Predictors of postoperative urinary retention after colorectal surgery

Laparoscopic colon surgery: time to leave the urinary catheter in the operating room?

INTRODUCTION

'Fast track' guidelines have incorporated multimodal measures to optimize perioperative outcomes in surgery, with laparoscopy being a pivotal component for its advantages in early recovery. In this setting, current recommendations regarding the use of a urinary catheter suggest its removal within the first 24-hours postoperatively.  However, few studies have assessed the feasibility of leaving the operating room without it. The purpose of this study is to compare the perioperative outcomes of patients undergoing elective laparoscopic colonic resections leaving the operating room with and without a urinary catheter.

METHODS

A retrospective study was conducted utilizing prospectively collected data from patients undergoing elective colon resections over a 17-month period. The patients were classified into two groups based on the presence or absence of a urinary catheter upon leaving the operating room, and subsequently, their perioperative outcomes were compared.

RESULTS

A total of 107 patients met the inclusion criteria (n = 28 with a urinary catheter and n = 79 without). Cancer was the most prevalent diagnosis (83.2%), and right hemicolectomy the most frequently performed surgery (32.7%). Two events of urinary catheter reinsertions were reported, both in the no-catheter group (0% vs 2.53%, p = 0.969), and there were no cases of urinary tract infections. The overall and severe complications rates exhibited no significant differences (25% vs. 26.6%, p = 1, and 7.14% vs. 5.06%, p = 1) and the length of stay was similar (p = 0.220).

CONCLUSION

Removing the urinary catheter before leaving the operating room appears to be safe and associated with very low rates of urinary retention in selected patients undergoing laparoscopic colonic or upper rectal resections.

Functional Outcomes After Transanal Total Mesorectal Excision (taTME) for Rectal Cancer: Results From the Phase II North American Multicenter Prospective Observational Trial

OBJECTIVE

To investigate fecal incontinence and defecatory, urinary, and sexual functional outcomes after transanal total mesorectal excision (taTME).

BACKGROUND

Proctectomy for rectal cancer may result in alterations in defecatory, urinary, and sexual function that persist beyond 12 months. The recent multicenter phase II taTME trial demonstrated the safety of taTME in patients with stage I to III tumors.

METHODS

Prospectively registered self-reported questionnaires were collected from 100 taTME patients. Fecal continence [Fecal Incontinence Quality of Life (FIQL), Wexner], defecatory function [Colorectal Functional Outcome (COREFO)], urinary function (International Prostate Symptom Score), and sexual function (Female Sexual Function Index-female, International Index of Erectile Function-male) were assessed preoperatively (PQ), 3 to 4 months postileostomy closure (FQ1), and 12 to 18 months post-taTME [postoperative questionnaire 2 (FQ2)].

RESULTS

Among 83 patients who responded at all 3 time points, FIQL, Wexner, and COREFO significantly worsened postileostomy closure. Between FQ1 and FQ2, FIQL lifestyle and coping, Wexner, and COREFO incontinence, social impact, frequency, and need for medication significantly improved, while FIQL depression and embarrassment did not change. International Prostate Symptom Score did not change relative to preoperative scores. For females, Female Sexual Function Index declined for desire, orgasm, and satisfaction between PQ and FQ1, and did not improve between FQ1 and FQ2. In males, International Index of Erectile Function declined with no change between FQ1 and FQ2.

CONCLUSIONS

Although taTME resulted in initial decline in defecatory function and fecal continence, most functional domains improved by 12 months after ileostomy closure, without returning to preoperative status. Urinary function was preserved while sexual function declined without improvement by 18 months post-taTME. Our results address patient expectations and inform shared decision-making regarding taTME.

Validation of measures for perioperative urinary catheter use, urinary retention, and urinary catheter-related trauma in surgical patients

BACKGROUND

The effects of non-infectious urinary catheter-related complications such as measurements of indwelling urinary catheter overuse, catheter-related trauma, and urinary retention are not well understood.

METHODS

This was a retrospective cohort study of 200 patients undergoing general surgery operations. Variables to measure urinary catheter use, trauma, and retention were developed, then surgical cases were abstracted. Inter- and intra-rater reliability were calculated for measure validation.

RESULTS

129 of 200 (65%) had an indwelling urinary catheter placed at the time of surgery. 32 patients (16%) had urinary retention, and variation was observed in the treatment of urinary retention. 12 patients (6%) had urinary trauma. Rater reliability was high (>90% agreement for all) for the dichotomous outcomes of urinary catheter use, urinary catheter-related trauma, and urinary retention.

CONCLUSIONS

This study suggests a persistent high rate of catheter use, significant rates of urinary retention and trauma, and variation in the management of retention.

Immediate urinary catheter removal after colorectal surgery with the enhanced recovery after surgery protocol

PURPOSE

The Enhanced Recovery After Surgery protocol for colorectal surgery recommends early urinary catheter (UC) removal after surgery. However, the optimal timing remains controversial. We aimed to evaluate the safety of immediate UC removal and risk factors of postoperative urinary retention (POUR) after colorectal cancer surgery.

METHODS

From November 2019 and April 2022, patients who underwent elective colorectal cancer surgery at Seoul St. Mary's hospital were collected retrospectively. A UC was inserted in the operating room after general anesthesia and removed in the operating room immediately after surgery. The primary outcome was the occurrence of POUR following immediate UC removal after surgery, and the secondary outcomes were the identification of POUR-related risk factors and postoperative complications.

RESULTS

Among 737 patients, 81 (10%) had POUR immediately after UC removal. No patient had urinary tract infection. The incidence of POUR was significantly higher in male and in those with a history of urinary disease. However, there were no significant differences in tumor location, surgical procedure, or approach. The mean operative time was significantly longer in the POUR group. Postoperative morbidity and mortality rates did not differ significantly between two groups. Multivariate analysis showed that risk factors for POUR were male, a history of urinary disease, and intrathecal morphine injection.

CONCLUSIONS

Immediate removal of UC immediately after colorectal surgery is safe and feasible in the trend of ERAS. Male, a history of benign prostatic hyperplasia, and intrathecal morphine injection were risk factors for POUR.

Medium-term surgical outcomes and health-related quality of life after laparoscopic vs open colorectal cancer resection: SF-36 health survey questionnaire

BACKGROUND

Previous studies that compared the postoperative health-related quality of life (HRQoL) outcomes after receiving laparoscopic resection (LR) or open resection (OR) in patients with colorectal cancer (CRC) have different conclusions.

AIM

To explore the medium-term effect of postoperative HRQoL in such patients.

METHODS

This study randomized 567 patients undergoing non-metastatic CRC surgery managed by one surgeon to the LR or OR groups. HRQoL was assessed during the preoperative period and 3, 6, and 12 mo postoperative using a modified version of the 36-Item Short Form (SF-36) Health Survey questionnaire, emphasizing eight specific items.

RESULTS

This cohort randomly assigned 541 patients to receive LR (n = 296) or OR (n = 245) surgical procedures. More episodes of postoperative urinary tract infection (P < 0.001), wound infection (P < 0.001), and pneumonia (P = 0.048) were encountered in the OR group. The results demonstrated that the LR group subjectively gained mildly better general health (P = 0.045), moderately better physical activity (P = 0.006), and significantly better social function recovery (P = 0.0001) 3 mo postoperatively. Only the aspect of social function recovery was claimed at 6 mo, with a significant advantage in the LR group (P = 0.001). No clinical difference was found in HRQoL during the 12 mo.

CONCLUSION

Our results demonstrated that LR resulted in better outcomes, including intra-operative blood loss, surgery-related complications, course of recovery, and especially some health domains of HRQoL at least within 6 mo postoperatively. Patients should undergo LR if there is no contraindication.

Risk factors for postoperative urinary retention in patients undergoing colorectal surgery: a systematic review and meta-analysis

PURPOSE

Postoperative urinary retention (POUR) is a common complication following colorectal surgery. The incidence of POUR among colorectal surgery patients varies widely, and the risk factors and outcomes of POUR are also debatable. This meta-analysis aims to systematically evaluate the risk factors for POUR in patients after colorectal surgery.

