A Guide to Robotic Laparoscopic Prostatectomy At Duke University Medical Center

Transcription

1 A Guide to Robotic Laparoscopic Prostatectomy At Duke University Medical Center You have elected to undergo a robotic laparoscopic prostatectomy. The primary purpose of a laparoscopic prostatectomy is to cure the cancer by removing the prostate gland completely. Other key goals are to preserve sexual function (erections) and to preserve urinary control or continence. This brochure is aimed at helping you understand your surgery, what will happen in the hospital, and what you can expect when you go home. Remember, the understanding and treatment of prostate cancer continues to change as our knowledge of prostate cancer grows. You should talk to your surgeon or a member of your healthcare team anytime you have concerns or questions. Please keep this information. You may want to read it again later. The Surgery A robotic laparoscopic prostatectomy is done through 6 small incisions in the abdomen and the assistance of the da Vinci robotic system. It involves the removal of the prostate and the seminal vesicles. The entire prostate is removed because the cancer cells tend to randomly spread throughout the prostate. The seminal vesicles are attached to the prostate storing fluid until it is needed for ejaculation. They are removed because they are sometimes one of the first places the cancer spreads. Also, by removing the entire prostate gland, the pathologists can accurately assess the extent and aggressiveness of the cancer, which can help your physicians decide if further treatment is necessary. It usually takes 10 to 14 days for the pathologists to finish their report. A copy will be sent to your referring physician if requested. You may also request a copy for yourself. *Insurance and precertification questions can be directed to the urology patient financial counselor at 1(919) Individual physicians offices donot do any precertification as this is done by the hospital s precertification department. Before Surgery Before your surgery, you will typically meet with your surgeon review the surgical procedure, potential risks of surgery and sign the operating permit. In addition, you will need to undergo a preoperative screening evaluation at clinic 2D

2 in Duke South. The preoperative evaluation typically consists of a physical exam, chest x-ray, blood tests, urine tests, an electrocardiogram (heart tracing), and other tests determined necessary for your health and safety prior to surgery. You may eat and drink on this day. At clinic 2D you will meet with representatives of the anesthesiologist. They will talk with you about what to expect the day of surgery and give you the opportunity to ask any questions you may have about having surgery at Duke. They will talk with you about your medications and which ones to take the morning before surgery. It is important to take along your medications in their original bottles to preop screening clinic 2D. If you take medications that effect the clotting of blood such as Coumadin, Plavix, Aspirin or any NSAID (i.e.: Motrin, Aleve, Ibuprofen) these should be reported to your surgeon and the anesthesia representative. These medications are usually stopped days before the day of surgery. If you have any concerns about withholding of these blood thinners, you will need to personally discuss this with the physicians who prescribed those medicines. The day before surgery you will need to have a bowel prep. The prep will consist of being on clear liquids for the whole day (clear liquids consist of: clear apple juice, ginger ale, tea, coffee, Jell-O, clear broth, and sodas). At 12 noon the day before surgery you will take either (1) 45ml of Fleets Phosphosoda mixed in! cup of a clear liquid of your choice, or (2) 1 bottle of Magnesium Citrate followed that evening by a Fleets Enema as directed by your surgeon. You will change from clear liquids to nothing by mouth after midnight the night before surgery. To find out what time you need to be at Duke North on the day of your surgery call (local number) or (long distance) between the hours of 4:30pm- 7:30pm the day before surgery. The Day of Surgery The Operating Room On the day of your surgery, you will report to the Duke North Hospital 3 rd floor waiting room at the time requested. The operating rooms are also on the 3 rd floor of the hospital. The attendants at the waiting room check-in will issue a beeper to your family or friends. The family can call from the waiting room and get updates from the operating room. After the surgery, the surgeon or a member of the surgery team will come and talk to the family if the family is located in the waiting room. The patient will typically spend 3 hours after surgery in the recovery room. Following the recovery room stay the patient will be transported to his room on the sixth floor- the Urology floor is in the 6300 wing. As you enter this wing, a large white board will have the patient s room assignment posted.

