Self-removal of catheter after robot-assisted radical prostatectomy: a feasibility study

Self-removal of urinary catheter as an option after robot-assisted radical prostatectomy (RARP) has never been explored in literature. We report the feasibility and outcome of the first study of this novel concept in our hospital. We conducted a prospective audit of self-TWOC (trial without catheter) in men who underwent consecutive RARP in our centre between April 2022 and September 2022. Men who had self-TWOC filled a questionnaire about the outcomes of self-TWOC. Carbon footprint and carbon offset for each hospital TWOC avoided were calculated. Of the 129 who underwent self-TWOC, 112 filled the questionnaire and were hence included in the final analysis. Self-TWOC was successful in all the 112 (100%) men in the study. 99.1% of men were satisfied with self-TWOC at home. We managed to avoid 79.6 ± 36.72 km of travel and 77 min of travel time for every self-TWOC. This also saved 85£/patient on clinic expenses and fuel cost savings of 9.87–15.99£ per patient depending on car engine size/type. The carbon footprint calculated was 20 kg CO2 assuming average engine sized diesel/petrol cars and 10 kg CO2 for an average UK petrol hybrid car. The calculated carbon offset per patient for diesel/petrol cars: 0.32£, petrol hybrid: 0.16£. Self-TWOC for 80–160 patients will save the carbon emissions equivalent to that of a passenger on a London–New York Trans-Atlantic flight. Self-TWOC is safe, affordable and is sustainable to the environment. Widespread acceptance of this practice change will be a small, but steady step towards greener health systems across the world.


Introduction
Robot-assisted radical prostatectomy (RARP) is the most common robotic operation performed in urology.With the rising incidence of prostate cancer, the number of RARPs performed worldwide is increasing.The global incidence of prostate cancer is expected to double over the next two decades (from 1.4 million in 2020 to 2.4 million new cases by 2040) [1].This places a significant burden on healthcare systems worldwide.The NHS England has performed 7913 RARPs in the year 2019 [2].The number is expected to grow with more installations of robotic platforms across the country, following the global trend.
Indwelling urinary catheters (UC) are everyday tools for urologists and are employed in most urological operations.While beneficial, UC are fraught with several complications including catheter block, infection, haematuria, calcifications, bladder stones, and urethral injury/strictures [3].Therefore, meticulous follow-up by the healthcare team is vital for the timely change or removal of these catheters.Clinic-based catheter removal requires the patient to make an appointment with a doctor or nurse, visit the hospital, and have scans to assess urinary retention-all time and resource-consuming processes.
Healthcare systems across the globe have enormous effects on emissions and climate change.The NHS UK is the most extensive public-funded health system in the world.Emissions from such healthcare systems are generally categorised into four groups-delivery of care, personal travel, supply chain, and clinical services procured from private healthcare providers.The NHS England contributed about 25 megatonnes (MT) of carbon dioxide (CO 2 ) in 2019.Though this is a significant reduction (about 26% from 1990), further steps are needed to achieve the target of nett zero NHS carbon footprint by 2040 [4].
Staff and patient commutes contributed to 10% of the carbon footprint of NHS England in 2019, and this can possibly be cut down by avoiding face-to-face clinics as much as possible.Furthermore, the recent COVID-19 pandemic has proved patient care can be safely continued even without face-to-face interactions.We expanded this concept to conduct a study on self-TWOC (trial without catheter) for men who underwent RARP in our hospital.We also calculated this novel approach's carbon offset, sustainability, and costeffectiveness in our study.To our knowledge, this is the first study in the literature on self-TWOC among RARP patients.

Inclusion criteria
We included consecutive RARPs performed in our centre between April 2022 and September 2022 for the self-TWOC (trial without catheter) programme.

Exclusion criteria
Men who had complex urethro-vesical anastomosis requiring a cystogram before TWOC, or with poor manual dexterity or had opted out, were excluded from the study.
All the men were explained the process of self-TWOC in the preoperative clinic by one of the urological surgeons/ specialist nurses.Demographic data, place of residence, postal code, and the distance of commute to the hospital were documented.

Surgical technique
All men underwent standard six-port transperitoneal RARPs in our hospital performed by consultants (all fellowship trained and well beyond the learning curve of robotic prostatectomy) and fellows under consultant supervision using dual console.Nerves were spared based on the risk stratification of prostate cancer and athermal dissection was performed for this step.The bladder neck was reconstructed as and when required on a case-to-case basis.Standard urethro-vesical anastomosis was performed after the modified Rocco's stitch and a 120 ml 'leak test' was done in all cases to ensure leak-proof anastomosis.Based on the difficulty of anastomosis, the surgeon decides for or against self-TWOC and communicates his decision to specialist nurses, including the date for self-TWOC.

