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Robot-assisted radical prostatectomy has become a standard of care for prostate cancer in the United States and in developed countries throughout the world. Minimally-invasive approaches to prostate cancer surgery were first pioneered in the 1990s, when laparoscopic radical prostatectomy was first performed. Based on the principles of open radical retropubic prostatectomy, laparoscopic radical prostatectomy conferred some advantages but was technically challenging and did not catch on in the United States. Robotic systems designed to aid laparoscopic surgeons were subsequently developed in the early 2000s and these made laparoscopic surgery for prostate cancer more reproducible. Maintaining the advantages of laparoscopy, robot-assisted radical prostatectomy (RARP) allows for magnified 3-D optics, wristed instrumentation, surgeon control of camera and multiple instruments simultaneously, none of which were easily achievable with traditional laparoscopy. Over the last decade, RARP has become the most commonly used approach for the surgical treatment of prostate cancer both at Johns Hopkins and nationwide. Johns Hopkins urologic surgeons have great expertise at nerve-sparing RARP, RARP for high-risk prostate cancer, and RARP in complex patients, such as those with prior abdominal, pelvic and/or inguinal surgery. Our surgical specialists are available to review your case individually, or can be encountered during a visit to the Johns Hopkins Precision Medicine Center of Excellence for Prostate Cancer.
NOTE: Patients must remember to bring all pathology reports and PSA values, and arrange to have their prostate biopsy slides reviewed at Johns Hopkins Pathology prior to their consultation appointment.For directions to Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center please click here
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) which may be optimal for patients who have had multiple prior abdominal operations.
The length of the operation may vary based on a patient's weight, size of the prostate, need for pelvic lymph node dissection, and the presence of scarring around the area. In general these cases last anywhere between 2 and 3 hours.
Transfusions are very rare with these minimally invasive techniques. This is one of the most significant advantages over open surgery as bleeding is drastically reduced as compared to open surgery with routinely only 100-200 cc of blood loss. Donation of blood is optional but not generally required nor recommended.
Patients often require a small amount of intravenous and/or oral narcotic pain medication during their hospital stay but often use only extra strength TylenolTM once discharged from the hospital.
Hospitalization is usually 1 night. Patients are able to walk the following day under their own power.
Removal of the catheter will be dependent on the surgeon's particular preference. In general, however, 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 7-10 days after surgery.
In general most patients can return to full activities by 3-4 weeks after surgery. However, urinary control and sexual function may take months and even up to a year or more to improve completely, just as in open surgery.
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 70% of men are dry at 3 to 6 months and 90% at 12 months following robotic prostatectomy.
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, preoperative erectile function, having an active sexual partner, whether one or both nerve bundles were spared, and time since surgery. Patience is critical to this process, as recovering from the nerve damage inherent to all forms of surgical treatment of prostate cancer takes time, much as recovering from a stroke (nerve damage) takes time.
Your first follow up appointment will be for the catheter removal some 7-10 dyas following surgery. Following this, a PSA test and office visit either to your local urologist or with your Hopkins urologist is recommended at 3 and 12 months and then typically annually thereafter.
Once the cancerous prostate gland is removed it is thoroughly evaluated by the 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 7 days.
Much of the decision on whether further treatment such as radiation or hormonal therapy is required will be based upon the pathologic stage of the cancer as well as the trend in PSA values following surgery. Low risk patients rarely need therapies other than surgery, while intermediate and high risk patients may or may not benefit from postoperative radiation and or hormonal therapy. Each case is individualized based on the findings at the time of surgery and on the final pathology report.
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 1-2 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 robot assisted radical prostatectomy (RARP), 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 that individual at 410-955-4048 for Johns Hopkins Hospital and 410-550-0412 for Johns Hopkins Bayview Medical Center.
Note: It is the responsibility of the patient to inform the Patient Service Surgery Coordinator of any scheduling changes/cancellations at least 4 weeks in advance of the surgery date out of courtesy to your surgeon, the operative staff, as well as other patients.