METHODS

PubMed, Web of Science, the Cochrane Library, Embase, Medline, and Chinese databases (CBM, CNKI, and WanFang Databases) were searched to identify relevant cohort studies (from inception to August 2022). Two researchers independently conducted literature quality evaluation and data extraction. All data were analyzed by using the Review Manager 5.4 software.

RESULTS

Nineteen studies with 101,025 patients were included in this meta-analysis. The risk factors for POUR in colorectal surgery patients were male sex, older age, diabetes mellitus, urological diseases, tumor location in the lower rectum, APR, laparoscopic surgery, operation time ≥ 4 h, postoperative date of urinary catheter removal, excessive intraoperative intravenous fluid volume, and postoperative ileus. The postoperative anastomotic leak, on the other hand, was not a risk factor for POUR.

CONCLUSIONS

Multiple risk factors influence the incidence of POUR in patients undergoing colorectal surgery. To reduce the incidence of POUR in colorectal surgery patients, medical staff should identify risk factors early and enforce interventions to prevent them.

Acute urinary retention and urinary tract infection after short-course urinary drainage in colon or high rectum anastomoses: Post hoc analysis of a multicentre prospective database from the GRACE group

AIM

The aim was to define the risk factors for acute urinary retention (AUR) and urinary tract infections (UTIs) in colon or high rectum anastomosis patients based on the absence of a urinary catheter (UC) or the early removal of the UC (<24 h).

METHOD

This is a multicentre, international retrospective analysis of a prospective database including all patients undergoing colon or high rectum anastomoses. Patients were part of the enhanced recovery programme audit, developed by the Francophone Group for Enhanced Recovery after Surgery, and were included if no UC was inserted or if a UC was inserted for <24 h.

RESULTS

In all, 9389 patients had colon or high rectum anastomoses using laparoscopy, open surgery or robotic surgery. Among these patients, 4048 were excluded because the UC was left in place >24 h (43.1%) and 97 were excluded because the management of UC was unknown (1%). Among the 5244 colon or high rectum anastomoses patients included, AUR occurred in 5.2% and UTI occurred in 0.7%. UCs were in place for <24 h in 2765 patients (52.7%) and 2479 did not have UCs in place (47.3%). Multivariate analysis showed that management of the UC was not significantly associated with the occurrence of AUR and that risk factors for AUR were male gender, ≥65 years old, having an American Society of Anesthesiologists score ≥3 and receiving epidural analgesia. Conversely, being of male gender was a protective factor of UTI, while being ≥65 years old, having open surgery and receiving epidural analgesia were risk factors for UTIs. The management of the UC was not significantly associated with the occurrence of UTIs but the occurrence of AUR was a more significant risk factor for UTIs.

CONCLUSION

UCs in place for <24 h did not reduce the occurrence of AUR or UTI compared to the absence of UCs.

Lower Incidence of Postoperative Urinary Retention in Robotic Total Mesorectal Excision for Low Rectal Cancer Compared with Laparoscopic Surgery

INTRODUCTION

The incidence and clinical significance of postoperative urinary retention (POUR) remain high. This study aimed to evaluate the incidence of POUR and related risk factors in patients who underwent total mesorectal excision (TMR) for low rectal cancer.

METHODS

This study is a retrospective review of a prospectively collected colorectal database from a single center. Data from patients who underwent surgery for low rectal cancer between September 2006 and May 2017 were analyzed to assess the risk factors of POUR. POUR was considered inability to void after urinary catheter removal requiring catheter reinsertion and difficulty in bladder emptying requiring intermittent catheterization.

RESULTS

Of 555 patients with low rectal cancer, 78 (14.1%) developed POUR. Based on multivariate logistic regression analysis, laparoscopic TMR (odds ratio [OR]; 2.114, 95% confidence interval [CI]; 1.212-3.689, p = 0.008) and postoperative ileus (OR; 2.389, 95% CI; 1.282-4.450, p = 0.006) were independent risk factors of POUR. Male gender, advanced age, neoadjuvant chemoradiation, longer operative time, abdominoperineal resection, and lateral pelvic lymph node dissection were not associated with POUR. Advanced age over 65 years also failed to show statistical significance (OR; 1.604, 95% CI; 0.965-2.668, p = 0.068).

CONCLUSION

Laparoscopic approach and postoperative ileus are risk factors for POUR after low rectal cancer surgery. We postulate that the benefits of robotic surgical systems compared to a laparoscopic approach may reduce the incidence of POUR.

Timing of urinary catheter removal after colorectal surgery with pelvic dissection: A systematic review and meta-analysis

Background

Urinary catheters are routinely placed before colorectal surgery. Enhanced recovery after surgery (ERAS) recommends their removal as soon as possible. However, premature removal risks urinary retention, and delayed removal increases risk of urinary tract infections (UTIs). This meta-analysis aims to synthesise the published literature on the optimal timing of urinary catheter removal following colorectal surgery with pelvic dissection.

Materials and methods

The protocol for this meta-analysis is registered on PROSPERO (CRD42019150030).Pubmed, Ovid and Web of Science databases were searched (January 2020). Primary outcomes included urinary retention and catheter associated UTI. The intervention was removal of urinary catheter following colorectal surgery with pelvic dissection on postoperative days 1–2 (early); 3–4 (intermediate); or 5+ (late). Meta-analysis was performed using Comprehensive meta-analysis V2.

Results

Eight papers were analysed. 883 patients had early catheter removal, 236 intermediate and 204 late. Early catheter removal was associated with increased risk of urinary retention when compared to late removal RR = 2.352 95% CI = 1.370–4.038 (p = 0.002). No significant difference in urinary retention was found between early and intermediate or intermediate and late catheter removal groups. Early catheter removal was associated with reduced risk of UTIs compared to late removal RR = 0.498, 95% CI 0.306–0.811, (p = 0.005). No significant difference in UTIs was found between early and intermediate or intermediate and late catheter removal groups.

Conclusions

Removal of urinary catheters on postoperative day 3–4 provides a balance between minimising the risks of urinary retention and UTIs. This analysis can be used to finesse future ERAS protocols concerning catheter removal in colorectal surgery involving pelvic dissection

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The removal of urinary catheters on postoperative day 3–4 provides a balance, minimising the risk of urine retention and UTIs.

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Early removal of urinary catheters after pelvic colorectal surgery is associated with increased risk of urinary retention.

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Leaving urinary catheters in for 5 days or more, increases urinary tract infection risk.

Avoidance of urinary drainage during perioperative period of open elective colonic resection within enhanced recovery after surgery programme

Background

Urinary catheterization (UC) is a conventional perioperative measure for major abdominal operation. Optimization of perioperative catheter management is an essential component of the enhanced recovery after surgery (ERAS) programme. We aimed to investigate the risk factors of urinary retention (UR) after open colonic resection within the ERAS protocol and to assess the feasibility of avoiding urinary drainage during the perioperative period.

Methods

A total of 110 colonic-cancer patients undergoing open elective colonic resection between July 2014 and May 2018 were enrolled in this study. All patients were treated within our ERAS protocol during the perioperative period. Data on patients’ demographics, clinicopathologic characteristics, and perioperative outcomes were collected and analysed retrospectively.

Results

Sixty-eight patients (61.8%) underwent surgery without any perioperative UC. Thirty patients (27.3%) received indwelling UC during the surgical procedure. Twelve (10.9%) cases developed UR after surgery necessitating UC. Although patients with intraoperative UC had a lower incidence of post-operative UR [0% (0/30) vs 15% (12/80), P = 0.034], intraoperative UC was not testified as an independent protective factor in multivariate logistic analysis. The history of prostatic diseases and the body mass index were strongly associated with post-operative UR. Six patients were diagnosed with post-operative urinary-tract infection, among whom two had intraoperative UC and four were complicated with post-operative UR requiring UC.

