You have recently been diagnosed with prostate cancer and it has been recommended that you have your prostate removed via a Robotic Assisted Laparoscopic Prostatectomy (RALP).

What is the prostate?

The prostate is a small gland found only in men and lies just below the bladder. It surrounds the first part of the urethra, the tube that carries urine from the bladder through the penis.

The prostate's main role is to produce semen.

Prostate cancer

One in eight men will be diagnosed with prostate cancer during their lifetime.

There are three main prostate cancer risk factors:

• getting older – it mainly affects men aged 50 or over
• having a family history of prostate cancer
• men of black ethnicity (this increases the risk to one in four men).

It is very common not to have any symptoms of prostate cancer.

Usually, prostate cancer is identified from a Prostate Specific Antigen (PSA) blood test. This blood test measures the amount of PSA in your blood.

PSA is a protein produced by normal cells in the prostate and by prostate cancer cells. It is normal to have a small amount of PSA in your blood and the amount rises slightly as you get older and your prostate gets bigger.

A raised PSA level may suggest you have a problem with your prostate, but not necessarily cancer.

Typical timeline of events

Since being diagnosed with prostate cancer, you may be wondering what the next step is. This timeline gives you a brief look at the stages ahead. The specific times will vary for each patient.

Surgery

Following your diagnosis of prostate cancer, removal of the prostate gland and seminal vesicles (sperm ducts) may be recommended.

Other options, depending on your medical history, may also have been discussed.

RALP is keyhole surgery used to remove the prostate gland using a robotic-assisted technique.

This is major surgery carried out under a general anaesthetic and uses a number of ports (small incisions) to allow access to the prostate gland.

Prior to surgery it is recommended to:

• start pelvic floor exercises
• increase cardiovascular fitness, for example walking, swimming and cycling.

Pelvic floor exercises

After surgery, you will need to rely on your pelvic floor muscles to help control your bladder and bowel.

Pelvic floor exercises can help strengthen your pelvic floor muscles to support your bladder and bowel and help improve or stop urine leakage. Having strong pelvic floor muscles may also help you achieve and maintain an erection.

Usually, you will be advised to do pelvic floor exercises before surgery. This helps to ensure that the muscles which hold urine in the bladder are strong before surgery, which may help reduce incontinence difficulties afterwards.

Finding your pelvic floor

1. Get into a comfortable position, either sitting or lying, with your tummy muscles, thighs and buttocks relaxed.
2. Try not to squeeze or tighten the muscles in your buttocks, thighs or tummy.
3. Breathe normally and try not to hold your breath when squeezing.
4. Focus on the muscles that you would normally use to stop yourself passing urine or passing wind.
5. You can feel if you are using the correct muscles by placing your fingertips on the skin behind your scrotum. When you tighten the muscles, you should feel them lift up away from your fingertips. You can also check by standing in front of a mirror without clothes and tightening the muscles. You should see the base of your penis pull up towards your tummy and your scrotum lift up.

Pelvic floor exercises

1. Complete four to six times per day while standing. If you struggle in standing, try sitting or lying down if you cannot feel the muscles squeeze.
2. Aim to squeeze for 10 seconds and relax. Rest for five seconds and repeat 10 times.
3. Aim to squeeze for one second and relax. Rest for five seconds and repeat 10 times.

Remember, this is a goal to work towards and you may find it difficult to begin with.

• the muscles may get tired at first, but they will get stronger the more you practise your exercises, so try to do a little more each time
• do not be tempted to speed up the process by doing more exercises during the day. Over-exercising the muscles can lead to muscle fatigue and slow the recovery process. Symptoms can include an ache around the tummy muscles and scrotum
• be patient and do not give up. It may take a couple of months before you notice improvement. Most men find they have fewer leaks after doing pelvic floor exercises for three months and it may take up to 12 months or more before full improvement occurs
• to help you remember to do your exercises, do them at the same time as another regular activity, for example breakfast, dinner, queuing for the bus or watching the news
• do not lift anything that is too heavy for you. When lifting, always remember to tighten your pelvic floor muscles.

