Surgery and Post-Op Details

OR, Recovery Room, and First Night after Surgery

The technical term for this surgery is TURBT, which stands for Trans-Urethral-Resection of Bladder Tumor. The doctor inserts a cystoscope, a small, lit camera, in through the urethra and into the bladder. A small tool with a wire loop at the end is inserted through the cystoscope. A high-frequency electric current passes through the wire tool removing and burning cancer cells. This method is called fulguration. In some situations, fulguration will not be enough to eradicate the tumor. Advanced scopes have blades as well, and the blades can be set to cauterize the wounded area (or not). Transurethral resection is often a successful treatment for patients with low-risk (noninvasive, papillary) cancers. The noninvasive characteristic keeps them from penetrating into deeper layers of tissue but does not prevent their recurrence. Up to seventy percent of patients with superficial bladder cancer have some recurrence within five years of treatment. Therefore, follow-up therapy is an important part of post transurethral resection therapy. More on this later… The plan for me was to cut the suckers out and then bake the bladder with chemo – this part should reduce recurrence by 10%, which is better than nothing.

The Operating Table was really more of an apparatus than a table. They had to add attachments for each of my arms and legs to get them into the desired positions and adjusted. Dr. Smith started the IV, and I hate that part, but he was the best I’d ever had. Dr. Hopkins was joking around with his personal assistants/nurses/whatever, totally ignoring me. As I eavesdropped I found that the procedure two before me was quite difficult and caused them to go from ahead of schedule to behind. And they had three more left, counting me. They talked about getting out of there by 7PM. It was about 3:00. Ever confident, Dr. Hopkins assured them that “These next three should be quick.” At this point I was clearly no longer the customer, but the raw material.

For my surgery there would be at least 5 people in the Operating Room, 2 MDs (Drs. Hopkins and Smith), 2 RNs (the OR Nurse and Dr. Hopkins’ personal nurse), and 1 assistant (pedigree unknown). There were many bachelor’s, graduate, and post-graduate degrees represented. Combine that all with state-of-the-art facilities, Nurse Vicki, the Recovery Room nurse, orderlies and staff, and one can appreciate the expense of it. I was happy to have it all at my disposal.

Since the leg cuffs looked like heavily padded stirrups that went up the calf, I asked if I was going to give birth. Dr. Smith said, “Yes, to two bouncing baby tumors!” I was starting to like Dr. Smith a lot, perhaps somewhat due to the chemicals he was giving me via IV. There was a minute or two of fussing about, and then he put something in the IV and time stopped completely.

Two seconds later I was in recovery – actual elapsed time unknown. The Recovery nurse (I never got her name) checked BP and pulse every 10 min or so, and talked small talk with me. I was in a hazy dreamlike state, and I asked her about whether I was on chemo. She informed me that I wasn’t having any, as the bladder wall had been breached. At the time I was just as happy not to have it. There was a catheter in my penis, and I was aware of it, but too dopey to be concerned. I had really no constant pain, but the bladder was spasming and radiating a pain wave down the tube ending in a very sensitive area, about once every 90 seconds or so. I talked to the recovery nurse about this, and her most curious solution was to give me a suppository of something I’d never heard of. It gradually slowed them down and decreased their intensity. I had a very strong urge to pee, and was assured this was normal for a catheter. How ironic that the device that drains the fluid also triggers the urge to drain! Eventually the nurse said she was going to kick me loose, and asked if I remembered talking to Dr. Hopkins earlier in recovery. I did not at all, and she seemed surprised. “He never came in here,” I insisted. So she says, “The important thing to remember is that the catheter has to stay in for a week.” This was the first I’d heard of THAT, and I was most annoyed. She solved that problem by having me carted back to the ambulatory ward.

After the orderlies got me settled and wished me luck, Nurse Vicki and Kathryn asked me how I was. “I’m really pissed off. I have to have this damn tube in for a week!” This was NOT news to them, having already talked to Dr. Hopkins. He told Kathryn that the chances of nicking the wall of the bladder were 15-20%, a bit higher than the 10-15% he’d told me. For some reason that added to my annoyance. The “good news” is that it might be 5-6 days and not a full week. Oh joy. Nurse Vicki quickly went to work getting me settled in the bed, doing more BP readings, and cleaned up the surgical area and “organized” my junk. Some shifts had changed, and a Certified Nurse’s Assistant (what I used to be) named Kyle came in and introduced himself. He had had the same procedure done a year or two earlier, and he truly knew what it was like. He shared some great lessons learned on what to do and what NOT to do.

