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Early removal of catheter after transurethral prostatectomy
EARLY REMOVAL
OF CATHETER
AFTER TRANSURETHRAL
PROSTATECTOMY
PHILIPG.
(C)
KLOTZ, M.D.,
F.R.C.S.
From the Mount Sinai Hospital, Toronto, Ontario, Canada
ABSTRACT -A prospective study of 100 patients with benign prostatic hypertrophy treated by transurethral prostatectomy with catheter removal as soon as possible after surgery was carried out. The results were compared with a retrospective review of 100 similar cases treated by long-term catheter drainage. Incidence of retention requiring recatheterization was equal (5 per cent versus 6 per cent); incidence of secondary hemorrhage was increased by early catheter removal (6 per cent versus 13 per cent); postoperative hospital stay was decreased by 50 per cent (8.2 versus 4.0 days); and patient comfort and acceptance were improved markedly.
At the present time the most effective method for treating benign obstructive enlargement of the prostate gland is prostatectomy. Of the variety of approaches available, transurethral prostatectomy has the lowest degree of morbidity and is the least uncomfortable method for the patient. Most of the discomfort associated with this operative technique is related to the indwelling catheter which is used almost universally following the procedure. In 1969 Cassl in Australia reported a series of 239 transurethral prostatic resections. Of these, 202 did not have an indwelling catheter after the operation. The remaining 37 required a catheter initially because of bleeding or “thin” capsule. Of the 202 cases without catheter drainage, only 28 per cent voided spontaneously. In the remainder, interim catheterization was done on the average of four times before the patient was able to void. Clot retention occurred in 2.5 per cent of the cases, and there were three deaths for a mortality rate of approximately 1.5 per cent. In 26 per cent of the cases, the patient was discharged from hospital in less than six days. Cass referred to six previous articles on “no catheter” retropubic prostatectomy but did not refer to any reports on “no catheter” transurethral resections. In a review of the literature, I was also unable to find such a series. In 1963 SpooneP reported 128 cases of transurethral prostatectomy
UROLOGY
/ SEF’TEMBER 1975 / VOLUME
VI, NUMBER 3
of which 101 were not treated by catheter drainage; 58 per cent required catheterization postoperatively. Other articles have been published on “no catheter” prostatectomy or early catheter removal following prostatectomy, but these have all been for open, retropubic-type prostatectomy. 3-6 Material and Methods The clinical study reported herein was done at the Mount Sinai Hospital, Toronto, Canada, beginning in November, 1971. In the control group of 100 patients with benign prostatic hypertrophy treated by transurethral resection the age range was forty-five to ninety-two years; in the study group of 100 patients, the age range was fifty-one to eighty-eight years. Weight of tissue resected was 4 to 90 Gm. (average 23.5 Gm.) in the control group, and 4 to 75 Gm. (average 23 Gm.) in the study group. For 100 consecutive patients in the trial study group, catheter removal was planned for twentyfour hours postoperatively. This was achieved in 77 patients only, and within forty-eight hours in another 14 patients; in the remaining 9 patients the catheter was removed on the third postoperative day in 7 patients and on the fourth postoperative day in 2 patients. Retrospectively, the 100 consecutive patients with the same diagnosis and treatment prior to
305
TABLE I.
Postoperative complications* Control
Re-insertion
of
catheter
2 5
I
Post-operative bleeding prior to discharge
5
Secondary requiring
1 (4
hemorrhage re-admission
Pre-operative urine culture Post-operative temp. ~38’ Epididymitis
positive
C.
Early Catheter Removal 3 I 6 I
once more than
once
5 days)
8 (30
19
12
23
9
2
2
days)
*Figures in parentheses are totals of days in hospital on readmission.
