Predictors of postoperative urinary retention

Preoperative Bladder Scanning Can Predict Postoperative Urinary Retention Following Total Joint Arthroplasty

BACKGROUND

As total joint arthroplasty (TJA) moves to the outpatient setting, it is becoming clear that postoperative urinary retention (POUR) is a potential impediment to same-day discharge. Although risk factors for POUR have been widely studied, the lack of their clinical utility warrants investigation of specific preoperative factors that can assist in surgical planning and patient optimization. The purpose of the current study was to determine whether preoperative symptom surveys and bladder scanning are useful tools in identifying POUR risk.

METHODS

We performed a prospective analysis of patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA) at a high-volume orthopaedic hospital between December 1, 2020, and September 30, 2021. A total of 507 patients (324 female and 183 male) undergoing TJA completed the American Urological Association (AUA) symptom index preoperatively and then again at 14 and 64 days postoperatively. Post-void bladder scans were obtained in the immediate preoperative setting. POUR was defined as a bladder volume of >500 mL that required catheterization. Chi-square and quintile analysis were used to compare bladder scanning volumes, and Student t tests were used to compare AUA scores.

RESULTS

The rate of POUR was 37% (66 female and 34 male) and 23% (37 female and 19 male) in the TKA and THA groups, respectively. Increasing post-void residual volume (PVRV) measured on preoperative bladder scanning was found to be predictive of POUR. Among the TKA cohort, younger age and lower body mass index were also associated with increased catheterization, although age was not statistically significant. The AUA symptom survey was not found to correlate with POUR in either population.

CONCLUSIONS

There was a predictable and exponential increase in the rate of catheterization as preoperative PVRV increased from 50 to 200 mL. The AUA symptom score showed no utility in predicting POUR in our study population. We propose that preoperative bladder ultrasonography become standard practice in TJA, especially among patients scheduled for same-day discharge.

LEVEL OF EVIDENCE

Prognostic Level II . See Instructions for Authors for a complete description of levels of evidence.

Preoperative Postvoid Residual Is Not Predictive of Postoperative Urinary Retention in Primary Total Joint Arthroplasty Patients

Background

Postoperative urinary retention is a common complication after total hip and knee arthroplasty. Postvoid residual (PVR) scanning is a noninvasive method commonly used to evaluate this complication. Preoperatively increased PVR (PrePVR) has been suggested as a risk factor for postoperative catheterization. The aim of this study was to prospectively assess the importance of PrePVR and its relationship with urinary catheter placement, urology consult, and length of stay postoperatively.

Methods

Data was prospectively and consecutively collected at a single institution. All patients were bladder scanned preoperatively to collect PrePVR and subsequently scanned on postoperative days zero and one to collect Postoperative PVR. Chart review was performed to determine the number of straight catheterizations, Foley placement, urology consult and length of stay as well as patient demographics.

Results

Ninety-four consecutive patients were included in this study. There was a significantly increased postoperative PVR as compared to PrePVR (48.0 mL vs 21.0 mL; P < .0001). A PrePVR >50 mL was not associated with a significant difference in PVR between before and after surgery (P = .13); length of stay (P = .08); need for straight catheterization (P = .11); postoperative Foley placement (P = 1.0); or urology consult (P = 1.0). The only significant risk factor identified for postoperative Foley catheter placement was age (77.7 vs 64.2; P = .02).

Conclusions

PrePVR >50 mL was not an accurate predictor of postoperative urinary retention after total joint arthroplasty. PVR significantly increased in all patients. Male sex and increasing age were associated with large increases in PVR postoperatively and an increased risk of catheterization.

Incidence of urinary incontinence after hip fracture surgery and associated risk factors: a prospective study

BACKGROUND

The contribution of the postoperative process to developing or worsening urinary incontinence (UI) after hip fracture surgery (HFS) remains unclear. We aimed to evaluate UI incidence and worsening among older patients undergoing HFS, and explore associated risk factors.