3 The Urology Floor and Your Room Once you are awake in the recovery room, you will be transferred to your room where you will be reunited with your family. Often people are awake and feeling good by this time. Some people are still sleepy from the medicines used during the operation. Occasionally the medicines used in the operation make some people feel nauseated. If you have pain or nausea, you can ask for medicine to help with this. Most patients find that they do not have a great amount of pain after surgery. The majority of patients use only oral pain medications to relieve the pain. You must ask for pain medication from your nurse for them to know that you need it. You will be receiving antibiotics to prevent any infection, laxatives, and IV fluids to prevent dehydration. Patients may also be ordered a medication called Ditropan, or equivalent, for bladder spasms. Frequently after prostate or bladder surgery, the bladder becomes irritated and undergoes uncontrollable squeezing. This can be felt as sharp shooting pain or spasms in the lower abdomen. If you feel these, ask for Ditropan, which will help assuage these spasms. Depending upon the time of your surgery, you may be allowed to have some clear liquids for dinner. Sometimes patients are only allowed their medications and ice chips. While in your room, you will be asked to wear leg hose and leg pumps, which will squeeze your legs to help prevent blood clots. You will also be asked to use an incentive spirometer (breathing device) every 1 hour while you are awake to prevent your lungs from getting an infection. The evening after surgery you may be asked to sit in a chair or walk around for a while. You are encouraged to walk, as this activity will speed along your recovery The Hospital and Who You Will Meet The hospital is a busy place. Once you get to your room, lots of people will be coming and going at all hours. You will have a primary nurse who may be assisted by a nurse s aide. They will be responsible for getting your medications, checking your vital signs, changing your dressings and helping you with any daily activities you may need. Your vital signs will be monitored frequently. They will also teach you how to take care of your incisions and catheter before you leave the hospital. The urology team will direct your care during your stay. The team is made up of an intern, 1 junior resident, 3 senior residents, and 2 chief residents all of whom are under direct supervision of your surgeon. There is a urology resident in the hospital at all times who are available in the event of an emergency or for answering questions. These residents may not have assisted in your surgery so direct specific questions about your surgery to your surgeon.

4 Day 1 After Surgery and Discharge Day On the morning after surgery, you will receive either a clear liquid diet or a regular diet depending on what you had the evening before. You will have blood drawn in the morning to check on kidney function and blood counts. There will be a small drain called a J-P drain coming out of one of the 6 incision sites. This drain is usually removed today. Most patients leave by 11:00 am on this day. Some who live far away may choose to stay at a hotel near Duke to have one more day to recuperate before traveling home. If you are traveling multiple hours, stop and walk around for 10 minutes every hour. You may not drive while taking pain medications or while you have the Foley catheter in place. Recovery After Your Prostatectomy The Catheter Immediately after surgery you will have a Foley catheter in your bladder to drain the urine and allow for post surgical healing of the tissue between your bladder and urethra. The catheter will not fall out due to the inflated water balloon holding it in place inside your bladder. Although difficult to pull out with the balloon inflated, caution should be used to prevent an accidental pull on the tubing for the patient s comfort and to prevent injury to the surgical site. The catheter will stay in place until your next appointment (approximately 1-2 weeks after surgery) with your surgeon or your local urologist. The catheter is connected to a bag that collects the urine. You will be given 2 urine collection bags when you leave the hospital. One bag is a leg bag that is strapped to your calf area for use under long loose fitting pants. The larger bag can be used at night or lounging at home. Both bags should be kept hanging lower than your bladder level. This will prevent back flow of urine into the bladder, which could increase the chance for infection.! Sometimes the catheter in the bladder causes irritation and bleeding. It is not uncommon to see some blood or bloody fluid mixed with urine.! It is important to drink at least eight, 8ounce glasses of water per day to decrease the concentration of the urine and the amounts of bladder spasms.! Even with the catheter in place some urine, glandular fluids, and blood can leak around the catheter. This happens more common after a bowel movement. You can clean your catheter with warm soapy water daily. You may take showers but do not take any baths.

5 ! You may put some Bacitracin or Neosporin ointment at the tip of the penis where the catheter exits several times a day to help lubricate and protect this junction.! When changing from the large (night) bag to the leg bag, first wash your hands well with warm soapy water. Then clean the connections with alcohol, allow them to dry, and then switch them.! You may continue to have bladder spasms after you go home. These may feel like intense cramping in the lower abdomen combined with the need to urinate. This is caused by the irritation of the catheter and will decrease in time. Your doctor may send you home with a prescription (ie: Ditropan, Detrol, or VESIcare, or equivalent) for these spasms, use as directed on the prescription.! Occasionally, the catheter may clog and stop draining. Always make certain urine is collecting in your drainage bag. In the rare event it is not, call your physician s office between 8-4 pm (M-F), Duke Urologist on-call (after normal working hours, weekends, and hospital operator), or go to your local emergency room. The catheter may need to be irrigated to get it flowing again.! Swelling and bruising in your scrotum and penis after surgery is not uncommon and should subside in a few weeks. Some people prefer to wear briefs or a jock strap for support. You may also elevate your scrotum and testicles when lying down by placing a rolled washcloth or towel under them.! It is not uncommon to feel occasional twinges or sharp pains in your penis or scrotum while the catheter is in place. Skin Care It is important to try to keep your skin clean and dry while the catheter is in and when it has been removed. This will help to prevent a rash around your scrotum. If you get a rash, wash the area with an antibacterial soap and warm water, then dry with a towel. Leave the area open to air dry as much as possible. Some people find applying creams such as Desitin to the area soothing. If you are taking an antibiotic, it is not uncommon to get a yeast infection. If you think you are getting a yeast or fungal infection (a red itchy rash) you may use a topical antifungal cream or powder such as Nystatin (FYI: A yogurt a day when on an antibiotic may help avoid yeast infections).

