A randomized, controlled trial evaluating 2 techniques of postoperative bladder testing after transvaginal surgery

Urge Symptoms after Vaginal Uterosacral Plication in Urinary Incontinence Patients without Proximal Urethral Mobility: A Prospective Study

INTRODUCTION

The primary objective of this study was to evaluate the impact of vaginal uterosacral plication on urge symptoms and quality of life in a cohort of patients with uterosacral ligament insufficiency and urge symptoms.

METHODS

A total of 40 female patients were included in the study, and their posterior fornix was supported with gauze to simulate the surgical procedure. Uterosacral plication was applied to patients who experienced a decrease in urinary incontinence, nocturia, a sense of urgency, and a decrease in urge urinary incontinence symptoms or complete recovery. Images of the bladder, bladder neck, urethra, and symphysis pubis were obtained preoperatively and 1 year postoperatively. POP-Q staging was also performed, and patients completed the Overactive Bladder Evaluation Form (OAB-V8) and the Incontinence Impact Questionnaire Short Form (ICIQ-SF).

RESULTS

Results from the OAB-V8 questionnaire showed that postoperative nocturia scores improved by 72.1% compared to preoperative scores, and the need to urinate at night and waking up scores improved by 68.3%. The mean bladder neck thickness and the mean detrusor thickness were significantly decreased from 10 to 9.2 (p < 0.0001) and from 8.7 to 6.4 (p < 0.0001), respectively. The ICIQ-SF questionnaire scores showed a 68.4% improvement in urinary incontinence affecting daily life after the operation.

CONCLUSION

This study adds to the clinical evidence that uterosacral ligament support improves symptoms of overactive bladder syndromes, including urgency and nocturia. The use of pelvic floor ultrasound and the apical tamponade test is important in patient selection for the correct indication.

Incidence of and Risk Factors for Post-Operative Urinary Retention Following Surgery for Perineal Tears Among Ugandan Women: A Prospective Cohort Study

INTRODUCTION AND HYPOTHESIS

We aimed to determine the incidence and risk factors for post-operative urinary retention (POUR) following surgery for perineal tears, and to determine the time to normal voiding after POUR.

METHODS

This was a prospective cohort study of women who underwent surgery for old (≥ 3 months) obstetric perineal tears from January 2022 to December 2023. The diagnosis of POUR was made in a woman who completely failed to void despite a full bladder or, one who had post-void residual (PVR) > 150 ml within 10 min of voiding. Return to normal voiding was considered if a patient with POUR had two consecutive PVRs of ≤ 150 ml. Descriptive analyses and multivariable logistic regression were performed to determine risk factors for POUR.

RESULTS

A total of 153 participants were enrolled in this study with a mean age of 35.9 (SD ± 10.8) years. The incidence of POUR was 19.6% (30/153, 95% CI 14.02-26.7), and the median time to normal voiding for these patients was 42.4 h (range 24-72). Risk factors for POUR included repeat perineal tear surgery (RR = 4.24; 95% CI 1.16-15.52; p = 0.029) and early urinary catheter removal (RR = 2.89; 95% CI 1.09-7.67; p = 0.033).

CONCLUSION

Post-operative urinary retention following surgery for perineal tears is common. The time to return to normal voiding in patients with POUR is short. Women having repeat perineal tear surgery and those in whom the urinary catheter is removed early were more likely to experience POUR. Delayed urinary catheter removal could be considered, especially in patients undergoing repeat perineal tear surgery.

Early Removal of Indwelling Catheter and Vaginal Pack After Vaginal Prolapse Surgery: A Retrospective Cohort Study

INTRODUCTION AND HYPOTHESIS

After vaginal pelvic organ prolapse (POP) surgery a vaginal pack and indwelling bladder catheter are inserted to reduce blood loss and bladder overdistension. The ideal timing of removal remains unclear. In this study we compared removal of vaginal pack and indwelling catheter 3 h post-surgery with removal the next day.

METHODS

This retrospective cohort study performed in the Netherlands included patients undergoing POP surgery between 1 January 2019 and 31 December 2020. Patients in whom the vaginal pack and catheter were removed the day after surgery (group A) were compared with patients in which the vaginal pack and catheter were removed 3 h post-surgery (group B). Both groups were compared regarding urinary retention and the need for re-intervention owing to active blood loss within 6 weeks postoperatively.

RESULTS

Baseline characteristics, such as age, type of operation and type of anaesthesia in group A (n = 280) and group B (n = 207) were comparable. No significant differences were found regarding complications such as urinary retention (17.2 versus 23.2%; p = 0.255). The rates of re-intervention because of active blood loss and occurrence of infection were also comparable.

CONCLUSIONS

Removal of the indwelling catheter and vaginal pack 3 h after vaginal POP surgery does not lead to more postoperative complications than removal the 1st day after surgery. Therefore, early removal is a feasible and safe alternative to the standard timing of removal the morning after surgery of women undergoing POP surgery. In the future this could help with introducing same-day discharge.

Assessment of Urinary Dysfunction After Midurethral Sling Placement: A Comparison of Two Voiding Trial Methods

STUDY OBJECTIVE

Temporary urinary retention after midurethral sling (MUS) surgery requiring indwelling catheter or self-catheterization usage is common. Different methods for assessment of immediate postoperative urinary retention have been described. This study aimed to compare postoperative voiding trial (VT) success after active vs passive VT in women undergoing MUS surgery.

DESIGN

Comparative retrospective cohort study.

SETTING

Female pelvic medicine and reconstructive surgery practice at a university-affiliated tertiary medical center.

PATIENTS

Patients with stress urinary incontinence who underwent surgical treatment during the study period were eligible for inclusion. Excluded were patients younger than the age of 18 years, combined cases with other surgical services, planned laparotomy, and a history of urinary retention and patients for whom their VT was performed on postoperative day 1. The cohort was divided into 2 groups: (1) patients who underwent an active retrofill of their bladder using a Foley catheter and (2) patients who were allowed to have a spontaneous void.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 285 patients met the inclusion criteria for the study. Of these subjects, 94 underwent an active VT and 191 underwent a passive VT. There were no statistically significant differences in immediate postoperative urinary retention (30.8% vs 29.3%; p = .79) or time from surgery end to VT (233.0 ± 167.6 minutes vs 203.1 ± 147.8 minutes; p = .13) between groups. Urinary retention, as defined by a failed VT, increased from 10% to 29.3% when MUS placement was accompanied by concomitant prolapse repair procedure. Multivariate logistic regression analysis revealed that undergoing a combined anterior and posterior colporrhaphy (odds ratio [OR], 5.13; p <.001) and undergoing an apical prolapse procedure (OR, 2.75; p = .004) were independently associated with immediate postoperative urinary retention whereas increased body mass index (OR, 0.89; p <.001) lowered likelihood of retention.

CONCLUSION

The method used to assess immediate postoperative urinary retention did not affect VT success. Concomitant combined anterior and posterior colporrhaphy and apical suspension were correlated with greater likelihood of VT failure whereas increased body mass index decreased odds of retention.

The Diagnostic Accuracy of a Retrograde Voiding Trial for Restoration of Spontaneous Voiding Function after Prolapse and Urinary Incontinence Surgery

STUDY OBJECTIVE

To assess the diagnostic accuracy of a retrograde voiding trial for the restoration of spontaneous voiding function after prolapse and urinary incontinence surgery and thereby determine whether the retrograde method can be a reliable alternative to the spontaneous voiding trial.

DESIGN

A retrospective cohort study.

SETTING

A single tertiary hospital in South Korea.

PATIENTS

Women who underwent operations for prolapse, urinary incontinence, or both.

INTERVENTION

Sequential voiding trials on postoperative day 1 or 2-retrograde voiding trial followed by spontaneous voiding trial.

MEASUREMENTS AND MAIN RESULTS

Of the 408 women analyzed, 278 (68.1%) passed the spontaneous voiding trial on the first day of assessment and none experienced urinary retention after a successful voiding trial. Receiver operating characteristic analyses of retrograde voiding trials evaluating voided volume (VV), postvoid residual (PVR), and voiding efficiency (VE) all demonstrated high diagnostic accuracy for restoration of spontaneous voiding function, whereas measuring PVR and VE had better discriminative ability than VV (area under the curve [95% confidence interval] = 0.93 [0.90-0.95] for PVR, 0.94 [0.91-0.96] for VE, and 0.88 [0.85-0.91] for VV; DeLong's test between PVR/VE and VV p < .01). The optimal cutoffs determined by the Youden index were 200 mL for VV (sensitivity 85.0%, specificity 78.0%), 100 mL for PVR (sensitivity 84.0%, specificity 87.0%), and 66.7% for VE (sensitivity 86.0%, specificity 88.0%).

