During your preoperative consultation, your surgeon will review your history, medical records, PSA values and any available radiology films or reports.
You will then undergo a full physical examination, followed by a discussion of treatment options for your stage of prostate cancer.
Your glass pathology slides will be submitted for review by the Johns Hopkins Pathology Department. Results of this review require one to two weeks, after which the slides will automatically be sent back to the original facility from which they came.
If your surgeon decides that you are a candidate for robotic-assisted radical prostatectomy, you will then meet with a patient service surgery coordinator to schedule a date for your operation. Any scheduling changes can be made directly through the surgery coordinator at 410-955-4048 for The Johns Hopkins Hospital and 410-550-0412 for Johns Hopkins Bayview Medical Center.
Note: It is the responsibility of the patient to inform the surgery coordinator of any scheduling changes/cancellations at least four weeks in advance of the surgery date out of courtesy to your surgeon, the operative staff and other patients.
What to Expect prior to Surgery
Since insurance companies will not permit patients to be admitted to the hospital the day before surgery to have tests completed, you must make an appointment to have preoperative testing done at your family doctor or primary care physician's office within one month prior to the date of surgery.
For The Johns Hopkins Hospital patients: These results need to be faxed by your doctor's office to the Preoperative Evaluation Center at 443-287-9358 two weeks prior to your surgery. Please call the Documentation Center at 410-955-9453 two weeks before your surgery date to confirm that this information was received.
For Johns Hopkins Bayview Medical Center patients: These results need to be faxed by your doctor's office to the Preoperative Evaluation Center at 410-550-1391 one week prior to your surgery. Please call the Documentation Center at 410-550-2495 before your surgery date to confirm that this information was received.
Once your surgical date is secured, you will receive a form along with a letter of explanation to take to your primary care physician or family doctor in order to have the following preoperative testing done prior to your surgery:
- Physical exam
- Electrocardiogram (EKG)
- Complete blood count (CBC)
- Blood coagulation profile (PT/PTT)
- Comprehensive metabolic panel (blood chemistry profile)
Preparation for Surgery
Medications to avoid prior to surgery
Aspirin, Motrin, ibuprofen, Advil, Alka-Seltzer, vitamin E, Ticlid, Coumadin, Lovenox, Celebrex, Voltaren, Vioxx, Plavix and some other arthritis medications can cause bleeding and should be avoided one week prior to the date of surgery. (Please contact your surgeon’s office if you are unsure about which medications to stop prior to surgery. Do not stop any medication without contacting the prescribing doctor to get their approval.)
Bowel preparation and clear liquid diet
Drink one bottle of magnesium citrate, which you can purchase at your local pharmacy, the evening before your surgery. Do not eat or drink anything after midnight. Patients also are advised to self-administer one Fleet enema the morning of surgery to evacuate the colon.
Drink only clear fluids for a 24-hour period prior to the date of your surgery. Clear liquids are liquids that you are able to see through. Please follow the diet below.
Clear liquid diet
Remember not to eat or drink anything after midnight the evening before your surgery.
Clear liquids are liquids that you are able to see through. Please follow the diet below.
- Clear broths (no cream soups, meat, noodles, etc.)
- Chicken broth
- Beef broth
- Juices (no orange juice or tomato juice)
- Apple juice or apple cider
- Grape juice
- Cranberry juice
- Hawaiian punch
- Tea (you may add sweetener but no cream or milk)
- Coffee (you may add sweetener but no cream or milk)
- Clear Jell-O (without fruit)
- Popsicles (without fruit or cream)
- Italian ices or snowballs (not marshmallow)
During Your Hospitalization
Immediately after the surgery you will be taken to the recovery room, then transferred to your hospital room once you are fully awake and your vital signs are stable.
- Hospital stay: Length of hospital stay for most patients is one to two days.
- Diet: You can expect to have an intravenous (IV) catheter in for one to two days. (An IV is a small tube placed into your vein so that you can receive necessary fluids and stay well hydrated; it also provides a route to receive medication.) Most patients are able to tolerate clear liquids the first day after surgery and a regular diet the following day. Once on a regular diet, pain medication will be administered by mouth instead of by IV or shot.
