Risk factor analysis for postoperative urinary retention after surgery for degenerative lumbar spinal stenosis

Leveraging machine learning to develop a postoperative predictive model for postoperative urinary retention following lumbar spine surgery

Introduction

Postoperative urinary retention (POUR) is the inability to urinate after a surgical procedure despite having a full bladder. It is a common complication following lumbar spine surgery which has been extensively linked to increased patient morbidity and hospital costs. This study hopes to development and validate a predictive model for POUR following lumbar spine surgery using patient demographics, surgical and anesthesia variables.

Methods

This is a retrospective observational cohort study of 903 patients who underwent lumbar spine surgery over the period of June 2017 to June 2019 in a tertiary academic medical center. Four hundred and nineteen variables were collected including patient demographics, ICD-10 codes, and intraoperative factors. Least absolute shrinkage and selection operation (LASSO) regression and logistic regression models were compared. A decision tree model was fitted to the optimal model to classify each patient's risk of developing POUR as high, intermediate, or low risk. Predictive performance of POUR was assessed by area under the receiver operating characteristic curve (AUC-ROC).

Results

903 patients were included with average age 60 ± 15 years, body mass index of 30.5 ± 6.4 kg/m2, 476 (53%) male, 785 (87%) white, 446 (49%) involving fusions, with average 2.1 ± 2.0 levels. The incidence of POUR was 235 (26%) with 63 (7%) requiring indwelling catheter placement. A decision tree was constructed with an accuracy of 87.8%.

Conclusion

We present a highly accurate and easy to implement decision tree model which predicts POUR following lumbar spine surgery using preoperative and intraoperative variables.

Risk Factors for Postoperative Urinary Retention After Lumbar Fusion Surgery: Anesthetics and Surgical Approach

INTRODUCTION

Postoperative urinary retention (POUR) after lumbar fusion surgery can lead to longer hospital stays and thus increased risk of developing other postoperative complications. Therefore, we aimed to determine the relationship between POUR and (1) surgical approach and (2) anesthetic agents, including sugammadex and glycopyrrolate.

METHODS

After institutional review board approval, L4-S1 single-level lumbar fusion surgeries between 2018 and 2021 were identified. A 3:1 propensity match of patients with POUR to those without was conducted, controlling for patient age, sex, diabetes status, body mass index, smoking status, history of benign prostatic hyperplasia, and the number of levels decompressed. POUR was defined as documented straight catheterization yielding >400 mL. We compared patient demographic, surgical, anesthetic, and postoperative characteristics. A bivariant analysis and backward multivariable stepwise logistic regression analysis ( P -value < 0.200) were performed. Significance was set to P < 0.05.

RESULTS

Of the 899 patients identified, 51 met the criteria for POUR and were matched to 153 patients. No notable differences were observed between groups based on demographic or surgical characteristics. On bivariant analysis, patients who developed POUR were more likely to have been given succinylcholine (13.7% vs. 3.92%, P = 0.020) as an induction agent. The independent predictors of POUR identified by multivariable analysis included the use of succinylcholine {odds ratio (OR), 4.37 (confidence interval [CI], 1.26 to 16.46), P = 0.022} and reduced postoperative activity (OR, 0.99 [CI, 0.993 to 0.999], P = 0.049). Factors protective against POUR included using sugammadex as a reversal agent (OR, 0.38 [CI, 0.17 to 0.82], P = 0.017). The stepwise regression did not identify an anterior surgical approach as a notable predictor of POUR.

CONCLUSION

We demonstrate that sugammadex for anesthesia reversal was protective against POUR while succinylcholine and reduced postoperative activity were associated with the development of POUR. In addition, we found no difference between the anterior or posterior approach to spinal fusion in the development of POUR.

Construction and validation of a predictive model for postoperative urinary retention after lumbar interbody fusion surgery

BACKGROUND

Postoperative urine retention (POUR) after lumbar interbody fusion surgery may lead to recatheterization and prolonged hospitalization. In this study, a predictive model was constructed and validated. The objective was to provide a nomogram for estimating the risk of POUR and then reducing the incidence.

METHODS

A total of 423 cases of lumbar fusion surgery were included; 65 of these cases developed POUR, an incidence of 15.4%. The dataset is divided into a training set and a validation set according to time. 18 candidate variables were selected. The candidate variables were screened through LASSO regression. The stepwise regression and random forest analysis were then conducted to construct the predictive model and draw a nomogram. The area under the curve (AUC) of the receiver operating characteristic (ROC) curve and the calibration curve were used to evaluate the predictive effect of the model.

RESULTS

The best lambda value in LASSO was 0.025082; according to this, five significant variables were screened, including age, smoking history, surgical method, operative time, and visual analog scale (VAS) score of postoperative low back pain. A predictive model containing four variables was constructed by stepwise regression. The variables included age (β = 0.047, OR = 1.048), smoking history (β = 1.950, OR = 7.031), operative time (β = 0.022, OR = 1.022), and postoperative VAS score of low back pain (β = 2.554, OR = 12.858). A nomogram was drawn based on the results. The AUC of the ROC curve of the training set was 0.891, the validation set was 0.854 in the stepwise regression model. The calibration curves of the training set and validation set are in good agreement with the actual curves, showing that the stepwise regression model has good prediction ability. The AUC of the training set was 0.996, and that of the verification set was 0.856 in the random forest model.

CONCLUSION

This study developed and internally validated a new nomogram and a random forest model for predicting the risk of POUR after lumbar interbody fusion surgery. Both of the nomogram and the random forest model have high accuracy in this study.

Preventing Postoperative Urinary Retention (POUR) in Patients Undergoing Elective Lumbar Surgery: A Quality Improvement Project

BACKGROUND AND OBJECTIVES

Postoperative urinary retention (POUR) is associated with significant morbidity. Our institution's POUR rate was elevated among patients undergoing elective lumbar spinal surgery. We sought to demonstrate that our quality improvement (QI) intervention would significantly lower our POUR rate and length of stay (LOS).

METHODS

A resident-led QI intervention was implemented from October 2017 to 2018 on 422 patients in an academically affiliated community teaching hospital. This consisted of standardized intraoperative indwelling catheter utilization, postoperative catheterization protocol, prophylactic tamsulosin, and early ambulation after surgery. Baseline data on 277 patients were collected retrospectively from October 2015 to September 2016. Primary outcomes were POUR and LOS. The focus, analyze, develop, execute, and evaluate (FADE) model was used. Multivariable analyses were used. P value <.05 was considered significant.

