Complete Prostatectomy Packet

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Frequently Asked Questions

Pre-operatively

How long does the operation take?


Barring unusual circumstances, the operation takes approximately 1.5 to 2.5 hours in the hands of Dr. Weeks.

Do I need to donate my own blood for the surgery?


As we have only transfused less than 1 % of all patients undergoing a laparoscopic prostatectomy, we do not encourage blood donation.

Post-operatively

How long will I expect to stay in the hospital after the operation?


Almost all patients of Dr. Weeks go home within 22-24 hours following the operation.

How long does it take to get the pathology results back?

The prostate, seminal vesicles and possible lymph node samples are sent to Pathology on the day of the operation. It usually takes 3-5 business days to receive the results and will be available for discussion at least by the time of your first follow up appointment. While cure rates depend on Gleason’s sum, PSA and the final cancer staging, the published data fror experienced surgeons of this technique demonstrate equal, and in some case, improved, cancer control rates when compared to the open technique.

Will I have ejaculation after the procedure?


You will not have ejaculatory fluid after the prostatectomy since we remove the seminal vesicles (which store the ejaculatory fluid) and the ejaculatory ducts within the prostate gland itself. Keep in mind that this is separate from erectile function and orgasmic function.

How long until I can return to work?


Typically, we recommend taking 2 weeks off of work in order to recover and concentrate of recovery of urinary control. However, some patients that have heavy exertional jobs may require a longer time off while more desk prone jobs may return faster. Long term disability is almost never necessary but can be addressed on an individual basis.

After the robotic prostatectomy, how long will it take to recover urinary control?

Every patient is different depending on age, size of the prostate, amount of disease and patient compliance with post-operative exercises (Kegels). When including all patients that have had a robotic prostatectomy, approximately 72% of patients are using less than a full pad per day at the 3 month mark and 98% will have achieved urinary control at the 12 month mark. The range of recovery for my patients are from 2 weeks to 13 months.

After the robotic prostatectomy, how long will it take to recover erectile function?


This is a difficult question to answer due to the many factors involved in erectile function. Every patient is different depending on age, pre-operative sexual function, size of the prostate, amount of disease, nerve sparing ability and patient compliance with erectile rehabilitation program.

General

Is the robotics technique safe for removal of my prostate?


I would refer you to their website, www.intuitivesurgical.com , for more information. The daVinci robot has been through rigorous testing, upkeep and calibration prior to every surgery in an effort to maintain its excellent safety history internationally. We have several replacement parts that are available should the need arise. If the robot ever became nonfunctional, we would simply convert to a purely laparoscopy minimally invasive procedure, though these chances are very minimal.

Is the daVinci robot technique considered experimental?


Absolutely not as we have merely extended the principles of minimally invasive surgery to urologic surgery. Approximately 55% of all prostate cancer operations are being performed with the robotic instrumentation across the country, illustrating the well established use of this technology.

Is it true that the surgeon has no sensation of touch when using the robotic approach?

Yes, this is true. However, with the amazing magnification of 12-14 times the naked eye, we are able to see our dissection so well that touch is not necessary. Also, with surgeon experience, it begins to develop what most experienced surgeons call “pseudo-tactile” sensation which is a visual appreciation of tissue texture and density. With vast experience and better visualization, we are able to improve the surgery over the open technique without real tactile sensation.

Many urologists feel that the daVinci robotic surgery is experimental and unproven?

As with any new advancements, it takes time to be understood by everyone in the field. In my opinion, the robotic technique offers so many benefits over the open surgery that it is certainly something I would recommend for my family members if surgery is an appropriate option for them. All of the benefits of minimally invasive surgery apply to the robotics procedure, including less blood loss, less pain, less scarring, less time in the hospital and a faster recovery and return to daily activities, including work and exercise. It has also been well established that return of urinary control is faster after the laparoscopic robotic approach. The return of cancer control and erectile function is at least as good if not slightly improved over the open procedure results. These findings have been well documented through many sources and is evident in my personal data collection as well.