METHODS

This prospective cohort study included patients ≥ 75 years admitted between October 2019 and October 2021 to the Traumatology Service of three hospitals in the Consorci Sanitari de Alt-Penedès i Garraf (Barcelona, Spain) with hip fracture requiring surgical treatment. UI was assessed using the first two questions of the International Consultation on Incontinence Questionnaire - Short Form (ICIQ-SF) at baseline and at days 30 (± 3 days) and 90 (± 3 days) after HFS. Surgery-related data and post-surgical complications were recorded.

RESULTS

A total of 248 patients with a mean (SD) age of 85.8 (6.78) years were included; 77.8% were female and 154 (62.1%) had UI at baseline. After HFS, 3.24% experienced urinary tract infections (UTIs), 3.64%, acute urinary retention (AUR), 8.57%, constipation, and 53.9%, prolonged catheterization (> 24 h). Fifty-eight patients without baseline UI developed UI at 30 days, resulting in a UI incidence of 61.7% (95% CI 51.1-71.54) between days 0 and 30. Of the 248 patients, 146 (59.1%) experienced worsening of UI. AUR and UTIs were identified as risk factors for UI development and worsening after HFS, respectively.

CONCLUSION

The incidence of UI in older patients after HFS is significant. Patient management protocols should consider AUR and UTIs to reduce or eliminate the incidence of UI in older patients undergoing HFS.

Preoperative Factors to Assess Risk for Postoperative Urinary Retention in Total Joint Arthroplasty: A Retrospective Analysis

Background

Methods

Results

Conclusions

A comparative study on the surgical options for male rectal prolapse

Purpose:

Rectal prolapse is known to be a rare condition in males compared to females. This study aimed to analyse the frequency of male rectal prolapse and compare the results of different surgical approaches performed at a single centre.

Patients and Methods:

The authors included patients who underwent surgical treatment for rectal prolapse from March 2016 to February 2021. The proportion of males, mean age and recurrence rates were calculated. Patients were divided into two groups, transanal approach and laparoscopic abdominal approach group, to identify the para-operative parameters including functional tests.

Results:

A total of 56 males, comprising 23.7% (56/236) of all patients. The mean age was 60.8 years, with a recurrence rate of 7 cases (12.5%) during 7.2 months of follow-up. Forty patients underwent transanal procedures, and fifteen underwent laparoscopic abdominal procedures. The mean operative time was longer in the laparoscopic group (transanal vs. abdominal, 57.5 vs. 70.6 min, P < 0.003), and intra-operative bleeding was greater in the transanal group (12.4 vs. 3.4 ml, P < 0.001). Full-layer prolapse (36.8 vs. 81.2% P = 0.003) and longer length (5.6 vs. 7.8 cm, P = 0.048) were more common in laparoscopic group. Time to feeding resumption was shorter after the transanal group (1.2 vs. 1.7 days, P = 0.028). There was no difference between the groups in terms of post-operative complications and recurrence rates. Both Wexner's constipation and incontinence scores showed significant improvement postoperatively.

Conclusion:

The frequency of male rectal prolapse was 23.7%, and perioperative factors differed between transanal and abdominal approaches, but recurrence rates and functional test results did not differ significantly.

Postoperative urinary retention: risk factors, bladder filling rate and time to catheterization: an observational study as part of a randomized controlled trial

Background

Knowledge of risk factors for postoperative urinary retention may guide appropriate and timely urinary catheterization. We aimed to determine independent risk factors for postoperative urinary catheterization in general surgical patients. In addition, we calculated bladder filling rate and assessed the time to spontaneous voiding or catheterization. We used the patients previously determined individual maximum bladder capacity as threshold for urinary catheterization.

Methods

Risk factors for urinary catheterization were prospectively determined in 936 general surgical patients. Patients were at least 18 years of age and operated under general or spinal anesthesia without the need for an indwelling urinary catheter. Patients measured their maximum bladder capacity preoperatively at home, by voiding in a calibrated bowl after a strong urge that could no longer be ignored. Postoperatively, bladder volumes were assessed hourly with ultrasound. When patients reached their maximum bladder capacity and were unable to void, they were catheterized by the nursing staff. Bladder filling rate and time to catheterization were determined.