RESULTS

We analyzed 699 patients (277 pre-intervention vs 422 post-intervention). The POUR rate (6.9% vs 2.6%, Δ confidence interval [CI] 1.15-8.08, P = .007) and mean LOS (2.94 ± 1.87 days vs 2.56 ± 2.2 days, Δ CI 0.066-0.68, P = .017) were significantly improved following our intervention. Logistic regression demonstrated that the intervention was independently associated with significantly decreased odds for developing POUR (odds ratio [OR] = 0.38, CI 0.17-0.83, P = .015). Diabetes (OR = 2.25, CI 1.03-4.92, P = .04) and longer surgery duration (OR = 1.006, CI 1.002-1.01, P = .002) were independently associated with increased odds of developing POUR.

CONCLUSIONS

After implementing our POUR QI project for patients undergoing elective lumbar spine surgery, the institutional POUR rate significantly decreased by 4.3% (62% reduction) and LOS, by 0.37 days. We demonstrated that a standardized POUR care bundle was independently associated with a significant decrease in the odds of developing POUR.

Enhanced Recovery After Surgery Protocols and Spinal Deformity

The authors outline a review of preoperative, intraoperative, and postoperative considerations surrounding adult spinal deformity. Preoperative management topics include imaging, hemoglobin A1c levels before spine surgery, osteoporotic management, and prehabilitation. Topics surrounding intraoperative management include the use of antibiotics, liposomal bupivacaine, and Foley catheters. The authors also discuss postoperative questions surrounding analgesia, nausea and vomiting, thromboembolic prophylaxis, and early mobilization. Throughout their discussion, the authors incorporate enhanced recovery after surgery protocols to hopefully lead to future discussions regarding optimizing complex spinal patients.

Prophylactic alpha blockers fail to prevent postoperative urinary retention following orthopaedic procedures: evidence from a meta-analysis and trial sequential analysis of comparative studies

Objective: The present systematic review and meta-analysis aimed to estimate the prophylactic effect of alpha blockers against postoperative urinary retention (POUR) in orthopaedic patients. Methods: PubMed, Embase, Web of Science and Cochrane Library databases were searched between 1 January 1990 and 1 March 2023. The studies reporting the preventive efficacy of alpha blockers on POUR after orthopaedic procedures were identified. The pooled rates of POUR in the Intervention group (patients receiving alpha blockers) and the Control group (patients not receiving alpha blockers) were estimated and compared. The risk ratios (RRs) were calculated using the random-effects model. Subgroup analysis was performed based on surgical type. Trial sequential analysis (TSA) was conducted to confirm the robustness of pooled results. Results: Seven studies containing 1,607 patients were identified. The rates of POUR were similar between the two groups (Intervention group: 126/748 [16.8%] VS. Control group: 168/859 [19.6%]; RR = 0.75; 95% confidence interval [CI] 0.51 to 1.09; p = 0.130; Heterogeneity: I2 = 67.1%; p = 0.006). No significant difference in the incidence of POUR was observed in either the Arthroplasty subgroup or Spine surgery subgroup. The result of TSA suggested that the total sample size of the existing evidence might be insufficient to draw conclusive results. Administrating alpha blockers was associated with a higher risk of complications (88/651 [13.5%] VS. 56/766 [7.3%]; RR = 1.73; 95% CI 1.27 to 2.37; p = 0.0005; Heterogeneity: I2 = 0%; p = 0.69). Conclusion: Prophylactic alpha blockers do not reduce the risk of POUR in orthopaedic procedures, and administrating these drugs was associated with a higher risk of complications. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=409388.

Risk Factors for Postoperative Urinary Retention Following Lumbar Spine Surgery: A Review of Current Literature and Meta-Analysis

STUDY DESIGN

Systematic Review and Meta-analysis.

OBJECTIVE

Postoperative urinary retention (POUR) is a common complication following lumbar spine surgery (LSS) and timely recognition is imperative to avoid long-term consequences. The aim of the current meta-analysis was to systematically review the literature in order to identify risk factors associated with POUR after LSS.

METHODS

In accordance with PRISMA guidelines, a systematic review of the literature was performed using Pubmed, EMBASE, and MEDLINE database for articles on POUR following LSS. A meta-analysis was performed comparing patients with and without POUR; and the factors associated with this adverse event were analyzed. The pooled data were reported as mean differences with 95% confidence intervals (CI; P < .05). Heterogeneity among the studies was evaluated using the I2 statistic.

RESULTS

The meta-analysis included 10 studies compromised of 30,300 patients. Based on our analysis, patients who were male, were older in age, underwent instrumented fusion, had diabetes mellitus, coronary artery disease, or benign prostatic hypertrophy had significantly higher risk of developing POUR. Additionally, patients in who developed POUR had significantly longer surgical times and higher volumes of intra-operative fluid administration, as compared with non-POUR patients. The POUR patients also had a significantly higher association with urinary tract infection. Prior surgery, BMI, length of stay, and smoking status did not reveal any statistical association with POUR.

CONCLUSIONS

Risk factors associated with POUR following LSS include male gender, older age, longer surgical times, fusion procedures, larger volumes of intraoperative infusions, and associated comorbidities like DM, CAD, and BPH.

Intraoperative bulbocavernosus reflex monitoring in posterior lumbar fusion surgery

OBJECTIVE

To assess the utility of intraoperative bulbocavernosus reflex (BCR) monitoring in posterior lumbar fusion surgery.

METHODS

We retrospectively evaluated 153 patients undergoing posterior lumbar fusion with intraoperative BCR monitoring. Voiding function was assessed at discharge and two follow-ups.

RESULTS

BCR was preserved in 151 patients and completely disappeared in two patients at the end of surgery. For patients in whom BCR was preserved, voiding difficulties at discharge and 1-month and 6-month follow-ups were noted in 16 (10.6%), 9 (6.0%), and 0 (0.0%) patients, respectively. However, patients with BCR loss experienced voiding difficulties at all three time-points. Statistical analysis showed a significant difference in voiding between those with preserved and disappeared BCRs at 6 months postoperatively. BCR disappeared during surgery but recovered before the end of surgery in six patients. Among these patients, one experienced transient voiding difficulties postoperatively but with good recovery. However, the other five patients did not experience postoperative voiding difficulties.

CONCLUSIONS

BCR had low sensitivity for voiding dysfunction at discharge, but had high accuracy at 6-month follow-up examinations. BCR loss was associated with new voiding dysfunction.

SIGNIFICANCE

Intraoperative BCR monitoring is a potentially useful tool for enhancing safety during posterior lumbar fusion by predicting postoperative voiding dysfunction.

Does tamsulosin decrease postoperative urinary retention in spine surgery? A double-blind, randomized controlled trial

OBJECTIVE

The authors' objective was to determine whether preoperative administration of tamsulosin decreases postoperative urinary retention after spine surgery.