Discharge Instructions for 
Robotic Laparoscopic Radical Prostatectomy 
(Removal of prostate due to prostate cancer)

  • The patient may eat a normal balanced diet once passing gas or bowel movement is appreciated. He should refrain from constipating foods but otherwise, has no restrictions. I recommend small frequent meals with adequate hydration (1.5 liters a day of clear, non-caffeinated beverage.
  • The patient will be discharged home on an antibiotic (typically Cipro 250mg orally twice a day unless the patient has a drug allergy to it), pain medication (Vicodin 1-2 tablets every 4-6 hours only as needed for pain), and a stool softener in case the pain medication causes constipation (Colace 100 mg orally twice a day for at least one week after narcotics are stopped). Ibuprofen products (Advil, Aleve, Motrin) are acceptable in most cases if the narcotics are no longer necessary. However, call our office for confirmation for your individual case.
  • Patient may shower on the second day following surgery (ie. If surgery was performed on Monday, the patient may shower on Wednesday). We recommend no bath as long as the catheter is in place.
  • Plain soap and warm water to incisions and the catheter only.
  • No driving for 2 weeks and no lifting more than a large phone book (10 pounds) for 2 weeks. Stairs are OK on a limited basis.
  • ALWAYS keep slack in the Foley catheter to minimize trauma to the urinary muscle that will provide control after the catheter is removed in our office.
  • It is normal for occasional urine to leak AROUND the catheter as long as it is still running THROUGH the catheter as well. This finding is due to a bladder spasm which is a good sign for bladder recovery. These spasms will likely stop after the catheter is removed at the appropriate time.
  • Do NOT allow anyone to remove the catheter if the patient has to visit an Emergency Room without express permission by the surgeon. It may require another procedure to replace it.
  • Generally, the Foley catheter will be removed in the office one week after discharge. At that time, we will also review Kegel exercises to speed recovery of urinary control. The erectile rehabilitation program will also be discussed and initiated in the appropriate patient during this visit.

Call our office if the catheter is not draining, if the patient has a temperature greater than 101 degrees Fahrenheit, if there is uncontrollable pain,nausea or any other concerns.

General catheter information

  • A urinary catheter is a slender rubber tube inserted into the bladder to drain urine. There is a balloon on the end of the catheter to hold it in the correct place. The catheter may remain in place for hours or up to 6 weeks depending on the appropriate management by your physician.
  • You will go home with the catheter in place, draining to a collection bag. There are 2 types of collection bags, referred to as leg bags and overnight bags. Both bags should be emptied when they are half full. I encourage all patients to wear the leg bag with both straps above the knee on the thigh to minimize the risk of tugging on the catheter. The leg bag is for daytime use only in order to provide you with easier mobility. At night, you should change to the larger overnight bag to rest better and help prevent infection or overflow.

Guidelines to catheter care

  • Do NOT pull or allow tension to be placed on the catheter at anytime as this may damage the muscle that provides you with urinary control. It may also cause pain and bleeding.
  • Always keep the drainage bag lower than your bladder in order to prevent urinary flow from returning into the bladder and prevent infection. If you are using the leg bag, do not lay down for periods longer than one hour and please release both leg straps to allow the bag to drain.
  • Do NOT puncture, cut or clamp the catheter as this may damage the catheter and require replacement.
  • Drink 6-8 glasses of water every day. Your urine should be clear to light yellow to indicate appropriate hydration.
  • Empty the drainage bags when half full to minimize the weight of the bag and risk of infection.
  • Daily cleansing around the catheter is necessary. The shower is the easiest time and place to do this daily. Do not take a bath as long as the catheter is in place.

Emptying the collection bags

  • Wash your hands
  • Open the valve as instructed on the small leg bag or open the clamp on the larger overnight bag and completely drain the urine. Do not touch the end of the drainage spout with your hands as this may increase risk of infection.
  • Once the bag is completely drained, close the valve of the leg bag or re-clamp the drainage spout of the overnight bag.
  • Wash your hands again.

Changing the collection bags

  • Wash your hands
  • Empty the collection bag
  • Without pulling on the catheter, carefully disconnect the catheter from the drainage bag and connect to the new drainage bag appropriately. You may pinch the catheter closed with your fingers to minimize risk of urine leakage. Do not touch the end of the drainage spout with your hands as this may increase risk of infection.
  • In order to keep the tips of the tubing for either bag clean, please replace the cap or use saran wrap or foil to cover the end when not in use. This will greatly minimize the risk of infection.

