Effect of postoperative partial bladder filling after minimally invasive hysterectomy on postanesthesia care unit discharge and cost: a single-blinded, randomized controlled trial

Robotic Surgery for Bladder Endometriosis: A Systematic Review and Approach

INTRODUCTION

Women with bladder endometriosis often present with more advanced stages of endometriosis. Robotic surgery has emerged as a promising approach to the management of bladder endometriosis. This systematic review aims to analyze the current literature on robotic surgery for bladder endometriosis and describe our systematic approach to surgical treatment.

METHODS

This review followed the PRISMA guidelines, which ensured a comprehensive and transparent approach to selecting and evaluating relevant studies. We conducted a thorough literature search to identify studies that investigated the use of robotic surgery for bladder endometriosis. Relevant databases were searched, and inclusion and exclusion criteria were applied to select eligible studies. Data extraction and analysis were performed to assess the outcomes and effectiveness of robotic surgery for the treatment of bladder endometriosis.

RESULTS

We did not find any randomized clinical trials with the use of robotics in the treatment of bladder endometriosis. We found only two retrospective studies comparing robotic surgery with laparoscopy, and another retrospective study comparing robotic surgery, laparoscopy, and laparotomy in the treatment of bladder endometriosis. All the other 12 studies were solely case reports. Despite the lack of robust evidence in the literature, the studies demonstrated that robotic surgery is feasible and is associated with reduced postoperative pain, shorter hospital stays, and faster recovery.

CONCLUSIONS

The utilization of robotic technology is a promising option for the surgical management of bladder endometriosis. We advocate a surgical systematic approach for the robotic treatment of bladder endometriosis. Robotic technology, with its 3D vision, instrumental degrees of freedom, and precision, particularly in suturing, may provide potential benefits over traditional laparoscopy.

Strategies and factors to maximize cost-effectiveness of robotic surgery in benign gynecological disease

Operating room procedures account for half of the gross hospital cost in the United States per annum. Hysterectomy is the eighth most common surgery nationally, with more than 300,000 cases every year. Since the introduction of robotic surgery in benign gynecology, concern has been raised regarding the increased cost without significant improvements in outcomes or practice. Surgeon volume, complication rates, length of hospital stay, and selected intraoperative instrumentation are all factors that have a direct effect on cost in robotic surgery. Cost is indirectly influenced by the OR team workflow, postoperative processes to expedite discharge, and converting surgery to the ambulatory setting. More research is needed to develop evidence-based practices for cost containment in robotic surgery.

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.

Active versus Passive Voiding Protocols after Same-day Minimally Invasive Hysterectomy

STUDY OBJECTIVE

To determine the proportion of patients discharged with a urinary catheter after a same-day benign gynecologic minimally invasive hysterectomy (MIH) according to active vs passive voiding protocols. The secondary objectives included assessing postanesthesia care unit (PACU) duration and postoperative urinary retention (POUR) rate ≤2 weeks of discharge.

DESIGN

Retrospective, observational cohort study.

SETTING

Large integrated healthcare system serving approximately 40% of the Northern California population.

PATIENTS

Patients aged 18 years or older undergoing same-day MIH without urogynecology procedures from 2015 to 2018 were categorized into active or passive voiding trial groups. Active voiding trials were defined as patients arriving in the PACU with a catheter, retrograde filling of the bladder with 300 mL saline then allowing for voiding ≥50% within 30 minutes. If the patients were unable to void this volume, they were discharged with a catheter to be removed within 24 hours. A passive voiding trial involved filling or not filling the bladder before PACU arrival without a catheter, then allowing for voiding or performing a straight catheterization if the patients were unable to void.

INTERVENTIONS

Retrospective cohort study.

MEASUREMENTS AND MAIN RESULTS

A total of 1644 (83.2%) patients underwent passive voiding trials, and 333 (16.8%) underwent active voiding trials. The proportion of patients discharged with a catheter was lower in the passive voiding group than in the active voiding group (5.4% vs 10.5%; p = .001). The passive group had a shorter mean PACU time than the active group (218 ± 86 vs 240 ± 93 minutes; p <.001). The crude POUR rates for the passive and active voiding groups were 1.8% and 3.0%, respectively (p = .16).

CONCLUSION

Within an integrated healthcare system, patients who underwent passive voiding trials compared with those who underwent active voiding trials were discharged home from the PACU after a shorter duration. In addition, a larger proportion of the patients who underwent passive voiding trials were discharged home without a urinary catheter. There were no differences in the POUR rates. Our findings suggest that passive voiding trials can be safely used after a benign MIH to reduce hospital duration, optimize healthcare resources, and improve patient experience.

Patterns of voiding following laparoscopic hysterectomy

OBJECTIVE

Clarify the normal patterns of voiding after minimally invasive hysterectomy. We also aim to identify perioperative factors associated with delayed time to void immediately following hysterectomy.

