Wednesday, August 17, 2011

Managing The Catheter After Prostatectomy Part II: After The Catheter Is Removed

In my last post, I explained the need for maintaining a catheter after a prostatectomy.  I also described what to expect with the catheter in place as well as red flags that may signal that something is wrong.  For men undergoing prostatectomy, the catheter can, indeed, be a daunting part of the journey.  Most men are quite relieved when the catheter is finally removed 1-2 weeks after the surgery.  Removing the catheter, however, is just another step in the recovery after prostatectomy.  After the catheter is removed, a whole new set of expectations and warning signals emerge that need to be understood by men after prostatectomy.  In this post, I will cover what to expect and look out for in the period immediately following the removal of the urinary catheter.

The Catheter Comes Out

For most men, the removal of the catheter is a very much anticipated milestone in the journey of recovery after prostatectomy.  The actual process of removing the catheter is not a huge undertaking, although it may appear a little daunting.  As I explained in my last post, the catheter is maintained in place by means of a balloon inflated within the bladder.  In order to remove the catheter, the doctor or nurse will attach a syringe to a port on the catheter and suck out the fluid from the balloon.  Once the balloon is deflated, the doctor can simply slide the catheter out from the penis.  Most patients describe the feeling of the catheter coming out as a “pop” that lasts for 1-2 seconds and then is associated with a feeling of relief.  In some men, the sensation can be more painful and last a little longer.

Some doctors will fill the bladder with fluid through the catheter prior to removing it.  The doctor will infuse water or saline through the catheter until the patient feels full and needs to urinate.  At that point, the catheter is removed and the patient is allowed to urinate.  The reason for this extra step is to make sure that the patient is able to urinate after the catheter is removed.  Other doctors simply remove the catheter and have the patient return if they cannot urinate.  Either way, the process last 1-5 minutes and is usually much less traumatic than anticipated.

What to Expect Post Catheter

  1. Leakage:  As I explained in a previous post, most if not all men leak urine immediately after the catheter comes out.  This leakage is due to the fact that the muscle responsible for controlling urination, the sphincter, needs to strengthen after the surgery.  While some men leak only a few drops with heavy activity, others leak profusely without much exertion at all.  Regardless, most men will regain continence within the first year after surgery.  As I mentioned in a previous post, some actions can be taken to expedite the process and regain continence sooner:
  2. Frequent urination:  A prostatectomy is generally very traumatic for the bladder.  First, the plumbing below the bladder is rearranged.  In addition, during the surgery, the bladder is opened and repeatedly manipulated. Finally, the bladder is continuously irritated by the catheter for 1-2 weeks after surgery.  As a result, by the time the catheter is removed, the bladder is usually very irritated.  The same contractions of the bladder that occurred with the catheter in place often continue after it is removed.  These bladder spasms cause the frequent urge to urinate even when not much urine is present.  As a result, men sometimes complain that they are constantly running to the bathroom to urinate after the catheter is removed.  Fortunately, as the bladder adjusts to life without the catheter, this frequency and urgency of urination diminishes.
  3. Slight blood in the urine: While in the bladder, the urinary catheter often puts pressure on the bladder and urethra, holding back any minor bleeding from some small veins that may be opened or cut during the surgery.  Once the catheter is removed, these veins may ooze a little.  Also, some old blood trapped by the catheter may be released once the catheter is removed.  As a result, some men do complain of some blood in the urine after the removal of the catheter.  This usually makes the urine look pink or cranberry colored and resolves within a few days.
  4. Burning with urination: After a prostatectomy, the urethra and bladder are often “raw” from irritation from both the surgery and the catheter.  As a result, many men do complain of some burning each time they urinate.  This feeling usually goes away after a day or two.