Results

Spinal anesthesia was the main independent modifiable risk factor for urinary catheterization (hyperbaric bupivacaine, relative risk 8.1, articaine RR 3.1). Unmodifiable risk factors were a maximum bladder capacity < 500 mL (RR 6.7), duration of surgery ≥ 60 min (RR 5.5), first scanned bladder volume at the Post Anesthesia Care Unit ≥250mL (RR 2.1), and age ≥ 60 years (RR 2.0). Urine production varied from 100 to 200 mL/h. Catheterization or spontaneous voiding took place approximately 4 h postoperatively.

Conclusion

Spinal anesthesia, longer surgery time, and older age are the main risk factors for urinary retention catheterization. Awareness of these risk factors, regularly bladder volume scanning (at least every 3 h) and using the individual maximum bladder capacity as volume threshold for urinary catheterization may avoid unnecessary urinary catheterization and will prevent bladder overdistention with the attendant risk of lower urinary tract injury.

Trial registration

Dutch Central Committee for Human Studies registered trial database: NL 21058.099.07.

Current Controlled Trials database: Preventing Bladder Catheterization after an Operation under General or Spinal Anesthesia by Using the Patient’s Own Maximum Bladder Capacity as a Limit for Maximum Bladder Volume. ISRCTN97786497. Registered 18 July 2011 -Retrospectively registered. The original study started 19 May 2008, and ended 30 April 2009, when the last patient was included.

Incidence, Outcomes, and Prediction of Postoperative Urinary Retention After a Nonurologic Procedure

PURPOSE

To develop a prognostic model to estimate postoperative urinary retention (POUR) after lower limb arthroplasty.

METHODS

One thousand two hundred twenty patients underwent 1,374 joint replacement operations (812 knees and 562 hips) between December 2008 and May 2014. Detailed variables were collected. A multivariable logistic regression model was used to identify the independent predictors for POUR. Boot strapping and stepwise elimination was used to design a predictive nomogram.

RESULTS

There were 124 incidents of POUR (9.02%) in 118 patients (90 knee, 34 hip, P = 0.001). On univariate analysis, patients who developed POUR were older (P < 0.001), had higher American Association of Anesthesiology scores (P = 0.007), underwent knee replacement (0.001), were obese (body mass index > 35) (P = 0.04), and were hypertensive (P = 0.029), with a history of benign prostatic hyperplasis (BPH) (P < 0.001) or neurologic disorders (P = 0.024). On multivariable analysis, age (60 to 69 years, P = 0.023, 70 to 79 yrs P = 0.008, >80 years P = 0.003), knee replacement (P = 0.014), and history of BPH (P = 0.013) were the independent predictors of POUR. A score was assigned to each predictor (total = 31). The C-index was 0.65. There were three risk categories as follows: 0 to 50, 51 to 85, and 86+ points resulting in 3.3%, 7.2%, and 14.0% risk of retention, respectively.

DISCUSSION

This nomogram reliably predicts the risk of POUR in patients undergoing hip and knee arthroplasties and may help planning preoperative interventions to decrease the risk of this complication.

Rate of urinary retention after ileostomy takedown in men and role of routine placement of urinary catheter

Ileostomy takedown has been proposed as one of the procedures where the placement of the catheters can be avoided, however, the rate of UR after ileostomy takedown is unknown. The aim of this study is to investigate the rate of UR after ileostomy takedown and the potential benefit of perioperative Tamsulosin. Retrospective cohort study of men undergoing ileostomy takedown after pelvic colorectal surgery between January 2009 and December 2016. A total of 100 patients were identified. The rate of UR after ileostomy takedown was high at 26%. There were no instances of urinary tract infection, however, most instances of UR were in patients who did not have catheter in surgery (96% vs. 4%, p = 0.044). Perioperative use of tamsulosin did not result in significant decrease in urinary retention. Rates of urinary retention after ileostomy takedown are high. Although not placing the catheter may be protective against urinary tract infections, patients should be counseled about the possibility of UR after ileostomy takedown.

Rectal-prolapse repair in men is safe, but outcomes are not well understood

Introduction

Rectal prolapse is a condition that occurs infrequently in men and there is little literature guiding treatment in this population. The purpose of this study was to evaluate the surgical approach and outcomes of rectal-prolapse repair in men.

Methods

A retrospective multicenter review was conducted of consecutive men who underwent rectal-prolapse repair between 2004 and 2014. Surgical approaches and outcomes, including erectile function and fecal continence, were evaluated.

