Low incidence of postoperative urinary retention with the use of a nurse-led bladder scan protocol after hip and knee arthroplasty: a retrospective cohort study

Disparate potential for readmission prevention exists among inpatient and outpatient procedures in a minimally invasive surgery practice

BACKGROUND

Administrators have focused on decreasing postoperative readmissions for cost reduction without fully understanding their preventability. This study describes the development and implementation of a surgeon-led readmission review process that assessed preventability.

METHODS

A gastrointestinal surgical group at a tertiary referral hospital developed and implemented a template to analyze inpatient and outpatient readmissions. Monthly stakeholder assessments reviewed and categorized readmissions as potentially preventable or not preventable. Continuous variables were examined by the Student's t test and reported as means and standard deviations. Categorical variables were examined by the Pearson χ2 statistic and Fisher's exact test.

RESULTS

There were 61 readmission events after 849 inpatient operations (7.2%) and 16 after 856 outpatient operations (1.9%), the latter of which were all classified as potentially preventable. Colorectal procedures represented 65.6% of readmissions despite being only 37.2% of all cases. The majority (67.2%) of readmission events were not preventable. Compared to the not-preventable group, the potentially preventable group experienced more dehydration (30.0% vs 9.8%, P = .045) and ileostomy creation (78.6% vs 33.3%, P = .017). The potential for outpatient management to prevent readmission was significantly higher in the potentially preventable group (40.0% vs 0.0%, P < .001), as was premature discharge prevention (35.0% vs 0.0%, P < .001).

CONCLUSION

The use of the standardized template developed for analyzing readmission events after inpatient and outpatient procedures identified a disparate potential for readmission prevention. This finding suggests that a singular focus on readmission reduction is misguided, with further work needed to evaluate and implement appropriate quality-based strategies.

Short-Term Indwelling Foley Catheters Do Not Reduce the Risk of Postoperative Urinary Retention in Uncomplicated Primary THA and TKA: A Randomized Controlled Trial

BACKGROUND

The purpose of this randomized controlled trial was to determine whether a short-term Foley catheter (inserted in the operating room and removed upon arrival to the orthopaedic floor) would reduce the risk of postoperative urinary retention (POUR) in patients undergoing primary total hip (THA) and total knee arthroplasty (TKA).

METHODS

Three hundred and eighty-eight patients undergoing inpatient primary TKA (n = 228) or THA (n = 160) with spinal anesthesia were randomized to receive a short-term Foley catheter (n = 194) or no Foley (n = 194). There were 143 male and 245 female patients. The primary outcome was POUR, defined as requiring ≥2 straight catheterizations or the placement of an indwelling urinary catheter when indicated by retention of ≥450 mL on bladder scans. Secondary outcomes included urinary tract infections (UTIs) within 3 weeks and the need for ≥1 straight catheterization. A power analysis determined that 194 patients per group were required to detect a 7% minimal clinically important difference in POUR rates at 80% power and alpha of 0.05. Intention-to-treat and as-treated analyses were performed (2 patients received the non-allocated treatment). Outcomes were compared between the groups using univariate and multivariate analyses, with alpha < 0.05.

RESULTS

Nine patients developed POUR: 4 in the short-term Foley group and 5 in the control group (2.1% versus 2.6%; p = 1.00). Of those who developed POUR, 8 were male and 1 was female (88.9% versus 11.1%; p = 0.002). Twenty-four patients required ≥1 straight catheterization: 10 in the Foley group and 14 in the control group (5.2% versus 7.2%; p = 0.40). Four patients developed UTIs: 3 in the Foley group and 1 in the control group (1.5% versus 0.5%; p = 0.62) on intention-to-treat analysis, and 4 in the Foley group and none in the control group (2.1% versus 0.0%; p = 0.12) on as-treated analysis.

CONCLUSIONS

The use of a short-term Foley catheter inserted in the operating room and removed on arrival to the orthopaedic floor does not decrease the rate of POUR.

LEVEL OF EVIDENCE

Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Spinal versus general anaesthesia in contemporary primary total knee arthroplasties

Aims

Spinal anaesthesia has seen increased use in contemporary primary total knee arthroplasties (TKAs). However, controversy exists about the benefits of spinal in comparison to general anaesthesia in primary TKAs. This study aimed to investigate the pain control, length of stay (LOS), and complications associated with spinal versus general anaesthesia in primary TKAs from a single, high-volume academic centre.

Methods

We retrospectively identified 17,690 primary TKAs (13,297 patients) from 2001 to 2016 using our institutional total joint registry, where 52% had general anaesthesia and 48% had spinal anaesthesia. Baseline characteristics were similar between cohorts with a mean age of 68 years (SD 10), 58% female (n = 7,669), and mean BMI of 32 kg/m2 (SD 7). Pain was evaluated using oral morphine equivalents (OMEs) and numerical pain rating scale (NPRS) data. Complications including 30- and 90-day readmissions were studied. Data were analyzed using an inverse probability of treatment weighted model based on propensity score that included many patient and surgical factors. Mean follow-up was seven years (2 to 18).