Conclusion

Avoidance of urinary drainage for open elective colonic resection is feasible with the implementation of the ERAS programme as the required precondition. Obesity and a history of prostatic diseases are significant predictors of post-operative UR.

Systematic review and meta-analysis of early removal of urinary catheter after colorectal surgery with infraperitoneal anastomosis

AIM OF THE STUDY

To review and to analyse the feasibility of using no urinary catheter or a catheter for less than 24 h compared with longer post-operative catheter after colorectal surgery with infraperitoneal dissection.

METHODS

We performed a systematic review and meta-analysis of studies comparing no urinary catheter or a catheter for less than 24 h (early removal, ER) and urinary catheter drainage for 2 days or longer (late removal, LR) after colorectal surgery with infraperitoneal dissection. Primary endpoint was acute urinary retention (AUR) requiring a re-catheterization. Secondary endpoints were urinary tract infection (UTI), overall morbidity and hospital length of stay. Meta-analysis met the PRISMA criteria, with a random model.

RESULTS

Out of 3659 articles found, 82 comparative studies on catheter duration were selected, of which five were in colorectal surgery: three randomized trials, one retrospective and one prospective series. There were 396 ER and 410 LR patients. All had undergone surgery with infraperitoneal dissection. There was no significant difference regarding AUR (OR = 2.09 [95%CI 0.97-4.52]) but significantly less UTI (OR = 0.39 [95%CI 0.22-0.67]) for early urinary catheter removal. The number needed to harm was much higher for AUR than for UTI (23.3 vs. 8).

CONCLUSION

This meta-analysis suggests that, in terms of benefit/risk ratio, in colorectal surgery with infraperitoneal anastomosis, early removal (< 24 h) of the urinary catheter would be beneficial (because of a more frequent UTI after LR than AUR after ER) and would reduce the occurrence of UTI if no AUR risk factors are present. However, these findings should be interpreted with caution because of the low quality of evidence.

Colorectal: Management of Postoperative Complications in Colorectal Surgery

The complications encountered in colorectal surgery can be categorized into early and late. The most consequential early complication is anastomotic leak, which can be managed with percutaneous drainage or reoperation, depending on the patient's clinical status. Other early complications include anastomotic bleeding, surgical site infection, ileus, postoperative urinary retention, and stoma-related complications. Most stoma-related complications can be managed without reoperation. Late complications, such as bowel dysfunction, sexual dysfunction, and anastomotic stricture, are usually managed expectantly and should be discussed in the preoperative setting. There is growing interest in prevention of postoperative outcomes with preoperative nutritional supplementation and prehabilitation.

The risk factors of acute urinary retention after laparoscopic colorectal cancer surgery in elderly patients receiving epidural analgesia

PURPOSE

Urinary retention (UR) is a frequent complication following laparoscopic colorectal surgery. The aim of the present study was to investigate the risk factors for acute UR after laparoscopic surgery for colorectal cancer in patients receiving epidural analgesia.

METHODS

A retrospective study was conducted of 201 patients who underwent laparoscopic surgery for colorectal cancer among those receiving epidural analgesia. Univariate and multivariate analyses were performed to determine the clinicopathological factors associated with acute UR. Acute UR was defined as Clavien-Dindo classification grade ≥ 1.

RESULTS

The overall incidence of acute UR was 17.9% (36/201). The univariate analysis showed that male gender (P = 0.043), a history of chronic heart failure (P = 0.009), an increased level of serum creatinine (P = 0.028), an increased intraoperative fluid volume (P = 0.016), and an early postoperative date of urinary catheter removal (P = 0.003) were both associated with acute UR. The multivariate logistic regression analysis revealed an increased intraoperative fluid volume (100-ml increments; odds ratio [OR]: 1.085, 95% confidence interval [CI]: 1.034-1.138, P < 0.001), history of chronic heart failure (OR: 6.843, 95% CI: 1.893-24.739, P = 0.003), and postoperative date of urinary catheter removal (OR: 0.550, 95% CI: 0.343-0.880, P = 0.013) were independent risk factors for acute UR.

CONCLUSION

Our findings suggest that an increased intraoperative fluid volume, history of chronic heart failure, and early removal of the urinary catheter are risk factors of UR after laparoscopic surgery for colorectal cancer in patients receiving epidural analgesia. An assessment using these factors might be helpful for predicting acute UR.

Effect of Lactobacillus plantarum Biofilms on the Adhesion of Escherichia coli to Urinary Tract Devices

Novel technologies to prevent biofilm formation on urinary tract devices (UTDs) are continually being developed, with the ultimate purpose of reducing the incidence of urinary infections. Probiotics have been described as having the ability to displace adhering uropathogens and inhibit microbial adhesion to UTD materials. This work aimed to evaluate the effect of pre-established Lactobacillus plantarum biofilms on the adhesion of Escherichia coli to medical-grade silicone. The optimal growth conditions of lactobacilli biofilms on silicone were first assessed in 12-well plates. Then, biofilms of L. plantarum were placed in contact with E. coli suspensions for up to 24 h under quasi-static conditions. Biofilm monitoring was performed by determining the number of culturable cells and by confocal laser scanning microscopy (CLSM). Results showed significant reductions of 76%, 77% and 99% in E. coli culturability after exposure to L. plantarum biofilms for 3, 6 and 12 h, respectively, corroborating the CLSM analysis. The interactions between microbial cell surfaces and the silicone surface with and without L. plantarum biofilms were also characterized using contact angle measurements, where E. coli was shown to be thermodynamically less prone to adhere to L. plantarum biofilms than to silicone. Thus, this study suggests the use of probiotic cells as potential antibiofilm agents for urinary tract applications.

Predictors of Postoperative Urinary Retention After Semiclosed Hemorrhoidectomy

Purpose

This study was performed to analyze the predictors that might contribute to urinary retention following semiclosed hemorrhoidectomy under spinal anesthesia.

Methods

This retrospective study enrolled 2,176 consecutive patients with symptomatic grade III to IV hemorrhoids who underwent semiclosed hemorrhoidectomy between September 2018 and September 2019.

Results

Among the 2,176 patients, 1,878 (86.3%) had no postoperative urinary retention, whereas 298 (13.7%) developed urinary retention after hemorrhoidectomy. The percentage of males was significantly higher in the retention group than in the non-retention group (60.4% vs. 48.1%; P=0.001). The risk of urinary retention was 1.52-fold higher in males than in females (95% confidence interval [CI], 1.13-2.04; P=0.005), 1.62-fold higher in old age (95% CI, 1.14-2.28; P=0.006), and 1.37-fold higher with high body mass index (BMI) (95% CI, 1.04-1.81; P=0.025). Patients with ≥4 resected hemorrhoids had a higher odds ratio (OR) of 1.46 (95% CI, 1.12-1.89; P=0.005) than patients with <4 resected hemorrhoids. Among the supplementary medication, patients who used analgesics had a higher OR of 2.06 (95% CI, 1.57-2.68; P=0.001) than those who did not.

Conclusion

Male sex, age, high BMI, number of resected hemorrhoids, and supplementary analgesics are independent risk factors for urinary retention after semiclosed hemorrhoidectomy.

Acute urinary retention rates following early removal or no placement in colon and rectal surgery: a single-center analysis

BACKGROUND

The adequate duration of urinary drainage following colorectal surgery remains debated. The purpose of this study was to compare acute urinary retention (AUR) rates among various durations of urinary catheterization following colon and rectal surgery.

METHODS

We conducted a retrospective analysis of patients undergoing elective colorectal resection enrolled in the Enhanced Recovery After Surgery (ERAS) protocol from 2018 to 2019. Patients were placed into four groups: no catheter placement (NC), catheter removed immediately after surgery (CRAS), removal less than 24 h (CR < 24), and removal greater than 24 h (CR > 24). Our primary endpoint was the rate of AUR in each group. Secondary endpoints included hospital length of stay and urinary tract infections (UTI). A multivariate logistic regression analysis was done to predict AUR.