DESIGN

Retrospective cohort study SELECTION: Women undergoing laparoscopic hysterectomy between September 2012 to October 2018 at a single academic university hospital.

RESULTS

450 minimally invasive hysterectomies were included in the final analysis, 274 (60.9%) robotically-assisted, and 176 (39.1%) conventional laparoscopy. The overall median postoperative time-to-void following a retrograde bladder filling of 150 mL normal saline was 179 min. Based on the 50th percentile of the distribution of the time-to-void, two groups were created. Demographic characteristics between the groups were similar, except those who were above the 50th percentile were more likely to be older, have a reported history of previous myomectomy, and had a longer postoperative PACU stay compared to those below or equal to the 50th percentile. The mean time-to-void following conventional laparoscopic hysterectomy was less than that of robotic surgery (187.3 vs 200.5 min) however the difference was not statistically significant (p=.22). The use of hydromorphone intraoperatively and the combination of oxycodone-acetaminophen postoperatively were more likely to be associated with the group of patients above the 50th percentile but there was no significant difference in perioperative utilization of median morphine milliequivalents (MME) between the two groups.

CONCLUSIONS

Following laparoscopic hysterectomy (either conventional or with robotic-assistance) with a retrograde bladder fill of 150 mL normal saline most patients will void within 4 h after surgery. This is consistent with historic data on normal voiding patterns facilitating safe same day discharge without prolonged time in the PACU.

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.

Retrograde Bladder Filling after Laparoscopic Gynecologic Surgery: A Double-blind Randomized Controlled Trial

Study Objective

To evaluate whether retrofilling the bladder on completion of elective laparoscopic gynecologic surgery for benign indications has an effect on the timing of the first postoperative void and the timing of discharge from the hospital.

Design

Double-blind randomized controlled trial.

Setting

Single academic surgical day hospital.

Patients

Patients undergoing outpatient laparoscopic gynecologic surgery, excluding hysterectomy or pelvic reconstructive surgery.

Interventions

On completion of surgery, patients were randomized to either retrograde filling of the bladder with 200 mL of saline before catheter removal or standard care (immediate catheter removal). Patients and postanesthesia care unit nurses (outcome assessors) were both blinded.

Measurements and Main Results

The primary outcome was the time to first void. The secondary outcomes were time to hospital discharge, postoperative urinary tract infection, and patient satisfaction. Over a 3-month period, 47 patients were approached on the day of surgery, 42 consented and were randomized (21 to intervention and 21 to control). There were no significant differences in baseline demographics between the groups. The median time to first void was significantly shorter for patients in the intervention arm than controls (104 ± 75 minutes vs 162 ± 76 minutes, p <.001). Patients who had retrofilled bladders were discharged faster from post-anesthesia care unit compared to controls (155.0 ± 74 minutes vs 227 ± 58 minutes, p = .001). There were no urinary tract infections in either group, and the proportion of satisfied or very satisfied patients was high (93.8% vs 88.2%, p = .512).

Conclusion

Retrograde filling of the bladder after outpatient laparoscopic gynecologic surgery is a safe, effective method that significantly reduces the length of hospital stay.

Impact of Retained Cystoscopy Fluid after Laparoscopic Hysterectomy: A Randomized Controlled Trial

STUDY OBJECTIVE

To investigate the impact of retained cystoscopy fluid after laparoscopic hysterectomy on time to spontaneous void, time to discharge, urinary retention, bladder discomfort, and patient satisfaction.

DESIGN

Single-blind randomized controlled trial.

SETTING

An academic medical center.

PATIENTS

One hundred and twenty patients who underwent laparoscopic hysterectomy with universal cystoscopy for benign indications, excluding pelvic organ prolapse and urinary incontinence indications.

INTERVENTIONS

From October 10, 2018, to October 17, 2019, we compared 200 mL retained cystoscopy fluid and complete bladder emptying after laparoscopic hysterectomy with universal cystoscopy.

MEASUREMENTS AND MAIN RESULTS

A total of 120 patients were enrolled and randomized (59 in the retained cystoscopy fluid group and 61 in the emptied fluid group). The primary outcome was time to first spontaneous void. The secondary outcomes were time to discharge, urinary retention rates, bladder discomfort, and patient satisfaction. A sample size of 120 was calculated to detect a 57-minute difference in time to spontaneous void. There were minimal differences in baseline demographics and surgical characteristics between the groups. There was an apparent, although not significant, difference in time to void of 25 minutes (143 minutes vs 168 minutes, p = .20). Time to discharge and urinary retention rates did not differ (199 minutes vs 214 minutes, p = .40, and 13.6% vs 8.2%, p = .51, respectively). There was no difference in postoperative bladder discomfort and patient satisfaction.

CONCLUSION

Retained cystoscopy fluid after laparoscopic hysterectomy did not significantly affect time to first spontaneous void, time to discharge, urinary retention, bladder discomfort, or patient satisfaction.