METHODS

In this randomized, double-blind, placebo-controlled clinical trial performed at a single institution between 2016 and 2019, eligible males aged 50 to 85 years were administered tamsulosin or placebo for 5 days prior to elective spine surgery. Patients were excluded if they were taking alpha adrenergic blocking drugs; were allergic to tamsulosin, lactose, or sulfa drugs; had a preexisting indwelling urinary catheter, orthostatic hypotension, history of urological surgery, or renal failure; or were scheduled for cataract surgery within 2 weeks. Screening identified 1051 eligible patients (140 declined participation, 150 did not meet the inclusion criteria, and 151 did not enroll for other reasons). A total of 610 patients were randomly assigned to receive 0.4 mg oral tamsulosin or an identical placebo capsule for 5 days preoperatively and 2 days postoperatively.

RESULTS

A total of 497 patients were included in the final statistical analysis. The overall rate of postoperative urinary retention was 9.7%, and tamsulosin had no observed effect on reducing the rate of postoperative urinary retention as compared with placebo (9.4% vs 9.9%, p = 0.96). There were no significant differences in the reported adverse events between groups. Multivariate logistic regression was performed to model the effects of patient, surgical, and anesthetic factors on postoperative urinary retention, and the study drug remained an insignificant factor.

CONCLUSIONS

This study did not detect an effect of perioperative tamsulosin on reducing the rate of postoperative urinary retention in male patients aged 50 to 85 years who underwent elective spine surgery. This study does not support the routine use of tamsulosin to reduce postoperative urinary retention in patients without a previous prescription. It is unknown if subpopulations exist for which prophylactic tamsulosin may reduce postoperative urinary retention.

Factors Causing Delay in Discharge in Patients Eligible for Ambulatory Lumbar Fusion Surgery

STUDY DESIGN

Retrospective review of prospectively collected data.

OBJECTIVE

To analyze the postoperative factors that led delayed discharge in patients who would have been eligible for ambulatory lumbar fusion (ALF).

SUMMARY OF BACKGROUND DATA

Assessing postoperative inefficiencies is vital to increase the feasibility of ALF.

MATERIALS AND METHODS

Patients who underwent single-level minimally invasive transforaminal lumbar interbody fusion and would have met the eligibility criteria for ALF were included. Length of stay (LOS); time in postanesthesia recovery unit (PACU); alertness and neurological examination, and pain scores at three and six hours; type of analgesia; time to physical therapy (PT) visit; reasons for PT nonclearance; time to per-oral (PO) intake; time to voiding; time to readiness for discharge were assessed. Time taken to meet each discharge criterion was calculated. Multiple regression analyses were performed to study the effect of variables on postoperative parameters influencing discharge.

RESULTS

Of 71 patients, 4% were discharged on the same day and 69% on postoperative day 1. PT clearance was the last-met discharge criterion in 93%. Sixty-six percent did not get PT evaluation on the day of surgery. Seventy-six percent required intravenous opioids and <60% had adequate pain control. Twenty-six percent had orthostatic intolerance. The median postoperative LOS was 26.9 hours, time in PACU was 4.2 hours, time to PO intake was 6.5 hours, time to first void was 6.3 hours, time to first PT visit was 17.7 hours, time to PT clearance was 21.8 hours, and time to discharge readiness was 21.9 hours. Regression analysis showed that time to PT clearance, time to PO intake, time to voiding, time in PACU, and pain score at three hours had a significant effect on LOS.

CONCLUSIONS

Unavailability of PT, surgery after 1  pm , orthostatic intolerance, inadequate pain control, prolonged PACU stay, and long feeding and voiding times were identified as modifiable factors preventing same-day discharge.

LEVEL OF EVIDENCE

4.

Effects of delayed postoperative void and preoperative urologic symptoms on delay in time of discharge for elective lumbar decompression surgery

BACKGROUND CONTEXT

Almost half of all patients undergoing lumbar spine surgery have preoperative lower urinary tract symptoms (LUTS). These symptoms could affect postoperative voiding and subsequently length of stay.

PURPOSE

To investigate the association between preoperative LUTS and time to first void and between time to first void and time to discharge among patients undergoing elective lumbar decompression surgery.

STUDY DESIGN/SETTING

Retrospective analysis of prospectively collected data among patients at a single academic medical center.

PATIENT SAMPLE

All patients ≥18 years of age undergoing elective lumbar decompression surgery between July 2017 and March 2020.

OUTCOME MEASURES

The physiologic measure of a delayed time to first void was defined as an initial postoperative void of > 4 hours after anesthesia stop time. The outcome of prolonged time to discharge was defined as a stay of >24 hours after anesthesia stop time.

METHODS

At their preoperative visit, patients completed the validated International Prostate Symptom Score (IPSS) (range, 0-35 points), which is applicable for LUTS assessment in both sexes. Clinically relevant LUTS are defined as an IPSS score of ≥8. Patients were followed from their preoperative visit to surgery admission discharge. Association of LUTS with time to first void and time to first void with admission discharge were estimated using risk ratios (RR) and 95% confidence intervals (CI) from a multivariable Poisson regression with a robust variance estimate adjusted for potential confounding variables including age, sex, IPSS, and intraoperative Foley catheter use.

RESULTS

The analytic cohort included 170 patients with an average age of 57 years and 103 (61%) were men. Preoperative LUTS prevalence was 45%, and 111 (65%) of patients voided within 4 hours after surgery. For patients with preoperative LUTS, the unadjusted RR for a first void of >4 hours was 1.04 (95% CI: 0.82-1.32) (p=.77). Adjustment for age, sex, intraoperative Foley catheter use, revision surgery, previous spine surgery, single versus multiple levels, and lumbar location did not materially alter the risk: the multivariable RR was 1.04 (95% CI: 0.82-1.31) (p=.74). The unadjusted RR for a discharge of > 24 hours for patients with a time to first void of > 4 hours was 2.17 (95% CI: 1.51-3.10) (p<.001). After adjusting for age, sex, intraoperative Foley catheter use, IPSS, revision surgery, previous spine surgery, single versus multiple levels, and lumbar location, the multivariable RR was 1.72 (95% CI: 1.22-2.41) (p=.002).

CONCLUSIONS

Regardless of preoperative LUTS status, an initial first void of >4 hours after surgery is associated with a longer time to discharge among patients undergoing elective lumbar decompression surgery. Future studies are needed to determine if encouraging early postoperative voiding results in timely discharge and shorter length of stay.

Spine Surgery Complications in the Ambulatory Surgical Center Setting: Systematic Review

STUDY DESIGN

This was a systematic review study.

PURPOSE

This study aims to review current literature to determine the rates of complications in relation to spine surgery in ambulatory surgery centers (ASC).