RESULTS

A total 641 patients were included in this study. 27 patients (4.2%) had NC with an AUR rate of 3.7%. 249 patients (38.8%) had CRAS with an AUR rate of 6.8%. 214 patients (33.4%) had CR < 24 with an AUR rate of 4.2%. 151 patients (23.6%) had CR > 24 with an AUR rate of 2.6%. There was no significant difference in AUR among the groups (p = 0.264). In our multivariant logistic regression, pelvic surgery was an independent risk factor for AUR (p = 0.008). There was a statistically significant higher hospital length of stay (p = 0.001) and rate of UTIs (p = 0.017) in patients with prolonged catheterization.

CONCLUSION

Deferral or early removal of urinary catheters is safe and feasible following colorectal surgery without a significant increase in AUR. Avoiding prolonged indwelling urinary catheterization may decrease associated complications such as UTI and hospital length of stay.

Risk Factors and Outcomes of Postoperative Catheter-Associated Urinary Tract Infection in Colorectal Surgery Patients: A Retrospective Cohort Study

Introduction

Catheter-associated urinary tract infection (CAUTI) is a relatively common cause of postoperative morbidity in colorectal surgery patients. It has been associated with increased length of stay and mortality.

Methods

We performed a retrospective cohort study of 620 colorectal surgeries to assess the prevalence of CAUTI and its relationship with preoperative and operative factors. We also sought to identify its association with postoperative outcomes.

Results

We found that CAUTI occurred in 20.6% of colorectal procedures. We found that CAUTI was associated with older patient age, female gender, higher BMI, higher American Society of Anesthesiologists (ASA) classification, lower hemoglobin, higher creatinine, lower albumin, urgent procedures, bilateral ureteric stent placement, usage of double-J (DJ) stents, postoperative abdominal sepsis, and perioperative steroid usage. CAUTI was also associated with the presence of underlying medical conditions such as hypertension, ischemic heart disease, chronic kidney disease, cerebrovascular disease, and diabetes. With regards to postoperative outcomes, it was associated with postoperative stroke, myocardial infarction, prolonged length of stay, Intensive care unit stay, and mortality.

Conclusion

CAUTI remains a significant cause of morbidity in colorectal patients. Our patient population had a significantly higher risk of CAUTI compared to other series. Though sometimes labelled a minor postoperative complication, its occurrence is associated with other more significant postoperative complications, including death.

Systematic Early Urinary Catheter Removal Integrated in the Full Enhanced Recovery After Surgery (ERAS) Protocol After Laparoscopic Mid to Lower Rectal Cancer Excision: A Feasibility Study

Purpose

Enhanced Recovery After Surgery (ERAS) programs advocate early urinary catheter removal after rectal cancer surgery; however, the optimal duration remains unclear. This study assessed the feasibility of the early urinary catheter removal protocol after rectal cancer surgery within an ERAS pathway and identified predictive factors for failure of this strategy.

Methods

Between March 2017 and October 2018, all unselected and consecutive patients who underwent rectal cancer resection and benefited from our ERAS program were included. Urinary complications (infection and retention) were prospectively recorded. Success was defined as catheter removal on postoperative day (POD) 3 without urinary complications.

Results

Of 135 patients (male, 63.7%; neoadjuvant chemoradiation, 57.0%; urology history, 17.8%), 120 had early urinary catheter removal with no complications (success rate, 88.9%), 8 did not have urinary catheter removal on POD 3 due to clinical judgment or prescription error, 5 experienced a urinary tract infection, and 2 had acute urinary retention. Obesity (odds ratio [OR], 0.16; P = 0.003), American Society of Anesthesiologists physical status classification > II (OR, 0.28; P = 0.048), antiaggregant platelet medication (OR, 0.12; P < 0.001), absence of anastomosis (OR, 0.1; P = 0.003), and prolonged operative time (OR, 0.21; P = 0.020) were predictive factors for failure. Conversely, optimal compliance with the ERAS program (OR, 7.68; P < 0.001), postoperative nonsteroidal anti-inflammatory drug use (OR, 21.71; P < 0.001), and balanced intravenous fluid therapy (OR, 7.87; P = 0.001) were associated with increased strategy success.

Conclusion

Withdrawal of the urinary catheter on POD 3 was successfully achieved after laparoscopic rectal resection and can be safely implemented in the ERAS program.

Long-term effects of laparoscopic lateral pelvic lymph node dissection on urinary retention in rectal cancer

BACKGROUND

The addition of lateral pelvic lymph node dissection (LPLND) in rectal cancer surgery has been reported to increase the incidence of post-operative urinary retention. Here, we assessed the predictive factors and long-term outcomes of urinary retention following laparoscopic LPLND (L-LPLND) with total mesorectal excision (TME) for advanced lower rectal cancer.

METHODS

This retrospective single-institutional study reviewed post-operative urinary retention in 71 patients with lower rectal cancer who underwent L-LPLND with TME. Patients with preoperative urinary dysfunction or who underwent unilateral LPLND were excluded. Detailed information regarding patient clinicopathologic characteristics, post-void residual urine volume, and the presence or absence of urinary retention over time was collected from clinical and histopathologic reports and telephone surveys. Urinary retention was defined as residual urine > 100 mL and the need for further treatment.

RESULTS

Post-operative urinary retention was observed in 25/71 patients (35.2%). Multivariate analysis revealed that blood loss ≥ 400 mL [odds ratio (OR) 4.52; 95% confidence interval (CI) 1.24-16.43; p = 0.018] and inferior vesical artery (IVA) resection (OR 8.28; 95% CI 2.46-27.81; p < 0.001) were independently correlated with the incidence of urinary retention. Furthermore, bilateral IVA resection caused urinary retention in more patients than unilateral IVA resection (88.9% vs 47.1%, respectively; p = 0.049). Although urinary retention associated with unilateral IVA resection improved relatively quickly, urinary retention associated with bilateral IVA resection tended to persist over 1 year.

CONCLUSION

We identified the predictive factors of urinary retention following L-LPLND with TME, including increased blood loss (≥ 400 mL) and IVA resection. Urinary retention associated with unilateral IVA resection improved relatively quickly. L-LPLND with unilateral IVA resection is a feasible and safe procedure to improve oncological curability. However, if oncological curability is guaranteed, bilateral IVA resection should be avoided to prevent irreversible urinary retention.

Prophylactic postoperative condom sheet placement: A randomized clinical trial to test a new concept

Objective

Postoperative urinary retention (POUR) is one of the most common complications after surgery with several risk factors. However, its precise etiology is not completely understood. So far, the effect of prophylactic condom sheet placement on the prevention of POUR has not been addressed. This study was designed to understand whether preventive condom sheet decreases the rate of POUR.

Materials and methods

This randomized clinical trial was carried out in an educational hospital during 2018-2019. All male patients, who underwent anorectal surgery with spinal anesthesia, were included and randomly allocated into two groups (with and without postoperative condom sheet placement).

Results

A total of 172 patients were included in this study (86 patients per group). Twenty-three (13.4%) patients developed POUR. The incidence of POUR was 15.1% among patients with condom sheets and 11.6% in patients without condom sheets, which was not significantly different (P > 0.5). POUR development had a significant correlation with the use of morphine and history of hypertension in both univariate and multivariate analyses.

Conclusion

Based on the present results, it seems that condom sheet placement did not effectively prevent POUR in patients; therefore, ambulation of patients after surgery is a more effective strategy for these patients.

Preoperative urinary function does not predict postoperative acute urinary retention in men after rectal resection

AIM

Acute urinary retention (AUR) is a well-known complication after rectal surgery. It can be associated with additional morbidity. Causes of postoperative AUR are often multifactorial - involving patient-, pathology- and treatment-related factors. A proportion of men undergoing total mesorectal excision (TME) have preexisting urinary dysfunction and this may predispose to AUR. The aim of this study was to prospectively assess the influence of preoperative urinary function on postoperative AUR in men undergoing TME.

