Good news first: Dr. Esposito told my wife and my brother (as I was still out from the anesthesia) that both nerve bundles were spared, and both lymph nodes were clear. He also believes there is a negative surgical margin, but final confirmation will come from the pathology. So far so good!
Funny how with all the research I did about the daVinci surgery, and the incontinence and impotence side effects, I didn't read up on issues associated with the post-op recovery from the surgery itself. For instance:
1. I went into the O.R. Monday morning at 7:00 am. At 11:50 am, when waking up from the anesthesia in the recovery room, I had severe pains from both the incision site with the J-P drain as well as from my herniated and bulging discs at L4 and L5 -- a pre-existing condition I discussed with my anesthesiologist in pre-op. Not that anything was done to my vertebra, it's just that being in the same position for so long on my back creates a strain that is quite discomforting. And with all this, I had to get up the strength to moan loud enough that someone wandered over and offered me some morphine, i.e., "describe your pain on a scale of 0 to 10." They wouldn't release me from recovery even though a room was available because I was still in pain, but a second dose of morphine took care of that.
2. I was drowsy, so my family left for a while and I had the room to myself, until Dr. Esposito's second RALP of the day showed up to become my roommate for the night. Neither one of us got any sleep due to stomach cramps and bloating. Or was it bladder cramps and bloating? Not really sure actually. And with the two drains in me (the J-P and the Foley) there wasn't much I could do to alleviate the pressure on my back since I had to stay in the one position. More morphine. And the hospital special menu of broth, jello, flavored ice and apple juice. But the night nurse assistant was nice to us, and at 3 in the morning we both got extra flavored ice.
3. By late Tuesday morning after a couple of suppositories from one of the nurses (my dignity being lost hours earlier) along with a couple of stool softeners, I had my first bowel movement, which is a prerequisite to being discharged (alternatively: passing gas). They also started me walking the floor, and I did at least a half dozen laps without incident. Then the physician on duty stopped by to take out the Jackson-Pratt (J-P) drain, which is an event all unto itself. I haven't read about this anywhere on the forum, so I'll describe it here for the uninformed: this is a small drain that hangs off the side of your abdomen to collect the leftover surgical blood from your abdominal cavity. Due to its shape, the nurses refer to it as the "hand grenade." It is sewn in place in such a way that the physician described its removal as "pulling on the thread like a purse string." This didn't sound too bad, and I wasn't expecting much even when the physician brought two interns with him to witness the procedure. He told me to take a deep breath, then exhale, and when I exhaled, he ripped out the drain and pushed as hard as he could on the spot to immediately pull the thread tight and stop any bleeding. When he pushed down as hard as he could, I did a "YIKES!" and imagined I had shot up in the air three feet. It was more the shock of the unexpected rather than the actual pain of the procedure, which if anything lasted ten seconds or so.
4. Finally they sent the head nurse over with my final care instructions, specifically, how to put on a leg bag and an overnight bag to collect the urine draining from the catheter that wouldn't come out until the following Tuesday (normally only a week later, but with next Monday being Memorial Day I have to suffer an extra day). It seems that no matter where the Statlock was placed on my leg it would tug on me if I moved a certain way. So we found a compromise location and I finished getting carefully into my sweatpants to go home. . .
5. . . . until they ran after me to say oops the doctor wants me to go to radiology for an ultrasound of my legs so I can't leave yet. I get wheeled down to the first floor and unceremonially left alone in the wheelchair for I don't know how long until someone came to get me. I then had to carefully take off my sweatpants and climb onto the ultrasound table, where two 20-something attractive young ladies took turns rubbing the ultrasound probe up and down my inner thighs. As I said earlier, my dignity was long gone by this point. As part of the process, my catheter Statlock and leg bag were removed from my leg. They attempted to relocate it in the original position, but not being experts in catheters it didn't happen. It was clear that I would need to take care of this upstairs, so I decided to wait until then to carefully get into my sweatpants again. At that point I had the less than enjoyable privilege of sitting outside radiology in the wheel chair for 15 minutes waiting to be rescued, with my sweatpants acting as a back pillow and a hospital gown camouflaging my memorable experience from the many hospital visitors walking the first floor hallways. Ah, dignity, where hast ye gone?
6. Finally I'm allowed to go home, and my wife and I have an entertaining discussion about whether it's better to fly over the bumps or go slowly over each and every one. Fortunately, Drs. Esposito and Lanteri opened a second office at the Jersey Shore close to my home (since nobody else at the hospital knew how to work the daVinci, so I'm told) so my journey is only about 15 minutes instead of an hour and a half. I made it upstairs alright and within a couple of hours discovered that the leg bag will need to be drained about once an hour. It was getting close to bedtime so I switched to the overnight bag and that's when my first interesting night began. With the wife in the guest room, I spent most of the night watching old movies on TCM and wondering why my catheter leaked blood every time I sat down on the toilet to try to move my bowels. Was the Statlock in the wrong place? Not enough slack in the catheter? This can't be good. I fashioned a hook out of a shirt hanger so that it would be easier to transport the overnight bag back and forth from the night table to the bathroom. The hanger also fits over the pull drawer at the sink. My wife retrieved our "extension arm grabber thing" from the garage so that I wouldn't have to bend over or reach down to pick something up. It also comes in handy reaching to the other side of the bed for the stack of discharge papers with the post-op instructions for me to read over and over again why my urine is pink or red colored in the bag and what to do about it. (Answer: keep drinking until the color changes.) On the night table within reach is water, jello, flavored ices, etc. just like in the hospital, along with my antibiotic, Tylenol with Codeine (Rx) and stool softener. On the bed within reach is my 12-hour nasal spray (TIP: don't try blowing a stuffy nose until you've healed), extra surgical tape to keep the catheter tubing in place on my leg, extra gauze to catch any catheter urine or blood leaks, and a thermometer. It didn't take long for me to realize that the urge to move my bowels is probably gas trying to come out. But lying on one's back with a full bladder makes it difficult for the gas to actually escape, and trying to turn over with the catheter in you presents a different challenge. Then there's always the possibility that it really is a bowel movement so the prudent thing to do is to get up and make your way to the bathroom anyway. I finally figured out that it's the straining to try to pass gas or have a BM that causes the blood leakage at the catheter, and somewhere else in the forum it's explained that this is caused by the abdominal muscles pushing the catheter out of position inside the bladder. Lovely. Every movement I make usually involves my abdominals, from sitting down, to standing up, and from getting into bed to getting out of bed. So I try to compensate by using my arms and neck muscles as much as possible. And now I have sore arms and a sore neck.