Caring for the collection bag

  • Gently wash in cool (not hot) water after emptying completely.
  • Rinse the bag inside and out with a solution of one (1) tablespoon of vinegar in one (1) quart of cool water. Another cleaning solution that may be used is 5 ounces of cold water and one ounce of bleach. Carefully pour either solution into the bag and agitate for 30 seconds.
  • Empty the bag, leave the drainage spout open and allow to air dry.
  • To minimize risk of infection, wash the area around the catheter at least twice a day using warm soap and water.
  • Never pull on the catheter or attempt to remove it yourself.
  • Apply antibacterial ointment (Neosporin or Bacitracin) to the tip of the penis where it meets the catheter twice a day to lubricate the catheter and improve comfort only if needed.
  • ALWAYS keep slack in the catheter and keep the tubing free of kinks or loops. This will ensure appropriate drainage and minimize trauma to the muscle that will provide your urinary control after the catheter is removed.
  • Drink at least 6-8 cups of water every day to encourage urine production.

Call us immediately if:

  • Urinary drainage from the catheter stops for longer than 2 hours
  • Temperature greater than 101F.

Urinary Rehabilitation Program

As the muscle that provides us with urinary control will need to gain strength following any prostate surgery, we have created a program to help speed the return of urinary control and resume normal activities as quickly as possible after the catheter has been removed. Recovery of urinary control relies mainly on the strength of the pelvic floor muscles. As with any exercise program, training before the event is as necessary as after the surgery. The exercises to increase the strength of the pelvic floor muscles are called Kegels.

Kegel Muscle Exercises

  • This program depends solely on you, the patient. I would encourage you to assume the role of an athlete in training. You will need to build strength and endurance of these pelvic floor muscles. As you are the only one that can speed urinary control recovery, this will require your commitment to these exercises on a daily level.
  • It is HIGHLY recommended that you start these Kegel exercises at least 4 weeks prior to surgery
  • To locate the pelvic floor muscles that you will need to exercise, try to slow or stop your urinary stream without using your hands or muscles of the buttocks, legs or abdomen. This is very important in order to determine the exact muscles that you need to target. Once you are able to slow or stop the stream, you have correctly found the muscles to workout in order to speed urinary control recovery. The muscles are similar to the ones you use to hold back from passing gas if that helps you localize them.
  • After you have located the correct muscles, I recommend you make the time to perform them 4 times a day (perhaps after each meal and prior to bedtime).
  • Squeeze these muscles and hold them tight for 10 seconds and then relax them slowly. Perform this cycle 10 times with each session. This may be increased to 20 seconds for 20 times as your strength returns.
  • If you cannot hold the contraction for 10 seconds, then start of easier and build yourself up. This is done by holding for 3-5 seconds and gradually increasing the time as your strength increases. If you are unsure whether or not you have found the exact muscles to exercise, please call and arrange an appointment for more one-on-one instruction as needed.
  • These exercises will be needed for the rest of your life and help improve many functions of the pelvic, including orgasmic function as well as bladder and bowel control.

Erection rehabilitation following prostatectomy

General

  • The erectile rehabilitation program is a voluntary program designed to help speed the recovery of erectile function after a nerve sparing radical prostatectomy, whether performed robotically or by open surgery. It is not a guarantee for erectile function to return but most literature will agree that by encouraging blood flow to the penis as soon as 4-6 weeks following surgery, the length of recovery time for spontaneous erections can be reduced by as much as 40%.
  • Not every patient is appropriate for this program as they may have had poor function before the surgery or we were not able to spare the nerves responsible for erectile function due to prostate cancer control.
  • Many patients report a loss of penile length and girth after a prostatectomy and this program goes long way in preventing this from occurring. We do hope that erections may return as early as 6- months but recovery may continue to occur for up to 2 years. It is important to realize that some men never regain the ability to obtain or maintain an erection after prostate cancer surgery, whether or not a nerve sparing procedure is performed. There are other treatment options available as well that are more invasive but effective and you are encouraged to discuss this with Dr. Weeks. Also, please remember that with orgasm, there will not be ejaculatory fluid anymore as the prostate and seminal vesicles have been removed surgically.
  • Any erectile fullness after surgery is a positive sign that some of the nerves are relearning proper function and encouraging spontaneous blood flow to the area. These signs indicate the beginning of recovery.
  • The components of the erectile rehabilitation program include the use of oral medications, (such as Viagra, Levitra or Cialis) and the Osbon ErecAid vacuum device. If the oral medications are not working after an appropriate time, please discuss the possible benefits of suppository or injection therapy with Dr. weeks at any time.