CONCLUSIONS

The retrograde voiding trial is an accurate predictor for restoration of spontaneous voiding function after prolapse and incontinence surgery and can be a useful alternative to the spontaneous voiding trial.

Methods of postoperative void trial management after urogynecologic surgery: a systematic review and meta-analysis

BACKGROUND

Voiding trials are used to identify women at risk for postoperative urinary retention while performing optimal voiding trial management with minimal burden to the patient and medical service team. We performed a systematic review and meta-analysis of postoperative void trials following urogynecologic surgery to investigate (1) the optimal postoperative void trial methodology and (2) the optimal criteria for assessing void trial.

METHOD

We searched PubMed, EMBASE, Cochrane Central Register of Controlled Trials, and relevant reference lists of eligible articles from inception to April 2022. We identified any randomized controlled trials (RCTs) in English that studied void trials in patients undergoing urogynecologic surgery. Study selection (title/abstract and full text), data extraction, and risk of bias assessment were conducted by two independent reviewers. Extracted study outcomes included the following: the correct passing rate, time to discharge, discharge rate without a catheter after the initial void trial, postoperative urinary tract infection, and patient satisfaction.

RESULTS

Void trial methodology included backfill-assisted and autofill studies (2 RCTs, n = 95). Backfill assistance was more likely to be successful than autofill (RR 2.12, 95% CI 1.29, 3.47, P = 0.00); however, no significant difference was found in the time to discharge (WMDs =  - 29.11 min, 95% CI - 57.45, 1.23, P = 0.06). The criteria for passing void trial included subjective assessment of the urinary force of stream and objective assessment of the standard voiding trial (3 RCTs, n = 377). No significant differences were found in the correct passing rate (RR 0.97, 95% CI 0.93, 1.01, P = 0.14) or void trial failure rate (RR 0.78, 95% CI 0.52, 1.18, P = 0.24). Moreover, no significant differences were found in the complication rates or patient satisfaction between the two criteria.

CONCLUSION

Bladder backfilling was associated with a lower rate of catheter discharge after urogynecologic surgery. The subjective assessment of FOS is a reliable and safe method for assessing postoperative voiding because it is less invasive.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022313397.

Postoperative Urinary Retention

ABSTRACT

This clinical consensus statement on the management of postoperative (<6 weeks) urinary retention (POUR) reflects statements drafted by content experts from the American Urogynecologic Society's POUR writing group. The writing group used a modified Delphi process to evaluate statements developed from a structured literature search and assessed for consensus. After the definition of POUR was established, a total of 37 statements were assessed in the following 6 categories: (1) incidence of POUR, (2) medications, (3) patient factors, (4) surgical factors, (5) urodynamic testing, and (6) voiding trials. Of the 37 original statements, 34 reached consensus and 3 were omitted.

Saline bladder infusion vs standard catheter removal in patients with acute urinary retention related to benign prostatic hyperplasia: The BLAPERF Study

PURPOSE

Bladder infusion, which involves filling the bladder with saline prior to catheter removal, has been associated with reduced time-to-discharge and increased success rates in trials without catheter (TWOCs) in perioperative setting. The objective of this study was to evaluate the applicability of this protocol in patients with acute urinary retention (AUR) related to benign prostatic hyperplasia (BPH).

METHODS

We conducted a retrospective single-center study comparing bladder infusion with at least 150mL of warm saline vs. standard catheter removal during TWOC in patients with BPH-related AUR between January and December 2021. The primary outcome was time to discharge. Secondary outcomes included: TWOC success, and early recurrence of urinary retention defined as recurrence within three months of successful TWOC.

RESULTS

A total of 75 men were included: 35 in the bladder infusion protocol and 40 in the standard protocol. Baseline characteristics were well balanced between groups. Overall, 35 patients (46.7%) had a successful TWOC without statistically significant difference between groups (P=0.10). Bladder infusion protocol was associated with a shorter median time to discharge (200 vs. 240min, P=0.003). However, patients in the bladder infusion group were associated with a higher risk of early recurrence of urinary retention (30% vs. 0%, P=0.02).

CONCLUSION

In patients with BPH-related AUR, the saline bladder infusion method reduced time-to-discharge with similar TWOC success rates. Larger studies are needed to properly analyze the risk of early recurrence of urinary retention before any clinical application.

LEVEL OF EVIDENCE

III.

Frailty and Acute Postoperative Urinary Retention in Older Women Undergoing Pelvic Organ Prolapse Surgery

IMPORTANCE

Acute postoperative urinary retention (POUR) is common after pelvic reconstructive surgery, occurring in 15-45% of women. There is a paucity of data on the relationship between frailty and POUR after prolapse surgery.

OBJECTIVE

This study aimed to examine the association between frailty and POUR in older women who underwent pelvic organ prolapse surgery.

STUDY DESIGN

This secondary analysis of a prospective study of postoperative delirium enrolled women 60 years and older undergoing prolapse surgery. The Fried Frailty Index was used to assess frailty before surgery. Acute POUR was defined as failure to pass a retrograde voiding trial at hospital discharge with postvoid residual volume of greater than 100 mL.

RESULTS

Analyses included 165 women, with a mean ± SD age of 72.5 ± 6.1 years and a body mass index of 28.0 ± 4.4 kg/m2. There were 49 laparoscopic/robotic apical suspension procedures (29.7%), 60 vaginal obliterative procedures (36.4%), 47 vaginal apical suspension procedures (28.5%), and 9 isolated anterior and/or posterior colporrhaphies (5.5%), of which 9 had a concomitant incontinence procedure. Seventy-eight women (47.3%) experienced acute POUR. Thirty-one (18.8%) met the criteria for "not frail," 115 (88.5%) were "prefrail," and 19 (11.5%) were "frail." Neither frailty status nor score was associated with POUR. In an analysis of individual Fried Frailty Index components, self-reported unintentional weight loss was significantly associated with POUR (odds ratio, 4.6; 95% confidence interval, 1.23-17.15). This remained significant on multivariable logistic regression (adjusted odds ratio, 4.06; 95% confidence interval, 1.01-16.39).

CONCLUSIONS

Frailty was not associated with POUR in older women undergoing prolapse surgery. The observed association between POUR and unintended weight loss before surgery warrants further investigation.

Voided Volume for Assessment of Bladder Emptying After Female Pelvic Floor Surgery: A Randomized Controlled Trial

IMPORTANCE

To study alternative voiding trial (VT) methods after urogynecologic surgery that may potentially decrease catheterization.

OBJECTIVE

The aim of the study is to compare voiding assessment based on a minimum spontaneous voided volume of 150 mL with the standard retrograde fill (RF) approach in women after urogynecologic procedures.

STUDY DESIGN

Women undergoing urogynecologic surgery were randomized to RF or spontaneous void (SV) groups. Women in the RF group had their bladders backfilled with 300 mL of saline before catheter removal, those in the SV group did not. To pass the VT, patients in the RF group were required to void 150 mL at one time within 60 minutes, and patients in the SV group had to do the same within 6 hours. The primary outcome was the VT failure rate. We also compared the false pass rate, urinary tract infections, satisfaction, and preference of VT method.

RESULTS

One hundred nine women were enrolled in the study, 54 had SV and 55 underwent RF. Baseline characteristics were not significantly different other than history of prior hysterectomy. There was no significant difference in procedures between the groups. There was no difference in VT failure rate between the groups-SV (7.4%) and RF (12.7%, P = 0.39). The false pass rate was 0 in each group. Urinary tract infection rates were similar between SV (14.8%) and RF (14.5%) groups ( P = 0.34). Patient satisfaction for VT method was not significantly different.

CONCLUSIONS

Spontaneous VT was not superior to retrograde void trial. Therefore, we cannot recommend one method of VT after urogynecologic surgery.CondensationVoiding assessment based on minimum SV of 150 mL is comparable with VT with RF after surgeries for prolapse and urinary incontinence.

Clinical benefits of retrograde bladder filling method prior to catheter removal after TURP for BPH: A prospective randomized trial

PURPOSE

To evaluate possible benefits and clinical feasibility of retrograde bladder filling method prior to intra-vesical catheter removal after transurethral prostatectomy (TURP) for benign prostatic hyperplasia (BPH).

MATERIALS AND METHODS

Male patients undergoing TURP for BPH from January 2019 to October 2019 were randomized in a 1:1 ratio into either retrograde filling (RF) or spontaneous voiding (SV) methods at a single institution to determine safety and efficacy of RF (NCT04309032), with surgeons blinded to allocation. Perioperative outcomes including postoperative complications were compared between two groups. Clinician/patients' satisfaction level which was evaluated with postoperative questionnaires were also compared.