7. Wednesday morning comes and I've hardly had any sleep. By 5 am I can't stand it any longer and I pound on the wall for my wife to come and get me some refills on my liquid diet, because I'm too unstable and nervous to navigate the stairs by myself in the dark. All goes well for a few hours and I finally get some much-needed sleep, only to wake up and find a stream of blood in my catheter and a bag full of pink liquid. More water, apple juice and Arizona green iced tea and stay off my feet for another day. Feeling flushed I check my temperature and it's 100 degrees, still under the limit. I call the doctor's office anyway and leave a message. The nurse from the hospital independently calls to follow-up. Fever under 101, pink urine, stomach cramps, are all normal. The doctor's office calls back, same thing. Okay, I keep drinking and it will go away. I start experimenting with solid food: chicken noodle soup, apple sauce, scrambled eggs, some prunes. No stomach issues, but no BM either. Well I don't want to strain any more, so as long as I stay gassy I'm happy for now.
8. Wednesday night I actually slept for 5 hours straight, which resulted in another deep pink bagful of urine by first light on Thursday. Back to the water to flush it out. I don't see any leakage at the catheter, so it's all part of the normal healing process, right? No need to panic. A couple of bottles of Arizona green iced tea later and the urine color is back to its normal clear pale yellow. For breakfast I have a couple of Weetabix cakes soaked in hot tea, which ordinarily leads to a soft BM within a half hour. Not this time, probably because there's nothing significant in my GI tract yet. Not to worry, it's good fiber. Fiber is good. More prunes. For lunch, I put on the boxer shorts my wife got me, which requires the empty bag to be folded and routed through the shorts leg in order for me to walk around the house using my shirt hanger. I decide the reclining end of the sofa is best and I sit there with my Arizona green iced tea and my chicken soup with noodles. Everything is fine until I try to get up an hour later, which requires my wife to help put the seat back down. I assist by giving the bottom of the chair a final push with both feet, and then regret that decision when the catheter "burps" a backflow at me. Yeeouch!
9. Thursday afternoon I send my wife out to the store for some apple cider after reading on the forum that it's good for promoting BMs. I note that my supply of Tylenol with Codeine is down to 10 and I don't think I can last the holiday weekend without a refill. But when my doctor finally calls me back he says I shouldn't be needing it as the pain by my incision should be going away any time now and OTC Tylenol Extra Strength should be good enough. I sure hope he's right. Before my wife gets home I feel a BM coming on so I get out of bed, still with the hose through the boxers and as I round the corner, some gas escapes, along with urine out the catheter, which promptly flows along the outside of the hose and down my leg. I instinctively drop my drawers to the floor and then realize that by doing so I'm unable to transport the bag at the proper height. I turn around to grab the "extension arm grabber thing" and use that to pull by boxers back up, so that I can empty the bag, so that I can reroute the empty bag back through the boxers, so that I can kick off the boxers and throw them into the bathtub. And only then can I clean up the mess I made. Oh and no BM to show for it after all. Meanwhile my 11-year old has gotten off the schoolbus and read my wife's note to her that it's okay to come see me because I'm wearing boxers. I stopped her just in time.
So here it is Thursday evening and I'm writing this as my wife prepares plain spaghetti for my supper. I am SO looking forward to my first non-straining BM. I really was unaware that the post-op phase of my journey would be so "entertaining."
Physical exam (01/22/2009): blood pressure 130/85, good EKG; basically all-around healthy
PSA 4.9 (02/05/2009)
Urologist DRE observed slightly hardened left lobe (02/19/2009)
Chest X-ray normal (02/23/2009)
PCa present in all sextants, <5% to 50%
Prostate gland 37 grams
Gleason score 7 (in two sextants, scored 6 elsewhere)
Cystoscopy (05/08/2009), showed clear
MRI (05/08/2009), "No findings are present to suggest extracapsular tumor."
Robot-assisted (daVinci) laparoscopic radical prostatectomy (05/18/2009) by Michael Esposito, M.D. and Vincent Lanteri, M.D. Both nerve bundles spared. Awaiting final pathology report to verify that PCa was contained within the capsule.
Surgery (daVinci robotic) consult with Michael Esposito, M.D., http://www.roboticurology.com/ (03/30/2009)
Radiation oncology (Varian IMRT/IGRT RapidArc) consult with Mark Macher, M.D., http://www.njneuro.org/fp/gammateam.asp (04/08/2009)
Other resources: Dr. Peter Scardino's Prostate Book (Peter Scardino (Sloan-Kettering), 2005); Urologic Robotic Surgery (Michael Esposito, Vincent Lanteri & Jeffrey Stock, 2007)