the onset of the study were compared from the standpoint of incidence of complications, especially secondary hemorrhage, frequency of postoperative catheterizations, and duration of hospital stay. Prior to the onset of the trial study, the catheter was usually not removed prior to the fourth postoperative day or whenever the drainage became clear. In the 100 control patients in our series the catheter was removed on postoperative day 2 in 1 patient, day 3 in 12 patients, day 4 in 42, day 5 in 23, day 6 in 11, day 7 in 7, and after the seventh postoperative day in 4 patients. These patients were discharged from the hospital an average of 8.2 days postoperatively (13 patients by five days, 64 by eight days, and the remainder by thirteen days). In the trial study series an attempt was made to discharge the patient a day or so following removal of the catheter, with an average hospital stay of 3.7 days (85 patients were discharged by five days, 95 by eight days). Five patients in the trial study series had hospital stays longer than eight days for reasons unrelated to surgery (hernia repair, knee transplant, colostomy for carcinoma of colon), with a corrected average stay of four days. There was no mortality in the trial study group. One patient in the control group died four weeks after discharge of acute myocardial occlusion. Preoperative investigation consisted of history, physical examination, urinalysis, urine culture, routine biochemistry, intravenous pyelography, electrocardiogram, chest x-ray film, and cystoscopy. Surgery was performed under a variety of anesthetics using the Stern-McCarthy re-
306
sectoscope; in each case the prostate was completely removed down to the capsule. A 22 F to 30 Foley catheter was left in the bladder. The immediate postoperative regimen consisted of full fluids orally, 2,000 cc. balanced electrolyte replacement fluid (Normosol R-D) intravenously in twenty-four hours, 1 Gm. sulfisoxazole (Gantrisin) every twelve hours into the intravenous tubing, 25 to 50 mg. meperidine (Demerol) as necessary for pain, and sterile saline irrigation as required until bleeding was minimal and then every four hours. On the following day, intravenous fluids and sulfonamides were discontinued. The patient was started on a regular diet, ambulated, and was given 1 Gm. sulfisoxazole orally four times a day for the following four weeks. If it were considered to be safe, the catheter was removed within twenty-four hours as described; otherwise, it was removed as soon as possible. The complications encountered in the control and trial groups are outlined in Table I. Comment Of 100 patients, catheter removal was achieved within twenty-four hours in 77 patients, and within forty-eight hours in 91. Table I illustrates that 6 per cent of patients required recatheterization, half of these on only one occasion. Comparison with this series shows no significant difference in recatheterization frequency as compared with the control series (in 2 patients once only and in 5 more than once). The incidence of postoperative hemorrhage appears significant. Thirteen per cent of the
UROLOGY / SEPTEMBER1975 / VOLUMEVI, NUMBER3
100 ;R;:<.:
80
100
Y)
100
; ;
- CONTROLS
_ STUDY
$#
PATIENTS
60
2 '; ci z
40
20
1
2
3
4
POST-OPERATIVE
FIGURE
1.
5
6
7
DAY
Postoperative hospital stay.
trial study group required cystoscopic fulguration or catheterization and irrigation, as compared with 6 per cent in the control series. Since early discharge from hospital was part of the trial study, 8 patients in this series required readmission. While the author was impressed with the increased patient comfort associated with early catheter removal, the added stress of readmission to hospital and subsequent control of hemorrhage has to be considered. The incidence of rise in temperature after surgery was statistically less in the early catheter removal group (9:23) with a corresponding increase in patient comfort. In two patients in each group epididymitis developed. Despite the increase in secondary hemorrhage, postoperative hospital morbidity was significant in terms of economics and patient acceptance (Fig. 1). When corrected for readmissions, the average stay was reduced by more than 50 per cent, from 8.2 to 4.0 days. The control group spent 824 days in
UROLOGY
/
SEPTEMBER 1975 /
hospital, as compared with 400 days for the group under study. Fifty per cent of the patients in the trial study group were home within seventy-two hours of surgery, and 85 per cent within five days. While it may be possible to perform transurethral prostatectomy without catheter drainage, Cass” study suggests that 72 per cent of patients will require catheterization and Spooner’s2 series required 58 per cent catheterization. In this study in which catheterization was reduced to one day in 77 per cent and two days in 91 per cent of cases, the patient comfort and acceptance was markedly increased and hospital morbidity halved. However, the incidence of secondary hemorrhage does appear to be more frequent. Provided the surgeon is aware of this possibility and acts promptly to correct such bleeding, the mortality rate is negligible. The incidence of recatheterization fell to 6 per cent in this series.
VOLUME VI, NUMBER 3
600 University Avenue (Suite 455) Toronto, Ontario M5G 1X5, Canada References prostatic resection without 1. CASS, A. S.: Transurethral catheter drainage, J. Urol. 101: 750 (1969). 2. SPOONER, J. S.: Report presented to Northeastern Section, American Urological Association, Inc., Canada, 1963. 3. MAGRI, J. : Prostatectomy - an optional no-catheter technique, Br. J. Urol. 40: 740 (1968). 4. GUNTER, D. : “No-catheter” prostatectomy, Proc. Urol. Sot. Australia 41: 601 (1969). 5. BRICKIN, M., and VAN DEN BULCKE, C.: Experiences with no-catheter prostatectomy, S. Afr. Med. J. 93: 583 (1969). 6. KUNOV, J., and THYSSEN, J.: Early catheter removal after transvesical prostatic adenectomy with primary bladder closure, Stand. J. Ural. Nephrol. 3: 90 (1969).
