- Preoperative Consultation
- Potential Risks and Complications
- Pre-surgical Testing
- Pre-Operative Preparation for Robotic Radical Prostatectomy
- Post-Operative Instructions for Robotic Radical Prostatectomy
- Kegal Exercises
If you and your doctor decide on surgery to treat your prostate cancer, you may be a candidate for a minimally invasive surgical procedure called robot-assisted laparoscopic radical prostatectomy. Radical prostatectomy is the surgical removal of the prostate to treat prostate cancer. The DaVinci robot is a state-of-the-art surgical system that utilizes fine instrumentation guided by a trained urologist who uses the equipment to surgically remove your prostate gland through several small incisions.
For most patients, potential advantages with robot prostatectomy over open radical prostatectomy include:
- Decreased blood loss and decreased likelihood of blood transfusion
- Improved visualization of the anatomy due to 3-D vision, increased magnification, and less blood loss
- Small incisions less than ½ an inch.
- Precise, fine surgical maneuvers guided by the surgeon
- Less pain after surgery, decreasing the need for pain medications
- Faster recovery. Most patients are well enough to leave the hospital less than 24 hours after surgery and resume routine activities 1–2 weeks after surgery.
- Overall fewer postoperative complications
During your initial consultation with your surgeon, your medical history, outside medical records, and outside X-ray films (e.g. CT scan, MRI) will be reviewed. A brief physical examination will also be performed at the time of your visit. Additionally, please bring your outside prostate biopsy pathology report for review.
If your surgeon determines that you are a candidate for surgery and you wish to proceed with surgery, our surgical scheduling coordinator will either meet with you at the time of your visit or contact you at a later date in order to schedule surgery.
IMPORTANT: Please remember to bring all outside reports for your surgeon to review.
All surgical procedures, whether minor or major, have potential risks and complications. Potential risks of robotic-assisted laparoscopic prostatectomy include:
- Bleeding: Blood loss during this procedure is typically minor and a transfusion is needed in less than 5% of patients. Please notify our office if you are interested in autologous blood transfusion (donating your own blood).
- Infection: All patients are treated with intraoperative and postoperative intravenous antibiotics over a 24-hour period to prevent wound and internal infection. If you develop any signs or symptoms of infection after the surgery (fever, drainage from your incisions, urinary frequency/discomfort, pain) please contact our office (202-444-4922) or the urologist on call if after hours (202-444-7243).
- Tissue / Organ Injury: These complications are rare. Injury to surrounding tissue and organs including rectum and surrounding vascular structures could require repair at the time of surgery. Scar tissue may also form in urethra requiring further surgery.
- Hernia: Hernias at incision sites rarely occur since all keyhole incisions are closed carefully at the completion of your surgery
- Conversion to Open Surgery: The surgical procedure may require conversion to the standard open operation if difficulty is encountered during the laparoscopic procedure. This could result in a larger than standard open incision and possibly a longer recuperation period.
- Urine Leak: Occasionally there is leakage from the repaired urethra at the point that it is sewn back to the bladder. This may require prolonged urethral catheterization.
- Urinary Incontinence: Urinary leakage is common immediately after removal of the catheter, however should gradually improve over time. Kegel exercises are an excellent way improve the musculature surrounding your urethra and thus promote earlier return of continence. You will be provided with instructions on how to perform Kegel exercises at your postoperative visit. Most men regain acceptable continence by one year following surgery.
- Erectile Dysfunction: Recovery of erectile and sexual function is dependent primarily on patient’s age, baseline function, and degree and quality of nerve-sparing. If interested, you may start a penile rehabilitation program following surgery that may assist in recovery of erectile dysfunction after removal of the urinary catheter. While some men may recover erectile function within 4–6 months following surgery, it may take other men up to 2 years to reach maximum erectile function.
You should make an appointment to have pre-operative testing done with your primary care physician within 1 month prior to the date of surgery. Some patients may also need to see a cardiologist prior to surgery depending on medical history. In addition to general physical exam, your primary care physician should obtain the following tests and laboratory work:
- EKG (electrocardiogram)
- CBC (complete blood count)
- PT / PTT (blood coagulation profile)
- Comprehensive Metabolic Panel (blood chemistry profile)
- Urinalysis These results need to be faxed to our office at 877-625-1478 at least 2 weeks prior to surgery.
Please read the below details regarding pre-operative instructions which should be followed prior surgery.
- Avoid taking aspirin products including non-steroidal anti-inflammatory drugs such as Ibuprofen, Naproxen, Advil, Aleve, Aspirin, Alka-seltzer, Celebrex, Voltaren, Vioxx, vitamin E and any vitamins and/or herbal supplements 10 days prior to your surgery date. If you are unsure of the medication please call the doctor that prescribed the medication to you.
