Urethral catheter removal 3 days after radical retropubic prostatectomy is feasible and desirable

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1 Urethral catheter 3 days after radical retropubic prostatectomy is feasible and desirable (2002) 5, ß 2002 Nature Publishing Group All rights reserved /02 $ JM Albani 1 * & CD Zippe 1 1 Section of Urologic Oncology, Urological Institute, Cleveland Clinic, Cleveland, Ohio, USA The purpose of this work was to assess the feasibility of urethral catheter 3 days after radical retropubic prostatectomy (RRP). Twenty-two patients who underwent RRP with a watertight eight-suture vesicourethral anastomosis had their urethral catheter removed usually on postoperative day (POD) 3. The average day of urethral catheter was POD 3.2. At 3 months, 56% of patients required no or one protective pad to stay dry and 68.4% of patients never leaked or leaked occasionally. Following RRP, the urethral catheter can be removed as early as POD 3 if the intraoperative anastomosis is watertight without compromising urinary continence. (2002) 5, doi: /sj.pcan Keywords: prostatectomy; catheterizaton; quality of life; continence Introduction The conventional urethral catheterization period after radical retropubic prostatectomy is 2 3 weeks. 1,2 This prolonged period of catheter drainage is a significant source of postoperative discomfort and is not supported by objective data. Removal of the catheter as early as possible without compromising postoperative outcome minimizes patient morbidity. Recent laparoscopic techniques for RRP have demonstrated impressive continence rates (over 84%) with early urethral catheter (2 4 days). 3 5 The objective of the current prospective study is to introduce a comparable open prostatectomy catheter pathway with urethral catheter in 3 days. Materials and methods Between January and June 2001, 22 consecutive patients underwent RRP with a watertight eight-suture (interrupted 2-0 PDS) vesicourethral anastomosis (VUA) by *Correspondence: JM Albani, MD, Urological Institute, A-100, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA. Received 10 February 2002; revised 5 April 2002; accepted 18 April 2002 a single surgeon (CZ) for clinically localized prostate cancer. One patient with a postoperative ileus and prolonged catheterization (7 days) was excluded from the study and two international patients were lost to followup. Thus, 19 of these patients (86.4%) were available for a follow-up of 3 months. Fifteen of these patients (78.9%) had their infraumbilical incision closed with a subcuticular suture, eliminating the need for the follow-up office visit for staple. Mean patient age was 60.6 y (range 47 71). Clinical stage was T1 in seven patients and T2 in 12 patients. An intraoperative watertight anastomosis was defined as careful inspection confirming no extravasation or only minimal seepage after instilling 120 cc of normal saline through the urethral catheter after all eight interrupted sutures were tied down. Gravity cystograms were performed on POD 3 for the initial 10 patients prior to catheter. The bladder was filled with cc of contrast until the patient noticed a sense of fullness and discomfort. Anteroposterior, oblique, and postdrainage films were then obtained. Subsequent cystograms were performed only if the intraoperative findings demonstrated extravasation. A control group was created from a retrospective review of a contemporary series of 26 patients (same surgeon) who underwent RRP from April to December These patients had their urethral catheter removed after a standard catheterization period of 14 days. Twenty-three of these patients (88.5%) were available for an equivalent follow-up. Mean patient age was

2 y (range 47 72). Clinical stage was T1 in 11 patients, T2 in 10 patients and T3a (adjuvant chemotherapy protocol) in two patients (Table 1). Both groups completed a telephone-questionnaire administered by an independent urologic physician to assess their urinary continence at 3 months postoperatively and to report any postoperative complications including urinary retention or vesical neck contracture. In addition, patients were asked to identify their greatest source of immediate postoperative complaints by selecting from one of four choices including: (1) incisional pain, (2) limited mobility; (3) urethral foley; and (4) bowel Table 1 Characteristic Patient demographics Early catheter (n ¼ 19) Regular catheter (n ¼ 23) P-value Age (y) PSA (ng/dl) Clinical