METHOD

A prospective multicentre cohort study was conducted. All adult men undergoing rectal resection between June 2016 and January 2018 were recruited. Combined pelvic resections, inability to void per urethra and emergency surgery were excluded. Preoperative urinary function was assessed with uroflowmetry, prostate ultrasound and the International Prostate Symptom Score (IPSS). The incidence of postoperative AUR, urinary tract infection (UTI) and length of hospital stay (LOS) were measured.

RESULTS

Seventy-seven patients (mean age 61 years) were recruited. The overall incidence of AUR was 21%. Preoperative urinary function, IPSS and past urological history were not predictive for postoperative AUR. AUR was not associated with UTI and did not affect LOS. Patients with UTI had a higher intravesical protrusion of the prostate.

CONCLUSION

Preoperative urinary dysfunction in men is not predictive of postoperative AUR after TME. It should not preclude early trial of void after TME. AUR did not predispose to UTI, nor did it prolong LOS.

Outcomes after Early versus Delayed Urinary Bladder Catheter Removal after Proctectomy for Benign and Malignant Disease in 2,429 Patients: An Observational Cohort Study

Background: There currently is no standard practice for optimal urinary catheter removal after rectal resection (proctectomy). Delayed removal may increase urinary tract infection risk, an important hospital quality metric. This study aimed to assess the effect of catheter duration on urinary tract infection rate. We hypothesized that early removal would be associated with fewer infections. Methods: We performed a retrospective review of patients who underwent proctectomy from January 2007 to December 2017 with urinary catheter placement in our colorectal surgery department. The main outcome measures were urinary tract infection, post-operative urinary retention, and length of stay. Patients were divided into early (post-operative day one or two) and late (day three or later) removal groups. Results: A series of 2,429 patients were included; 1,176 in the early and 1,253 in the late group. The early group had a shorter median length of stay (5.26 versus 7 days). The urinary tract infection (n = 77) multivariable logistic regression model showed no association between timing of removal and infection; however, females had more infections (odds ratio [OR] 2.70, 95% confidence interval [CI] 1.65-4.41). The post-operative urinary retention model (n = 280) showed no association between the timing of removal and retention; however, patients who underwent pre-operative radiation (OR 1.55; 95% CI 1.15-2.09) or total proctocolectomy (OR 1.74; 95% CI 1.21-2.49) or were male (OR 1.35; 95% CI 1.02-1.78) were more likely to have retention. When analyzed by specific removal day, each one-day delay in removal increased the odds of infection by 21% (OR 1.21; 95% CI 1.09-1.35] and decreased the odds of retention by 12% (OR 0.88; 95% CI 0.80-0.97] with a cross-over at 9 days. Patients who experienced retention were not more likely to have infection. Conclusion: Early urinary catheter removal after proctectomy was associated with a lower urinary tract infection rate and a shorter hospital stay.

Urine drainage management in colorectal surgery

INTRODUCTION

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

OBJECTIVE

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

RESULTS

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

Rate of urinary retention after ileostomy takedown in men and role of routine placement of urinary catheter

Ileostomy takedown has been proposed as one of the procedures where the placement of the catheters can be avoided, however, the rate of UR after ileostomy takedown is unknown. The aim of this study is to investigate the rate of UR after ileostomy takedown and the potential benefit of perioperative Tamsulosin. Retrospective cohort study of men undergoing ileostomy takedown after pelvic colorectal surgery between January 2009 and December 2016. A total of 100 patients were identified. The rate of UR after ileostomy takedown was high at 26%. There were no instances of urinary tract infection, however, most instances of UR were in patients who did not have catheter in surgery (96% vs. 4%, p = 0.044). Perioperative use of tamsulosin did not result in significant decrease in urinary retention. Rates of urinary retention after ileostomy takedown are high. Although not placing the catheter may be protective against urinary tract infections, patients should be counseled about the possibility of UR after ileostomy takedown.

Optimal timing of urinary catheter removal following pelvic colorectal surgery: a systematic review and meta-analysis

PURPOSE

Acute urinary retention (AUR) is a common postoperative complication in colorectal surgery. In pelvic colorectal operations, the optimal duration for postoperative urinary catheter use is controversial. This systematic review and meta-analysis aims to compare early (POD 1), intermediate (POD 3), and late (POD 5) urinary catheter removal.

METHODS

Medline, EMBASE, CENTRAL, and PubMed databases were searched. Articles were eligible for inclusion if they compared patients with urinary catheter removal on POD 1 or earlier to patients with urinary catheter removal on POD 2 or later in major pelvic colorectal surgeries. The primary outcome was rate of postoperative AUR. The secondary outcome was rates of postoperative urinary tract infection (UTI).

RESULTS

From 691 relevant citations, five studies with 928 patients were included. Comparison of urinary catheter removal on POD 1 versus POD 3 demonstrated no significant difference in rate of urinary retention (RR 1.36, 95%CI 0.83-2.21, P = 0.22); however, compared to POD 5, rates of AUR were significantly higher (RR 2.58, 95%CI 1.51-4.40, P = 0.0005). Rates of UTI were not significantly different between POD 1 and POD 3 urinary catheter removal (RR 0.40, 95%CI 0.05-3.71, P = 0.45), but removal on POD 5 significantly increased risk of UTI compared to POD 1 (RR 0.50, 95%CI 0.31-0.81, P = 0.005).

CONCLUSION

Risk of AUR can be minimized with late postoperative urinary catheter removal compared to early removal, but at the cost of increased risk of UTI. Patient-specific factors should be taken into consideration when deciding upon optimal duration of postoperative urinary catheterization.

Early removal of urinary drainage in patients receiving epidural analgesia after colorectal surgery within an ERAS protocol is feasible

BACKGROUND

ERAS guidelines recommend early removal of urinary drainage after colorectal surgery to reduce the risk of catheter-associated urinary tract infections (CAUTI). Another recommendation is the postoperative use of epidural analgesia (EA). In many types of surgery, EA was shown to increase the risk of postoperative urinary retention (POUR). This study determines the impact of early urinary catheter removal on the incidence of POUR and CAUTI under EA after colorectal surgery.

METHODS

Eligible patients were scheduled for colorectal surgery within the local ERAS protocol between April 2015 and September 2016. Urinary drainage was removed on the first postoperative day while EA was still in place (early removal group (ER)). The incidences of POUR and CAUTIs were recorded prospectively. Results were compared with a historical control (CG), which was operated between October 2013 and March 2015.

RESULTS

POUR occurred significantly more often in the ER (ER 7.8%; CG 2.6%), while CAUTIs were significantly less frequent in the ER (13.8%) compared with the CG (30.4%). Patients who developed POUR were characterised by a significantly higher rate of abdominoperineal resections, by a higher frequency of rectal cancer, and a higher male-to-female ratio compared with patients who did not develop POUR.

CONCLUSION

Early removal of urinary drainage after colorectal surgery while EA is still in place is feasible; it reduces the incidence of CAUTI but increases the risk of POUR. Thus, screening for POUR in patients with failure to void after six to 8 h is mandatory under these clinical conditions.

The risk factors for urinary dysfunction after autonomic nerve-preserving rectal cancer surgery: a multicenter retrospective study at Yokohama Clinical Oncology Group (YCOG1307)

AIM

The aim of this retrospective study was to evaluate the frequency and risk factors of urinary dysfunction after autonomic nerve-preserving surgery for rectal cancer.

METHODS

This was a retrospective multiinstitution study of 1002 rectal cancer patients conducted between January 2008 and December 2012 in Yokohama Clinical Oncology Group. Patients who had preoperative urinary dysfunction or had not undergone autonomic nerve preservation surgery were excluded. Urinary dysfunction was defined as that with a Clavien-Dindo classification grade ≥ 2. Patient-, tumor-, and surgery-related variables were examined by univariate and multivariate analyses.

