Robotic radical prostatectomy: frequently-asked questions

Now that you are preparing to go home, we hope that your stay in Addenbrooke’s has been satisfactory and that this information serves as a useful guide as to what to expect in the first few weeks following surgery.

Who will look after the port wounds?

We shall fax a referral to your local district nurse team informing them of your operation. We would recommend that you make an appointment with your local GP practice nurse in the next day or two after your discharge so that your wounds can be checked, and if there are any concerns then they can contact Ward M4 for advice.

1. You may have surgical 'glue' on your wounds which does not need to be changed or specially cleaned. This glue will slough off as you shed skin naturally.
2. You can shower with the glue or plastic dressings in place.

If a wound becomes tender, red, smelly or discharges a lot of fluid, you should contact your district nurse or GP for immediate advice about possible infection.

What is the purpose of the catheter?

The catheter is a soft, silicone tube which drains urine directly from the inside of your bladder. It has a small, inflatable balloon near its tip, filled with sterile water, to hold it in place and to prevent it from falling out.

The purpose of the catheter is to act as a 'stent' in your urethra (water pipe) so that the area where the urethra has been re-joined to the bladder during your surgery can heal without formation of scar tissue which may result in a stricture (narrowing).

How do I look after the catheter?

While at home, you will need to care for the catheter and drainage system. The different component parts of this are:

• The catheter – You need do nothing to the catheter apart from keeping it clean on the outside by washing your penis, under the foreskin and the catheter tube itself. Ensure that the end of your penis and foreskin are dried gently and thoroughly to prevent soreness.
• The leg-bag (for daytime use) – This is attached directly to the catheter tube and will collect all the urine produced during the day. It will, of course, become heavier as it fills so do not allow it to become too full as this carries the risk of pulling out the catheter. Always wash your hands before and after using the tap on the end of the bag to empty urine into the toilet.
• The leg-bag support – This is rather like a footless sock, and is used to keep your leg-bag securely attached to your leg.

• The G-strap – This prevents the catheter from being pulled. It has a velcro strap around the catheter and your leg to hold the catheter firmly in position.
• The night drainage bag – This is connected directly to your leg-bag at night without disconnecting the leg-bag. To connect the night drainage bag:
  1. Wash your hands carefully.
  2. Empty the leg-bag and, with the tap still open, push the end of the night bag into the small piece of tubing at the end of the tap. This should form a direct route for urine to collect in the night bag.
  3. Attach the night bag to its stand; this stays on the floor by the side of your bed.
  4. In the morning, turn off the tap at the bottom of the leg-bag. Disconnect the night bag, empty the urine into the toilet and rinse the night bag through with warm water. It is then ready to be used again the next night.

You will be sent home with a small supply of leg and night bags. These should be changed only once a week unless there is a problem with one of them. You will also have been sent home with a catheter care leaflet.

If you have to dispose of your bag, it should be rinsed out with water, put into a plastic bag and put out with your normal household waste.

How much fluid should I drink?

You need to ensure that you are drinking about two litres (8 to 10 cups) of fluid each day. Try to include plenty of water. It may help to drink at least 200ml of cranberry juice every day.

What if I get bladder spasms?

Bladder spasms (which feel like abdominal cramps) are quite common when you have a catheter in your bladder. The bladder may try to squeeze out the balloon (which it sees as a foreign body) and this causes the spasm. Although this can be uncomfortable, it is not a cause for concern. If you are unable to tolerate this sensation, your GP can prescribe a drug called Tolerodine which stops the cramps.

What happens if I leak around the catheter?

Urine leakage around the outside of the catheter is called 'bypassing'. It is sometimes the result of bladder spasms or can take place when you open your bowels. If it does happen, please check that urine is still draining into your leg-bag; if it is not, you need to contact your district nurse or make an appointment to see your practice nurse.

What about my bowel movements?

