What are the risk factors associated with urinary retention after orthopaedic surgery?

Early Diet Liberalization After Anterior Lumbar Interbody Fusion Improves Postoperative Recovery

STUDY DESIGN

Retrospective Cohort Study.

OBJECTIVES

The objective of this study was to assess the impact of diet liberalization on short-term outcomes in patients undergoing anterior interbody lumbar fusion (ALIF).

METHODS

A retrospective review was performed for patients undergoing ALIF at our tertiary care center institution from 2010 to 2022. Electronic medical records were reviewed for demographics, surgical characteristics, and 90-day postoperative outcomes.

RESULTS

We included 515 patients in this study with 102 patients receiving a full diet on the same day as their operation. All other patients had a delay of at least 1 day (average 1.6 days) until a full diet was provided. This group was found to have a higher rate of postoperative ileus (10.2% vs 2.9%) and urinary retention (16.0% vs 3.9%). The readmission rate and percent of patients presenting to the emergency department within 90 days postoperatively were similar. On multivariate regression analysis, same-day, full-diet patients had decreased odds of developing urinary retention (OR = .17) and a shorter length of hospital stay (Estimate: -.99). Immediate full diet had no impact on the development of ileus (OR: .33).

CONCLUSIONS

An immediate postoperative full diet following an anterior approach to the lumbar spine was not found to be associated with an increased risk of postoperative ileus in patients deemed appropriate for early diet liberalization. Moreover, an early full diet was found to reduce length of hospitalization and risk of postoperative urinary retention. Reconsideration of postoperative diet protocols may help optimize patient outcomes and recovery.

Should urinary catheters be avoided in patients with total joint arthroplasty?

ABSTRACT

Patients undergoing total joint arthroplasty typically have indwelling urinary catheters placed preoperatively to decompress the bladder, assess urinary output, and prevent postoperative urinary retention. However, catheterization is associated with several complications and increased hospital length of stay, and research supports eliminating routine placement of urinary catheters in most patients undergoing elective joint arthroplasty and certain general surgeries lasting no more than 2 hours.

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.

Postoperative Urinary Retention after Pediatric Orthopedic Surgery

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

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

A prediction model for postoperative urinary retention after thoracic surgery

Background

Urinary retention remains a frequent postoperative complication, associated with patient discomfort and delayed discharge following general thoracic surgery (GTS). We aimed to develop and prospectively validate a predictive model of postoperative urinary retention (POUR) among GTS patients.

Methods

We retrospectively developed a predictive model using data from the Society of Thoracic Surgeons GTS Database at our institution. The patient study cohort included adults undergoing elective in-patient surgical procedures without a history of renal failure or Foley catheter on entry to the recovery suite (August 2013 to March 2017). Multivariable logistic regression models identified factors associated with urinary retention, and a nomogram to aid medical decision making was developed. The predictive model was validated in a cohort of GTS patients between April 2017 and November 2018 using receiver operating characteristic (ROC) analysis.

Results

The predictive model was developed from 1484 GTS patients, 284 of whom (19%) experienced postoperative urinary retention within 24 hours of the operation. Risk factors for POUR included older age, male sex, higher preoperative creatinine, chronic obstructive pulmonary disease, primary diagnosis, primary procedure, and use of postoperative patient-controlled analgesia. A logistic nomogram for estimating the risk of POUR was created and validated in 646 patients, 65 of whom (10%) had urinary retention. The ROC curves of development and validation models had similar favorable c-statistics (0.77 vs 0.72; P > .05).

Conclusions

Postoperative urinary retention occurs in nearly 20% of patients undergoing major GTS. Using a validated predictive model may help by targeting certain patients with prophylactic measures to prevent this complication.

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.

Would early removal of indwelling catheter effectively prevent urinary retention after hip fracture surgery in elderly patients?

BACKGROUND

This study aimed to investigate the incidence and risk factors of postoperative urinary retention (POUR) among elderly patients who underwent hip fracture surgery and to evaluate the effect of indwelling catheterization on the occurrence of POUR.

MATERIALS AND METHODS

From January 2012 to January 2015, consecutive patients aged over 70 years who underwent hip fracture surgery were enrolled in this study. All patients underwent indwelling catheterization due to voiding difficulty upon admission. Demographic data, perioperative variables, and postoperative duration of patient-controlled analgesia and indwelling catheterization, postoperative complications, and mortality were collected. The incidence of POUR was investigated, and the risk factors related to POUR were analyzed using a logistic regression analysis. The cutoff value for the timing of catheter removal was determined using receiver operating characteristic (ROC) curve analysis.

RESULTS

POUR developed in 68 patients (31.8%) of the 214 patients. Of these, 24 (35.3%) were male. The indwelling catheter was left in place for an average of 3.4 days (range, 0-7 days) postoperatively. A significant difference was noted in gender and duration of indwelling catheterization between patients with POUR and without. The cutoff value for the timing of catheter removal as determined by ROC curve analysis was 3.5 postoperative day with 51.4% sensitivity and 71.5% specificity. Multiple logistic regression revealed that the duration of the indwelling catheter [odds ratios (OR), 0.31; p = 0.016)] and male gender (OR, 2.22; p = 0.014) were independent risk factors related to the occurrence of POUR.