RESULTS

A total of 887 patients were analyzed. Postoperative urinary dysfunction was observed in 77 patients (8.8%). A multivariate logistic analysis showed that a tumor location in lower rectum (odds ratio [OR] 2.16; 95% confidence interval [CI] 1.15-3.71; p = 0.02), tumor diameter ≥ 40 mm (OR 2.07; 95% CI 1.19-4.44; p < 0.01), operation time ≥ 240 min (OR 2.07; 95% CI 1.19-4.44; p < 0.01), blood loss ≥ 300 ml (OR 2.35; 95% CI 1.12-3.84; p = 0.02), and diabetes (OR 3.26; 95% CI 1.80-5.89; p < 0.01) were independent risk factors of urinary dysfunction. The incidence of urinary dysfunction exceeded 20% in patients with 3 preoperative predictors (tumor location, tumor diameter, diabetes).

CONCLUSIONS

This result demonstrated that high-risk patients with more than two risk factors should be informed of the risk of urinary dysfunction.

TRIAL REGISTRATION

UMIN000033688.

Postoperative Urinary Retention After Laparoscopic Colorectal Resection with Early Catheter Removal: A Prospective Observational Study

BACKGROUND

Early catheter removal is essential to enhance postoperative mobilization and recovery, but may carry a risk of urinary retention. This study aimed to evaluate a standardized regimen for early postoperative catheter removal and re-catheterization in patients undergoing elective laparoscopic colorectal cancer surgery within an optimal ERAS setting.

METHODS

This was a single-center prospective study of patients undergoing elective minimally invasive colorectal resection and postoperative catheter removal within 24 h, with a re-catheterization threshold of 800 ml bladder volume. The primary outcome was postoperative urinary retention rate, and the secondary outcomes were time of catheter removal and length of stay with a special focus on differences between colon and rectal resections.

RESULTS

A total of 113 patients were included in the study, and 87 patients were eligible for the final analysis. Rectal resection was performed in 22 of 87 patients, and all operations were performed with minimally invasive technique. The conversion rate was 3.5%, and 30-day mortality was 0%. More than 95% of the patients had their catheter removed within 24 h with no difference between rectal and colonic resections. Postoperative urinary retention was observed in 9% of all patients (rectum 18% vs. colon 6%, p = 0.11). One patient had an indwelling catheter at discharge, but all patients had free voluntary micturition at 30-day follow-up. Median length of stay was 3 days (1-13 days).

CONCLUSIONS

Catheter removal within 24 h of surgery using a re-catheterization threshold of 800 ml is safe and reduces unnecessary re-catheterizations following minimally invasive colorectal resection.

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.

Outcomes of Early Removal of Urinary Catheter Following Rectal Resection for Cancer

PURPOSE

Early postoperative urinary catheter removal decreases urinary tract infection (UTI) rate and accelerates patient mobilization. The aim of this study is to determine the results of systematic urinary catheter removal on postoperative day (POD) 1 in patients undergoing rectal resection for cancer.

PATIENTS AND METHODS

Using a prospectively maintained database of 469 patients who underwent rectal resection for cancer, a retrospective review of all patients with urinary catheter removal on POD1 was conducted. Patients unable to void 6 h after catheter removal underwent in and out urinary catheterization (IOC group) and were compared with patients who voided spontaneously (non-IOC group) to determine risk factors for IOC.

RESULTS

A total of 417 patients were identified, including 274 (66%) men. Median age was 59 (50-68) years. Abdominoperineal resection (APR) was performed in 134 (32%), and complex surgery with resection of at least one other organ in 72 (17%) patients. Non-IOC and IOC groups included 245 (59%) and 172 (41%) patients, respectively. Five independent predictive factors for IOC were male gender, obesity, history of obstructive urinary disease, APR, and metastatic disease. The cumulative risk of IOC in patients with zero, one, two, and at least three risk factors was 8%, 31%, 52%, and 68% on POD1, and 2%, 12%, 23%, and 30% on POD5, respectively (p < 0.001). Thirteen patients (3%) developed UTI.

CONCLUSIONS

Early removal of urinary catheter resulted in 59% of patients voiding spontaneously with no need for IOC following rectal resection. Patients without any predictive factors had less than 10% risk of urinary dysfunction.

Early Urinary Catheter Removal Following Pelvic Colorectal Surgery: A Prospective, Randomized, Noninferiority Trial

BACKGROUND

Because of the potential increased incidence of acute urinary retention, optimal timing of urinary catheter removal after major pelvic colorectal surgery remains unclear.

OBJECTIVE

This study aims to compare the incidence of urinary retention following early catheter removal on postoperative day 1 vs standard catheter removal on day 3.

DESIGN

This is a randomized, noninferiority trial.

SETTING

This study was conducted at an urban teaching hospital.

PATIENTS

Patients undergoing colorectal surgery below the peritoneal reflection were selected.

INTERVENTIONS

A 1:1 randomization to early or standard catheter removal was performed. Patients in the early arm were administered an α-antagonist (prazosin 1 mg oral) 6 hours before catheter removal.

MAIN OUTCOME MEASURES

The primary outcome measured was the incidence of acute urinary retention.

RESULTS

One hundred forty-two patients were randomly assigned to early (n = 71) or standard (n = 71) catheter removal. Mean age was 44.8 ± 16.9 years, and the study cohort included 54% men. The most common operations were IPAA (66%) and low anterior resection (18%). The overall rate of retention was 9.2% (n = 13), with no difference between early (n = 6; 8.5%) or standard (n = 7; 9.9%) catheter removal (RR, 0.86; 95% CI, 0.30-2.42). The risk difference was -1.4% (95% CI, -8.3 to 11.1), confirming noninferiority. The rate of infection was significantly lower in early vs standard catheter removal (0% vs 11.3%; p = 0.01). Length of stay was significantly shorter after early vs standard catheter removal (4 days, interquartile range = 3-6 vs 5 days, interquartile range = 4-7; p = 0.03).

LIMITATIONS

Patients and investigators were not blinded; a nonselective oral α-antagonist was used.

CONCLUSIONS

Following pelvic colorectal surgery, early urinary catheter removal, when combined with the addition of an oral α-antagonist, is noninferior to standard urinary catheter removal and carries a lower risk of symptomatic infection and shorter hospital stay.

CLINICAL TRIAL REGISTRATION

http://www.clinicaltrials.gov (NCT01923129). See Video Abstract at http://links.lww.com/DCR/A738.

Effect of Diagnosis on Outcomes in the Setting of Enhanced Recovery Protocols

BACKGROUND

Implementation of enhanced recovery protocols in colectomy reduces length of stay and morbidity, but it remains unknown whether benefits vary by clinical diagnosis.

OBJECTIVE

Outcomes after colectomy in the setting of enhanced recovery protocols were compared for 3 diagnoses: 1) neoplasm, 2) diverticulitis, and 3) IBD.

DESIGN

This was a retrospective registry-based cohort study.

SETTINGS

Novel enhanced recovery variables were released in the American College of Surgeons National Surgical Quality Improvement Program in 2014.

PATIENTS

Patients with enhanced recovery variable data undergoing elective colectomy (July 2014 to December 2015) for neoplasm, diverticulitis, or IBD were included.

MAIN OUTCOME MEASURES

The primary outcome of interest was prolonged length of stay. Additional outcomes included surgical site infection, death/serious morbidity, reoperation, readmission, and days to achieve per os pain control, tolerance of a diet, and return of bowel function.

RESULTS

We identified 4620 patients with neoplasm, 1730 patients with diverticulitis, and 593 patients with IBD. Patients undergoing colectomy for IBD were more likely to have prolonged length of stay (OR, 1.98; 95% CI, 1.46-2.69), death/serious morbidity (OR, 1.62; 95% CI, 1.13-2.32), and readmission (OR, 1.54; 95% CI, 1.15-2.08) compared with patients with neoplasm. Patients with IBD took longer than patients with neoplasm or diverticulitis to achieve per os pain control (mean, 4.2 days vs 3.4 and 3.5 days, p < 0.001) and tolerate a diet (mean, 4.1 days vs 3.7 and 3.5 days, p < 0.001). No statistically significant differences in outcomes between patients with neoplasm and diverticulitis were seen.

