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

Strategies for the removal of short-term indwelling urethral catheters in adults

BACKGROUND

Urinary catheterisation is a common procedure, with approximately 15% to 25% of all people admitted to hospital receiving short-term (14 days or less) indwelling urethral catheterisation at some point during their care. However, the use of urinary catheters is associated with an increased risk of developing urinary tract infection. Catheter-associated urinary tract infection (CAUTI) is one of the most common hospital-acquired infections. It is estimated that around 20% of hospital-acquired bacteraemias arise from the urinary tract and are associated with mortality of around 10%. This is an update of a Cochrane Review first published in 2005 and last published in 2007.

OBJECTIVES

To assess the effects of strategies for removing short-term (14 days or less) indwelling catheters in adults.

SEARCH METHODS

We searched the Cochrane Incontinence Specialised Register, which contains trials identified from CENTRAL, MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, CINAHL, ClinicalTrials.gov, WHO ICTRP, and handsearching of journals and conference proceedings (searched 17 March 2020), and reference lists of relevant articles.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) and quasi-RCTs that evaluated the effectiveness of practices undertaken for the removal of short-term indwelling urethral catheters in adults for any reason in any setting.

DATA COLLECTION AND ANALYSIS

Two review authors performed abstract and full-text screening of all relevant articles. At least two review authors independently performed risk of bias assessment, data abstraction and GRADE assessment.

MAIN RESULTS

We included 99 trials involving 12,241 participants. We judged the majority of trials to be at low or unclear risk of selection and detection bias, with a high risk of performance bias. We also deemed most trials to be at low risk of attrition and reporting bias. None of the trials reported on quality of life. The majority of participants across the trials had undergone some form of surgical procedure. Thirteen trials involving 1506 participants compared the removal of short-term indwelling urethral catheters at one time of day (early morning removal group between 6 am to 7 am) versus another (late night removal group between 10 pm to midnight). Catheter removal late at night may slightly reduce the risk of requiring recatheterisation compared with early morning (RR 0.71, 95% CI 0.53 to 0.96; 10 RCTs, 1920 participants; low-certainty evidence). We are uncertain if there is any difference between early morning and late night removal in the risk of developing symptomatic CAUTI (RR 1.00, 95% CI 0.61 to 1.63; 1 RCT, 41 participants; very low-certainty evidence). We are uncertain whether the time of day makes a difference to the risk of dysuria (RR 2.20; 95% CI 0.70 to 6.86; 1 RCT, 170 participants; low-certainty evidence). Sixty-eight trials involving 9247 participants compared shorter versus longer durations of catheterisation. Shorter durations may increase the risk of requiring recatheterisation compared with longer durations (RR 1.81, 95% CI 1.35 to 2.41; 44 trials, 5870 participants; low-certainty evidence), but probably reduce the risk of symptomatic CAUTI (RR 0.52, 95% CI 0.45 to 0.61; 41 RCTs, 5759 participants; moderate-certainty evidence) and may reduce the risk of dysuria (RR 0.42, 95% CI 0.20 to 0.88; 7 RCTs; 1398 participants; low-certainty evidence). Seven trials involving 714 participants compared policies of clamping catheters versus free drainage. There may be little to no difference between clamping and free drainage in terms of the risk of requiring recatheterisation (RR 0.82, 95% CI 0.55 to 1.21; 5 RCTs; 569 participants; low-certainty evidence). We are uncertain if there is any difference in the risk of symptomatic CAUTI (RR 0.99, 95% CI 0.60 to 1.63; 2 RCTs, 267 participants; very low-certainty evidence) or dysuria (RR 0.84, 95% CI 0.46 to 1.54; 1 trial, 79 participants; very low-certainty evidence). Three trials involving 402 participants compared the use of prophylactic alpha blockers versus no intervention or placebo. We are uncertain if prophylactic alpha blockers before catheter removal has any effect on the risk of requiring recatheterisation (RR 1.18, 95% CI 0.58 to 2.42; 2 RCTs, 184 participants; very low-certainty evidence) or risk of symptomatic CAUTI (RR 0.20, 95% CI 0.01 to 4.06; 1 trial, 94 participants; very low-certainty evidence). None of the included trials investigating prophylactic alpha blockers reported the number of participants with dysuria.