Self-TWOC procedure
The self-TWOC was done on the eighth postoperative day.Once recovered from anaesthesia, the patient's willingness to proceed for self-TWOC is re-confirmed in the postoperative ward rounds.The surgeon/specialist nurses demonstrate removing the UC using dummy catheters.The catheter can be removed either by deflating the balloon using a syringe or cutting the side port, which collapses the balloon.A leaflet containing the date of TWOC, catheter removal instructions and contact numbers are provided before discharge (Appendix 1).

Follow-up questionnaire
The patients removed their catheters on the planned date at home, early in the morning at 08:00.The specialist nurses then contacted the patients at 12:00 to check on them.The patients were able to call the specialist nurses or on-call urology fellow in case they had any problem with catheter removal.The men also filled out a questionnaire (Appendix 2) and emailed it back to the specialist nurses.Any concerns during catheter removal were noted.They were advised to contact us in case of any difficulty post-TWOC and safety netted for urinary retention and urinary tract infection.They were able to contact us via phone in case of any difficulty.In case of difficulty or retention, the on-call urology team will be notified and the patient will be transferred to our centre for subsequent management.All men were followed up as per the standard RARP follow-up, with their first PSA checked in 3 months.

Ethical clearance and data collection
This project was conducted at our hospital with the approval number SU-CA-21-22-106.All patients signed up for the surgery, and informed consent was obtained from every patient regarding self-TWOC.This was carried out as part of the standard treatment protocol for prostate cancer in our centre.The data was collected from every patient and entered in Excel spreadsheets.

Statistical analysis
The carbon dioxide emissions and carbon offset were calculated from DEFRA (UK Department for Environment, Food and Rural Affairs)-approved online calculator, assuming an average UK car of less than 2000 cc engine capacity [5].Descriptive analysis of the data was performed using Microsoft Excel 2021 version.

Results
All the 170 men who had RARP between April 2022 and September 2022 were approached regarding self-removal of their catheters.Of them, 129 underwent self-TWOC [27 men refused due to personal choices and 14 men were TWOCed in the clinic (surgeon decision due to technical complexity of the anastomosis)].Of these 129 patients, 112 filled the follow-up questionnaire and were hence included in the final analysis.Self-TWOC was successful in all the 112 men included in the study (100%).Patient satisfaction was high, as shown in Table 1.All men were contacted on the day of self-TWOC and there were no unexpected calls from patients after self-TWOC.97.32% mentioned they would prefer having self-TWOC again if needed and the remaining 2.68% of men cited 'discomfort on removal' as the main reason for not wanting to do it at home the next time.The average distance of travel avoided per patient is 79.6 ± 36.72 km (mean ± standard deviation) and the average travel time saved per patient is 77 min.On an average, 4 h of waiting/appointment time was avoided for each patient undergoing self-TWOC.This also saved 85£ per patient for the hospital (Table 2).
The calculated average fuel cost saving was 9.87£-15.99£per patient depending on car engine size/ type.The carbon footprint calculated per self-TWOC was 0.02 t of CO 2 assuming average engine sized (< 2.0 L capacity) diesel/petrol cars and 0.01 t of CO 2 for average (< 2.0 L capacity) UK petrol hybrid car.Based on the type of vehicle used (diesel or hybrid car) 80-160 self-TWOCs will save the carbon emissions equivalent to a passenger's carbon emissions on a one-way Trans-Atlantic flight from London to New York [6].The calculated carbon offset per patient for diesel/petrol cars was 0.28£, and the petrol hybrid cars was 0.14£ (Table 3).