RESULTS

A total of 56 patients were randomized into two groups and 56 were included in final analysis (28 men in RF group, 26 in SV group). No significant differences in baseline characteristics including age, prostate volume, or perioperative uroflowmetry were observed. However, RF significantly facilitated time to void (67.0±63.2 vs. 144.0±78.7 min; p<0.001) and time to discharge (168.4±57.2 vs. 218.9±106.9 min; p=0.046). Immediate postoperative complications were comparable in both methods with no significant difference. Overall patient and medical staff satisfaction showed tolerable and similar response by either procedure.

CONCLUSIONS

RF method for intra-vesical catheter removal is a safe and satisfactory method that can facilitate early voiding detection and shorten the time to discharge. Further trials are required to further validate our results.

Are Formal Voiding Trials Necessary After Posterior Compartment Reconstructive Surgery?

IMPORTANCE

Posterior compartment surgery is considered a risk factor for postoperative urinary retention because of the impact of postoperative pain on the pelvic floor; however, few studies have examined the association between posterior compartment reconstructive surgery and urinary retention.

OBJECTIVE

The aim of the study was to compare rates of urinary retention in patients undergoing vaginal reconstructive surgery, without hysterectomy, in the posterior compartment only versus any apical and/or anterior compartment (with or without posterior compartment).

STUDY DESIGN

In this retrospective cohort study, we evaluated patients who underwent surgery, without hysterectomy, in the posterior compartment only versus any apical and/or anterior compartment (with or without posterior compartment) from January 2015 to November 2020. Our primary outcome was rate of postoperative urinary retention, defined as a failed voiding trial before discharge. Secondary outcome was days of catheterization. Multivariable logistic regression was performed to assess variables associated with a failed voiding trial.

RESULTS

Of 362 patients, 141 (39.0%) underwent surgery in the posterior compartment only and 221 (61.0%) underwent vaginal apical and/or anterior compartment surgical procedures. Rate of retention was significantly lower in the posterior compartment only group (9.9% vs 41.6%, P < 0.001). The median numbers of days of catheterization were significantly fewer in the posterior compartment only group (0 [0,0] vs 0 [0,3], P < 0.001). In multivariable logistic regression, posterior compartment only surgery was associated with passing the voiding trial (odds ratio, 6.0; 95% confidence interval, 2.97-12.03).

CONCLUSIONS

Rates of postoperative urinary retention after surgery in the posterior compartment are low, and these patients may not require formal voiding trials after surgery.

A risk calculator for postoperative urinary retention (POUR) following vaginal pelvic floor surgery: multivariable prediction modelling

OBJECTIVE

To determine the perioperative characteristics associated with an increased risk of postoperative urinary retention (POUR) following vaginal pelvic floor surgery.

DESIGN

A retrospective cohort study using multivariable prediction modelling.

SETTING

A tertiary referral urogynaecology unit.

POPULATION

Patients undergoing vaginal pelvic floor surgery from January 2015 to February 2020.

METHODS

Eighteen variables (24 parameters) were compared between those with and without POUR and then included as potential predictors in statistical models to predict POUR. The final model was chosen as the model with the largest concordance index (c-index) from internal cross-validation. This was then externally validated using a separate data set (n = 94) from another surgical centre.

MAIN OUTCOME MEASURE

Diagnosis of POUR following surgery while the patient was in hospital.

RESULTS

Among the 700 women undergoing surgery, 301 (43%) experienced POUR. Preoperative variables with statistically significant univariate relationships with POUR included age, menopausal status, prolapse stage and uroflowmetry parameters. Significant perioperative factors included estimated blood loss, volume of intravenous fluid administered, operative time, length of stay and specific procedures, including vaginal hysterectomy with intraperitoneal vault suspension, anterior colporrhaphy, posterior colporrhaphy and colpocleisis. The lasso logistic regression model had the best combination of internally cross-validated c-index (0.73, 95% CI 0.71-0.74) and a calibration curve that showed good alignment between observed and predicted risks. Using this data, a POUR risk calculator was developed (https://pourrisk.shinyapps.io/POUR/).

CONCLUSIONS

This POUR risk calculator will allow physicians to counsel patients preoperatively on their risk of developing POUR after vaginal pelvic surgery and help focus discussion around potential management options.

Retrograde Bladder Filling After Outpatient Gynecologic Surgery: A Systematic Review and Meta-analysis

OBJECTIVE

To systematically review and meta-analyze randomized controlled trials (RCTs) comparing postoperative bladder retrofilling to passive filling after outpatient gynecologic surgery to evaluate effects on postoperative outcomes.

DATA SOURCES

We searched MEDLINE, PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, and ClinicalTrials.gov from 1947 to August 2020.

METHODS OF STUDY SELECTION

Two reviewers screened 1,465 articles. We included RCTs that compared postoperative bladder retrofilling to passive filling in patients who underwent outpatient gynecologic surgery by any approach. The primary outcome was the time to first void. Secondary outcomes included time to discharge, postoperative urinary retention, urinary tract infection, and patient satisfaction. Mean differences and relative risks (RRs) were calculated for the meta-analysis. Risk of bias was assessed using the Cochrane Risk of Bias Tool.

TABULATION, INTEGRATION, AND RESULTS

We included eight studies with 1,173 patients. Bladder retrofilling in the operating room resulted in a significant decrease in the time to first void (mean difference -33.5 minutes; 95% CI -49.1 to -17.9, 4 studies, 403 patients) and time to discharge (mean difference -32.0 minutes; 95% CI -51.5 to -12.6, eight studies, 1,164 patients). Bladder retrofilling did not shorten time to discharge when performed in the postanesthetic care unit (mean difference -14.8 min; 95% CI -62.6 to 32.9, three studies, 258 patients) or after laparoscopic hysterectomy (mean difference -26.0 min; 95% CI -56.5 to 4.5, five studies, 657 patients). There were no differences in postoperative urinary retention (RR 0.77; 95% CI 0.45-1.30, five studies, 910 patients) or risk of urinary tract infection between the retrofill and passive fill groups (RR 0.50; 95% CI 0.14-1.77, four studies, 387 patients). Patient satisfaction was comparable between groups.

CONCLUSION

Retrofilling the bladder in the operating room after outpatient gynecologic surgery modestly reduces the time to first void and discharge with no increase in adverse events.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42020203692.

Bladder Backfilling versus Standard Catheter Removal for Trial of Void after Outpatient Laparoscopic Gynecologic Surgery: A Systematic Review and Meta-Analysis

OBJECTIVE

To compare the rate of postoperative urinary retention and time to discharge between bladder backfilling and standard catheter removal for trial of void (TOV) after outpatient laparoscopic gynecologic surgery. Our secondary objectives were to compare the time to void, postoperative complications, and patient satisfaction.

DATA SOURCES

We searched the PubMed, Ovid MEDLINE, Embase, Cochrane Library databases, and relevant reference lists of eligible articles up to March of 2021.

METHODS OF STUDY SELECTION

This review included randomized controlled trials (RCTs) of TOV after outpatient laparoscopic gynecologic surgery. Odds ratios (ORs) with 95% confidence interval (CI) and weighted mean differences (WMDs) were reported. The quality of the studies was assessed according to the Cochrane Handbook for Systematic Reviews of Interventions. Data were analyzed with Review Manager 5.4 software (RevMan 5.4.1; Cochrane Collaboration, London, United Kingdom).

TABULATION, INTEGRATION, AND RESULTS

Five RCTs (N = 488) were included. The bladder backfilling group had a significantly shorter time to void than the standard TOV group (WMD, -25.19 minutes; 95% CI, -44.60 to -5.77; p = .01). Successful TOV was not significantly different between the 2 (OR, 0.92; 95% CI, 0.51 to -1.65; p = .77), without significant heterogeneity (I² = 24%). There was also no significant difference in the time to discharge between the 2 TOV techniques (WMD, -25.19 minutes; 95% CI, -44.60 to -5.77; p = .01). There was no significant difference in complication rates or patient satisfaction between the 2 groups.

CONCLUSION

The bladder backfilling technique of TOV after outpatient laparoscopic gynecologic surgery may reduce the time to first spontaneous void without affecting patient satisfaction or postoperative complications, but it does not significantly affect the time to discharge or urinary retention.

Risk factors for postoperative voiding dysfunction following surgery for pelvic organ prolapse

OBJECTIVE

Short-term postoperative voiding dysfunction (POVD) is common in women undergoing surgery for pelvic organ prolapse. It results in increased catheter burden for patients and health services, and catheter-associated urinary tract infections (CAUTIs), thereby escalating the overall cost of treatment. Our aim was to determine the risk factors for voiding dysfunction following surgery for POP in our unit.

