What Can I Expect Before And After Robotic Prostatectomy?
If after consulting with Dr. Engel, becoming educated on the topic of prostate cancer, potentially seeking other opinions, and being presented all options, a patient opts for robotic prostatectomy, he will then be taken extensively through what to expect. Dr. Engel currently performs robotic surgery exclusively at George Washington University Hospital, and a date and time will be scheduled for surgery there. The patient will generally be urged to see his internist for a pre-operative physical, although this can also be accomplished at the hospital itself. Tests to rule out spread of cancer such as a bone scan and CT scan, looking for spread to bones and lymph nodes, may be performed in higher risk cases. 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 intestine or rectum during the surgery. If this occurs, a bowel prep will likely keep this from being a life threatening problem.
Day Of Surgery
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. Dr. Engel will also be there to answer any last minute questions and to meet the entire family. There will be many papers to sign, and Dr. Engel tends to try to expedite this process as much as possible.
The surgery itself will take approximately 2-3 hours total, and Dr. Engel 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 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 throughout the body, a phenomenon known as metastasis. This is purely the job of the psa test after surgery. Typically, the only pertinent information in the pathology report is the lymph node status, as if these are positive we know that prostate cancer has spread. But, in the absence of positive lymph nodes, we must wait for the PSA.
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 5-6 days. 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 the evening of surgery 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
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.
Once at home, the sign that one is recovering well is simple. As long as the patient is feeling better overall each day, there is no cause of concern. There really have been no exceptions to this rule in over 2000 cases. Yes, there will be things like bruising or swelling or bloating or even gas pains as the intestines wake up. But, patients and families are urged always, before raising concern, to step back and ask whether the patient is feeling better overall than the previous day. If so, then there will typically be nothing to do but wait, and remember that a major surgery was just performed. On the other hand, feeling sicker or weaker each day is not normal, nor would vomiting or fevers at any time. In such circumstances the patient must go very specifically back to the GW emergency room to be evaluated. No other hospital is a substitute, as Dr. Engel would then not be able to care for the patient, and often will not even be informed. Also, if a patient has a swollen leg, particularly if only on one side, that does not get smaller with simple leg elevation, he must go to the GW ER immediately to rule out a blood clot which is a rare but nonetheless always present complication. Fortunately, complications like bowel/rectal injury, bleeding (that typically would be in the recovery room, not at home), infection, blood clots, contractures and fluid collections are extremely rare. In the review of Dr. Engel’s series published in the Journal of Urology, all of these complications combined added up to approximately 1% of all patients. Nevertheless, patients must be aware of them, and aggressively take care of them by going to the GW ER if they are suspected. If a patient is not feeling better each day, a phone call reporting this situation will almost always be answered by being told to go to the GW Emergency Room.
The Recovery Process
So what are normal parts of the recovery process? At home, the catheter may at times become clogged and need to be flushed, but insuring that the catheter leg bag is being worn above the knee and walking around will usually prevent problems. Bruising, sometimes very dramatic, in the scrotum or around the flank is extremely common. Similarly, the scrotum will commonly swell once a patient starts walking more at home, usually with little pain. This can be very striking, but generally if a man can still see the head of his penis despite the swelling it will be of no concern to Dr. Engel. This edema is a normal response to pelvic surgery and will fade away over a few days. Many patients will complain of rectal pain while sitting or pain from their pre-existing hemorrhoids. This also will fade with time. Abdominal bloating is a normal part of the healing process, and the patient may actually have cramping during the first post-operative week 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.
Other very normal things to expect after robotic prostatectomy are a high urine output for the first several days after surgery, bladder spasms at times, which feel like bladder and pelvic cramping that comes to a crescendo, causes leakage around the catheter and then dies down, and blood in the urine. Blood in the urine is never to be a cause of concern unless it completely clogs the catheter, in which case the catheter would have to be flushed. Also, just as with scrotal swelling, one’s ankles can swell symmetrically in the first few days after surgery as the body tries to get rid of the extra fluid given during surgery. If getting worse or if not symmetric, it may necessitate an ultrasound to rule out a blood clot.
But the most important thing to realize about recovery after a robotic prostatectomy is that patients are fully expected to feel as if little has occurred within 10-14 days aside from their incontinence of urine. Patients are usually back to work, if they wish to be, within this time frame. If problems arise, or if this goal is not achieved at 14 days, this will usually trigger an evaluation.
At the catheter removal appointment six days after surgery, we will make sure the patient knows how to squeeze their urinary sphincter. Dr. Engel does not ask patients to perform Kegel exercises, but rather to anticipate leakage by realizing what acts will trigger leakage. In this visit the patient will see that their sphincter functions, and thus that they can hold their urine perfectly, if for only five seconds or so, and that they can urinate as they did before. Patient’s will learn that leakage is not constant, but rather triggered by predictable acts such as standing, sitting, coughing, sneezing, etc.. A patient can learn to leak less if he squeezes his sphincter before such acts, and doing so does give the patient a psychological feeling of being more in control of the situation, but Dr. Engel does not see any correlation between this and getting fully dry or out of pads. Getting dry is a function of the bladder healing and then functioning, and it is for this reason that Dr. Engel does not find Kegel exercises per se to be useful. Please refer to the next FAQ for a more detailed discussion of incontinence.
We will review the pathology report during this visit as well. Again, the only telling news on the report would be if the lymph nodes are positive, which is rare. Otherwise, it will tell us what the final Gleason score was, how much cancer there was, margin status, stage etc. But, it must again be stressed that the report will not tell us what patients deservedly truly want to know – if they are cured. This is the job of the PSA three months later.
At this point, the patient will be in pads that they would have been told to bring to this visit (Depends for men or similar), and will be on their own unless they are having problems for three months. The PSA test will be tested at the first three month visit and should be undetectable and remain so. In terms of continence, most patients are either out of pads or down to one pad which may or not be necessary by this time as well. You can see then that by three months, a patient is usually recovered, all indications ar that they are cured, and incontinence is behind them. This therefore makes erectile dysfunction the main focus of the three month visit. Please refer to the next FAQ for a much more detailed discussion of erectile function and incontinence after prostatectomy, its inevitability, and how Dr. Engel helps patients regain their function in both regards.
Follow Up Care
The PSA will be checked every three months for the first year, every six months for the second and every year from then on. Dr. Engel at times may add radiation therapy to the treatment regimen, but typically only in the setting of recurrence. In higher risk cases, the PSA may be checked more frequently. Please see our discussion regarding what it means to have a detectable psa after prostatectomy and what we do about it.