AUTHORS' CONCLUSIONS

There is some evidence to suggest the removal of indwelling urethral catheters late at night rather than early in the morning may reduce the number of people who require recatheterisation. It appears that catheter removal after shorter compared to longer durations probably reduces the risk of symptomatic CAUTI and may reduce the risk of dysuria. However, it may lead to more people requiring recatheterisation. The other evidence relating to the risk of symptomatic CAUTI and dysuria is too uncertain to allow us to draw any conclusions. Due to the low certainty of the majority of the evidence presented here, the results of further research are likely to change our findings and to have a further impact on clinical practice. This systematic review has highlighted the need for a standardised set of core outcomes, which should be measured and reported by all future trials comparing strategies for the removal of short-term urinary catheters. Future trials should also study the effects of short-term indwelling urethral catheter removal on non-surgical patients.

Medical and non-medical interventions for post-operative urinary retention prevention: network meta-analysis and risk-benefit analysis

Aims

To assess the efficacy in lowering post-operative urinary retention, urinary tract infection and lower urinary tract symptoms and the incidence of adverse events among 12 interventions and to perform risk-benefit analysis.

Methods

Previous randomized controlled trials were identified from MEDLINE, Scopus and CENTRAL database up to January 2020. The interventions of interest included early ambulation, fluid adjustment, neuromodulation, acupuncture, cholinergic drugs, benzodiazepine, antispasmodic agents, opioid antagonist agents, alpha-adrenergic antagonists, non-steroidal anti-inflammatory drugs (NSAIDs) and combination of any interventions. The comparators were placebo or standard care or any of these interventions. Network meta-analysis was performed. The probability of being the best intervention was estimated and ranked using rankogram and surface under the cumulative ranking curve. Risk-benefit analysis was done. Incremental risk-benefit ratio (IRBR) was calculated and risk-benefit acceptability curve was constructed.

Results

A total of 45 randomized controlled trials with 5387 patients was included in the study. Network meta-analysis showed that early ambulation, acupuncture, alpha-blockers and NSAIDs significantly reduced the post-operative urinary retention. Regarding urinary tract infection and lower urinary tract symptoms, no statistical significance was found among interventions. Regarding the side effects, only alpha-adrenergic antagonists significantly increased the adverse events compared with acupuncture and opioid antagonist agents from the indirect comparison. According to the cluster ranking plot, acupuncture and early ambulation were considered high efficacy with low adverse events, corresponding to the IRBR.

Conclusion

Early ambulation, acupuncture, opioid antagonist agents, alpha-adrenergic antagonists and NSAIDs significantly reduce the incidence of post-operative urinary retention with no difference in adverse events. Regarding the risk-benefit analysis of the medical treatment, alpha-adrenergic antagonists have the highest probability of net benefit at the acceptable threshold of side effect of 15%, followed by opioid antagonist agents, NSAIDs and cholinergic drugs.

A randomized controlled trial of neuromuscular electrical stimulation for chronic urinary retention following traumatic brain injury

BACKGROUND

This study aimed to evaluate the effectiveness of neuromuscular electrical stimulation (NMES) therapy for chronic urinary retention (CUR) following traumatic brain injury (TBI).

METHODS

This 2-arm randomized controlled trial (RCT) enrolled 86 eligible patients with CUR following TBI. All included patients were randomly allocated to a treatment group (n = 43) or a sham group (n = 43). The administration of NMES or sham NMES, as intervention, was performed for an 8-week period treatment, and 4-week period follow-up. In addition, all subjects were required to undergo indwelling urinary catheter throughout the study period. The primary outcome was assessed by the post-voiding residual urine volume (PV-VRU). The secondary outcomes were evaluated by the voided volume, maximum urinary flow rate (Qmax), and quality of life, as assessed by Barthel Index (BI) scale. In addition, adverse events were also recorded during the study period. All primary and secondary outcomes were measured at baseline, at the end of 8-week treatment, and 4-week follow-up.