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 pre-operative testing done at your family doctor or primary care physician's office within 1 month prior to the date of surgery.
For Johns Hopkins Hospital Patients: These results need to be faxed by your doctor's office to the Pre-operative 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 Pre-operative 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 preoperative testing done prior to your 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 1 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
Do not eat or drink anything after midnight the night before the surgery and drink one bottle of Magnesium Citrate (can be purchased at your local pharmacy) the evening before your surgery. Also, patients are advised to self administer one Fleets 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 and do not include dairy or creamers.
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.
Nerve-sparing robotic assisted radical
prostatectomy is a well established procedure at Johns Hopkins
and is performed with the assistance of an experienced and
dedicated laparoscopic surgical team including nurses, anesthesiologists,
operating room technicians, many of whom you will meet the
day of surgery.
Robotic prostatectomy is accomplished with the assistance of a experience and dedicated laparoscopic and robotic operating room staff including nurses,anesthesiologist, and technicians many of whom you will meet the day of surgery (Figure 1).
RARP is accomplished using the daVinci Surgical System, a sophisticated robotic device that uses a high quality three dimensional camera image to provide a superior view of the prostate gland and surrounding anatomy during laparoscopic radical prostatectomy.
Once a patient is anesthetized, laparoscopic (keyhole-sized) incisions are made into the pelvic area, through which miniaturized robotic instruments are passed (Figure 2). These allow the surgeon to dissect the prostate and sew the bladder to the urethra with great precision.
This is in contrast to the conventional open radical retropubic prostatectomy where a lower midline abdominal incision is required for dissection and removal of the prostate gland (Figure 3).
During RARP, a telescopic lens is inserted into one of the keyhole incisions, providing a three dimensional and magnified view of delicate structures surrounding the prostate gland (e.g. nerves, blood vessels, muscles), thus allowing optimal preservation of these vital structures. The cancerous prostate gland is dissected free from the bladder and urethra, and the bladder and urethra are sewn together without the surgeon's hands ever entering into the patient's body. A robotic pelvic lymph node dissection may or may not also be a part of your operation depending on the risk profile of your cancer. The prostate is eventually placed into a watertight entrapment sac and removed intact through the keyhole incision located at the belly button by extending this incision by a few cm. A Foley catheter is placed through the penis to drain the bladder and allow healing of the bladder-urethra reconnection. In addition, a small drain is placed around the surgical site, exiting through one of the keyhole incisions.
For most of the surgery, the surgeon is seated at a computer console and manipulates the wristed robotic instruments with finger controls (Figure 4). The surgery is performed adhering to the same anatomic principles of open surgery, but without the surgeon's hands entering into the patient's body cavity. In some cases the approach is pelvic (extraperitoneal) and in some cases it is abdominal (transperitoneal). Each approach has distinct advantages and disadvantages but each provides comparable outcomes when performed by expert surgeons.
All surgical steps of nerve-sparing robotic assisted radical prostatectomy can be viewed in the Video Resources section of this site. Once the prostate gland is dissected free from the bladder, rectum, and urethra, it is placed in a small plastic bag and eventually removed by extending the incision at your belly button to accommodate the prostate. The bladder is sewn back to the urethra to restore continuity of the urinary tract using laparoscopic suturing techniques inside the body. A Foley catheter is placed through the penis to drain the bladder and allow healing of the bladder-urethra connection. In addition, a small drain is placed around the surgical site, exiting one of the keyhole incisions.
The length of operative time for robotic assisted radical prostatectomy can vary greatly (generally 2-4 hours) from patient to patient depending on the size of the prostate gland, shape of the pelvis, weight of the patient, and presence of scarring or inflammation within the pelvis due to infection or prior abdominal/pelvic surgery. Blood loss during robotic-assisted radical prostatectomy is routinely less than 300 cc. Transfusions are very rarely required. Donation of blood prior to surgery for autologous blood transfusion can however be arranged if the patient desires.
Warning: these video clips include footage from an actual surgery which some viewers may find difficult to watch.
