Moving Forward In Your Recovery After Radical Prostatectomy

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1 Moving Forward In Your Recovery After Radical Prostatectomy

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3 Moving Forward In Your Recovery After Radical Prostatectomy The diagnosis of prostate cancer has been confirmed and the type of treatment depends on the extent and stage of your cancer. Treatment possibilities include: Watchful waiting (also referred to as active surveillance) Radical Prostatectomy: o Robotic-Assisted Prostatectomy o Open Radical Retropubic Prostatectomy o Perineal Prostatectomy External beam radiation Brachytherapy (also referred to as seeds implantation) Hormone ablation therapy This handout gives you as much information as possible about what to expect after having surgery for your prostate cancer. You can have either the robotic-assisted prostatectomy or the open radical retropubic prostatectomy. The perineal prostatectomy is possible, but is not done as often. With any of these surgeries, the entire prostate gland is removed during surgery. In some cases, the lymph nodes in the pelvis and lower abdomen may be biopsied. Before Surgery 1. To be in the best possible condition before surgery Exercise Eat healthy diet Take iron supplement only if ordered 2. Practice Kegel exercises before surgery. Knowing how to do these ahead of time will make it easier to do them after surgery What to Expect after Having Radical Prostatectomy Immediately after surgery, you will have: A tube in your arm called an IV to give you fluids through the vein Oxygen tube in your nose A soft rubber drain next to the incision for wound drainage A tube called a Foley catheter in your penis to drain urine out of your bladder. You will go home with the catheter. Elastic stockings (TEDS) and inflatable stocking wraps (Venodynes)

4 Hospital Stay You will be in the hospital: o Overnight for robotic-assisted prostatectomy o 2 nights for open radical prostatectomy o 2 nights for perineal prostatectomy Foley Catheter You will have a Foley catheter and go home with it in place: o The catheter is placed through your urine channel (urethra) into your bladder to drain urine while healing is taking place. o Catheter stays in for 1-2 weeks depending on the type of surgery you had generally 1 week for robotic and 2 weeks for open approach. After catheter removal, we suggest that you wait for 5 days before starting Kegel exercises. After that, you will do the Kegel exercises on a more regular basis. Incision For the robotic-assisted radical prostatectomy, you will have 5-6 small incisions in your lower abdomen. These are closed with surgical glue. No staples or sutures will need to be removed. For the open radical prostatectomy, you will have an incision in the lower abdomen from the belly button to the pubic bone. Staples are used to close the incision and are removed 1 week later at your follow up appointment. For the perineal radical prostatectomy, your incision will be made between the scrotum and the rectum. Sutures that will dissolve are used to close the incision. Wash your incision with a mild soap and water, rinse well, and pat it dry. Wear a bandage if it is draining, your clothes rub on it, or it is in a skin fold. Change the bandage everyday or more often if it gets wet. No lotion, powder, or ointment on your wound. Activity While in the Hospital You may be out of bed soon after surgery. Moving, getting up in the chair, and walking speeds up your recovery. You will be asked to walk 4 times a day and sit in a chair for each meal. Pain pills will make it easier for you to move

5 Bladder, Prostate and Urethra

6 Robotic Assisted Prostatectomy You will have 5-6 small incisions in your lower abdomen. These incisions are surgically glued on the skin surface.

7 Open Radical Retropubic Prostatectomy You will have one incision from your belly button (navel) down to your pubic bone. The incision is closed with staples on the skin surface.

8 Perineal Prostatectomy You will have an incision between the scrotum and the rectum. Sutures that will dissolve are used to close the incision.

9 Medicines Most patients can start taking their usual medicines after surgery. Pain medicine: Most patients will have pain after surgery. The amount of pain is different for each person. Tylenol (Acetaminophen) may be enough to help with the pain. Some people will need stronger narcotic pain medicines. Patients should not take non-steroidal anti-inflammatory (NSAIDS) medicines such as Advil (ibuprofen), Aleve (Naproxen), or Aspirin for 1-2 weeks after surgery. Your surgeon, cardiologist and/or your regular doctor will let you know when you can start taking your Plavix, Warfarin/Coumadin, Xarelto, Pradaxa or Eliquis. Antibiotics: You will be sent home on antibiotics to take while you have the catheter. This is to help prevent infection. Stool Softeners: You will be told to take stool softeners. Possible Risks of Surgery Infection Bleeding Loss of bladder control. This may be a short term, or a long term issue. Problems with erections (10-30%). This depends on different factors. Rectal injury Scarring at the bladder neck At Home after Surgery Home Care You may shower, but no tub baths, swimming or hot tubs while the catheter is in and until your wounds are healed. This is often days. You may climb stairs and take short walks several times a day. Nothing strenuous such as jogging, aerobics, or running, for the first 4 weeks. Slowly increase weekly. Do not lift over 20 pounds for the first 3 weeks. Expect your urine to be light cherry to pink. It will clear over time. Drink at least 8 to 10 (8 oz.) glasses of fluid each day while you have the catheter in. After the catheter is out, you only need 6 to 8 glasses of fluid daily. For the first 4-5 days after surgery, eat small meals throughout the day. Do not eat large meals as this may cause bloating. No driving for 2 weeks and while you are on narcotic pain medicine. When you go home, you will be given antibiotics, pain pills, and stool softeners. Do not strain, avoid constipation.

