General Post-Operative Instructions

+ General Precautions

It is common to experience fatigue, incisional pain and swelling, discharge (sometimes bloody) from wound or through/around a catheter, and voiding symptoms (urgency, frequency, blood in urine) for up to 3 or 4 weeks after a urological procedure. In most patients, (especially following endoscopic and minimally invasive procedures), such symptoms are usually very mild and of short duration.

In general, you should report any of the following concerns to your urologist:

• fever over 38.5 C
• severe pain, not relieved by prescribed medications
• blocked catheter
• catheter has come out before the time of scheduled removal (eg. after prostatectomy, urethroplasty)
• inability to urinate (eg. after sling surgeries, TURP)
• separation of incision or very red and tender incision with foul-smelling discharge

+ Care of the Incision

If you have had a surgery through an incision, there are some things you should know about caring for your surgical wound. Most often, your incision will be held together or closed with dissolvable stitches in the skin (often buried under the skin surface). These usually dissolve within 2-4 weeks but sometimes last up to 3 months after your surgery depending on the incision site and type of suture used to close the skin. If you do not have dissolving stitches in the skin, arrangements will be made to remove skin staples or stitches usually 1-2 weeks after your surgery.

You will have a dressing over your incision immediately after your procedure. Dressings can usually be removed 24 hours after your procedure. You may also have "steri-strips" (sticky pieces of surgical tape) over your incision. They are NOT responsible for holding the incision together, so there will not be a problem if they come off early. Steri-strips will eventually curl up and fall off. If they haven't come off on their own after about 10-14 days, then you can carefully remove them by pulling them off - often easier if they are wet.

You will need to keep your incision clean. You may begin showering or sponge-bathing 24 hours after your procedure. Avoid pools and hot tubs for about 1 month following surgery. You can use soap and water to clean around the incision site.

Special Tips for Comfort and Healing of Your Incision

Cosmesis: there are a few things that you can do to optimize healing of the incision and minimize scar formation.

1. Wounds heal best when they do not become overly dry. Sparingly applying an ointment such as Polysporin to the wound will prevent it from drying out.
2. Avoid prolonged, direct sunlight on the wound for 6 months. Hyperpigmentation (a dark scar) can result from excessive sun exposure during the healing phase.
3. Utilize a silicon tape (example: Mepitac) on flat incisions for about 12 weeks following the procedure. The tape can be washed and reused and provides a thin barrier between your incision and your clothing. Check with your pharmacy or medical supply store to see if they carry this product.

Discomfort: you can minimize incisional pain that occurs with coughing or moving by applying pressure to the wound with your hand or a towel if you anticipate a sudden movement. An abdominal binder may also provide comfort - you can do a web search using 'post-operative abdominal binders' to find out what is available

+ Diet

Minor Surgery: In most cases, a regular diet can be resumed within 24-48 hours after the effects of the anesthetic have worn off. Beware that some pain medications can cause nausea (e.g. Tylenol #3 with codeine).

Major Surgery: Any surgery occurring within the abdomen (anything in which you have a cut on the belly) can have a larger effect on bowel function. Gradually progression to a regular diet may be necessary. Tips:

1. Start slow: have smaller, more frequent meals
2. Keep well hydrated by drinking fluids
3. Increase fibre (beans, vegetables, fruits) and avoid constipating foods (meat, dairy)
4. Chewing gum and getting out of bed can help
5. Limit the use of narcotics (e.g. T#3, Percocet, Oxycodone) which can cause nausea and constipation; try and use non-steroidal anti-inflammtories whenever possible (e.g. ibuprofen/Advil, diclofenac/Voltaren)
6. Use over-the counter laxatives (e.g. colace or lactulose); Miralax is good for severe constipation

+ Activity, Bathing & Work

Activity Aside from avoidance of vigorous activity or heavy lifting (anything over about 30 lbs), there are few limitations after surgery. Be gentle with your body as it heals, especially during the first 6 weeks during which healing is most rapid. If you rush back to activities and injure yourself, the total recovery time may be markedly prolonged. Tips:

1. You should be up and about, walking as soon as you can after surgery.
2. Stairs are fine.
3. Avoid putting too much pressure on your 'saddle area' (e.g. with a bike seat) for 6 weeks after any surgery on your urethra, vagina or prostate (e.g. urethroplasty, TVT, TURP or radical prostatectomy). Sitting on a chair or cushion is fine.
4. As a general rule, if it hurts don't do it.
5. Walking and light activity may lead to presence of blood in the urine or through the catheter (especially after surgery on the prostate, bladder or for kidney stones). This is not a concern unless it leads to inabililty to urinate/blockage of the catheter or is progressive or persistent despite resting and drinking plenty of water.
6. Driving: You are legally prohibited for 24 hours after surgery under general anesthetic (also avoid use of power tools, signing legal documents). Medications which have sedative properties (many of the pain medications) and pain can impair your ability to react appropriately such that you may not be able to drive for several days after surgery. In most instances, it will be safe to drive 7 days after major surgery. Consult your physician for specific advice.