Results

Patients treated with spinal anaesthesia required fewer postoperative OMEs (p < 0.001) and had lower NPRS scores (p < 0.001). Spinal anaesthesia also had fewer cases of altered mental status (AMS; odds ratio (OR) 1.3; p = 0.044), as well as 30-day (OR 1.4; p < 0.001) and 90-day readmissions (OR 1.5; p < 0.001). General anaesthesia was associated with increased risk of any revision (OR 1.2; p = 0.021) and any reoperation (1.3; p < 0.001).

Conclusion

In the largest single institutional report to date, we found that spinal anaesthesia was associated with significantly lower OME use, lower risk of AMS, and lower overall 30- and 90-day readmissions following primary TKAs. Additionally, spinal anaesthesia was associated with reduced risk of any revision and any reoperation after accounting for numerous patient and operative factors. When possible and safe, spinal anaesthesia should be considered in primary TKAs. Cite this article: Bone Joint J 2022;104-B(11):1209–1214.

Continuous Cold Flow Device Following Total Knee Arthroplasty: Myths and Reality

Background and Objectives: To assess the effect of continuous cold flow (CCF) therapy on pain reduction, opioid consumption, fast recovery, less perioperative bleeding and patient satisfaction in patients undergoing a total knee arthroplasty. Materials and Methods: Patients affected by knee osteoarthritis between September 2020 and February 2022 were enrolled in this case-control study. Patients were randomly divided into two groups (n = 50, each): the study group received postoperative CCF therapy while the control group was treated by cold pack (gel ice). The CCF device is a computer-assisted therapy with continuous cold fluid, allowing a selective distribution, constant and uniform, of cold or hot on the areas to be treated. In both groups, pre- and postoperative evaluations at 6, 24, 72 h and at the fifth day were conducted using Visual Analogic Scale (VAS), opioid consumption, passive range of motion, preoperative hematocrit, total blood loss by Gross formula, transfusion requirement and patient satisfaction questionnaire. Results: One hundred patients, 52 women (52%), were included in the study. Reduction of pain, opioid consumption and increase in passive range of movement were statistically significantly demonstrated in the study group on the first and third days. Patients were satisfied with adequate postoperative pain management due to CCF therapy (p = 0.01) and they would recommend this treatment to others (p = 0.01). Conclusions: A continuous cold flow device in the acute postoperative setting after total knee arthroplasty is associated with pain reduction and improving early movement. Patients were almost satisfied with the procedure. The management of perioperative pain control could improve participation in the early rehabilitation program as demonstrated by the increase in ROM, psychological satisfaction and reduction in opioid use.

Postoperative Urinary Retention after Pediatric Orthopedic Surgery

Purpose: This study aims to describe the incidence of postoperative urinary retention among pediatric patients undergoing orthopedic surgery and identify risk factors. Methods: The Pediatric Health Information System was used to identify children aged 1−18 years who underwent orthopedic surgery. Collected from each patient’s record were demographic information, principal procedure during hospitalization, the presence of neurologic/neuromuscular conditions and other complex chronic medical conditions, the total postoperative length of stay, and the presence of postoperative urinary retention. Results: The overall incidence of postoperative urinary retention was 0.38%. Children with complex chronic neuromuscular conditions (OR 11.54 (95% CI 9.60−13.88), p = < 0.001) and complex chronic non-neuromuscular medical conditions (OR 5.07 (95% CI 4.11−6.25), p ≤ 0.001) had a substantially increased incidence of urinary retention. Surgeries on the spine (OR 3.98 (95% CI 3.28−4.82, p ≤ 0.001) and femur/hip (OR 3.63 (95% CI 3.03−4.36), p ≤ 0.001) were also associated with an increased incidence. Conclusions: Children with complex chronic neuromuscular conditions have a substantially increased risk of experiencing postoperative urinary retention. Complex chronic non-neuromuscular medical conditions and surgeries to the spine, hip, and femur also carry a notably increased risk.

Key Components, Current Practice and Clinical Outcomes of ERAS Programs in Patients Undergoing Orthopedic Surgery: A Systematic Review

Enhanced recovery after surgery (ERAS) protocols have led to improvements in outcomes in several surgical fields, through multimodal optimization of patient pathways, reductions in complications, improved patient experiences and reductions in the length of stay. However, their use has not been uniformly recognized in all orthopedic fields, and there is still no consensus on the best implementation process. Here, we evaluated pre-, peri-, and post-operative key elements and clinical evidence of ERAS protocols, measurements, and associated outcomes in patients undergoing different orthopedic surgical procedures. A systematic literature search on PubMed, Scopus, and Web of Science Core Collection databases was conducted to identify clinical studies, from 2012 to 2022. Out of the 1154 studies retrieved, 174 (25 on spine surgery, 4 on thorax surgery, 2 on elbow surgery and 143 on hip and/or knee surgery) were considered eligible for this review. Results showed that ERAS protocols improve the recovery from orthopedic surgery, decreasing the length of hospital stays (LOS) and the readmission rates. Comparative studies between ERAS and non-ERAS protocols also showed improvement in patient pain scores, satisfaction, and range of motion. Although ERAS protocols in orthopedic surgery are safe and effective, future studies focusing on specific ERAS elements, in particular for elbow, thorax and spine, are mandatory to optimize the protocols.

