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COMPARATIVE STUDY BETWEEN OUTCOME OF EARLY AND CONVENTIONAL CATHETER REMOVAL AFTER TRANSURETHRAL RESECTION OF PROSTATE

Objectives: To compare the effect of early and conventional catheter removal after TURP. Methods: The cases were selected from the admitted patients with BPH by using simple purposive sampling technique. Sixty (60) cases were included in the study fulfilling selection criteria of the patient and numbered chronologically according to their data and time of operation. Odd numbers of cases were included in group-A (n=30) for early catheter removal within 48 hours and even numbers of cases in group-B (n=30) for conventional catheter removal within 3-5 days. Results: Postoperative hospital stay 47.12 (±7.92) hours in group A and 113.23(±10.8) hours were in group B (p<0.001) that was statistically highly significant. Conclusion: Early catheter removal within 48 hours following Transurethral Resection of Prostate (TURP) is safe. It reduces the catheter related morbidity and postoperative hospital stay.


Introduction:
Benign Prostatic Hyperplasia (BPH) is the most common disease in male and its incidence is age related. Prevalence of BPH is 88% in 80 years and reaching nearly 100% in 90 years of age 1 .
BPH conveys its morbidity through lower urinary tract symptoms (LUTS) and complications such as acute urinary retention, obstructive uropathy, urinary tract infections, renal insufficiency. To prevent complications intervention is necessary. Although the management of BPH has been dramatically modified during the past decade, transurethral resection of prostate (TURP) remains the gold standard 2 .
In recent years issues of cost, morbidity and complications have lead to the development of new surgical treatment modalities such as transurethral needle ablation, microwave thermotherapy, laser ablation and vaporization 3 . Conventional catheterization period (3-5 days) after TURP and prolong hospital stay is an obstacle, as patient cannot be able to resume his normal life early. Length of hospital stay after TURP due to prolong post operative catheterization is considered to be cost disadvantage when compared with new treatment methods. These disadvantage can be overcome by means of early catheter removal (<48 hours) after TURP when it is appropriate and safe 4,5 .
Conventionally it is practiced among the urologist to remove the catheter following TURP from 3rd to 5th POD. However, in recent years a policy of early catheter removal has arisen. Catheter removed on 2 nd POD, 1 st POD and day case TURP have been found to be safe and effective in selected patients 4,6 . In Bangladesh, continuous debate has been going on among the Urologists about post TURP catheterization period. This study has been designed to compare the result of catheter removal within 48 hours and conventional catheter removal (3-5 days) following TURP.

