The incidence of postoperative urinary retention in patients undergoing elective hip and knee arthroplasty

Risk factors of postoperative urinary retention following total hip and knee arthroplasty

Aims

The aim of this meta-analysis was to determine the pooled incidence of postoperative urinary retention (POUR) following total hip and knee arthroplasty (total joint replacement (TJR)) and to evaluate the risk factors and complications associated with POUR.

Methods

Two authors conducted searches in PubMed, Embase, Web of Science, and Scopus on TJR and urinary retention. Eligible studies that reported the rate of POUR and associated risk factors for patients undergoing TJR were included in the analysis. Patient demographic details, medical comorbidities, and postoperative outcomes and complications were separately analyzed. The effect estimates for continuous and categorical data were reported as standardized mean differences (SMDs) and odds ratios (ORs) with 95% CIs, respectively.

Results

A total of 31 studies were included in the systematic review. Of these, 29 studies entered our meta-analysis, which included 3,273 patients diagnosed with POUR and 11,583 patients without POUR following TJR. The pooled incidence of POUR was 28.06%. Demographic risk factors included male sex (OR 1.81, 95% CI 1.26 to 2.59), increasing age (SMD 0.16, 95% CI 0.04 to 0.27), and American Society of Anesthesiologists grade 3 to 4 (OR 1.39, 95% CI 1.10 to 1.77). Patients with a history of benign prostatic hyperplasia (OR 1.99, 95% CI 1.41 to 2.83) and retention (OR 3.10, 95% CI 1.58 to 6.06) were more likely to develop POUR. Surgery-related risk factors included spinal anaesthesia (OR 1.44, 95% CI 1.19 to 1.74) and postoperative epidural analgesia (OR 2.82, 95% CI 1.65 to 4.82). Total hip arthroplasty was associated with higher odds of POUR compared to total knee arthroplasty (OR 1.10, 95% CI 1.02 to 1.20). Postoperatively, POUR was associated with a longer length of stay (SMD 0.21, 95% CI 0.02 to 0.39).

Conclusion

Our meta-analysis demonstrated key risk variables for POUR following TJR, which may assist in identifying at-risk patients and direct patient-centered pathways to minimize this postoperative complication.

Patient-Controlled Analgesia and Peripheral Nerve Block Increase the Risk of Post-operative Urinary Retention after Total Knee Arthroplasty in Asian Patients

Introduction

Post-operative urinary retention (POUR) is a common complication after total knee arthroplasty (TKA) and may result in severe complications such as urinary tract infection and deep joint sepsis, leading to prolonged hospital stay and increased medical costs. Hence a retrospective study was performed to identify the incidence and modifiable factors associated with POUR after elective TKA in Asian patients with the aim to prevent POUR and its undesirable consequences.

Materials and Methods

The medical records of 496 consecutive patients who underwent elective TKA between 1 August 2017 and 30 July 2018 were reviewed. There were 154 male (31.0%) and 342 female (69.0%) patients with an average age of 68 years old. The incidence of POUR was analysed with respect to various modifiable and non-modifiable risk factors, including patient demographics, medical comorbidities, duration of surgery, type of intra-operative anaesthesia and post-operative analgesia and early initiation of physiotherapy using univariate and multivariate analyses.

Results

A total of 120 (24.2%) of the 496 patients who underwent elective TKA developed POUR. The odds of a patient with patient-controlled analgesia (PCA) and peripheral nerve block (PNB) developing POUR were 4.2 times and 4.7 times that of a patient without PCA and PNB, respectively. Age, male gender and type of anaesthesia were not found to be significant.

Conclusion

In our study population, the incidence of POUR after elective TKA was 24% with major modifiable risk factors being associated with the use of PCA and PNB as post-operative anaesthesia. POUR can have deleterious effects thus alternative post-operative analgesia should be considered.

Pericapsular Nerve Group (PENG) Block Results in Significant Opioid Reduction in Total Hip Arthroplasty: A Retrospective Analysis

PURPOSE

The purpose of this retrospective study was to determine the effectiveness of pericapsular nerve group (PENG) block for pain control intraoperatively in patients undergoing total hip arthroplasty (primary-27130) (THA), compared to opioid based analgesia. The PENG block is an emerging regional anesthesia technique that aims to provide hip analgesia with preservation of motor function offering benefit over existing regional techniques while reducing overall opioid requirements.

DESIGN

A retrospective cohort chart review and analysis.

