Robotic Prostatectomy to Treat Prostate Cancer
A robotic prostatectomy involves the removal of the entire (radical prostatectomy) prostate gland along with the structures that make semen (seminal vesicles) in men due to prostate cancer. Robotic Prostatectomy is now almost the only way that prostate removal for cancer is now performed.
A Brief History of Robotic Prostatectomy
With the advent of PSA screening in the early nineties, there was an explosion of treatment of early-stage prostate cancer in America. We know now that many patients in this era never needed to be treated, but the high volume of cases being presented then lent itself to constant improvement in the ways to address this disease. Early on, external beam radiation was standard but very non-focused and very morbid. Surgery was an option but was limited to what is called a perineal prostatectomy, which was performed via an incision under the scrotum. Back then, it was felt that surgeries had to be radical, and thus, there was no concept of sparing the erectile nerves or hugging the prostate closely. To limit the impact on continence and erections, surgery advanced with the open nerve-sparing radical prostatectomy, performed through a lower abdominal incision, and radiation advanced with seed implantation or brachytherapy. Unfortunately, seed implantation was shown not to cure prostate cancer cases that actually needed curing and had similar side effects to surgery or worse. Open surgery was very bloody and not particularly minimally invasive, and because of this, severe, permanent incontinence was prevalent. Catheter times after surgery were typically 2-3 weeks and physical recovery was usually 4-6 weeks. Radiation improved with better, more focused forms of external beam radiation that continues to evolve today. Surgery moved into the minimally invasive arena first with laparoscopic radical prostatectomy. Laparoscopy is a style of abdominal surgery where the abdomen is filled with gas which allows a camera and instruments to be placed into the abdomen using tiny incisions called ports instead of one large one. When applied to radical prostatectomy, this style of surgery proved to be very cumbersome and difficult with long operative times and was mostly applied by experts in Europe. However, once robotic instruments for laparoscopy were introduced things rapidly advanced to the point where nearly every radical prostatectomy done now is robotic. Robotic surgery is laparoscopy with far better instruments that move just like the human hand and are controlled by the surgeon in a separate console in the corner of the operating room. Now the surgery is also not so radical, and we know now that we can spare the tissues surrounding the prostate including the nerves for erection and the urinary sphincter without jeopardizing cure. Robotic surgery turns a very inaccessible place to do surgery, the human pelvis, into a much larger and open field to the surgeon. Much of this has been stated in the prostate cancer section of this site, but the discussion regarding robotic prostatectomy is far more expansive here.
Dr. Engel is considered a pioneer in popularizing the robotic approach to what it is today. He was the first to do this surgery in the mid-Atlantic region and defended this technology vehemently from its many critics since starting his series in 2004. He has published many papers on outcomes associated with the robotic approach and to date has done well over 3000 robotic surgeries. Dr. Engel was one of the few robotic surgeons who was performing over 200 cases a year that saw all his patients back personally for at least the first six months of their care. This put him in the unique position to not only perfect the surgery but also to perfect his own personal understanding of ED and incontinence after surgery and how best to manage those changes. He established the program at George Washington University and served as Vice Chairman and Clinical Director of Urologic Robotic surgery there for many years. More recently Dr. Engel has left GW in favor of operating in a private practice setting at Reston Hospital in order to keep operating with his surgical assistant Eric Strother, without the obligation to teach residents, as he has for the past 20 years.
What Is a Robotic Prostatectomy?
A Robotic Prostatectomy or any prostatectomy for cancer is an operation whereby the prostate is separated from the rectum and bladder and the urethra is severed. The seminal vesicles, the structures that make semen, are integrated with the prostate and thus must be removed at the same time. The bladder is then sewn to the urethra to complete the operation. The entire prostate is removed during any prostatectomy for cancer. Typically select lymph nodes on each side are also removed for cancer staging purposes.