307
OF CATHETER
AFTER TRANSURETHRAL
PROSTATECTOMY
PHILIPG.
(C)
KLOTZ, M.D.,
F.R.C.S.
From the Mount Sinai Hospital, Toronto, Ontario, Canada
ABSTRACT -A prospective study of 100 patients with benign prostatic hypertrophy treated by transurethral prostatectomy with catheter removal as soon as possible after surgery was carried out. The results were compared with a retrospective review of 100 similar cases treated by long-term catheter drainage. Incidence of retention requiring recatheterization was equal (5 per cent versus 6 per cent); incidence of secondary hemorrhage was increased by early catheter removal (6 per cent versus 13 per cent); postoperative hospital stay was decreased by 50 per cent (8.2 versus 4.0 days); and patient comfort and acceptance were improved markedly.
At the present time the most effective method for treating benign obstructive enlargement of the prostate gland is prostatectomy. Of the variety of approaches available, transurethral prostatectomy has the lowest degree of morbidity and is the least uncomfortable method for the patient. Most of the discomfort associated with this operative technique is related to the indwelling catheter which is used almost universally following the procedure. In 1969 Cassl in Australia reported a series of 239 transurethral prostatic resections. Of these, 202 did not have an indwelling catheter after the operation. The remaining 37 required a catheter initially because of bleeding or “thin” capsule. Of the 202 cases without catheter drainage, only 28 per cent voided spontaneously. In the remainder, interim catheterization was done on the average of four times before the patient was able to void. Clot retention occurred in 2.5 per cent of the cases, and there were three deaths for a mortality rate of approximately 1.5 per cent. In 26 per cent of the cases, the patient was discharged from hospital in less than six days. Cass referred to six previous articles on “no catheter” retropubic prostatectomy but did not refer to any reports on “no catheter” transurethral resections. In a review of the literature, I was also unable to find such a series. In 1963 SpooneP reported 128 cases of transurethral prostatectomy
UROLOGY
/ SEF’TEMBER 1975 / VOLUME
VI, NUMBER 3
of which 101 were not treated by catheter drainage; 58 per cent required catheterization postoperatively. Other articles have been published on “no catheter” prostatectomy or early catheter removal following prostatectomy, but these have all been for open, retropubic-type prostatectomy. 3-6 Material and Methods The clinical study reported herein was done at the Mount Sinai Hospital, Toronto, Canada, beginning in November, 1971. In the control group of 100 patients with benign prostatic hypertrophy treated by transurethral resection the age range was forty-five to ninety-two years; in the study group of 100 patients, the age range was fifty-one to eighty-eight years. Weight of tissue resected was 4 to 90 Gm. (average 23.5 Gm.) in the control group, and 4 to 75 Gm. (average 23 Gm.) in the study group. For 100 consecutive patients in the trial study group, catheter removal was planned for twentyfour hours postoperatively. This was achieved in 77 patients only, and within forty-eight hours in another 14 patients; in the remaining 9 patients the catheter was removed on the third postoperative day in 7 patients and on the fourth postoperative day in 2 patients. Retrospectively, the 100 consecutive patients with the same diagnosis and treatment prior to
305
TABLE I.
Postoperative complications* Control
Re-insertion
of
catheter
2 5
I
Post-operative bleeding prior to discharge
5
Secondary requiring
1 (4
hemorrhage re-admission
Pre-operative urine culture Post-operative temp. ~38’ Epididymitis
positive
C.
Early Catheter Removal 3 I 6 I
once more than
once
5 days)
8 (30
19
12
23
9
2
2
days)
*Figures in parentheses are totals of days in hospital on readmission.
