After your Robotic Radical Prostatectomy

After your Robotic Radical Prostatectomy

We have written this handout for you to help you prepare for your Robotic-Assisted Laparoscopic Radical Prostatectomy (RALRP). It is good to review this prior to surgery and then refer to it after surgery. It will answer most of the questions you will likely have about the surgery and your care afterwards. If you have questions which are not answered here, please call our office to talk to the medical assistant or your surgeon.

CATHETER CARE:

Your catheter is very important to allow the bladder and the urethra to heal up watertight. You will be sent home from the hospital with both leg bags or overnight bags. Always keep the bag below your bladder level. Use the overnight bag at all times unless you will be upright, such as when you are walking around the neighborhood. At those times, you can use the leg bag as it will be below your bladder level. Drain urine from the bag before it gets too full. It is common to see blood in the urine, especially after activity. If you see that the urine becomes red, try resting for a while and drink some extra fluids to wash this through. It is rare for the blood to block the flow of urine from the catheter. The tip of the penis may get sore from the catheter rubbing. Use plain soap and water to wash this area daily or more often as needed. Apply a topical antibiotic such as Neosporin to the tip of the penis where the catheter goes in several times a day. This will help lubricate the catheter and minimize irritation. Usually one week after surgery, you will undergo an x-ray procedure called a gravity cystogram. We will arrange for this to be done at the x-ray department prior to your first post-op office visit. In this procedure, the staff will gradually fill your bladder with contrast material which shows on x-ray and watch on monitors to see if there is any leakage from the area where the bladder and urethra are sewn together. They will then drain the contrast from the bladder and send you to our office. If there is no leakage, we will remove your catheter in our office. This takes only a few seconds in isn’t a big deal.

DIET:

You may return to your normal diet immediately. Because of the raw surface in the bladder from the surgery, alcohol, spicy foods and drinks with caffeine may cause some irritation or sense of the need to void despite the fact that the catheter is emptying the bladder. However, if these foods don't bother you there is no reason to avoid them in moderation. More important is to keep your urine flowing freely by drinking plenty of fluids during the day (8 - 10 glasses). The type of fluids (except alcohol) is not as important as the amount. Water is best, but juices, coffee, tea, and soda are all acceptable. Food rich in protein will aid in wound healing. Fluid, fiber, and fruits in your diet will help prevent constipation. Constipation is the most common problem people have after surgery, usually caused by the narcotic pain medicine. Follow dietitian recommendations if instructed.

ACTIVITY:

Your physical activity is to be restricted, especially during the first week at home. During this time use the following guidelines:

a. No strenuous exercise or lifting heavy objects (anything greater than 10 lbs).

b. No driving a car for the first week. You can resume driving once you are off of narcotic pain medications and when you can twist your body as you would need to do for driving without causing any pain. Limit long car rides. If you must take long rides, plan to stop, get out of the car every hour and walk a bit to reduce the risk of getting blood clots in your legs.

c. It is okay to climb stairs as needed.

d. Listen to your body and use good judgment. Take walks several times a day with time in between to rest. If you have an increase in your pain, exercise less and rest more.

BOWEL FUNCTION:

Before surgery, the rectum and the prostate are next to each other. After surgery, any large and hard stools that require straining can cause bleeding. You will be given stool softeners (usually) but these are not laxatives. A bowel movement every other day is reasonable. Use a mild laxative if needed and call if you are having problems. All of the laxatives which were previously prescription drugs are now available over the counter. (Milk of Magnesia 2-3 Tablespoons, 2 Dulcolax tablets, or a Dulcolax suppository or even a Fleets enema)

MEDICATION:

You should resume your pre-surgery medication unless told not to. You may be discharged with stool softeners to keep the stool soft. Pain pills (Tylox or Tylenol with Codeine) may also be given to help with wound and catheter discomfort. Use these narcotic pain medicines only if needed as they will tend to make you constipated. Tylenol (acetominophen) or Advil (Ibuprofen) which have no narcotics are better if the pain is not too bad (and you can tolerate those medications!) You may be sent home with Celebrex to take twice a day. This is an anti-inflammatory medication which is a great postoperative pain medicine. It is as effective as Tylox but does not have the narcotic side effects. Do not take ibuprofen if you are still on Celebrex.