Although this procedure has proven to be very safe, as in any surgical procedure there are risks and potential complications. The safety and complication rates compare favorably to open surgery. Potential risks include:
Bleeding: Although blood loss during this procedure is relatively low compared to open surgery, a transfusion may still be required if deemed necessary by your surgeon either during the operation or afterwards during the postoperative period.
Infection: All patients are treated with intravenous antibiotics, prior to the start of surgery to decrease the chance of infection from occurring within the urinary tract or at the incision sites.
Adjacent Tissue / Organ Injury: Although uncommon, possible injury to surrounding tissue and organs including bowel, vascular structures, pelvic musculature, and nerves could require further procedures. Transient injury to nerves or muscles can also occur related to patient positioning during the operation.
Hernia: Hernias at incision sites rarely occur since all keyhole incisions are closed under direct laparoscopic view.
Conversion to Open Surgery: The surgical procedure may require conversion to a pure laparoscopic procedure (performed without the robotic system) or even to the standard open operation if extreme difficulty is encountered during the robotic procedure (e.g. excess scarring or bleeding). This could result in a standard open incision and possibly a longer recuperation period, but thankfully occurs <1% of the time.
Urinary Incontinence: As with open radical prostatectomy, urinary incontinence is common following robotic prostatectomy, but is often temporary and improves over time. Younger age, increasing time from surgery, a nervesparing approach, and lack of development of bladder neck contracture are factors associated with return to urinary control. The use of Kegel exercises, which help strengthen the urinary sphincter muscle, also helps with recovery of urinary control.
Erectile Dysfunction: Similar to open radical prostatectomy, a nerve-sparing technique is attempted during robotic dissection of the prostate gland unless there is obvious involvement of adjacent nerve tissue by tumor. The return of erectile function following prostatectomy is a function of patient age, quality of preoperative erectile function, technical precision of the nerve-sparing technique, and increasing time from surgery. Most urologists prescribe phosphodiesterase type 5 inhibitors (e.g. Viagra, Cialis) for use as needed after surgery to help with erections, though these have not been shown to improve the natural recovery of erectile function over time.
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 1 - 2 days.
Diet: You can expect to have an intravenous catheter (IV) in for 1-2 days. (An IV is a small tube placed into your vein so that you can receive necessary fluids and stay well hydrated; in addition it provides a route to receive medication.) Most patients are able to be advanced to a regular diet the day after surgery. Once on a regular diet, pain medication will be administered by mouth instead of by IV or shot.
Post Operative Pain: You may experience minor transient shoulder pain (1-2 days) related to the carbon dioxide gas used to inflate your pelvis during the laparoscopic surgery. There will also be initial catheter–related discomfort and some crampy bowel pains may be encountered as the bowels regain function postoperatively. 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.
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 typically transient and 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 some 7-10 days 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 in case leakage develops. This drain is typically removed in 1-2 days or at discharge by the time 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 important parts of your recuperation and help prevent pneumonia and other pulmonary complications.
Ambulation: On the night of and certainly by the morning 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 SCD's (sequential compression devices) along with tight white stockings on your legs to decrease the chance of blood clots 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 even at home will also help to prevent constipation. Narcotic pain medication can exacerbate constipation and therefore patients are encouraged to discontinue any narcotic pain medication as soon after surgery as tolerated.
Pain Control: You can expect to have some incisional discomfort that may require narcotic pain medication for a few days after discharge, and thereafter 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 2 weeks after surgery. You may have adhesive strips across your incisions. They will either fall off on their own or can be removed in approximately 1-2 weeks. Please reinforce the tape securing your catheter to our leg after showering with a fresh piece of tape if the area gets wet.
Incisions and suture: Your incisions will be closed with sutures beneath the skin, which will dissolve within 4 – 6 weeks. By about one year after surgery, the incisions in many patients are barely perceptible(Figure 5).
