Robotically Assisted Laparoscopic Prostatectomy
Postoperative Information and Instructions
Congratulations, you have successfully made it through surgery! I have prepared the following to give you a sense of what to expect once you return home, and instructions for future follow-up. For emergencies, always call my office at 310-794-7224 twenty four hours a day, seven days a week. The page operator will put you in touch with myself or a member of my team for any emergency. For non-urgent messages, just leave a voice mail or a message with JoAnn or Maria, and one of us will call you as soon as possible.
I. Upon Discharge and the first weeks
Once we are secure that there are no postoperative problems such as bleeding or other untoward event, you will be discharged to home.
Medications. Prescriptions will be written by the residents and fellows prior to your discharge, and these can be filled at the hospital or at a pharmacy of your choice. In general, you will receive the following medicationsnote that you may not receive all of these, as they are tailored to the individual.
Drain: After surgery a drain is placed that exits from the abdominal wall. The drain is there to remove and fluids used to irrigate during surgery, as well as any blood, urine or lymphatic fluid that accumulates after surgery. The drain will usually be removed the morning after surgery prior to discharge, but will be left in place should it continue to accumulate significant amounts of fluid, particularly urine. Urine can leak through the anastomosis (connection) made between the bladder and urethra until it heals completely. As long as urine if removed from the body, it causes no harm. Therefore, if there is a leak, the drain will be kept in place until the anastomosis seals. The nurses will give you instructions on how to manage the drain. The amounts of fluid should be recorded when it is emptied. You should call my office daily to let us know the amount drained during a 24 hour period. Once the amounts decline significantly, we will ask you to come to the office for the nurse to remove the drain. Sometimes, we will check an Xray to make sure the bladder-urethra connection is intact before taking out the drain. Rest assured that in 14 years of practice and more than a thousand prostate surgeries, I have never seen a connection that failed to heal on its own!!
Bandages: You will go home without many bandages except some steri-strips (bandaids) on the incisions, and perhaps a dressing over the drain site. Once home, you can remove all dressings leaving only the steri-strips. It is OK to change the dressing if any liquid is still draining; however, these sites usually close within a few hours of having the drain removed. The stiri-strips will come off by themselves over time. There are no sutures to be removed. Everything is absorbable.
Catheter: A foley catheter is placed into the bladder at the end of surgery. This acts like a cast over which the anastomosis of bladder to urethra heals. In general, the catheter will be left in place for 7 days. This is really the minimum number of days required for healing, but more than 95% of men will have their catheters removed at this time. Please call my office to schedule an appointment to come in and have the catheter removed. If your surgery was on a Monday, come in the following Monday. If it was on Friday, come in the following Friday.
If we leave your drain in place upon discharge, I may choose to keep your catheter in more than 7 days. I will inform you how long and when to come in to have it removed. Generally, I will wait 2-4 days from the time the drain ceases to put out fluids before taking out the catheter.
Signs to watch: If your catheter falls out, call my office immediately. If it is beyond the fifth day, we may leave it alone, but if earlier, it may need replacement. This can ONLY be done by a qualified urologist. The urine in the catheter may be yellow, pale, or blood tinged. This is normal. It is normal to have some urine or blood drain around your catheter, especially during bowel movements. This is caused by bladder spasm and is common and you should not be concerned, Make sure, however, that urine is always flowing through the catheter. If it is not, please call us immediately, since the catheter could become plugged up or have become dislodged and may need irrigation or replacement in the office.
Catheter management: The nursing staff will instruct you on how to care for the catheter. During the daytime, you will be given a leg bag that attaches to your leg and can be worn underneath your pants. This will allow you better mobility and discretion during the day. At night, you may choose to use the larger drainage bag at your bedside to avoid the need to get up during the night. For all men, I recommend placing Bacitracin/Neosporin antibiotic ointment on the tip of the penis at least two or three times daily to lubricate the catheter, reduce discomfort and prevent bacteria from getting into the urethra.
Bowel function: The combination of anesthesia and surgery will cause your bowels to shut down for a period of time. You may experience significant gas and bloating during the postoperative period. In my experience, this is the most common cause of pain and will get better as you walk and exercise. Time will fix this problem. In general, you should start to pass gas within 3-4 days of surgery, to be followed one or two days later by your first bowel movement. It may take some weeks before your bowel movements return to normal. You can eat regular food and drink even before your bowel function returns. In fact, we will feed you the night of your surgery! If, however, you are nauseated, ease up on food and drink as much as possible until your bowels begin to function. If you cannot keep down fluids, call my office. If your bowels do not begin to function by the fourth or fifth day after surgery, call my office. We may prescribe a laxative (milk of magnesia, oral dulcolax) to help things along.