HYGIENE:

You may shower as soon as you get home. You will have steri-strips over your incisions when you go home. Leave these in place until they fall off. They will help your incisions heal nicely. Just pat these dry after your shower.

PROBLEMS YOU SHOULD REPORT TO US

· Call immediately if your catheter falls out or stops draining.

· Any increase in redness, or swelling in the incisions.

· If feeling chilled or feverish, take temperature and report if over 100.5 degrees.

· Nausea, vomiting, or abdominal distention.

· Persistent constipation, diarrhea, or blood in stool.

· Pain not relieved by pain medication and rest.

· Difficulty, frequency, or burning with urination.

· Shortness of breath, cough, or chest congestion/pain

· Drug reactions (Hives, rash, nausea, vomiting, diarrhea).

· Bleeding from incision

FOLLOW-UP:

You will need a follow-up appointment to monitor your progress. This will usually be arranged for your surgery. Call for this appointment at the number above when you get home or from the phone in your hospital room before leaving if your appointment is not already arranged. Usually the first appointment will be about 6-8 days after your surgery to have the x-ray test as discussed above and to remove the catheter if the x-ray is okay. Most people will not have good urinary control at first. Come to the office with a small supply of adult incontinence pads that can be purchased at any drug store. It is not necessary to buy adult diapers. Wear jockey type underwear instead of boxers to hold a pad in place. We usually will have your final pathology report to discuss at that first appointment as well.

You should make the following plans prior to being admitted to the hospital:

PREPARATION FOR HOME CARE

Make arrangements for someone to pick you up from the hospital. The usual discharge time is 11:00 a.m., but you may be released later in the day. You will probably be discharged the day after surgery. Some people will require two nights in the hospital.

Have someone available who will be able to assist you at home if needed following your discharge from the hospital. This can be any person such as a spouse, adult child, friend, or neighbor who will be available to you at your home or can be reached by telephone. You will not needed to be constantly tended at home.You will be able to take care of yourself for the most part. You should not drive or do any lifting of more than about 10 pounds in the first week.-

FREQUENTLY ASKED QUESTIONS ABOUT SURGERY:

"Will I have pain?"

-Pain after surgery is normal and decreases over time.

"What pain medication will I have?"

-Pain medication is available to you. It will not completely relieve your pain, but should allow you to move around and get out of bed and walk. It is important to begin walking as soon as possible after surgery to reduce risks. Most of the RALRP patients use very little of the oral narcotics after leaving the hospital.

-It is important that you tell your nurse if the pain medication is not working.

-Pain medication is given to you in different ways including PCA, Epidural and pills by mouth

What is Patient Controlled Analgesia (PCA)?

This is a machine that allows you to give pain medication to yourself through your intravenous(IV) line by pushing a button. The dose and the frequency of the dosing is controlled making this safe to use. The dose can be increased by the nurse if you are not getting enough relief of your pain.

What is an epidural catheter?

And epidural is a small tube placed in your back prior to the surgery by the anesthesiologist. This is sometimes used along with general anesthesia, although not commonly with the RALRP. After surgery, pain medication can be given through the epidural catheter.

Oral medication (pills)

Once you begin eating you will receive pain pills. You will go home with this kind of medication.

"When will I be getting up?"

-You will sit up in bed the evening of surgery assisted by the nursing staff. Some patients will be ready to get up and walk the same evening, especially surgery was in the morning.

-You will get up to a chair and walk at least three times a day the day following your surgery.

"What tubes will I have?"

You may have all or some of the following:

Intravenous lines (I.V.) to provide fluids until you are able to eat and drink and to allow us to give you pain medicine in your veins.

Oxygen, usually by a plastic tube that sits in front of your nose, until your blood oxygen level is normal.

Urinary catheter, placed into your bladder during surgery, to drain the urine from your bladder. This helps the physician/nurse monitor kidney function and allows your bladder and urethra to heal up watertight. The catheter remains in place for one to two weeks at home.

Small drains may be placed during surgery to remove extra fluid from the area operated on. The tube will be attached to a plastic bulb which provides constant suction. They are usually removed before you go home.