Robotic prostatectomy represents the application of engineering to all of the failings of both the laparoscopic and open approaches to radical prostatectomy. Visualization is perfect with a 3D camera, not a 2D camera as standard laparoscopy uses. Now, the surgeon can actually see the nerves as he/she is dissecting them in a far less bloody operative field. There is no more blind dissection or guessing as could be the case with open radical prostatectomy. This allows the surgeon to nearly always perform at least a partial nerve sparing operation on both sides, on every patient, regardless of risk stratification. Blood loss is still low due to the laparoscopic platform robotic surgery is built on, and this keeps hospital stay to less than a day and shortens recovery from 4-6 weeks to 10-14 days. Most importantly, unlike standard laparoscopic instruments, robotic instruments completely mimic the human hand. This allows for a much better connection between the urethra and bladder that is nearly always water-tight. This is why catheterization time has been reduced from 10-14 days to 5-7 days. Sparing the erectile nerves is now far more elegant and reproducible as well.
In experienced hands, Dr. Engel believes that robotic surgery provides advantages in nearly every way when compared to previous forms of surgery, with no disadvantages, and should be applied nearly any time surgery for localized prostate cancer is considered. However, robotic surgery alone does not trump experience and experience with this operation has been shown to clearly matter in nearly every outcome parameter. Fortunately, since nearly every prostatectomy is done robotically now, most patients will have no problem finding more than one highly experienced provider in their area. Now, the robotic approach has become standard for Dr. Engel in nearly all of his abdominal surgeries, such as partial nephrectomy, pyeloplasty, cystectomy for bladder cancer , and distal ureteral surgery such as repair of ureteral injury, strictures, ureteral implantation, and most recently robotic vasectomy reversal.
Probably the best way to understand what robotic surgery is would be to actually see one. We have embedded an actual narrated operative video for you below of Dr. Engel performing a robotic prostatectomy with accompanying explanations of the structures and other key points to the operation.
This video represents an actual Robotic Prostatectomy – Warning, Content is graphic
The Pros and Cons of Robotic Prostatectomy
An extensive discussion of all the different treatments that exist to treat localized prostate cancer may be found in our Prostate Cancer Treatment Overview found in the Common Procedures section of this site. Dr. Engel tells his patients that the main advantage of surgery specifically is the closure it brings with the ability to know afterwards if one is cured or not. Patients that choose surgery often welcome the fact that on surgery day their cancer will likely be cured, and that the problems that come with surgery are all front loaded so that the recovery process can happen and be put behind them. And aside from the very rare surgical complications that can come with any abdominal surgery, what we are mainly talking about in terms of down sides with surgery are impotence and incontinence. Also comforting is knowing that if surgery fails radiation can be the next option, whereas the reverse is not true in that surgery is largely not feasible after radiation. Ultimately, patients generally seek the treatment with the highest cure rate and the fewest side effects, and in recent years robotic prostatectomy most commonly fits that profile as it avoids the necessity of hormone therapy. We will discuss ED and incontinence in great detail below, along with what the rare surgical complications can be after robotic prostatectomy.
Robotic surgery is a truly fascinating technology, but it is important to understand that although it allows the surgeon to minimize problems, it does not eliminate them.
And although most robotic surgeons do believe that this set of tools leads to a minimization of impotence and incontinence and fewer overall complications, unfortunately the side effects of ED and incontinence are a part of every man’s recovery after any prostatectomy, regardless of how it is performed or who performs it. Many men will recover quickly and completely, but this should not be expected as the norm at all.
Dr. Engel is very experienced but still has some patients that leak permanently and certainly has men that have permanent erectile dysfunction after surgery and need help. Highly skilled robotic surgeons like Dr. Engel just have fewer of them, and he is committed to providing help to those who need or want it.