Figure 5. Postoperative Incisions
Diet: You may return to your normal diet immediately upon discharge from surgery. However, adhering to foods such as rice, soups, 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 an anesthesia. Because of the raw surface in your bladder and urethra, alcohol, spicy foods and drinks with caffeine may cause some irritation or sense of the need to void despite the fact that the catheter is emptying the bladder. If these foods don't bother you however there is no reason to avoid them in moderation. More importantly is to keep your urine flowing freely, drink plenty of fluids during the day (8 - 10 glasses). The type of fluids (except alcohol) is not as important as the amount. Water is best but juices, coffee, tea, soda are all acceptable.
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 approximately 2 weeks after surgery. Most patients return to full activity an average of 3-4 weeks after surgery. However, heavy lifting (greater than 20 pounds) or vigorous exercising (jogging, swimming, treadmill, biking) is not recommended for a full four weeks or until instructed by your doctor.
Catheter care: Your catheter is very important to allow 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 back up 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 KY jelly or another water-based lubricant 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.
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. Please ask your surgeon about the resumption of blood thinning medications. 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 catheter removal appointment.
Follow up appointment: The first postoperative appointment will be to remove the catheter, usually done at 7-10 days after surgery. Your surgeon will decide on the timing of this, and the appointment will be arranged through the urology clinic (410-955-6707 for 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 (e.g. DEPENDS) that can be purchased at any drug store. Once your catheter is removed it is recommended that you avoid caffeine, alcohol, and excessive fluid intake for 1-2 months as this can aggravate incontinence.
Pathology Results: Pathology results are usually available approximately 7 days following surgery. These results will be reviewed with you in the office. Alternatively, you can contact your surgeon by phone or email at one week.
Long-term Follow-up: A prostate-specific antigen (PSA) test is drawn at 3 months following surgery. Patients are evaluated every 3-12 months lifelong. This can be easily accomplished over the telephone for patients who do not live close to the Baltimore area.
PROBLEMS YOU SHOULD REPORT TO US:
If this is an emergency, the Urologist On-Call can be contacted at 410-955-6070 for Johns Hopkins Hospital or at 410-550-0100 for Bayview patients.
a. Fevers over 101 degrees Fahrenheit as this may be a sign of infection.
b. Heavy bleeding or clots in the urine.
c. Calf or thigh pain or swelling as this may be a sign of a blood clot.
d. Difficulty breathing or chest pain as this may be a sign of a pulmonary embolus or heart attack.
e. Skin rash or hives as these may be signs of potential medication reactions.
f. Nausea, vomiting, diarrhea which may be a sign of infectious diarrhea (e.g. Clostridium difficile)
g. Call immediately if your catheter stops draining completely or falls out.
PELVIC MUSCLE EXERCISES TO IMPROVE BLADDER CONTROL (MALE)
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.
It is recommended that you start doing Kegel exercises six-eight weeks prior to surgery.
Begin by locating the muscles to be exercised:
Now you are ready to exercise regularly:
(This paper was written by a patient, describing his views about recovery from radical prostatectomy. If you have something to add or suggest, please don't hesitate to let us know your 'Picks to Click' as they say. 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 Lazy 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 "one size fits all" ladies T shirt, which can be found at Wal Mart 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 begins "the return to the diaper" stage. The Depend Company makes two basic styles of diaper: (a) the "bikini" style, shaped like a "V" and supported by elastic straps which 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 de catheterization, 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 daily. 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 5:00 or 6:00 pm.
As far as water drinking 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 which will increase your comfort is Carrington Perineal Cleansing Foam for Incontinent Care. It is an aerosol preparation that is easily applied and then wiped away, leaving the sticky, messy, irritated area clean and comfortable and 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 on-line.
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, more
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
ifs almost back to normal. At 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 the bikini type!
(The Prefer Incontinent Brief can be purchased at many health supply stores.)
When you finally get to the stage that you are almost "dry" and experience only occasional dribbles during the day, another Depend product is great. It is the "Poise Pad," which has an adhesive tape on the outer surface that sticks to the inner surface of your ordinary jockey type shorts. Get the extra absorbent long 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.