Suprapubic bladder drainage in elective colorectal surgery

Urine drainage management in colorectal surgery

INTRODUCTION

Enhanced recovery programs (ERP) is aimed at reducing a patient's surgical stress response, specifically by reducing the duration of catheterization. In cases of colorectal surgery, there is pronounced heterogeneity in urinary catheterization, which is largely explained by fear of acute urinary retention (AUR).

OBJECTIVE

The objective of the work is to report on the current literature on postoperative urinary catheterization following colorectal surgery, particularly with regard to the risk of AUR, and thereby contribute to the standardization of perioperative practices.

RESULTS

In colon surgery without preoperative urinary disorders, catheterization must not exceed 24h. In rectal surgery, catheter removal starting on postoperative D2 seems reasonable in the absence of AUR risk factor (RF). Male sex, past history of lower urinary tract obstruction, abdomino-perineal amputation (APA) and low rectal anastomosis are AUR risk factors that must be taken into account when deciding to withdraw the urinary catheter. While the role of a suprapubic catheter is not clearly defined, it may be of use following APA. The epidural catheter is another AUR risk factor, but it seems possible to withdraw the urinary catheter on postoperative D1, before the epidural catheter, provided that the other risk factors have been taken into full account. Lastly, up until now no satisfactorily conducted study has assessed the prophylactic value of systematic perioperative alpha-blocker treatment in colorectal surgery.

A prospective study of early removal of the urethral catheter after colorectal surgery in patients having epidural analgesia as part of the Enhanced Recovery After Surgery programme

AIM

Early removal of the urethral catheters is part of the enhanced postoperative recovery programme (ERAS). The effect of epidural anaesthesia on urinary retention was investigated in patients after colorectal resection.

METHOD

A prospective cohort study of all patients having colorectal surgery within an ERAS programme that included insertion of an epidural catheter over the last 5 years.

RESULTS

Two-hundred and ten patients had an epidural and a urethral catheter postoperatively. The duration of catheterization was not recorded in one patient who was therefore excluded from the study. One-hundred and eighteen patients had a trial without catheter (TWOC) prior to stopping the epidural (early TWOC). Ninety-one patients had TWOC after the epidural was stopped (late TWOC). Sixteen (7.6%) patients went into urinary retention (14 early TWOC and two late TWOC). The rate of urinary retention in the early TWOC group was significantly higher than that in the late TWOC group (11.9% vs 2.2%; χ(2), P = 0.009). Those who underwent a laparoscopic resection were significantly more likely to have undergone an early TWOC (χ(2), P = 0.001); however, there was no difference in retention rates between open and laparoscopic surgery (χ(2), P = 0.402). Pelvic surgery was not significantly associated with an increased risk of postoperative urinary retention (χ(2), P = 0.627). Male sex was not significantly associated with urinary retention (χ(2), P = 0.087). In the early TWOC group 86% had the catheter removed within 24 hours of surgery.

CONCLUSION

Early TWOC with epidural analgesia running significantly increases the risk of urinary retention; however, it was still successful in 88% of patients.

A meta-analysis comparing suprapubic and transurethral catheterization for bladder drainage after abdominal surgery

BACKGROUND

Although bladder drainage is widely used for general surgical patients undergoing laparotomy, there is little consensus on whether suprapubic or transurethral catheterization is better.

METHOD

A systematic database search was undertaken to find all studies of suprapubic catheterization. Randomized controlled trials were identified for inclusion. Endpoints for analysis were bacteriuria, patient satisfaction and recatheterization rates. A meta-analysis was performed using fixed-effect or random-effect models as appropriate, depending on heterogeneity.

RESULTS

After abdominal surgery, transurethral catheterization is associated with significant bacteriuria (relative risk (RR)=2.02, P<0.001, 95 percent confidence interval (c.i.) 1.34 to 3.04) and pain or discomfort (RR=2.94, P=0.004, 95 percent c.i. 1.41 to 6.14). Recatheterization rates using the transurethral method were not increased significantly (RR=1.97, P=0.213, 95 percent c.i. 0.68 to 5.74) with heterogeneity between studies.

CONCLUSION

The suprapubic route for bladder drainage in general surgery is more acceptable to patients and reduces microbiological morbidity.

Early complications after low anterior resection for rectal cancer using the EEA stapling device. A prospective trial

Complications following 178 low anterior resections for rectal carcinoma with the EEA autosuture device are reported prospectively. The operative mortality was 2.8 percent. Clinical anastomotic leakage developed in 27 patients, but in none of the 30 patients over 76 years of age. Two of the five hospital deaths were related to leakage. Long-term steroid treatment and previous pelvic radiotherapy were associated with increased risk of leakage. Severe stenosis following anastomotic leakage was seen in one patient. Intraoperative diverting colostomy was done in 16 patients, but no benefit could be demonstrated. It was concluded that use of the upper sigmoid colon for anastomosis probably is not associated with a higher mortality and morbidity than that after more extensive resections reported in the literature. Future randomized trials should exclude very old patients, in whom no leak was seen, when the upper sigmoid colon was used for stapling after low anterior resection.