BACKGROUND

Recent improvements in anesthesia, surgical techniques, and technological advances have facilitated a rise in the use of ASC. Despite the benefits and lower costs associated with ASCs, there is inconsistent reporting of complication rates.

METHODS

This systematic review was completed utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Pertinent studies were identified through Embase and PubMed databases using the search string ((("ambulatory surgery center") AND "spine surgery") AND "complications"). Articles were excluded if they did not report outpatient surgery in an ASC, did not define complications, were in a language other than English, were non-human studies, or if the articles were classified as reviews, book chapters, single case reports, or small case series (≤10 patients). The primary outcome was the frequency of complications with respect to various categories.

RESULTS

Our query identified 150 articles. After filtering relevance by title, abstract, and full text, 22 articles were included. After accounting for 2 studies that were conducted on the same study sample, a total of 11,245 patients were analyzed in this study. The most recent study reported results from May 2019. While 5 studies did not list their surgical technique, studies reported techniques including open (6), minimally invasive surgery (2), endoscopic (4), microsurgery (1), and combined techniques (4). The following rates of complications were determined: cardiac 0.29% (3/1027), vascular 0.25% (18/7116), pulmonary 0.60% (11/1839), gastrointestinal 1.12% (2/179), musculoskeletal/spine/operative 0.59% (24/4053), urologic 0.80% (2/250), transient neurological 0.67% (31/4616), persistent neurological 0.61% (9/1479), pain related 0.57% (20/3479), and wound site 0.68% (28/4092).

CONCLUSIONS

After literature review, this is the first study to comprehensively analyze the current state of literature reporting on the complication profile of all ASC spine surgery procedures. The most common complications were gastrointestinal (1.12%) and the most infrequent were vascular (0.25%). Case reports varied significantly with regard to the type and rate of complications reported. This study provides complication profiles to assist surgeons in counseling patients on the most realistic expectations.

The Modified 11-Item Frailty Index and Postoperative Outcomes in Patients Undergoing Lateral Lumbar Interbody Fusion

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The aim of this study was to analyze postoperative complications and recovery patterns in different modified 11-item frailty index (mFI-11) groups after lateral lumbar interbody fusion (LLIF) surgery.

SUMMARY OF BACKGROUND DATA

The relationship between the mFI-11 score and LLIF surgery has not been previously reported.

METHODS

A single-center, consecutive series of patients who underwent LLIF with at least two years of follow-up were retrospectively reviewed. Complications after LLIF surgery were recorded. Clinical outcomes, including the visual analog scale (VAS) for back/leg pain and the Oswestry Disability Index (ODI), were evaluated preoperatively and at 1 and 2 years postoperatively. The proportions of patients who achieved substantial clinical benefit (SCB) for the VAS-B, VAS-L, and ODI were also analyzed.

RESULTS

One hundred fifty-two patients included in the present study were grouped according to their mFI-11 score: 0 (n = 39), 0.09 (n = 69), 0.18 (n = 31), and ≥0.27 (n = 13). An mFI-11 score ≥0.27 was a significant predictor of urinary complications (adjusted odds ratio: 3.829, P = 0.013). At 2 years postoperatively, patients in all frailty categories experienced improvements in the VAS for back pain, VAS for leg pain, and ODI, without significant differences between the four groups (p = 0.182, 0.121, and 0.804, respectively). There were also no significant differences in the proportions of patients achieving SCB for back/leg pain and the ODI between the four groups (P = 0.843, 0.957, and 0.915, respectively).

CONCLUSION

An mFI-11 score was found to be independently associated with urologic complications in patients who underwent LLIF. Patients in all frailty categories experienced significant improvements in back pain, leg pain, and the ODI at 1 year and 2 years postoperatively. LLIF surgery may be useful for patients with high frailty index.Level of Evidence: 4.

Postoperative Urinary Retention Following Thoracolumbosacral Spinal Fusion: Prevalence, Risk Factors, and Outcomes

Objective

Postoperative urinary retention (POUR) is an often-underestimated common complication following spine surgery, and it is essential to avoid its untoward long-term consequences. Besides, a dilemma exists regarding the appropriate timing for the postoperative removal of indwelling catheter (IDC). Hence, we aim to describe the prevalence, risk factors, and outcomes of POUR and also come up with recommendations for the removal of IDC.

Methods

Electronic records of patients who underwent elective thoracolumbosacral spinal fusion surgery from January 2017 to December 2019 were retrospectively reviewed. Excluded were those who underwent fusion for indications such as trauma, cauda equina syndrome, infection, and malignancy. Both surgery-related and patient-related risk factors were tabulated, and their association with the likely development of POUR was assessed by univariate and multivariate analysis.

Results

One hundred sixty-eight patients (median age=64.1 years; 58.9% female) were included, with the incidence of POUR being 7.8%. Our findings suggest surgery-related factors, both intra- and postoperative, including operating time (p=0.008), anesthetic time (p=0.005), number of fusion levels (p<0.001), mobilization status prior to trial off catheter (TOC; p=0.021), and TOC timing (p=0.029) may have an association with POUR. In addition, patient-related factors, including the use of beta-blockers (p=0.020) and pre-operative mobility status (p<0.001), may also be associated with the likely development of POUR.

Conclusion

POUR seems to be a frequent complication following thoracolumbosacral spinal fusion surgery, which was found to have an association with some surgery-related and patient-related factors. While most of these factors are non-modifiable, certain modifiable risk factors provide the surgeon an opportunity to prevent POUR. Considering these factors, we recommend appropriate and timely mobilization of the patient prior to removal of IDC, which is to be performed preferably in the daytime.

Risk factors for postoperative urinary retention following elective spine surgery: a meta-analysis

BACKGROUND CONTEXT

Limited studies have investigated risk factors for postoperative urinary retention (POUR) following elective spine surgery. Furthermore, some discrepancies have been found in the results of existing observational studies.

PURPOSE

This study aimed to review the available literature on risk factors associated with POUR following elective spine surgery.

STUDY DESIGN

A systematic review with meta-analysis was performed.

PATIENT SAMPLE

A total of 31,251 patients (POUR=2,858, no POUR=28,393) were included in the meta-analysis.

OUTCOME MEASURES

Demographics, type of elective spine surgery, country, definition of POUR, and potential risk factors for POUR were evaluated.

METHODS

The Cochrane Library, Embase, and Medline electronic databases were searched to identify relevant studies. Binary outcomes were reported as odds ratio (OR). Weighted mean differences (WMD) or standardized mean differences (SMD), with 95% confidence intervals (CI), were used for meta-analysis of continuous outcomes.

