Robotic Prostatectomy: Preparing and Recovering

Before surgery

Medications

Medications you may take the day of surgery:

• Take half of your insulin dose
• Heart pills
• Blood pressure pills
• Seizure pills

Medications you may NOT take the day of surgery:

• Water pills
• Diabetic pills
• Aspirin (stop 7 to 10 days prior to surgery)
• Coumadin (generally stop 7 days prior to surgery — this must be cleared by the prescribing physician)

• Bring all medications in their labeled containers with you the day of surgery.
• DO NOT take aspirin or aspirin products for 7 to 10 days prior to surgery to reduce the risk of bleeding.
• DO NOT take ibuprofen or other non-steroidal anti-inflammatory drugs for 7 days prior to surgery. Do not take coumadin or warfarin for 7 days prior to your surgery. As noted above, you need to discuss stopping of coumadin or warfarin with your prescribing doctor.
• Stop using certain herbal remedies such as Ginseng and St. John’s Wort for 30 days before surgery. Vitamin E and garlic supplements should be stopped because they can increase the risk of bleeding during surgery.
• If you have taken any of these or if you have any other concerns, contact your surgeon’s office.

Preoperative testing

Once you have scheduled your surgery, the next step is to schedule your pre-operative testing. This generally consists of a chest x-ray, some blood work and an EKG, which is an electrical tracing of your heart. You may be required to do further cardiac testing based on the recommendations of your primary physician. This pre-operative testing needs to be done no more than six weeks prior to your surgery date.

Diet and bowel prep — the day before your surgery

• You should drink only clear liquids. This includes clear juices, tea, water, clear broth and Jell-O. You should consume as much liquid as possible to prevent dehydration during bowel prep.
• During the day you should consume one bottle of Magnesium Citrate (which can be purchased over the counter in any drug store). This will begin to clean out your bowels by inducing frequent bowel movements.
• In the evening, prior to going to bed you should give yourself one or two (if you are still passing solid stool) FLEET Enemas (also sold over the counter in any pharmacy).

Other preparation

• Do not bring jewelry and other valuables with you. If you wear contact lenses, glasses or false teeth, you must bring your cases to store them during surgery.
• Start doing Kegel’s exercises six to eight weeks prior to surgery if possible.

Kegel’s exercises

Pelvic muscle exercises to improve bladder control for men

Pelvic muscle exercises strengthen the group of muscles called the pelvic floor muscles. These muscles relax and contract to control the opening and closing of your bladder. When these muscles are weak, urine leakage may result. However, you can exercise them and in many cases, regain your bladder control.

To achieve the best results when performing these exercises, imagine yourself as an athlete in training. You need to build the strength and endurance of your muscles. THIS REQUIRES REGULAR EXERCISE.

It is recommended that you start doing Kegel’s exercises six to eight weeks prior to surgery if possible.

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. This is very important. Using other muscles will defeat the purpose of the exercise.
2. When you are able to stop or slow the stream of urine, you know that you have located the correct muscles. Feel the sensation of muscles pulling inward and upward.

Tips

• You may squeeze the area of the rectum to tighten the anus as if trying not to pass gas. This helps locate the correct muscles.
• Remember NOT to tense the abdominal, buttock, or thigh muscles.

Now you are ready to exercise regularly. Work up to the following routine:

1. Squeeze your muscles to the slow count of five. Then, relax the muscles completely to the slow count of five. The five second contraction and the five second relaxation make one repetition.
2. Do 15 repetitions to make a set.
3. Do three sets twice a day. Rest 45 seconds between sets.

More tips

• In the beginning, check yourself frequently by looking in the mirror and 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.
• If you are unsure that you are contracting the correct muscles, at your next exam, ask your urologist to help you identify the proper muscles.
• Your bladder control should begin to improve in three to four weeks. If you keep a record of urine leakage each day, you should begin to notice fewer instances of bladder leakage.
• Exercise your pelvic muscles regularly for a lifetime to improve and maintain bladder control.
• Pelvic muscle exercises also improve orgasmic function. Whether you are doing pelvic muscle exercise to improve or maintain bladder control or to improve orgasmic function, or both, they must be done faithfully. Make them part of your daily routine.
• Use daily activities such as eating meals, watching the news, stopping at traffic lights, and waiting in lines as times to do a few pelvic muscle exercises.