METHODS

A single-site, retrospective chart review was performed for individuals undergoing THAs at a community hospital from 2019 to 2022 (N = 123). Anesthesia records were collected and observed for multiple data points including peripheral nerve block provided, micrograms of fentanyl administered before and during the case, additional medications given, and additional nerve blocks performed. The demographic data included birth date, sex, and procedure date.

FINDINGS

For statistical analysis only, patients receiving PENG (59) were compared to those receiving only intravenous analgesia (No Block-57). Statistically and clinically significant reductions in fentanyl administration and morphine equivalents were found in the population receiving PENG blocks. The mean intraoperative fentanyl given to the No Block group was 292.98 mcg versus 50.42 mcg in the PENG group (P < .05). Mean morphine equivalents given in the No Block group was 23.51 mg versus 11.21 mg in the PENG group (P < .05).

CONCLUSIONS

Receiving a PENG block preoperatively resulted in clinically and statistically significant opioid reduction during the perioperative period when compared with patients who did not receive a regional block.

Impact of Anesthetic Choice on Time to Discharge for Same-Day Discharge Joints

INTRODUCTION

As total joint arthroplasty programs continue to move towards same-day discharge (SDD), time to discharge is an increasingly important performance indicator. The primary objective of this study was to determine the impact of the choice of anesthetic on the time to discharge after SDD primary hip and knee arthroplasty.

METHODS

A retrospective chart review was conducted within our SDD arthroplasty program, with 261 patients identified for analysis. Baseline characteristics, length of surgery, anesthetic drug, dose, and perioperative complications were extracted and recorded. The time from the patient leaving the operating room (OR) to physiotherapy (PT) assessment, and from OR to discharge were recorded. These were referred to as ambulation time and discharge time respectively.

RESULTS

The ambulation time was significantly reduced when hypobaric lidocaine was used in a spinal block compared to isobaric or hyperbaric bupivacaine-135 minutes (range, 39 to 286), 305 minutes (range, 46 to 591), 227 minutes (range, 77 to 387) respectively-p<0.0001). Similarly, the discharge time was also significantly lower with hypobaric lidocaine compared to isobaric bupivacaine, hyperbaric bupivacaine, and general anesthesia-276 minutes (range, 179 to 461), 426 minutes (range, 267 to 623), 375 minutes (range, 221 to 511), 371 minutes (range, 217 to 570) respectively-(p<0.0001). No cases of transient neurologic symptoms were reported.

CONCLUSIONS

Patients receiving a hypobaric lidocaine spinal block experienced significantly reduced ambulation time and time to discharge compared to other anesthetics. Surgical teams should feel confident in using hypobaric lidocaine during spinal anesthesia as it is quick and efficacious.

Prophylactic doxazosin reduces urinary retention and promotes recovery after total joint arthroplasty: A randomized controlled trial

Background: Postoperative urinary retention (POUR) is a common and disruptive complication following total joint arthroplasty (TJA). The aim of this study is to investigate whether doxazosin can decrease the incidence of POUR and promote recovery under the setting of modern enhanced recovery after TJA. Methods: In this randomized placebo-controlled trial, patients over 35 years of age undergoing primary unilateral TJA were recruited. Patients received doxazosin (4 mg once) or placebo 2 h before surgery. The primary outcome of interest was the development of POUR, which was diagnosed when patients with a urine volume over 400 ml or overflow incontinence. Postoperative recovery was assessed in terms of hospital length of stay after surgery, daily ambulation distance, visual analogue scale (VAS) pain score and opioid consumption. Results: A total of 170 male patients were equally randomized into Doxazosin group (mean age 54.2 ± 13.7 years, range 36-88 years) and Placebo group (mean age 54.6 ± 13.9 years, range 38-81 years). The POUR rate was significant lower in Doxazosin group (17.6%) than in Placebo group (36.5%) (p = .006). The mean LOS in the Doxazosin group was 3.1 ± 1.1 days compared to 3.6 ± 1.7 days in the Placebo group (p = .030). Doxazosin group had a longer daily mobilization distance than Placebo group on postoperative day 1 (26.8 ± 11.1 vs. 22.8 ± 9.7; p = .015). Postoperative pain assessed by VAS score and opioid usage was comparable between two groups. Conclusion: Our results support the routine use of prophylactic doxazosin in male patients to decrease POUR rate and promote postoperative recovery under the setting of modern enhanced recovery after TJA.

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.