Cleaning and Bathing After Surgery

1. You may shower or sponge bathe starting 24 hours after your surgery.
2. Avoid submerging in baths, hot-tubs or pools for about 4 weeks after any surgery that involves a skin incision.

Return to Work

Returning to work duties will depend on the type of surgery, your recovery and your work requirements. This should be discussed with your urologist before your procedure so you can make appropriate arrangements. If you have had major surgery, you are advised not to travel outside the country or remote areas for approximately 6 weeks post-operatively. If a post-operative issue arises while you are outside the country, most insurance plans will not cover the medical costs as they constitute a pre-existing medical condition.

+ Urethral (Foley) Catheters

You may require a urethral catheter after your procedure. The most common type of catheter is called a Foley catheter - named for the physician who invented the inflatable balloon retention mechanism. A catheter allows for continuous drainage of urine from your bladder. You do not need to go to the washroom to urinate.

Your urologist will make a plan for catheter removal. Sometimes patients are given instructions how and when to remove their own catheters - Instructions for removal of catheters can be found here. Other times (eg. after radical prostatectomy or urethroplasty) an appointment is made for you in our office for catheter removal. Infrequently, you will need a test or x-ray (eg. urethrogram or cystogram) before your catheter can be removed.

What to expect with your your urinary catheter

These instructions apply to patients who have had surgery including removal of stones, radical prostatectomy, transurethral resection of the prostate, transurethral resection of bladder tumors, or urethroplasty:

1. Some blood is normal. It is normal for there to be some blood in the drainage tubing and around the outside of the catheter at the urethral meatus (at the tip of the penis or at the opening to the vagina).
2. Some debris and/or clot is normal so long as the catheter is draining.
3. Some urgency to urinate and discomfort at the tip of the penis is normal.
4. Bladder spasms are common with a catheter and should be considered normal. Bladder spasms are when the bladder tries to expel the catheter and the wall pushes against the catheter balloon inside, giving rise to discomfort and/or blood or urine leakage around the catheter. This is usually transient. Tends to be more common when having a bowel movement.

IF YOU HAVE HAD A RADICAL PROSTATECTOMY (REMOVAL FOR PROSTATE CANCER), ONLY A UROLOGIST SHOULD REMOVE YOUR CATHETER. MAKE NO ATTEMPT TO REMOVE THE CATHETER ON YOUR OWN AND NEVER ALLOW ANYONE ELSE TO ATTEMPT TO REMOVE THE CATHETER WITHOUT PRIOR DISCUSSION WITH YOUR UROLOGIST (See note)

NOTE: In patients who have had a radical prostatectomy, the bladder and urethra have been sewn together - this is called an anastomosis. It is critical that the catheter stay in place for as long as directed by the urologist, usually between 1 and 3 weeks. If the catheter is removed prematurely or an attempt is made to replace the catheter, there is the potential for serious damage to the anastomosis which may result in contracture or incontinence. Under no circumstances should you or another health care provider make any attempt to remove or replace the catheter unless directed by your urologist.

What to do about blood in the catheter The amount of blood loss around or through the catheter is usually minimal. The major issue is if a blood clot blocks off the tubing and urine cannot drain from the bladder. You can minimize the chances of problems by:

1. Increasing your intake of fluid, especially water, until the urine clears. Drink as much fluid as is necessary to keep the urine relatively clear (color of fruit punch or better).
2. Limit physical activity if increased bleeding is noted.
3. Ensuring catheter movement is reduced by attaching the catheter to your leg with tape. Normally you will have been sent home with the catheter fixed to your leg. If the catheter comes free, you may use any tape to attach the tubing to your leg. Allow enough slack so that movement does not tug on the catheter.
4. Avoiding constipation. Drink fluids, try laxatives.
5. Apply a lubricant such as Polysporin ointment to where the catheter exits the body - the urethral meatus. Wash the area with a gentle soap while in the shower. Tips to decrease catheter discomfort
6. Keep the outside of the catheter clean where it meets the meatus (opening of the urethra on the head of the penis). You may shower and wash with gentle soap and water.
7. Apply a lubricant such as vasaline, polysporin or KY-Jelly to catheter where it enters the body.
8. Minimize movement of the catheter by attaching the catheter to the leg with tape. Most patients are sent home with a catheter fixation device. Make sure there is enough slack so that leg movement does not pull on the catheter.

Web Resources

How to care for your catheter care (from Vancouver Coastal Health) Please refer to our instructions first.

How to remove your catheter.

+ Clean Intermitent Catherization (CIC)

Clinical intermittent catheterization is used when the bladder muscle was not strong enough to enter the bladder. This is done several times a day, as many times as he would normally need to void. Training is typically done with our nurse continence advisor at the Richmond Hospital urologic care center.taking the RIGHT catheter is sometimes a matter of trial and error. If you are having difficulty placing the catheter then having some samples to try his helpful.

You can obtain samples and assistance with fitting with Corey Knott (NCA at Richmond Hospital) and with Nightengale Medical Supplies.