Results

During the study period, 58 men underwent rectal-prolapse repair and the mean age of repair was 52.7 ± 24.1 years. The mean follow-up was 13.2 months (range, 0.5–117 months). The majority of patients underwent endoscopic evaluation (78%), but few patients underwent anal manometry (16%), defecography (9%) or ultrasound (3%). Ten patients (17%) underwent biofeedback/pelvic-floor physical therapy prior to repair. Nineteen patients (33%) underwent a perineal approach (most were perineal proctosigmoidectomy). Thirty-nine patients (67%) underwent repair using an abdominal approach (all were suture rectopexy) and, of these, 77% were completed using a minimally invasive technique. The overall complication rate was 26% including urinary retention (16%), which was more common in patients undergoing the perineal approach (32% vs. 8%, P = 0.028), urinary-tract infection (7%) and wound infection (3%). The overall recurrence rate was 9%, with no difference between abdominal and perineal approaches. Information on sexual function was missing in the majority of patients  both before and after surgery (76% and 78%, respectively).

Conclusion

 Rectal-prolapse repair in men is safe and has a low recurrence rate; however, sexual function was poorly recorded across all institutions. Further studies are needed to evaluate to best approach to and functional outcomes of rectal-prolapse repair in men.

Urinary retention as a postoperative complication associated with functional decline in elderly female patients with femoral neck and trochanteric fractures: A retrospective study of a patient cohort

Urinary retention (UR) has been recognized as one of the most common postoperative complications after hip surgery in elderly. The objective of the present study was to evaluate risk for postoperative complications of UR in elderly female patients with femoral neck fractures.We recruited 221 female patients (age 85.3 ± 7.0 years) with a history of hip surgery carried out at Toyama Municipal Hospital. UR occurred in 34 out of 221 cases (15.4%). Multiple logistic regression analysis was conducted to investigate the risk factors for UR, including age, body mass index (BMI), serum albumin, cognitive impairment, and activities of daily living (ADL).The results showed significant association of UR with cognitive impairment (P = .005, odds ratio [OR] 4.11, 95% confidence interval [CI] 1.53-11.03), and ADL (P = .029, OR 2.61, 95% CI 1.11-6.18), under adjustment with age and BMI.This study demonstrated that cognitive function and ADL were the important risk factors for UR, suggested that the postoperative management of UR is important with taking account of neurofunctional assistance and nursing care in daily living, especially in elderly female patients receiving surgery of femoral neck and trochanteric fractures.

Adverse events and their risk factors 90 days after cervical spine surgery: analysis from the Michigan Spine Surgery Improvement Collaborative

OBJECTIVE

The Michigan Spine Surgery Improvement Collaborative (MSSIC) is a statewide, multicenter quality improvement initiative. Using MSSIC data, the authors sought to identify 90-day adverse events and their associated risk factors (RFs) after cervical spine surgery.

METHODS

A total of 8236 cervical spine surgery cases were analyzed. Multivariable generalized estimating equation regression models were constructed to identify RFs for adverse events; variables tested included age, sex, diabetes mellitus, disc herniation, foraminal stenosis, central stenosis, American Society of Anesthesiologists Physical Classification System (ASA) class > II, myelopathy, private insurance, anterior versus posterior approach, revision procedures, number of surgical levels, length of procedure, blood loss, preoperative ambulation, ambulation day of surgery, length of hospital stay, and discharge disposition.

RESULTS

Ninety days after cervical spine surgery, adverse events identified included radicular findings (11.6%), readmission (7.7%), dysphagia requiring dietary modification (feeding tube or nothing by mouth [NPO]) (6.4%), urinary retention (4.7%), urinary tract infection (2.2%), surgical site hematoma (1.1%), surgical site infection (0.9%), deep vein thrombosis (0.7%), pulmonary embolism (0.5%), neurogenic bowel/bladder (0.4%), myelopathy (0.4%), myocardial infarction (0.4%), wound dehiscence (0.2%), claudication (0.2%), and ileus (0.2%). RFs for dysphagia included anterior approach (p < 0.001), fusion procedures (p = 0.030), multiple-level surgery when considering anterior procedures only (p = 0.037), and surgery duration (p = 0.002). RFs for readmission included ASA class > II (p < 0.001), while preoperative ambulation (p = 0.001) and private insurance (p < 0.001) were protective. RFs for urinary retention included increasing age (p < 0.001) and male sex (p < 0.001), while anterior-approach surgery (p < 0.001), preoperative ambulation (p = 0.001), and ambulation day of surgery (p = 0.001) were protective. Preoperative ambulation (p = 0.010) and anterior approach (p = 0.002) were protective of radicular findings.