Discussion
Our study assessed the and feasibility of self-TWOC at one of the highest volume units for RARP in the UK.We included 112 men-all had successful self-TWOC, and none had untoward side effects.This is the first study reporting the outcomes of self-TWOC after RARP.Self-TWOC saved the cost of running a TWOC clinic, saved time and money for the patients while at the same time being sustainable for the environment.With a success rate of 100% in our study, self-TWOC was practical and doable in all men who were motivated and willing to remove their catheters by themselves after RARP.Most men (97.32%) were confident they can do self-TWOC in the future, if required.Self-TWOC saves time and money not only for patients, but also for hospitals/ organisations.This is important in times of rising inflation, not only in the UK, but also globally.Leapmen et al. assessed the carbon emissions of prostate biopsies and MRI scan.A prostate MRI scan with biopsy contributes to 80.7 kg of CO 2 emissions as per their conclusion [7].Shatkin-Margolis et al. published a study on self-TWOC among 157 women who had postoperative urinary retention after pelvic reconstructive procedures.The 157 women were assigned to self-TWOC or TWOC in the clinic a week after surgery.There were significantly lesser patient encounters with self-TWOC (42 out of 78, 53.8%) compared to clinic TWOC (79 out of 79, 100%).The self-TWOC group had better pain scores and more likelihood of doing self-TWOC again (p < 0.05) [8].However, there are no antecedent studies on the environmental impact of self-TWOC after RARP, and hence our study's significance.
UK being a nett importer of emissions, 60% of its emissions happens out of the borders (half in Europe and China) and 40% within the country [9].In this era of climate change, the health hazards of trade and economic activities are widely discussed.However, healthcare systems' emissions and associated health hazards are more important than thought [10].Healthcare-related activities generate heavy emissions of greenhouse gases and health organisations around the world have started to take steps to mitigate their carbon footprint over the last decade [11,12].
The UK's NHS with 17 million admissions, 270 million primary care appointments and 1.1 billion prescriptions in a year is the largest single-payer healthcare system in the world.The NHS UK can leverage its size to mitigate its own emissions thereby setting a model for the world [13].Healthcare in acute trusts providing more resource-intense healthcare contributes to 56% of the overall emissions of the NHS.Staff and patient commute contributes 10% to the carbon footprint of the NHS [13].
The NHS England is in the forefront of mitigating its own carbon footprint.It aims to be the first carbon-neutral healthcare system in the world.The NHS "Delivering a 'Nett Zero' National Health Service" report indicates almost 98% of the NHS staff recognise the significance of measures to cut back emissions in the NHS [4,14].While the NHS is clearly ahead of the game in comparison to other healthcare systems, there is a risk of becoming complacent because the NHS is now pioneering sustainability at different levels.While top-bottom approaches are ideal for implementing new systems and pathways, the bottomup approach is better for sustainability and climate change mitigation as the drive to act comes from people working on the ground [15].This calls for upskilling NHS staff to implement sustainable patient care pathways.
Reduction in the number of appointments required per patient is a key factor in the cost-effectiveness of any healthcare system.The COVID-19 pandemic has reinforced this idea as connected stethoscopes, connected vitals monitors, and virtual diagnostics could be safely and effectively implemented during the pandemic to reduce the burden of multiple clinical appointments [16,17].Self-TWOC can be considered an offshoot of this concept, which not only saves time and cost, but also helps in achieving sustainable healthcare if implemented in a larger scale.Depending upon the type of vehicle used, 80-160 self-TWOCs can negate the carbon emissions equivalent to that of a passenger on a Trans-Atlantic flight from London to New York [5].

Merits of the study
This is the first study reporting the feasibility of self-TWOC in RARP patients.The study being conducted prospectively in a high-volume centre with good sample size further adds to the strength of the study.This also proves that self-TWOC is safe in RARP, with no report of urinary retention/infection/failure to remove the catheter in our study.The cost and environmental benefits of self-TWOC are more pronounced in hospitals with wider catchment areas.Self-TWOC can be considered an initiative to bring the NHS England a step closer towards attaining its goal of 'nett zero emissions by 2040'.

Limitations and recommendations
Our study is not without limitations.The study is based on patient-reported outcomes which are subjective and prone to 'recall bias'.However, this is the most practical method to analyse these outcomes after self-TWOC.To reduce recall bias, the questionnaire was administered on the same day as self-TWOC.The questionnaire used in our study is not validated.Extension of self-TWOC to other urological surgeries (bladder outlet surgeries, transurethral resection of bladder tumours, sling surgeries) can be possible, but challenging due to the risk of urinary retention.It does have a huge potential in endourology, prostate surgeries, sling surgeries and pelvic operations if accepts the risk of retention at home.With most patients and the clinicians concerned about incontinence rather than retention of urine after catheter removal post-RARP, self-TWOC is a suitable alternative for hospital TWOC in these patients.

Conclusion
Self-TWOC after RARP is feasible, safe and cost-effective for both the hospital and patients.It is safe and has good success rates.It has a vast potential to save costs and reduce unnecessary travel for patients and healthcare providers (which amounts to 10% of the NHS carbon emissions).Of course, appropriate case selection and providing the correct information is the key for a successful self-TWOC.With 7913 robotic prostatectomies in UK per year alone, our programme, if expanded to other units, can save at least 158 t of CO 2 emissions per year, depending on the catchment area of the hospitals.

Table 3
Cost analysis of self-TWOC