Mitigation of postoperative urinary retention among total joint replacement patients using the ERAS protocol and applying risk-stratified catheterization

BACKGROUNDS

We intended to identify the incidence and risk factors (RFs) for Postoperative urinary retention (POUR) after applying a risk-stratified catheterization optimization method in enhanced recovery after surgery (ERAS)-total joint arthroplasty (TJA).

METHODS

A total of 381 patients were prospectively monitored for POUR. POUR diagnosis was done by a perioperative specialist. Data on potential risk factors (RFs) for POUR were accumulated. Univariate analysis (UA) was conducted to identify possible indicators of POUR, followed by multivariate analysis (MA) of identified indicators.

RESULTS

POUR occurred in 5.5% of cases, including 8 (3.4%) patients underwent total knee arthroplasty and 13 (10.4%) patients underwent total hip arthroplasty. In UA, age, sex, American Society of Anesthesiologists (ASA) score, and the type of operation were significantly different on UA (P = 0.046, P = 0.022, P = 0.000 and P = 0.049, respectively). Other additional predictors, including body mass index (BMI), international prostate symptom score (IPSS) score, preoperative haemoglobin (Hb), duration of operation, estimated intraoperative blood loss, intraoperative fluid volume, fluid infusion volume within 24 h postoperatively were not associated with POUR (P > 0.05). MA results demonstrated that age, ASA score, type of operation and standard intraoperative placement of an indwelling bladder catheter (SIP-IBC) were strongly associated with POUR development risk (P < 0.05).

CONCLUSION

Overall, we had a low POUR incidence in our study cohort. However, with the shift from non-ERAS TJA to ERAS TJA protocol, it is crucial to closely monitor the male gender, advanced age, THA and SIP-IBC, as these variables can markedly enhance POUR risk.

Same-Day Outpatient Lower-Extremity Joint Replacement: A Critical Analysis Review

➢ The economics of transitioning total joint arthroplasty (TJA) to standalone ambulatory surgery centers (ASCs) should not be capitalized on at the expense of patient safety in the absence of established superior patient outcomes. ➢ Proper patient selection is essential to maximizing safety and avoiding complications resulting in readmission. ➢ Ambulatory TJA programs should focus on reducing complications frequently associated with delays in discharge. ➢ The transition from hospital-based TJA to ASC-based TJA has substantial financial implications for the hospital, payer, patient, and surgeon.

Postoperative Urinary Retention in Modern Rapid Recovery Total Joint Arthroplasty

Postoperative urinary retention (POUR) is a disruptive complication after modern rapid recovery total joint arthroplasty. This review aims to synthesize the recent literature on POUR in the setting of total joint arthroplasty. The incidence of POUR ranges from 5.5% to 46.3%. The lack of a standardized definition of POUR accounts for some of this variability. Risk factors previously associated with the development of POUR include increasing age, male sex, benign prostatic hyperplasia, use of bupivacaine and intrathecal morphine in spinal anesthesia, glycopyrrolate, and volume of intraoperative intravenous fluid administered. Predictive scoring assessments, such as the International Prostate Symptom Score and a newer predictive nomogram, have not been adequately validated by high-quality studies. The treatment of POUR comprises either intermittent or indwelling urethral catheterization. Higher quality prospective studies are needed to allow for the standardization of all aspects of POUR from its diagnostic criteria to its treatment.

A Nurse-Led Voiding Algorithm for Managing Urinary Retention After General Thoracic Surgery

BACKGROUND

Untreated postoperative urinary retention (POUR) leads to bladder overdistension. Treatment of POUR involves urinary catheterization, which predisposes patients to catheter-associated urinary tract infections. The hospital's rate of POUR after lobectomy was 21%, exceeding the Society of Thoracic Surgeons' benchmark of 6.4%. Nurses observed that more patients were being catheterized after implementation of a newly revised urinary catheter protocol.

OBJECTIVE

To reduce the incidence of POUR by implementing a thoracic surgery-specific nurse-led voiding algorithm.

METHODS

Experts validated the voiding algorithm that standardized postoperative assessment. It was initiated after general thoracic surgery among 179 patients in a thoracic surgery stepdown unit of a large Magnet hospital. After obtaining verbal consent from patients, nurses collected demographic and clinical data and followed the algorithm, documenting voided amounts and bladder scan results. Descriptive statistics characterized the sample and the incidence of POUR. Associations were determined between demographic and clinical factors and POUR status by using the t test and χ2 test.

RESULTS

The POUR-positive group and the POUR-negative group were equivalent with regard to demographic and clinical factors, except more patients in the POUR-positive cohort had had a lobectomy (P = .05). The rate of POUR was 8%. Society of Thoracic Surgeons reports revealed a rapid and sustained reduction in the hospital's rates of POUR after lobectomy: from 21% to 3%.