Oral Medications (PDE5-I)

  • PDE5 Inhibitors (Phosphodiesterade 5 Inhibitors) are designed to support an erection by increasing blood flow to the penis. It will not create an erection on its own and the patient should realize that it will take effort, time and patience for the recovery of erectile function following a prostatectomy. The medication will be prescribed to the interested patient at the time of catheter removal. The preferred use would be at least 3 times a week, on a relatively empty stomach, without alcohol at bedtime. The purpose is to encourage spontaneous nighttime erections, though it will be some time before sexual penetration is possible.
  • Side effects of the medication include headache, visual color changes, nasal congestion, facial flushing, light sensitivity or upset stomach. These medications should NEVER be taken if you are requiring nitroglycerin tablets for cardiac issues within the last 6 months. If these negative side effects occur, please stop the medications immediately and call your physician.
  • Insurance will typically support up to 6 tablets a month though the program will require approximately 15 tablets a month. Dr Weeks and his staff will help all they can with samples when available.

Vacuum Erection Device (VED)

  • The vacuum erection device (VED) is made by Osbon ErecAid. Four to six weeks after the surgery, we recommend using the VED twice a day to passively supply blood to the penile erectile tissue. The goal is to supply fresh blood to aid in healing, and stretch the tissues to prevent scarring or fibrosis from occurring. We encourage the use of the VED with the PDE5I when the medication is scheduled to provide active and passive encouragement of blood flow and maximize the chances of erectile recovery.
  • A specialist will be able meet with you in our office to provide one-on-one instruction, ordering of the product, answer and help with insurance issues and any other assistance along the way. DVD demonstrations and pamphlets are available from Dr. Weeks. The Osbon ErecAid is typically covered by insurance with an appropriate co-pay. It also boasts a 100% money back guarantee for 90 days.

For questions regarding reimbursement or equipment issues, please contact Osbon Customer Service at the number provided at the initial meeting.

Post-Prostatectomy Medication Protocol

Take Viagra 50mg (or one half of a 100mg tablet) every other day (M, W, F or T, Th, Sa) on an empty stomach. The effects will be hampered by alcohol and a fatty meal.

Equivalent dosing of Viagra 50 mg = Levitra 10 mg and Cialis 10 mg.

Equivalent dosing of Viagra 100 mg = Levitra 20 mg and Cialis 20mg.

Do NOT expect erections by starting this medication following your prostatectomy. This medication is designed to support an erection that is already present. However, the purpose of this protocol is to speed up the natural recovery of post-procedural erectile dysfunction. The goal is to encourage oxygenated blood flow to the penis, promote healing, and prevent scarring from unused tissue. There can be recovery of erectile function even up to 2 years following a radical prostatectomy, depending on the preoperative function and the surgery itself.
Side effects possible from these medications include and not limited to facial flushing, headache, chest palpitations, visual changes (blue dots), and priapism (erections lasting longer than 4 hours – go to Emergency Room!), nasal congection and hearing changes.
If these side effects occur, please simply lay down for the evening and the effects will resolve in 4-6 hours after calling the physician to inform them of these symptoms.

*** ABSOLUTELY DO NOT take these medications if you currently need nitrogen based medications for heart disease, have had a recent cardiac procedure (stenting, bypass), or have active chest pain. They may cause dangerous effects to the blood pressure in these situations.

Do not be too discouraged if these medications do not help as there are several other options available if necessary.

This protocol is voluntary and serves the purpose of potential erectile function rehabilitation following a prostatectomy surgery only. This protocol is not designed to be applied to other uses of this medication.