10 No intercourse for 6 weeks. No biking for 8 weeks after surgery. This includes mobile bikes, stationary bikes, or recumbent bikes. Bleeding You may have a bloody discharge around the catheter when you strain to have a bowel movement. Do not worry if you see some blood in the urine. This may happen for different reasons. These include exercise, taking aspirin, straining to have a bowel movement, or it may just happen. Drinking more fluids will help thin the blood so that it does not clot off the catheter. Blood in the urine usually stops on its own. Leakage around the Catheter You may notice urine leakage around the catheter especially when you are walking around. The balloon that holds the catheter in the bladder sometimes moves the tip of the catheter away from the bladder neck, which may cause urine to leak around the catheter. Bladder Spasms Bladder spasms can happen when you have a catheter in your bladder. You may feel a sudden, strong bladder fullness or pressure. Your lower abdomen may be tender and you may notice leakage around the catheter. Sometimes this may happen when you are having a bowel movement. If these spasms become severe and uncomfortable, call the clinic and we may place you on bladder calming medicine. Urinary Tract Infection We discharge patients with an antibiotic to be taken daily. This is to help prevent getting an infection as a result of having the catheter in place. Clots in the Legs During the first 4-6 weeks after surgery you must be careful of getting a blood clot in your leg. This happens in 1 to 2% of patients and is called a deep vein thrombosis (DVT). This can cause pain and/or swelling in your calf, ankle or leg. If a clot breaks loose, it can travel to the lung and cause a life threatening condition called a pulmonary embolus. Symptoms are chest pain, shortness of breath, sudden onset of weakness or fainting, and/or coughing up blood. If you get any of these symptoms, you should immediately call us or your local doctor and go to any emergency room.

11 Diet After surgery, your appetite may be lower than normal. You may eat whatever you like, but sometimes it helps to eat 5-6 small meals throughout the day. Be sure to eat foods that are easy to digest. While you have the catheter in place, it helps to drink up to glasses of fluid each day. This may include water, tea, juice, coffee, or soda. You can decrease to 8 glasses of any fluid of your choice when the catheter is taken out. Drink alcohol in moderation. You should not drink if you are taking narcotic pain medicines. Avoid constipation by eating a lot of fruits and vegetables. This will also keep your stools soft for easier elimination. Do not use rectal suppositories or enemas for the next 6 to 8 weeks after surgery. Activity We encourage walking after surgery. Take several short walks during the day and rest when you get tired. You can climb stairs, but avoid using this activity for exercise. Avoid heavy lifting (no more than 20 pounds) for 4-6 weeks after surgery. No vigorous exercise (swimming, jogging, running, golfing, tennis, biking, or fast walking) for 6 weeks from the day of surgery. During the first 4 weeks after surgery, avoid sitting upright in a firm chair for more than 1 hour. It is better to sit in a reclining chair, sofa, or in a comfortable chair with a foot stool. You may drive 2-3 weeks after surgery. It takes at least 6 weeks for a firm scar tissue to develop in both your wound and in the areas where you had surgery. If you over-do before that time, you may disrupt the delicate connection between your bladder and urethra. This could lead to long term problems with urinary control or a hernia in the incision. Urinary Control Loss of bladder control is common after the catheter is removed. Do not be discouraged. Urinary control returns in 3 phrases: Phase I You are dry when lying down at night. Phase II You are dry when walking around. Phase III You are dry when you get up from a seated position. This is the last part of continence that returns. Everyone is different and it is hard to know when you will be dry.

12 To speed up recovery after your catheter is removed, start pelvic exercises (Kegels). You should practice these exercises before your surgery. This will help identify the muscles needed to do them. These exercises help strengthen the muscles that control urination. Sexual Function Erections return gradually be patient. The return of erections depends on many things such as age, state of erectile function before surgery and the extent of the tumor. Erections return gradually and they get better month to month. There are some patients who may not recover potency until 2 years after surgery. Most patients continue to see improvement of erections over time after surgery. Do not wait for the perfect erection before trying intercourse. With orgasm, there will be no semen because the prostate and the seminal vesicles have been taken out. Some studies have shown that making plans to help erections come back play a role in penile therapy. Using erectogenic medicines and/or vacuum erection devices may keep the penile tissues healthy. This may increase the chances of more erectile recovery. These plans will be discussed after surgery. Long Term Evaluation After catheter removal, your next clinic appointment would be in 3 months and your PSA will be checked for the first time after surgery. The PSA level should be undetectable. The first year after surgery your PSA will be checked every 3-4 months. The second year it will be checked every 6 months, and then every year. Pelvic Exercises after Radical Prostatectomy Pelvic exercises (Kegel) are done to strengthen the muscles around the bladder and bladder opening. This will help with urinary incontinence. The exercises are done by contracting the muscle that is used to control the urinary sphincter. This contraction is also felt in the rectum and perineum, the muscles behind the scrotum and in front of the rectum. You should practice these exercises before surgery. Identifying the pelvic muscles Tighten your rectum as if trying not to have a bowel movement or not to pass gas. Imagine that you are stopping the flow of urine. Do not do the exercises by actually stopping the flow of your urine. Do not tighten the muscles in your abdomen, buttocks, legs or thighs as part of the exercise.