"Will I be able to eat right away?"

Your diet will start with ice chips and progress to clear liquids. After you tolerate this well, your diet will be progressed as your doctor prescribes. You may return to your normal diet as soon as you can tolerate it, usually by the day after surgery. An American Diabetes Association (ADA) diet will be provided for patients with diabetes. If needed, our dietitian will give you information about your diet so that you can continue it at home.

"How can I speed my recovery?"

Caring for your Lungs

-It is important after your surgery and anesthesia to exercise your lungs

-Your nurse will listen to your lungs and instruct you in your deep breathing exercises. Use a pillow to splint your incisions (the nursing staff will show you how to do this). Breathe as deeply as possible, 10 times every hour while you are awake. This will help to fully expand your lungs. You may get a breathing exerciser, called an "Incentive Spirometer" to help with this process.

-Smoking is not allowed during your hospital stay. Information and support will be provided to smokers to help you manage without cigarettes during your hospital stay, and get started on a smoking-cessation program. If you are a smoker, do your best to stop smoking prior to admission to the hospital.

Promoting Circulation

-It is important to wiggle your toes and bend your feet up and down frequently while in bed. This is called calf pumping. We will have you start walking as soon as possible which is the best thing to promote circulation and prevent clots in the leg veins. You should continue to do this at home until your activity level is normal.

-Before starting the operation, we will place pneumatic compression devices on your legs. These will squeeze your calves intermittently, squeezing the veins in your legs to prevent the formation of clots while you are under anesthesia. These devices will stay on until you are walking regularly.

-Avoid crossing your legs at the knees or ankles.

"What will my incisions be like?"

-You will probably have six small incisions in your abdomen up to a half inch in size. The incision near your umbilicus (bellybutton) will be larger than this as this is the spot that we make bigger in order to remove the prostate at the end of the operation. Usually the incisions will only be covered by Steri-Strips. You may notice some blood or serum which oozes from the incisions. This is normal. If needed, you can wear a bandage over the incisions to keep your clothes clean. Showering over the incision can be done within 48 hours of the surgery. You will not need to cover the incisions for this.

You may also have bruising near your incision. The bruising may migrate down into your groin and/or scrotum. Don't worry about the scrotal skin getting dark for the first week after surgery. It is normal and represents the blood in the tissues finding the lowest spot of gravity to come to a rest. Like a black eye, it all goes away.

"Will I have difficulty with bowel movements?"

Surgery and pain medication and decreased activity may lead to constipation. To prevent constipation:

-Keep active, take walks as instructed by your doctor.

-Drink plenty of fluids.

-Eat high fiber foods such as bran, raw fruits and vegetables.

-Use this tool softeners and laxatives as noted above.

"Will I be impotent?"

-For men who have had a radical prostatectomy for prostate cancer, the nerves that control the flow of blood into and out of the penis may be cut or removed. This is usually decided prior to surgery based on your tumor stage and grade. These nerves do not control the sensation to the penis, nor are they responsible for the orgasm that occurs with sexual intercourse. Only the firmness of the penis is affected.

-If nerve sparing was done during your procedure, the return of erections could take as long as six to 18 months. Once your catheter has been removed, we encourage you to start stimulating the penis regularly to encourage the return of erections. There are numerous studies which have shown that men who are actively doing things to encourage erections are more likely to have return of function than men who wait for it to happen. Think of this as a fun physical therapy. It is normal for the erections to take a while to return. Partial erections at first are a good sign. Frequently we give patients medications like Viagra to help stimulate the return of erections. We encourage patients to use these medicines at least three times a week. Even if you are not attempting sexual activity, we encourage you to use a medicine at bedtime as this is felt to encourage the return of nighttime erections associated with dream sleep. If the oral medications don't do the job, we have other options. Vacuum constriction devices have been shown to help prevent shrinkage of the penile tissues which can occur if patients are not getting erections for a long period of time. Some surgeons are routinely recommending the use of the vacuum device daily to stretch the tissues. Using the vacuum constriction device with a constricting band can be used to have sexual activity. Another option is the use of penile injection therapy. Although this sounds terrible, we can teach you to do this quite painlessly and this will most often work even if the pills don't. The first time we do this, the doctor will inject you and monitor you in the office to see the result. We will then have you return for a second visit at which time we will teach you to inject yourself. Most of the time we are able to send patients out able to do the injections at this point. For patients using penile injection therapy, we recommend that they inject themselves three times a week as this has been shown to help with the recovery of spontaneous erections.