STUDY DESIGN

A retrospective case-control study conducted in a tertiary center in the U.K. The study cohort included all women who underwent surgery for pelvic organ prolapse between March 2017 and March 2019 and had a failed trial without catheter (TWOC). The control group comprised consecutive women on the surgical database who passed TWOC. Relevant data, including demographic details, past medical history, intraoperative and postoperative factors, were collected. We used the Chi-square test to calculate the statistical significance and multiple logistic regression analysis using SPSS software to identify the risk factors.

RESULTS

286 surgeries were performed. After exclusion, 43 patients were included in each group. Baseline demographics were similar in both groups. The incidence of POVD was 15%, and none of our patients had long-term voiding problems. Logistic regression analysis identified five risk factors - advanced pelvic organ prolapse (OR = 2.654, p = 0.029), comorbidities (OR = 4.583, p = 0.019), preoperative anticholinergics and/or antidepressants (OR = 4.440, p = 0.004), sacrospinous hysteropexy/colpopexy (OR = 2.613, p = 0.041) and postoperative opioid use (OR = 3.529, p = 0.004).

CONCLUSION

We identified five risk factors to recognize the women who would benefit from advanced counseling and management plan following surgery for pelvic organ prolapse.

Postoperative urinary retention after pelvic organ prolapse surgery: influence of peri-operative factors and trial of void protocol

PURPOSE

Transient postoperative urinary retention (POUR) is common after pelvic floor surgery. We aimed to determine the association between peri-operative variables and POUR and to determine the number of voids required for post-void residuals (PVRs) to normalize postoperatively.

METHODS

We conducted a retrospective cohort study of 992 patients undergoing pelvic floor surgery at a tertiary referral centre from January 2015 to October 2017. Variables assessed included: age, BMI, ASA score, anaesthesia type, type of surgery, length of postoperative stay, surgeon, bladder protocol used, and number of PVRs required to "pass" the protocol.

RESULTS

Significant risk factors for POUR included: placement of MUS during POP surgery, anterior repair and hysterectomy with concomitant sacrospinous vault suspension. A total of 25.1% were discharged requiring catheterization. Patients receiving a concomitant mid-urethral sling (MUS) were 2.2 (95% CI1.6-2.9) and 2.3 (95% CI 1.8-3.1) times more likely to have elevated PVR after their second TOV and third TOV (p < 0.0001), respectively, compared with those without concomitant MUS. Permitting a third TOV allowed an additional 10% of women to pass the voiding protocol before discharge. The median number of voids to pass protocol was 2. An ASA > 2 and placement of MUS were associated with increasing number of voids needed to pass protocol.

CONCLUSIONS

While many women passed protocol by the second void, using the 3rd void as a cut point to determine success would result in fewer women requiring catheterization after discharge. Prior to pelvic floor surgery, women should be counselled regarding POUR probability to allow for management of postoperative expectations.

Wide Variation in Post-Void Residual Management after Urogynecologic Surgery: A Survey of Urogynecologists' Practices

To date there is no standardized regimen or evidence-based practical guideline concerning post-void residual (PVR) measurement after urogynecologic surgeries. This survey aimed to evaluate current practice patterns and the approach taken among urogynecologists surrounding PVR measurement. An online survey was sent to members of several urogynecologic societies assessing pre- and postoperative management of patients undergoing urogynecologic surgery. A total of 204 urogynecologists from 21 countries participated in the survey. The vast majority of urogynecologists perform some kind of voiding trial to assess voiding function postoperatively. The cut-off values to perform catheterization, the methods of measurement, and the number of successfully passed voiding showed strong differences. Only 34.4% of the respondents consider routine PVR measurement after urogynecologic surgery to be evidence-based. PVR measurement after urogynecologic surgeries is widely performed and if pathological, it almost always provokes invasive treatment. However, there is a wide variation of implemented strategies, methods, and cut-off values. Scientific societies are challenged to devise a standardized regimen based on evidence for the management of urinary retention after urogynecologic surgery.

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.

Streamlining Postoperative Void Trials: A Study Comparing Standard Backfill Versus Backfill in the Operating Room

OBJECTIVE

The standard backfill void trial (VT) performed after urogynecologic surgery is time-consuming. We adopted a new VT protocol in which the bladder is backfilled in the operating room (OR). We hypothesized that this protocol would result in (1) shorter postoperative care unit (PACU) stay and (2) lower rates of postoperative catheterization compared with standard VT.

METHODS

We performed a retrospective cohort study of women who underwent same-day urogynecologic surgery between August 2018 and March 2019. Basic demographic and procedure information was collected. Patients were divided into 2 groups based on VT performed. Continuous and categorical variables were compared using Student t tests and χ2 tests, respectively. A linear regression model for PACU length of stay was used to control for confounders.

RESULTS

Two hundred twenty-five women were included. One hundred eleven (49.3%) had the OR backfill VT and 114 (50.7%) had the standard VT. There were no statistically significant between-group differences in demographics or procedures performed. The average time in PACU was 15 minutes shorter in the OR backfill compared with the standard VT group (154.8 ± 60.6 vs 169.8 ± 83.2, P = 0.12). After adjusting for confounders, having the OR backfill VT resulted in a 23-minute reduction in PACU time (β = -23.7; 95% confidence interval, -41.3 to -6.1; P = 0.009). The overall VT failure rate was 21.3% and was not significantly different between groups (24.3% vs 18.4%, P = 0.28).

CONCLUSIONS

The OR backfill VT resulted in a shorter stay in PACU without increasing the incidence of postoperative catheterization. With the transition to enhanced recovery after surgery protocols, streamlining PACU activities is a priority.

Guidelines for vulvar and vaginal surgery: Enhanced Recovery After Surgery Society recommendations

This is the first collaborative Enhanced Recovery After Surgery Society guideline for optimal perioperative care for vulvar and vaginal surgeries. An Embase and PubMed database search of publications was performed. Studies on each topic within the Enhanced Recovery After Surgery vulvar and vaginal outline were selected, with emphasis on meta-analyses, randomized controlled trials, and prospective cohort studies. All studies were reviewed and graded according to the Grading of Recommendations, Assessment, Development and Evaluation system. All recommendations on the Enhanced Recovery After Surgery topics are based on the best available evidence. The level of evidence for each item is presented.

Bladder infusion versus standard catheter removal for trial of void: a systematic review and meta-analysis

PURPOSE

To compare the efficacy and time-to-discharge of two methods of trial of void (TOV): bladder infusion versus standard catheter removal.

METHODS

Electronic searches for randomized controlled trials (RCTs) comparing bladder infusion versus standard catheter removal were performed using multiple electronic databases from dates of inception to June 2020. Participants underwent TOV after acute urinary retention or postoperatively after intraoperative indwelling catheter (IDC) placement. Quality assessment and meta-analyses were performed, with odds ratio and mean time difference used as the outcome measures.

RESULTS

Eight studies, comprising 977 patients, were included in the final analysis. Pooled meta-analysis demonstrated that successful TOV was significantly higher in the bladder infusion group compared to standard TOV (OR 2.41, 95% CI 1.53-3.8, p = 0.0005), without significant heterogeneity (I²=19%). The bladder infusion group had a significantly shorter time-to-decision in comparison to standard TOV (weighted mean difference (WMD)-148.96 min, 95% CI - 242.29, - 55.63, p = 0.002) and shorter time-to-discharge (WMD - 89.68 min, 95% CI - 160.55, - 18.88, p = 0.01). There was no significant difference in complication rates between the two groups.

CONCLUSION

The bladder infusion technique of TOV may be associated with a significantly increased likelihood of successful TOV and reduced time to discharge compared to standard TOV practices.

Optimal timing of a second postoperative voiding trial in women with incomplete bladder emptying after vaginal reconstructive surgery: a randomized trial

BACKGROUND

Rates of postoperative incomplete bladder emptying vary significantly after pelvic reconstructive surgery. With enhanced recovery protocols the paradigm is shifting towards same-day discharge and the rates of incomplete bladder emptying are expected to increase. The optimal length of time for postoperative catheter drainage has not been clearly established. There are no current studies that assess the optimal timing of a repeat voiding trial in women who have unsuccessful same day voiding trials.

OBJECTIVE

This study aimed to compare the outcomes of a second voiding trial performed 2-4 days (earlier group) vs 7 days (later group) postoperatively in women with incomplete bladder emptying after vaginal prolapse surgery. Secondary aims included postoperative urinary tract infection rates, total days with a catheter, and patient-reported catheter bother between groups.

