A randomised controlled trial comparing immediate versus delayed catheter removal following vaginal prolapse surgery

AUGS-IUGA Joint Clinical Consensus Statement on Enhanced Recovery After Urogynecologic Surgery: Developed by the Joint Writing Group of the International Urogynecological Association and the American Urogynecologic Society. Individual writing group members are noted in the Acknowledgements section

INTRODUCTION AND HYPOTHESIS

Enhanced recovery after surgery (ERAS) evidence-based protocols for perioperative care can lead to improvements in clinical outcomes and cost savings. This article aims to present consensus recommendations for the optimal perioperative management of patients undergoing urogynecological surgery.

METHODS

A review of meta-analyses, randomized clinical trials, large nonrandomized studies, and review articles was conducted via PubMed and other databases for ERAS and urogynecological surgery. ERAS protocol components were established, and then quality of the evidence was both graded and used to form consensus recommendations for each topic. These recommendations were developed and endorsed by the writing group, which is comprised of the American Urogynecologic Society and the International Urogynecological Association members.

RESULTS

All recommendations on ERAS protocol items are based on best available evidence. The level of evidence for each item is presented accordingly. The components of ERAS with a high level of evidence to support their use include fasting for 6 h and taking clear fluids up to 2 h preoperatively, euvolemia, normothermia, surgical site preparation, antibiotic and antithrombotic prophylaxis, strong antiemetics and dexamethasone to reduce postoperative nausea and vomiting, multimodal analgesia and restrictive use of opiates, use of chewing gum to reduce ileus, removal of catheter as soon as feasible after surgery and avoiding systematic use of drains/vaginal packs.

CONCLUSIONS

The evidence base and recommendations for a urogynecology-relevant ERAS perioperative care pathway are presented in this consensus review. There are several elements of ERAS with strong evidence of benefit in urogynecological surgery.

Catheter-Associated Urinary Tract Infections in the Adult Patient Group: A Qualitative Systematic Review on the Adopted Preventative and Interventional Protocols From the Literature

Catheter-associated urinary tract infections (CA-UTIs) are among the most common nosocomial infections acquired by patients in health care settings. A significant risk factor for CA-UTIs is the duration of catheterization. To summarize the current strategies and interventions in reducing urinary tract infections associated with urinary catheters, use and the need for re-catheterization on the rate of CA-UTIs, we performed a systematic review. A rapid evidence analysis was carried out in the Medline (via Ovid) and the Cochrane Library for the periods of January 2005 till April 2021. The main inclusion criterion required to be included in this review was symptomatic CA-UTI in adults as a primary or secondary outcome in all the included studies. Only randomized trials and systematic reviews were included, reviewed, evaluated, and abstracted data from the 1145 articles that met the inclusion criteria. A total of 1145 articles were identified, of which 59 studies that met the inclusion criteria were selected. Studies of relevance to CA-UTIs were based on: duration of catheterization, indication for catheterization, catheter types, UTI prophylaxis, educational proposals and approaches, and mixed policies and interventions. The duration of catheterization is the contributing risk factor for CA-UTI incidence; longer-term catheterization should only be undertaken where needed indications. The indications for catheterization should be based on individual base to base cases. The evidence for systemic prophylaxis instead of when clinically indicated is still equivocal. However, antibiotic-impregnated catheters reduce the risk of symptomatic CA-UTIs and bacteriuria and are more cost-effective than other impregnated catheter types. Antibiotic resistance, potential side effects and increased healthcare costs are potential disadvantages of implementing antibiotic prophylaxis. Multiple interventions and measures such as reducing the number of catheters in place, removing catheters at their earliest, clinically appropriate time, reducing the number of unnecessary catheters inserted, decrease antibiotic administration unless clinically needed, raising more awareness and provide training of nursing personnel on the latest guidelines, can effectively lower the incidence of CA-UTIs.

A Systematic Review of Randomized Trials Investigating Methods of Postoperative Void Trials Following Benign Gynecologic and Urogynecologic Surgeries

OBJECTIVE

To perform a systematic review of randomized controlled trials (RCTs) studying postoperative void trials (VTs) following gynecologic and urogynecologic surgery to investigate (1) the optimal postoperative VT methodology and (2) the optimal time after surgery to perform a VT.

DATA SOURCES

PubMed, Embase, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov.

METHOD OF STUDY SELECTION

We systematically searched the aforementioned data sources from inception to November 22, 2019, using a combination of subject headings and keywords for the following 3 concepts: gynecologic surgery (prolapse, benign gynecologic, and incontinence surgery), postoperative period, and voiding. We identified any RCT in English that studied VT methodology or timing in patients undergoing benign gynecologic or urogynecologic surgery. Discrepancies were adjudicated by a third reviewer. We followed the standard systematic review methodology and used the Jadad scoring system to assess bias. Extracted study outcomes included the following: proportion of patients discharged home with catheter, proportion of VT failure, surgery for retention, retention after initial VT, postoperative calls and visits, time in postanesthesia care unit (PACU), time to discharge, time to spontaneous void, duration of catheterization, patient and provider burden, and urinary tract infection (UTI).