CONCLUSION

The use of this nurse-led voiding algorithm effectively reduced and sustained rates of POUR.

Urinary catheter use in patients with hip fracture: Are current guidelines appropriate? A retrospective review

Background:

Guidelines for urinary catheterization in patients with hip fracture recommend limiting catheter use and using intermittent catheterization preferentially to avoid complications such as urinary tract infection (UTI) and postoperative urinary retention (POUR). We aimed to compare current practices to clinical guidelines, describe the incidence of POUR and UTI, and determine factors that increase the risk of these complications.

Methods:

We retrospectively reviewed the charts of patients with hip fracture who presented to a single large tertiary care centre in southeastern Ontario between November 2015 and October 2017. Data collected included comorbidities, catheter use and length of stay. We compared catheter use to guidelines, and investigated the incidence of and risk factors for POUR and UTI.

Results:

We reviewed the charts of 583 patients, of whom 450 (77.2%) were treated with a catheter, primarily indwelling (416 [92.4%]). Postoperative urinary retention developed in 98 patients (16.8%); however, it did not affect length of stay (p = 0.2). Patients with indwelling catheters for more than 24 hours after surgery had a higher incidence of POUR than those who had their catheter removed before 24 hours (65/330 [19.7%] v. 10/98 [10.2%]) (odds ratio [OR] 2.2, 95% confidence interval [CI] 1.06–4.38). A UTI developed postoperatively in 62 patients (10.6%). Catheter use was associated with a 6.6-fold increased risk of UTI (OR 6.6, 95% CI 2.03–21.4). Patients with indwelling catheters did not have a significantly higher incidence of UTI than those with intermittent catheterization (57/416 [13.7%] v. 2/34 [5.9%]) (p = 0.2). Patients who developed a UTI had significantly longer catheter use than patients who did not (p < 0.002).

Conclusion:

Indwelling catheters were used frequently, which suggests low compliance with clinical guidelines. Longer duration of catheter use led to higher rates of UTI and POUR. Further investigation of the reasons for the common use of indwelling rather than intermittent catheterization is needed.

Risk Factors for Prolonged Time to Discharge in Total Hip Patients Performed in an Ambulatory Surgery Center due to Complaints of the Inability to Void

BACKGROUND

Postoperative urinary retention (POUR) is among the reasons for delay in discharge after outpatient total hip arthroplasty (THA), occurring in 2%-46% of patients. We hypothesized that the frequency of POUR following outpatient THA in the ambulatory surgery center (ASC) is low compared to previously reported rates and that management can be effective in the perioperative period when it is encountered.

METHODS

Three hundred seventy-seven THA patients (409 hips) who had arthroplasties in the ASC over a 5-year period were identified. Preoperatively, appropriate demographic information and medical comorbidities were collected from patient health history questionnaires completed during clinic visits. Intraoperatively, albumin volume administered and estimated blood loss were recorded. Postoperatively, post-anesthesia care unit medications, patients who reported an inability to urinate, and those who required urinary catheterization were recorded.

RESULTS

POUR occurred in only 2 patients but complaints of the inability to void occurred in 38 others for an incidence of 9.8%. Factors associated with POUR and the inability to urinate included older age, time spent in the ASC, and intraoperatively albumin volume administered. No significant differences were found in body mass index, preoperative hematocrit, estimated blood loss, surgical time, or operating time.

CONCLUSION

POUR was infrequent but the reported inability to urinate was not (9.8%) and can be safely managed when it does occur and we found that increased age and albumin volume over 500 mL may increase the risk for a prolonged length of stay due to the inability to urinate.

Orthogeriatric co-management for the care of older subjects with hip fracture: recommendations from an Italian intersociety consensus

BACKGROUND

Health outcomes of older subjects with hip fracture (HF) may be negatively influenced by multiple comorbidities and frailty. An integrated multidisciplinary approach (i.e. the orthogeriatric model) is, therefore, highly recommended, but its implementation in clinical practice suffers from the lack of shared management protocols and poor awareness of the problem. The present consensus document has been implemented to address these issues.

AIM

To develop evidence-based recommendations for the orthogeriatric co-management of older subjects with HF.

METHODS

A 20-member Expert Task Force of geriatricians, orthopaedics, anaesthesiologists, physiatrists, physiotherapists and general practitioners was established to develop evidence-based recommendations for the pre-, peri-, intra- and postoperative care of older in-patients (≥ 65 years) with HF. A modified Delphi approach was used to achieve consensus, and the U.S. Preventive Services Task Force system was used to rate the strength of recommendations and the quality of evidence.

RESULTS

A total of 120 recommendations were proposed, covering 32 clinical topics and concerning preoperative evaluation (11 topics), perioperative (8 topics) and intraoperative (3 topics) management, and postoperative care (10 topics).

CONCLUSION

These recommendations should ease and promote the multidisciplinary management of older subjects with HF by integrating the expertise of different specialists. By providing a convenient list of topics of interest, they might assist in identifying unmet needs and research priorities.