STUDY DESIGN

Across 2 sites, women undergoing multicompartment vaginal repair were enrolled. Within 6 hours postoperatively, subjects had an active retrograde voiding trial. Those who passed this voiding trial exited the study; those who had persistent incomplete bladder emptying (postvoid residual >100 mL) had a transurethral indwelling catheter placed and were randomized to return for an earlier (postoperative day 2-4) vs later (postoperative day 7) follow-up office voiding trial. Subjects were followed for 6 weeks after surgery. The primary outcome was the rate of unsuccessful repeat office voiding trial. Secondary outcomes included rates of urinary tract infection, total days with a catheter, and subjective catheter bother. A power calculation based on a projected 31% difference, a power of 0.8, and an alpha of 0.05 revealed that 30 subjects were needed in each group.

RESULTS

A total of 102 subjects were enrolled; 38 exited on postoperative day 0, leaving 64 subjects for randomization (4 of whom withdrew after randomization). A comparison of data revealed that randomization was effective, with no differences between the earlier and later groups in terms of demographic data or surgical procedures. Using an intention-to-treat analysis, women in the earlier group were more likely to be unsuccessful in their follow-up office voiding trial (23.3%) than the later group (3.3%), with a risk difference of 20% (95% confidence interval, 3.56-36.44) and a relative risk of 7.00 (95% confidence interval, 0.92-53.47; P=.02). A number-needed-to-treat calculation found that for every 5 patients using a catheter for 7 days postoperatively, 1 case of persistent postoperative incomplete bladder emptying was prevented. Rates of catheter bother did not differ between groups at the time of the follow-up office voiding trial or at 6 weeks (P=.09 and P=.20, respectively). Urinary tract infection rates were higher in the earlier group but did not reach statistical significance (23% vs 7%, P=.07). Regression analysis revealed that subjects who required additional pain medication refills were 9.6 times (95% confidence interval, 1.24-73.77) more likely to have persistent incomplete bladder emptying after the follow-up office voiding trial.

CONCLUSION

Women with incomplete bladder emptying after multicompartment prolapse repair had a 7-fold higher risk of an unsuccessful repeat office voiding trial if performed within 4 days of surgery than when performed within 7 days of surgery. In addition, requiring additional prescriptions for analgesia increased the risk of an unsuccessful follow-up office voiding trial.

Postoperative Urinary Retention Rates after Autofill versus Backfill Void Trial following Total Laparoscopic Hysterectomy: A Randomized Controlled Trial

STUDY OBJECTIVE

To compare the rate of postoperative urinary retention (POUR) after total laparoscopic hysterectomy (TLH) using the autofill vs the backfill void trial. Secondary objectives were to compare the time to discharge from the recovery room, rate of postoperative urinary tract infection (UTI), perceived bladder condition, the effect of bladder function on life, and patient satisfaction.

DESIGN

Randomized controlled trial.

SETTING

Single academic medical center.

PATIENTS

Women who underwent TLH by conventional laparoscopy or robotic-assisted laparoscopy for benign non-urogynecologic indications.

INTERVENTIONS

After TLH, participants were randomized to have an autofill void trial (group A) or a backfill void trial once they were able to ambulate (group B). Failure rate, time to discharge, and UTI rate were assessed. Participants completed the patient perception of bladder condition and the incontinence impact questionnaire-short form questionnaires. Patient satisfaction was assessed. Multiple regression analysis was performed to determine the predictors of POUR.

MEASUREMENTS AND MAIN RESULTS

Eighty-two participants completed the study after randomization, 42 in group A and 40 in group B. There were no statistically significant differences in demographic or perioperative outcomes. Seven participants had POUR in group A (16.7%) and 11 in group B (27.5%) (p = .36), respectively. The median time to discharge was 176 minutes for group A (160.5, 255.5) and 218 minutes for group B (180, 265) (p = .01), respectively. There were no statistically significant differences in rate of postoperative UTI (p >.99), patient perception of bladder condition scores (p = .24), incontinence impact questionnaire-short form scores (p = .23), and patient satisfaction scores (p = .26). A stepwise logistic regression analysis did not demonstrate any predictors of POUR.

CONCLUSION

Backfill void trial once the participant was able to ambulate was not superior to the autofill void trial with respect to the rate of POUR. The autofill void trial resulted in faster same-day discharge.

A urinary catheter valve is non-inferior to continuous bladder drainage with respect to post-operative UTIs: a randomized controlled trial

INTRODUCTION AND HYPOTHESIS

Urinary tract infections (UTIs) are common with indwelling catheter use. Our primary aim was to compare UTI rates in women sent home after surgery with continuous bladder drainage versus a urinary catheter valve.

METHODS

This was a non-inferiority prospective randomized controlled study between June 2016 to June 2019. Women who were being discharged home with a Foley catheter following urogynecologic surgery due to urinary retention were randomized to a continuous urinary drainage bag or a urinary catheter valve. The primary outcome of this study was post-operative UTI rates within 30 days of surgery. The secondary outcome was patient satisfaction, as determined by a Foley satisfaction questionnaire.

RESULTS

Out of 97 women, 51 were randomized to continuous drainage and 46 to the urinary catheter valve. Comparing UTI rates, the urinary catheter valve (32.6%) was non-inferior to the continuous urinary drainage bag (33.3%). The upper bound of the 95% CI was less than the predetermined non-inferiority margin (difference 0.7%, 95% CI: -0.195, 0.180), and therefore non-inferiority criteria were met. Patients were more satisfied with the urinary catheter valve than with the continuous drainage bag (p ≤ 0.001).

CONCLUSIONS

Use of this urinary catheter valve increased patient satisfaction without affecting the post-operative UTI rate. This easy and inexpensive device could help patients have a better catheter experience and should be considered in women being discharged home with a urinary catheter.

Voided volume for postoperative voiding assessment following prolapse and urinary incontinence surgery

INTRODUCTION AND HYPOTHESIS

The objective was to compare the safety and accuracy of voided volume with the standard retrograde fill approach for voiding assessment after pelvic floor surgery.

METHODS

This cohort represents all women in our repository who underwent postoperative voiding assessment following procedures for pelvic floor disorders between September 2011 and June 2014. One surgeon utilized a spontaneous voiding (SV) protocol and allowed any patient who voided 150 ml or more at one time to pass the trial. The other surgeon used a retrograde fill (RF) protocol. This involved instilling the bladder with 300 ml of water or until maximum capacity immediately after the outpatient procedures and on the first postoperative day for hospitalized patients. For this protocol, a voided volume of 200 ml was considered sufficient to pass the trial.

RESULTS

In this cohort, 431 women had a voiding trial with SV, and 318 with RF. The groups were similar with respect to baseline characteristics but more women in the RF group had a sling-only procedure. The failure rates of the RF (22.8%) and SV (20.0%) groups were similar (p = 0.46). Among women who passed the voiding trial, similar percentages of women returned with urinary retention and needed catheter insertion after the RF (1.6%) and SV (0.9%) methods (p = 0.65).

CONCLUSION

Spontaneous voiding trial based on a minimum voided volume of 150 ml is a safe and reliable alternative to the retrograde fill method after female pelvic floor procedures.

Self-Removal of a Urinary Catheter After Urogynecologic Surgery: A Randomized Controlled Trial

OBJECTIVE

To evaluate whether self-discontinuation of a transurethral catheter is noninferior to office discontinuation in patients requiring indwelling catheterization for postoperative urinary retention after pelvic reconstructive surgery.

METHODS

In this randomized noninferiority trial, patients with postoperative urinary retention after pelvic reconstructive surgery were assigned to self-discontinuation or office discontinuation of their catheter 1 week after surgery. The primary outcome was a noninferiority comparison of postoperative urinary retention at 1 week. Self-discontinuation patients were instructed on home catheter removal on postoperative day 7. Office discontinuation patients underwent a standard voiding trial on postoperative day 6-8. Postoperative urinary retention at 1 week was defined as continued catheterization on postoperative day 6-8. Secondary outcomes included urinary tract infections (UTI), residual volume at 2 weeks, duration of catheter use, recurrent postoperative urinary retention, number of patient encounters, and visual analog scales (VAS) regarding patient experience. Given a known incidence of postoperative urinary retention at 1 week (16%) and 15% noninferiority margin, a sample size of 74 per group (n=148) was planned.