RESULTS

Eleven studies (2 prospective and 9 retrospective) were included in the analysis. Patients with POUR were older than those without POUR (WMD, 7.13; 95% CI, 4.50-9.76). Male patients were found to have an increased risk of POUR (OR, 1.31; 95% CI, 1.04-1.64). The following variables were also identified as significant risk factors for POUR: benign prostatic hyperplasia (BPH; OR, 3.79; 95% CI, 1.89-7.62), diabetes mellitus (DM; OR, 1.50; 95% CI, 1.17-1.93), and previous urinary tract infection (UTI; OR, 1.70; 95% CI, 1.28-2.24). Moreover, longer operative time (WMD, 19.88; 95% CI, 5.01-34.75) and increased intraoperative fluid support (SMD, 0.37; 95% CI, 0.23-0.52) were observed in patients with POUR. In contrast, spine surgical procedures involving fewer levels (OR, 0.75; 95% CI, 0.65-0.86), and ambulation on the same day as surgery (OR, 0.65; 95% CI, 0.52-0.81) were associated with a decreased risk of POUR.

CONCLUSIONS

Based on our meta-analysis, older age, male gender, BPH, DM, and a history of UTI are risk factors for POUR following elective spine surgery. We also found that longer operative time and increased intravenous fluid support would increase the risk of POUR. Additionally, multi-level spine surgery may have a negative effect on postoperative voiding.

Incidence and Risk Factors for Postoperative Urinary Retention Following Lumbar Spine Fusion

STUDY DESIGN

This was a prospective cohort study (observational-retrospective chart review).

OBJECTIVE

The objective of this study was to determine clinical rates and correlations of postoperative urinary retention (POUR) in elective spine decompression and fusion procedures.

SUMMARY OF BACKGROUND DATA

POUR is a common postoperative complication that often has a major adverse impact on a patient's recovery from elective lumbar spine surgery. The etiology of POUR in most cases is unknown. Patients undergoing lumbar spine surgery are considered to be at increased risk for POUR due to prone positioning during surgery and intraoperative cauda equina nerve root manipulation. Current studies reporting on POUR after elective spine surgery provide limited insight regarding risk factors and effective prevention strategies for this at-risk population. The purpose of this study is to identify risk factors for POUR after elective lumbar spine surgery and strategies for reducing its incidence.

MATERIALS AND METHODS

Two hundred consecutive patients aged 50 years or older undergoing combined lumbar decompression and fusion procedures over a 5-month period at a single institution were prospectively observed. Demographic and clinical data were prospectively recorded, including: medical history, surgical data, medications administered, complications, and postoperative hospital course. Factors correlating with POUR through a univariate analysis with P≤0.20 were considered for multivariate analysis.

RESULTS

POUR occurred in 19 of 200 patients. Those with POUR were more likely to be male (20% vs. 4%, odds ratio=6.2). Administration of scopolamine (P=0.02), neostigmine (P=0.01), and the total number of levels operated on (P=0.02) were found to be independent risk factors for the development of POUR. Length of surgery, surgical level, the performance of an interbody fusion did not have a bearing on the development of POUR (P>0.05).

DISCUSSION

We describe a single institution's experience of POUR incidence in 200 consecutive patients aged 50 years or older undergoing single or multilevel lumbar spine fusion procedures by 1 of 4 surgeons. Specific demographic and clinical risk factors were identified and a codified classification for POUR in a surgical population is presented.The results of this study will help clinicians appropriately counsel patients undergoing elective lumbar fusion about the potential development of POUR. The perioperative administration of scopolamine and neostigmine should be cautiously considered in men over 50 years of age due to the increased POUR risk.

CONCLUSIONS

Perioperative scopolamine and neostigmine administration in men over 50 should be avoided when possible to minimize the risk of POUR.

LEVEL OF EVIDENCE

Level III.

Bladder management in patients undergoing spine surgery: An assessment of care delivery

BACKGROUND

Lower urinary tract dysfunction is common in the early postoperative phase after spine surgery. Although it is essential for an optimal patient management to balance benefits and harms, it is not known which patient benefit from a perioperative indwelling catheter. We therefore evaluated urological parameters prior and after spine surgery performing a quality assessment of our current clinical practice in bladder management.

METHODS

Preoperatively, all patients completed the International Prostate Symptom Score and were interviewed for urological history. Decision for preoperative urethral catheter placement was individually made by the responsible anesthesiologist according to an in-house protocol. Within and between group analyses using univariate and probability matching statistics were performed for patients with intraoperative urethral catheter-free management (n = 54) and those with a preoperatively placed catheter (n = 46). Post void residual (PVR) was measured prior and after surgery or after removal of the urethral catheter, respectively. The outcome measures consisted of postoperative urinary retention (POUR) and postoperative urological complications (PUC), defined as POUR and any catheter-related adverse events.

RESULTS

Hundred patients undergoing spine surgery were prospectively evaluated. Sixteen of the 54 (30%) patients with urethral catheter-free management developed POUR. Length of surgery and volume of intravenous infusion were associated with POUR (p < 0.05). In the 46 preoperatively catheterized patients, re-catheterization was required in 6 (13%). In a fairly homogenous subgroup of 72 patients with a probability of PUC between 15 and 40%, no significant association between intraoperative urethral catheter-free management and the occurrence of PUC was found (odds ratio 2.09, 95% confidence interval 0.69 to 6.33; p = 0.193).

CONCLUSIONS

In case of postoperative PVR monitoring allowing de novo catheterization as appropriate, urethral catheter-free management seems to be a valuable option in spine surgery since it does not to increase PUC but minimizes unnecessary catheterizations with their related complications.

Evaluation of Risk Factors for Postoperative Urinary Retention in Elective Thoracolumbar Spinal Fusion Patients

STUDY DESIGN

Retrospective case series.

OBJECTIVES

Postoperative urinary retention (POUR) represents a common postoperative complication of all elective surgeries. The aim of this study was to identify demographic, comorbid, and surgical factors risk factors for POUR in patients who underwent elective thoracolumbar spine fusion.

METHODS

Following institutional review board approval, patients who underwent elective primary or revision thoracic and lumbar instrumented spinal fusion in a 2-year period in tertiary and academic institution were reviewed. Sex, age, BMI, preoperative diagnosis, comorbid conditions, benign prostatic hyperplasia, diabetes, primary or revision surgery status, narcotic use, and operative factors were collected and analyzed between patients with and without POUR.

RESULTS

Of the 217 patients reviewed, 54 (24.9%) developed POUR. The average age for a patient with POUR was 67 ± 9, as opposed to 59 ± 10 for those without (P < .0001). Single-level fusions were associated with a 0% incidence of POUR, compared with 54.5% in 6 or more levels. The average hospital stay was increased by 1 day for those who had POUR (5.8 ± 3.3 vs 4.9 ± 3.9 days). There was no significant association with other demographic variables, comorbid conditions, or surgical factors.