Warning Signs After Catheter Removal

  1. Inability to urinate: A small minority of men are unable to urinate after the catheter is removed.  For most men, this problem is caused by swelling at the surgical connection between the bladder and urethra called the anastamosis.  This problem is usually solved by reinserting the catheter and keeping it in for another week or so to allow time for the swelling to subside.  Some doctors also give medicine to help speed up the process.  Either way, with a little time, the swelling usually goes away and the ability to urinate returns.  As I mentioned in my previous post, replacement of the catheter after a prostatectomy should only be performed by the urologist.  Improper placement can lead to a disruption of the anastamosis, an emergent return to the operation room, and a lifetime of incontinence.
  2. Significant blood in the urine:  While a small amount of blood in the urine is normal, urine that looks like pure blood is not.  This is especially true if large blood clots are also noted to pass in the bloody urine for a prolonged period of time.  This type of blood in the urine is a sign of ongoing bleeding that needs to be addressed.  Usually, it is due to bleeding from outside the prostate and bladder that is seeping in through the anastamosis.  Without a catheter in place, such bleeding can create a large blood clot (called a hematoma) in the pelvis and actually rip open the anastamosis, separating the bladder from the urethra.  Such a complication can be prevented through early recognition and management of the problem.  Again, such problems after prostatectomy should only be managed by the urologist and not by emergency room staff. 
  3. Air or debris in the urine:  Occasionally, after the catheter is removed, a patient may complain of passing some air through the penis when urinating.  While this can be normal for the first few times after catheter removal (because air was introduced into the bladder from the indwelling catheter), sustained air in the urine is definitely not normal.  Similarly, small bits of debris in the urine can be occasionally seen after the catheter is removed.  These bits are old blood clots.  However, continued passage of air and debris in the urine after catheter is a sign of a fistula between the urethra and the rectum.  A fistula is an artificial connection which allows contents from one organ to be passed to another.  In this case, an unrecognized injury to the rectum during a prostatectomy allows a hole in the rectum to attach itself to the anastamosis or a small hole in the urethra.  With time, this fistula grows and matures, allowing more and more air and stool to be passed into the urine from the rectum.  On occasion, urine is also allowed to pass into the rectum, causing diarrhea.  If this problem is not addressed in a timely fashion, the mixing of urine and stool can cause a serious and occasionally life threatening infection.

Take Home Message

The removal of the urinary catheter is an important milestone in the recovery from a radical prostatectomy.  The actual process of removing the catheter is usually very quick and straightforward, resulting in minimal discomfort.  Nonetheless, some common issues should be expected after removal, including leakage and some burning with urination.  In addition, patients having their catheters removed should know about red flags such as the inability to urinate as well as blood, air, or debris in the urine.  Reporting these issues to the urologist expediently can prevent significant problems from becoming dramatically worse.

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Tuesday, August 9, 2011

Managing The Catheter After Prostatectomy Part I: Expectations And Warning Signs

Men undergoing prostatectomy for prostate cancer face a recovery period that is somewhat different from other surgeries.  Unlike other surgeries, a radical prostatectomy requires a patient to wear a urinary catheter for 1-2 weeks after surgery.  This catheter is a narrow rubber hose that transports urine from the bladder, through the penis, and out to a bag outside of the body.  As you can imagine, this catheter takes some getting used to.  While most men do adjust well, others can have problems dealing with the catheter as well as complications associated with the device.  In this post, I will explain why a catheter is necessary after prostatectomy, what to expect when the catheter is in place, and common problems to look out for during this period.

Why is a Catheter Necessary?

In a previous post, I described the anatomy of the prostate and its relation to the bladder and urethra.  I think the best way to picture that layout is to imagine the bladder as an upside down fishbowl that pours urine through a donut (the prostate), and into a straw (the urethra within the penis).  During a prostatectomy, the prostate is removed and the bladder is directly connected to the urethra via stitches.  A catheter is passed through this connection (called the anastomosis) to allow it to heal without being disturbed by urine.  Generally, an anastomosis needs to keep dry to allow proper healing.  Otherwise, urine will leak through the anastomosis, creating a contracture (narrowing composed of scar tissue) which can impede the normal flow of urine out of the bladder. 