RESULTS

From January 2017 through March 2019, 217 women were screened and 157 were analyzed: 78 self-discontinuation and 79 office discontinuation. Demographic characteristics and surgeries performed were similar. Eleven patients in each group experienced postoperative urinary retention at 1 week (14.1% self-discontinuation vs 13.9% office discontinuation, P=.97), establishing noninferiority (difference 0.2%, 95% CI: -1.00, 0.10). There were significantly fewer patient encounters with self-discontinuation (42/78, 53.8% vs 79/79, 100%). Self-discontinuation patients demonstrated better VAS scores regarding pain, ease, disruption, and likelihood to use the same method again (all P<.05). Though the rate of UTI was high, there was no difference between groups (59.0% self-discontinuation vs 66.7% office discontinuation, P=.32). Residual volume at 2 weeks, recurrent postoperative urinary retention, and duration of catheter use were also similar.

CONCLUSION

Self-discontinuation of a transurethral catheter was noninferior to office-based discontinuation in the setting of postoperative urinary retention after pelvic reconstructive surgery. Self-discontinuation resulted in fewer patient encounters and improved patient experience.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT02996968.

Postoperative Bladder Filling After Outpatient Laparoscopic Hysterectomy and Time to Discharge: A Randomized Controlled Trial

OBJECTIVE

To determine whether backfilling the bladder postoperatively will reduce time to discharge in patients undergoing outpatient laparoscopic hysterectomy.

METHODS

In a single-blind, randomized, controlled trial among women undergoing outpatient laparoscopic hysterectomy, patients were randomly assigned to a backfill-assisted void trial or a trial of spontaneous voiding. The primary outcome was time to discharge assessed by length of time spent in the postanesthesia care unit. Secondary outcomes included time to first spontaneous void, urinary retention rates, and postoperative complications within 8 weeks. We estimated that 152 patients (76/group) would provide greater than 80% power to identify a 30-minute difference in the primary outcome with a SD of 56 minutes and a two-sided α of 0.05.

RESULTS

Between June 2017 to May 2018, 202 women were screened, 162 women were randomized, and results were analyzed for 153 women. Seventy-five patients (group A) who had a backfill-assisted voiding trial and 78 patients (group B) who had a spontaneous voiding trial were included in the analysis. The mean time to discharge was 273.4 minutes for group A vs 283.2 minutes for group B, which was not found to be significant (P=.45). The mean time to first spontaneous void was 181.1 minutes in group A vs 206.0 minutes in group B. There was a statistically significant reduction of 24.9 minutes in time to first spontaneous void with patients randomized to the backfill group (P=.04). Five of 75 patients (6.7%) in group A and 10 of 78 patients (12.8%) in group B developed urinary retention postoperatively and required recatheterization before discharge, which was also not significant (P=.20).

CONCLUSION

Bladder filling before removing the Foley catheter is a simple procedure shown to reduce time to first spontaneous void, but not time to discharge in patients undergoing outpatient laparoscopic hysterectomy.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT03126162.

Predictors of Admission After the Implementation of an Enhanced Recovery After Surgery Pathway for Minimally Invasive Gynecologic Surgery

BACKGROUND

Enhanced recovery after surgery (ERAS) pathways in gynecologic surgery have been shown to decrease length of stay with no impact on readmission, but no study has assessed predictors of admission in this population. The purpose of this study was to identify predictors of admission after laparoscopic hysterectomy (LH) and robotic-assisted hysterectomy (RAH) performed under an ERAS pathway.

METHODS

This is a prospective observational study of women undergoing LH/RAH for benign indications within an ERAS pathway. Data collected included same-day discharge, reason for admission, incidences of urgent clinic and emergency room (ER) visits, readmissions, reoperations, and 9 postulated predictors of admission listed below. Patient demographics, markers of baseline health, and clinical outcomes were compared between groups (ERAS patients discharged on the day of surgery versus admitted) using Fisher exact and Student t tests. Multivariable logistic regression was used to assess the potential risk factors for being admitted, adjusting for age, race, body mass index, American Society of Anesthesiologists (ASA) physical status score, preoperative diagnosis indicative of hysterectomy, preoperative chronic pain, completion of a preprocedure pain-coping skills counseling session, procedure time, and compliance to the ERAS pathway.

RESULTS

There were 165 patients undergoing LH/RAH within an ERAS pathway; 93 (56%) were discharged on the day of surgery and 72 were admitted. There were no significant differences in ER visits, readmissions, and reoperations between groups (ER visits: discharged 13% versus admitted 13%, P = .99; 90-day readmission: discharged 4% versus admitted 7%, P = .51; and 90-day reoperation: discharged 4% versus admitted 3%, P = .70). The most common reasons for admission were postoperative urinary retention (n = 21, 30%), inadequate pain control (n = 21, 30%), postoperative nausea and vomiting (n = 7, 10%), and planned admissions (n = 7, 10%). Increased ASA physical status, being African American, and increased length of procedure were significantly associated with an increased risk of admission (ASA physical status III versus ASA physical status I or II: odds ratio [OR], 3.12; 95% confidence interval [CI], 1.36-7.16; P = .007; African American: OR, 2.47; 95% CI, 1.02-5.96; P = .04; and length of procedure, assessed in 30-minute increments: OR, 1.23; 95% CI, 1.02-1.50; P = .04).

CONCLUSIONS

We were able to define predictors of admission for patients having LH/RAH managed with an ERAS pathway. Increased ASA physical status, being African American, and increased length of procedure were significantly associated with admission after LH/RAH performed under an ERAS pathway. In addition, the incidences of urgent clinic and ER visits, readmissions, and reoperations within 90 days of surgery were similar for patients who were discharged on the day of surgery compared to those admitted.

Prediction of urinary retention after surgery for rectal cancer using voiding efficiency in the 24 h following Foley catheter removal

PURPOSE

Postoperative urinary retention is a common adverse effect after rectal surgery. Current methods for assessing postoperative urinary retention (residual urine volume) are inaccurate and unable to predict long-term retention. Voiding efficiency is an effective indicator of postoperative urinary retention in urological and gynaecological fields, but not in colorectal surgery. We aimed to determine whether voiding efficiency in the initial 24 h after urinary catheter removal was more effective in predicting the incidence of postoperative urinary retention than residual urine volume.

METHODS

In this retrospective, observational study using prospectively collected data from patients who visited the colorectal department of a single institution, 549 patients who underwent rectal cancer surgery between April 2012 and May 2016 were initially enrolled, of which 46 were excluded and 503 finally included.

RESULTS

The incidence of postoperative urinary retention was 18.5% (93/503). Multivariable logistic regression analyses revealed that the association of postoperative urinary retention with voiding efficiency < 50% was stronger than that with residual urine volume > 100 mL (odds ratio, 38.30 (residual urine volume) and 138.0 (voiding efficiency)). Voiding efficiency was significantly lower in patients with long-term than in those with short-term postoperative urinary retention (adjusted p value = 0.02), whereas residual urine volume was not different between the two groups. Multivariable logistic regression analysis for long-term postoperative urinary retention showed the strongest association with voiding efficiency < 20% (odds ratio, 25.70).

CONCLUSIONS

Voiding efficiency is a more effective predictor of postoperative urinary retention than residual urine volume in rectal cancer patients.

Preoperative and postoperative ultrasound assessment of stress urinary incontinence

INTRODUCTION

The role of ultrasound imaging in urogynecology is not defined. Significant developments in visualization techniques and interpretation of images allowed to study structures of the lower genitourinary tract and pelvic floor.

EVIDENCE ACQUISITION

PubMed and Scopus database were searched for publications on the following item: stress urinary incontinence, ultrasound, perineal ultrasound and preoperative and postoperative assessment.

EVIDENCE SYNTHESIS

The role of ultrasound in urogynecology could be helpful in diagnosing of urinary incontinence and urethral hypermobility, to document pelvic floor anatomy and to assess anatomic and functional changes before and after surgery.

CONCLUSIONS

Ultrasound could be an important step during preoperative and post-operative assessment of patients affected by stress urinary incontinence.

Early catheter removal after pelvic floor reconstructive surgery: a randomized trial

INTRODUCTION AND HYPOTHESIS

Studies have yet to examine the impact of day-of-surgery voiding trials on post-operative urinary retention in women undergoing obliterative and apical suspension procedures for pelvic organ prolapse. Our objective was to evaluate if time to spontaneous void after these procedures is shorter when a voiding trial is performed on the day of surgery compared with our standard practice of post-operative day 1.

METHODS

We conducted a randomized, parallel-arm trial in patients undergoing major pelvic floor reconstructive surgery. Women were randomized 1:1 to an early (4 h post-operatively on the day of surgery) or a standard (6 am on post-operative day 1) retrograde voiding trial.