CONCLUSIONS

POUR was a common complication in our patient cohort, with an incidence of 24.9%. Our findings demonstrate that patients who developed POUR are significantly older and have larger constructs. Patients who developed POUR also had longer in-hospital stays. Although our study supports other findings in the spine literature, more prospective data is needed to define diagnostic criteria of POUR as well as its management.

Pathway for enhanced recovery after spinal surgery-a systematic review of evidence for use of individual components

BACKGROUND

Enhanced recovery in spinal surgery (ERSS) has shown promising improvements in clinical and economical outcomes. We have proposed an ERSS pathway based on available evidence. We aimed to delineate the clinical efficacy of individual pathway components in ERSS through a systematic narrative review.

METHODS

We included systematic reviews and meta-analysis, randomized controlled trials, non-randomized controlled studies, and observational studies in adults and pediatric patients evaluating any one of the 22 pre-defined components. Our primary outcomes included all-cause mortality, morbidity outcomes (e.g., pulmonary, cardiac, renal, surgical complications), patient-reported outcomes and experiences (e.g., pain, quality of care experience), and health services outcomes (e.g., length of stay and costs). Following databases (1990 onwards) were searched: MEDLINE, EMBASE, and Cochrane Library (Cochrane Database of Systematic Reviews and CENTRAL). Two authors screened the citations, full-text articles, and extracted data. A narrative synthesis was provided. We constructed Evidence Profile (EP) tables for each component of the pathway, where appropriate information was available. Due to clinical and methodological heterogeneity, we did not conduct a meta-analyses. GRADE system was used to classify confidence in cumulative evidence for each component of the pathway.

RESULTS

We identified 5423 relevant studies excluding duplicates as relating to the 22 pre-defined components of enhanced recovery in spinal surgery. We included 664 studies in the systematic review. We identified specific evidence within the context of spinal surgery for 14/22 proposed components. Evidence was summarized in EP tables where suitable. We performed thematic synthesis without EP for 6/22 elements. We identified appropriate societal guidelines for the remainder of the components.

CONCLUSIONS

We identified the following components with high quality of evidence as per GRADE system: pre-emptive analgesia, peri-operative blood conservation (antifibrinolytic use), surgical site preparation and antibiotic prophylaxis. There was moderate level of evidence for implementation of prehabilitation, minimally invasive surgery, multimodal perioperative analgesia, intravenous lignocaine and ketamine use as well as early mobilization. This review allows for the first formalized evidence-based unified protocol in the field of ERSS. Further studies validating the multimodal ERSS framework are essential to guide the future evolution of care in patients undergoing spinal surgery.

Efficacy of intraoperative bulbocavernosus reflex monitoring for the prediction of postoperative voiding function in adult patients with lumbosacral spinal tumor

Lumbosacral spinal tumor surgery is associated with a relatively high risk of postoperative voiding dysfunction. This study aimed to investigate the correlation between intraoperative bulbocavernosus reflex (BCR) changes and postoperative voiding function in adult patients with lumbosacral spinal tumors. We retrospectively reviewed 63 patients who underwent intradural conus and cauda equina tumor surgeries with intraoperative BCR monitoring. We evaluated patients' voiding functions for 6 months postoperatively. BCR was maintained in 60 patients and disappeared in 3 patients at the end of the surgery. Among the patients in whom BCR was maintained, examinations conducted at discharge and at 1- and 6-month follow-ups revealed that 7 (11.7%), 4 (6.7%), and zero (0.0%) patients experienced voiding difficulty, respectively. However, all 3 (100%) patients without BCR experienced voiding difficulty at the three corresponding follow-ups. Data analysis indicated no significant difference in voiding between the maintained and disappeared BCR groups 6-months postoperatively. The sensitivity, specificity, positive predictive, and negative predictive values of intraoperative BCR monitoring for detecting new and worsening difficulty in voiding were all 100% 6 months postoperatively. Our results shows that intraoperative BCR monitoring is a reliable predictor of voiding function following surgery in adult patients undergoing lumbosacral spinal tumor surgery. Intraoperative BCR monitoring can be useful for assessing and monitoring the integrity of the voiding function during lumbosacral spinal tumor surgery.

Risk Factors Associated With Development of Urinary Retention Following Posterior Lumbar Spinal Fusion: Special Attention to the Use of Glycopyrrolate in Anesthesia Reversal

STUDY DESIGN

The study is designed as a retrospective cohort study.

OBJECTIVE

The aim of this study was to identify modifiable and nonmodifiable risk factors of postoperative urinary retention in spine surgery patients.

SUMMARY OF BACKGROUND DATA

Postoperative urinary retention is a common complication in patients undergoing operative procedures requiring anesthesia. Current studies have shown significant risk factors for postoperative urinary retention, but most are nonmodifiable and subsequently of limited usefulness in preventing this complication. Several new studies have shown possible modifiable risk factors, but current data are inconsistent in terms of their statistical significance.

METHODS

A total of 814 consecutive patients who underwent open posterior lumbar laminectomy and fusion were included in the retrospective cohort study. Pre, intra-, and postoperative characteristics were collected in all patients to identify risk factors for postoperative urinary retention.

RESULTS

Glycopyrrolate use (odds ratio [OR] 2.60; P = 0.001), decreased body mass index (OR 0.96; P = 0.018), previous diagnosis of benign prostate hyperplasia (OR 3.34; P ≤ 0.001), and postoperative urinary tract infection (OR 5.60, P = 0.005) were associated with postoperative urinary retention. Previous history of lumbar spine surgery (OR 0.55; P = 0.019) was associated with decreased rates of postoperative urinary retention.

CONCLUSION

Glycopyrrolate use, benign prostate hyperplasia, and postoperative urinary tract infection were independent risk factors for postoperative urinary retention. The use of glycopyrrolate is a potentially modifiable risk factor for postoperative urinary retention.Level of Evidence: 3.

Spinal surgery and urinary retention: A review of the literature

Objective:

Postoperative urinary retention is a common complication for patients recovering from general anesthesia or invasive surgery near the spinal column. However, no study has systematically reviewed the incidence of postoperative urinary retention for spinal surgeries performed at the cervical, thoracic, or lumbar spinal regions. In this review, we critically analyze and summarize the known literature on the incidence and risk factors associated with postoperative urinary retention after spinal surgery.

Methods:

A comprehensive literature review was performed at the end of September 2019 within the PubMed database.

Results:

The average incidence of postoperative urinary retention from nine of the 10 studies was 17.2% with one paper that did not report on postoperative urinary retention incidence. Furthermore, age, male gender, location and history of spinal surgery, duration of surgery, benign prostatic hypertrophy, and Foley catheter were reported as major risk factors for postoperative urinary retention and spinal surgery.