CONCLUSIONS

A multivariate analysis from a large, multicenter, prospective database identified the common adverse events after cervical spine surgery, along with their associated RFs. This information can lead to more informed surgeons and patients. The authors found that early mobilization after cervical spine surgery has the potential to significantly decrease adverse events.

Postoperative urinary retention after inguinal hernia repair: a single institution experience

PURPOSE

Inguinal hernia repair is a common general surgery procedure with low morbidity. However, postoperative urinary retention (PUR) occurs in up to 22% of patients, resulting in further extraneous treatments.This single institution series investigates whether patient comorbidities, surgical approaches, and anesthesia methods are associated with developing PUR after inguinal hernia repairs.

METHODS

This is a single institution retrospective review of inguinal hernia from 2012 to 2015. PUR was defined as patients without a postoperative urinary catheter who subsequently required bladder decompression due to an inability to void. Univariate and multivariate logistic regressions were performed to quantify the associations between patient, surgical, and anesthetic factors with PUR. Stratification analysis was conducted at age of 50 years.

RESULTS

445 patients were included (42.9% laparoscopic and 57.1% open). Overall rate of PUR was 11.2% (12% laparoscopic, 10.6% open, and p = 0.64). In univariate analysis, PUR was significantly associated with patient age >50 and history of benign prostatic hyperplasia (BPH). Risk stratification for age >50 revealed in this cohort a 2.49 times increased PUR risk with lack of intraoperative bladder decompression (p = 0.013).

CONCLUSIONS

At our institution, we found that patient age, history of BPH, and bilateral repair were associated with PUR after inguinal hernia repair. No association was found with PUR and laparoscopic vs open approach. Older males may be at higher risk without intraoperative bladder decompression, and therefore, catheter placement should be considered in this population, regardless of surgical approach.

Morbidities after closure of ileostomy: analysis of risk factors

PURPOSE

Low anterior resection is commonly performed for carcinoma of the distal rectum. Diverting ileostomy has been used to decrease the septic consequence of anastomotic leakage and to reduce the re-operation rate. Nevertheless, subsequent closure of ileostomy can be associated with considerable morbidities. This study aimed to evaluate the morbidities after closure of ileostomy and to identify possible risk factors associated with the morbidities.

METHODS

Data of patients who underwent closure of ileostomy, after a previous low anterior resection and defunctioning ileostomy for rectal cancer, was reviewed retrospectively. Patient's demographics, coexisting morbidities, operative details, and post-operative outcomes were analyzed.

RESULTS

From January 2000 to September 2012, 213 patients who underwent ileostomy closure were included. Thirty-five patients developed post-operative complications. The overall complication rate was 16.4 %. The majority of complications could be managed by conservative treatment. Only one patient required re-operation due to intestinal obstruction. There was no 30-day mortality. Age >80 years was an independent risk factor for post-operative complications. Age >80 years was also an independent risk factor for developing urinary retention (p = 0.001) and prolonged ileus (p = 0.02). Closure of ileostomy with hand-sewn techniques showed a higher incidence of post-operative intestinal obstruction (p = 0.049) compared to closure using stapler.

CONCLUSION

Closure of ileostomy following low anterior resection is associated with acceptable morbidities. Elderly patients tend to have a more complicated post-operative course and require more medical attention. The use of stapler is the preferred method for ileostomy closure as it is associated with less post-operative intestinal obstruction.

High rates of postoperative urinary retention following primary total hip replacement performed under combined general and spinal anaesthesia with intrathecal opiate

BACKGROUND

Postoperative urinary retention (POUR) occurs frequently following hip replacement.