It is very important that the patient and his family have a clear understanding of what average results are and not outlying examples of what the best results are. We also find that a patient’s attitude and willingness to accept and positively work on these two post-operative problems very much affect the eventual outcome. A major problem today is the fact that several centers quote success rates that are generated by defining these problems in a way that overestimate success in these areas, or report outcomes only on select groups. Although this certainly attracts patients to these centers, it tends to create disappointment among many men during their recovery.
Please visit our webinar on Life After Prostate Cancer in the education video section of the site
Erectile Dysfunction After a Robotic Prostatectomy
Let’s talk about impotence, perhaps the most dreaded problem to some when facing prostate cancer treatment. Quoting absolute rates unfortunately is very difficult to do, and this can be frustrating to patients who are trying to compare surgeons. This is because there are several factors that affect potency after robotic prostatectomy. Although the sparing of the erectile nerves is often stressed, and Dr. Engel firmly believes that robotic surgery allows him to do that more consistently and elegantly, unfortunately, this is not necessarily the most important factor in the recovery of erections after surgery. Dr. Engel believes that the primary problem after prostatectomy is decreased blood flow. Blood flow is why younger men and those with better pre-operative cardiovascular status fare better, and it is why men as they age tend to lose erectile function naturally. Aging does not cause erectile nerve malfunctioning. In fact, it was the advent of robotic surgery, where suddenly the nerves are spared perfectly in nearly every case that caused the factors leading to erectile dysfunction after prostatectomy to be re-examined by many. Before open surgery, visualization of the nerves was poor, so when a man regained his erections one assumed the nerves had been spared. Now, with robotic surgery, even though nerves are nearly always spared, all men still will have erectile problems after surgery. Dr. Engel has thus come to the conclusion that nerves alone cannot be the answer.
Dr. Engel has found, as have others, that beyond blood flow in general, partner interest
in sexuality is perhaps the strongest factor, followed by how strong and reliable a
patient’s erections are before surgery. Whether there is any pre-operative need for
medicines to aid erection, obesity, smoking, and general cardiovascular health is also very important. In addition, mood and depression play a role, as does the health of the patient’s
relationship with their spouse. Most rates that are quoted on the internet are select
groups of patients that are optimal in all of these categories, and potency is defined very
loosely and not in a way a patient would usually define it. Therefore, for a surgeon to
quote success rates in terms of impotence, he/she would have to know how well a
patient is doing in each of these categories to give an accurate estimate.
Unfortunately, most men in their fifties and sixties and certainly in their seventies are not
optimal in all of these categories. This is the major challenge of erectile dysfunction after
prostatectomy. The reality is that although a surgeon can affect the outcome here to
some degree by the skill with which the surgery is performed and the sparing of the
nerves, most of the parameters above are outside of the surgeon’s control. Dr. Engel
firmly believes that his erection rates rival anyone’s in the country, or the world for that
matter, but he is very careful to be honest about the difficulties of getting erections back
after surgery for all those men that are not optimal in all of these categories. Even if
completely optimal, results are not always linearly associated.
The graph below is a very important one, and one that is almost identical for every high-volume robotic surgeon that is considered very experienced and skilled at prostatectomy. It represents the first 500 robotic prostatectomies in Dr. Engel’s series. The IIEF survey is the gold standard questionnaire best suited to judge true potency and the standard by which published series are compared. Patients tend to first report successful intercourse at a score of 17 or so. You can see that it takes a year on average to get there after surgery. Also, one can see that there is continued improvement between years one and two, and that even though most are successful at that point it is still not back to baseline. Please also notice that this is WITH the use of Viagra nearly daily, and that this cohort of men were picked such that all had perfect erections to start and a high degree of interest in both patient and partner.
Dr. Engel was the only surgeon in the U.S. that made this curve readily available and visible to the public, and he has always been known as one of the few early adopters that tried to be very transparent with his results so that realistic patient expectations could be reached. For this reason, Dr. Engel appeared several times in the New York Times, NPR and also Nature Reviews Urology to comment on erectile dysfunction after prostatectomy and the disparity between early claims regarding robotic surgery and reality.