"How do I check out of the hospital?"

-Discharge time is 11 a.m. if you are ready. To be ready for discharge, he need to show that you can take in some food without nausea, take oral medications, take care of your catheter and walk in the halls. For most patients, this will happen on the first day after surgery. Some people will have some residual nausea from the anesthetic or surgery and may need to stay an extra day. The length of your hospital stay is determined by your progress. It is not determined in advance or by your insurance company. We like for patients to be discharged as soon as they meet the criteria above. Most patients find that they are more comfortable at home, and they certainly sleep better without the disturbances which occur at the hospital.

"Can I shower or bathe?"

-Yes. You may shower within 48 hours of the surgery. Bathing should be witheld until the catheter is removed..

"When can I return to work?"

-It varies, depending on how physical your job is. Men who can do their job from home with the telephone or computer off and start working as soon as they get home from the hospital. Men whose jobs require strenuous physical activity may need to be out of work for six to eight weeks. For most men, the time off work is between these two. Some men will be most comfortable if they begin working part time before returning to a full day. Some men may be uncomfortable returning to work in the initial days after having their catheters removed while they are distracted by their recovering urinary control. If your job requires sitting at a desk, you should be sure to adequately pad your chair or sit on an inflatable donut, especially while you still have a catheter. Many employers require forms to be filled out. Your surgeon will be happy to fill this out for you, but please give us adequate time to do so.

MALE URINARY CATHETER CARE SUGGESTIONS

You have been discharged with a urinary catheter. These tubes (usually called "Foley", named after the inventor) are used to drain the urinary bladder of urine normally stored in the bladder. Your physician can explain the reasons for the catheter's use and its expected length of stay.

Design: The catheter is a hollow tube with a hole on each end. A side arm can be seen on the catheter and this allows a small balloon to be filled in the bladder so that the catheter does not fall out.

Connection: The catheter needs to be connected to a drainage bag to allow continuous and unimpeded drainage. It is important not to obstruct the flow of urine, unless you are specifically asked to do so.

Drainage Bags: These are the plastic bags to which the catheter is connected. The bags vary in design but all have a connection adapter for the catheter and a drainage port or spigot at the bottom to empty the bag. Larger bags have long tubes so that they can be attached to the bed or carried. Larger bags are used around the house and overnight because of their larger capacity. Small bags or 'leg bags' have no tubing and must be attached to the leg with straps. They must be emptied every 2-4 hours depending on how much you drink. Leg bags are easy to conceal under you pants and allow you to go outside with complete privacy.

Note: both bags must be kept below the level of your bladder to drain properly.

To change Bags: Patients will switch between bags as mentioned above. Before leaving the hospital, your nurse will teach you to do this. To change bags properly, good hygeine must be observed. Wash your hands first. Before disconnecting the current bag, clean the connector of the drainage bag that you wish to use with alcohol (if the end looks clean) or soap and water, then alchohol, if the end is dirty or crusted. Pinching the catheter end to prevent leakage pull and twist the catheter from the connector. Then firmly attach the catheter to the new bag connector. Wash the old bag with soap and water, if available, and rinse well. Store in a clean place for later use.

Care: The major cause of irritation is at the tip of the penis. You should wash this area daily with a mild soap and water at least twice a day. In most cases, you will have less irritation of the tip of the penis if the catheter is secured to the leg with a gentle curve. Tape is the best and least expensive way of securing the catheter. The hospital may send you home with a device to secure the catheter. These are also available in medical supply stores. Movement or tugging on the catheter will then pull on the tape, not on the penis. Apply a topical antibiotics such as Neosporin to the tip of the penis where the catheter goes in several times a day. This will help lubricate the catheter and minimize irritation.

Cleaning the drainage bags: Rinse bags with warm water and soap every day or two, depending on how dirty and how much odor is present. One teaspoon of vinegar may be used in the rinse water to reduce the odor.