METHODS

94 consecutive primary hip arthroplasty patients were assessed prospectively for POUR. 80 patients followed our anaesthesia protocol with combined general and spinal anaesthesia using bupivacaine and intrathecal diamorphine.

RESULTS

29 instances of POUR with higher rates in men and younger patients (under-50s), independent of either pre-existing renal impairment or opiate strength. POUR was observed to increase length of stay by 1.6 days.

CONCLUSIONS

We report a 36% overall rate of POUR. Males demonstrated a 3-fold increased risk. Patients should be counselled pre-operatively on the risk of urinary retention.

Perioperative use of tamsulosin significantly decreases rates of urinary retention in men undergoing pelvic surgery

PURPOSE

Urinary retention is a common complication of pelvic surgery, leading to urinary tract infection and prolonged hospital stays. Tamsulosin is an alpha blocker that works by relaxing bladder neck muscles. It is used to treat benign prostatic hypertrophy and retention. We aim to investigate the potential benefits of preemptive tamsulosin use on rates of urinary retention in men undergoing pelvic surgery.

METHODS

This is a retrospective review of an institutional colorectal database. All men undergoing pelvic surgery between 2004 and 2013 were included. Patients given 0.4 mg of tamsulosin 3 days prior and after surgery at discretion of surgeon starting in 2007 were compared with patients receiving expectant postoperative management.

RESULTS

One hundred eighty-five patients were included in the study (study group: N = 30; control group: N = 155). Study group patients were older (56.8 vs. 50.1 years). Overall urinary retention rate was 22% with significantly lower rates in the study group compared with control (6.7 vs. 25%; p = 0.029). Study group had higher rates of minimally invasive surgery (61 vs. 29.7%); however, this did not impact urinary retention rate (20.6 vs. 22.7% for minimally invasive surgery vs. open surgery; p = 0.85). Independent predictors of urinary retention included lack of preemptive tamsulosin (odds ratio (OR), 7.67; 95% confidence interval (CI), 1.4-41.7) and cancer location in the distal third of the rectum (OR, 18.8; 95% CI, 2.1-172.8).

CONCLUSIONS

Preemptive perioperative use of tamsulosin may significantly decrease the incidence of urinary retention in men undergoing pelvic surgery. This may play a role in avoidance of urinary retention, particularly in patients with distal rectal cancer.

Risk factors and preventive measures for acute urinary retention after rectal cancer surgery

BACKGROUND

Although several risk factors for acute urinary retention after rectal cancer surgery have been proposed, few studies have enrolled a homogeneous group of patients without preoperative urinary dysfunction. We aimed to identify risk factors and preventive measures for acute urinary retention after rectal cancer surgery.

METHODS

This study was a retrospective review of prospectively collected data from included patients who underwent rectal cancer surgery at a single center. Preoperative urinary function was evaluated using the International Prostate Symptom Score (IPSS). Clinical data were collected prospectively and analyzed to assess the risk factors for acute urinary retention, which was defined as the inability to self-void after removing the urinary catheter requiring catheterization or reinsertion of an indwelling catheter.

RESULTS

Of 352 patients with mild preoperative IPSS (0-7), 48 (13.6 %) experienced acute urinary retention. Multivariate logistic regression analysis showed that male sex (odds ratio [OR] 2.240, p = 0.039), laparoscopic operation (OR 2.421, p = 0.024), intraoperative intravenous fluid ≥ 2,000 mL (OR 3.794, p < 0.001), and urinary catheter removal on postoperative day 1 or 2 (OR 3.650, p = 0.017) were independent risk factors for acute urinary retention after rectal cancer surgery. Patients with two risk factors had a significantly higher risk of acute urinary retention than patients with none or one risk factor.

CONCLUSIONS

This study suggests the maintenance of a urinary catheter for a period longer than 2 days and intraoperative fluid restriction to prevent acute urinary retention after rectal cancer surgery.

Risk factors of postoperative urinary retention after hip surgery for femoral neck fracture in elderly women

AIM

The aim of the present study was to evaluate risk factors for postoperative urinary retention (POUR) in female patients with femoral neck fractures.

