*Corresponding author:David Caddick, Dip Nursing (adult), MSc. Surgical Advanced Nurse Practitioner, Christie NHS Hospital Foundation Trust, Wilmslow Road, Manchester, England
Received: January 25, 2020; Published: February 04, 2020
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Research question: Does reducing the time between the Robotic Assisted Laparoscopic Prostatectomy (RALP) operation date and the removal of the urinary catheter have any effect on the rate of urine infection, acute urinary retention, haematuria or dysuria.
Research problem: This study seeks to compare two groups of RALP patients, one with the urinary catheter in situ for 10 days and one group with the catheter in situ for 7 days. The reduction in the time to remove the catheter may have an impact on the frequency of various catheter associated problems including haematuria, rates of urinary infection, dysuria and acute urinary retention and this study seeks to investigate any differences between these groups.
Literature Review: Robotic Assisted Laparoscopic Prostatectomy (RALP) surgery has been increasingly popular over conventional laparoscopic or open prostatectomy due to the suggested reduction in complications and improved recovery time [1-4]. The potential reductions have obvious benefits for reducing length of stay and therefore cost. Although this is offset with larger capital expenditure for the Robot device themselves as well as the maintenance and purchase of the per-patient equipment [5-7] however suggest a more mixed picture in terms of outcomes between laparoscopic and robotic surgery and in fact more complications laparoscopically, such as erectile dysfunction and incontinence but less transfusions and respiratory complications. They do not however distinguish between the robotic and the non-robotic cases, which confuses the picture.
During the procedure a catheter is inserted preoperatively to maintain the bladder patency after the prostate is removed [8- 10] and stays in situ till removed at a later date to give the anastomotic join at the bladder neck time to heal, become patent and therefore water tight.
Time to trial without catheter (TWOC) lengths vary across intuitions from as short as 2 days to as long as 14 with the most frequent duration to be at around 7 days [11;12;8;10;13;15].
At our institution, a large Cancer hospital in the UK, TWOC duration (the time between the operation date and the TWOC date) historically has been 10 days post-operative for RALP patients and had relatively low complication rates at this duration. The TWOC duration was suggested to be reduced from 10 days to 7 as many patients find the catheters uncomfortable and therefore the less time, they are in situ the better the patient experience. In fact, there is evidence that the patency of the anastomosis is secured within a few days.  showed that by day 3 or 4 only 3 out of 381 patients showed a leak on cystogram (0.8%). Therefore, the TWOC duration was decreased from 10 to 7 days to improve patient experience and to bring us in line with other centres. There were concerns that changing the TWOC duration would have a deleterious effect on the patients. It was suggested that this could affecting the risk of urinary infection (UTI), the rates of dysuria, acute retention of urine (AUR) and haematuria after the catheter is removed.
Catheters are associated with an increased risk of infection (UTI) which occurs very soon after insertion. Indeed, it is suggested that this happens in nearly all patients who are catheterised long term (28 days) and up to 50% of short term catheterisations (<7 days) are found to been colonised . A Cochrane review (Phipps et al, 2006) has shown that the shorter the duration of the catheter being in situ, the less UTI risk there was. A shorter TWOC duration should reduce the rate of urine infections seen.
Dysuria can become an issue when the catheter is present  this is likely due to the bladder losing tone. In fact using flip flow valves rather than catheter bags improves the likelihood of successful voiding after the catheter is removed in one study from 63% to 83%  which suggests that bladders which lose the filling and emptying function even for a short time tend to have more problems returning to a normal function. However flip flow values are not indicated in RALP surgery as there needs to be little or no bladder pressure from urine filling the bladder putting strain on the bladder neck anastomosis.  highlighted that just the existence of an indwelling catheter is associated with increased dysuria. The less time the catheter is in situ, it seems a reasonable to suggest that dysuria rates should also improve.
Retention of urine after removing the catheter post RALP is also a concern, although rare . There is some evidence to suggest that longer catheter durations improve the rates of retention. In the study by  740 patients were stratified into a TWOC at day 4 and day 7. They found that acute retention was significantly higher (p=0.004) at day 4 (4.5%) than day 7 (0.2%). Another study of 1026 patient by  spilt RALP patients into groups with or without acute urinary retention. The duration the catheter was in situ was shorter for the retention group at 4.1 days than the non-retention group at 5.7, suggesting that slight increases in TWOC duration should reduce the incidence of retention. This may be related to the increased surgical oedema in the immediacy of the surgery which improves over time. It appears that longer TWOC durations in some situations may reduce the rates of urinary retention.
Although multiple studies have shown that laparoscopic prostatectomy surgery causes much less blood loss compared to open surgery. In fact, Robotic surgery in particular is consistently lowest in blood loss volumes [19,20]. Some haematuria is expected in the case of RALP patients as result of surgery, catheters themselves by abutting and irritating the delicate mucosa of the urethra can cause haematuria . Therefore, it seems likely that having a catheter in place for less time should reduce the likely hood of trauma and bleeding, however this may be offset by the post op bleeding expected from the RALP procedure itself. In other words, TWOC too early and haematuria may be related to the operation itself, whereas too late and it may be attributable to the catheter. This will be difficult to test which is the cause for this study however this study will also investigate any changes in rates of haematuria.
This study was designed to measure and identify if reducing the TWOC duration from 10 days to 7 days had any effect on the incidence of UTI, dysuria, haematuria and AUR.
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