Stage T1c 7 (36.8) 11 (47.8) T2a/b 10 (52.6) 9 (39.1) T2c 2 (10.5) 1 (4.3) T3a a 0 (0.0) 2 (8.7) Ave POD Foley out POD ¼ postoperative day; PSA ¼ prostate specific antigen; ( ) ¼ percentage; a Patients treated with preoperative adjuvant chemotherapy docetaxel (Taxotere) 6 weeks prior to surgery. complaints (Figure 1). Patients also indicated if they would rather remain in the hospital an extra day if they could be discharged without the urethral catheter. Control patients who were discharged home with the catheter were asked to assess their Bother Score from the urethral catheter on a scale from 0 1 (no bother) to 4 5 (greatly bothersome). Two separate instruments were employed to most accurately assess urinary continence: patients objectively reported the number of pads per 24 h period required to stay dry. Subjectively, patients chose from a previously validated quality of life survey qualifying their urinary incontinence ( never leak to no control ). 6 Statistical analysis comprised of a two-tailed Student s t-test, with statistical significance indicated at P < Results The average day of urethral catheter was 3.2 days after RRP with 84.2% (16/19) removed on POD 3, and 15.7% (3/19) removed on POD 4. All patients had their catheter removed prior to discharge. Three of these patients remained in the hospital for 4 days due to transportation issues only. All intraoperative VUAs performed in this study were watertight upon inspection. Gravity cystograms were performed on POD 3 for the initial 10 patients of the study. These demonstrated no extravasation, confirming the intraoperative findings of a Figure 1 Telephone questionnaire.

3 watertight anastomosis. Subsequent cystograms were not deemed necessary and not performed. In this follow-up interval, no patient required urethral catheterization for urinary retention and no vesical neck contractures were observed. In the control group, two patients (8.9%) developed a bladder neck stricture and no patients developed acute urinary retention. Three months after RRP, 42.1% of the early catheter group required no pads and 15.8% required one pad to stay dry and 31.6% never leaked while 36.8% only leaked occasionally. The early catheter group required an average of 2.2 pads per day to stay dry and was not different from the control group s requirement (2.4 pads per day). There was no statistical difference in the number of patients that never leaked or only leaked occasionally between the two groups, nor in the number of patients with no control 3 months after RRP (Table 2). Table 2 Urinary continence 3 months after catheter Postoperative continence Early catheter (n ¼ 19) Regular catheter (n ¼ 23) P-value Total number of pads/day pads/day 8 (42.1) 7 (30.4) 1 pad/day 3 (15.8) 2 (8.7) 2 4 pads/day 4 (21.1) 9 (39.1) > 4 pads/day 4 (21.0) 5 (21.8) Never leak 6 (31.6) 2 (8.7) Leak occasionally 7 (36.8) 12 (52.2) Leak weekly 0 (0) 2 (8.7) Leak daily 1 (5.3) 4 (17.4) Dribble occasionally 2 (10.5) 1 (4.4) Dribble frequently 3 (15.8) 1 (4.3) No control 0 (0) 1 (4.3) ()¼ percentage. In response to the question, What was most bothersome to you immediately after surgery? 78.3% of the control patients reported that the urethral catheter was their greatest source of postoperative discomfort and more bothersome than incisional pain, limited mobility or bowel complaints (Figure 2). When asked to rate a bother score regarding the urethral catheter postoperatively, 60.9% patients were greatly bothered, 30% were somewhat bothered, and 9% noted little or no bother (Figure 3). When given the option to remain in the hospital an extra day if they could be discharged home without the catheter, 100% of patients (both groups) preferred to stay an extra day. Discussion While the recent laparoscopic techniques of Abbou, Guillonneau, Vallancien, and Gill have introduced a catheter protocol of 2 4 days, early catheter is not a novel idea. Several groups performing open RRP have investigated early catheter (Table 3). In 1989, Dalton et al were the first to establish an early catheter protocol determined by negative cystography. 