Return of Erectile Function After Robotic Prostatectomy – Click Here For More Info
The unfortunate reality is that all men will suffer severe erectile dysfunction immediately following surgery, and the hope is that erections return, likely with the use of medicines such as Viagra or Cialis, over 1-2 years. One idea that many patients hear about holds that men can affect this length of time and overall impotence rate by rehabilitating their penis by taking medicines soon after the surgery or even before, nearly every day for the first year after surgery. However, Dr. Engel’s often cited large multi-institutional study on this topic comparing MUSE (an intra-urethral suppository for erection) with Viagra, published in the Journal of Urology, did not support this hypothesis. Even larger, more powerful studies came to the same conclusion. This literature has caused Dr. Engel to abandon this approach. Any papers that did weakly support this hypothesis were shown really to be only selecting for patients with a high degree of motivation. Instead, in such motivated patients, Dr. Engel seeks to harness that zeal and encourage a treatment that will actually produce success. Dr. Engel usually encourages motivated couples to look to injections to achieve usable erections in the first year, and once continence is achieved patients are encouraged to learn to self-administer injections to achieve a very usable erection until their own function returns. The key is to succeed so the patient and partner “stay in the game” and not give up. A vacuum erection device is another alternative, but Dr. Engel’s own landmark study on the topic suggests this is not a reliable solution until some of the patient’s own function returns, perhaps after six to nine months from when the robotic prostatectomy was performed. Some will still ask to take daily ED meds despite this so as not to squander any chance that this may help, and Dr. Engel does not discourage this as meds are now cheap, but does not feel that penile rehabilitation should act as a substitute to a successful solution.
Couples that are very interested in sex during the first year after surgery should thus expect to need help, but the help is certainly there to override the system and achieve erection so that a healthy sex life can be maintained. Dr. Engel finds that many men and/or their partners lack the interest in sex to ask for this help and that many patients feel as if the need to use such help in the form of injections or a pump represents failure. If men more correctly view the use of this help as simply a part of their normal recovery, we find that men are far less disappointed and may have better eventual outcomes. Typically, Dr. Engel offers injections three months after surgery when the patient is usually out of pads and mentally ready. One’s own function usually gradually starts to return between 6-12 months, and when almost having an erection PDE-5 inhibitors are encouraged. It should be noted that since the seminal vesicles are removed during surgery, an orgasm will not produce semen. The pleasurable experience of orgasm remains, however, and the ability to achieve orgasm never leaves as it is moderated by a separate mechanism. For this reason, many patients and partners adapt to this and prefer just to wait and skip injections. Most that do get their function back will use Viagra or Cialis, and even if they could technically succeed without them continued use is typical now, particularly given their far lesser cost than in years past as they are now generic.
What About Incontinence After a Robotic Prostatectomy?
Please visit our webinar on Male Urinary Incontinence in our Educational Videos section on this site
Unlike ED after a robotic prostatectomy, the good news is that incontinence is almost always temporary and usually resolves much faster than recovery of erections. Why men leak after robotic prostatectomy is discussed in detail below, but suffice it to say it is usually self-limited and not as much of a long term challenge as erections are. The first thing here that all patients must understand is that they will leak urine after prostatectomy – the question is how much and for how long. The hope is that over the next three months the need for pads will resolve, and fortunately this is almost always achieved. Patients must understand continence is reached in steps, and they are taught these steps so that they can know they are improving on schedule even though they are still leaking. The first milestone is that one gets dry at night while sleeping. The second is the ability to hold one’s urine to get up from bed to go to bathroom in the morning after sleeping. Next, a patient will stay dry until perhaps noon. The last thing to dry up is leakage in the afternoon, or after drinking alcohol. By their first three-month visit, most men are wearing one pad all day and night and typically need encouragement to let go of this “confidence pad”. Many will be pad-free the day after that visit after being told that they will always leak until they take themselves out of their comfort zone of the pad and realize they do not need one.