6 Catheter Removal Catheter removal will occur at your postoperative visit or by your local physician usually 1-2 weeks after your surgery. The balloon will be deflated and the catheter will slide out. Bring an undergarment pad with you to clinic the day the catheter will be removed and expect to wear pads for protection for a period of time until your urinary control returns. Urinary Control Once the catheter is removed, it takes some time for the bladder to learn how to function properly again. As your bladder learns how to hold more urine and the muscles in the bladder and urethra heal, your control will improve. While some people regain control quickly, most men require a period of time before their control returns. By three months after surgery, over 60% of men have fairly good control. This improves to about 80% by 6 months, and approximately 90% at one year. Some men will continue to have mild leakage or stress incontinence when they bend over, lift, cough, or exercise vigorously. This gets worse when the bladder is full, you are tired, or you have consumed alcohol or caffeine.! Kegel Exercises: Kegel is an exercise to strengthen the pelvic floor muscle, which helps to control urine leakage. The pelvic floor muscles are the muscles with which you stop the flow of urine. After surgery these muscles need to get back into shape through repetitive tightening. o You may sit, stand or lie down as you slowly tighten the pelvic muscles and hold for 5-10 seconds. Relax for 4 seconds. Repeat this exercise 5 times. Repeat this sequence three times a day. o Remember to breathe normally, in through your mouth and out through your nose. o Be sure to keep your buttocks, shoulders, and stomach muscles relaxed. o Duke has a pelvic floor muscular strengthening clinic that is highly recommended to facilitate your recovery. Ask your surgeon about a referral if you feel you would benefit from this service. o The National Association for Continence (NAFC) offers a training booklet and audiotape that teaches proper Kegel exercises ( )

7 Sexual Function The operation may affect your sexual function in several ways but it does not prevent you from enjoying a sex life after surgery. For men, sexual function involves erection, ejaculation, and orgasm. With the removal of the seminal vesicles with the prostate you will have little to no fluid ejaculated with an orgasm. Erections occur when the penis fills up with blood. This usually occurs in response to nerve signals. These nerve signals are carried in 2 bundles that run along both sides of the prostate. During your surgery attempts may be made to preserve these nerves, but even preservation of these nerves does not guarantee the return of the erections. The return of erections after surgery is usually slower than the return of urinary control. The average time until recovery of erections is 12 months, and can still improve for as long as 2 to 3 years after the operation. Your surgeon may begin you on an erection rehabilitation program after your prostatectomy, using regular doses of oral medication such as Viagra, Levitra, or Cialis 3 days a week or every other day. This is now known to improve the chances of sexual recovery after a nerve-sparing operation. Most insurance companies will allow for 4 to 6 pills per month on their plan. Your surgeon may also recommend the use of a vacuum erection device. Other methods used to aid in erections after surgery include the use of Trimix (an injection) or Muse (urethral suppositories). We suggest waiting at least 4-6 weeks after surgery before using any of these methods. You may attempt sex after the catheter is removed, your incision is healed, your urinary control is satisfactory, and you feel well enough to do so. You will not be able to father children after this operation. Activity at Home " It is important to walk several times daily. This improves circulation and helps prevent blood clots from forming in your legs. Daily exercise such as walking or slowly climbing stairs will help you recover quickly. " Do no heavy lifting (over 10 pounds) for 6 weeks to allow the incisions to heal completely. " Remove any gauze dressings that are left over your incisions when you get home. " Your incisions are closed with dissolving sutures or tissue glue, and may be covered with steristrips. Activity will not harm these sutures and the steristrips usually will fall off in about 2 weeks, if applicable.

8 Diet and Bowel Function You may resume your typical diet when home. A low-fat, lean protein diet with 5-9 servings of fruits and vegetables is highly recommended for postoperative healing. Constipation is a common problem after surgery and with the use of narcotics for pain relief. Drinking at least 8 (8ounce) glasses of water or juice a day will help avoid constipation and keep your urine clear. Your doctor will give you instructions regarding laxatives everyday until you no longer are taking pain medications. DO NOT give yourself an enema or put anything in your rectum for at least two months after surgery. Work Some people return to work as early as 2 weeks after surgery. However, you should plan on being away from work for at least 4 weeks since everyone recovers at a different pace. If your occupation requires heavy lifting as part of your job requirements you may need to extend your medical leave to 6 weeks. Call your surgeon if you have. A temperature >101 F Pain not controlled by pain medication Uncontrolled nausea and vomiting Constipation that does not respond to laxatives Decrease or absence of urine output Purulent drainage, redness, and/or separation of incision site Tenderness/pain in your calves that does not go away After 5 pm, holidays, and weekends call: and ask for the Urology Resident on 2 nd call. Follow-ups and Pathology report You will be given a return appointment in 7 to 14 days for catheter removal in the clinic or you may call your local urologist for a catheter removal appointment. Your surgeon will discuss pathology results with you at your followup appointment. You will need to have regular follow-up PSA tests, usually beginning at 3 months after your operation.