7 In this series, 55 consecutive radical prostatectomy patients underwent gravity cystography to direct early catheter. Cystograms were performed on POD 7 and repeated on POD 11 and 14 if moderate or severe extravasation was noted. The catheter was removed if no extravasation was evident. This led to catheter-free status in patients in 22%, 62%, 80% of patients by POD 8, POD 11, and POD 14, respectively. With an average follow-up of 8 months, 84% of patients reported excellent control, 18% developed anastomotic strictures and 9% developed acute urinary retention after the catheter was removed. The author concluded that a 293 Figure 2 Greatest source of immediate postoperative complaints. Figure 3 Bother score from urethral catheter. Table 3 Early catheter investigations Study Avg. POD Foley out No. Pts Anastomosis Surgeons VNC (%) Retention (%) Cystography Control Continence (%) F/U Mean (mo) Open RRP Dalton, sutures Multiple Yes No Little Jr, sutures Multiple Yes No Coogan, sutures Multiple Yes No Souto, or 5 e sutures Multiple Yes Yes 46.7 a, 83.3 b 13.7 Santis, sutures Single No No Lepor, sutures Single Yes Yes Albani, sutures Single Yes, initially Yes 57.9 c, 68.4 d 3. Laparoscopic RRP Abbou, hemicirc f Multiple NR No 84.% 1.mo Guillonneau, sutures (interrupted) Multiple NR NR No No NR NR Nadu, days 96 Continuous Multiple Yes No 93.% 7.mo a Early cotinence not defined; b late continence not defined; POD ¼ postoperative day; c based on no. pads/day; d subjective evaluation; VNC ¼ vesical neck contracture; e average not clearly defined; f first 10 patients, interrupted sutures, then two hemicircumferential running sutures; NR ¼ not recorded.

4 294 negative cystogram could safely direct early catheter. In a pilot study at Indiana University in 1995, Little et al removed the catheter prior to hospital discharge on POD 3 or 4 if minimal or no extravasation was noted on cystography. 8 Twenty-seven of 33 (82%) patients had their catheter removed at a mean of POD 4.2. With a mean follow-up of 8.5 months, urinary continence was reported as excellent (no pads) in 70%, clot retention was reported in 3.7% and no anastomotic strictures were noted. Two years later at the same institution, Coogan et al updated the previous study with an extended follow-up of 17.4 months. 9 In this updated series of 43 patients, the mean catheter was 4.1 days after RRP and continence rates were reported as excellent (no pads required for urinary leakage) in 69%. Postoperative complications included one patient who required catheter reinsertion and one patient who developed an anastomotic stricture. Recently, Souto et al reported the Brazilian experience with early urethral catheter. 10 In this series, 30 of 42 (71.4%) patients had their catheter removed after negative cystography on POD 4 or 5. While not clearly defined, early and late continence were stated as 46.7% and 83.3% with a mean follow-up of 13.7 months and did not differ significantly from a control group who underwent catheter at 14 days. Postoperative complications included a urinary retention rate of 6.7% and no patients with early catheter experienced a vesical neck contracture. Santis et al also recently retorted the outcome of 100 consecutive patients undergoing early catheter. In this series, the urethral catheter was removed at an average of 8.5 days after RRP with cystography performed only on the initial five patients. 11 At a mean follow-up of 21 months, 76% of patients required no pads, 2% developed urinary retention, and 9% developed a vesical neck contracture. In a recent publication, Lepor et al reported a series of 100 prostatectomy patients who underwent cystography on POD 7 and subsequently had the catheter removed early if no extravasation was present. 12 In this series at 3 months after surgery, 72% of men required no or a single pad to stay dry. Postoperative complications included a 12% incidence of acute urinary retention and 2% incidence of anastomotic strictures. These outcomes were not significantly different from control patients (same surgeon) who had their catheter removed at 14 days. Our study is unique in that it is the first reported series of RRP performed by a single surgeon incorporating a 3- day early catheter discharge protocol. Like other investigations, this study incorporated cystography initially to confirm the integrity of the VUA postoperatively. However, we were able to accurately assess the anastomosis intraoperatively and to correlate this with the radiographic findings of no extravasation. This precluded the need for further cystography since a known watertight eight suture anastomosis was performed. All patients in our study had their catheter removed prior to discharge, with 84.2% (16/19) removed on POD 3 and 15.7% (3/19) removed on POD 4 and all patients (100%) demonstrated the desire to be discharged from the hospital without the catheter. No significant difference in continence outcomes or postoperative complications were noted when compared to the contemporary controls, suggesting that early catheter does not compromise established post RRP outcomes. Our early continence data were comparable to those reported in Leport et al after catheter on POD 7 and other reports of early continence in the literature. 