- Postoperative pain: Pain medication can be controlled and delivered by the patient via an intravenous patient-controlled analgesia (PCA) pump or by injection (pain shot) administered by the nursing staff. You may experience minor transient shoulder pain (one to two days) related to the carbon dioxide gas used to inflate your abdomen during the laparoscopic surgery.
- Bladder spasms: Bladder spasms are commonly experienced as a moderate cramping sensation in the lower abdomen or bladder and are quite common after prostatectomy. These spasms are usually transient and often decrease over time. If severe, medications can be prescribed by your doctor to decrease the episodes of these spasms.
- Nausea: You may experience transient nausea during the first 24 hours following surgery, which can be related to the anesthesia. Medication is available to treat persistent nausea.
- Urinary catheter: You can expect to have a urinary catheter (Foley) draining your bladder (which is placed in the operating room under anesthesia) for approximately one to two weeks after the surgery. It is not uncommon to have blood-tinged urine for a few days to a week after your surgery.
- Pelvic drain: The pelvic drain is placed in the operating room and drains the pelvic space around the bladder-urethra anastomosis. This drain is usually removed in two to three days when the drainage is minimal.
- Fatigue: Fatigue is common and should start to subside in a few weeks.
- Incentive spirometry: You will be expected to do some very simple breathing exercises to help prevent respiratory infections by using an incentive spirometry device (these exercises will be explained to you during your hospital stay). Coughing and deep breathing are an important part of your recuperation and help prevent pneumonia and other pulmonary complications.
- Ambulation: On the day after surgery it is very important to get out of bed and begin walking with the supervision of your nurse or family member to help prevent blood clots from forming in your legs. You can expect to have sequential compression devices (SCDs) along with tight white stockings on your legs to prevent blood clots from forming in your legs while you are lying in bed.
- Constipation/gas cramps: You may experience sluggish bowels for several days following surgery as a result of the anesthesia. Suppositories and stool softeners are usually given to help with this problem. Taking a teaspoon of mineral oil daily at home will also help to prevent constipation. Narcotic pain medication can also cause constipation and therefore patients are encouraged to discontinue any narcotic pain medication as soon after surgery as tolerated.
What to Expect after Discharge from the Hospital
- Pain control: You can expect to have some incisional discomfort that may require pain medication for a few days after discharge. Afterward, Tylenol should be sufficient upon returning home to control your pain.
- Showering: You may shower at home. Your wound sites can get wet but must be padded dry. Tub baths can soak your incisions and therefore are not recommended in the first two weeks after surgery. You will have adhesive strips across your incisions. They will either fall off on their own or can be removed in approximately five to seven days.
- Incisions and suture: Your incisions will be closed with sutures beneath the skin, which will dissolve within four to six weeks (Figure 6).
- Activity: Taking daily walks is strongly advised. Prolonged sitting or lying in bed should be avoided and can increase your risk for forming blood clots in the legs as well as developing pneumonia. Climbing stairs is possible but should be limited. Driving should be avoided for at least two weeks after surgery. Absolutely no heavy lifting (greater than 20 pounds) or exercising (jogging, swimming, treadmill, biking) for six weeks or until instructed by your doctor. Most patients return to full activity an average of three to four weeks after surgery.
- Medications: You can resume your usual medications after surgery with the exception of aspirin or other blood thinners, which can increase the risk of bleeding.
- Follow-up appointment: The first postoperative appointment will be to remove the catheter, usually done at one to two weeks after surgery. Your surgeon will decide on the timing of this, and this appointment will be arranged through the urology clinic (410-955-6707 for The Johns Hopkins Hospital and 410-550-7008 for Johns Hopkins Bayview Medical Center). Most people will have some difficulty initially with urinary control at the time the catheter is removed. Therefore, come to the office with a small supply of adult diapers or insert pads (Attends or Depend) that can be purchased at any drug store. Once your catheter is removed, we recommend that you avoid caffeine, alcohol and excessive fluid intake for one to two months, as this can aggravate incontinence.
- At this appointment, patients occasionally undergo a cystogram (if deemed necessary by your surgeon) in the Radiology Department. The cystogram is an X-ray study of the bladder that determines whether the bladder has healed completely to the urethra. At that same visit, your urologist will decide whether the catheter can be safely removed after reviewing your cystogram X-ray films or whether it will need to remain in for a longer period of time to allow for healing.