After the anaesthetic, as a result of the surgery and some of the drugs you will have been given, your bowels may take some time to return to normal functioning. If you have been given laxatives whilst in hospital, it is equally important that you maintain soft bowel motions when you get home. Syrup of figs, Milpar® and Senokot® are all suitable laxatives to take at home so that you do not have to strain to open your bowels.

If you have haemorrhoids (piles), the operation may cause them to become inflamed so you will need to take particular care to keep your bowel movements soft.

How do I control my pain?

You will probably experience a little discomfort after your surgery. Some men find they notice pain in the perineum (the area between the scrotum and the anus) due to bruising from the operation. Occasionally, men feel pain in their shoulder region; this is due to the gas that was used during the operation irritating the diaphragm and sending referred pain to the shoulder. This usually settles after a few days.

Due to your positioning during surgery, slight swelling and soreness can occur around the head and in the eyes. This latter problem is probably caused by inflammation of the cornea. Try to avoid rubbing your eyes and this discomfort will ease spontaneously within a day or two. Simple painkillers such as Paracetamol or Ibuprofen should be taken as directed by the manufacturer. You will normally be given painkillers to go home with by the ward; these will be explained to you before you leave the ward.

The tip of the penis can also become sore as a result of the catheter rubbing on this sensitive area. Apart from ensuring that it is clean and dry, you may wish to buy some local anaesthetic gel (Instillagel®) over the counter at a pharmacy.

What if I see blood in my urine?

This is a common occurrence after radical prostatectomy. When you are at home and becoming more mobile, the catheter can cause inflammation in the bladder and this may lead to blood staining in the urine. This is only of concern if you can see large clots or solid pieces of debris passing down the catheter.

If this happens, please contact your nurse practitioner for advice as it may cause a blockage.

What if the catheter blocks?

This will become an emergency situation if not dealt with in a timely fashion. If you notice that urine has not been draining, check that:

• the drainage bag is below the level of your bladder
• the catheter has no kinks or twists in it
• you cannot see pieces of debris or blood clots in the catheter tube
• you have been drinking enough fluid
• you are not constipated

Contact your district nurse immediately, or get in touch with your prostate nurse practitioner or urology surgical care practitioner. They may need to do a bladder washout (using a syringe of fluid to release the blockage).

Do not allow anyone other than a trained urologist to remove your catheter at this stage because re-insertion can be very difficult and usually requires x-ray guidance or inserted under vision using a flexible cystoscope.

What if I get a urine infection?

If you notice any of the following symptoms, contact your GP to determine whether you need some antibiotics:

• cloudy urine
• cystitis (burning sensation)
• strong, unpleasant smelling urine
• a high temperature and feeling unwell

How and when is the catheter removed?

After a robotic prostatectomy, the catheter needs to stay in place for about a week for healing of the urethra to take place.

Before you go home from Addenbrooke’s, please ask your named nurse or the ward clerk to check that your details have been passed to the specialist nurses to arrange an appointment for removal of your catheter. This is called a ‘TWOC appointment’.

Removal takes about 15 seconds and feels peculiar but is not painful. We normally put a small amount of fluid into the bladder before the catheter is removed. The nurse practitioner may ask you to empty your bladder into a flow-rate monitor and you will then have a bladder scan to make sure that you have emptied your bladder completely.

After the catheter is removed, remember that your bladder has not been filled with urine for a while and that the outlet has been kept open artificially. The body tissues at the site of the surgery are affected by swelling and temporarily lose their elasticity. As a result, you will not have full control of the flow of urine and you will have some leakage for the first few days or weeks. It is important to carry out your pelvic floor exercises several times a day to regain control of your sphincter muscles (the muscles which control continence).

A very small minority of patients may experience total incontinence following removal of the catheter (ie a continuous flow of urine), necessitating the use of pads/conveens for a few weeks or months. If this occurs, additional support can be provided by the continence specialist nurses at Addenbrooke’s (or at your local hospital) or by the community continence advisers (contact details available via district nurses). If you need to contact your district nurse and do not have a telephone contact number, your GP practice will be able to supply this.