13 At our institution, the evolution of laparoscopic RRP has stimulated our interest in an early catheter pathway. With the progression of an interrupted eight suture anastomosis to the current continuous method of VUA, urethral catheter 3 5 days after laparascopic RRP with a negative cystogram has become standard practice. The high percentage of watertight anastomoses and negative cystography associated with a running vesicourethral anastomosis led to the modification in our open surgical technique from a six to an eight suture vesicourethal anastomosis. This eight suture closure best reproduces the running anastomosis and is consistent with the number of sutures placed by surgeons experienced in perineal prostatectomy. Certainly as with any new protocol, caveats exist and there were limitations in our study. Our retrospective control group may have had difficulty accurately recollecting their bother rate or continence long after their surgery. In addition, while no postoperative complications were noted in the early catheter group, the short follow-up interval may have under-reported these complications and thus failed to recognize potentially significant consequences such as urinary leaks, pelvic abscesses, or urethral strictures. Controlled, randomized, prospective studies with extended postoperative followup are needed to address these limitations properly. Conclusions Following RRP, there is evolving evidence that the urethral catheter can be removed as early as POD 3 when the intraoperative anastomosis is watertight. Several investigations have demonstrated that negative cystography allows one to remove the urethral catheter early and to do so safely. Our series suggests that an eight suture watertight VUA allows the urethral catheter to be removed at 3 days prior to hospital discharge. Early catheter is desirable with the majority of patients reporting the catheter as their greatest source of postoperative complaints and 100% of all patients preferring to stay an extra day in the hospital to be discharged without the catheter. Whether an eight suture VUA best simulates a running anastomosis in providing a watertight anastomosis remains to be seen, but early results are encouraging. Undoubtedly, our study and prior investigations clearly demonstrate that the longstanding nonevidence based standard catheterization period of 2 or even 3 weeks after RRP warrants further review. References 1 Walsh PC. Anatomic radical retropubic prostatectomy. In: Walsh PC, Retik B, Vaughn ED et al (eds). Campbell s Urology, 7th edn. WB Saunders: Philadelphia, 1998, pp

5 2 Sanda MG, Osterline JE, Montie JE. Postoperative care. In: Resnick MI, and Thompson IM Jr (eds). Surgery of the Prostate. Churchill Livingstone: New York, Abbou CC et al. Laparoscopic radical prostatectomy: Preliminary results. Urology 2000; 55: Guillonneau B, Vallancien G. Laparoscopic radical prostatectomy: The Montsouris Technique. J Urol 2000; 163: Nadu A et al. Early of the catheter after laparoscopic radical prostatectomy. J Urol 2001; 166: Litwin M et al. Quality-of-life outcomes in men treated for localized prostate cancer. JAMA 1995; 273: Dalton DP et al. Radiographic assessment of the vesicourethral anastomosis directing early decatheterization following nervesparing radical retropbubic prostatectomy. J Urol 1989; 141: Little S Jr et al. Early urethral catheter following radical prostatectomy: a pilot study. Urology 1995; 46: Coogan C et al. Urethral catheter prior to hospital discharge following radical prostatectomy. Urology 1997; 49: Souto CA et al. Experience with early catheter after radical retropubic prostatectomy. JUrol2000; 163: Santis WF, Hoffman MA, Dewolf WC. Early catheter in 100 consecutive patients undergoing radical retropubic prostatectomy. BJU Int 2000; 85: Lepor H, Nieder A, Fraiman M. Early of urinary catheter after radical retropubic prostatectomy is both feasible and desirable. Urology 2001; 58: Kielb S et al. Assessment of early continence recovery after radical prostatectomy: patient reported symptoms and impairment. J Urology 2001; 66: