Preoperative Instructions
There are a number of things that you can do to assist in helping get the best outcome from you prostate surgery.
The weeks before surgery
Get in shape
Typically Dr Berry likes to wait 10-12 weeks after your biopsy before performing surgery. The reason of this is to let the bruising that occurred in the biopsy process heal. This is very important to maximize the chance of performing nerve sparing surgery allowing the inflammation to fully resolve. A smoother recovery is often the result of entering surgery in the best shape you can. Use the time between your diagnosis and the surgery to actively exercise.
For men with a higher BMI (>28) and a low risk, low volume prostate cancer (Gleason 6 with PSA under 4 and fewer than 50% of your cores positive) there is a 6-12 month window for treatment to be performed. Dr Berry may suggest trying to lose 10-20 lbs during this time period. There is an association between preoperative weight and post procedure continence. To maximize your chance of good post procedure continence you should try to maintain an ideal weight and perform Kegel exercises.
Scheduling
The majority of prostate cancers that we diagnose are low risk (Gleason 6). While many patients have anxiety about their cancer it is important to remember there is up to a 6-12 month window in which an operation can be safely performed without the risk of the cancer spreading. This window for intermediate risk patients (Gleason 7) is likely 3-9 months.
We are able to work with you to help schedule the surgery at a time that allows you to have people around you to support you through the post operative period when you will be restricted in some of your movements and activities.
The week before surgery
Kegel Excercises
One of the keys to continence following robotic prostate surgery are Kegel exercises. These are familiar to many women who are encouraged to perform Kegel exercises after childbirth to minimize their chance of urinary leakage with cough or sneeze. Similarly Kegel exercises have been shown to help men regain their continence much quicker following pelvic surgery compared to not doing the exercises. They are very simple to perform and I encourage men to start performing Kegel exercises the week before surgery.
How to perform Kegel exercises
Begin by locating the muscles to be exercised:
Practice trying to stop or slow the urine without tensing the muscles of your legs, buttocks, or abdomen. It is very important not to use other muscles, becasue only the pelvic floor muscles help with bladder control
If you are able to slow or stop the stream or urine, you have located the correct muscles. Feel the sensation of the muscles pulling inward and upward.
Hint: Squeeze the muscles in the rectal area to tighten the rectum as if trying to hold back gas. You will be using the correct muscles.
You should hold each contraction for 6 seconds and then relax for 6 seconds. Each set of Kegel's has 5 contractions. You should perform 6 sets of Kegel excercises per day for a minimum of 6 weeks after your surgery.
Make pelvic muscle exercises a part of your daily routine: You must do them regularly to maintain bladder control. A full set takes less than a couple of minutes to perform and can be performed while watching TV, reading or stopped at a traffic light.
Do not perform Kegel exercises while the catheter is in place as this leads to discomfort but restart after the catheter is removed.
Blood thinners
Please remember to stop all blood thinners 7 days before surgery. These include prescription medications and over the counter non-steroidal medications such as
- Aspirin
- Coumadin
- Motrim
- Ibuprofen
- Advil
- Eleve
Please check with your primary doctor to assure that it is safe to cease these medications. If there is a history of heart disease, please check with your cardiologist to ensure that general anesthesia is safe.
Day before surgery
To prepare for your surgery you will be given instructions to maintain a liquid diet for 24 hours prior to surgery and a small bowel cleanser will have been prescribed. This helps us to better visualize the bladder and the prostate during surgery.
Clear liquids include chicken broth, jello, apple juice, cranberry juice, coffee without milk etc.). You will also take a bowel prep the day before surgery called Magnesium Citrate. You should drink a single 10-ounce bottle the day before your surgical procedure. It should begin working within 30 minutes to 3 hours. The bowel prep with magnesium citrate will not apply if you suffer from kidney disease or renal insufficiency
Postoperative Instructions
What to expect after surgery
When you wake up
When you wake up you will notice the urinary catheter is in place. In addition there is a small pelvic drain coming from one of the abdominal incisions. The most important thing you can do is walk from you hospital bed to the door of your hospital room the evening of your surgery. The pelvic drain is typically removed on the 1st day after surgery.
Hospital stay
Patients typically are discharged the first or second day after robotic prostatectomy.
Diet
Patients are encouraged to take primarily clear fluids such as broth, soup, Popsicles, jelly and light foods such as toast and scrambled eggs that are easy to digest for 72 hours after surgery. We recommend this approach since anesthesia puts the bowel 'to sleep' and it takes 48-72 hours to clear these medications from the body. You should stay on liquids and soft foods until after your first bowel movement.
During the first 1-2 weeks from the date of your surgery, it is important to be "a person of leisure". You should avoid lifting and straining, which also means that you should avoid constipation. This can be done by any of 3 ways: 1) modify your diet, 2) use stool softeners which have been prescribed for you as well as things such as prune juice, and 3) use gentle laxatives such as Milk of Magnesia which can be purchased at your local drug store.
Postoperative pain
Pain is managed immediately after surgery with a combination of IV and oral pain medications. You will be discharged with a prescription for Vicodin which should primarily be used in the evening to prevent you from waking while rolling in bed. Minor aches that continue for 1-2 weeks following surgery are treated with over-the-counter acetaminophen (Tylenol) or ibuprofen (Motrin). Occasionally, patients experience bladder spasms due to irritation from the urinary catheter. You may recognize this with urine coming out around your catheter. This can be controlled with oral medication so please call the office for a prescription if this is occurring.