- Pathology results: Pathology results are usually available approximately seven days following surgery. These results will be reviewed with you in the office. Alternatively, you can contact your surgeon by phone or email after one week.
- Long-term follow-up: A PSA test is drawn at three months following surgery. Patients are evaluated every three to 12 months. This can be easily accomplished over the telephone for patients who do not live close to the Baltimore area.
Your catheter is very important for allowing healing of the bladder to the urethra. The catheter should drain your bladder continuously. It should not be put on tension at any time. If you feel pulling or tugging, this means that your catheter needs to be fastened higher up on your leg to allow for some slack on the catheter as you move and walk. Your surgeon should be notified immediately if the catheter stops draining completely or if it falls out.
The urine collection bag must be positioned at all times below the bladder for proper draining by gravity. Drain the bag before it gets too full as this will result in a backup of urine in the bladder. Although use of the larger collection bag is advised, a smaller leg bag is available and can be worn under clothing. The larger bag is required at night, as the smaller bags are likely to fill up too quickly.
The tip of the penis may get sore from catheter irritation. Use plain soap and warm water to wash this area daily. You may use Vaseline to prevent dryness and discomfort at the tip of the penis. A small amount of blood-tinged urethral secretions or even urine may leak around the catheter at the tip of the penis, especially during bowel movements. This occurs due to mild straining and is completely normal.
It is common for your urine to turn pink- or red-tinged as you become more active, simply from the catheter rubbing against your bladder lining. If this occurs, reduce your walking and increase your fluid intake. It is permissible to bring the urine collection bag in the shower.
You may return to your normal diet immediately upon discharge from surgery. However, adhering to foods like rice, soups and noodles and avoiding high-fiber meals (e.g., vegetables such as celery) is advised, as your intestines may take up to a week to recover from the surgery and anesthesia. Because of the raw surface in your bladder and urethra, alcohol, spicy foods and drinks with caffeine may cause some irritation or the sensation of needing to void, despite the fact that the catheter is emptying the bladder. However, if these foods don't bother you, there is no reason to avoid them in moderation. More importantly, keep your urine flowing freely by drinking plenty of fluids during the day (eight to 10 glasses). The type of fluid (except alcohol) is not as important as the amount of fluid. Water is best, but juices, coffee, tea and soda are all acceptable.
Your physical activity should be restricted, especially during the first two weeks home. During this time use the following guidelines:
- Taking six to eight separate short walks a day is advised to prevent pneumonia from forming in the lungs and blood clots in the legs.
- Climbing stairs is permitted if necessary but should be taken slowly. Climbing stairs is otherwise not a necessary activity in terms of exercise.
- Do not lift heavy objects (anything greater than 10 pounds).
- Do not drive a car. Limit long car rides.
- No strenuous exercise for four to six weeks. After this, patients can return to their normal activities of daily living.
Your bowels should return to normal after the surgery (over the course of two to four weeks), though pain medication can cause constipation, and therefore should be discontinued as soon as tolerated. The rectum and the prostate are next to each other, and any very large and hard stools that require straining to pass can cause bleeding in the urine. Use a mild laxative (e.g., milk of magnesium) or stool softener (e.g., Colace) if needed, and call if you are having problems.
You should resume your presurgery medication unless told not to. We recommend staying off aspirin or aspirin-containing products until after the catheter comes out and for at least four weeks following surgery. You will be given a prescription for pain pills (e.g., Tylox) for incisional discomfort. Most men following robotic prostatectomy rely only on extra strength Tylenol at home and do not require narcotic pain medication. You will also be given a prescription for an antibiotic (e.g., ciprofloxacin) to take around the time the catheter comes out. Typically it will be a three-day course of antibiotics, which we ask you to start the day prior to your scheduled cystogram appointment.
You may shower or bathe as soon as you get home. Dab your incision sites dry following a shower and avoid heavy creams or ointments on your incisions. Keeping them dry and open to air is adequate.