Methods:
A hospital based quasi-experimental study was conducted in the Department of Urology of Sir Salimullah Medical College Mitford Hospital Dhaka from October 2012 to March 2014, on patient with bladder outlet obstruction due to benign prostatic hyperplasia (BPH) managed by transurethral resection of prostate (TURP). The cases were selected from the admitted patients with BPH by using simple purposive sampling technique. Sixty (60) cases were included in the study fulfilling selection criteria of the patient and numbered chronologically according to their data and time of operation. Odd number of cases were included in group-A (n=30) for early catheter removal within 48 hours and even numbers of cases in group-B (n=30) for conventional catheter removal within 3-5 days All patient were evaluated by history, physical examination including DRE, IPSS Score (in non catheterized patients), urine-R/M/E & C/S, serum electrolytes, serum creatinine, serum PSA, USG of KUB and prostate with MCC and PVR, uroflowmetry, RBS, CXR, ECG with Echocardiography-2D in selected cases, blood grouping and Rh-typing with screening & cross matching. Patients with documented UTI were treated with appropriate antibiotic and became culture negative before surgery.
Prophylactic injectable antibiotic was given according to urine C/S just before induction of anaesthesia. After urethrocystoscopic evaluation TURP was done by Nesbit technique. A 26 Fr. Resectoscope with continuous sheath (Storz) was used during TURP and 1.5% W/V Glycine were used as irrigation solution during procedure in all cases. At the end of resection, interior of the prostate was inspected thoroughly and all bleeding vessels were coagulated and haemostasis was ensured.
Operation was completed if color of effluent was almost clear or faint pink and water test was good. A 22 Fr. Trichannel urethral Foley catheter was introduced into bladder and its balloon was inflated with 40-60 ml distilled water. Continuous bladder irrigation started immediately with normal saline. Catheter traction was applied for 6 hours.
In the post-operative period all patients were monitored closely for vital parameters, color of catheter effluent to asses degree of hematuria, clot retention and transurethral resection syndrome. Patient resume a normal diet and ambulated as soon as recovered from anaesthesia. Patients were given a stool softener and cautioned to avoid straining at defecation.
Criteria for catheter removal included normal vital signs. Adequate urine output, absence of clots, the color of catheter effluent (clear) and physical status which permits independent voiding. In immediate postoperative period (within 6 hours) who met the criteria for catheter removal irrigation was decreased at 10 drops/min and urethral catheter was removed within 48 hours in group-A and within 3-5 days in group-B after TURP. In all patients urine sample was collected for culture and sensitivity just before catheter removal. Most of the patients were discharged with advice after they could pass urine freely and with a good stream of 2-3 times. Discharge was delayed until the next day if there is any complication such as voiding difficulties, fever or if the urine is unexpectedly bloody.
All cases were followed up at 14th POD and at 1 month for further clinical evaluation. During postoperative period every patient was instructed to report in urology ward if there is any bleeding, urinary retention, and fever after discharge from hospital.

Results:
A total of 60 cases of benign enlargement of prostate patients were selected for the purpose of the study. All of them were treated with TURP and 30 patients catheter was removed within 48 hours in Group-A and 30 patients catheter was removed conventionally 3-5 days in Group-B.
No statistically significant difference found regarding age, weight of prostate, resection time, weight of resected prostatic tissue, preoperative UTI, IPSS, PVR and Qmax as well as postoperative hematuria, urinary retention and UTI after catheter removal.
Postoperative hospital stay 47.12 (±7.92) hours in group A and 113.23(±10.8) hours were in group B (p<0.001) that was statistically highly significant.
Postoperative IPSS, PVR and Qmax after catheter removal were improved significantly in both groups in 14 th POD and 1 month after operation. But there was no statistically significant difference among the groups.

Discussion:
TURP is the gold standard for management of BPH 2 . Although there is nearly 100% consensus amongst urologists on the necessity of using a foley catheter, we are not unanimous in identifying when the catheter should be removed. The most important parameters in determining the time of catheter removal are normal vital signs, adequate urine output, absence of clot and acceptable character of the catheter effluent 4 .
In this study mean age 68.59 (±5.67) yrs were in group A and 69.56(±4.86) yrs were in group B. It is similar to the age group mentioned by Agarwal SK et al. (1995) where mean age was 69.9yrs.
In present study comparison of the mean weight of the prostate between two groups, 45.6 (±12.75) gm were in group A and 44.7 (±11.83) gm were in group B (p>0.05) that was not statistically significant.  In present study post-operative urinary retention after catheter removal was present 03(10%) in group A and 01(3.3%) in group B (p>0.05) that was not statistically significant. The predominant management of complication in previous studies were reinsertion of the catheter, which was required in 12-14% of patients in one study by Dodds et al. (1995) and 17.5% in another by Gordon. Above study including my study show that early catheter removal following TURP does not significant increase the incidence of urinary retention.
In this study post-operative urine culture and sensitivity was done and the culture showed significant bacterial growth (colony count >1X 10 5 CFU/ml) in 14 cases. Among them 06(20%) was in group A and 08(26.67%) in group B (p>0.05) that was not statistically significant.
In study of Nakagawa and Toguri (2006)

Conclusion:
Early catheter removal within 48 hours following Transurethral Resection of Prostate (TURP) is safe, reduces the catheter related morbidity and postoperative hospital stay.