Post-Operative Instructions: Robotic Radical Prostatectomy

Post-Operative Instructions: Robotic Radical Prostatectomy

Following robotic radical prostatectomy, your attention to proper post-operative follow-up will contribute to the success of your surgery. You are being provided with written instructions and information that addresses common questions and concerns. Please review this information and feel free to ask any further questions.

Immediately after Surgery

  • You will wake up in the recovery area called the “PACU”.
  • There you will be monitored for about one hour and until a hospital bed is available on the floor unit
  • You will wake up with a tube in the penis and may have a tube coming out of one of the belly incisions.
  • You will also likely have a mask on your face that will deliver oxygen.
  • Once you get to your room, you may still feel sleepy but as soon as you wake up, it is necessary for you to be out of bed as quickly as possible in order to prevent blood clots and to build up stamina.
  • Don’t wait for the nurse to offer you to move and get out of bed. Instead, when you feel ready and feel like your pain is well controlled to move, call for the nurse to be in the room and assist you at least the first time you get up. Someone must supervise you at least the first time to make sure you’re steady.
  • My advice is to first sit at the edge of the bed dangling your feet. Do not be frightened if you feel lightheaded. This is not unusual. If this happens, lie down.
  • Sitting up in a chair will be your first experience out of bed. Walking will be your next.

Leaving the Hospital

  • Patients will be generally discharged from the hospital approximately 24-48 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.
  • Walking is very important after surgery. You are allowed to climb steps and walk as much as you can tolerate.

Diet

  • 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:
    • Cereal
    • Chicken Noodle Soup
    • Sweet Potatoes
    • Scrambled Eggs
    • Oatmeal
    • 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
  • I encourage patients to practice moderation as they re-introduce food into their diet. Five or six small meals throughout the day may be more advantageous than a few large meals.

Restrictions

  • 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

Wound Care

  • All the sutures used on the skin dissolve on their own and do not need to be removed.
  • A "skin glue" is used to cover the incision, so it is okay to get the incisions wet. You should shower daily at home.
  • Application of antibiotic or other ointments to incisions is not recommended.
  • A small amount of redness at the edges of the incision and bruising, as well as a small amount of clear or bloody leakage from the wound, is acceptable and common.
  • Redness greater than ½ inch from the incision should be reported to Dr. Gorbatiy.
  • If you had an abdominal drain removed before your left the hospital, then it is recommended that you keep a gauze secured with some tape (both of which are provided before you leave the hospital) to prevent your clothes from getting wet. It is common and normal to drain quite a bit the first few days. It will eventually stop. To shower, please remove the gauze and shower with soap and water. Don’t avoid cleaning the incision. After the shower, re-cover the incision if it is still draining. If it stopped draining you make keep it open to air and no longer cover it up with gauze or band aids.

Catheter Care

  • You will be released from the hospital with a penile catheter in place (also known as a “Foley”). At the end of the catheter there is a balloon which prevents the catheter from falling out of the penis. Do not try to remove the catheter on your own.
  • The catheter will remain in place for approximately 7 days. It will be removed at our office.
  • 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.
  • It is normal to have urine and blood leak around the catheter. This is particularly normal when you are experiencing bladder spasms.
  • Blood/blood clots in the urine are also normal. If you see this occurring be sure to hydrate yourself in an effort to flush out any clots.
  • Kegel exercises are not permitted while the catheter is in place. Once it has been removed, you can resume doing the exercises.
  • Apply a small amount of Neosporin or Triple antibiotic to the tip of penis where catheter exits will reduce discomfort and ease the movement of the catheter.
  • You will be provided with two catheter collection bags, a smaller bag to be worn (above the knee) during the day beneath trousers, and a larger bag to be used a night. These bags can be removed and exchanged as needed.
  • The catheter collection bag may be removed during showering. Gently pull the clear plastic tubing of the bag from the catheter and allow urine to run into the shower. Once you are done showering, you may reconnect the tubing.
  • Should your catheter fall out on its own, it is critical that you notify Dr. Gorbatiy or one of his associates immediately. Do NOT allow a non-urologist (nurse or doctor) to replace it.