Diet: You will go home on a regular diet. We encourage you to drink more than one liter of fluids a day. You should also try to eat as much protein as possible in order to build your strength. In order to build up your blood count, you should eat foods rich in iron, such as meat, fish and spinach, as tolerated. High fiber diets, or those supplemented with Metamucil, will help your bowel movements return to normal.
Over the long-term, there is evidence that weight control and a diet low in fat, high in omega 3 fatty acids from fish, and rich in vegetables and fruit, can reduce the risk of recurrence and/or slow the growth of cancer if it returns. In general, a heart-healthy diet is a prostate-healthy diet.
Activity: We want you up and around immediately after surgery and upon your return home. This means out of bed and walking at least three times a day, preferably more. It is OK to climb stairs, walk around the block, drive in a car etc. You can shower, but no bathing until the incisions have healed. You can drive once your catheter is removed and assuming you are not taking any narcotics. You also must be pain-free before you can drive, in order to avoid an accident if you need to brake your car emergently. Please increase your activity according to how you feel. Let you body tell you what you can and cannot do. By the second or third week, you can return to the gym for light workoutsno lifting more than 20 lbs for one month. You can play golf or other nonstrenous activity as long as you feel up to it by the third week. By six weeks, there are no limitationsjust do whatever, you feel up to. Recognize that there is no one size fits all for recovery. It depends
Back to work: You are free to return to work as soon as you feel strong enough to do so. The only caveat, as noted above, is that if your job involves significant weight lifting or physical exertion, you may need longer to return to full activity, generally 4-6 weeks. Always use your best judgement. Start slow and build up to full activity. Travel is fine, as long as you stand up and walk frequently to avoid blood clots, and drink plenty of fluid. My office will provide you with whatever forms are needed for you to return to work as soon as you want. Most men return to work around 2-4 weeks after surgery.
Miscellaneous: Please call the office immediately if you experience any of the following: fever greater than 101 degrees, dizziness or fainting, increasing abdominal pain or bloating, shortness of breath, calf tenderness or pain. I or one of my team is on-call 24/7. Please never hesitate to call if there is an emergency. I cannot stress this enough. We are here to take care of you!
II. Follow-uppost-op and beyond:
Catheter removal: Your first appointment will be one week after surgery (unless notified otherwise) to remove your catheter. You will be seen by the nursing staff, who will remove the catheter. Schedule the visit with my office upon returning home. At the visit, the nurse will fill your bladder with water, then deflate the balloon that holds the catheter in place, and gently slide the catheter out. This is not painful. After removal, he/she will ask you to hold your bladder to see if you have some bladder control. He/she will then ask you to empty the bladder and to stop and start the stream as you empty. The purpose of this exercise is to teach you what Kegel exercises entailbasically, a Kegel means squeezing the pelvic floor muscles that stop urination. You should do these exercises at home every few hours, squeezing as long as you can, then relaxing. You should do 5-10 repetitions. Do not be concerned if you have little control at this first visit. There is no correlation of your ability one week after surgery with that one year later.
Pathology: The results of your surgical pathology will become available 1-2 weeks after surgery. I, or one of my team, will call you to go over the results and will explain what they mean and what comes next. Most men will need no further treatment. If the disease is advanced, however, you may need additional treatment with radiation or hormones or both. I will guide you in these decisions, based on both the medical evidence as well as more than 20 years of experience treating men with prostate cancer. The primary variables we will discuss are (a) Gleason score (b) tumor size and location (c) surgical margins (d) seminal vesicles (e) lymph nodes.
Follow-up visits: The first official visit will be at three months, at which time we will check your PSA, We will also go over your recovery, focusing on your pathology, your urinary control, and your sexual recovery. After this first visit, I will continue to see you every 3-4 months for the first two years, then every 6 months for a third year, and then yearly thereafter. For those men who live a considerable distance away or who were referred by a primary urologist, you should continue to see the primary urologist as dictated by them. I request that you send me your PSAs, as well as other records of your visits, since I keep track of all patients I operate on for 15+ years, so that we can learn about the nature of this disease and keep track of our operative success in order to improve the operation and in order to inform others of our surgical outcomes.