Sometime later Dr. Hopkins came in. There had been enough time for me to calm down from angry to annoyed, and the spasms had returned, and the urge to pee was unbearable. Despite his faults the Doc knows his stuff, and instantly ducked out and grabbed an irrigation kit with a ginormous syringe. He jammed in about 60cc of sterile solution and then reversed the plunger to suck it back out. A dozen or so little clots came with it – they had been blocking the catheter and my bladder was indeed full. He did several more “plunges” and made a huge mess all over me and Nurse Vicki’s work. But I felt oh so much better! He sent the kit home in case it happened again. Vicki came back with TWO Lortabs plus Tylenol, and she insisted that I take them even though there was no real pain. I did, and another hour passed while they made sure I was ready to roll. Got dressed in very loose warmup pants and scrub shirt (mine), and Kyle wheelchaired me to the entrance. While we waited for Kathryn to retrieve the car, he laid a whole bunch more advice on me. Scooch and pivot, don’t bend at the waist. Exhale when you move – don’t hold your breath! Don’t eat much. Avoid dairy products while on Lortab. Constipation is highly probable and your worst enemy. Since I had already told Kathryn I wanted a turkey pot pie and a milkshake, I was very glad to get Kyle’s experience. We switched to whole wheat toast (with butter) and tea for my “dinner.”

The ride home took just over an hour, with a stop at Target for Oreos, Lortab generic, antibiotic, and a stool softener. You need to eat something when you take Lortabs, and the hospital recommended crackers. Being a process improvement guy, I decided that 5 Golden Oreos would do just as well, taste better, and wash down easily with tea. REVISION – Still being a process guy and in the interest of continuous improvement: You will need some food like peanut butter or almond butter and a spoon, or a bowl of grapes, walnuts, or almonds to cushion the effects of taking the Lortabs. (Because sugar and starch cause glucose spikes in the bloodstream and glucose is cancer’s favorite food, I have revised my previous idea to avoid things like crackers or cookies.) For the ride home the Honda Pilot was reasonably comfortable, but I was locked into one position (sitting upright) the whole time, drinking water constantly. In retrospect reclining the seat about halfway would have been a very good idea.

When we got home my bladder was full and I needed to irrigate. I pushed 50cc in, more gently than the doc, and pulled back. Nothing would come out, even when pulling vacuum on the syringe. I added another 10cc. Same results. Now the problem was MUCH worse, and I had a strong urge to pee AROUND the catheter. My hospital experience from the 80s was enough to know this was WAY BAD. I had Kathryn phone the emergency pager from the urologist’s office. After 10 minutes of sheer agony I could hardly think. In abject panic I called Dr. Chuck while Kathryn called the paging service back and left a detailed message about the situation. Chuck was able to calm me a bit and “talk me down.” He said to move around a bit – walk, sit, stand, lie & gently turn from side to side. He felt that the movement would free up one of the multiple holes on the catheter intake and allow some space for the fluid to drain naturally. Once things were flowing the urine would tend to dissolve the clots over time. When I stood a bunch did drain. After 5 minutes or so enough had drained out the tube that I felt less pressure. Moved around a bit and did some more gentle irrigation and drain. Panic over. Many thanks to a good friend for saving me a trip to the ER! About half an hour later the on-call urologist called back. His assessment was that it was all OK, and I should be able to handle it for 5+ days. He urged me to be less gentle on the irrigations. Easy for him to say. Sadist.

I eventually got to sleep and woke at 12:30AM with spasms. Went to the toilet to irrigate and discovered that the reason my bladder was full was that the catheter bag was full – 1 liter plus. Wow. God had opened the floodgates and I was passing about a liter an hour for the next several. I cut my Lortab dose from 2 to 1 at 4AM. Got up at 7AM and the “runoff” had changed from the consistency of tomato juice to cranapple juice. Over the next several hours it has gotten progressively more yellowish. Clots are washing out now and then and the liquid is mostly clear. The next morning around 10AM a nurse from the urologist’s office called, because “Dr. Hopkins is concerned about you.” I reported to her a short version, and she assured me that this was ALL VERY GOOD NEWS INDEED. Now running about half a liter an hour in and out. I have not had a Lortab since 8AM, and no deep pain. Going to see if I can make it 6 hours, but no intentions of trying to be heroic about it!

Synopsis – The Doc cut out the 2 tumors and sent them to the lab. He also nicked the bladder wall, so I am hooked to a tube for 5-6 days instead of 1-2. Doc says the tumors look non-invasive, which is good news – and he rarely offers such opinions. I am flying high on Lortab (narcotic), so there is essentially no pain. There is a lot of discomfort, though. I can walk, slowly, and read and watch TV and type emails (if I slouch, take my time, and keep the keyboard on top of my belly). Is is unlikely that I will be able to attend church Sunday or go to work on Monday.