RESULTS

At the end of 8-week treatment, the patients in the treatment group did not achieve better outcomes in PV-VRU (P = .66), voided volume (P = .59), Qmax (P = .53), and BI scores (P = .67), than patients in the control group. At the end of 4-week follow-up, there were also no significant differences regarding the PV-VRU (P = .42), voided volume (P = .71), Qmax (P = .24), and BI scores (P = .75) between 2 groups. No adverse events occurred in either group.

CONCLUSIONS

In summary, the findings of this study showed that NMES therapy may not benefit patients with CUR following TBI.

Systematic review of interventions for the prevention and treatment of postoperative urinary retention

Background

Postoperative urinary retention (PO‐UR) is an acute and painful inability to void after surgery that can lead to complications and delayed hospital discharge. Standard treatment with a urinary catheter is associated with a risk of infection and can be distressing, undignified and uncomfortable. This systematic review aimed to identify effective interventions for the prevention and treatment of PO‐UR that might be alternatives to urinary catheterization.

Methods

Electronic databases were searched from inception to September 2017. Randomized trials of interventions for the prevention or treatment of PO‐UR were eligible for inclusion. Studies were assessed for risk of bias using the Cochrane (2.0) tool. Two reviewers were involved at all review stages. Where possible, data were pooled using random‐effects meta‐analysis. The overall quality of the body of evidence was rated using the GRADE approach.

Results

Some 48 studies involving 5644 participants were included. Most interventions were pharmacological strategies to prevent PO‐UR. Based on GRADE, there was high‐certainty evidence to support replacing morphine in a regional anaesthetic regimen, using alpha‐blockers (number needed to treat to prevent one case of PO‐UR (NNT) 5, 95 per cent c.i. 5 to 7), the antispasmodic drug drotaverine (NNT 9, 7 to 30) and early postoperative mobilization (NNT 5, 4 to 8) for prevention, and employing hot packs or gauze soaked in warm water for treatment (NNT 2, 2 to 4). Very few studies reported on secondary outcomes of pain, incidence of urinary tract infection or duration of hospital stay.

Conclusion

Promising interventions exist for PO‐UR, but they need to be evaluated in randomized trials investigating comparative clinical and cost effectiveness, and acceptability to patients.

Androgen receptor (AR) promotes male bladder cancer cell proliferation and migration via regulating CD24 and VEGF

Increasing evidence has proved the pivotal roles of androgen receptor in various diseases, including prostate cancer and bladder cancer. The CD24 has been proved to be correlated to bladder cancer metastasis and tumorigenesis in recent study. This study was aimed to investigate the roles of AR in bladder cell proliferation and metastasis and to explore its potential mechanism. Expressions of AR in two kinds of bladder tumor cells (T24 and UM-UC-3) were analyzed using the CRISPR Activation Plasmid transfection or siRNA-mediated gene. The effects of AR on tumor cell proliferation and migration were also analyzed. Moreover, the effects of CD24 and influence of AR on cell proliferation and metastasis-related protein were also analyzed. The results showed that AR was significantly down-regulated in T24 cells but was significantly overexpressed in UM-UC-3 cells. The up-regulated T24 promotes cell proliferation, but this enhance effect was blocked by silencing CD24. Additionally, the AR overexpression significantly increased the VEGF and CD24 expression. Besides, the migrated bladder cells was increased by the up-regulated AR, but was decreased by silencing CD24 or silencing VEGF. Taken together, our study suggested that the up-regulated AR enhances the male bladder tumor cell proliferation and metastasis via modulating the CD24 and VEGF. This study may provide theoretical basis for the possibility of AR to be a therapeutic target for bladder cancer.