What can I expect during and after robotic radical prostatectomy?

Introduction

In the last year or so, I’ve spent quite a bit of time writing about choosing a treatment for prostate cancer, and even more time writing about life after treatment in terms of nerve regeneration and continence. What isn’t often discussed is the actual operation itself, and the several weeks of recovery that follow afterwards. This has been echoed in my patients, who I have discovered are arriving for surgery poorly prepared as to what to expect after the operation. I therefore wanted to spell out exactly what patients can expect during and after robotic radical prostatectomy, and the post below is a slightly modified version of what my patients receive themselves. If there is an area of the process that you’d like me to write more about, write a comment below and I’ll add it in.

Admission

You will be admitted on the day of surgery and will see the anaesthetist and surgeon before your operation. Inevitably, there will be some forms for both you and the nurses to fill in. You will already have attended the hospital 1-2 weeks before to have some routine blood and urine tests done, in addition to an ECG (heart trace). This is the time to ask any remaining questions. You may need to have an enema to cleanse the bowel, depending on surgeon preference. The anaesthetist will discuss with you the pros (better pain relief) and cons (1 in 500,000 risk of serious complications) of having spinal anaesthesia (an injection in the back that numbs you from the waist down for 4-6 hours) before your general anaesthetic. This is induced in the Anaesthetic Room (adjacent to the Operating Room) by an injection in the back of the hand whilst you breathe oxygen and maintained during the operation by an anaesthetic gas. Once you are asleep, you are wheeled through into the Operating Room where preparations begin.

The operation

This will take on average 2 hours, depending on the degree of complexity and/or difficulty. The prostate and seminal vesicles will be removed, together with the lymph nodes that drain the prostate if indicated.

In the Recovery Room

When you wake up the nurse looking after you will ask you if you have pain and/or sickness so that drugs can be given if needed to counter these. You will have a catheter in the bladder, a drip in the arm to provide you with fluids until you can drink freely, drains in the tummy to drain blood and the serous fluid that collects after surgery, an oxygen mask or nasal prongs, a blood pressure cuff and a plastic clip on a finger to measure your blood’s oxygen saturation. If all of your observations are normal you will be wheeled to your room after 2 hours.

On the ward

Ring your bell if you need attention for pain relief or anti-sickness medicine. You will be allowed initially to drink only sips of water but if you don’t feel sick you will be allowed to drink whatever you want within a few hours. During the first night after your operation you will probably only sleep intermittently because of the blood pressure cuff on your arm and the staff checking on you. You can catch up on sleep the following afternoon by taking a nap.

The first day after surgery

After your surgeon has seen you the oxygen can be discontinued, the drip taken down and the drains removed. You will be given a light breakfast and a catheter bag will be strapped to your thigh to allow you to move around your bed and the room freely. You will see the physiotherapist to go through breathing and pelvic floor exercises that will build your erectile function in the coming months. Drink plenty of fluids but don’t eat too much as this will cause abdominal distension.

Day 2 post-op.

Expect to do a bit more physically. This might be a little more uncomfortable so take your painkillers offered.

Day 3 post-op.

Once home, remove the dressings from your wounds and get in the shower to keep your wounds clean. Pad your wounds dry.

Rest and exercise

• During the first few weeks after surgery you will probably feel less energetic and want to take a nap in the afternoon. This is your body’s way of telling you that you need to slow down for a while to allow it to heal.
• It is important to balance rest and activity. Each day you should walk outside, gradually increasing the distance, and to potter around the house and garden in between.
• You should avoid strenuous exercise, contact sports, any lifting for 6 weeks and heavy lifting for 12 weeks.
• You shouldn’t ride a bicycle for 3 months.

Wound Care

• You will have dissolvable sutures both internally and externally. Most of the dressings will be removed prior to discharge. Just occasionally you may need to go home with a dressing or external drain bag on and there may still be a small amount of oozing of blood-stained fluid from the wounds. However, wounds heal faster when allowed to dry out so ideally dressings should be removed after the first 48 hours and you should get them wet in the bath or shower at least once a day.
• If the wounds become red and hot to touch you should contact us for further advice this may be a sign of infection.

Scrotal swelling

Expect some bruising and/or swelling of the abdomen, scrotum, penis and sometimes legs. The scrotal swelling can be quite alarming (up to the size of a grapefruit) but will settle completely over the course of 2-3 weeks. Wearing supportive underwear (Y-fronts rather than boxer shorts) will help.

Discoloration of the urine

Expect to see some blood both in the urine and at the end of the penis from time to time. This is likely to become more pronounced each time you open your bowels, especially if you strain, or if you are overdoing things. You should drink more fluids until it clears.

Catheter care

Your catheter should be secured to your thigh by a strap or other device and should not be under tension. Clean off any crusty exudate that dries on it daily with moistened toilet tissue. If it stops draining urine, check the tubing for kinks. If the catheter drains little urine or stops draining altogether then you must phone as soon as possible for advice.

Pain and Discomfort

You should take pain relief if you have pain or discomfort. We recommend that you take pain relief regularly for the first 48hrs following discharge then as required. Paracetamol and Ibuprofen work very well together. The areas of discomfort are likely to be the wound sites and the perineum (between the scrotum and the back passage).