Incidence and Predictive Risk Factors of Postoperative Urinary Retention After Primary Total Knee Arthroplasty

BACKGROUND

Postoperative urinary retention (POUR) after total knee arthroplasty (TKA) may cause urologic injury and delay patient discharge. This study measures the incidence of POUR and identifies predictive risk factors.

METHODS

Two-hundred seventy-one consecutive patients undergoing primary unilateral TKA were prospectively enrolled. Bladder scans were performed in the postanesthesia care unit (PACU) and every four hours thereafter. POUR was defined as >400cc with inability to void and was treated with catheterization. Patient demographics, urologic history, operative data, perioperative medications, and bladder scanner volumes were investigated with the univariate and multivariate logistic regression analysis.

RESULTS

Fifty-five patients (20%) developed POUR. Compared with non-POUR patients, PACU bladder scan volumes were greater in patients who developed POUR (344cc vs 120cc, P < .001). POUR patients had lower BMI (27.8 vs 29.4, P = .03), longer operative duration (83.9 vs 76.0 minutes, P = .002), and lower ASA scores (2.2 vs 2.4, P = .02). Total intravenous fluid was equivalent between groups (1134cc vs 1185cc, P = .41). POUR patients received less narcotics measured by morphine milligram equivalents (16.1 vs 23.9, P < .001). Fifteen variables including spinal type (bupivacaine and ropivacaine) and paralytic use were not predictive of POUR. Potentially predictive variables included anesthetic types administered (spinal, general, regional, and combination) and perioperative administration of nonsteroidal anti-inflammatory drugs (NSAIDs), glycopyrrolate, and muscle relaxants. The multivariate analysis showed that NSAIDs (P = .05) and glycopyrrolate (P = .04) were significant predictors.

CONCLUSION

A significant percentage of patients develop POUR after TKA. Select patient demographics and PACU bladder scanning may identify those at risk. Appropriate pain control and judicious use of perioperative NSAIDs and glycopyrrolate may help minimize the risk of POUR.

Onset PrevenTIon of urinary retention in Orthopaedic Nursing and rehabilitation, OPTION-a study protocol for a randomised trial by a multi-professional facilitator team and their first-line managers' implementation strategy

BACKGROUND

The Onset PrevenTIon of urinary retention in Orthopaedic Nursing and rehabilitation, OPTION, project aims to progress knowledge translation vis-à-vis evidence-based bladder monitoring in orthopaedic care, to decrease the risk of urinary retention, and voiding complications. Urinary retention is common whilst in hospital for hip surgery. If not properly identified and managed, there is a high risk of complications, some lifelong and life threatening. Although evidence-based guidelines are available, the implementation is lagging.

METHODS

Twenty orthopaedic sites are cluster randomised into intervention and control sites, respectively. The intervention sites assemble local facilitator teams among nursing and rehabilitation staff, including first-line managers. The teams receive a 12-month support programme, including face-to-face events and on-demand components to map and bridge barriers to guideline implementation, addressing leadership behaviours and de-implementation of unproductive routines. All sites have access to the guidelines via a public healthcare resource, but the control sites have no implementation support. Baseline data collection includes structured assessments of urinary retention procedures via patient records, comprising incidence and severity of voiding issues and complications, plus interviews with managers and staff, and surveys to all hip surgery patients with interviews across all sites. Further assessments of context include the Alberta Context Tool used with staff, the 4Ps tool for preference-based patient participation used with patients, and data on economic aspects of urinary bladder care. During the implementation intervention, all events are recorded, and the facilitators keep diaries. Post intervention, the equivalent data collections will be repeated twice, and further data will include experiences of the intervention and guideline implementation. Data will be analysed with statistical analyses, including comparisons before and after, and between intervention and control sites. The qualitative data are subjected to content analysis, and mixed methods are applied to inform both clinical outcomes and the process evaluation, corresponding to a hybrid design addressing effectiveness, experiences, and outcomes.

DISCUSSION

The OPTION trial has a potential to account for barriers and enablers for guideline implementation in the orthopaedic context in general and hip surgery care in particular. Further, it may progress the understanding of implementation leadership by dyads of facilitators and first-line managers.

TRIAL REGISTRATION

The study was registered as NCT04700969 with the U.S. National Institutes of Health Clinical Trials Registry on 8 January 2021, that is, prior to the baseline data collection.

Pre-Operative Urodynamic Assessment Has Poor Predictive Value for Developing Post-Operative Urinary Retention

BACKGROUND

Post-operative urinary retention (POUR) following primary total joint arthroplasty (TJA) has a reported prevalence up to 35%. Risk factors for POUR have included surrogate markers such as the presence or absence of urologic disease. Pre-operative dynamic measurement with post-void residual volumes (PVR) has not been investigated as a tool for assessing POUR risk.