TABULATION, INTEGRATION, AND RESULTS

We double screened 618 abstracts and clinical trial descriptions, assessed 56 full-text articles, and ultimately included 21 RCTs. The evidence was of low to moderate quality overall. The studies were divided into the following 2 categories: VT methodology (10 studies) and VT timing (11 studies). VT methodology included backfill-assisted (in operating room vs PACU), autofill, and force of stream studies. One RCT compared backfill-assisted with and without postvoid residual volume check. Outcomes were similar for all VT methods, except backfill-assisted decreased time to spontaneous void compared with autofill. In the VT timing category, earlier VT performance correlated with a shorter time to discharge, time to spontaneous void, duration of catheterization, and lower patient burden and UTI rate but had a higher rate of retention after initial VT. There was no difference between earlier vs later VT timing for proportion of discharged home with catheter or rate of VT failure. No studies reported outcomes of provider burden or postoperative calls.

CONCLUSION

In comparing VT methodologies, VT by backfill-assisted (in operating room vs PACU, ± postvoid residual volume), autofill, and force of stream resulted in similar outcomes with no one method being superior. Performing VT at an earlier postoperative time point results in shorter time to discharge and spontaneous void, shorter duration of catheterization, lower patient burden, and lower UTI risk, but it may increase the risk of retention after initial VT.

Cranberries after pelvic floor surgery for urinary tract infection prophylaxis: A randomized controlled trial

AIMS

Urinary tract infection (UTI) is a common complication after pelvic floor surgery. Antibiotics as prophylaxis may reduce the prevalence of UTI's by 50%, but bacterial resistance may be a large disadvantage, necessitating the search for other possible prophylactic options. Recent research found a 50% reduction in the rate of UTI's with the use of cranberry capsules after elective gynecologic surgery, suggesting that cranberry capsules may serve as a good prophylaxis. The aim of this study was to assess whether perioperative cranberry prophylaxis reduces the risk of clinical overt UTI after elective pelvic floor surgery with indwelling catheter.

METHODS

We conducted a single-center randomized, double-blind, placebo-controlled trial. Women were given cranberry capsules twice daily or identical placebo for 6 weeks, starting the day before surgery. The main endpoint of the trial was the incidence of UTI within 6 weeks after surgery, defined as clinical diagnosis and treatment of UTI by the medical doctor. Analyses were performed with the intention to treat.

RESULTS

Two hundred ten participants were included, 105 in each arm. There was no significant difference in the prevalence of UTI between the cranberry arm (n = 13, 12.4%) and the placebo arm (n = 21, 20.0%; P = .13), but the prevalence in both arms was lower than anticipated.

CONCLUSIONS

This trial shows no beneficial effect of adequately dosed cranberry prophylaxis in women undergoing pelvic floor surgery, although such effect cannot be ruled out in settings with a higher prevalence of UTI's.

Catheter-Associated Urinary Tract Infections in Adult Patients

BACKGROUND

Urinary tract infections are among the more common types of nosocomial infection in Germany and are associated with catheters in more than 60% of cases. With increasing rates of antibiotic resistance worldwide, it is essential to distinguish catheter-associated asymptomatic bacteriuria from catheter-associated urinary tract infection (CA-UTI).

METHODS

This review is based on publications from January 2000 to March 2019 that were retrieved by a selective search in Medline. Randomized clinical trials and systematic reviews in which the occurrence of CA-UTI in adult patients was a primary or secondary endpoint were included in the analysis. Two authors of this review, working independently, selected the publications and extracted the data.

RESULTS

508 studies were identified and 69 publications were selected for analysis by the prospectively defined criteria. The studies that were included dealt with the following topics: need for catheterization, duration of catheterization, type of catheter, infection prophylaxis, education programs, and multiple interventions. The duration of catheterization is a determinative risk factor for CA-UTI. The indications for catheterization should be carefully considered in each case, and the catheter should be left in place for the shortest possible time. The available data on antibiotic prophylaxis do not permit any definitive conclusion, but they do show a small benefit from antibiotic-impregnated catheters and from systemic antibiotic prophylaxis.

CONCLUSION

Various measures, including careful consideration of the indication for catheterization, leaving catheters in place for the shortest possible time, and the training of nursing personnel, can effectively lower the incidence of CA-UTI. The eous in some respects, and thus no recommendations can be given on certain questions relevant to CA-UTI.

Mid-urethral sling in a day surgery setting: is it possible?