13 How to do Pelvic Exercises Start by tightening and holding your pelvic muscles for 2 to 3 seconds. Relax for as long as you tightened the muscles. Do not hold your breath. Breathe normally during the exercises. Do 10 sets of the exercise at a time, at least 3 times a day. The second week after the catheter is removed, increase the amount of time you contract the sphincter for 4 seconds. The third week and beyond, increase the time of contraction to 5 to 10 seconds. You will notice an increase in being able to control your urine. Generally, this is better in the morning than in the afternoon. As your muscles get stronger, increase the length of time that you tighten and hold the muscles to 10 seconds. When to do Pelvic Exercises The exercises can be done any time and anywhere. You can do them standing, sitting or lying down. The important thing is to do them on a regular basis. After your surgery, we would like you to monitor the following things: 1. Temperature take 2 to 3 times daily. If it is higher than F, call our office. 2. Catheter is draining freely- Check output bag often. If there is no drainage, you may flush the catheter with a syringe filled with 30 ml of sterile or distilled water. Inject the water through the larger port on the catheter into the bladder. Try to aspirate; you may not be able to pull back on the syringe. This is okay, but the tube should start draining. Your nurse will go over these instructions with you before you leave the hospital. They will send supplies home with you. 3. If you get a feeling of fullness, this may mean that your catheter is not draining. Try to flush. 4. Keep your catheter tubing secured to your upper thigh to keep it from coming off. This will also reduce discomfort from the catheter. 5. If you have shortness of breath, chest pain, or lower leg swelling go to the emergency room. 6. Make sure your bowel movements stay soft. You will be given a stool softener to help with this. Try not to strain with bowel movements. Put nothing in the rectum for several weeks after surgery (suppositories or enema). 7. Do not lift anything over 20 pounds for four weeks. You will find information about activities and exercise on our website at 8. Stay active - taking several small walks during the day will help you recover.

14 9. Do most of your sleeping at night. 10. If your wound becomes red or has drainage, call our office. 11. For the first few days after surgery, you should eat 5 to 6 small meals during the day to help with abdominal bloating. You may eat anything you wish. More information about nutrition for the cancer patient may be found on our website at It is normal to see some leakage around the catheter, especially with bowel movements. A small amount of mucoid discharge is common around the catheter. 13. Scrotal swelling and perineal discomfort happens in most men after this procedure. This is temporary and will usually be gone in 4-6 weeks. 14. You may have some urine leakage with ejaculation at first. 15. For any abnormal or concerning symptoms, call us immediately. We are here to answer your questions. Your follow-up care and clinic visits will depend on the type of surgical approach you had. Robotic-Assisted Prostatectomy: 1 Week after surgery You will return to clinic after your surgery. There will be a voiding trial and the catheter will be taken out. At this visit, we will review your final pathology and talk about sexual activity, erections, and the use of Viagra /Cialis /Levitra. Radical Retropubic Prostatectomy (Open): 1 Week after surgery You will return to clinic after your surgery. Your staples will be removed and we will review your final pathology. The catheter will stay in place. 2 Weeks after surgery This appointment is for a voiding trial and catheter removal. We will also talk about sexual activity, erections, and the use of Viagra /Cialis /Levitra. After the catheter is taken out, expect to have dribbling or loss of urinary control, this most often occurs when going from lying to standing. Please bring some adult diapers with you for this visit. You will start do Kegel exercises a few days after the catheter is out. These can help strengthen the muscles that control urination. Men that do these exercises notice improvement in their incontinence after the catheter is removed. You will be given directions on how to do this exercise. If you have problems urinating or notice a decrease in urinary stream, please call the clinic. There may be narrowing in the healing area between the bladder and the urethra.

15 When to Call the Doctor Temperature over F by mouth, for two readings taken 4 hours apart Shaking chills Increasing redness, swelling, or warmth of an incision Pus or excess blood from an incision Pain not controlled by pain pills Swelling, tenderness or pain in your feet, legs, calves, or thighs Catheter is not draining Large blood clots or bloody urine you cannot see through If you have shortness of breath or chest pain Call 911 Phone Numbers UW Health Urology UW Health at The American Center Urology UW Health One South Park Urology After Hours, Nights, Weekends, and Holidays, the clinic number is answered by the paging operator. Ask for the Urology Doctor on call. Leave your name and phone number with the area code. The doctor will call you back. Toll Free: Your health care team may have given you this information as part of your care. If so, please use it and call if you have any questions. If this information was not given to you as part of your care, please check with your doctor. This is not medical advice. This is not to be used for diagnosis or treatment of any medical condition. Because each person s health needs are different, you should talk with your doctor or others on your health care team when using this information. If you have an emergency, please call 911. Copyright 7/2015 University of Wisconsin Hospitals and Clinics Authority. All rights reserved. Produced by the Department of Nursing. HF#7530