METHODS

All male TJA patients underwent an institutional pre-operative screen for POUR, including PVR measurements, patient-derived subjective urinary retention scores, and assessment of urologic disease. The prospectively collected data were retrospectively reviewed. Proportions were evaluated with the chi-squared test, while continuous variables were evaluated by logistic regression analysis. Receiver-operator characteristic curves were utilized to determine the efficacy of using urodynamic variables as a predictor of developing POUR.

RESULTS

Two hundred fifty-two male patients were reviewed who had a mean age of 64.9 years and mean body mass index of 30.8 kg/m². The overall rate of POUR was 5.1%. Patient urinary retention scores were not associated with POUR. Elevated pre-operative PVR (>10 cc) alone and in combination with a history of urologic disease was significantly associated with POUR. However, both had low positive predictive values (10.5% and 18.2%), despite high negative predictive values (99.2% and 97.9%). Utilization of PVR resulted in moderate sensitivity (91.6%) and low specificity (72.1%) with an area under the curve of 0.69.

CONCLUSION

Urodynamic measurements and patient urinary retention scores, as part of an institutional pre-operative screening protocol, have limited value in determining which patients are at increased risk of POUR. The utility of obtaining these measurements pre-operatively is questionable.

Predictors of Postoperative Urinary Retention Following Pulmonary Resection

To identify predictors of postoperative urinary retention (POUR) following pulmonary resection. Retrospective chart review from a single academic institution of all patients who underwent pulmonary resection between June 2004 and January 2020. The surgical procedures consisted of pneumonectomy, lobectomy and sublobar resections. The primary outcome was occurrence of POUR within 30 days following surgery, defined as painful and palpable bladder, when the patient is unable to pass any urine, and requiring catheterization. A total of 6004 consecutive patients underwent pulmonary resection among which 306 pneumonectomies (5.1%), 3467 lobectomies (57.7%) and 2231 sublobar resection (37.2%). The surgical approach was a thoracotomy (n = 3546; 59.1%), a video-assisted [VATS] (n = 2075; 34.5%) or a robot-assisted thoracoscopy [RATS] (n = 383; 6.4%). POUR occurred in 301 cases (5%). On multivariable logistic regression analysis, male gender (OR 2.30 [1.70-3.17]; P < 0.001), age (OR 1.02 [1.01-1.03]; P < 0.001), benign prostatic hyperplasia (OR 7.08 [4.57-10.83]; P < 0.001), and COPD (OR 1.52 [1.13-2.01]; P = 0.004) were significant predictors of POUR. Conversely, VATS (OR 0.62 [0.46-0.83]; P = 0.001) had a protective effect on the occurrence of POUR. In a large single-center study, we disclosed significant clinical predictors of POUR after pulmonary resection, including age, sex, comorbidities and surgical approach. Prospective studies are necessary to evaluate the efficacy of chemoprophylaxis by perioperative α-blockers in order to prevent POUR.

Urinary retention after total joint arthroplasty of hip and knee: Systematic review

PURPOSE

Postoperative urinary retention (POUR) is a common complication after total joint arthroplasties (TJAs). The POUR is managed with urinary catheterization, which is associated with a risk of urinary tract infection and subsequent periprosthetic joint infection. The purpose of this review was to afford a comprehensive understanding of POUR and its management.

METHODS

We identified 15 original articles concerning POUR after TJA, which were published from January 2010 to February 2019. The diagnostic method, incidence, risk factors, and management of POUR of the 15 studies were reviewed.

RESULTS

The incidence of POUR was ranged from 4.1% to 46.3%. Ultrasound was used for the detection of POUR among the total of the 15 studies. The following factors of old age, male gender, benign prostatic hypertrophy, history of urinary retention, spinal/epidural anesthesia, excessive fluid administration, patient-controlled analgesia, the use of opiates, underlying comorbidities, and poor American Society of Anesthesiologists (ASA) grade were risk factors for POUR. Most of the studies did not use indwelling catheterization during surgery. The POUR patients were managed with intermittent catheterization. The most common volume criterion for bladder catheterization was 400 mL. In inevitable use of an indwelling catheter, it should be removed within 48 h.

CONCLUSIONS

This review provided an up-to-date guide for the detection and management of POUR.

LEVEL OF EVIDENCE

Level III.

Analysis of Risks and Consequences of Postcatheter Urinary Retention After Primary Total Hip and Knee Arthroplasty

Background

Postoperative urinary retention (POUR) in total joint arthroplasty (TJA) is common. However, risk factors for POUR and its consequences, specifically on postoperative renal function, have not been well defined.

Methods

We performed a review of prospectively collected data on consecutive adult patients undergoing primary total joint arthroplasty from August 2014 to December 2015. Catheters were placed preoperatively and removed on the first or second postoperative day. The exclusion criterion was traumatic catheter insertion or the presence of fracture or neoplasm. Univariate and multiple logistic regression identified associations with POUR and its invasive therapies. Subgroup analysis of renal function by incidence of preoperative bladder outlet obstruction (BOO) and POUR was performed with nonparametric testing.