LIMITATIONS

There may be heterogeneity among implemented enhanced recovery protocols.

CONCLUSIONS

Patients undergoing colectomy for neoplasm and diverticulitis have improved outcomes in comparison with patients undergoing colectomy for IBD. Knowledge of expected outcomes for patients with different diagnoses may inform clinician and patient expectations. See Video Abstract at http://links.lww.com/DCR/A623.

Early Urinary Dysfunction after Laparoscopic Rectal Cancer Surgery: Does Surgeons’ Learning Curve Matter?

Poor early urinary outcomes after laparoscopy were reported in studies comparing laparoscopic versus open rectal cancer surgery. One possible explanation was that these studies might include a number of patients on the laparoscopic surgeons’ learning curve. This study aims to evaluate whether the learning curve of laparoscopic rectal cancer surgery influences early postoperative urinary dysfunction. Between September 2009 and December 2014, 208 consecutive patients undergoing laparoscopic rectal resection for rectal cancer were enrolled in the present study. All the clinical data were obtained from a prospectively compiled database. The primary outcomes were the incidences of postoperative urinary retention (POUR) and major urinary dysfunction requiring long-term urinary catheterization. POUR and major urinary dysfunction rate were 20.2 per cent (42/208) and 4.3 per cent (9/208), respectively. The learning curve analysis for operative time using the moving average method showed stabilization at 80 cases. Surgeon experience was divided into two periods: learning curve period (1–80 cases) and experienced period (81–208 cases). Multivariate analysis showed that older age (OR = 3.250, P = 0.006) and learning curve (OR = 2.241, P = 0.024) were independent risk factors for POUR. Learning curve was not significantly associated with increased rates of major urinary dysfunction (OR = 3.378, P = 0.092). Learning curve is a significant risk factor for increased rate of POUR after laparoscopic rectal cancer surgery. Technical training may be key to shorten the learning curve and limit its impact on the postoperative urinary complications.

Near-perfect compliance with SCIP Inf-9 had no effect on catheter utilization or urinary tract infections at an academic medical center

BACKGROUND

The Joint Commission's SCIP Inf-9 mandated early removal of indwelling urinary catheters (IUCs), but the impact of compliance on catheter-associated urinary tract infection (CAUTI) and postoperative urinary retention (POUR) are unknown.

METHODS

Retrospective pre- and post-intervention study at a single tertiary academic medical center of all patients undergoing general surgery procedures with an IUC placed at the time of surgery who were admitted for at least two days before and after a Best Practice Advisory was put in place to improve compliance with SCIP Inf-9.

RESULTS

A total of 1036 patients were included (468 pre-intervention; 568 post-intervention). POUR occurred in 13% of patients and CAUTI in 0.8%. There was no change in POUR, CAUTI, or catheter utilization after the Best Practice Advisory was initiated. Both POUR and CAUTI predicted longer lengths of stay.

CONCLUSIONS

Near-perfect SCIP Inf-9 compliance had no effect on the CAUTI rate at our institution.

American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative (POQI) joint consensus statement on prevention of postoperative infection within an enhanced recovery pathway for elective colorectal surgery

BACKGROUND

Colorectal surgery (CRS) patients are an at-risk population who are particularly vulnerable to postoperative infectious complications. Infectious complications range from minor infections including simple cystitis and superficial wound infections to life-threatening situations such as lobar pneumonia or anastomotic leak with fecal peritonitis. Within an enhanced recovery pathway (ERP), there are multiple approaches that can be used to reduce the risk of postoperative infections.

METHODS

With input from a multidisciplinary, international group of experts and through a focused (non-systematic) review of the literature, and use of a modified Delphi method, we achieved consensus surrounding the topic of prevention of postoperative infection in the perioperative period for CRS patients.

DISCUSSION

As a part of the first Perioperative Quality Initiative (POQI-1) workgroup meeting, we sought to develop a consensus statement describing a comprehensive, yet practical, approach for reducing postoperative infections, specifically for CRS within an ERP. Surgical site infection (SSI) is the most common postoperative infection. To reduce SSI, we recommend routine use of a combined isosmotic mechanical bowel preparation with oral antibiotics before elective CRS and that infection prevention strategies (also called bundles) be routinely implemented as part of colorectal ERPs. We recommend against routine use of abdominal drains. We also give consensus guidelines for reducing pneumonia, urinary tract infection, and central line-associated bloodstream infection (CLABSI).

Urinary Retention following Colorectal Surgery

Literature on postoperative urinary retention (POUR) after colorectal resections is limited. The aim of our study was to evaluate the incidence of and risk factors for POUR after elective colorectal resections in men ≥55 years without genitourinary issues. A retrospective review of elective colorectal resections (June 1, 2014 to June 1, 2015) in men ≥55 years without genitourinary conditions was performed at our institution. Patient demographics, American Society of Anesthesiologist score, body mass index (BMI), surgical history, type of disease, extent of resection, surgical approach, operating room (OR) time, volume of OR fluids administered, and intra- and postoperative urine output were included for analysis. Seventy patients were identified. Nine (12.9%) experienced POUR. Patients with POUR experienced longer OR time (324 vs 239 minutes; P = 0.048) and had a lower median BMI (23.8 vs 28 kg/m2; P = 0.038). There were no significant differences in regards to age, comorbidities, diagnosis, type of resection, surgical approach, intravenous fluids administered operatively, or postoperative urine output. The incidence of POUR in male patients at least 55 years of age after elective colorectal resection in our institution was 12.9 per cent. Longer operative time and lower BMI were associated with a higher incidence of POUR.

Urinary Retention in Surgical Patients

Urinary retention is an important and potentially avoidable postoperative complication. Identifying risk factors for retention is important given expedient bladder decompression is important for long-term outcomes. Age, benign prostatic hyperplasia, and lower urinary tract symptoms are patient factors that predispose to retention. Surgery-related factors include operative time, intravenous fluid administration, type of anesthesia, and procedure type. The mainstay for treatment in the acute setting is Foley catheter placement. Starting alpha-blockers in men is also indicated as they increase voiding trial success. Long-term solutions for chronic retention include a variety of surgeries, with transurethral prostatectomy as the gold standard.

Postoperative urinary retention in colorectal surgery within an enhanced recovery pathway

BACKGROUND

Enhanced recovery after surgery (ERAS) guidelines for colorectal surgery suggest routine transurethral bladder drainage with early removal to prevent urinary tract infection (UTI). The aim of this study was to identify risk factors for urinary retention (UR).

METHODS

This retrospective analysis included all colorectal patients since ERAS implementation in May 2011-November 2014. From the prospective ERAS database, over 100 items related to demographics, surgery, compliance, and outcome were analyzed. Risk factors for UR were identified by multiple logistic regressions; then, UR was correlated to functional outcomes and UTI and acute kidney injury rates.

RESULTS

The study cohort consisted of 513 consecutive patients. Of these, 73 patients (14%) presented with UR. Multivariate analysis identified male gender (odds ratio 1.4; 95% CI, 1-1.8; P = 0.045) and postoperative thoracic epidural analgesia (EDA; odds ratio 2.6; 95% CI, 1.6-4.3; P ≤ 0.001) as independent risk factors for postoperative UR. Functional recovery was impeded in patients with UR, who were less mobile (mobilization day 1 >4 h: 57% versus 70%, P = 0.024) and gained more weight (2.8 ± 2.5 kg versus 1.6 ±3 kg on day 1, P = 0.001) due to fluid overload. Furthermore, patients with urinary catheters reported more pain (visual analog scales day 3: 3.1 ± 2.5 versus 2.2 ± 2.4, P = 0.002) and depended longer on intravenous fluid administration (termination of intravenous fluids later than day 1: 53% versus 39%, P = 0.021). Ten of 73 patients (14%) developed UTI in patients with UR and 42 of 440 (10%) in patients without UR (P = 0.276). Six of 73 patients (8%) developed acute kidney injury in patients with UR and 36 of 440 (8%) in patients without UR (P = 0.991).