To be prepared for your catheter removal, and any potential temporary urine leakage, you should ensure that you have your own personal supply of bladder weakness products (pads designed for male underwear) at home, prior to this TWOC appointment.

The pads can be obtained from various sources:

• Your local pharmacy or supermarket – they may need to be specially ordered.
• By telephone – you can place an order by calling Tena Direct on 0800 393 431 (this is a Freephone number). You can pay by credit or debit card. Lines are open Monday to Friday 09:00 (9am) to 17:00 (5pm) – calls may be diverted to an answering machine if all lines are busy.
• Online – Tenadirect website (opens in a new tab) - where you can select the products you need and complete your purchase using the secure online payment system.

We would recommend that you obtain your supply in good time so that you have them at home following surgery as you may find it difficult to obtain them in the short period between discharge and your appointment for catheter removal.

Prevention of deep vein thrombosis (clots)

Before you leave hospital, the team will ensure you are safe to be discharged home. In order to reduce your risk of developing deep vein thrombosis (clots), we will teach you to self-inject dalteparin under your tummy skin, once daily for two to four weeks after discharge. Dalteparin is a drug that helps keep your blood thin to avoid clot formation. We also recommend that you wear the elasticated (TED) stockings for four weeks after discharge.

When you leave hospital, you will be given a discharge summary of your admission. This holds important information about your inpatient stay and your operation. If, in the first few weeks after your discharge, you need to call your GP for any reason or to attend another hospital, please take this summary with you to allow the doctors to see details of your treatment. This is particularly important if you need to consult another doctor within a few days of your discharge.

Will pelvic floor exercises help me?

Yes, they will. These should have been explained to you before your operation but here is a summary of what you should do:

• You need to increase your awareness of the pelvic floor muscles. While passing urine, try to stop the flow by contracting your muscles upwards and inwards, then let go. Do not worry if the flow does not stop altogether. Remember the sensation of which muscles you used. Once you have done this, there is no need to keep on stopping and starting the flow. The next stage is to pretend you are trying to stop an attack of diarrhoea by pulling tight the muscles of your back passage.
• These front and back muscles, when used together, are your pelvic floor muscles. They form a cradle of muscles that support the back passage and the urethra, together with the urinary sphincter muscle which controls the ‘on/off’ mechanism for passing urine.
• To do the pelvic floor muscle exercises properly, draw up these muscles, hold for a count of five, then let go gently. Pause for a count of five. Repeat this until you have done a total of five contractions. You should aim to keep your stomach; thigh and buttock muscles relaxed and use only your pelvic floor muscles.
• It is very important to do these exercises six times a day after surgery. In addition, you should also perform short, sharp pelvic floor contractions six times a day. Please speak to your specialist nurse if you are unsure.
• Try to perform these exercises in a variety of positions ie sitting, standing and lying down.

It is likely that several weeks of regular exercise will be required before an improvement is apparent to you. However, you should persevere and continue the exercises even after you start to notice the improvement. Try to make the exercises part of your daily routine by scheduling them to accompany a particular activity. Please do not become disheartened if you are not dry immediately – one third of patients manage this straight away, one third are dry within three months of surgery and almost all the remainder become fully continent within one year.

Do not let your bladder become too full, as the extra pressure can make it harder to control your sphincter muscle. Equally, you should not go to the toilet ‘just in case’ because you need to allow your bladder time to fill and provide you with the correct sensation of wanting to go. Moderate your intake of tea, coffee, cocoa and cola since these can all cause irritation of your bladder and make you want to go more often than necessary.

How quickly can I expect to recover?

Once the catheter is out, you will feel more comfortable, and the pain at the tip of the penis will subside. However, you may find that you tire more easily than expected. Do not, therefore, try to return to your normal routine for at least four weeks.

Ideally, it is advisable to try to begin gentle exercise such as walking or swimming for about 15 minutes every day. Listen to your body and always rest when you feel particularly tired – your body has a lot of healing to do.