Dr. Engel has noticed four patterns of return of continence after prostatectomy. 15-20% of men will have very early continence and be out of pads within a few weeks. This should never be expected by a patient, though; such patients should just be pleasantly surprised. The typical pattern, seen in perhaps 70% of men, is a scenario where they must use four to five pads a day that they change when they go to the bathroom with gradual improvement until six weeks or so when dramatic and steady improvement is seen. These patients are usually ready to stop wearing pads by three months. Another 10% or so will take longer than three months to get dry. These typically are patients that had significant voiding symptoms before surgery, longer catheterization time after surgery or who had a bit more oozing of blood in their pelvis after surgery. Unfortunately, regardless of surgical performance, there will be approximately 5% of patients that will be left with some degree of permanent incontinence, typically 1-2 pads per day that remains at one year. At that point, Dr. Engel aggressively pursues surgical treatment of incontinence with either an AdVance Male Sling for 2 pads per day or less or an artificial urinary sphincter for the much rarer moderate to severe incontinence. Both will yield a greater than 90% cure rate of incontinence in such cases, and Dr. Engel performs these surgeries himself.
Pelvic Floor or Kegel Exercises
Let’s talk about pelvic floor exercises or Kegel exercises. As mentioned below, at the six-day visit after surgery, the urinary catheter is removed. As part of that process, patients will be asked to demonstrate that they know what their urinary sphincter is and that they can use it to hold their urine and then stop their urine flow midstream. This visit will be conducted by our nurse practitioner, Ndidi Okanu, and the patient will actually be graded on their ability to do this. Men are encouraged to learn that they can do this successfully before surgery so that it can be demonstrated at catheter removal. We call the act of squeezing the muscles that a man would use to cut off his urinary stream, squeeze out the last few drops of urine at a urinal, or pinch off his anus, a “kegel exercise”. Dr. Engel has given this technique the nickname of a “turtle”. That is because when a man is using these muscles correctly, he will be able to see his penis drawn back towards his abdomen. This should be obvious and should not involve the abdominal or thigh muscles at all. It should not require a man to strain or hold his breath. Doing a “turtle” is not a new skill at all. It is something a man does every day of his life, and the ability to do it is not affected by a robotic prostatectomy. The key is for a patient to simply be conscious of the act so it can be done on demand. Some patients show confusion over this or can’t do it because they never learned in their lifetime. We are seeking to identify these men at this visit and will often set up a separate time a week later to try to learn the act when they may feel less pressured. Those that cannot master this over the next three months will at times be referred to a physical therapist to learn. Some can never learn them, and they also can and do dry up eventually. In these men there is simply more leakage on average and a longer recovery period.
Leakage is usually predictable and not constant. It tends to come with activity or straining, acts like standing up or bending over, or coughing or sneezing. It is for this reason that incontinence resolves first at night when one is lying down and sleeping. What Dr. Engel asks his patients to do is simple and follows common sense. Now that the patient is aware that he can hold his urine for 3-5 seconds successfully, he simply must squeeze his sphincter just before performing the activity that might cause leakage. It is a function of anticipating leakage and stopping it before it happens. It must be understood though that following this strategy will not get one out of pads. It will only lessen leakage. Time and healing of the bladder is what gets one dry.
Dr. Engel does not prescribe Kegel exercises or the act of squeezing one’s sphincter repeatedly to strengthen the sphincter. This might make sense to do in women so that a sagging pelvic floor and vagina can be bulked up to better support the bladder in a woman. This is the cause of stress urinary incontinence in women. Dr. Engel has observed that incontinence after prostatectomy has nothing to do with a weak pelvic floor or a sagging vagina of course. It happens because the bottom of the bladder, or the bladder neck, which normally puckers on its own relaxes after surgery. It senses trauma, may have blood clots around it, has stitches through it, and has had a catheter crossing it. Really, what a man is waiting for after prostatectomy is for his bladder neck to wake up, or “pucker”. Until it does, a man will leak. Thus, Dr. Engel really only uses the Kegel or “turtle”, applied at the right time, as a crutch to be used until the bladder heals itself. This is why patients get dry at different rates. Those who do not get dry have bladder necks that never fully closed. The amount of residual leakage relates to how to open the bladder neck, and the surgeries used to fix post-prostatectomy incontinence basically either add another bladder neck or add more pucker to it.
