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hen I was young, in England, I went to a boarding school where the boys’
lavatory was outside. We used to pee against the wall and see who could get the stream up the highest. By the time I was 50, my stream had slowed, and I had other urinary symptoms, such as frequency, urgency, and hesitancy; I never had any nocturia. By age 60, these symptoms had increased greatly. Repeated annual digital rectal examinations did not indicate malignancy, and results of a prostatic biopsy were normal, as were results of serial prostate- specifi c antigen tests. My family doctor put me on terazosin hydrochloride dihydrate, which produced a dramatic and immediate improvement in my fl ow.
At age 70, my symptoms had increased again so that, in my opinion, some sort of surgical interven- tion had to be considered, and my family doctor referred me to a urologist. Having been a family physician and anesthesiologist for 40 years, and having seen many prostate procedures up close, including radical prostatectomies and transure- thral prostatic resections, I did not exactly relish the thought of any such procedures being carried out on me. But I knew I had no option.
So I went to see my urologist, who performed a digital rectal examination and asked me to urinate into his uroflowmeter, which measured my urine fl ow and volume. I knew this was well below normal by the way my urine simply trickled out that day. I then had an ultrasound examination of my bladder.
A cystoscopy followed, after some lidocaine hydro- chloride jelly had been used, and was quite painless.
Then I had the verdict. My flow was highly abnormal, my bladder was not emptying, and, as my specialist said in a soothing voice, “We can eas- ily take care of that.”
He told me that my treatment would be a hol- mium laser prostatectomy, and that it would be
done as day surgery. I would have a catheter in for about a day and would be required to remove it myself at home. He also told me that I could choose to have general or spinal anesthetic. I learned that this procedure had been in use for several years, that there were minimal complications, practi- cally no bleeding, and that I could return to work in a week or two. I must say that I was suitably impressed, particularly when I compared the oper- ation with the procedures that I had witnessed so many times.
I was given a pamphlet providing appropriate preoperative and postoperative instructions. After my procedure there was to be no coff ee, tea, soft drinks, spicy foods, or alcohol for 2 weeks; now that was going to be a bit of a challenge. Walking and driving were permitted immediately, however, and swimming and gardening in 2 weeks. I believed I would be able to manage all these things.
My procedure was booked for 6 weeks later, a very acceptable delay, I thought. During that time there was the mandatory visit to my doctor for a preoperative examination and a visit to the hospital for bloodwork and electrocardiography.
On the appointed day, my wife took me to the hospital, and I was admitted quickly and effi ciently.
I was told, however, that I would have to stay over- night because my operation had been delayed until 5:00 PM; this was a very minor glitch. I spent the afternoon dozing and doing crossword puzzles, interrupted only by the IV nurse who inserted a catheter into my hand. At the appointed hour I was transferred to the operating room and met my anesthesiologist. He was young, professional, and attentive; we discussed my options, eventually set- tling on a spinal anesthetic, accompanied by some intravenous sedation. Having spent the last decade of my career administering intravenous sedation
FOR PRESCRIBING INFORMATION SEE PAGE 1022
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My experience with prostate laser surgery
Mike Tibbetts, MB BS, DA
hen I was young, in England, I went to a boarding school where the boys’
lavatory was outside. We used to pee against the wall and see who could get the stream
W
958 Canadian Family Physician • Le Médecin de famille canadien dVOL 5: JULY • JUILLET 2005
Refl ections
in dental offi ces, I was anxious to experience this fi rst-hand.
I received some fentanyl citrate and midazolam hydro- chloride and slowly started to feel detached. Then there was a little prick in my back followed by anesthesia and paralysis of my lower limbs. I believe I was in the operating room for about 45 minutes, but my memory is a blur and I cannot recall any conversation that took place. I certainly felt no discomfort of any sort. Back in postanesthetic recovery, the first thing I can recall is the nurse comment- ing on my low pulse rate. When asked if I could lift my legs, I said I could not, but looking down I could see my knees were raised up, and it was evident that my motor function had returned before proprioception.
Back in my bed, I slept for most of the evening, and the next morning, I felt great. My catheter was removed, and then the trou- ble began. I knew that as soon as I urinated I would be discharged, but I had neither the desire nor the ability to pass a drop. I drank litres of water, to no avail. Every so often a nurse would pop her head round the door, and each
time I would shake my head.
Then at noon, the nurse came, armed with catheter, and tried to insert it. This failed and an attempt was made with a more rigid variety, which also failed.
By this time I was becoming con- cerned, and when another, even more rigid, catheter was sug- gested, I suddenly got the urge to pee, ran up the corridor to the men’s room, and emptied my bladder as I hadn’t done for sev- eral decades. When I got back to my room, the nurse remarked
“We must have scared it out of you!” Th en it seemed to me that I was discharged with almost indecent haste and my wife drove me home. I understand that this temporary postoperative reten- tion is quite unusual.
My convalescence was remark- ably quick, or so I thought. Th ere was some dysuria for the first few days, but less than I had experienced after my cystos- copy. The urine was a bit dark for a while, but I never saw any frank blood. But my stream was simply amazing, and I honestly believe it was, and is, better than when I was a young man. By my 10th postoperative day, I had no urinary symptoms whatsoever.
I had booked 2 weeks off work, but in retrospect, I am quite sure I could have gone back to work after 7 days.
Six weeks after the operation, I went down for a repeat uro- fl ow test, which confi rmed what I already knew. Not only was my stream normal, but my bladder was emptying completely.
When I think back, I can remember all those postop- erative transurethral prostatic resection patients walking up and down hospital corridors for 3 or 4 days with their irri- gation catheters. I can hardly believe that the holmium laser treatment has so dramatically improved outcome for patients with symptoms due to benign prostatic hypertrophy. Just think of the number of hospital inpa- tient days that have been saved, not to mention how quickly patients can return to work or to their regular activities. I believe that family doctors should be aware of this and be prepared to convey this information to their patients.
Dr Tibbetts is a retired family physician and anesthesiologist in Victoria, BC.
FOR PRESCRIBING INFORMATION SEE PAGE 1025➛