METHODS

We recruited 72 female patients (age 86.5 ± 6.7 years) from among 90 cases of hip surgery carried out between January and December 2011 at Goto Chuo Hospital. We evaluated the risk factors for POUR, including the administration of anticholinergic drugs, diabetes mellitus, preoperative dementia and/or delirium, neurological disorders, age, hypertension, overactive bladder, and the postoperative duration of the use of an indwelling urethral catheter using a multiple logistic regression analysis.

RESULTS

In the present study, POUR occurred in eight out of 72 cases (11.1%). The multivariate analysis showed that the indwelling period of the urethral catheter (per 1-day increase; P = 0.04, OR 0.33 95% CI 0.11-0.96), and preoperative dementia and/or delirium (P = 0.03, OR10.4, 95%CI 1.21-89.2) correlated with the occurrence of POUR. Diabetes mellitus (P = 0.78), anticholinergic agents (P = 0.23), neurological disorders (P = 0.83), age (P = 0.86), hypertension (P = 0.76) and overactive bladder (P = 0.34) did not significantly correlate with the occurrence of POUR.

CONCLUSIONS

The present study showed that the early removal of the urethral catheter, and preoperative dementia and/or delirium had significant correlations with POUR. The femoral neck fractures and the surgical procedure used for the hip surgery do not induce damage to the bladder and nerve system related to the voiding function, and the voiding function in all of the patients recovered after short-term intermittent catheterization. Physicians should not place permanent indwelling urethral catheters without carrying out urological assessments.

Avoiding bladder catheterisation in total knee arthroplasty: patient selection criteria and low-dose spinal anaesthesia

BACKGROUND

Bladder catheterisation may be inconvenient for patients, delay mobilisation and risk complications. We hypothesised that by excluding pre-operatively patients at high risk of post-operative urinary retention, the majority of patients could avoid perioperative catheterisation during low-dose spinal anaesthesia.

METHODS

Patients undergoing total knee arthroplasty were assigned if fit for spinal anaesthesia and without severe symptoms of lower urinary tract obstruction, gross incontinence, mobilisation difficulties hindering micturition and > 200 ml residual urine volume. Bladder volume was monitored by ultrasound and temporary catheterisation advised if > 400 ml.

RESULTS

Fifty-two patients (men 54%, age 65 ± 9 years, body mass index 31 ± 5, 30% with history of urinary tract problems) were included. Intrathecal hyperbaric bupivacaine given was 7.8 ± 1.08 mg and always 7.5 μg sufentanil providing sufficient anaesthesia in all cases. Crystalloid given during surgery was 8.5 ± 4.0 ml/kg. Voluntary micturition was reached by 46 patients (88%, confidence interval (CI) 79-97%), but six (12%, CI 3-21%) needed temporary catheterisation once (four men/two women). Larger bladder volumes were found in those catheterised than those with voluntary micturition on the pre-operative (131 ± 76 ml vs. 68 ± 57 ml, P = 0.03) and first post-operative bladder scan (445 ± 169 ml vs. 271 ± 129 ml, P = 0.004). All but two patients (96%) could be mobilised the same day. No patient suffered bladder dysfunction.

CONCLUSION

Low-dose spinal anaesthesia combined with simple selection criteria allowed for early mobilisation (96%) and avoidance of bladder catheterisation in the vast majority (88%) of patients undergoing total knee arthroplasty, and the rest (12%) only needed a single temporary catheterisation.

Pain reporting, opiate dosing, and the adverse effects of opiates after hip or knee replacement in patients 60 years old or older

Our goal was to determine whether there were age-related differences in pain, opiate use, and opiate side effects after total hip or knee arthroplasty in patients 60 years old or older. We hypothesized that there would be no significant differences between age groups in (1) mean pain score, (2) opiate use after adjusting for pain, or (3) opiate side effects after adjusting for opiate use and pain score. We retrospectively reviewed the electronic and paper charts of all patients undergoing total joint replacements at our institution over 3 years who met the following criteria: (1) 60 years old or older, (2) primary single total knee or total hip replacement, and (3) no preoperative dementia. Preoperative, intraoperative, and postoperative course data were collected using a customized data entry process and database. We divided the patients into 2 age groups, those 60 to 79 years old and those 80 years old or older. Using a marginal model with the panel variable of postoperative day, we investigated the associations between age group and pain, age group and pain adjusting for opiate use, and age group and complications (respiratory depression, naloxone usage as a measure of respiratory arrest, delirium, constipation, and urinary retention) adjusting for opiate use (Xtgee, Stata10, Stata Corp. LP, College Station, Texas). Significance was set at P < .05. We found no significant difference in pain scores between groups, but the older group had significantly fewer opiates prescribed yet significantly more side effects, including delirium (odds ratio 4.2), than did the younger group, even after adjusting for opiate dose and pain score.