the onset of the study were compared from the standpoint of incidence of complications, especially secondary hemorrhage, frequency of postoperative catheterizations, and duration of hospital stay. Prior to the onset of the trial study, the catheter was usually not removed prior to the fourth postoperative day or whenever the drainage became clear. In the 100 control patients in our series the catheter was removed on postoperative day 2 in 1 patient, day 3 in 12 patients, day 4 in 42, day 5 in 23, day 6 in 11, day 7 in 7, and after the seventh postoperative day in 4 patients. These patients were discharged from the hospital an average of 8.2 days postoperatively (13 patients by five days, 64 by eight days, and the remainder by thirteen days). In the trial study series an attempt was made to discharge the patient a day or so following removal of the catheter, with an average hospital stay of 3.7 days (85 patients were discharged by five days, 95 by eight days). Five patients in the trial study series had hospital stays longer than eight days for reasons unrelated to surgery (hernia repair, knee transplant, colostomy for carcinoma of colon), with a corrected average stay of four days. There was no mortality in the trial study group. One patient in the control group died four weeks after discharge of acute myocardial occlusion. Preoperative investigation consisted of history, physical examination, urinalysis, urine culture, routine biochemistry, intravenous pyelography, electrocardiogram, chest x-ray film, and cystoscopy. Surgery was performed under a variety of anesthetics using the Stern-McCarthy re-
306
sectoscope; in each case the prostate was completely removed down to the capsule. A 22 F to 30 Foley catheter was left in the bladder. The immediate postoperative regimen consisted of full fluids orally, 2,000 cc. balanced electrolyte replacement fluid (Normosol R-D) intravenously in twenty-four hours, 1 Gm. sulfisoxazole (Gantrisin) every twelve hours into the intravenous tubing, 25 to 50 mg. meperidine (Demerol) as necessary for pain, and sterile saline irrigation as required until bleeding was minimal and then every four hours. On the following day, intravenous fluids and sulfonamides were discontinued. The patient was started on a regular diet, ambulated, and was given 1 Gm. sulfisoxazole orally four times a day for the following four weeks. If it were considered to be safe, the catheter was removed within twenty-four hours as described; otherwise, it was removed as soon as possible. The complications encountered in the control and trial groups are outlined in Table I. Comment Of 100 patients, catheter removal was achieved within twenty-four hours in 77 patients, and within forty-eight hours in 91. Table I illustrates that 6 per cent of patients required recatheterization, half of these on only one occasion. Comparison with this series shows no significant difference in recatheterization frequency as compared with the control series (in 2 patients once only and in 5 more than once). The incidence of postoperative hemorrhage appears significant. Thirteen per cent of the
UROLOGY / SEPTEMBER1975 / VOLUMEVI, NUMBER3
100 ;R;:<.:
80
100
Y)
100
; ;
- CONTROLS
_ STUDY
$#
PATIENTS
60
2 '; ci z
40
20
1
2
3
4
POST-OPERATIVE
FIGURE
1.
5
6
7
DAY
Postoperative hospital stay.
trial study group required cystoscopic fulguration or catheterization and irrigation, as compared with 6 per cent in the control series. Since early discharge from hospital was part of the trial study, 8 patients in this series required readmission. While the author was impressed with the increased patient comfort associated with early catheter removal, the added stress of readmission to hospital and subsequent control of hemorrhage has to be considered. The incidence of rise in temperature after surgery was statistically less in the early catheter removal group (9:23) with a corresponding increase in patient comfort. In two patients in each group epididymitis developed. Despite the increase in secondary hemorrhage, postoperative hospital morbidity was significant in terms of economics and patient acceptance (Fig. 1). When corrected for readmissions, the average stay was reduced by more than 50 per cent, from 8.2 to 4.0 days. The control group spent 824 days in
UROLOGY
/
SEPTEMBER 1975 /
hospital, as compared with 400 days for the group under study. Fifty per cent of the patients in the trial study group were home within seventy-two hours of surgery, and 85 per cent within five days. While it may be possible to perform transurethral prostatectomy without catheter drainage, Cass” study suggests that 72 per cent of patients will require catheterization and Spooner’s2 series required 58 per cent catheterization. In this study in which catheterization was reduced to one day in 77 per cent and two days in 91 per cent of cases, the patient comfort and acceptance was markedly increased and hospital morbidity halved. However, the incidence of secondary hemorrhage does appear to be more frequent. Provided the surgeon is aware of this possibility and acts promptly to correct such bleeding, the mortality rate is negligible. The incidence of recatheterization fell to 6 per cent in this series.
VOLUME VI, NUMBER 3
600 University Avenue (Suite 455) Toronto, Ontario M5G 1X5, Canada References prostatic resection without 1. CASS, A. S.: Transurethral catheter drainage, J. Urol. 101: 750 (1969). 2. SPOONER, J. S.: Report presented to Northeastern Section, American Urological Association, Inc., Canada, 1963. 3. MAGRI, J. : Prostatectomy - an optional no-catheter technique, Br. J. Urol. 40: 740 (1968). 4. GUNTER, D. : “No-catheter” prostatectomy, Proc. Urol. Sot. Australia 41: 601 (1969). 5. BRICKIN, M., and VAN DEN BULCKE, C.: Experiences with no-catheter prostatectomy, S. Afr. Med. J. 93: 583 (1969). 6. KUNOV, J., and THYSSEN, J.: Early catheter removal after transvesical prostatic adenectomy with primary bladder closure, Stand. J. Ural. Nephrol. 3: 90 (1969).
307