Pain

  • Pain is seen with every abdominal surgery, however, laparoscopic approach offers small incisions and thus less pain compared to open surgery.
  • During the hospitalization, we will be giving IV pain medications at the same time as you try pills for pain control. We need you to try the pills because this is what you will be going home with. We need to know if you can tolerate the pain medications before your leave the hospital. Narcotic pain medications are best taken with some food and not on an empty stomach. Mild nausea, dizziness, sleepiness and constipation are common from the narcotic pain medications. We encourage you to try the simpler Tylenol or Advil for pain, but don’t be shy to use the narcotics as well. You may alternate these pain medications as needed.
  • Pain seems to be greater in patients with very developed abdominal muscles. The more you move, the more pain you may experience. However, we need you to move as much as you can because this will hasten your bowel function and eventually decrease pain from incisions as well.
  • Pain will be greatest the first few days. Take enough pain medications so you may be able to move more — not just to lay comfortably.
  • Mild pain behind the scrotum as well as scrotal swelling and soreness can linger for a few weeks.
  • Another type of pain that is seen after surgery is related to bladder cramps (spasms). This pain is generally felt below the belly button and usually comes and goes. It is generally related to the catheter irritating the bladder.
  • Medications (like Hyoscyamine or Oxybutinin) are sometimes provided for this problem.

Breathing

  • Deep breathing and coughing is very important after surgery. During the operation, a breathing machine does the job of moving air in and out of your lungs. However, it usually causes the lungs to deflate a bit. In order to expand your lungs and prevent pneumonia and improve oxygenation after surgery, you should be doing deep breathing and hacking up mucus.
  • Your nurse will provide you with a device through which you take deep breaths — an incentive spirometer. You will be able to track the volume of air your you inhale and gauge your progress. We encourage you to breathe in at least 1000-1500 mL of air on your incentive spirometer. If you don’t see a spirometer next to your bed, please remind the nurse to get you that device.
  • It is normal to have coughing with the use of the spirometer. We want you to cough up and prevent a lung infection.
  • Hug a pillow around your belly to help you deal with pain when you cough while using the spirometer.
  • If you have a history of sleep apnea and use a CPAP machine, it is VERY important for you to bring the machine with you so you may use it after surgery during sleep.

Activities

  • Following discharge from the hospital, you will be fully ambulatory and are encouraged to walk at least 3 times a day.
  • You are advised to refrain from driving until the catheter has been removed.
  • You can return to moderately strenuous activity such golfing and slow jogging 4 weeks after surgery.
  • You should refrain from vigorous activity (running, bicycling and heavy lifting) for 6 weeks after your surgery. After 6 weeks, you may resume full activities except for bicycling, motorcycling or horse-riding which you can resume 3 months following surgery.
  • Perineal discomfort (pain between your rectum and scrotum) is frequently seen after surgery. This may last for several weeks but it should resolve on its own. Use a donut pillow for sitting. This is worse with the catheter in place but eventually goes away.
  • When you return to work depends on your occupation and your recovery from surgery. Typically most patients return to work 2 - 4 weeks after the surgery.

Urinary Control

  • Most men have difficulty with urinary control for a limited time following catheter removal. You should bring an adult diaper (Depends, etc) with you the day your catheter is removed.
  • You should expect to wear pads for a while because normal urinary control may not be regained for several months from the time of your surgery.
  • Keep in mind that everyone is different; some men achieve control within one week while others require 6 months to achieve normalcy. Don't be discouraged!
  • Things will get better with time. You will typically leak more when standing up, moving, coughing and laughing than when sitting or lying down. Leakage is also typically worse later in the day as your sphincter muscle gets tired.
  • Restricting fluid intake, particularly caffeine and alcohol can reduce the amount of leakage. Going to urinate at a scheduled time (every 3 hours) can also help.
  • 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.
  • The operation removed your prostate and affected your secondary urinary control mechanisms. Your external sphincter muscle must now take over all responsibility for control. You may be able to help this muscle by doing regular Kegel exercises (see above).