Results

A total of 591 operations met inclusion criteria. The incidence of POUR was 6.4% and was directly related to a positive history of BOO (odds ratio [OR]: 4.15) and increased the duration of urinary catheterization (OR: 1.04). These factors, in addition to preoperative incontinence (OR: 8.36, 28.69) and lengthier hospitalizations (OR: 1.37, 1.30), were significantly associated with intermittent straight catheterization and reinsertion of an indwelling catheter to treat POUR. Serum creatinine increased with combined preoperative BOO and POUR (+0.22 mg/dL) but was preserved in others (+0.02-0.04 mg/dL) (P < 0.01).

Conclusions

Preoperative BOO and longer catheterization increased the risk of POUR and were associated with the use of invasive modalities to treat POUR. POUR was associated with a longer hospitalization and impaired renal function in those with preoperative BOO; therefore, renal function should be monitored closely and nephrotoxic medications used cautiously when using urinary catheters in this patient population.

Level of Evidence

Retrospective Analysis, Level IV.

Reasons for Unsuccessful Same-Day Discharge Following Outpatient Hip and Knee Arthroplasty: 5½ Years' Experience From a Single Institution

BACKGROUND

Outpatient joint arthroplasty (OJA) is considered safe and feasible in selected patients but should be further optimized to improve success rates. The purposes of this study are to (1) identify the main reasons of unsuccessful same-day discharge (SDD) following hip and knee arthroplasty; (2) determine the hospital length of stay (LOS) following unsuccessful SDD; and (3) assess which independent variables are related to specific reasons for unsuccessful SDD.

METHODS

Five hundred twenty-five patients undergoing total hip arthroplasty (THA), total knee arthroplasty (TKA), and unicompartmental knee arthroplasty between 2013 and 2019 were retrospectively identified. SDD to home was planned in all patients. Specific reasons for unsuccessful SDD and LOS were assessed. Bivariate analysis was performed to find differences in independent variables between patients experiencing a specific reason for unsuccessful SDD and control patients.

RESULTS

One hundred ten patients (21%) underwent unsuccessful SDD. The main reason was postoperative reduced motor function and sensory disturbances (33%). The mean LOS in the unsuccessful SDD group was 1.7 days (standard deviation ± 1.0 days). Postoperative transient reduced motor function and sensory disturbances occurred more often in patients undergoing TKA (P < .001).

CONCLUSION

An option for overnight stay should be available when performing outpatient hip and knee arthroplasty. The main reason for unsuccessful SDD in this study was transient postoperative reduced motor function and sensory disturbance, most likely due to intraoperative local infiltration analgesia in TKA. No other studies have found local infiltration analgesia to be an issue preventing SDD.

Predictors of (Un)successful Same-Day Discharge in Selected Patients Following Outpatient Hip and Knee Arthroplasty

BACKGROUND

It is generally accepted that only selected patients are suitable for outpatient joint arthroplasty (OJA); however, no consensus exists on the optimal selection criteria. We believe patients undergoing OJA should undergo risk stratification and mitigation in an attempt to optimize quality and minimize costs.

METHODS

Patient factors of 525 patients who were selected to have primary elective unicompartmental knee arthroplasty (N = 158), total knee arthroplasty (N = 277), or total hip arthroplasty (N = 90) in an outpatient setting were retrospectively reviewed. A complete case multivariable logistic regression analysis of 440 patients was conducted to identify factors that were independently associated with (un)successful same-day discharge (SDD).

RESULTS

One hundred ten patients (21%) were not able to be discharged on the day of surgery. Charnley class B2 was associated with a higher chance of successful SDD (odds ratio [OR], 0.29; 95% confidence interval [CI], 0.12-0.72), whereas female gender (OR, 1.7; 95% CI, 1.0-2.8), total knee arthroplasty (OR, 1.9; 95% CI, 1.1-3.4), and a higher American Society of Anesthesiologists (ASA) physical function score (ASA II: OR, 1.9; 95% CI, 1.1-3.3; ASA III: OR, 3.9; 95% CI, 1.1-13) were associated with a higher risk of unsuccessful SDD.

CONCLUSION

These results in a preselected population suggest the need for further specifying and improving selection criteria for patients undergoing OJA and emphasize the importance of an in-hospital backup plan for patients at risk of unsuccessful SDD. Previous contralateral joint arthroplasty is a protective factor for successful SDD.

Magnesium Sulfate Treatment During Total Knee Arthroplasty Decreases Postoperative Urinary Retention: A Retrospective Propensity Score-Matched Analysis

Postoperative urinary retention (POUR) is a common complication after total knee arthroplasty. Currently, there are no clinical data regarding the effects of magnesium sulfate on POUR. Here, we investigated the effects of intraoperative magnesium sulfate infusion in patients with POUR following total knee arthroplasty. We reviewed the medical records of patients who underwent elective unilateral total knee arthroplasty under spinal anesthesia between June 2016 and May 2018. The patients were grouped based on whether they were treated with magnesium (magnesium group) or not (control group). We investigated the incidence of POUR and the postoperative analgesic requirement. Totally, 483 patients were included in the analysis. After propensity score matching with the control group, the magnesium group showed a lower incidence of POUR (odds ratio, 0.49; 95% CI, 0.29–0.83; p = 0.011) and lesser opioid consumption (p = 0.049) than the control group. Multivariate logistic regression analysis revealed that intraoperative continuous infusion of magnesium (p = 0.008) and age (p = 0.001) were significantly related to the incidence of POUR. This retrospective observational study demonstrated that administration of magnesium sulfate was associated with a lower incidence of POUR following total knee arthroplasty.