CONCLUSIONS

The significant risk factors of POUR among elderly patients undergoing hip fracture surgery were early indwelling catheter removal and male gender. Therefore, early removal of indwelling catheter in elderly patients following hip fracture surgery may increase the risk of POUR, especially in male patients.

Factors Influencing Postoperative Urinary Retention Following Elective Posterior Lumbar Spine Surgery: A Prospective Study

Study Design

Prospective observational study.

Purpose

To determine the incidence of postoperative urinary retention (POUR) in patients undergoing elective posterior lumbar spine surgery and identify the risk factors associated with the development of POUR.

Overview of Literature

POUR following surgery can lead to detrusor dysfunction, urinary tract infections, prolonged hospital stay, and a higher treatment cost; however, the risk factors for POUR in spine surgery remain unclear.

Methods

A prospective, consecutive analysis was conducted on patients undergoing elective posterior lumbar surgery in the form of lumbar discectomy, lumbar decompression, and single-level lumbar fusions during a 6-month period. Patients with spine trauma, preoperative neurological deficit, previous urinary disturbance/symptoms, multiple-level fusion, and preoperative catheterization were excluded from the study. Potential patient- and surgery-dependent risk factors for the development of POUR were assessed. Univariate analysis and a multiple logistical regression analysis were performed.

Results

A total of 687 patients underwent posterior lumbar spine surgery during the study period; among these, 370 patients were included in the final analysis. Sixty-one patients developed POUR, with an incidence of 16.48%. Significant risk factors for POUR were older age, higher body mass index (BMI), surgery duration, intraoperative fluid administration, lumbar fusion versus discectomy/ decompression, and higher postoperative pain scores (p<0.05 for all). Sex, diabetes, and the type of inhalational agent used during anesthesia were not significantly associated with POUR. Multiple logistical regression analysis, including age, BMI, surgery duration, intraoperative fluid administration, fusion surgery, and postoperative pain scores demonstrated a predictive value of 92% for the study population and 97% for the POUR group.

Conclusions

POUR was associated with older age, higher BMI, longer surgery duration, a larger volume of intraoperative fluid administration, and higher postoperative pain scores. The contribution of postoperative pain scores in the multiple regression analysis was a significant predictor of POUR.

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.

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.

Pathophysiology, Clinical Importance, and Management of Neurogenic Lower Urinary Tract Dysfunction Caused by Suprasacral Spinal Cord Injury

Management of persistent lower urinary tract dysfunction resulting from severe thoracolumbar spinal cord injury can be challenging. Severe suprasacral spinal cord injury releases the spinal cord segmental micturition reflex from supraspinal modulation and increases nerve growth factor concentration in the bladder wall, lumbosacral spinal cord, and dorsal root ganglion, which subsequently activates hypermechanosensitive C-fiber bladder wall afferents. Hyperexcitability of bladder afferents and detrusor overactivity can cause urine leaking during the storage phase. During urine voiding, the loss of supraspinal control that normally coordinates detrusor contraction with sphincter relaxation can lead to spinal cord segmental reflex-mediated simultaneous detrusor and sphincter contractions or detrusor-sphincter dyssynergia, resulting in inefficient urine voiding and high residual volume. These disease-associated changes can impact on the quality of life and life expectancy of spinal-injured animals. Here, we discuss the pathophysiology and management considerations of lower urinary tract dysfunction as the result of severe, acute, suprasacral spinal cord injury. In addition, drawing from experimental, preclinical, and clinical medicine, we introduce some treatment options for neurogenic lower urinary tract dysfunction that are designed to: (1) prevent urine leakage arising because of detrusor overactivity during bladder filling, (2) preserve upper urinary tract integrity and function by reducing intravesical pressure and subsequent vesicoureteral reflux, and (3) prevent urinary tract and systemic complications by treating and preventing urinary tract infections.

Intramuscular Administration of Drotaverine Hydrochloride Decreases Both Incidence of Urinary Retention and Time to Micturition in Orthopedic Patients under Spinal Anesthesia: A Single Blinded Randomized Study

Purpose. Postoperative urinary retention (POUR) increases the duration of hospitalization and frequency and risk of urinary bladder catheterization. The objective of this study was to analyze the efficacy of intramuscularly administered drotaverine hydrochloride in the prevention of POUR in orthopedic patients. Methods. Two hundred and thirty patients 17–40 years of age undergoing lower limb orthopedic procedures under spinal anesthesia were enrolled in the study. The study group received 40 mg of drotaverine hydrochloride intramuscularly; the second group was the control. The main outcome measure was (1) the time to micturition and (2) the incidence of urinary bladder catheterization and time to catheterization. Results. Two hundred and one patients of 230 enrolled participants completed the study. Compared to the control group, the male patients in study group exhibited a shorter time to spontaneous micturition (441 versus 563 minutes, 95% CI of the difference of means between 39 and 205 minutes) and a lower incidence of urinary bladder catheterization (4/75 versus 10/54) (RR 0.29, 95% CI: 0.1–0.87; P = 0.0175). Conclusions. Intramuscular administration of drotaverine hydrochloride decreased the time to spontaneous micturition and decreased the incidence of urinary bladder catheterization in male patients who underwent orthopedic surgery under spinal anesthesia. This trial is registered with NCT02026427.