INTRODUCTION AND HYPOTHESIS

Several studies have shown that immediate catheter removal following pelvic surgery is associated with several advantages. The aim of this case-control study is to compare immediate versus delayed catheter removal following mid-urethral sling surgery, to determine if indwelling catheterisation is necessary after this procedure. The secondary outcomes were subjective and objective cure rate after at least a 1-year follow-up.

METHODS

Cases were defined as all the women who underwent a TVT Abbrevo for urodynamically proven stress incontinence. In every case the Foley catheter was removed by the surgeon at the end of the procedure. A voided volume >200 ml with a post-void residual of <100 ml, was considered a complete voiding trial. Patients who successfully completed the voiding trial and who did not develop any complications were discharged on the day of the surgery. We created a matched control cohort of women who underwent a TVT Abbrevo with delayed catheter removal (24 h after the procedure).

RESULTS

Eighty women with immediate catheter removal were included. Each case was individually matched with one control. No statistically significant differences in voiding dysfunctions, postoperative re-catheterisation, postoperative urinary tract infection, early and late onset of overactive bladder (OAB) and vaginal erosion were found between the study groups. No significant differences in either subjective or objective outcome were observed.

CONCLUSIONS

Immediate catheter removal allows the patient with urodynamically proven stress incontinence without OAB symptoms, prolapse and voiding dysfunctions, to be admitted, treated and discharged on the same day in an outpatient setting, with a high subjective and objective outcomes after at least a 1-year follow-up.

Reducing postoperative catheterisation after anterior colporrhaphy from 48 to 24 h: a randomised controlled trial

INTRODUCTION AND HYPOTHESIS

There is a distinct lack of literature on postoperative management after anterior colporrhaphy (AC). Our traditional postoperative protocol consisted of 24 h of indwelling catheterisation followed by 24 h of self-intermittent catheterisation. We hypothesised that a new protocol consisting of only 24 h of indwelling catheterisation might produce better results without additional complications.

METHODS

From April 2014 to July 2017, all candidates for AC were randomised to catheter removal 24 or 48 h after surgery. The primary outcome was the postoperative urinary retention (POUR) rate. Secondary outcomes included: asymptomatic bacteriuria (AB), urinary tract infection (UTI) and postoperative pain after 24 h.

RESULTS

A total of 79 patients were recruited. Thirty-seven and 40 patients were randomised to follow the 48-h protocol and the 24-h protocol respectively. There were no significant differences in relation to the POUR rate: 3 patients (8.1%) vs 1 (2.5%) in the 48-h vs the 24-h group respectively (p = 0.346). The UTI rate was 2 (8.1%) vs 0 patients respectively (p = 0.139) and the postoperative AB rate was 3 (9.1%) vs 0 patients (p = 0.106). In the postoperative pain evaluation, the visual analogue scale score was significantly higher in the 48 h group (0.35 vs 0.13, p = 0.02).

CONCLUSIONS

According to our results, reducing the catheterisation from 48 to 24 h after AC does not increase the risk of POUR and decreases the rate of UTI, AB and postoperative pain. This new postoperative management protocol of pelvic floor surgery would improve postoperative outcomes and shorten the stay in hospital.

A systematic review of outcome and outcome-measure reporting in randomised trials evaluating surgical interventions for anterior-compartment vaginal prolapse: a call to action to develop a core outcome set

Introduction

We assessed outcome and outcome-measure reporting in randomised controlled trials evaluating surgical interventions for anterior-compartment vaginal prolapse and explored the relationships between outcome reporting quality with journal impact factor, year of publication, and methodological quality.

Methods

We searched the bibliographical databases from inception to October 2017. Two researchers independently selected studies and assessed study characteristics, methodological quality (Jadad criteria; range 1–5), and outcome reporting quality Management of Otitis Media with Effusion in Cleft Palate (MOMENT) criteria; range 1–6], and extracted relevant data. We used a multivariate linear regression to assess associations between outcome reporting quality and other variables.

Results

Eighty publications reporting data from 10,924 participants were included. Seventeen different surgical interventions were evaluated. One hundred different outcomes and 112 outcome measures were reported. Outcomes were inconsistently reported across trials; for example, 43 trials reported anatomical treatment success rates (12 outcome measures), 25 trials reported quality of life (15 outcome measures) and eight trials reported postoperative pain (seven outcome measures). Multivariate linear regression demonstrated a relationship between outcome reporting quality with methodological quality (β = 0.412; P = 0.018). No relationship was demonstrated between outcome reporting quality with impact factor (β = 0.078; P = 0.306), year of publication (β = 0.149; P = 0.295), study size (β = 0.008; P = 0.961) and commercial funding (β = −0.013; P = 0.918).

Conclusions

Anterior-compartment vaginal prolapse trials report many different outcomes and outcome measures and often neglect to report important safety outcomes. Developing, disseminating and implementing a core outcome set will help address these issues.

