a haematoma, or an abscess. The abscess was postulated because my white blood cell count was high, indicative of a possible infection, and the haematoma postulated because my red blood cell count was low, indicating that I may be bleeding internally.

I always thought that a hematoma was the medical term for a blood clot. Wordnet (copywrite Princeton University) defines a hematoma as "A localized swelling filled with blood" . In most cases the hematoma is eventually re-absorbed by the body, however in my situatuon it needed to be removed as soon as possible.

A cystogram shows what's going on with the bladder. A catheter is inserted through the urethra into the bladder and a contrast dye is fed into the bladder. X-rays (which will detect the dye) are taken of the filled bladder, and the images shown on a computer monitor.

The CT scan and cystogram showed that the mass was pressing against the neck of my bladder, causing the anastomosis to leak urine through the sutures into my abdomen.

The anastomosis is the rejoining (by suturing)) of the urethra to the bladder, after the prostate had been removed. In order to remove the prostate the urethra must be first severed from the bladder, and then reattached.

Now the mystery was close to being solved, and it was not a pretty picture; urine was leaking into my abdomen, and the presence of the hematoma or abcess, together with my low red blood cell count, indicated that blood was also leaking into my abdomen. My white cell count was high, indicating a possible infection and my blood pressure was falling to dangerously low levels, which could lead to shock, and possibly death.

Second Hospital Stay

When my surgeon examined the scans, he immediately arranged for a drain to be inserted through my abdomen and into the mass. This was done in the late afternoon using guided computer tomography. As the bulk of the fluid drained out of my abdomen, the pain disappeared within minutes. The mass did turn out to be a haematoma, and a sample of the fluid was sent to the laboratory for analysis. Fortunately, my blood pressure had stabilized, and was no longer a threat.

Computer tomography is a medical imaging method that generates a three dimensional image of an object in the body. The surgeon used the image as a guide to insert a thin hollow needle, attached to a tube, through my abdominal wall and into the mass. The fluid in the mass was then drained from my abdomen. The mass was about 4 inches in diameter. I was then transferred from the ER to a hospital room, where I stayed for 5 days, and then released.

My surgeon also arranged for an infectious diseases doctor to take blood samples to check for bacterial infection. Some types of bacteria have to be grown in a culture medium before they can be identified, and this takes two or three days before results are known. Preliminary results showed no sign of infection, and my white blood cell count was returning to normal. Antibiotics were administered by drip for the duration of my stay, and then I continued on oral antibiotics for about 6 weeks after I went home.

So, now I was back in the hospital, thankfully in a private room, with a catheter which continuously drained my urine into a bag attached to my leg, a drain in my abdomen connected to a JP bottle, and saline, glucose and antibiotic drips into my veins, and a oxygen tube in my nose. A JP bottle is a small thick-walled plastic container that operates under vacuum (created by manually squeezing most of the air from the bottle, and then connecting it to the drain tube).

The fluids in the urine bag and JP drain were periodically drained and the volume noted by the nursing staff. I had to a wear a diaper, as the catheter does not seal off all the urine as it exists my urethra. I would be wearing diapers for three months after the operation, and as the incontinence gradually decreased, I switched to pads.

I was still unable to eat solid foods, and on the morning of the third day, I got up to brush my teeth for the first time since my return to the hospital, and either the toothpaste or the brushing motion, made me throw up. This relieved my nausea and pain but did nothing for my appetite - I still ate nothing. In fact, I could not stand the smell of hospital food and waved it away at meal times.

Hallucinations

On the second or third day, I started hallucinating. I would see a show that resembled a cartoon type movie (no sound) on the wall facing my bed. The show would run for a few minutes and then would be replaced by a new one. I remember one show showing a village, with children walking to schools, cars driving in the streets, and people strolling on the sidewalks. The village had shops, schools, a church and other buildings. It was actually very pleasant. All of the other shows consisted of normal everyday events, and I was not subjected (or created, I should say), to any horrors. At the bottom of the shows appeared credits such as "Produced by Steven Spielberg" and other well-known producers and directors. One show's credit was "Supplied by Adobe Acrobat 8"!

In my medicated state (pain killers and anti-nausea medications), I first thought that the show was coming from a projector from either behind my bed, or was coming from a projector behind the wall! Only when I looked away did I realize that I was hallucinating, as the show followed my gaze and appeared on any object I looked at. The hallucinations continued at full bore for about 3 days, and then gradually tapered off over a period of about a week. I did not tell anybody about these hallucinations, as I knew that morphine could cause them, and I simply could not bear the thought of possibly having psychiatrists, psychologists, neurologists and who knows what other discipline, descending on me.

Recovering

At the age of 69, and having had two inguinal surgeries, and now prostate surgery, I no longer feel any embarrassment when medical staff have to treat and examine my pelvic area. However, one incident did cause me considerable embarrassment: In the small hours of the morning, I was awakened by the door being opened. The room was dark and I could only see a silhouette, against the passage lighting, of a woman pushing a large cart. "Are you the cleaning lady," I asked, to which she replied, "No, I am your nurse". I just wanted to shrink under the bedcovers with embarrassment - but no such luck - she had come to check my temperature, blood pressure and other vital signs. The large cart, of course, was a fully equipped computer cart.

I have a theory why the hospital gowns are open at the back. If patient is lying in the bed a back-opening gown can easily be removed without requiring the patient to sit up or get out of bed. The gown is actually a blanket with sleeves.

On the fourth day the infectious diseases doctor informed me that I had no infection. In addition, the draining volume had decreased. The next day my surgeon released me from the hospital (with my catheter and drain still attached).

Patient Advocate

During all this drama, I had the best patient advocate you can have - my wife. She happens to work at the hospital where I had the surgery, and part of her job there is to process the medical insurance for patient admissions and discharges from the hospital. She is assertive, alert (nothing misses her eagle eye), knows how to deal with people, but can become confrontational if necessary. She ensured that every pill, injection, test, and procedure be identified for her, and that it was intended for me. Any insurance issues were, of course, dealt with. The doctors were also subjected to her scrutiny on all aspects of my treatment.

Home Again

Came home with a urinary catheter attached to a bag, and an abdominal drain attached to a JP bag. Twice a day my wife and I recorded the volume discharged into the JP bag, and thankfully after about a week the discharge rate decreased to almost zero. The surgeon removed the drain, and a few weeks later, the catheter. What a relief! My recovery then followed the normal path of post-operative surgery, and as at this time of writing, my 3- monthly checkups showed zero PSA, and no urine abnormalities.

I got copies of all my reports, including electronic copies of all the x-rays and scans, and studied them when I was back home. The wonders of medical technology combined with the skills and dedication of the doctors and nurses is amazing.

Looking back at this experience I did not remember having any fears of dying - all I wanted was for the abdominal pain to stop, and after that, I think the pain and anti-nausea medications kept me sufficiently tranquilized. In addition, having my family around was a great source of comfort. The truth is: I am afraid of dying, but I am not deathly afraid.

List of sources:

George A. Miller, WordNet. Cognitive Science Laboratory, Princeton University