After surgery

Diet

Take clear liquids such as Jell-O, broth, or juices (no soda or carbonated beverages) until you are passing gas and/or feel less bloated. You may then resume a regular soft diet such as oatmeal, toast, scrambled eggs, etc. Eating smaller meals frequently rather than three large meals per day is helpful. Avoid gas producing foods such as beans and broccoli.

Activity level

• It is good for you to walk around, but please do not “over do” it.
• Do not sit in one place for longer than 45 minutes at a time.
• Absolutely no biking, motorcycling, or horseback riding for four weeks.
• You can do as much walking and stair climbing as you can tolerate. Go slowly and work your way back to your pre-surgery activity level.
• You may take a shower 48 hours after surgery. Do not take tub baths, swim in a pool, or get in a hot tub for four weeks after surgery.
• Do not drive if you still have a catheter or if you are taking narcotics.

Skin integrity

• You will have five port sites (small incisions the surgery is performed through) and one extraction site that may have Steri-strips (small pieces of tape) over them. Alternatively, some of the incisions may have Dermabond on them which is a purple skin glue that protects the wound. This glue will dissolve on its own.
• It is common to have a small amount of drainage from these areas.
• There are no staples or stitches to be taken out.

Urinary catheter (Foley catheter)

During surgery you will have a urinary catheter placed in your bladder. A urinary catheter is a tube that carries urine from your bladder to the outside of your body into a bag. This urinary catheter will stay in place until your anastomosis (new connection between the bladder and the urethra) heals. This varies between four and 14 days. At night, the catheter should drain into a large bag. When you want to go out, you can wear a smaller bag under your pant leg. You and your family will receive instructions about the care of your urinary catheter before discharge from the hospital.

Drain

You may go home with a drainage tube that comes out of one of the port sites on your abdomen. You will be instructed on how to care for it and when it will come out.

Medications

• You may resume your regular medications as soon as you are discharged from the hospital. The only exceptions to this are Aspirin and Coumadin. These are generally resumed after the Foley catheter is removed, but this will be discussed prior to discharge.
• An antibiotic will be prescribed for you to take by mouth. This should be taken for 3-5 days after discharge and should be restarted the day before you come in to have your catheter taken out and continue this medication for 3 full days.
• A pain medication to be taken by mouth will be prescribed for you. You will receive a prescription the day of your discharge.
• A stool softener should be taken by mouth three times a day. Generally this will be Colace 100 mg 3x/day. You can buy this medication over the counter and do not need a prescription. All narcotic pain medications are constipating and a stool softener will help to prevent this.
• Acetaminophen or ibuprofen, an anti-inflammatory, helps reduce discomfort after surgery. Both of these are available without a prescription.

Clothing

After surgery, your abdomen will be bloated and it will be difficult to fit into your regular button pants. Black or dark blue elastic waist pants are recommended.

Recovery time

• The operation lasts three to six hours and the hospitalization usually lasts 48 hours. All patients are discharged with a catheter in place to drain the urine into a bag. Some patients also go home with a drainage tube as noted above.
• You will be seen seven to fourteen days after the surgery in the office.
• You can usually return to work two weeks after the catheter is removed although some patients choose to return to work earlier.
• Most men have difficulty with urinary control when the catheter is removed and will require some form of protection, such as a pad that fits inside your underpants. That is why it is important at the first visit to bring a few pads for men and a couple of pairs of Jockey-type tight fitting underpants.
• Within three months, most men have good urine control and require minimum protection, if any. Sometimes, the recovery of continence is slower, but it rarely takes more than six months. You can perform your routine activities once the catheter is out and if you are comfortable.
• Kegel’s exercises should be started/resumed after the Foley catheter is removed if you have no perineal pain/discomfort. These exercises will help you to regain your continence. At first it may be hard to find these muscles, but this can be done by starting and stopping your urine stream. Once you find the correct muscles, repeat the flexing and relaxing of these muscles without urinating. Begin by squeezing the muscles for a count of 3, then relax for a count of 3. Work up to repeating these exercises 15 times two to three times per day. These will help to strengthen your muscles around the bladder’s shut-off valve.
• If you are experiencing perineal pain after surgery, wait until this has subsided (sometimes a few weeks) before beginning Kegel’s exercises. These exercises may aggravate the pain.
• The recovery of erections after prostatectomy can be slow. Even though the nerves to the penis can be spared, there is still some injury from trauma or stretching during the operation. These damaged nerves need time to heal. At each follow-up visit, I will discuss issues regarding sexual function with you. If you have any other questions or concerns, we can make an appointment for you to discuss these issues in more detail.