- If you are taking Coumadin or Plavix you must stop taking them 10 days prior to surgery. These medications can cause excessive bleeding and increase the risk of surgical complications.
- If you are on medications for high blood pressure, thyroid problems or asthma, you may take them the morning of surgery with a sip of water. (Coffee, Tea or Juices are not permitted). If you are diabetic and take medication, do not take them on the morning of surgery. If you take insulin, only use half the normal dose the morning of surgery.
- The day prior to your surgery you must follow a clear liquid diet and avoid all solid foods. A clear liquid diet includes broths, Jell-O, popsicles, etc. (If you can’t see through it, you probably can’t have it). If you need some suggestions, try Gatorade or the items listed on the Clear Liquid Diet page below.
- You surgeon may ask you to drink 1 bottle of Magnesium Citrate the day before your surgery at approximately 3–4 p.m. Magnesium Citrate is available over the counter at your local pharmacy.
- After midnight the night prior to your surgery, you are not allowed to have anything to eat or drink. In addition, you are not allowed to have breakfast or drink anything the morning of surgery.
- If your surgery is booked at 3 or 4 p.m. you can eat until noon time the day before your surgery and then begin your clear liquids for the rest of the day.
- You will be asked to apply a Fleets enema 2 hours prior to your surgery. This can be purchased over the counter at any pharmacy.
To prevent dehydration and feeling of weakness, it is important to maintain adequate fluid and caloric intake. You should have a minimum of 8–10 (8-ounce) portions of clear liquids in a 24-hour period. You should have these clear liquids at your normal meal times and also between meals. Examples are clear broth, Jell-O, flavored ices, clear fruit juices and soda such as ginger ale, Seltzer, Sprite and Gatorade.
- Postoperative Pain: Pain is primarily controlled with oral narcotic medicine with intravenous medication available for breakthrough pain. Narcotic medication may only be necessary for 2–3 days following surgery, after which you can transition to over-the-counter anti-inflammatory medication such as ibuprofen or Tylenol. You may experience some minor transient shoulder pain (1–2 days) related to the carbon dioxide gas used to inflate your abdomen during the laparoscopic surgery.
- Drain: You can expect to have a small drain coming out of an incision from your abdomen for approximately 1–2 days. If persistent drainage occurs, you may have to go home with the drain and have it removed in your doctor's office.
- Urinary (Foley) Catheter: You will return home with a urethral catheter for 7–10 days, as this allows for healing at the anastomosis (connection) where the urethra is sutured back to the bladder after the prostate is removed. It is not uncommon to have blood-tinged urine for a few days after your surgery. If there is a urine leak, you may need your catheter to stay in place for a longer period of time.
In an effort to ensure optimal recovery, it is essential that you carefully read and follow the below instructions. While robotic prostatectomy is performed routinely, it is still a relatively major surgery, which will require some time and effort to recover.
- Patients will be generally discharged from the hospital approximately 24 hours after surgery.
- You are not permitted to drive home by yourself, so please coordinate to have someone pick you up upon leaving the hospital. Driving is not permitted until your catheter is removed.
- You are not permitted to shower until 48 hours after surgery.
- Walking is very important after surgery. You are allowed to climb steps and walk as much as you can tolerate.
- If you have a fever above 101°F please call the office at 202-444-4922
You can expect to have some pain that may require narcotic pain medication 1–2 days after discharge. Following that time, Tylenol or ibuprofen should be sufficient to control your pain.
- Remain on a clear liquid diet such as Jell-O, broth, apple juice, water, Gatorade and sorbet until you have passed gas rectally.
- Once you have passed gas, you can begin to consume a soft diet consisting of:
- Chicken Noodle Soup
- Sweet Potatoes
- Scrambled Eggs
- Toasted Bread
- After your first solid bowel movement you can begin a regular diet except the following for one week: carbonated drinks such as soda, ginger ale and seltzer in addition to gassy foods such as broccoli, beans, cabbage and spicy foods
- Diet: Most patients are able to tolerate ice chips and small sips of liquids the day of the surgery and regular food the next day. However, it may take up to a week to regain your full appetite. You may experience sluggish bowels for several days or several weeks. Suppositories and stool softeners are usually given to help with this problem. Narcotic pain medication can also cause constipation and therefore patients are encouraged to discontinue any narcotic pain medication as soon after surgery as tolerated.