Conclusion:

Overall, spinal cord and postoperative urinary retention remains a poorly understood area requiring further investigation into the incidence, risk factors, and surgical methods influence postoperative urinary retention and post-operative outcomes. We believe an overview of such data can help revise guidelines for the management of postoperative urinary retention and raise awareness of its prevalence in elderly patients undergoing spinal surgery.

Level of evidence:

Not applicable for this multicentre audit.

Postoperative Urinary Retention in Patients Who Undergo Joint Arthroplasty or Spine Surgery

Postoperative urinary retention (POUR) may result from orthopaedic procedures and potentially lead to bacteremia and chronic voiding difficulties. Risk factors for POUR include age, undergoing joint arthroplasty, male sex, intraoperative intravenous fluid administration, operative time, and history of benign prostatic hyperplasia. Indwelling catheterization is the preferred management strategy for patients at risk for developing POUR. A consistent definition of POUR is needed in order to draw conclusions from future studies.

Postoperative management factors affect urinary retention following posterior spinal fusion for adolescent idiopathic scoliosis

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

This study investigates postoperative urinary retention (POUR) following posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) and the effects of postoperative analgesia and mobility on retention. High opioid use and decreased postoperative mobility are proposed risk factors for retention in adults. There is a paucity of literature on POUR in the adolescent population undergoing surgery for AIS. The impact of pain control and mobility on POUR in these patients is unknown.

METHODS

A retrospective cohort study was conducted of adolescents (11-18 years) undergoing elective PSF for AIS at a single institution (2012-2018). POUR was defined as the inability to void > 8 h after catheter removal. Possible risk factors for retention including opioid usage and ambulatory status at the time of catheter removal were assessed on univariate and binomial logistic regression analyses.

RESULTS

One hundred and thirty-six patients were included, with 21 (15.4%) experiencing POUR. On the day of catheter removal, 24 patients had not attempted ambulation; these patients had 2.5 times higher rate of POUR than those who were walking (30% vs. 12%, p = 0.04). Patients who developed retention ambulated a mean threefold shorter distance than those without POUR (45 vs. 136 feet, p = 0.04). On binomial logistic regression, decreased ambulation distance was associated with retention (p = 0.038). While opioid use was not significant on univariate analysis, higher opioid use on the day of catheter removal predicted retention on logistic regression (p = 0.001). POUR resolved in all patients (median duration 0.5 days, range 0-12 days).

CONCLUSIONS

The development of POUR after PSF for AIS affects one in six patients but resolves quickly. Non-ambulatory patients and patients who received large doses of opioids on the day of catheter removal were more likely to develop POUR.

LEVEL OF EVIDENCE

III.

Intraoperative Fluid Management in Patients Undergoing Spine Surgery: A Narrative Review

Fluid management has been widely recognized as an important component of the perioperative care in patients undergoing major procedures including spine surgeries. Patient- and surgery-related factors such as age, length of the surgery, massive intraoperative blood loss, and prone positioning, may impact the intraoperative administration of fluids. In addition, the type of fluid administered may also affect post-operative outcomes. Published literature describing intraoperative fluid management in patients undergoing major spine surgeries is limited and remains controversial. Therefore, we reviewed current literature on intraoperative fluid management and its association with post-operative complications in spine surgery.

Considering healthcare value and associated risk factors with postoperative urinary retention after elective laminectomy

BACKGROUND

Mitigating common complications such as postoperative urinary retention (POUR) following elective spine surgery is prudent. Identifying patients at risk for POUR and recognizing associated factors, to avoid a more complicated postoperative episode should be a priority and easily achievable. Understanding the financial burden of complications, such as POUR, is also important for value-based healthcare, not only for providers, but for employers and payors as well.

PURPOSE

The purpose of this study is to examine patient and surgical factors that may lead to increased risk for POUR and its associated cost following elective lumbar laminectomies.

STUDY DESIGN/SETTING

This is a retrospective study of the incidence of postoperative urinary retention after elective one- and two-level primary lumbar laminectomies.

PATIENT SAMPLE

We followed patients undergoing one- and two-level primary elective lumbar laminectomies performed between April 2014 and December 2016.

OUTCOME MEASURES

Patient factors included age, gender, body-mass index, and comorbidities. Surgical factors included surgical time, intraoperative fluid volume requirements, anesthesia type, and surgical levels involved. Other outcome variables included length of stay, discharge disposition, 30-day all-cause readmissions and emergency department visits, 90-day complications, and variable direct costs.

METHODS

The incidence of POUR was evaluated and compared with patient and surgical factors and cost-specific variables to identify correlations and potential risk for POUR after one- and two-level primary lumbar laminectomies.

RESULTS

Analysis included 333 patients - 203 one-level laminectomies and 130 two-level laminectomies. The overall incidence of POUR was 17.4%. Age, male gender, and history of urinary retention were significantly associated with POUR. There was a significantly increased risk of POUR with increased surgical time, but not with anesthesia type. There were also no significant differences in body-mass index, other study comorbidities, intraoperative fluid requirements, readmission, emergency department visit, and complication rates between groups. On average, patients with POUR had a significantly longer length of stay than patients without POUR. In addition, more POUR patients were discharged to acute rehabilitation facilities and had higher average variable direct cost compared tonon-POUR patients.

CONCLUSIONS

POUR is a significant risk after elective laminectomy. This study supports several widely accepted beliefs regarding POUR risk, while challenging others. It also highlights the burden of POUR development after surgery. At our institution, we developed a protocol supported by these findings.

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.

Risk factors and associated complications for postoperative urinary retention after lumbar surgery for lumbar spinal stenosis

BACKGROUND CONTEXT

Postoperative urinary retention (POUR) is a very common postoperative complication of all surgeries (5%-70%) that may lead to complications such as urinary tract infection (UTI), bladder overdistension, autonomic dysregulation, and increased postoperative length of stay (LOS). Within the field of spine surgery, the reported incidence rate of POUR is highly variable (5.6%-38%). Lack of clear stratification of surgical level, spinal pathology, and inadequate sample size are major limitations of available studies concerning POUR following spine surgery, which may lead to inconsistency in the incidence of POUR and the ability to model its occurrence and consequences.

PURPOSE

This study examines the incidence, predictive factors, and complications of POUR in patients undergoing elective posterior lumbar decompression with or without fusion for lumbar stenosis to eliminate bias from studying procedures done in different anatomical regions and with different approaches. Additionally, this study intends to identify the consequences of POUR.

STUDY DESIGN AND SETTING

A retrospective consecutive cohort analysis was performed to examine patients undergoing posterior lumbar decompression who did and did not develop POUR.