What is common after surgery

• Bruises around the incision sites: These are common and should not alarm you. They will resolve over time.
• Abdominal distention, constipation or bloating: Make sure you are taking your stool softener as directed. If you don’t have a bowel movement or pass gas or are feeling uncomfortable 48 hours after the surgery, try taking Milk of Magnesia as directed on the bottle. DO NOT use rectal suppositories or enemas.
• Weight gain: Do not be alarmed. This is due to fluid shifts. You will be back to your pre-operative weight in about five to seven days.
• Scrotal/penile swelling and bruises: This is common and should not alarm you. It may appear immediately after surgery or it may start four to five days after surgery. Your scrotum may become as big as an orange or a grapefruit. It should resolve in about seven to 14 days. You may elevate your scrotum on a small towel or washcloth that you have rolled up when you are sitting or lying down to decrease the swelling. It also helps to wear Jockey or snug-fitting underwear for support, even with the catheter in place.
• Bloody drainage around the Foley catheter or in the urine: Especially after increased activity or after a bowel movement is common. Resting for a short period of time and drinking water will improve the situation.
• Leaking around the catheter: Urine, mucus or blood may leak around the tube — this is OK. If this happens, wear your underwear with a pad inside for protection/absorption. Most of the urine should drain into the collection bag.
• Bladder spasms: These are common. You may feel mild to severe bladder pain or cramps, the sudden urgent need to urinate, or a burning sensation when you urinate. Call us if this persists without relief.
• Perineal pain (pain between your rectum and scrotum)/testicular discomfort: This may last several weeks after surgery, but it will resolve. Call us if the pain medication does not alleviate this. You can also try elevating your feet on a small stool when you have a bowel movement, using Anusol ointment, and increasing the fiber and water intake in your diet.
• Lower legs/ankle swelling: This is not abnormal when it occurs in both legs and should not alarm you. It should resolve in about seven to fourteen days. Elevating your legs while sitting will help. Call us if it is in one calf or becomes painful.

Follow-up appointments

• One to two weeks after surgery: A cystogram (an x-ray of the bladder) may be taken to see if enough healing has occurred in order to remove the Foley catheter. At this appointment, you will need to bring a pair or two of Jockey-type underpants and several pads for men. Remember to start your antibiotics 24 hours prior to coming to this appointment and continue for three days time.
• Two months after surgery and every three to four months after that: You will need to get a PSA test prior to each appointment.

Caring for your Foley catheter

The Foley catheter, held in place by a balloon inside the bladder, allows continuous urine drainage into a collection bag.

• During the day, use the smaller leg bag that straps around your thigh. It lets you move around more easily, but it must be emptied every 1-2 hours, or as needed.
• During the night, you will use the larger, hospital-type bag. It does not need to be emptied as often. When you get into bed, be sure to arrange the drainage tubing so it does not kink or loop.

To empty the collection bag

1. Wash your hands.
2. Remove the stopper on the small bag, or open the clamp on the large bag, and drain the urine. (DO NOT TOUCH THE END OF THE DRAINAGE SPOUT).
3. Replace the stopper or re-clamp the drainage spout.
4. Wash your hands.

To change the collection bag

1. Wash your hands.
2. Empty the collection bag.
3. Carefully (without pulling on the Foley catheter) disconnect the catheter from the drainage tube. Connect the catheter and the new drainage tube. (DO NOT TOUCH THE OPEN END OF THE CATHETER OR THE DRAINAGE TUBE).
4. Wash your hands.

To care for your collection bag

1. Wash the outside in warm (not hot) water.
2. Rinse the inside with a solution of 1 tablespoon of vinegar in 1 quart of water.
3. Leave the drainage spout open and hang the collection bag to air dry.

To prevent infection in your collection bag

1. Wash the penis where the catheter comes out at least twice a day with soap and water. Apply antibiotic ointment to the opening.
2. NEVER pull on your catheter or try to remove it yourself.
3. Attach the catheter or the drainage tube to your thigh with a Velcro strap.
4. Keep the drainage tubing free of kinks and loops.
5. ALWAYS keep the collection bag below the level of the bladder.
6. Drink at least eight large glasses of water every day.
7. Keep the bag attached to the catheter at all times, even when showering.

About the operation itself: robotic prostate surgery.