Mepivacaine Versus Bupivacaine Spinal Anesthesia for Primary Total Joint Arthroplasty: A Systematic Review and Meta-Analysis

BACKGROUND

Mepivacaine is an intermediate acting amide local anesthetic that can be used for neuraxial anesthesia in total joint arthroplasty (TJA) with a shorter duration of action (1.5-2 hours) compared to the more commonly used local anesthetic bupivacaine. The purpose of this study was to perform a systematic review and meta-analysis comparing bupivacaine and mepivacaine spinal anesthesia during elective TJA and the surgical outcomes of the time to full neurologic motor return, pain, mobility, length of stay (LOS), and complications including transient neurologic symptoms and urinary function.

METHODS

PubMed, Ovid MEDLINE, and Ovid Embase were screened for "arthroplasty, spinal anesthesia, bupivacaine, and mepivacaine," in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A total of 159 studies were screened and 5 studies were evaluated. Data were compared regarding motor function return, mobility (distance ambulated), pain (visual analog scale [VAS]), LOS, and postoperative complications.

RESULTS

Full-text screening yielded 5 studies (3 randomized controlled trials and 2 retrospective cohort studies), with a total of 1,550 patients. Mepivacaine spinals had an earlier return to motor function (154 minutes vs 170 minutes, 95% CI: [-31.6, -0.9], P = .04), shorter LOS (25.95 hours vs 29.96 hours, 95% CI: [-6.8, -1.2], P = .01), and decreased urinary retention (7.15% vs 10.58%, 95% CI: [-6.3%, -0.6%], P = .02) with no differences in pain (VAS 3.57 vs 3.68, 95% CI: [-2.1, 1.9], P = .90) or distance ambulated (94.2 ft vs 89.1 ft, 95% CI: [-15, 25.2], P = .60) compared to bupivacaine spinal anesthesia.

CONCLUSIONS

The method of anesthesia administration has been an increasing area of focus for quicker and safer recovery to allow for early ambulation and facility discharge. The rapid recovery facilitated by mepivacaine may further enable outpatient TJA and enhance patient recovery.

LEVEL OF EVIDENCE

III.

Postoperative Urinary Retention in Modern Rapid Recovery Total Joint Arthroplasty

Postoperative urinary retention (POUR) is a disruptive complication after modern rapid recovery total joint arthroplasty. This review aims to synthesize the recent literature on POUR in the setting of total joint arthroplasty. The incidence of POUR ranges from 5.5% to 46.3%. The lack of a standardized definition of POUR accounts for some of this variability. Risk factors previously associated with the development of POUR include increasing age, male sex, benign prostatic hyperplasia, use of bupivacaine and intrathecal morphine in spinal anesthesia, glycopyrrolate, and volume of intraoperative intravenous fluid administered. Predictive scoring assessments, such as the International Prostate Symptom Score and a newer predictive nomogram, have not been adequately validated by high-quality studies. The treatment of POUR comprises either intermittent or indwelling urethral catheterization. Higher quality prospective studies are needed to allow for the standardization of all aspects of POUR from its diagnostic criteria to its treatment.

Enhanced recovery after surgery for major orthopedic surgery: a narrative review

Background

With increasing interest in enhanced recovery after surgery (ERAS), the literature on ERAS in orthopedic surgery is also rapidly accumulating. This review article aims to (1) summarize the components of the ERAS protocol applied to orthopedic surgery, (2) evaluate the outcomes of ERAS in orthopedic surgery, and (3) suggest practical strategies to implement the ERAS protocol successfully.

Main body

Overall, 17 components constituting the highly recommended ERAS protocol in orthopedic surgery were identified. In the preadmission period, preadmission counseling and the optimization of medical conditions were identified. In the preoperative period, avoidance of prolonged fasting, multimodal analgesia, and prevention of postoperative nausea and vomiting were identified. During the intraoperative period, anesthetic protocols, prevention of hypothermia, and fluid management, urinary catheterization, antimicrobial prophylaxis, blood conservation, local infiltration analgesia and local nerve block, and surgical factors were identified. In the postoperative period, early oral nutrition, thromboembolism prophylaxis, early mobilization, and discharge planning were identified. ERAS in orthopedic surgery reduced postoperative complications, hospital stay, and cost, and improved the patient outcomes and satisfaction with accelerated recovery. For successful implementation of the ERAS protocol, various strategies including the standardization of care system, multidisciplinary communication and collaboration, ERAS education, and continuous audit system are necessary.