Pelvic drain
A small drain placed in the pelvis after surgery is usually removed the first or second day after surgery.
Urinary catheter
The urinary catheter is normally left in place for 7-10 days to allow for complete healing of the bladder-urethral connection. The nurses will explain to you how to keep it clean and how to use the drainage bag. You are able to shower 48hrs after the procedure and may disconnect the catheter to get in the shower. The catheter can be cleaned with soap and water at the tip of the penis to prevent dried mucus build up.
Dried mucus irritates the urethral opening causing penile tip pain. Some patients find that placing antibiotic ointment (Bacitracin or Neosporin) sparingly around the catheter at the tip of the penis will reduce irritation.
Most people find that catheter drainage into the "overnight bag" is most convenient because it simply holds more urine and does not require frequent emptying as does the leg bag. Also, it may be more convenient to wear loose fitting pants, like sweat pants or exercise pants with side snaps. The leg bag may be clipped to the pants and conveniently carried. When wearing the leg bag be careful that it does not overfill. In addition, a leg bag should be worn only during walking times because when sitting the urine may back up into the catheter. It is normal to pass small clots through the catheter although in general the urine should be clear. Your surgeon will remove the catheter in the office.
It is not uncommon to sometimes have urine come out around the catheter. This happens when your bladder squeezes from catheter irritation. As long as this is a small amount there is no need for further medication. If this is persistent please call the office since we can prescribe a medication that will reduce the frequency of this occurring.
Recovery
Overall physical recovery (not including urinary and sexual function) averages 3-4 weeks, slightly shorter than after open surgery. You should not lift anything heavier than 10lbs (a gallon of milk) for 4 weeks after surgery to minimize the chance of hernia from the small incision above your belly button where the prostate was removed.
Dr Berry recommends minimal activity in the first two weeks. In particular you should limit your driving mostly because getting in and out of a car will strain your incision and your bladder will want to empty more frequently during the healing stages.
Regaining Continence - Keep doing the Kegel's
Kegel Excercises
You should hold each contraction for 6 seconds and then relax for 6 seconds. Each set of Kegel's has 5 contractions. You should perform 6 sets of Kegel excercises per day for a minimum of 6 weeks after your surgery.
Tips to improve your bladder control
Use a bathroom regularly, if necessary have a urinal near your bed or in the car
Wear clothes that are easy to remove when it is time to use the toilet
Train your bladder. Use a clock to schedule times to toilet. Start by going every hour then gradually increase the interval until you arrive at a satisfactory schedule.
Remain at the toilet until your bladder is empty. Don't rush.
Empty your bladder before you start a trip of one hour or longer
Learn to squeeze before you sneeze - and before you cough, laugh, get out of chair, or lift something heavy
Establish regular bowel habits. Constipation affects bladder control.
Consider avoiding foods that we know affect the bladder, such as tomatoes, chocolate, spicy foods, and beverages, including alcohol and caffeine. These make the bladder more irritable and increase incontinence.
Watch your weight.
Stop smoking. Smoking is irritating to the bladder, and a smoker's cough may cause bladder leakage.
When you have the urge to urinate try the following:
- Stop and sit down or stand still. Relax your body by taking a few deep breaths
- Do some quick Kegel squeezes 3 or 4 times without relaxing
- Concentrate hard on suppressing the urge to urinate and wait until the urge passes or subsides
Follow-up
At your first office visit after surgery two important events will occur
- discussion of final pathology
- removal of indwelling urinary catheter
You will have been given a prescription for continence pads in the hospital. Please bring pads to your first postoperative visit to wear on your departure.
You will be seen in the office 6 weeks after the procedure where your PSA will be checked for the first time and your penile rehabilitation program, if desired, will be started. You will have your PSA reviewed at 3, 6, 9 and 12 months after the procedure and visit at Dr Berry's office at months 3, 6 and 12, then every 6 months for year 2 and yearly for 10 years after that.
Hospital Prescriptions
You will have the following prescriptions to go home with. These are
- Vicodin - for pain relief
You will use 2 tablets per night to sleep. You will probably only need these for 2-4 nights. During the day you can alternate Tylenol and/or Motrin (Ibuprofen) every 3 hours for mild pain.
- Colace - bowel softener
Anesthesia puts your bowel to sleep for 3 days. Please use the bowel softener until you feel your bowel habits are regular and you are no longer taking vicodin pills.
- Bactrim - antibiotic
You are given a prescription for 6 tablets. Take one tablet twice a day the day before, day of and day after the your catheter is removed. This reduces the chance of developing a post operative bladder infection.
- Bacitracin Cream
Can be purchased at your local pharmacy. You should apply sparingly to the tip of your penis where the catheter enters. This will reduce irritation that can occur from dry mucus scratching the urethral opening.
- Continence liners
Please bring to your followup appointment. They are easier to wear with tighter fitting underwear rather than boxer shorts.
PROBLEMS YOU SHOULD REPORT TO US:
a. Fevers over 101.5 Fahrenheit.
b. Heavy bleeding, or clots.
c. Drug reactions (Hives, rash, nausea, vomiting, diarrhea).
d. Leakage from around the catheter or catheter falling out
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