Emptying bags: Hold any bag over the toilet or suitable container and open the spigot at the bottom of the bag. Let urine flow until empty and then close the spigot.

Problems: The more urine that flows, the less the chance for a blockage. You should be drinking 4-8 ounces of water every hour while awake.

Bleeding: Bleeding can be seen on occasion with any catheter. Small amounts of blood or clots are usually of little concern. Bleeding sufficient enough to make it impossible to see through the urine should be brought to your physician's attention.

Blockage: Urine should drain constantly into the bags. If you see no flow for more than an hour and feel the need to urinate, a blockage of the tube may be present. Debris or blood clots are the most common causes and will need to be dealt with in your physician's office, if open, or the emergency room. The catheter will either be irrigated until it is clear or the catheter changed.

KEGEL EXERCISES

Pelvic muscle exercises, also called Kegel (kay-gull) exercises after Dr. Arnold Kegel, who developed them, strengthen the pelvic floor muscles. The actual name of the exact muscles are the 'pubococcygeus' muscles. These muscles contract and relax under your command to control the opening and closing of your urethral sphincters, or the muscles that give you urinary control. When they are weak, urine leakage results. However, through regular exercise, you may be able to build up their strength and endurance and, in many cases, regain bladder control.

Post Radical Prostatectomy Anatomy

Begin by locating the muscles to be exercised:

1. As you begin urinating, try to stop or slow the urine without tensing the muscles of your legs, buttocks, or abdomen. It is very important not to use these other muscles, because only the pelvic floor muscles help with bladder control.

2. When you are able to slow or stop the stream of urine, you have located the correct muscles. Feel the sensation of the muscles pulling inward and upward.

Helpful hint: Squeeze in the rectal area to tighten the anus as if trying not to pass gas. You will be using the correct muscles.

Now you are ready to exercise regularly:

1. When you have located the correct muscles, set aside two times each day for exercising: morning and evening .

Set # 1 Quick Contractions (QC) Tighten and relax the sphincter muscles as rapidly as you can.

Set # 2 Slow Contractions (SC) Contract the sphincter muscle and hold to a count of 3, (gradually increasing to 10 seconds per exercise daily) then RELAX completely before the next contraction.

In the beginning, check yourself frequently by looking in the mirror or by placing a hand on your abdomen and buttocks to ensure that you do not feel your belly, thigh, or buttock muscles move. If there is movement, continue to experiment until you have isolated just the muscles of the pelvic floor.

Your bladder control should begin to improve in 3 to 6 weeks. If you keep a record of urine leakage each day, you should begin to notice fewer marks in the bladder leakage column.

The notation

5 QC, 10 3 sec SC, 5 QC means 5 quick contractions, then 10 3 sec slow contractions, then 5 quick contractions. The 3 sec slow contraction means holding the contraction for 3 seconds.)

20 QC, 25 10 sec SC, 20 QC means 20 quick contractions, then 25 10 sec slow contractions, then 20 quick contractions.

KEGEL EXERCISES CONTINUED........

Make pelvic muscle exercises a part of your daily routine: Whether you are doing pelvic muscle exercises to improve or maintain bladder control, you must do them regularly on a lifetime basis. Use daily routines such as watching TV, reading, stopping at traffic lights, and waiting in the grocery checkout line as cues to perform a few exercises.

These 10 healthy habits will help improve your bladder control:

1. Use the toilet regularly and make toilet facilities convenient, which may mean a bedside commode, bedpan or urinal placed near the bed.

2. Wear clothes that are easy to remove when it is time to use the toilet.

3. Train your bladder. Use a clock to schedule times to toilet. Every hour, then every 1 1/2 hours, etc. until you achieve a satisfactory schedule. Avoid frequent trips to the toilet "just in case."

4. Remain at the toilet until you feel your bladder is empty. Don't rush. If you feel there is still some urine in the bladder, move around or stand up if you were sitting, sit back down, and lean forward slightly over the knees.

5. Empty your bladder before you start on a trip of an hour or more. Don't try to wait until you get home or until it's more convenient.