Other visits: Our goals are to cure your cancer while maintaining your quality of life, especially your urinary and sexual quality of life. Therefore, it is our strong feeling that you should keep in close touch with us in order that we can help you to return to complete health. This is of particular important when it comes to your sexual and urinary function. Studies DO show that YOU can do much to help your recovery and that we can assist your rehabilitation. Therefore, we are here to see you at any time during your recovery to aid your sexual and urinary function. On the sexual side, we want to see you within the first 4-6 weeks after surgery to discuss your options for sexual recovery and to teach you how to do it (see below). To do this, call my office to set up an appointment to see either our physician assistant or my colleague Dr. Jacob Rajfer, an international authority on sexual dysfunction. They will discuss the options of vacuum devices, penile injection therapy, intraurethral suppository therapy, medical therapy etc. and will teach you how to do them. On the urinary side, if your control is not improving significantly by 6-8 weeks after surgery, set up an appointment to see us or call to get a referral to see a physical therapist who specializes in pelvic floor training and biofeedback. More on these below.
Urinary Functrion: There are two types of urinary control problems that can occur after surgery: stress incontinence and urgency incontinence.
Stress incontinence means that you will leak urine when you cough, laugh, bear down, stand up etc. Almost all men will have this problem. In our experience, it will improve dramatically over the first 6-12 weeks after surgery, but will continue to improve up to 2 ½ years after surgery. By 3 months, half of men no longer need any pads, and by 1 year, fewer than 10% do. By 2 years, only 5% of men have any notable stress incontinence. A the time of surgery, we avoid any dissection around your sphincter and use special techniques to reconstruct your urinary control mechanism as close to the way we found it as it possible. So I am optimistic that you will recover. However, there is much that you and we can do to speed recovery, or when it does not return to normal by itself, help it recover. The following options will be discussed.
Urgency incontinence refers to a sense of frequency or urgency (when you gotta go!). It may on occasion lead to incontinence. It is common for men after prostate surgery to have a sensation that they have to go to the bathroom more often. This can be caused by damage to the nerves behind the bladder that are involved in bladder sensation. It can also just be caused by irritation to the bladder from the catheter and surgery itself. This almost always gets better by itself. However, there are safe, effective medicines that can help you store more urine for longer. Just let us know and we will prescribe them to you.
Sexual Function: Prostatectomy involves the mobilization of the neurovascular bundles that supply your penis off the prostate. This can temporarily (most of the time) or even permanently damage your erectile function. It will have no effect on your sensation or ability to orgasm (ie you can be sexually active without erections). I use the latest and most effective techniques to preserve your nerves when feasible (ie the cancer does not involved the nerves) and my results are as good as any reported in the field. However, even with the latest techniques, nerves are jostled or even damaged. Although time will solve the problem for most men, there is increasing data that sexual activity with the use of medications or other aids can speed the natural recovery of sexual function. As noted above, I strongly encourage everyone to make an appointment to see me, Dr. Rajfer, or my physician assistant as soon as you are ready to return to sexual activity, but no later than 3 months after surgery! We will discuss the following options:
Medication: You will go home with a prescription for Cialis or other medication to take routinely. The purpose of this is to maintain blood flow and proper oxygen supply to the penis. For sexual function, you may need a higher dose (20 mg of Cialis, 100 mg of Viagra, 20 mg of Levitra) or alternate medication. Some men respond better to on-demand Viagra or Levitra than Cialis. We will try multiple medicines to find what works best for you. However, medication will probably not work unless you have at least some partial spontaneous erections. Even if medicine does not work the first few months, it may work later on. So keep the faith!
Again, the most important thing to remember is that we encourage you to become sexually active as soon as you are ready (as soon as two weeks after surgery). It can take up to 18 months (usually much less) for your natural erections to return, but there is no need to wait. As they say, use it or lose it.
Conclusion: I have covered the most common issues and instructions of the postoperative period, but this of course is not exhaustive. Like any surgery, there are rare complications or side effects that can occur, and these will be discussed when needed. The most important instruction I can give is that my office and I are here for you. Keep in touch and let us know how you are doing and we will do everything we can to make sure you recover fully, free of cancer!!
Robert E. Reiter, MD, MBA
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