The final message Dr. Engel wants patients to know then is that no matter how much they leak, or how well they anticipate their leakage and squeeze, it is never their fault or a sign that the patient is doing anything wrong. Surgical skill does play a role, but in large part, the timing of getting dry has a lot to do with plain luck. Just as with erectile dysfunction after prostatectomy, proper education and expectation is the key to avoiding disappointment.
Potential Complications of a Robotic Prostatectomy
All of Dr. Engel’s patients will have been fully briefed on all possible complications, but we will discuss the most common of them below. One of the most worrisome, and fortunately one of the rarest, would be an inadvertent injury to abdominal contents such as the intestines. This is the reason that all patients will undergo a formal bowel regimen beforehand. The risk of bowel injury is increased somewhat if a patient has had previous abdominal surgery, but in experienced hands this does not preclude the ability to perform robotic prostatectomy. Another possible complication of course is bleeding as is the case with all surgeries. In this case, it will almost always be slow bleeding and occurs in the recovery room. As discussed below we try to minimize this by having the patient sit up both in the recovery room and in their hospital room the night of surgery so that pressure is applied to the surgical site. Very rarely, a transfusion, or even a trip back to the operating room is necessary. Other rarer complications are blood clots, scarring at the site of the surgery, lymph collections or events somewhat unrelated to the surgery such as cardiac events. For this reason, all patients will be asked to have a formal physical examination by their internist so as to minimize risk during surgery.
What to Expect Before and After Robotic Prostatectomy With Dr.Engel
By the day of surgery, you will have received written instructions regarding pre-operative clearance for anesthesia and instructions regarding a bowel prep. It is like a colonoscopy but different in that it includes antibiotics and may be a different solution to drink than what you are used to. This is to make more space for your surgery and to decrease risk in case of the extremely rare circumstance of a bowel injury, so we ask that you adhere to the instructions as much as possible.
Dr. Engel now does these surgeries at Reston Hospital, and the hospital will have already contacted you about registration and what time to arrive at the hospital. After registering you will come to the pre-op area and be interviewed by pre-op nurses and the anesthesia team. You will also meet the circulating nurse from your operating room. Several consent forms will be signed and an IV will be started. Dr. Engel will then meet you there to answer any final questions, sign a few more forms, and most importantly to walk you through your hospital stay in great detail. This will include an explanation of how technically you will be admitted to a hospitalist but that all aspects of surgical care will be managed by Dr. Engel and his team in the office. Whereas for much of his career Dr. Engel had a team of residents or a fellow to manage all aspects of hospital care after surgery, now having a very smooth hospital stay that allows for discharge on time the next day relies on adherence to a specific plan that Dr. Engel has created. This will include explaining what to do and accomplish the night of surgery and for the next day at several points throughout the day to ensure that discharge happens the next day around 2pm. Once this is explained and all questions are answered, medicine may be given to you for relaxation while you go back to the operating room. The anesthesiologists will have explained that they will perform a special block while you are asleep that numbs the abdomen and makes for a less painful post-operative experience.
From this point onward, there will commonly be little memory of the surgery, and the patient will ultimately wake up in the recovery room. In Dr. Engel and his team’s hands, this surgery typically will be performed in less than 100 minutes such that the patient will be in and out of the operating room in 2.5 to 3 hours. Eric Strother, Dr. Engel’s expert surgical assistant for over 20 years, will have assisted in all aspects of the surgery. Dr. Engel will often speak to the family regarding how the operation went, but at times will need to go to another room so this communication may not occur. The family will of course want news regarding the status of the prostate cancer, but almost always there is no news to share from the surgery. This comes from the pathology report to be reviewed when the catheter is removed and from the psa in three months. Reston Hospital has an excellent updating system to keep loved ones fully posted as to where we are with the operation and when we leave the room.