Following surgery

• expect some swelling and bruising around the incision sites and your perineum (between your testicles and back passage)
• you will be discharged with a catheter and shown how to manage it at home. It is important that you do not do your pelvic floor exercises whilst the catheter is in place
• it is common to experience bypassing around the catheter, especially when opening your bowels
• blood may ooze from around the catheter and this is normal. You may also experience the sensation of needing to pass urine even though the catheter is in place. If this happens, relax and do not push or attempt to pass urine. Allow the catheter to do the work
• a follow-up appointment will be arranged to remove your catheter and surgical clips, normally one to three weeks after surgery
• do not worry if you leak urine after the catheter has been removed. Almost everyone experiences a period of bladder recovery and may need to wear protective pads
• once the catheter has been removed, you should restart your pelvic floor exercises
• a PSA blood test will be arranged eight weeks after the procedure.

Important note

• after the catheter has been removed, if you experience difficulty emptying your bladder, feel as though you need to pass urine but cannot, please attend A&E.

Constipation

Following surgery, it is common to experience difficulty opening your bowels. This is often related to both the surgery and any pain relief medication you have taken.

The following may help:

1. a high-fibre diet, including brown pasta, brown bread, fruit and vegetables
2. drinking at least 1.5 litres of fluid each day
3. placing your feet on a stool when opening your bowels to improve your position
4. instead of straining, try making "moo" or "sss" sounds when gently bearing down.

Urine frequency

It is normal to need to pass urine more often during the first few hours after the catheter has been removed, sometimes as often as every 30 minutes.

This is nothing to be concerned about and usually settles within a day or two.

Be aware of bladder irritants such as caffeine (tea and coffee), citrus fruits, spicy food and alcohol, as these may increase your need to use the toilet.

Urine urgency

This is extremely common after catheter removal and means that you receive very little warning before needing to pass urine.

Urine incontinence

It is normal to have reduced bladder control and urinary leakage after catheter removal.

Any incontinence or loss of bladder control usually improves with time, although this can take several months.

Most patients notice gradual improvement. It is essential that you continue to perform your pelvic floor exercises regularly as this will help improve bladder control.

Many people find they are drier in the mornings than in the afternoons. Leakage is often worse in the evening because the sphincter muscle that controls the release of urine becomes tired during the day.

Fluid and diet intake

It is important to drink enough fluid each day. This helps maintain hydration, keeps the catheter draining well, prevents blockages and reduces the risk of infection.

Aim to drink approximately five mugs (1.5 to 2 litres) of fluid each day.

Limit bladder irritants including caffeine, alcohol and fizzy drinks.

Eating five portions of fruit and vegetables each day, as recommended by the Department of Health, is important to help avoid constipation. Constipation can cause drainage problems with the catheter.

Monitor the colour of your urine. It should be a straw or light-yellow colour. If it is darker, it may be a sign that you need to drink more water.

Returning to work

You will need a signed doctor's certificate (Fit Note) before leaving hospital.

Your consultant will advise you when to return to work. This is usually between six weeks and three months after surgery, depending on the type of work you do.

Sexual relationships

It is possible that you may be unable to achieve an erection for some time after your operation.

Your consultant and clinical nurse specialist will discuss this further with you.

Driving after surgery

It is your responsibility to make sure you are fit to drive after any surgical procedure.

We recommend that you do not drive for at least four to six weeks after your operation.

You only need to contact the DVLA if your ability to drive is likely to be affected for more than three months. If this applies to you, check with your insurance company before driving again.

Previous patients' advice

Over the years we have treated many men following RALP surgery and the following advice has been shared by previous patients.

"Slip-on shoes, elasticated waist trousers and roomy trouser legs help accommodate the catheter bag."

"Set a timer to remind you when to take painkillers and injections. Make sure a family member is shown how to empty the drain and catheter before you leave hospital."

"Read and follow the advice given by the physiotherapists. Everything they said would happen, happened. The first four to six weeks were the hardest, but it became easier when the catheter was removed."

"Follow all the advice given and do your pelvic floor exercises to support recovery. I would strongly recommend physiotherapy appointments to discuss progress and build confidence. Do not try to do it on your own. It is good to ask questions."

"Try to improve your fitness before surgery. My friend did not and felt much more fatigued afterwards."

"Speak freely about the problem and do not be embarrassed to ask personal questions. The team are there to help, provide reassurance and support your recovery."

"Listen to the physiotherapists and trust them. They know what they are talking about."

Useful resources

Prostate Cancer UK
https://prostatecanceruk.org/