Taking daily walks are strongly advised. Prolonged sitting or lying in bed should be avoided. Climbing stairs is possible, but should be taken slowly. Driving should be avoided for at least 1 week after surgery while on narcotic pain medication. Absolutely no heavy lifting (greater than 10 pounds) or exercising (jogging, swimming, treadmill, biking) for 4–6weeks or until instructed by your doctor. Return to work depends on your profession and recovery, however most patients return to work within 2–4 weeks following surgery.
- Avoid straining/pushing during bowel movements
- Avoid sitting in one position for more than 45 minutes
- Avoid exercising or any sports activities
- Avoid taking a bath or swimming
- Avoid heavy lifting (anything greater than 10 lbs, or the weight of a gallon of milk or phone book)
The Foley catheter travels from your urethra into the bladder, running through the area sewn together after removal of the prostate. The Foley drains by the force of gravity, and thus will not work if the bag is above the level of the bladder.
- Each patient will leave the hospital with a urinary catheter in place. This catheter is known as a Foley catheter which is held in place by a balloon inside the bladder. Do not try to remove this catheter on your own.
- The catheter will remain in place for approximately 7 days. It will be removed either at our MedStar Georgetown or Chevy Chase office at your first postoperative visit, depending on your preference.
- It is very important that your Foley catheter remain in a stable position; for this reason, it is important that the catheter be fastened to your inner thigh at all times. Be careful around pets and children to ensure that no tugging occurs on the Foley. For this same reason, that we ask that you avoid driving with the Foley in place if possible.
- If you don’t have any urine output for 3 hours and you are feeling discomfort in your lower abdomen, you must go to your nearest emergency room and contact our office.
- You will be provided with a large bag upon leaving the hospital which should be used at home for draining. When you are going out, you can use a smaller “leg bag” which is strapped to the leg and can be placed under your pants. When using the leg bag, please alternate which leg you attach the bag to in order to minimize risk of blood clots. The larger bag should be considered your “work horse” and should be worn the majority of time. Both bags can be worn into the shower. Be sure to keep both bags adequately drained.
- It is normal to have urine and blood leak around the catheter. This is particularly normal when you are experiencing bladder spasms.
- Don’t be surprised if you see blood in your urine intermittently over the next several weeks. As the bladder expands and contracts, bleeding will occur until the wounds are completely healed. You may see blood in your urine for quite some time. If you see this occurring be sure to hydrate yourself in an effort to flush out any clots.
- You may notice blood or urine “escaping” around the tip of the penis outside of your catheter. This happens when your bladder spasms (contracts) and urine passes around the sides of the balloon. It may be helpful to wear a sanitary pad in your undergarments until the Foley catheter is removed.
- You can use Lidocaine gel or any antibiotic ointment (bacitracin, Neosporin) to lubricate the outside of the catheter where it enters the tip of your penis. The ointment will reduce inflammation and discomfort to the urethra. Apply it as needed.
- Abdominal Distention, Constipation or Bloating: These are normal reactions to surgery. You may take a stool softener as directed.
- Bladder Spasms: Bladder spasms are typically associated with a sudden onset of lower abdominal discomfort, a strong urge to urinate or with sudden leakage of urine from around the catheter. Take the Detrol LA also known as Ditropan which is given at the time of discharge. It is important to discontinue these medications the day before the catheter is removed.
- Bloody Drainage around the Foley catheter or in the urine: Having pink-cranberry tinged urine or the occasional bright red drops at the beginning or end of urination or with a bowel movement is normal for approximately six weeks after surgery even after having clear urine for weeks.
- Bruising Around the Wound Sites: This is normal and the bruises will heal over time.
- Lower Leg/ Ankle Swelling: Swelling is normal and should go away within a week or two. Elevating your legs while sitting will help. Call immediately if swelling is present in only one leg. A blood clot or DVT in your leg can occur with this surgery. You are encouraged to flex your legs. Walking also helps to prevent blood clots.
- Perineal Discomfort (pain between your rectum and scrotum): This may last for several weeks after surgery, but it should resolve on its own. Use a donut for sitting. This discomfort eventually goes away. If you are feeling significant pain despite pain medication, contact us.
- Scrotal/ Penile Swelling and Bruising: This is not abnormal and is not a cause for serious concern. You might notice scrotal/penile swelling any time from immediately after surgery to five days later. It should go away on its own in a week or two. You might try elevating your scrotum on a small rolled up towel when you are sitting or lying down to reduce swelling. Also, wearing supportive underwear (briefs, not boxer shorts) is advisable.
- Showering: You may shower 48 hours following surgery. Your wound sites can get wet, but must be padded dry immediately after showering. Tub baths are not recommended in the first 2 weeks after surgery as this increases the risk of infection. You may have adhesive strips across your incision. These are not to be removed and should fall off on their own within 2 weeks. Sutures will dissolve in 4–6 weeks.