Postoperative Urinary Retention in Patients Undergoing Lung Resection: Incidence and Risk Factors

BACKGROUND

The purpose of this study was to (1) determine the incidence of postoperative urinary retention (POUR) in patients undergoing lung resection at our institution, (2) identify differences in potential risk factors between patients with and without POUR, and (3) describe patient outcomes across POUR status.

METHODS

The medical records of 225 patients between 2016 and 2017 were reviewed, and 191 met criteria for inclusion. The institution's catheterization removal protocol was followed in all patients. Recatheterization was defined as requiring in-and-out catheterization or Foley catheter placement. Fisher exact and Wilcoxon tests were used for analysis.

RESULTS

POUR developed in 35 patients (18%). Patients with POUR were older (P = .01), had increased baseline creatinine (P = .04), and a higher prevalence of benign prostatic hyperplasia (P = .007). POUR patients were also less likely to get a Foley catheter intraoperatively (P = .0002). Other intraoperative factors, such as surgical approach and extent of resection, were not significantly different between patients with and without POUR. Postoperative factors (epidural use or days with chest tube) were similar. Although patients with POUR were more likely to be discharged with a Foley catheter (13% vs 0%, P = .002), no difference in length of stay, incidences of urinary tract infections, or 30-day readmission were observed.

CONCLUSIONS

POUR develops in approximately 1 in 5 patients undergoing lung resection. Patients with POUR were more likely to not have a Foley catheter placed intraoperatively. However, patients who had POUR did not have worsened patient outcomes (urinary tract infections, length of stay, or 30-day readmission).

Decreasing the Incidence of Postoperative Urinary Retention and Incontinence With Total Joint Replacement Patients After Spinal Anesthesia in the Postanesthesia Care Unit: A Quality Improvement Project

PURPOSE

Patients with postoperative urinary retention (POUR) can develop bladder atrophy, urinary incontinence, and hypertension. The purpose of this quality improvement project was to implement standardized guidelines for bladder scanning for patients who have total knee or hip replacement to decrease POUR and incontinent episodes.

DESIGN

A retrospective descriptive study was implemented in a 425-bed Magnet community hospital.

METHODS

Patients were bladder scanned within the first hour of postanesthesia care unit admission. Straight catheterization was performed for those who had more than 400 mL of retained urine. The protocol included both total knee and total hip replacement surgeries with spinal anesthesia. Compliance with scanning, percentages with POUR, and incontinent episodes were reviewed.

FINDINGS

POUR was detected in 46% of total knee replacement patients and 36% of total hip replacement patients. Incontinence rates for knee replacement patients decreased by 14% and by 2% for patients with total hip replacements.

CONCLUSIONS

A bladder scanning protocol decreases postoperative incontinence. Bladder scanning also helps to decrease POUR by decreasing the potential risk of complications.

Reduced opiate use after total knee arthroplasty using computer-assisted cryotherapy

PURPOSE

Despite multimodal pain management and advances in anesthetic techniques, total knee arthroplasty (TKA) remains painful during the early postoperative phase. This trial investigated whether computer-assisted cryotherapy (CAC) is effective in reduction of pain and consumption of opioids in patients operated for TKA following an outpatient surgery pathway.

METHODS

Sixty patients scheduled for primary TKA were included in this prospective, double-blind, randomized controlled trial receiving CAC at 10-12 °C (Cold-group, n = 30) or at 21 °C (Warm-group, n = 30) during the first 7 days after TKA according to a fixed schedule. All patients received the same pre-, peri- and postoperative care with a multimodal pain protocol. Pain was assessed before and after every session of cryotherapy using the numerical rating scale for pain (NRS-pain). The consumption of opioids was strictly noted during the first 4 postoperative days. Secondary outcomes were knee swelling, visual hematoma and patient reported outcome measures (PROMs). These parameters were measured pre-, 1, 2 and 6 weeks postoperatively.

RESULTS

In both study groups, a reduction in NRS-pain after every CAC session were seen during the postoperative period of 7 days. A mean reduction of 0.9 and 0.7 on the NRS-pain was seen for respectively the Cold- (P = 0.008) and Warm-group (n.s.). A significant (P = 0.001) lower number of opioids were used by the Cold-group during the acute postoperative phase of 4 days, 47 and 83 tablets for respectively the Cold and Warm-group. No difference could be observed for secondary outcomes and adverse effects between both study groups.

CONCLUSIONS

Postoperative CAC can be in added value in patients following an outpatient surgery pathway for TKA, resulting in reduced experienced pain and consumption of opioids during the first postoperative days.