Problems you should report to us
In an emergency, the urologist on call can be contacted at 410-955-6070 for The Johns Hopkins Hospital or at 410-550-0100 for Bayview:
- Fevers over 101 degrees Fahrenheit, as this may be a sign of infection
- Heavy bleeding or clots in the urine
- Calf or thigh pain or swelling, as this may be a sign of a blood clot
- Difficulty breathing or chest pain, as this may be a sign of a pulmonary embolus or heart attack
- Skin rash or hives, as these may be signs of potential medication reactions
- Nausea, vomiting or diarrhea, which may be a sign of infectious diarrhea (e.g., Clostridium difficile)
- Call immediately if your catheter stops draining completely or falls.
Pelvic muscle exercises to improve bladder control
Pelvic muscle exercises strengthen the group of muscles called the pelvic floor muscles. These muscles relax and contract under your command to control the opening and closing of your bladder. When these muscles are weak, urine leakage may result. However, you can exercise them and in many cases, regain your bladder control.
To achieve the best results when performing these exercises, imagine yourself an athlete in training. You need to build the strength and the endurance of your muscles. This requires regular exercise.
We recommend that you start doing Kegel exercises six to eight weeks prior to surgery.
Begin by locating the muscles to be exercised:
- As you begin urinating, try to stop or slow the urine WITHOUT tensing the muscles of your legs, buttocks or abdomen. This is very important. Using other muscles will defeat the purpose of the exercise.
- When you are able to stop or slow the stream of urine, you know that you have located the correct muscles. Feel the sensation of the muscles pulling inward and upward.
- You may squeeze the area of the rectum to tighten the anus as if trying not to pass gas and that will be using the correct muscles.
- Remember NOT to tense the abdominal, buttock or thigh muscles.
- Now you are ready to exercise regularly:
- After you have located the correct muscles, set aside time each day for three to four exercise sessions (morning, midday and evening)
- Squeeze your muscles to the slow count of five. Then, relax the muscle completely to the slow count of five. The five-second contraction and the five-second relaxation comprise one set.
When your pelvic floor muscles are very weak, you should begin by contracting the muscles for only three to five seconds. Begin doing what you can and continue regularly. In a few weeks, you should be able to increase the amount of time you are able to hold the contraction and the number of exercise sets you are able to do. Your goal is to hold each contraction for 10 seconds, relax for 10 seconds and complete 25 to 30 sets each of the three to four exercise sessions per day.
In the beginning, check yourself frequently by looking in the mirror or placing a hand on your abdomen and buttocks to ensure that you do not feel your belly, thigh or buttock muscles move. If there’s movement, continue to experiment until you have isolated just the muscles of the pelvic floor.
If you are unsure that you are contracting the correct muscles, at your next exam ask your urologist to help you identify the proper muscle contraction.
It is important to know that full control of urination may take even up to one year to return completely following surgery. Most men experience improvement within three to six months. By six months, 70 percent of patients are pad-free, and 90 percent are pad-free at one year.
Exercise your pelvic muscles regularly over your lifetime to improve and maintain bladder control.
Pelvic muscle exercises also improve orgasmic function. Whether you are doing pelvic muscle exercise to improve or maintain bladder control, orgasmic function or both, they must be done regularly. Make them part of your routine.
Use daily activities, such as eating meals, watching the news, stopping at traffic lights and waiting in lines, as clues to do a few pelvic muscle exercises.
Avoid caffeine, alcohol or excessive fluid intake for first one to two months after surgery, as this will exacerbate urinary leakage.
From One Patient to Another: Tips for Easier Recovery following Radical Prostate Surgery
(This paper was written by a patient about his recovery from radical prostatectomy. If you have something to add or suggest, please don't hesitate to let us know your “Picks to Click.” Some of the products may take some searching or calling.)
Upon arriving home from the hospital, the patient will find it much more comfortable (if not absolutely necessary) to spend most of the time in a La-Z-Boy-type recliner chair, since it is almost impossible to lie on the flat surface of a bed because of the catheter. The adjustability of the reclining chair permits comfortable sleeping as well as sitting.
Another item needed for comfort because of the catheter is a nightshirt. An inexpensive substitute is an XXL or one-size-fits-all ladies’ T-shirt, which can be found at Walmart stores. Because of the catheter, replacing the conventional toilet seat with one having a split front will make use of the toilet much more comfortable and convenient.