Lack of preoperative predictors of the immediate return of postoperative bladder emptying after uterosacral ligament suspension

OBJECTIVES

To determine whether preoperative postvoid residual volume (PVR), pelvic organ prolapse quantification (POPQ) stage, patient characteristics, or concurrent operations are predictors of immediate postoperative bladder emptying after uterosacral ligament suspension (USLS).

METHODS

A review of patients undergoing USLS in 2008 and 2009 was performed. The factors analyzed included patient age, body mass index, parity, preoperative PVR, POPQ stage, concurrent anterior repair, posterior repair, hysterectomy and/or sling procedures, and postoperative voiding trial status.

RESULTS

During the study interval, 151 patients underwent USLS with various combinations of concurrent procedures. The mean preoperative PVR was 90 mL. Seventy-five patients (50%) passed the postoperative voiding trial on postoperative day 1. Patients who passed the postoperative voiding trial and those who failed had similar average preoperative PVR (P = 0.94), similar age (P = 0.14), body mass index (P = 0.45), parity (P = 0.82), and preoperative POPQ stage (P = 0.80). There was no difference (P ≥ 0.14) among concurrent surgical procedures in the proportion of patients who passed the postoperative voiding trial based on univariate analyses.

CONCLUSIONS

In our cohort of patients, preoperative PVR, POPQ stage, and other patient characteristics were not predictors of immediate postoperative bladder emptying after USLS. Postoperative voiding function is one of the most unpredictable aspects of pelvic reconstructive surgery.

Risk factors of post-operative urinary retention in hospitalised patients

BACKGROUND

Post-operative urinary retention (POUR) is most accurately determined by using ultrasound to measure bladder volume. The aim of this study was to define the risk factors of POUR in the recovery room in hospitalised patients.

METHODS

An ultrasound-determined bladder volume ≥400 ml at arrival in the recovery room was used to define POUR. Multivariate regression analysis was used to identify patient and system factors linked to POUR in 773 consecutive hospitalised patients who had undergone orthopaedic, abdominal, gynaecological or plastic surgery without an indwelling urinary catheter.

RESULTS

We found the incidence of POUR to be 13%. The lack of pre-operative voiding, use of regional anaesthesia, anaesthesia time >2 h and emergency surgery were all independent risk factors for POUR.

CONCLUSIONS

The detected incidence of POUR at arrival in the recovery room was rather high but had easily identifiable risk factors. We recommend pre-operative voiding whenever possible. Routine bladder scanning at arrival in the recovery room should be considered, especially after spinal anaesthesia, emergency surgery or when the anaesthesia time exceeds 2 h.

High incidence of acute urinary retention associated with immediate catheter removal after laparoscopic Nissen fundoplication

BACKGROUND

Laparoscopic Nissen fundoplication, a common treatment for medically refractory gastroesophageal reflux disease, is associated with a high rate of postoperative urinary retention. This study explored the incidence of urinary retention and external factors.

METHODS

A retrospective chart review was performed for inpatient records of patients who underwent laparoscopic Nissen fundoplication for the treatment of reflux disease from 1 December 2004 through 31 December 2008 at a community teaching medical center.

RESULTS

A review of 111 inpatient records found a 21.6% (n=24) incidence of acute urinary retention after laparoscopic Nissen fundoplication. Acute urinary retention was not significantly associated with a longer hospital stay (2.39 vs. 2.79 days). More importantly, 79.2% (n=19) of the patients with postoperative acute urinary retention had removal of their Foley catheters immediately after surgery.

CONCLUSIONS

Urinary retention rates after laparoscopic Nissen fundoplication may be lowered by postponing the removal of the Foley catheter for several hours.