Clean Intermittent Catheterization (CIC) instructions FOR MENClean Intermittent Catheterization (CIC) instructions for WOMEN

+ Suprapubic Cathethers

These are tubes that drain the bladder through an opening in the lower abdomen. Placement of these catheters requires a minor surgical procedure. The management of suprapubic catheters is similar to that of urethral catheters with a couple of exceptions:

1. Go to emergency and call the office if a suprapubic catheter comes out before it is supposed to. The opening in the skin can close off quickly within 12-24 hours of removal and prevent the easy placement of a new catheter.
2. It is not uncommon to sometimes see some urine come from the urethra if a suprapubic catheter is placed. So long as some urine is draining from the suprapubic catheter, there is usually no concern.

+ Ureteral Stents

Ureteral stents are like small straws which sit within the tube that carries urine from the kidney to the bladder, the ureter. They are usually about 2 mm (1/10th of an inch) wide and between 22-26 cm (8-10 inches) long. Most stents have a curl on either end which can be straigtened during insertion, but prevent movement of the stent out of position. In reference to the curls on the end of the stent, they are sometimes referred to as pig-tail or JJ (double J) stents.

Stents are placed for a number of reasons, but the most common reason is to relieve obstruction of the ureter, such as from stone. They are also placed following surgery on the ureter, such as ureteroscopy for stone, in order to prevent obstruction from spasm of ureter or blockage from stone fragments or blood clot.

ALL STENTS ARE TEMPORARY AND MUST EVENTUALLY BE REMOVED OR REPLACED. Most stents can remain in place for 6-12 months, but are often removed or replaced much sooner. If you have a stent which you believe has been in place for more than 6 months, please contact your urologist immediately. If stents are left in place for too long, stone may form on the stent making removal difficult. This is knowns as stent encrustation.

How are stents placed?

Stents are usually placed within the ureter through by placing a cystoscope into the bladder through the urethra. The opening of the ureter into the bladder is identified and the stent is inserted. This is known as 'retrgrade stent placement' and is exclusively done by urologists. Occasionally, stents are placed 'top down' - 'antegrade stent placement'. The renal pelvis is punctured through the skin and the stent passed from outside the body, into the renal pelvis and from there down to the bladder. This can be done by a radiologist, and sometimes by urologists. Proper positioning of the stent is confirmed with X-ray.

How are stents removed?

Stent removal is usually a simple, out-patient procedure. Flexible cystoscopy is performed and the end of the stent in the bladder is secured and the stent then pulled out through the urethra. This usually takes 1-2 minutes. No special preparation is required. You do not need to fast (stop eating) beforehand.

Very rarely, a stent may migrate (move) upwards such that the end in the baldder cannot be seen. In this case, a trip to the operating room for retrieval may be required.

What sort of symptoms can be expected with a stent?

A stent is a piece of plastic. While they are quite soft, they can irritate the bladder. In addition, urien can 'backwash' up the stent into the kidney. As long as the stent is in place, the following symptoms can be expected and are normal:

1. Urinary urgency and frequency - you may feel the need to go to the washroom often, even though very little urine comes out.
2. Stanguria - this is pain at the end of urination caused by the bladder wall collapsing down on the end of the stent in the bladder.
3. Flank pain - you may feel pain in your side, especially when you urinate. This is urine 'backwashing' up the stent and putting pressure in the kidney. This is not harmful to the kidney.
4. Blood and occasional clot in the urine.

Things that can be done to reduce stent symptoms.

Stents tend to be fairly well tolerated by most patients. In fact, some patients have stents which are replaced indefinitely. There are no specific limitations as to what activities can be done with a stent in place. However, some patients will have stent-related symptoms, occasionally severe. Things which can be done to reduce these symptoms include:

1. Increase fluid intake if bleeding is noted. This will flush the blood out before clot can form.
2. Bladder relaxants can help with urinary frequency, urgency and flank pain occurring with urination. Medications used include: oxybutyinin (Ditropan) and tolterodine (Detrol)
3. Alpha blockers such as tamsulosin (Flomax) may decrease bladder sensitivity and relax the ureter
4. Phenazopyridine (Pyridium) is a bladder anesthetic. Not all pharmacies carry this. Check here for more info. Web Resources

CUA discharge instructions on ureteral stents. Please refer to our instructions first.

+ Medications

Usually, you will have a prescription for some medications to take after your procedure. In general, antibiotics need to be taken as prescribed until the pills are finished. Pain medication may be taken on an as needed basis. It is often a good idea to take the pain medication regularly for 24-48 hours after your procedure as a preventative measure. In addition, you make take over-the-counter pain medication such as tylenol or ibuprofen every 4-6 hours regularly for 2-5 days following your procedure unless you cannot take these medications due to allergy or other medical issues.

You may begin your usual medications when you leave hospital unless you have been instructed otherwise.

If you take blood thinning medication such as aspirin, plavix or warfarin/coumadin, you will be advised when you can start them again.

Pain Medications in Children

Tylenol liquid 10-15 mg/kg q4H

Oral morphine dosing: 0.2-0.5 mg/kg/dose po q4H to q6H (maximum 15 mg/dose)