Conclusion

The ERAS pathway enhanced patient recovery with a shortened length of stay, reduced postoperative complications, and improved patient outcomes and satisfaction. However, despite the significant progress in ERAS implementation in recent years, it has mainly focused on major surgeries such as arthroplasty. Therefore, further efforts to apply, audit, and optimize ERAS in various orthopedic surgeries are necessary.

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.

The Role of Intraoperative Urinary Catheters on Postoperative Urinary Retention after Total Joint Arthroplasty: A Multi-Hospital Retrospective Study on 9,580 Patients

Background

Urinary catheters (UC) are used by some surgeons during total joint arthroplasty (TJA). This study investigated the impact of intraoperative urinary catheters on postoperative urinary retention (POUR) following TJA cases.

Methods

We conducted a retrospective comparative study across 11 medical centers on 9,580 TJA patients. Visits to urgent care or the emergency department within 7 and 30 postoperative days were reviewed. Medical records over a 12-month period for all patients older than 18 years old were used to gather demographic and surgical data as well as the incidence of urinary tract infection (UTI). Chi-squared tests (RStudio) were used to determine statistical significance against P-Values (P) < 0.05.

Results

13 (0.14%) patients returned within 7 days for POUR. POUR was more common in males [10 (0.3%) vs. 3 (0.1%) females, (P = 0.01)]. There was no difference in POUR when comparing total hip and knee arthroplasty procedures [0.16% vs. 0.12%, (P = 0.60)]. Of all operations, 25% had intraoperative UC use. There was no difference in POUR between the UC and no UC groups [0.21 vs. 0.11%, (P = 0.26)]. However, there was an increase in UTI in UC vs. no UC use within 7 postoperative days [0.92 vs. 0.43%, (P = 0.005)] and 30 postoperative days [2.60 vs. 1.50 %, (P < 0.001)].

Conclusion

In our study, there was no difference in POUR rates between the intraoperative UC vs. no UC groups. Therefore, the use of intraoperative UC may not decrease the rate of POUR following TJA procedures. Additionally, UTI risk was higher in the UC group which may be attributable to other factors, especially when comparing female vs. male patients.

Incidence and Predictive Risk Factors of Postoperative Urinary Retention After Primary Total Knee Arthroplasty

BACKGROUND

Postoperative urinary retention (POUR) after total knee arthroplasty (TKA) may cause urologic injury and delay patient discharge. This study measures the incidence of POUR and identifies predictive risk factors.

METHODS

Two-hundred seventy-one consecutive patients undergoing primary unilateral TKA were prospectively enrolled. Bladder scans were performed in the postanesthesia care unit (PACU) and every four hours thereafter. POUR was defined as >400cc with inability to void and was treated with catheterization. Patient demographics, urologic history, operative data, perioperative medications, and bladder scanner volumes were investigated with the univariate and multivariate logistic regression analysis.

RESULTS

Fifty-five patients (20%) developed POUR. Compared with non-POUR patients, PACU bladder scan volumes were greater in patients who developed POUR (344cc vs 120cc, P < .001). POUR patients had lower BMI (27.8 vs 29.4, P = .03), longer operative duration (83.9 vs 76.0 minutes, P = .002), and lower ASA scores (2.2 vs 2.4, P = .02). Total intravenous fluid was equivalent between groups (1134cc vs 1185cc, P = .41). POUR patients received less narcotics measured by morphine milligram equivalents (16.1 vs 23.9, P < .001). Fifteen variables including spinal type (bupivacaine and ropivacaine) and paralytic use were not predictive of POUR. Potentially predictive variables included anesthetic types administered (spinal, general, regional, and combination) and perioperative administration of nonsteroidal anti-inflammatory drugs (NSAIDs), glycopyrrolate, and muscle relaxants. The multivariate analysis showed that NSAIDs (P = .05) and glycopyrrolate (P = .04) were significant predictors.

CONCLUSION

A significant percentage of patients develop POUR after TKA. Select patient demographics and PACU bladder scanning may identify those at risk. Appropriate pain control and judicious use of perioperative NSAIDs and glycopyrrolate may help minimize the risk of POUR.

