When should a Trial Of Voiding (TOV) or Trial Without Catheter (TWOC) be considered for a Transurethral Resection of the Prostate (TURP) patient?

Timing of Trial Without Catheter (TWOC) After TURP

A trial without catheter (TWOC) should be performed 3 days after TURP to optimize the chances of successful voiding while minimizing catheterization time.

Factors Influencing TWOC Timing

The timing of TWOC after TURP should be based on several key considerations:

Optimal Timing

• Standard recommendation: 3 days post-TURP is the recommended duration for catheterization before attempting TWOC 1
• Alpha blockers should be administered for at least 3 days prior to attempting TWOC to improve success rates 1

Risk Factors for TWOC Failure

Several factors increase the risk of unsuccessful voiding after catheter removal:

• Advanced age (≥90 years) 2
• Poor performance status (WHO performance status ≥3) 2
• Pre-operative urinary retention with large volumes (>1500 mL) 2
• Spinal surgery patients 3
• Mode of presentation - patients with chronic retention or acute-on-chronic retention have higher failure rates (38% and 44% respectively) compared to those with acute retention (10%) 4

Hematuria Considerations

• Gross hematuria typically resolves within 3 weeks after TURP 5
• The duration of postoperative bleeding correlates significantly with:
  • Weight of tissue resected
  • Operation time 5
• High fluid intake should be maintained for at least 3 weeks post-TURP 5

Special Considerations

Patients with Advanced Prostate Cancer

Patients undergoing palliative TURP for advanced prostate cancer have:

• Higher rates of initial voiding trial failure
• Increased need for reoperation
• Greater likelihood of requiring chronic drainage 6

Post-TWOC Management

• Patients who pass a successful TWOC should be informed they remain at increased risk for recurrent urinary retention 1
• For patients with irritative voiding symptoms post-TURP:
  • Phenazopyridine can provide symptomatic relief from pain, burning, and discomfort 7
  • Consider alpha blockers for persistent LUTS 1

TWOC Success Rates

• Overall success rates for TWOC after TURP range from 67-80% 2, 3, 4
• In selected elderly patients without risk factors, catheter-free rates can reach 88.8% at 12 months 2

Algorithm for TWOC After TURP

1. Day 0-2 post-TURP:

   • Maintain catheter drainage
   • Start alpha blocker therapy
   • Monitor for hematuria and clot retention

2. Day 3 post-TURP:

   • Attempt TWOC if no significant hematuria
   • Continue alpha blocker therapy

3. If TWOC fails:

   • Re-catheterize
   • Consider extended catheterization (additional 2-4 days)
   • Re-attempt TWOC with continued alpha blocker therapy

4. If second TWOC fails:

   • Consider urodynamic evaluation
   • Assess for detrusor underactivity
   • Consider intermittent self-catheterization training if appropriate