CONCLUSIONS

Male gender and EDA were independent risk factors for postoperative UR which appeared to be a significant impediment for functional recovery.

A safety study of transumbilical single incision versus conventional laparoscopic surgery for colorectal cancer: study protocol for a randomized controlled trial

Background

Single-incision laparoscopic surgery (SILS) is an emerging minimally invasive surgery to reduce abdominal incisions. However, despite the increasing clinical application of SILS, no evidence from large-scale, randomized controlled trials is available for assessing the feasibility, short-term safety, oncological safety, and potential benefits of SILS compared with conventional laparoscopic surgery (CLS) for colorectal cancer.

Methods/Design

This is a single-center, open-label, noninferiority, randomized controlled trial. A total of 198 eligible patients will be randomly assigned to transumbilical single incision plus one port laparoscopic surgery (SILS plus one) group or to a CLS group at a 1:1 ratio. Patients ranging in age from 18 to 80 years with rectosigmoid cancer diagnosed as cT1-4aN0-2 M0 and a tumor size no larger than 5 cm are considered eligible. The primary endpoint is early morbidity, as evaluated by an independent investigator. Secondary outcomes include operative outcomes (operative time, estimated blood loss, and incision length), pathologic outcomes (tumor size, length of proximal and distal resection margins, and number of harvested lymph nodes), postoperative inflammatory and immune responses (white blood cells [WBC], neutrophil percentage [NE %], C-reactive protein [CRP], interleukin-6 [IL-6], and tumor necrosis factor-α [TNF-α]), postoperative recovery (time to first ambulation, flatus, liquid diet, soft diet, and duration of hospital stay), pain intensity, body image and cosmetic assessment, 3-year disease free survival (DFS), and 5-year overall survival (OS). Follow-up visits are scheduled for 1 and 3 months after surgery, then every 3 months for the first 2 years and every 6 months for the next 3 years.

Discussion

This trial will provide valuable clinical evidence for the objective assessment of the feasibility, safety, and potential benefits of SILS plus one compared with CLS for the radical resection of rectosigmoid cancer. The hypothesis is that SILS plus one is feasible for the radical resection of rectosigmoid cancer and offers short-term safety and long-term oncological safety comparable to that of CLS, and that SILS plus one offers better cosmetic results and faster convalescence compared to CLS.

Trial registration

ClinicalTrials.gov: NCT02117557 (registered on 16 April 2014).

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-015-1067-5) contains supplementary material, which is available to authorized users.

Perioperative use of tamsulosin significantly decreases rates of urinary retention in men undergoing pelvic surgery

PURPOSE

Urinary retention is a common complication of pelvic surgery, leading to urinary tract infection and prolonged hospital stays. Tamsulosin is an alpha blocker that works by relaxing bladder neck muscles. It is used to treat benign prostatic hypertrophy and retention. We aim to investigate the potential benefits of preemptive tamsulosin use on rates of urinary retention in men undergoing pelvic surgery.

METHODS

This is a retrospective review of an institutional colorectal database. All men undergoing pelvic surgery between 2004 and 2013 were included. Patients given 0.4 mg of tamsulosin 3 days prior and after surgery at discretion of surgeon starting in 2007 were compared with patients receiving expectant postoperative management.

RESULTS

One hundred eighty-five patients were included in the study (study group: N = 30; control group: N = 155). Study group patients were older (56.8 vs. 50.1 years). Overall urinary retention rate was 22% with significantly lower rates in the study group compared with control (6.7 vs. 25%; p = 0.029). Study group had higher rates of minimally invasive surgery (61 vs. 29.7%); however, this did not impact urinary retention rate (20.6 vs. 22.7% for minimally invasive surgery vs. open surgery; p = 0.85). Independent predictors of urinary retention included lack of preemptive tamsulosin (odds ratio (OR), 7.67; 95% confidence interval (CI), 1.4-41.7) and cancer location in the distal third of the rectum (OR, 18.8; 95% CI, 2.1-172.8).

CONCLUSIONS

Preemptive perioperative use of tamsulosin may significantly decrease the incidence of urinary retention in men undergoing pelvic surgery. This may play a role in avoidance of urinary retention, particularly in patients with distal rectal cancer.

Risk factors and preventive measures for acute urinary retention after rectal cancer surgery

BACKGROUND

Although several risk factors for acute urinary retention after rectal cancer surgery have been proposed, few studies have enrolled a homogeneous group of patients without preoperative urinary dysfunction. We aimed to identify risk factors and preventive measures for acute urinary retention after rectal cancer surgery.

METHODS

This study was a retrospective review of prospectively collected data from included patients who underwent rectal cancer surgery at a single center. Preoperative urinary function was evaluated using the International Prostate Symptom Score (IPSS). Clinical data were collected prospectively and analyzed to assess the risk factors for acute urinary retention, which was defined as the inability to self-void after removing the urinary catheter requiring catheterization or reinsertion of an indwelling catheter.

RESULTS

Of 352 patients with mild preoperative IPSS (0-7), 48 (13.6 %) experienced acute urinary retention. Multivariate logistic regression analysis showed that male sex (odds ratio [OR] 2.240, p = 0.039), laparoscopic operation (OR 2.421, p = 0.024), intraoperative intravenous fluid ≥ 2,000 mL (OR 3.794, p < 0.001), and urinary catheter removal on postoperative day 1 or 2 (OR 3.650, p = 0.017) were independent risk factors for acute urinary retention after rectal cancer surgery. Patients with two risk factors had a significantly higher risk of acute urinary retention than patients with none or one risk factor.

CONCLUSIONS

This study suggests the maintenance of a urinary catheter for a period longer than 2 days and intraoperative fluid restriction to prevent acute urinary retention after rectal cancer surgery.

Early removal of urinary catheters after rectal surgery is associated with increased urinary retention

BACKGROUND

Urinary retention after rectal resection is common and managed prophylactically by prolonging urinary catheterization. However, because indwelling urinary catheterization is a well-established risk factor for urinary tract infection, the ideal timing for urinary catheter removal following a rectal resection is unknown.

OBJECTIVE

We hypothesized that early urinary catheter removal (on or before postoperative day 2) would be associated with urinary retention.

DESIGN

This study is a retrospective review of medical records.

SETTING

This study was conducted at a colorectal surgery service at a tertiary care academic teaching hospital.

PATIENTS

Adults undergoing rectal resection operations by colorectal surgeons in 2005 to 2010 were selected.

MAIN OUTCOME MEASURE

The primary outcome measured was urinary retention.

RESULTS

Of 205 patients included, 41 (20%) developed urinary retention. Male sex (OR, 3.9; 95% CI, 1.7-9), increased intraoperative intravenous fluid (OR for each liter, 1.2; 95% CI, 1.04-1.48), and urinary catheter removal on postoperative day 2 or earlier (OR, 3.8; 95% CI, 1.4-10.5) were associated with urinary retention on multivariable analysis. Early catheter removal was not associated with decreased urinary tract infection rates (p = 0.29) but was associated with shorter length of stay (6.5 vs 8.9 days; p = 0.005).

LIMITATIONS

The retrospective nature of this study did not allow for a precise definition of urinary retention. Preoperative urinary function was not available, and the patient sample was heterogeneous, including several indications for rectal resection. Urinary catheters were not removed per protocol and therefore subject to bias. The study is likely underpowered to detect differences in urinary tract infection between urinary catheter removal groups.

CONCLUSION

In patients undergoing rectal resection, we found that urinary catheter removal on or before postoperative day 2 was associated with urinary retention (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A172).