The amount of time the catheter spends in place depends on the type of prostatectomy performed.  For men undergoing open or traditional prostatectomy, the catheter time is usually 10-14 days.  In contrast, those men undergoing robotic prostatectomy usually only have to wear a catheter for 5-7 days.  This disparity has to do with the different ways the anastomosis is created in the two surgeries.  Robotic surgery tends to create an anastomosis that is usually more water tight and, so, heals a bit quicker.  As a result, the catheter does not need to stay in as long.

Common Complaints about the Catheter

1.      I feel like I am sitting on a ball:  One of the most frequent complaints I hear from men immediately after surgery is that they feel that they are sitting on a ball.  The reason for this feeling is often the part of the catheter located in the bladder.  The catheter is kept in place via an inflatable balloon which sits in the bladder.  After the catheter is placed, the balloon is inflated which prevents the catheter from sliding out the urethra.  This balloon is then deflated just prior to removal of the catheter.  Men often complain about feeling like they are sitting on a ball because they are actually sitting on one: the balloon of the catheter.  Fortunately, most men get adjusted to this feeling over time.

2.      I need to urinate:  Most men waking up from a prostatectomy will feel an overwhelming desire to urinate.  Even when they are told that they have a catheter in place draining their urine, they still feel like they have to urinate but cannot.  This uncomfortable feeling is also caused by the balloon in the bladder.  The bladder is used to nothing but urine within it at any time.  As a result, the presence of a foreign body in the bladder (the catheter/balloon) is highly irritating to the bladder.  To try to rid itself of the irritant, the bladder contracts.  Because the catheter is in place, this bladder contraction (called a bladder spasm) just pushes the urine located within the bladder out into the bag.  Because the balloon remains in place however, the bladder continues to try to expel it through repeated spasms.  In most men, this very bothersome desire to urinate goes away within a day or so.  For some men, however, the feeling persists.  Fortunately, there are pills available that can be given in the hospital and at home which relax the bladder, relieving the bladder spasms and the overwhelming desire to urinate.

3.      I have pain at the tip of my penis: This sensation is also caused by the bladder spasms described above.  Nerves travelling from the bladder to the tip of the penis are stimulated by the spasms and create pain impulses travelling down the shaft of the penis and to the tip.  Of course, the very presence of the catheter in the penis also leads to some discomfort.  Medicine for bladder spasms often decreases this pain in the penis as well.

4.      I have blood in the urine:  A small amount of blood in the urine can be normal.  After all, surgery can lead to bleeding and a prostatectomy is certainly no exception.  As a result, the urine can be light pink for a day or two after surgery.  In addition, a small amount of blood in the urine may be noticed after walking with the catheter in place.  This bleeding is caused by the balloon from the catheter rubbing on the bladder.  Nothing really needs to be done for this amount of blood in the urine.

In contrast, pure blood or clots coming out of the catheter and into the bag is a serious problem that requires immediate attention.  This is a sign of serious bleeding, usually outside of the bladder, that creeps in through gaps in the anastomosis.  Such bleeding can cause disruption of the anastomosis and actually break the bladder free from the urethra. In severe cases, such bleeding may require a return trip to the operating room to stop the bleeding and repair the anastomosis.  Often times, however, it only requires washing out the blood from the bladder by irrigating the bladder through the catheter with saline or sterile water.  In any case, significant blood in the urine is a red flag which deserves immediate attention from a physician.

5.      My catheter is not draining: This, too, can be a serious problem. While in place, a catheter is a life line for a man after prostatectomy.  It is the only conduit allowing urine to leave the body.  As a result, if the catheter malfunctions, there is no way for the urine to exit the bladder.  Sometimes, men identify a catheter malfunction when they notice that the bag into which the urine drains is empty for a prolonged period of time.  In other cases, however, a malfunctioning catheter can cause significant pain as trapped urine accumulates in the bladder and stretches it.