Bowels

Following surgery it can be 3-4 days before you open your bowels. If your tummy is bloated and uncomfortable you should reduce your food intake but continue to drink plenty of fluids. Exercise, having a cooked breakfast and taking a laxative all help.

Pelvic Floor Exercises

You should continue to do your pelvic floor exercises at home, following the advice leaflet and Physiotherapist’s instructions. You may experience discomfort in the perineum (between the scrotum and back passage) during and after these exercises and if this discomfort is significant then stop doing pelvic floor exercises until after the catheter has been removed.

Driving

You should refrain from driving for at least 7 days and until you can comfortably do an emergency stop. Check your insurance details as some say longer after major surgery. A good idea is to try sitting in a stationary car and stamping your foot hard on the brake. If this hurts in the abdomen you shouldn’t be driving.

Return to work

It is sensibly to give yourself enough time to recover from your major surgery before returning to work. We suggest you take 3-6 weeks off, depending on your job and your progress. If you require a certificate please ask for one.

General advice

• Take adequate rest periods it allows your body to heal.
• If you are uncomfortable take some pain relief.
• If you are worried or concerned please contact us.

Catheter removal at 2 weeks after the operation

Patients with a urethral catheter (one that comes out of the penis)

You will need to attend the hospital for half a day (or overnight if you live more than 1 hour’s drive from the hospital) for catheter removal and observation to monitor the urine output and the efficiency of the bladder to empty satisfactorily. This is assessed by measuring the volume of urine that you pass on a chart and by using a bladder ultrasound scanner.

Patients with a suprapubic catheter (one that comes out of the lower abdomen)

• Clamp the suprapubic catheter at 09:00 on the date advised by Prof. Eden (usually 8 days post-operation) using the Flip Flo valve attached to the end of the catheter.
• Release the clamp if you are unable to pass urine or experience abdominal, pelvic or genital pain.

E-mail Prof. Eden at [email protected] at 16:00 on the same day with the following information:-

• Number of voids e.g. 6.
• Volume of each void in ml e.g. 150 ml, 300 ml, etc.
• Amount of leakage e.g. nil, 1 small pad lightly damp.
• Any other information that you think is relevant.

Following catheter removal

Incontinence

• You may experience some incontinence of urine and the amount of leakage of urine varies greatly from person to person. The main reason for the incontinence is the presence of stitches in the valve, which prevents its normal range of movement. Once the stitches weaken and dissolve (this process starts at 6 weeks) this tethering of the valve reduces and continence improves, plateauing a year after surgery.
• In all but 1-2% of patients the incontinence is temporary. If you fall into this group then a small operation may be necessary to resolve the problem.
• It is advisable to wear the incontinence pants supplied in the first few weeks. If there is little leakage the small pad is ideal for day to day wear thereafter. These pads shouldn’t be flushed down the toilet as they will block it.
• You will initially want to pass urine quite frequently – this will improve over the course of the following 2 weeks.
• Reducing fluid intake after 7 p.m. and avoiding too much caffeine (in tea and coffee), fizzy drinks and alcohol will also help.
• Don’t be alarmed if when passing urine you see some suture material, a small metal clip or some blood. This is all normal.
• It is important that you continue to do your pelvic floor exercises regularly.

Erectile function

• For patients who have had either partial or full nerve sparing operations, it can take up to 3 years for your erections to return to normal. You may begin experimenting trying to get erections following the removal of your catheter. It is beneficial to get the blood flowing into the penis early as this will aid recovery of sexual function. Don’t be too discouraged if nothing happens initially. See our blog article Taking Viagra after a prostatectomy for more information on this aspect of rehabilitation.
• If you agree, your GP will be asked to prescribe Viagra, Levitra or Cialis when you see the Consultant at your follow-up consultation.
• You may attempt sexual intercourse when you feel comfortable. You will experience normal sensations during intercourse and when you climax no fluid will come out.
• In patients who have had both nerves removed for reasons of cancer control, unfortunately erections won’t return to normal. However, you can be made potent again with either an injection or pellet inserted into the penis. Your Consultant, Urology Practice Nurse or GP will be able to discuss these with you further.

Wound Care

• The bruising and swelling will be subsiding by now but it may take at least another week or two to completely go.
• All internal and external stitches dissolve after about 6 weeks. Your wounds will gradually soften, flatten and become less noticeable during the first 12 months.

Histology results and follow-up appointment

You will have an appointment at 4 weeks post-operation. Between your operation and this date, your prostate will have been sent to a laboratory where it is thoroughly inspected to produce a final report on the precise details of your cancer. This is called a ‘histology report’. During this appointment you will be given the histology results, detailing the final Gleason grade (aggressiveness) and stage (extent) of tumour, which is very important in determining your prognosis and the probability of the need for additional treatment, such as radiotherapy.

Longer-term follow-up

Your first PSA test should be done at your GP practice at 10 weeks post-op and you should obtain the result and bring it to your 3-month check-up with your surgeon. This PSA test and checkup needs to be repeated every 3 months during the first year, every 6 months for the next 2 years and annually thereafter.

Final words

This may have been a rather long list to digest, but I hope that it makes things a bit clearer for all men considering surgery as an option! As ever, please post your comments below if there are aspects you would like clarified or expanded upon.