Since 2004, when less than 5% of prostatectomies in America were performed robotically, Dr. Engel has seen this figure grow to well over 98%. As a pioneer in the field, it has been gratifying to Dr. Engel to be a part of this transition.
Recovery After a Robotic Prostatectomy
The patient will wake up in the recovery room with little pain, with a catheter in the bladder through the penis and roughly half of the time a drain coming out of the abdomen through one of the laparoscopic incisions. The decision to leave a drain or not is made in the operating room and depends on anatomy, oozing of blood or worry about urine leaking where things were sewn together. Although narcotics may be given in the recovery room, a non-narcotic medicine called Toradol will be given on the floor. Patients will at first typically feel as if they must urinate. Once fully awake, this feeling dissipates.
After being in the recovery room for an hour or two, the patient will be moved to the surgery floor where all rooms are private, and a loved one may stay in the room if they wish. That same evening, the patient must sit in a chair upright for three hours and walk in the hallways at least once but hopefully more. Only after those two activities are done should the patient lie down and get in bed. These steps are crucial to faster recovery and less bleeding after surgery, so they are mandatory. You will only get clear liquids to eat the night of surgery. You will get a non-narcotic IV pain medicine called Toradol, and typically this is all you will need. Please only accept further pain medicine from the nurse, even if offered pain meds, for moderate or severe pain. Pain meds are to avoid suffering, but not to try to get to a state where one is unaware that surgery was performed. Opiates cause constipation and can lead to abdominal distention and delayed discharge.
We will be following you by calling you and not necessarily seeing you in person as the Hospitalist will. We need you thus to carry a cellphone with you throughout the day, so we ask that you have your charged phone with you at all times and to not screen calls. We are expecting by 10am for you to be out of bed in your chair and to have picked at some food. Mostly we want to know whether you can drink plenty of water so that we can stop the IV. We will know at that point the results of your lab tests and if the drain can come out if present. Hopefully by that call you will have walked a few times as well. If all those milestones are achieved it is at this time that we will ask you to call the nurse to have your urinary catheter bag changed to a leg bag to go home with, the IV to be capped and the drain likely to be removed. The nurse should be asked to text Dr. Engel for confirmation of those orders at that time so that hopefully they are all done by 11 AM. Please ensure that you are NOT given an overnight urinary bag as changing the urine bag can lead to disruption of the catheter. Also ensure that the catheter is not secured to your leg in any way other than the two straps of the leg bag which should both be above your knee, not below, even though the catheter will not be taught and straight which is by design.
We will then be calling you again at 1pm on your cellphone. By that time, you should have been able to eat more regular food. You should have some mild bloating but not feel nausea and your pain will be well controlled. More walking in the hallways should have been done by this time also and mostly you should be in your chair and not your bed. If at that time all this has been achieved, you are ready to go home. Again, we will ask you to call for the nurse so that your IV can be removed and so that you can be discharged. The nurse will go over the care of the catheter at home and how to empty the bag, which is a very simple matter. We will ask you to tell the nurse that all your prescriptions, including Tramadol for pain, colace (docusate sodium) as a stool softener and antibiotic to be started a day before your catheter removal appointment the following Tuesday, have already been given to you by Ruby. Tell the nurse also of your follow-up appointment the following Tuesday in our downtown office. Once again, ask the nurse to then page Dr. Engel for confirmation. At home we find that half of the patients do not use the pain killer at home and use only Tylenol. As you can see, typically we are very much in contact with you via phone, more so than if we were to make in person social rounds in the morning. Rest assured though; we are fully available to come to see you in person at any time if the need arises.