- Fatigue: Fatigue is common for the first few weeks following surgery.
- Fever of 101°F, swelling, redness or large amount/smelly drainage from abdominal surgical incisions. A little yellowish/bloody drainage is acceptable
- Nausea, vomiting, unrelieved abdominal distention and pain
- Significantly large amount of blood with blood clots in urine
- Significant decrease in urine output and/or inability to urinate
- Pain or swelling in one leg or calf
- Chest pain or shortness of breathe
- Extra Strength Tylenol or Ibuprofen is suggested to help comfort your pain. In the event that the Tylenol is not helping, an alternative medication will be prescribed upon discharge such as Percocet or Vicodin.
The below medications may also be prescribed upon your departure:
- Detrol LA/Ditropan: (anti bladder spasm). One tablet is to be taken once a day and stopped one day before catheter removal.
- Cipro: (antibiotic). One tablet is to be taken twice a day and started one day before catheter removal.
- Colace: (stool softener). Take one tablet after a meal, three times a day for the first week after your surgery. If diarrhea occurs stop the Colace.
- Cialis: (erectile aid). To be taken as directed by your physician to maintain adequate blood flow to the erectile tissue postoperatively.
Begin these exercises approximately 4 weeks prior to your surgery. You may be asked to see physical therapy prior to your surgery as well as postoperatively to start working on these exercises.
Radical prostatectomy will cause a period of incontinence for most patients. Every patient is different, so do not compare notes. On average, most patients by two months are dry but there are patients that will never leak and some that will take much longer. The leaking can vary and can be influenced by a certain position. Some patients can experience a squirt of urine as a result of a certain position there in or they may experience a lot of leakage where your entire pad is saturated. During recovery you can have an urge incontinence (when you feel an immense need to go) so it will be advantageous to urinate before you have a strong urge. Most patients will not leak at night but might have to wake up every hour or two to urinate. For most patients, doing the Kegels is the first and only thing needed to regain control. The Kegel exercise builds up the muscles around the bladder opening. It is important that you start these exercises approximately 4 weeks before surgery in an effort to eliminate any incontinence issues after surgery.
Kegels can be done standing, sitting, or lying down. The correct way is to tighten your rectal muscle as if you did not want to pass gas. It should be a contraction that you ease into and sustain. It is not a vigorous clamping down where your legs, buttocks, and abdomen should not tighten. You should not strain or hold your breath. You may notice your penis move up when done but do not concentrate on making your penis go up and down. Do not focus on stopping urine; concentrate on stopping gas or a bowel movement. If done correctly, while urinating, kegeling should stop the urine flow. This can be used to check the technique but you should not be routinely kegeling while urinating.
The Kegels should be 10 repetitions in a row holding each contraction for a count of 10 with a few seconds of relaxing the muscle in between each contraction. Before surgery, doing 4–8 sets of 10 reps every day in the weeks preceding surgery would be helpful. The first few days after the catheter is removed three sets a day can be done. For the remainder of that first week you should increase to 10 reps every other hour. After that, you can increase to every waking hour. When done correctly you should not squirt urine while tightening or relaxing, become sore, or have a lack of control. If you experience any of these symptoms, please notify our office.
After the catheter is removed, with position change, coughing, sneezing, or straining, you may notice a spritz/squirt (stress incontinence). It is fine to kegel through these movements that make you leak. For example, at night you probably will not leak but you might have to wake up every hour or two. You can tighten up (kegel) and hold the urine until you get to the bathroom. On the other hand, if you are out walking and you are getting a consistent drip, you cannot sustain a kegel for extended periods of time. It is detrimental and you are wearing a pad. Of note, the best pads are the small ones such as Depends Guards for Men which are fitted briefs.
Call our office at 202-444-4922 after your surgery to schedule a postoperative visit as instructed by your surgeon, usually within 7–10 days of surgery. Your pathology report is usually available 7 days following surgery, and can be reviewed in the office at the time of your postoperative visit or on the phone if your report is not yet available at that time.
- Catheter removal: Your catheter will likely be removed at the time of your first postoperative visit, unless there is a concern that the urethra is not yet completely healed. You will be provided with an antibiotic prescription at the time of your discharge, which you should start taking on the morning of your postoperative visit and catheter removal.
- Drain removal: If you are sent home with a surgical drain, this will also be removed in your surgeon’s office at a time deemed appropriate by your surgeon. These are generally removed when the drainage has decreased to an acceptable amount.
- PSA testing: Your PSA will be checked periodically postoperatively to monitor for prostate cancer recurrence. The follow-up schedule for PSA checks will vary depending on your final pathology report.