Once the catheter is removed, a new phase called "the return to the diaper" begins. Depend makes two basic styles of diaper: (a) the bikini style, shaped like a V and supported by elastic straps that button to the diaper, and (b) the typical diaper similar to that used on babies, which covers a much larger area than the bikini style and attaches by three sticky tabs on each side. When in place, this diaper resembles a boxer style brief.
For at least the first few weeks following decatheterization, the boxer style diaper is needed to absorb urine that at times may be difficult to control or unpredictable. The diaper will probably require changing two or three times a day. During this time, an absorbent pad should be used to cover the chair seat. Once some control of bladder function returns, fewer diaper changes will be required. It's a good idea to change to a fresh diaper before retiring for the night, as well as to keep the drinking of liquids to a minimum after 5 or 6 p.m.
As far as drinking water is concerned, two liters or more should be taken during the course of the day. (A two-liter soft drink bottle used as a water jug is a good measure of the amount of water intake.) Also, keeping the color of the urine in the catheter bag clear is also an indicator of proper fluid intake. Increase water consumption if the urine becomes amber or darker.
The scrotum and groin area will become irritated from being continually wet with urine. An excellent cleansing material that will increase your comfort is Carrington perineal cleansing foam for incontinent care. It is an aerosol preparation that is easily applied and wiped away, leaving the sticky, messy, irritated area clean and comfortable. It will make life much more pleasant during this trying period. Nothing beats a good bath and soaking upon awakening in the morning, but Carrington's perineal cleansing foam applied when necessary during the day is the next best thing. Another alternative for skin protection from moisture is BAZA Clear Skin Protectant Ointment, which may be available at certain pharmacies or can be obtained online.
About three weeks following removal of the catheter and after reacquiring major bladder control, you may find it possible to sleep without the diaper at night and really enjoy comfortable sleep. Once you become active during the day, however, the diaper will be necessary again.
By this time, you can switch to the bikini style diaper, which allows for more freedom and more comfortable movement. Buy the extra absorbency form of the diaper to reduce changes, because by this time you will have become much more mobile. Once you become more mobile and socially active and even feel that you can return to a limited work schedule, you will find that discarding the diaper for an incontinent brief will make your life feel like it’s almost back to normal. A very nice incontinent brief is the Prefer incontinent brief, which has a zippered front into which can be inserted an absorbent pad. What an improvement over wearing the diaper — even over the bikini type! (The Prefer incontinent brief can be purchased at many health supply stores.)
When you finally get to the stage where you are almost dry and experience only occasional dribbles during the day, another Depend product is great. The Poise Pad has adhesive tape on the outer surface, which sticks to the inner surface of your ordinary jockey type shorts. Get the long extra-absorbent Poise Pad.
You've gotten this far in your recuperation, so you're in the home stretch. Just don’t get too frisky and overdo anything: work, exercise or anything else. Take it easy, eat properly, drink lots of fluids, get a lot of rest, follow your doctor's instructions and get well completely.
Frequently Asked Questions
How do I know if I am a candidate for robotic-assisted radical prostatectomy?
Most men who are considered candidates for open surgery are also good candidates for a minimally invasive approach. Patients with a history of multiple prior abdominal or pelvic surgeries, hernia repairs, large prostate glands (e.g., over 100 grams) or morbid obesity are often more challenging; however, these conditions are not absolute contraindications for robotic surgery. Robotic-assisted radical prostatectomy surgery can also be performed extraperitoneally (without entering the abdomen) for patients who have had multiple prior abdominal operations.
How long is the operation?
The length of the operation may vary based on a patient’s weight, the size of the prostate and the presence of scarring around the area. In general, it can last anywhere between two and four hours.
Will I need a transfusion? Do I need to donate blood?
Transfusions are very rare with these minimally invasive techniques. This is one of the most significant advantages over open surgery: Bleeding is drastically reduced compared to open surgery, with routinely only 100 cc to 200 cc of blood loss. Donation of blood is optional but not generally required nor recommended.
How much pain will I have after surgery?
Patients often require a small amount of intravenous and/or oral narcotic pain medication during their hospital stay but often use only extra strength Tylenol once discharged from the hospital.
How long is the hospitalization?