A malfunctioning catheter that does not drain urine is truly an emergency.  Allowing the bladder to distend too far can lead to a disruption of the anastomosis or even rupture of the bladder.  As a result, I always tell my patients that if the catheter does not work, they need to seek medical attention right away.  Because catheter malfunctions follow Murphy’s Law, they usually occur in the middle of the night, when the urologist’s office is closed.  As a result, a malfunctioning catheter often leads to a visit to the emergency room.  This is where it gets tricky.  As I mentioned before, the catheter is a life line after prostatectomy.  As such, it has to be treated with caution.  Removing the catheter prematurely or attempting to replace the catheter with another can create significant damage that may require a return to the operating room.  Such damage can cause a lifetime of incontinence.  That is why management of a malfunctioning catheter after a prostatectomy should ONLY be undertaken by an urologist.  An emergency room nurse or physician should NOT try to fix it, even if they have the best intentions.  I tell my patients to NEVER allow anyone other than an urologist to manipulate the catheter after a prostatectomy.  The stakes are just too high.

6.      I am draining urine around the catheter: Once in a while, after a prostatectomy, a patient calls me to tell me that urine is draining out of his penis around the catheter.  This problem is caused by one of two problems.  In some men, bladder spasms can be so severe that urine is expelled both through and around the catheter.  In other men, a malfunctioning catheter can distend the bladder to the point that trapped urine escapes around rather than through the catheter.  These two scenarios can often be distinguished by whether or not some urine is draining through the catheter and into the bag.  Bladder spasms will usually cause urine to drain both through and around the catheter.  A malfunctioning catheter, in contrast, will not allow drainage into the bag so urine will only be seen leaking out of the penis.  Regardless, drainage of urine around the penis should be expeditiously addressed by an urologist.

Take Home Message

The urinary catheter can make recovering from a prostatectomy a difficult endeavor.  For those men who never had to wear a catheter previously, the experience can be quite scary and foreign.  However, understanding what to expect can prevent a great deal of unnecessary anxiety.  Similarly, knowing what red flags to look for can prevent significant discomfort and complications.  In my next post, I will cover the next step in the catheter saga: what to expect when the catheter is removed.

This blog is not a medical practice and cannot provide specific medical advice. This information should never be used to replace or discount the medical advice you receive from your physician

Monday, August 1, 2011

Lymph Nodes And Prostate Cancer Part II: When The Lymph Nodes Are Positive

In my last post, I discussed lymph node dissection for men undergoing prostatectomy.  Specifically, I focused on who does and does not need a lymph node dissection based on the risk of lymph node involvement by prostate cancer.  But what happens when prostate cancer is actually identified in the lymph nodes?  In the past, managing men with lymph node positive prostate cancer was not very complicated.  Most men were monitored until symptomatic spread of the cancer was noted.  After symptoms of metastatic disease emerged, palliative therapy with hormones was initiated.  The prognosis was always poor.  Today, however, the situation is quite different.  First, the prognosis is not the same for all men with lymph node positive disease but, rather, varies with the extent of lymph node involvement.  Also, therapy is usually initiated very soon after lymph node disease is diagnosed.  Finally, different treatment modalities are being implemented beyond just hormonal therapy.   In this post, I will describe these new approaches to treating men with prostate cancer in the lymph nodes.

Not All Lymph Node Positive Prostate Cancer Is The Same

When I was training to be an urologist, all men with prostate cancer found in the lymph nodes were lumped into one category.  These men were generally given a relatively poor prognosis with a 10 year survival rate ranging from 50-80% depending on whether or not they received hormonal therapy.  Recently, however, studies have demonstrated that not all lymph node disease is the same.  Men with greater than 2 lymph nodes involved by prostate cancer, for example, have been shown to have more than twice the likelihood of dying from prostate cancer as compared to those men with 2 or fewer positive lymph nodes.  After 10 years of follow up, the cancer-specific survival rates (chances of surviving prostate cancer) for these two groups were reported to be 33% and 79%, respectively.  Similar differences were noted based on the density of positive lymph nodes.  One study, for example, compared the outcomes of men in whom less than 20% of the lymph nodes removed (during a dissection) were found to harbor cancer with those of men in whom greater than or equal to 20% of the lymph nodes removed were cancerous.  The study reported that those men with the lower percentage of positive lymph nodes (<20%) enjoyed a 72% chance of living free of metastatic disease after 10 years as compared to only 47% of men with the greater density of positive lymph nodes. 

