1. Robotic Prostatectomy Course Carrie A. Collin R.N., B.S.N. Carrie A. Collin R.N., B.S.N. CSG - Division of Urology

2. Prior to Surgery  Pre op labs  Necessary MD visits for clearance, i.e., PCP, Cardiologist, etc.  Stop all aspirin and aspirin containing medicines (Excederin, Anacin) at least 7 days before surgery  Stop all blood thinners 5-7 days before surgery UNLESS directed otherwise.  Stop all NSAIDS (Motrin, Aleve, Naprosyn) 7 days before surgery  Please check with prescribing MD!  May restart 5 days after surgery unless directed otherwise

3. Prior to Surgery  Start Kegels if not started already  Some will have anesthesia consults at HH  Clear liquids diet to start at noon, day prior to surgey  Bowel prep, per paperwork  NO food or drink after midnight, night before surgery, except a sip of water to take pills

4. HBOT Study  Certain criteria Age 65 or less Age 65 or less Bilateral nerve sparing, pt specific Bilateral nerve sparing, pt specific Good erectile function before surgery (without need for Viagra, etc) Good erectile function before surgery (without need for Viagra, etc) Must meet inclusion criteria (verified by research coordinator) Must meet inclusion criteria (verified by research coordinator) Must come in for consent and hyperbaric education session prior to surgery Must come in for consent and hyperbaric education session prior to surgery

5. HBOT Study  Viagra starts POD#15 for the study  Half the patients will be given room air, half will be given hyperbaric oxygen  Double blind study – neither patient or doctor will know what you receive  Call the research coordinator at least 7-10 days before surgery

6. HBOT Study PROS FREE VIAGRA FOR ONE YEAR!!! CONS Daily trips to HH Daily trips to HH 5-10 sessions 5-10 sessions 90 min in the room 90 min in the room Not everyone qualifies Not everyone qualifies

7. Day of Surgery  First case of the day goes straight to OR, otherwise report to where the hospital tells you  NO food or drink, sips of water to take needed medications  Shower with Hibiclens soap provided by the hospital, if not provided Dial works as well  Approximate length of surgery is anywhere from 2-5 hours depending on size of prostate, level of difficulty and if there is lymph node dissection

8. Post Op  Diet - post op will be clear liquids, diet will be advanced when passing gas  Activity - Out of bed as tolerated, minimum of at least once  Incentive spirometry -10x every hour while awake

9. Post Op  JP drain – To drain any blood or fluid. Most likely will be removed prior to leaving hospital  5 bandages and/or Dermabond

10. Foley Catheter  Tube coming out of the penis to drain urine  Stays in until 1 st post op visit  2 types of drainage bags

11. 2 Types of Drainage Bags  Large bag or Overnight bag Can hold more urine  Leg bag Easily hidden under clothes, smaller capacity

12. Catheter Care  Clean hands prevent infection!  Gently clean around the catheter  Place small amount of bacitracin ointment around catheter near opening of penis, do not allow it to cake up. This helps the catheter move easily  May shower, disconnect bag first  When switching bags, wipe connection of bag with alcohol swab

13. Discharge Home  Diet Slow progression as tolerated Slow progression as tolerated  Bowel Regimen Daily or twice daily stool softener such as Colace Daily or twice daily stool softener such as Colace If no bowel movement by 3 days take Milk of Magnesia If no bowel movement by 3 days take Milk of Magnesia NO self placed enemas! NO self placed enemas! Any increase of abdominal pain, nausea, or vomiting call the office Any increase of abdominal pain, nausea, or vomiting call the office

14. Discharge Home  May drive when off narcotics and catheter is out  May gradually resume normal activities and exercise as tolerated. Everyone will be at a different pace.  Start Viagra

15. No Worries  Leaking from around catheter – as long as urine is draining into bag  Leakage from JP sites – if requiring frequent dressing changes, call office for bag  Scrotal and perineal pain and swelling, 3-5 days after surgery  Bladders spasms  Bloody urine – increase fluids  Small blood clots – increase fluids  Bruising

16. Worries  Incisions that are red, have pus, hot, worsening of pain or severe pain in general  Nausea/vomiting  Temperature >100.5, chills  Shortness of breath, chest pain  Foley came out or not draining  Large blood clots or heavy bleeding  Calf pain and or leg swelling Both legs likely normal. If one leg is painful, red, hot, more swollen could be a blood clot

17. 1 st Post Op Visit  7-1o days after surgery  Start antibiotics the day before, morning of, and the day after  Catheter removal !  Incontinence/Stress Incontinence Please bring pads or adult diaper to this visit Leaking will improve, be patient!! Avoid excessive fluids Best if able to avoid caffeine and alcohol consumption

18. 1 st Post Op Visit  May resume sexual activity  Kegel exercises Continue!! Continue!! 4x/day, 10 sets each 4x/day, 10 sets each Muscles need exercise, helps improve strength of pelvic muscles Muscles need exercise, helps improve strength of pelvic muscles  Pathology report Pathology report will be discussed with you and the MD. If you are seeing the RN and not the MD for catheter removal, the MD will call to discuss report. Pathology report will be discussed with you and the MD. If you are seeing the RN and not the MD for catheter removal, the MD will call to discuss report.

19. Incontinence  BE PATIENT!  Limit alcohol and caffeine, which can irritate the bladder  Will gradually improve  Lucky patients will regain control in a few weeks  Average patient in 3-6 months  Unlucky patient 6-12 months  By month 12 93% no pads 93% no pads 6% pads 6% pads 1% severe leaking that may require another intervention 1% severe leaking that may require another intervention  TIME IS THE GREATEST FACTOR!

20. Penile Rehabilitation  Oral Medications Viagra - 50mg daily (1/2 dose) or 100mg (full dose) 1 hr before sex and works better on an empty stomach Cialis – taken 2 hrs before activity and can be taken with or without food Levitra – taken 1 hour before activity and can be taken with or without food

21. Oral Medications  Side effects Headache Headache Facial flushing Facial flushing Lightheadedness Lightheadedness Upset stomach Upset stomach Muscle aches Muscle aches Visual disturbances Visual disturbances Auditory distubances Auditory distubances Erection lasting more than 4 hrs, call MD Erection lasting more than 4 hrs, call MD

22. Penile Rehabilitation  Vacumn Therapy System User friendly User friendly 98% effective 98% effective Some insurances cover Some insurances cover www.stamenmedicalsystems.com www.stamenmedicalsystems.com www.stamenmedicalsystems.com

23. Penile Rehabilitation  Injection Therapy Needle injected in the penis Needle injected in the penis Relaxes penile blood flow which allows blood to flow freely into the penis to cause an erection Relaxes penile blood flow which allows blood to flow freely into the penis to cause an erection  Muse Medicated pellet inserted into the urethra via an applicator Medicated pellet inserted into the urethra via an applicator Opens bloods vessels to increase blood flow into the penis Opens bloods vessels to increase blood flow into the penis  Penile implant Not until all other efforts are exhausted, at least 2 years after Not until all other efforts are exhausted, at least 2 years after

24. 1 st Year Follow up

25. 2 nd Year Post Op  Lab work  PSA and  Office Visit  every 6 months

26. 3 rd, 4 th, & 5 th Year  Yearly PSA and Office visits  May resume care with usual urologist whenever desired