PATIENT SAMPLE

All patients undergoing posterior lumbar decompression with or without fusion for lumbar stenosis with claudication from January 2014 through December 2015 at our institution were evaluated. Patients under the age of 18 and patients with spinal malignancies or infections were excluded.

OUTCOME MEASURES

Physiological measures included identification of POUR by evidence of reinsertion of a Foley catheter, use of straight catheterization postoperatively, or by a clear medical diagnosis with pharmacologic treatment. Other physiological measures included identification of development of UTI, sepsis, acute kidney injury (AKI), surgical site infection (SSI), or readmission within 90 days after surgery, as well as LOS and discharge disposition.

METHODS

The electronic medical record was searched for all patients meeting inclusion and exclusion criteria. Postoperative urinary retention was defined as reinsertion of a Foley catheter, use of straight catheterization postoperatively, or a clear medical diagnosis with pharmacologic treatment. Statistical analysis was performed in R statistical software package version 3.3.2. Multiple variable selection techniques were used to determine appropriate variables for regression models, and logistic models were fit to the development of POUR and postoperative complications, whereas a linear regression model was used for LOS.

RESULTS

Data were collected on 1,592 consecutive patients. Among the sample population, the mean age at surgery was 67 (standard deviation 10.1) and 45% of patients were women. The incidence rate of POUR was 17.1% (273/1592). Increased age (odds ratio [OR]=1.04; 95% confidence interval [CI], 1.02-1.06; p<.001), benign prostatic hyperplasia (BPH) (OR=1.92; 95% CI, 1.32-2.78); p<.001), previous AKI (OR=3.29; 95% CI, 1.11-9.29; p=.025), and previous UTI (OR=1.69; 95% CI, 1.24-2.24; p<.001) significantly increased the probability of developing POUR. Factors including increased body mass index, coronary artery disease, congestive heart failure, diabetes mellitus, chronic obstructive pulmonary disease, tobacco use, and fusion were found to be non-significant and were excluded from the model. With respect to complications, POUR was found to be associated with development of UTI (OR=4.50; 95% CI, 3.14-6.45; p<.001), sepsis (OR=4.05; 95% CI, 1.16-13.55; p=.022), increased LOS (p<.001), increased likelihood to be discharged to a skilled nursing facility (SNF) (OR of discharge to home=0.44; 95% CI, 0.32-0.62; p<.001), and increased risk of readmission within 90 days of the index surgery (OR=1.60; 95% CI, 1.11-2.26; p=.009). Development of POUR did not increase the risk of developing AKI (OR=2.45; 95% CI, 0.93-6.30; p=.063) or a SSI (OR=1.09; 95% CI, 0.56-2.02; p=.79).

CONCLUSIONS

Overall, POUR was a significant risk factor for the development of UTI, sepsis, increased LOS, discharge to a SNF, and readmission within 90 days. Surgeons and anesthesiologists should take preventative measures against POUR in individuals with increased age, BPH, AKI, and UTI within 90 days before surgery, as these factors were found to significantly increase the risk of POUR.

Risk and Management of Postoperative Urinary Retention Following Spinal Surgery

Purpose

Postoperative urinary retention (POUR) is a common complication after spinal surgery. However, no clear definition of POUR currently exists, and no studies have evaluated the management of POUR. We aimed to investigate the prognostic factors for eventual POUR-free status in spinal surgery patients.

Methods

The records of patients who received a urologic consultation for POUR from January 2015 to December 2016 were reviewed. POUR-free status was defined as a voiding volume (VV) >100 mL and a VV ratio >50%. Patients with an indwelling Foley catheter and those with any postoperative complications were excluded. The patients were divided into 2 groups according to the primary management method (Foley catheterization [FC] or intermittent catheterization [IC]).

Results

In total, 205 patients (median age, 70.6 years) were evaluated. Significant prognostic factors for eventual POUR-free status were intraoperative FC, previous spinal surgery, operative level (L3–5), lumbar fusion, and total volume (TV) at the time of POUR. Bladder training and medication did not reduce the time to POUR-free status. In patients who underwent FC, the duration of indwelling FC was a significant prognostic factor for POUR-free status. In a subanalysis, the TV (≥500 mL) and VV ratio at the time of POUR were significant prognostic factors for POUR-free status after primary management. Among the patients who achieved a POUR-free status, 8 (6.4%) experienced recurrent POUR. The VV ratio (<62.0%) was the only predictor of recurrent POUR.

Conclusions

The criterion of POUR-free status is useful after spinal surgery. IC and FC were similar in their efficacy for the management of these patients.

Postoperative Urinary Retention is an Independent Predictor of Short-Term and Long-Term Future Bladder Outlet Procedure in Men

PURPOSE

Postoperative urinary retention is a common complication across surgical specialties. To our knowledge no literature to date has examined postoperative urinary retention as a predictor of long-term receipt of surgery for bladder outlet obstruction.

MATERIALS AND METHODS

We retrospectively reviewed the records of inpatients who underwent nonurological surgery in California between 2008 and 2010. Postoperative urinary retention during the index admission was identified, as was receipt of a bladder outlet procedure (transurethral prostate resection, prostate photoselective vaporization or suprapubic prostatectomy) at a subsequent encounter. Patients were matched using propensity scoring of demographics, comorbidities and surgery type. Adjusted Kaplan-Meier analysis was performed to determine the cumulative incidence of subsequent bladder outlet procedures by patient group, including group 1-age 60 years or greater and postoperative urinary retention, group 2-age 60 years or greater and no postoperative urinary retention, group 3-age less than 60 years and postoperative urinary retention, and group 4-age less than 60 years and no postoperative urinary retention.

RESULTS

Of 769,141 eligible male patients postoperative urinary retention developed in 8,051 (1.1%). Following hospital discharge 1,855 patients (0.24%) underwent a bladder outlet procedure. Those treated with a bladder outlet procedure were significantly more likely to have experienced postoperative urinary retention during the index admission (6.3% vs 1.0%, p <0.001). On matched analysis the bladder outlet procedure rate at 3 years was 7.1%, 2.2%, 0.8% and 0.0% in groups 1, 2, 3 and 4, respectively.

CONCLUSIONS

In men 60 years old or older postoperative urinary retention identified those with an increased incidence of bladder outlet procedures within 3 years. Men younger than 60 years had a low rate of subsequent bladder outlet procedures regardless of a postoperative urinary retention diagnosis.

Analysis or evaluation of risk factors and predictability of postoperative urinary retention following spinal surgery

Lee S, Kim CH, Chung CK, Park SB, Yang SH, et al. Risk factor analysis for postoperative urinary retention after surgery for degenerative lumbar spinal stenosis. Spine J 2017:17:469-77 (in this issue).