When Should You Start Treatment For Lymph Node Positive Prostate Cancer?

When prostate cancer invades the lymph nodes, it is considered to be metastatic.  As a result, as I mentioned previously, treatment for men with lymph node positive disease in the past was often delayed until symptoms were noted.  The reasoning for this treatment approach was that, because the cancer is already metastatic and hormonal therapy is palliative as opposed to curative, there is no compelling reason to start treatment right away. After all, what is the rush in treating a cancer that you cannot cure, right?  In 1999, however, a study was published in the New England Journal of Medicine, which completely refuted this line of thinking.  The study evaluated a group of about 100 men diagnosed with lymph node positive prostate cancer.  About half of these men received hormonal therapy immediately after diagnosis, while the other half did not receive treatment until they developed symptomatic metastatases.  The study reported that after 7 years, 85% of men undergoing immediate hormonal therapy were alive as opposed to only 64% of men receiving delayed therapy.  This study led to a paradigm shift in treatment.  Since that time, most men with positive lymph nodes will undergo immediate hormonal therapy.  Interestingly, however, the recent data suggesting significantly better prognoses for men with a small number of positive lymph nodes has led many experts to rethink the need for immediate hormonal therapy in all men.  Some have argued that men with minimal lymph node spread may be better served with observation rather than immediate hormonal therapy, particularly in the context of the side effects and dangers of hormonal therapy.  Unfortunately, no good data yet exists to support or refute this approach.

Is Hormonal Therapy The Only Option For Managing Lymph Node Disease?

Until recently, the answer was a resounding yes.  As I mentioned above, lymph node involvement by prostate cancer has always been considered to be metastatic disease.  As such, it has not been considered curable and any treatment has been considered palliative.  The mainstay of treatment for metastatic disease has been hormonal therapy, which works to prevent the prostate cancer from spreading further by restricting the fuel for its growth, the male hormone Testosterone. 

Recently, however, studies out of Europe have demonstrated that, when added in combination with hormonal therapy, radiation therapy can substantially increase survival in men with lymph node positive disease.  A study published just this year, for example, evaluated approximately 360 men with prostate cancer found in their lymph nodes.  Of these men, 117 underwent a combination of hormonal therapy and radiation while 247 underwent hormonal therapy alone.  The study reported that , after 10 years of follow up, men undergoing the combination therapy enjoyed a cancer specific survival rate of 86% versus only 70% for those men undergoing hormonal therapy alone.  Similarly, the overall survival rate of men undergoing the combination therapy was also higher at 10 years as compared to those undergoing hormonal therapy alone (74% versus 55%, respectively).  I should stress that the results of this study, while impressive, are by no means definitive and have not yet changed the standard treatment protocol for men with lymph node positive disease.  Nonetheless, the data provides food for thought and a topic for discussion between men with lymph node positive prostate cancer and their urologists/oncologists. 

Take Home Message

The treatment of men with prostate cancer found in their lymph nodes has undergone significant changes.  Lymph node positive disease is no longer one entity but, rather, a spectrum of diseases with varying severities and prognoses depending on the number of positive lymph nodes.  While considered metastatic disease, lymph node positive prostate cancer should still be managed early as such expedient treatment has been demonstrated to improve survival. Similarly, early data seems to support the combination of radiation with hormonal therapy in order to optimize survival outcomes for men with lymph node positive prostate cancer.  As always, men should thoroughly discuss these and other issues pertaining to the management of prostate cancer with an urologist and/or oncologist prior to making any decisions about their care.

This blog is not a medical practice and cannot provide specific medical advice. This information should never be used to replace or discount the medical advice you receive from your physician