Sexual Function

  • The operation will affect sexual function in several ways, but it should not prevent you from having a fulfilling sex life when you recover.
  • There are three components to sexual function in men: sexual drive, sensation, erection and climax (orgasm). Although these three normally occur together, they are really separate functions.
  • Erections occur due to a complex sequence of events involving stimulation of the cavernosal nerves and engorgement of the penis with blood.
  • The cavernosal nerves run alongside the prostate, only millimeters away from where cancer often occurs. Even if these nerves have been successfully spared they are often bruised or damaged during the surgery.
  • It often takes more than one year from the time of surgery for these nerves to completely heal. It is for this reason that it usually takes anywhere from 3 to 18 months for erections to return.
  • The use of Viagra, Cialis or Levitra can hasten the healing process, as well as help to obtain an erection during sexual stimulation.
  • While you are waiting for erections to return, a number of different therapies can be used to achieve satisfying erections. This include a vacuum erection device (ie VED or Erectaide), urethral suppository (MUSE) or inter-cavernosal injections (Caverject).
  • Orgasm (climax) will not be affected by the surgery, but ejaculation (the release of fluid during orgasm) will no longer occur. This is because the seminal vesicles, which store fluid for ejaculation, and the vas deferens, the tubes that carry sperm to the prostate, are removed and cut during the operation. In addition to creating a dry ejaculation, this means that you will be infertile (no longer be able to father children).
  • Some men experience mild penile shortening after the operation. However, the penis typically stretches to the pre-surgery length during an erection. To reduce the risk of penile shortening, we encourage patients to use the vacuum erection device to stretch the penile compartments.

Scrotal Care

  • The scrotum may be swollen and or black and blue when you leave the hospital or within a few days after.
  • Do not worry this should resolve in 7-14 days. To help alleviate any swelling elevate the scrotum when you are at rest.
  • This can be accomplished by using a towel as a sling under the scrotum and across the top of your thighs.

Bowel Care

  • Patients often experience constipation and/or bloating following the surgery.
  • To help alleviate this home take stool softener, Colace, as prescribed unless you are having loose bowel movements or diarrhea.
  • Passage of gas is a great sign of good bowel function and usually seen the first 24 hours after surgery.
  • After surgery, it is quite normal for the bowel tract not to work for two to five days or longer.
  • You do not need to have a bowel movement before discharge from the hospital. If constipation remains a problem for more than 2 days after you have left the hospital you can take Milk of Magnesia to help move things along.
  • During those days you will receive all the necessary nutrients through an intravenous or by taking liquids (including soup, etc.) until you are having satisfactory bowel movements.
  • DO NOT use an enema or a suppository as this could risk disrupting the connection between the bladder and the urethra.

Medications

  • Most patients have minimal discomfort that can be controlled with Tylenol (acetaminophen), Motrin (Ibuprofen).
  • If you still have significant pain despite Motrin or Tylenol, you may use the stronger pain-killers, but if these do not help with pain, then contact Dr. Gorbatiy or one of his associates.
  • Most narcotic medications will also contain Tylenol (acetaminophen) with it as well. Do not exceed more than 4000 mg of acetaminophen per day, thus do not exceed the dose on the prescription and monitor how much tylenol you take in addition to the narcotic.
  • At the time of discharge you will receive a prescription for the following medications:
    • Pain Medications: Typically Percocet or Vicodin is taken at one tablet every 4 hours as needed for pain (see above regarding pain control)
    • Antibiotics: Take the prescribed antibiotic medication starting one day before catheter removal for a total of 3 days.
    • Stool Softener: Colace (docusate sodium) 100 mg orally twice a day.
    • Anti-Bladder Spasm/Cramping Medication: Hyoscyamine 0.125 mg quick dissolving tablet placed under the tongue every 4-6 hours as needed.

Mood

  • Within the first weeks after surgery, you may experience some minor depression. This is a natural feeling following a surgical event. Once whatever pain and discomfort you have subsides and you are able to resume your normal activities, your sense of well being will also improve.

Follow-up

  • You will be seen in the office 6 - 8 days after surgery for catheter removal.
  • The catheter will be removed by one of Dr. Gorbatiy’s nurses.
  • Dr. Gorbatiy will discuss with your pathology report as soon as it is available (typically within 5 - 7 days from the time of surgery).
  • You will be seen by Dr. Gorbatiy again at 6 weeks and 3 months following surgery. Your first post-operative PSA will be obtained just prior to your 6-week visit.

Reportable Signs and Symptoms that require immediate medical attention:

  • 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 breath

You should alert Dr. Gorbatiy or one of his associates if any of the above occur. If you have any additional concerns or questions, please do not hesitate to call our office (954)-463-6408.

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