6. Learn to squeeze before you sneeze --and before you cough, laugh, get out of a chair, or pick up something heavy.

7. Establish regular bowel habits. Constipation affects bladder control.

8. Consider avoiding foods that are known to affect the bladder, such as tomatoes, chocolate, spicy foods, and beverages, including alcohol and those containing caffeine. These make the bladder more irritable and therefore increase incontinence.

9. Watch your weight. Obesity makes bladder control more difficult. Ask your regular doctor about a sensible diet if you are overweight.

10. Stop smoking. Smoking is irritating to the bladder, and a smoker's cough may cause bladder leakage.

When you have the urge to urinate try the following:

Stop what you doing and sit down or stand still and remain quiet. Relax you body by taking a few deep breaths.

Do some quick Kegel squeezes (pelvic floor excercises) quickly 3 or 4 times without relaxing.

Concentrate hard on suppressing the urge to urinate and wait until the urge passes or subsides.

Once the urge has subsided, walk at a regular pace to the bathroom. Don't run. Continue to do the Kegel squeezes as you walk.

You can also get more information from the National Association for Continence at 1-800-BLADDER or www.nafc.org. Address: PO Box 8310 Spartanburg, SC 29305-8310

Request their Male Pelvic Muscle Training Kit

KEGEL EXCERCISE CHART

FOR EXAMPLE: DURING WEEK 1, DO 5 QUICK CONTRACTIONS, 10 SLOW CONTRACTIONS TO A COUNT OF 3, AND 5 QUICK CONTRACTIONS

Week 1 Week 5

5 QC, 10 3 sec SC, 5 QC 20 QC, 25 10 sec SC, 20 QC

Date DAY AM PM Date Day AM PM

____ MON ___ ___ ____ MON ___ ___

____ TUES ___ ___ ____ TUES ___ ___

____ WED ___ ___ ____ WED ___ ___

____ THURS ___ ___ ____ THUR ___ ___

____ FRI ___ ___ ____ FRI ___ ___

____ SAT ___ ___ ____ SAT ___ ___

____ SUN ___ ___ ____ SUN ___ ___

WEEK 2 WEEK 6

10 QC, 15 4 sec SC, 10 QC 30 QC, 30 10 sec SC, 30 QC

Date Day AM PM Date Day AM PM

____ MON ___ ___ ____ MON ___ ___

____ TUES ___ ___ ____ TUES ___ ___

____ WED ___ ___ ____ WED ___ ___

____ THUR ___ ___ ____ THUR ___ ___

____ FRI ___ ___ ____ FRI ___ ___

____ SAT ___ ___ ____ SAT ___ ___

____ SUN ___ ___ ____ SUN ___ ___

WEEK 3 WEEK 7

15 QC, 20 5 sec SC, 15 QC 40 QC, 40 10 sec SC, 40 QC

Date Day AM PM Date Day AM PM

____ MON ___ ___ ____ MON ___ ___

____ TUES ___ ___ ____ TUES ___ ___

____ WED ___ __ ____ WED ___ ___

____ THUR ___ ___ ____ THUR ___ ___

____ FRI ___ ___ ____ FRI ___ ___

____ SAT ___ ___ ____ SAT ___ ___

____ SUN ___ ___ ____ SUN ___ ___

WEEK 4 Week 8

15 QC, 20 10sec SC, 15 QC 50 QC, 50 10 sec SC, 50QC

Date Day AM PM Date Day AM PM

____ MON ___ ___ ____ MON ___ ___

____ TUES ___ ___ ____ TUES ___ ___

____ WED ___ ___ ____ WED ___ ___

____ THUR ___ ___ ____ THUR ___ ___

____ FRI ___ ___ ____ FRI ___ ___

____ SAT ___ ___ ____ SAT ___ ___

____ SUN ___ ___ ____ SUN ___ ___

CONTINUE AT RATE OF 50, MAY INCREASE MORE IF DESIRED. THE TOTAL NUMBER CAN BE DIVIDED UP OVER THE COURSE OF THE ENTIRE DAY.

FROM ONE PATIENT TO ANOTHER

Feel free to call the reference patients from our list to ask for suggestions and tips. These are the same patients you may have called to ask about surgery before you made a decision on treatment. These men have all been through the process, and may have good ideas for you regarding how to make your recovery easier.