When should the catheter come out after a radical prostatectomy?

One of the biggest concerns for men diagnosed with prostate cancer, when making decisions about treatment for localized disease, is the risk for long-term incontinence. Many factors can affect this risk, and an important one is the quality of physiological recovery and tissue repair post-surgery.

The reason that an indwelling urinary catheter is requisite for every surgical patient immediately after his operation is to help with the stabilization of sensitive tissues and suturing immediately post-surgery. This is regardless of the type of surgery (open, laparoscopic, or robot-assisted). Historically, such catheters remained in place for as long as 21 days post-surgery, but this has fallen over the past 20+ years with better surgical technique and a great deal of pressure from patients to just “lose the tube” as soon as possible after surgery. It is well recognized that an indwelling urinary catheter is not exactly conducive to a high quality of life!

However, it also has to be recognized that there are limited objective data on just how long a urinary catheter should remain in place in order to maximize the quality of recovery post surgery — in particular in terms of recovery of good continence. We have no good data suggesting that long-term time frames are important and we have some data from small studies suggesting that relatively short timeframes are sufficient.

Now we also have data from a small, randomized clinical trial just reported in BMC Urology by Matsushima et al. (The full test of this article is available on line.)

The authors carried out this study in a cohort of 113 Japanese patients, all of whom were diagnosed with localized prostate cancer and treated surgically — with a laparoscopic radical prostatectomy. They were then randomized into two groups, as follows:

  • Patents in Group 1 (n = 57) had their catheter removed on the second day post-surgery.
  • Patient in Group 2 (n = 56) had their catheter removed on the fourth day post-surgery.

All patients were then followed for a year after removal of their catheter to evaluate their recovery of continence. Full continence was defined as a patient having complete, pad-free status.

Here are the core findings reported by Matsushima et al.:

  • All 113 patients were treated between March 2012 and September 2014 by a single, experienced surgeon.
  • The average (mean) age of the patients was 65.9 ± 5.5 years.
  • There were no major, evident differences in the clinical features of the men in Group 1 and Group 2.
  • After removal of the catheters, acute urinary retention was observed in
    • 13/57 patients (22.8 percent) in Group 1
    • 8/56 patients (14.3 percent) in Group 2
  • Continence rates over the next year in all patients were
    • 21.8 percent in Group 1 and 34.5 percent in Group 2 at 3 months (p = 0.138)
    • 41.1 percent in Group 1 and 66.0 percent in Group 2 at 6 months (p = 0.009)
    • 58.0 percent in Group 1 and 79.2 percent in Group 2 at 9 months (p = 0.024)
    • 71.4 percent in Group 1 and 83.7  percent in Group 2 at 12 months (p =0.146),
  • Continence rates over the next year in the 21 patients who exhibited acute urinary retention at catheter withdrawal were
    • 0.0 percent in Group 1 and 37.5 percent in Group 2 at 3 months (p = 0.017)
    • 23.1 percent in Group 1 and 75.0 percent in Group 2 at 6 months (p = 0.020)
    • 38.5 percent in Group 1 and 87.5 percent in Group 2 at 9 months (p = 0.027)
    • 54.5  percent in Group 1 and 87.5  percent in Group 2 at 12 months (p = 0.127)
  • Acute urinary retention at the time of catheter withdrawal on day 2 as opposed to day 4 appears to be the only predictive factor for incontinence at 6 and 9 months post-surgery (based on multivariate analysis).

Matsushima et al. conclude that their study data show that removal of the catheter early (i.e., on day 2 as opposed to day 4) “may increase the risk of incontinence.” It is also worth noting that this prospective study appears to be the first to identify a relationship between the risk of incontinence and acute urinary retention following early catheter removal.

Although this was still a relatively small study, with only 113 patients enrolled and randomized, it is strongly suggestive of the idea that patients recovered continence better if the indwelling catheter remained in place for at least 4 days as opposed to just 2. What this study does not yet tell us is whether even better recovery of continence might be seen in men whose catheters remained in place for (say) 6 or 7 days as opposed to 4 days.

However, on the upside, this study also tells us that, among the patients whose catheters remained in place for 4 days, 66.0 percent were completely continent at 6 months and just under 80 percent were completely continent at 9 months, so this gives us a data set against which to measure the quality of continence in other patient series over time.

It seems likely to The “New” Prostate Cancer InfoLink that the quality of continence post-surgery will be found to vary based on all sorts of additional factors, of which the skill and experience of the surgeon and the age and urinary health status of the patient pre-surgery may be among the two most important. However, timing of catheter removal and exactly how this is done is something over which all physicians have a high degree of control. From a patient perspective, learning what the very best time frame is for catheter removal post-surgery should be relatively easy to accomplish — right along with the best way to remove the catheter with minimal risk for further damage to the urinary tract.

3 Responses

  1. This study surprises me in that 2 days vs. 4 days is insignificant. Mine was in for 13 days because blood and clots were still in the bag after open surgery. Lack of blood and clots for 2 days was the determinant my surgeon used for catheter removal. But I was continent after 13 weeks which is a lot better than the men in the subject study. I see no reason to lose the bag so early that it hinders recovery of full continence. The bag ain’t that bad!

  2. I believe that the majority of urologists recommend 5 days before removal, with that removal date determined by successful surgical removal with no complications. Likely if there are known complications of any kind catheter removal would be extended a few more days.

  3. “Historically such catheters remained in place for as long as 21 days” surely applies to open surgeries as used 20+ years ago. 5 days still seems to be the norm for robot-assisted surgeries. Do we expect big differences between the application of laparoscopic (as used in this study) and robot-assisted (as mainly used now in this country) surgeries? Probably not; so, most of the results may be applicable.

    Now, more advanced cancer centers have moved from the traditional urinary catheters to suprapubic catheters. Quite a different technology and it would be interesting to find out if the results of the study are applicable to the new suprapubic catheters as well.

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