At home, normal recovery means simply feeling better each day. At day two or three, bloating and some gas pains can be a normal part of recovery and might seem like a setback. As long as there is not vomiting, NEW localized pain in the abdomen or fevers this should be addressed with a mild over the counter laxative and/or suppository such as Dulcolax. If at any point one is not doing better each day, examples of which being increased pain, nausea and vomiting, severe abdominal distention, fevers, or leg swelling in one leg that does not go down with elevation (may be the sign of a blood clot), patients must go to the Reston Hospital Emergency Room if possible right away to be evaluated. A phone call to us will not suffice and the doctors at the ER will be able to contact us. We recognize that this might not be your closest hospital, but going elsewhere may at times result in the Urologists there seeking to transfer you so that your problem is managed by Dr. Engel and not them. Conversely, things such as gas pains, bruising, swelling, blood in the urine or any other symptom or sign that is not making the patient feel worse overall is typically not a cause for concern.
Patients want to know what they can eat at home and what activity they can do. The answers here are simple. The patient should eat what his body tells him he can eat, and the patient can do whatever activity their body tells them they can do (except driving). These are cardinal rules that Dr. Engel has never seen exceptions to. In other words, listen to your body.
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 ensuring that the catheter leg bag is being worn with both straps 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 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 almost 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 it gets 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 in 14 days, this will usually trigger an evaluation.
Catheter Removal and Longer-Term Recovery
By the time the patient comes in to have his catheter removed six days later on Tuesday, he will typically look very healthy. Patients will feel fully recovered by 10-14 days and may resume all activities at that point (other than driving which Dr. Engel advises to avoid for one month for liability reasons). Once again, any activity that a patient feels he can do in this first two weeks is what he should do. By the same token, any food that is desired in this period is what should be eaten. Dr. Engel advises his patients that they should listen to their body and do what it tells one to do. It is nearly always right.
The catheter removal visit is used to teach pelvic floor exercises as described above and to go over the pathology report. Regarding the pathology report, all that is truly pertinent will be the lymph node status. The presence of positive nodes means that cancer has metastasized and the patient is most likely not cured. Fortunately, this is rare. Virtually any other information on the report, which will state how much cancer was present, how aggressive it was, and whether the cancer was confined or not, will not tell us whether the patient is cured. For that, we must wait three months for the PSA, which should be undetectable at that point since the source of it, the prostate, has been removed. The main focus of this visit is to discuss incontinence. Patients are thus expected to bring pads or pullups, available on Amazon or any supermarket are drug store, to this visit.
The act of removing the catheter is a chance to learn perfect pelvic floor exercises, so it is treated as a teaching point/lesson. This is an important skill, so a description of them bears repeating. The patient will be asked to demonstrate that they know how to squeeze the muscles they would normally use to stop their urine stream. Then, the bladder will be filled, and the catheter removed slowly. The patient will be asked to try to hold the water that had been put into the bladder. Then they will urinate and show that they can stop their stream just as they could before. Dr. Engel does not believe that formal Kegel exercises or the act of squeezing one’s sphincter for a fixed number of times in a row help. However, if one knows what movement will cause leakage, what should be done is simply to hold the urine during that action, and then relax when that action is over. An example is standing up or sitting down. If done religiously, a patient will have many opportunities to do this during the day. But never are they asked to do a “set” of 20 or so. What Dr. Engel’s approach does is lessen leakage, gives the patient a sense of control over the situation, and decreases but does not eliminate pad usage. For that, we must wait for the bladder to heal. That is a function of time, not exercise.
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. The psa may get checked more frequently than this for higher risk cases. Dr. Engel at times may add radiation therapy to the treatment regimen, but typically only in the setting of recurrence, and only in certain patients based on the rate of rise of the psa, their overall health and their risk stratification. . Please see our discussion regarding what it means to have a detectable psa after prostatectomy and what we do about it.