RESULTS

A total of 57 women consented. Mean age and BMI were 65 ± 11 and 27.9 ± 4.4. Most women had stage III pelvic organ prolapse (77.2%). Groups had similar baseline characteristics. In the intention-to-treat analysis (n = 57), there was no difference in time to spontaneous void in the early versus standard voiding trial groups (15.9 ± 3.8 vs 28.4 ± 3.1 hours, p = 0.081). In the adjusted analysis using mutlivariable linear regression, an early voiding trial decreased the time to spontaneous void (abeta -2.00 h, p = 0.031) when controlling for vaginal packing and stage IV prolapse. In the per-protocol analysis, which excluded 4 patients for crossover, spontaneous void occurred 17 hours faster in the early voiding trial group (14.6 ± 3.7 vs 31.8 ± 2.9 hours; p = 0.022). Early voiding trial patients experienced ambulation sooner and more often than the standard group (p = 0.02).

CONCLUSIONS

A day-of-surgery voiding trial did not prolong catheter use after obliterative and apical suspension procedures.

Improving Postoperative Efficiency: An Algorithm for Expedited Void Trials After Urogynecologic Surgery

OBJECTIVES

To evaluate the relation between voided volume and void trial "success" to create an algorithm that minimizes the need for postvoid residual volume (PVR) assessment in backfill-assisted void trials.

METHODS

This article is an ancillary analysis of deidentified data from a randomized trial evaluating prophylactic antibiotics after urogynecologic surgery. Void trials were routinely performed after surgery; voided volumes, PVR, and void trial outcomes were collected. The void trial regimen was as follows: the bladder was backfilled with 300 mL of normal saline or until the patient reported the urgency to void, the catheter was removed, and the participant was prompted to void immediately. PVR volume was measured either by sonographic bladder scan or catheterization. Voided volumes were categorized in 25-mL increments from 50 to 225 mL. For each voided volume range, the PVR and void trial outcome data were incorporated to calculate sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) in terms of ability of voided volume alone to predict a passing void trial result. An algorithm was created using the voided volumes that optimize PPV and NPV.

RESULTS

The study population included 255 participants. Voided volumes <100 mL and ≥200 mL were identified as optimal thresholds to predict failure and passage of backfill-assisted void trials, respectively. When patients voided <100 mL, 3% passed their void trial (NPV odds ratio 96.7, 95% confidence interval 88.6-99.5). When patients voided ≥200 mL, 97% passed (PPV odds ratio 97.4, 95% confidence interval 93.5-99.3).

CONCLUSIONS

We propose an algorithm for void trials after urogynecologic surgery. After backfilling the bladder if voided volume is ≥200 mL, the void trial is successful and no PVR is needed; if voided volume is between 100 and 199 mL, the void trial is indeterminate and PVR is recommended; and if voided volume is <100 mL, the void trial is unsuccessful and catheterization is needed. Applying this algorithm to our study population would have eliminated the need for PVR in 85% of patients. Calculated PPVs and NPVs depend on the prevalence of voiding dysfunction in the population being studied, and therefore may be unique to our institution.

Effect of Scopolamine Patch Use on Postoperative Voiding Function After Transobturator Slings

OBJECTIVES

The aim of this study was to determine whether the use of a preoperative transdermal scopolamine (TDS) patch for postoperative nausea and vomiting prophylaxis affects the success of a voiding trial after a transobturator tape sling procedure.

METHODS

This study is a retrospective cohort study of adult women who underwent a transobturator tape sling procedure without concomitant procedures from February 1, 2009 through August 1, 2010. The exposed group included all eligible women who received a preoperative TDS patch. For each exposed woman, we selected the next 2 consecutive eligible women who did not receive a TDS patch to be included in the unexposed group. The primary outcome was postoperative voiding trial failure.

RESULTS

We identified 35 women who met eligibility criteria and used a preoperative TDS patch, and included 70 women who did not use a preoperative TDS. A significantly higher proportion of women in the TDS patch group (54.3%) failed their voiding trial than in the group that did not receive TDS (7.1%, P ≤ 0.001). A history of an incontinence procedure, older age, and higher body mass index strengthened the association between TDS patch and voiding trial failure. The adjusted model yielded a risk ratio for voiding trial failure of 13.8 (95% confidence interval, 5.2-36.5) for women who received TDS patch compared with those who did not.

CONCLUSIONS

The results of this study demonstrate that use of TDS patches for postoperative nausea and vomiting prophylaxis may negatively affect the success of voiding trials after transobturator tape sling procedures.

Clinical Comparison of 2 Trial-of-Void Methods After Outpatient Midurethral Sling Placement

OBJECTIVES

This study aimed to assess the efficacy, efficiency, and costs of 2 methods of trial of void (TOV) after midurethral sling (MUS) placement.

METHODS

A retrospective chart review was performed on women who underwent outpatient MUS between January 2013 and April 2014 by 3 urologists. Patients were excluded if they had a concomitant prolapse repair, hysterectomy, bladder/urethral injury, or any procedure that may prolong recovery room (RR) stay. Trial of void was performed by either (1) bladder instillation, catheter removal in the operating room (OR) fill with attempted void in RR, or (2) bladder instillation and catheter removal with immediate attempted void in the RR fill. Intraoperative, postoperative, and cost data were analyzed.

RESULTS

Ninety-one of 183 women (mean age, 55.9 ± 12 years; mean body mass index, 28.8 ± 5.8 kg/m) met inclusion criteria. Eighty-three had a transobturator sling. Forty-nine (54%) had an OR fill and 42 (46%) had an RR fill; age and body mass index were similar between groups. The OR fill group had shorter median operative time (15 vs 22 minutes; P = 0.003) and median RR time (138 vs 161, P = 0.033). The OR fill and RR fill groups did not differ in TOV failure rate (3/49 vs 6/42; P = 0.29), overall mean LOS (4.96 vs 5.51 hours; P = 0.055), and median RR costs ($627 vs $678; P = 0.065). No patient had urinary retention after successful TOV.

CONCLUSIONS

After MUS placement, both OR fill and RR fill TOV methods are effective and efficient with similar TOV failure rates.

One normal void and residual following MUS surgery is all that is necessary in most patients

INTRODUCTION AND HYPOTHESIS

There is considerable variation worldwide on how the assessment of voiding function is performed following midurethral sling (MUS) surgery. There is potentially a financial cost, and reduction in efficiency when patient discharge is delayed. Using our current practice of two normal void and residual (V&R) readings before discharge, the aim of this retrospective study was to evaluate the likelihood of an abnormal second V&R test if the first V&R test was normal in order to determine if a policy of discharge after only one satisfactory V&R test is reasonable.

METHODS

Data from 400 patients who had had MUS surgery with or without other procedures were collected. Our unit protocol included two consecutive voids of greater than 200 ml with residuals less than 150 ml before discharge. The patients were divided into the following groups: MUS only, MUS plus anterior colporrhaphy (AR) plus any other procedures (MUS/AR), and MUS with any non-AR procedures (MUS+).

RESULTS

Complete datasets were available for 335 patients. Once inadequate tests (low volume voids <200 ml) had been excluded (28% overall), the likelihood of an abnormal second V&R test if the first test was normal was 7.1% overall, but 3.6% for MUS, 11.5% for MUS/AR and 8.6% for MUS+.

CONCLUSION

The findings in the MUS-only group indicate that it is probably safe to discharge patients after one satisfactory V&R test, as long as safety measures such as 'open access' are available so that patients have unhindered readmission if problems arise.

Predictors of early postoperative voiding dysfunction and other complications following a midurethral sling

BACKGROUND

The rates reported for postoperative urinary retention following midurethral sling procedures are highly variable. Determining which patients have a higher likelihood of failing a voiding trial will help with preoperative counseling prior to a midurethral sling.

OBJECTIVE

The objective of the study was to identify preoperative predictors for failed voiding trial following an isolated midurethral sling.

STUDY DESIGN

A retrospective, multicenter, case-control study was performed by including all isolated midurethral sling procedures performed between Jan. 1, 2010 to June 30, 2015, at 6 academic centers. We collected demographics, medical and surgical histories, voiding symptoms, urodynamic evaluation, and intraoperative data from the medical record. We excluded patients not eligible for attempted voiding trial after surgery (eg, bladder perforation requiring catheterization). Cases failed a postoperative voiding trial and were discharged with an indwelling catheter or taught intermittent self-catheterization; controls passed a voiding trial. We also recorded any adverse events such as urinary tract infection or voiding dysfunction up to 6 weeks after surgery. Bivariate analyses were completed using Mann-Whitney and Pearson χ² tests as appropriate. Multivariable stepwise logistic regression was used to determine predictors of failing a voiding trial.