Hospitalization is usually one night. Patients are able to walk the following day under their own power.
How long will I have to have the bladder catheter?
Removal of the catheter will depend on the surgeon’s preference. In general, because of the excellent visualization offered by robotic techniques, a water-tight connection between the bladder and urethra can be easily achieved, allowing for safe removal of the bladder catheter within one to two weeks after surgery. The surgeon may perform a cystogram (bladder X-ray test) to confirm that the connection between the bladder and urethra are healed sufficiently.
When can I return to normal activities?
In general, most patients can return to full activities by three to four weeks after surgery. However, just as in open surgery, urinary control and sexual function may take months and even up to a year or more to improve completely.
What is my chance of urinary incontinence?
Most men experience at least some degree of stress urinary incontinence — for example, when sneezing or coughing. This generally improves with time and with vigilance in performing Kegel exercises. We have found that approximately 80 percent of men are dry at three to six months, and 90 percent are dry at 12 months following robotic prostatectomy.
What is my chance of erectile dysfunction?
The return of erectile function is perhaps the most difficult outcome measure to predict. Many factors are involved in the return to sexual function following surgery, including age of the patient, having an active sexual partner, whether one or both nerve bundles were spared and amount of time since surgery. When we evaluated preoperatively potent men who underwent nerve-sparing minimally invasive radical prostatectomy, we found that 48 percent of men who had both nerve bundles spared reported successful intercourse at six months and 72 percent at one year following surgery with or without the use of oral medications (e.g., Viagra or Cialis). Younger men (less than 58 years old) appear to have a higher potency rate compared to older men (more than 58 years old) at one year (74 percent versus 41 percent, respectively) (Figure 7).
Finally, in younger men (less than 58 years old) who had both nerves spared, 82 percent reported intercourse at one year. These results are very similar to results reported with open nerve-sparing prostatectomy performed at our institution.
Will I need to follow up at Johns Hopkins after my surgery?
Your first follow-up appointment will be for the catheter removal (or cystogram) in one to two weeks following surgery. Following this, a PSA test and office visit either to your local urologist or with your Hopkins urologist is recommended at three, six and 12 months and then typically annually thereafter.
When will the pathology results be available?
Once the cancerous prostate gland is removed, it is thoroughly evaluated by Johns Hopkins pathologists. They are able to identify the Gleason grade, location and extent of the cancer. In general, these results are made available to the surgeon in five to seven days.
Will I need further treatment following surgery for my prostate cancer?
Much of the decision on whether further treatment, such as radiation or hormonal therapy, is required will be based on the pathologic stage of the cancer, as well as the trend in PSA values following surgery. Most patients nowadays have early cancers detected by PSA screening and therefore are by and large curable with surgery. Therefore, most patients do not require additional therapy following surgery. However, each case is unique.
Professor of Oncology
Executive Vice Chairman, Department of Urology
Director of Adult Urology
Director, Minimally Invasive and Robotic Surgery
Associate Professor of Oncology
Associate Professor of Surgery
Director of Urologic Oncology
Deputy Director, Johns Hopkins Greenberg Bladder Cancer Institute
Professor of Oncology
David Hall McConnell Professor of Urology and Oncology
Medical Director, Credentials Committee, Johns Hopkins Hospital
Director, Urology Informatics
Professor of Oncology
Professor of Pathology
Urologist-in-Chief, The Johns Hopkins Hospital
Jakurski Family Professor
Director, Department of Urology
Professor of Oncology
Director, Prostate Cancer Active Surveillance Program
Director, Urologic Oncology Fellowship
Associate Professor of Oncology
Director, Division of Testis Cancer
Director of Social Media
The Johns Hopkins Hospital Patients: 410-955-6100
Johns Hopkins Bayview Medical Center Patients: 410 550 7008
In the event of an emergency and you need to contact someone in the evening hours or on the weekend, please call the paging operator at 410-955-6070 for The Johns Hopkins Hospital or 410-550-0100 for Johns Hopkins Bayview Medical Center and ask to speak to the urologist on call.
Note: Patients must remember to bring all pathology reports, prostate-specific antigen (PSA) values and glass pathology slides to their consultation appointment. The pathology slides will be submitted for review at Johns Hopkins.