Laparoscopic and robotic surgery: Into the 21st Century

What can I expect before and after robotic prostatectomy?

Once a patient has decided to undergo a robotic prostatectomy with us, they will be given a date and time of the surgery and will be prepared for surgery. The patient will generally be urged to see his internist for a pre-operative physical. This can also be achieved at the hospital itself. We mostly operate at George Washington University Hospital, but are now also offering these surgeries at Sibley Memorial Hospital. The patient will be given detailed instructions regarding a bowel preparation regimen and the patient must follow this strictly. The purpose of the bowel prep is not only to create more space in the abdomen, but also for safety in the very unlikely event that there is an inadvertent injury to the bowel during the surgery. If this occurs, a bowel prep will likely keep this from being a life threatening problem.

On the day of surgery, the patient will be asked to arrive two hours early, and to check in to the admission desk of the hospital. He will then be guided to the pre-operative area where an I.V. will be started, and where the patient will be met by the nursing and anesthesia team. Drs. Engel or Frazier will also be there to answer any last minute questions and to meet the entire family. Often, the patient will be asked to demonstrate his skill at performing the "turtle" exercise right there in the pre-op area, and the need to perfect it over the coming week will be stressed.

The surgery itself will take 2-3 hours, and we will come out to inform the family of the findings and report on how well the surgery went. Although the family typically will ask questions regarding the extent of the cancer at this time, little information can be given regarding this from the operative findings. Take note that we will not know if a patient is cured until we check the patient's first post-operative psa until 3 months after the surgery. There will be a pathology report generated from the surgery, and it will contain information regarding things such as capsules, margins, nodes, etc.. However, none of these things tell us with certainty whether there are no cells that have spread from the prostate, a phenomenon known as metastasis. This is purely the job of the psa test after surgery.

The family will be able to see their loved one approximately one hour after surgery in the recovery room. There, the patient typically has little pain, but may feel as if he has to urinate due to the presence of the urinary catheter, which will stay in for approximately one week. There will also be a drain coming from one of the five small incisions, and this will be taken out typically the next day just before going home. When in their room upstairs, it is absolutely crucial that the patient sits up for one to two hours in a chair to allow for the bladder and urethra to come together properly and for the drain to function well. Also, unless getting to the room late at night, the patient will be asked to walk at least once in the hallway.

The following day, regular food will be given, the patient will be given instructions regarding catheter care and the leg bag that goes with it, and usually discharged. At home, we want the patient to be active, lying in bed only to sleep. In general, the more active the better, but common sense must be applied. We simply instruct patients that over the following week the patient must feel better each day overall. If this is the case, then very little can be going wrong. If the patient is feeling sicker, his abdomen becoming more distended and not less, if he is getting less hungry and not more, if the catheter is not functioning and the patient has the urge to urinate, or if high fevers greater than 101 degrees occur, then we must hear from the patient immediately by calling our office. Also, if a patients has a swollen leg that does not get smaller with simple leg elevation, he must seek medical attention immediately to rule out a blood clot. Fortunately, these are all rare events. If an emergency room is needed, the patient must come to the George Washington E.R. and not their local E.R.. Drs. Engel and Frazier specifically want their patients to call their assistants, (call Ruby for Dr. Engel, call Sade for Dr. Frazier), to confirm the catheter removal appointment and to report on progress two days after surgery.

So what are normal parts of the recovery process? At home, the catheter may at times become clogged and need to be irrigated, but commonly insuring that the catheter leg bag is being worn above the knee and walking around will clear it. Bruising, sometime very dramatic, that is in the scrotum or tracks around the flank is extremely common, and rarely of any concern. Similarly, the scrotum will commonly swell, usually with little pain. This is a normal response to pelvic surgery and will fade away over a few weeks. At least half of the patients will complain of rectal pain while sitting. We assume this to be a function of the dissection, combined with a flare up of the patients' own hemorrhoids, and has always resolved over a few weeks to a month. Abdominal bloating is a normal part of the healing process, and the patient may actually have cramping during the first post-operative weeks as the bowels are waking up. Patients will often not have a bowel movement for several days after surgery, and their first movements can be very watery. As with all of these normal events, this is usually nearly completely resolved by two weeks after surgery. Other normal events that we have seen are reactions to the leg bag strap or tape, high urine output for a few days after surgery, bilateral ankle swelling that responds to leg elevation, and nearly any degree of blood in the urine. Blood in the urine is never a problem as long as the catheter continued to function. Lastly, just before catheter removal, the patient will commonly experience bladder spasms, a sudden urge to urinate accompanied by bladder pressure that then leads to blood in the urine and urinary leakage around the catheter. This is usually just a healthy sign that the bladder is healing and is ready to have the catheter removed.

At the catheter removal appointment one week later, the patient will be taught to apply the "turtle" to every act that causes leakage such as standing, sitting, coughing, sneezing, etc.. If truly diligent, the patient will be doing the "turtle" hundreds of times per day, all throughout the day. Because the patient will certainly have leakage after catheter removal, Depends pads for men or Serenity pads for men should be brought to this appointment. The pathology report will be gone over as well during this visit. Nearly every patient will feel fully recovered and ready to go back to work two weeks after surgery. When seen at one week, common findings are bruising, blood in the urine, some remaining abdominal bloating, and constipation or diarrhea to some degree. Also common is rectal discomfort which usually resolves over a month or so. All of these things, especially blood in the urine, are perfectly normal. Remember, as long as the patient keeps progressing each day, none of these things are of concern.

Unless enrolled in a clinical trial the patient will be on their own for the next three months, with the task of preforming daily kegel exercises to improve their chances of early contience. The patient may be asked to start medicines such as Viagra or Cialis one month after surgery as part of a penile rehabilitation program, but will not see the doctor for three months. At that visit, the first PSA will be checked which should be undetectable. Continence status will be checked, and if doing well erection status will then be addressed aggressively. The typical patient will have an undetectable psa at three months, be dry or suddenly notice significant improvement in dryness at three months, but have no erection. Erections return, if they do, much more slowly than dryness so the patient must manage their expectations here. At three months, we will have a frank discussion with the patient regarding the importance of sex in their relationship. Couples that seek an active sex life can always succeed here with help. That couple must simply ask for that help and we can always provide a reliable erection while we are waiting the 1-2 years for spontaneous function to hopefully return. We find that many couples are not very motivated in this regard, but for those that are we can always help.

From then on, the psa will be checked every three months for the first year, every six months for the second and every year from then on. Please see our section entitled "Prostate Cancer" for a discussion regarding what it means to have a detectable psa after surgery and what we do about it.

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