RESULTS

A total of 464 patients had an isolated sling (70.9% retropubic, 28.4% transobturator, 0.6% single incision); 101 (21.8%) failed the initial voiding trial. At follow-up visits, 90.4% passed a second voiding trial, and 38.5% of the remainder passed on the third attempt. For the bivariate analyses, prior prolapse or incontinence surgery was similar in cases vs controls (31% vs 28%, P = .610) as were age, race, body mass index, and operative time. Significantly more of the cases (32%) than controls (22%) had a Charlson comorbidity index score of 1 or greater (P = .039). Overactive bladder symptoms of urgency, frequency, and urgency incontinence were similar in both groups as was detrusor overactivity in those with a urodynamic evaluation (29% vs 22%, P = .136), but nocturia was reported more in the cases (50% vs 38%, P = .046). Mean (SD) bladder capacity was similar in both groups (406 [148] mL vs 388 [122] mL, P = .542) as was maximum flow rate with uroflowmetry and pressure flow studies. Cases were significantly more likely to have a voiding type other than detrusor contraction: 37% vs 25%, P = .027, odds ratio, 1.79 (95% confidence interval, 1.07-3.00). There was no difference in voiding trial failures between retropubic and transobturator routes (23.1% vs 18.9%, P = .329). Within 6 weeks of surgery, the frequency of urinary tract infection in cases was greater than controls (20% vs 6%, P < .001; odds ratio, 3.51 [95% confidence interval, 1.82-6.75]). After passing a repeat voiding trial, cases were more likely to present with acute urinary retention (10% vs 3%, P = .003; odds ratio, 4.00 [95% confidence interval, 1.61-9.92]). For multivariable analyses, increasing Charlson comorbidity index increased the risk of a voiding trial failure; apart from this, we did not identify other demographic information among the patients who did not undergo urodynamic evaluation that reliably forecasted a voiding trial failure.

CONCLUSION

The majority of women will pass a voiding trial on the first attempt after an isolated midurethral sling. Current medical comorbidities are predictive of a voiding trial failure, whereas other demographic/examination findings are not. Patients failing the initial voiding trial are at an increased risk of postoperative urinary tract infection or developing acute retention after passing a subsequent voiding trial.

Assessing ureteral patency using 10% dextrose cystoscopy fluid: evaluation of urinary tract infection rates

BACKGROUND

Intravenous indigo carmine has routinely been used to confirm ureteral patency after urogynecologic surgery. Recent discontinuation of the dye has altered clinical practice. In the absence of indigo carmine, we have used 10% dextrose in sterile water (D10) as cystoscopic fluid to evaluate ureteral patency. Glucosuria has been associated with urinary tract infection (UTI) in vivo and significantly enhanced bacterial growth in vitro. The concern is that the use of D10 would mimic a state of glucosuria albeit transient and increase the risk of postoperative UTI.

OBJECTIVES

The objectives of this study were to compare the rates of postoperative UTI and lower urinary tract (LUT) injuries between patients who underwent instillation of D10 vs normal saline at the time of intraoperative cystoscopy after urogynecological surgery.

STUDY DESIGN

This was a retrospective cohort study of all women who underwent cystoscopic evaluation of ureteral patency at the time of urogynecological surgery from May through December 2014 at a tertiary care referral center. We compared patients who received D10 cystoscopy fluid vs those who used normal saline. Outcomes included UTI and diagnosis of ureteral or LUT injuries. UTI was diagnosed according to Centers for Disease Control and Prevention guidelines by symptoms alone, urine dipstick, urinalysis, or urine culture. Descriptive statistics compared the rates of UTI between the 2 groups, and a multivariable model was fit to the data to control for potential confounders and significant baseline differences between the groups.

RESULTS

A total of 303 women were included. D10 was used in 113 cases and normal saline (NS) was used in 190. The rate of UTI was higher in the D10 group than the NS group: 47.8% (95% confidence interval [CI], 38.3-57.4) vs 25.9% (95% CI, 19.8-32.8, P < .001). After adjusting for age, pelvic organ prolapse stage, use of perioperative estrogen, days of postoperative catheterization, menopausal status, diabetes mellitus, and history of recurrent UTI, the UTI rate remained significantly higher with the use of D10 (adjusted odds ratio, 3.4 [95% CI, 1.6-7.5], P = .002) compared with NS. Overall, 3 cases of transient ureteral kinking (1.0%) and one cystotomy (0.3%) were identified intraoperatively. However, ureteral and LUT injuries were not different between groups. No unidentified injuries presented postoperatively.

CONCLUSION

Although the use of D10 cystoscopy fluid has been successful in identifying ureteral patency in the absence of indigo carmine, it is associated with an increased rate of postoperative UTI compared with NS.

Assessment of voiding after sling: a randomized trial of 2 methods of postoperative catheter management after midurethral sling surgery for stress urinary incontinence in women

OBJECTIVE

The objective of this study was to compare the backfill standard voiding trial (SVT) that relies on the assessment of voided volume to subjective patients' evaluation of their voiding based on the assessment of the force of stream (FOS) after an outpatient midurethral sling surgery.

STUDY DESIGN

This double-blinded randomized trial included patients undergoing an outpatient midurethral sling surgery without any other concomitant surgery. Participants were randomized to either the SVT group or to the FOS group. The primary outcome was the rate of catheterization any time up to 6 weeks after surgery. Both groups underwent the same backfill voiding trial protocol postoperatively. Measurements of the voided amount, postvoid residual, and the response to the FOS visual analog scale were collected. The criteria for passing the voiding trial in the SVT group was voiding at least two-thirds of the instilled amount; while the criteria for passing the trial in the FOS group was assessment of FOS at least 50% of the baseline, regardless of the voided volume. Participants were interviewed preoperatively and 2-4 days, 7-9 days, and 6 weeks postoperatively. All postoperative interviews included assessments of pain, tolerance of physical activity, urinary FOS, as well as satisfaction with the surgery. Validated questionnaires (Incontinence Severity Index and Urinary Distress Inventory, short form) before the surgery and 6 weeks after were used to evaluate urinary symptoms.

RESULTS

A total of 108 patients were enrolled and randomized, and 6-week follow-up data were available for 102 participants (FOS 50, SVT 52). The 2 groups were similar with respect to demographic characteristics and urinary symptoms. The incidence of catheterization was also similar between the groups (FOS 13 [26%], SVT 13 [25.5%]; P=.95). Amount voided had a moderate correlation with FOS assessment (Spearman rho 0.5; P<.001). There was no significant difference in mean catheter days, pain scores, Incontinence Severity Index, and Urinary Distress Inventory, short form scores between the 2 groups. Of the patients who were discharged home without a catheter in either group none required catheter reinsertion within 6 weeks after the surgery.

CONCLUSION

Patient's subjective assessment of the urinary FOS correlated well with the measured voided amount and no difference in catheterization days was noted between the subjective and objective assessment of voiding. Thus subjective evaluation of the FOS is a reliable and safe method to use after outpatient midurethral surgery.

Prevention and management of postoperative urinary retention after urogynecologic surgery

Postoperative urinary retention (POUR) is a frequent consequence of gynecologic surgery, especially with surgical correction of urinary incontinence and pelvic organ prolapse. Estimates of retention rates after pelvic surgery range from 2.5%–43%. While there is no standard definition for POUR, it is characterized by impaired bladder emptying, with an elevation in the volume of retained urine. The key to management of POUR is early identification. All patients undergoing pelvic surgery, especially for the correction of incontinence or prolapse, should have an assessment of voiding function prior to discharge. There are several ways to assess voiding function – the gold standard is by measuring a postvoid residual. Management of POUR is fairly straightforward. The goal is to decompress the bladder to avoid long-term damage to bladder integrity and function. The decision regarding when to discontinue catheter-assisted bladder drainage in the postoperative period can be assessed in an ongoing fashion by measurement of postvoid residual. The rate of prolonged POUR beyond 4 weeks is low, and therefore most retention can be expected to resolve spontaneously within 4–6 weeks. When POUR does not resolve spontaneously, more active management may be required. Techniques include urethral dilation, sling stretching, sling incision, partial sling resection, and urethrolysis. While some risk of POUR is inevitable, there are risk factors that are modifiable. Patients that are at higher risk – either due to the procedures being performed or their clinical risk factors – should be counseled regarding the risks and management options for POUR prior to their surgery. Although POUR is a serious condition that can have serious consequences if left untreated, it is easily diagnosed and typically self-resolves. Clinician awareness of the condition and vigilance in its diagnosis are the key factors to successful care for patients undergoing surgical repair.