After four weeks, you can attempt more vigorous activities but again, do not overdo it or you may encourage a hernia to develop and you will not regain your urinary control so quickly. We normally advise that patients can drive about two weeks following robotic surgery, providing you feel confident about controlling the car; this is particularly important in an emergency stop situation when full force on the pedals will naturally use your abdominal muscles very abruptly.

If, before your operation, your sex life has been satisfactory, you may wish to resume sexual activity and we would strongly encourage this. This will depend on whether a nerve-sparing procedure was possible at the time of surgery and this will be discussed with you. If the nerves were preserved, we will normally prescribe drugs to help erectile function at your six-week appointment. Please be aware that the return of erectile function can take up to 24 months.

If you find that your erections are less than perfect, do not hesitate to use the tablets that have been prescribed for you and, if these do not work satisfactorily, please contact either your GP or your nurse practitioner so that alternative treatments can be tried.

Most patients are ready to return to work after four to six weeks at home but some jobs requiring heavy lifting mean that you may need to discuss with your employer a suitable way to ease yourself back into work more gradually.

With regard to holidays and travel, there is no reason why you should not fly within six weeks after surgery. If you fly any earlier, you may be at increased risk of developing a DVT because surgery and anaesthesia interfere with your blood-clotting mechanisms.

You must mention that you have had prostate surgery for insurance purposes but there should be no additional premium because of this. If you need a letter for the insurance company explaining your circumstances, we would be happy to write this for you – please contact your nurse practitioner or your consultant’s secretary.

What if I feel that something is wrong in the first few weeks after surgery?

If you feel unwell or are concerned about your health you should contact us straight away. During office hours, you should contact the registrar or the on-call urology fellow via the Contact Centre (01223 245151).

Will there be any outpatient follow-up?

You will receive an appointment to return to the outpatient clinic about six weeks after surgery. This is to allow the consultant or specialist registrar to find out how you are getting on with your recovery and to discuss with you the findings of the pathology report on your prostate specimen.

The purpose of the operation is to remove the prostate and all the prostate cancer. Occasionally, the prostate cancer may have spread microscopically outside the specimen that was removed. In this case, your consultant will advise you about having further treatment (usually radiotherapy but, occasionally, hormone therapy) to ensure the complete eradication of any remaining cancer cells. You will also have a PSA (prostate specific antigen) blood test taken at this visit to record your post-operative level.

After this appointment, you will be followed up by the nurse practitioner at three-monthly intervals for the first year. You will need to have a PSA blood test at your GP surgery about 10 days before your appointment so that a record can be kept of your PSA levels. If you have any queries about your clinical management, please talk to your urology nurse practitioner.

It is important that your follow-up appointments are scheduled around the times outlined above.

Useful contact telephone numbers

Please contact the staff at the hospital from which you were originally referred if there are any other points you wish to clarify. Their contact numbers are shown below:

• Addenbrooke's Hospital
  Clinic 4A - 01223 216575
  Nurse practitioners - 01223 216897
  Consultant’s secretary - 01223 568819
  Urology surgical care practitioner - 01223 348590
• West Suffolk Hospital
  Nurse practitioner - 01284 712735
• Hinchingbrooke Hospital
  Nurse practitioner - 01480 419974
• Peterborough Hospital
  Nurse practitioner - 01733 875373
• Bedford Hospital
  Nurse practitioner - 01234 355507
• Queen Elizabeth II Hospital, King's Lynn
  Nurse practitioner - 01553 613613

Who can I contact for more help or information?

• Patient Advice & Liaison Service (PALS)
  PALS, Box No 53, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge CB2 2QQ
  01223 216756 / cuh.pals@nhs.net
  PatientLine *801 (from patient bedside telephones only)
• Chaplaincy and multi-faith community
  The Chaplaincy, Box No 105, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge CB2 2QQ
  01223 217769 / cuh.chaplaincy@nhs.net
• MINICOM System (‘type’ system for the hard of hearing)
  01223 274604
• Access Office (travel, parking & security information)
  01223 586969