Perioperative interventions in pelvic organ prolapse surgery

BACKGROUND

Pelvic organ prolapse (POP) affects as many as 50% of parous women, with 14% to 19% of women undergoing a surgical correction. Although surgery for the treatment of POP is common, limited supportive data can be found in the literature regarding the preoperative and postoperative interventions related to these procedures. The main goal of perioperative interventions is to reduce the rate of adverse events while improving women's outcomes following surgical intervention for prolapse. A broad spectrum of perioperative interventions are available, and although the benefits of interventions such as prophylactic antibiotics before abdominal surgery are well established, others are unique to women undergoing POP surgeries and as such need to be investigated separately.

OBJECTIVES

The aim of this review is to compare the safety and effectiveness of a range of perioperative interventions versus other interventions or no intervention (control group) at the time of surgery for pelvic organ prolapse.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In Process, ClinicalTrials.gov, WHO ICTRP, handsearching of journals and conference proceedings (searched 30 November 2017), and reference lists of relevant articles. We also contacted researchers in the field.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of women undergoing surgical treatment for symptomatic pelvic organ prolapse that compared a perioperative intervention related to pelvic organ prolapse surgery versus no treatment or another intervention.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recommended by Cochrane. Our primary outcomes were objective failure at any site and subjective postoperative prolapse symptoms. We also measured adverse effects, focusing on intraoperative blood loss and blood transfusion, intraoperative ureteral injury, and postoperative urinary tract infection.

MAIN RESULTS

We included 15 RCTs that compared eight different interventions versus no treatment for 1992 women in five countries. Most interventions were assessed by only one RCT with evidence quality ranging from very low to moderate. The main limitation was imprecision, associated with small sample sizes and low event rates.Pelvic floor muscle training (PFMT) compared with no treatment (three RCTs) - peri-operative intervention The simplest of the PFMT programmes required women to attend six perioperative consultations in the three months surrounding prolapse surgery. Trial results provided no clear evidence of a difference between groups in objective failure at any site at 12 to 24 months (odds ratio (OR) 0.93, 95% confidence interval (CI) 0.56 to 1.54; two RCTs, 327 women; moderate-quality evidence). With respect to awareness of prolapse, findings were inconsistent. One RCT found no evidence of a difference between groups at 24 months (OR 1.07, 95% CI 0.61 to 1.87; one RCT, 305 women; low-quality evidence), and a second small RCT reported symptom reduction from the Pelvic Organ Prolapse Symptom Questionnaire completed by the intervention group at 12 months (mean difference (MD) -3.90, 95% CI -6.11 to -1.69; one RCT, 27 women; low-quality evidence). Researchers found no clear differences between groups at 24-month follow-up in rates of repeat surgery (or pessary) for prolapse (OR 1.92, 95% CI 0.74 to 5.02; one RCT, 316 women; low-quality evidence).Other interventionsSingle RCTs evaluated the following interventions: preoperative guided imagery (N = 44); injection of vasoconstrictor agent at commencement of vaginal prolapse surgery (N = 76); ureteral stent placement during uterosacral ligament suspension (N = 91); vaginal pack (N = 116); prophylactic antibiotics for women requiring postoperative urinary catheterisation (N = 159); and postoperative vaginal dilators (N = 60).Two RCTs evaluated bowel preparation (N = 298), and four RCTs assessed the method and timing of postoperative catheterisation (N = 514) - all in different comparisons.None of these studies reported our primary review outcomes. One study reported intraoperative blood loss and suggested that vaginal injection of vasoconstrictors at commencement of surgery may reduce blood loss by a mean of about 30 mL. Another study reported intraoperative ureteral injury and found no clear evidence that ureteral stent placement reduces ureteral injury. Three RCTs reported postoperative urinary tract infection and found no conclusive evidence that rates of urinary tract infection were influenced by use of a vaginal pack, prophylactic antibiotics, or vaginal dilators. Other studies did not report these outcomes.

AUTHORS' CONCLUSIONS

There was a paucity of data about perioperative interventions in pelvic organ prolapse surgery. A structured programme of pelvic floor muscle training before and after prolapse surgery did not consistently demonstrate any benefit for the intervention; however, this finding is based on the results of two small studies. With regard to other interventions (preoperative bowel preparation and injection of vasoconstrictor agent, ureteral stent placement during uterosacral ligament suspension, postoperative vaginal pack insertion, use of vaginal dilators, prophylactic antibiotics for postoperative catheter care), we found no evidence regarding rates of recurrent prolapse and no clear evidence that these interventions were associated with clinically meaningful reductions in adverse effects, such as intraoperative or postoperative blood transfusion, intraoperative ureteral injury, or postoperative urinary tract infection.