Developing an enhanced recovery after surgery program for oncology patients who undergo hip or knee reconstruction surgery

Enhanced recovery after surgery (ERAS) protocols are applied in orthopedic surgery and are intended to reduce perioperative stress by implementing combined evidence-based practices with the cooperation of various health professionals as an interdisciplinary team. ERAS pathways include pre-operative patient counselling, regional anesthesia and analgesia techniques, post-operative pain management, early mobilization and early feeding. Studies have shown improvement in the recovery of patients who followed an ERAS program after hip or knee arthroplasty, compared with those who followed a traditional care approach. ERAS protocols reduce post-operative stress, contribute to rapid recovery, shorten length of stay (LOS) without increasing the complications or readmissions, improve patient satisfaction and decrease the hospital costs. We suggest that the ERAS pathway could reduce the LOS in hospital for patients undergoing total hip replacement or total knee replacement. These programs require good organization and handling by the multidisciplinary team. ERAS programs increase patient's satisfaction due to their active participation which they experience as personalized treatment. The aim of the study was to develop an ERAS protocol for oncology patients who undergo bone reconstruction surgeries using massive endoprosthesis, with a view to improving the surgical outcomes.

Indwelling catheter increases the risk of urinary tract infection in total knee arthroplasty: A meta-analysis of randomized controlled trials

BACKGROUND

The purpose of this meta-analysis was to assess whether a urinary catheter is necessary for all patients in primary total knee arthroplasty (TKA).

METHODS

PubMed, EMBASE, the Cochrane Library, Web of Science, and China National Knowledge Infrastructure were systematically searched for randomized controlled trials (RCTs). All RCTs were compared with receive either an indwelling urinary catheter or no urinary catheter in TKA. Primary outcomes were urinary retention and urinary tract infection. Secondary outcomes were the length of stay, duration of the surgery, and the first urination time.

RESULTS

A total of 6 RCTs involving 1334 patients were included in the meta-analysis. No significant difference between the 2 groups was found in urinary retention (P = .52), length of stay (P = .38), duration of the surgery (P = .55). However, patients with an indwelling catheter were associated with a higher risk of urinary tract infections and longer time for the first urination than patients without indwelling catheters (P = .009 and P = .004).

CONCLUSION

The available evidence indicates that patients without using the indwelling catheters could reduce urinary tract infections and the time for the first urination, without increase in the incidence of urinary retention in primary TKA.

LEVEL OF EVIDENCE

Level I, therapeutic study.

Postoperative urinary retention: risk factors, bladder filling rate and time to catheterization: an observational study as part of a randomized controlled trial

BACKGROUND

Knowledge of risk factors for postoperative urinary retention may guide appropriate and timely urinary catheterization. We aimed to determine independent risk factors for postoperative urinary catheterization in general surgical patients. In addition, we calculated bladder filling rate and assessed the time to spontaneous voiding or catheterization. We used the patients previously determined individual maximum bladder capacity as threshold for urinary catheterization.

METHODS

Risk factors for urinary catheterization were prospectively determined in 936 general surgical patients. Patients were at least 18 years of age and operated under general or spinal anesthesia without the need for an indwelling urinary catheter. Patients measured their maximum bladder capacity preoperatively at home, by voiding in a calibrated bowl after a strong urge that could no longer be ignored. Postoperatively, bladder volumes were assessed hourly with ultrasound. When patients reached their maximum bladder capacity and were unable to void, they were catheterized by the nursing staff. Bladder filling rate and time to catheterization were determined.

RESULTS

Spinal anesthesia was the main independent modifiable risk factor for urinary catheterization (hyperbaric bupivacaine, relative risk 8.1, articaine RR 3.1). Unmodifiable risk factors were a maximum bladder capacity < 500 mL (RR 6.7), duration of surgery ≥ 60 min (RR 5.5), first scanned bladder volume at the Post Anesthesia Care Unit ≥250mL (RR 2.1), and age ≥ 60 years (RR 2.0). Urine production varied from 100 to 200 mL/h. Catheterization or spontaneous voiding took place approximately 4 h postoperatively.

CONCLUSION

Spinal anesthesia, longer surgery time, and older age are the main risk factors for urinary retention catheterization. Awareness of these risk factors, regularly bladder volume scanning (at least every 3 h) and using the individual maximum bladder capacity as volume threshold for urinary catheterization may avoid unnecessary urinary catheterization and will prevent bladder overdistention with the attendant risk of lower urinary tract injury.

TRIAL REGISTRATION

Dutch Central Committee for Human Studies registered trial database: NL 21058.099.07. Current Controlled Trials database: Preventing Bladder Catheterization after an Operation under General or Spinal Anesthesia by Using the Patient's Own Maximum Bladder Capacity as a Limit for Maximum Bladder Volume. ISRCTN97786497 . Registered 18 July 2011 -Retrospectively registered. The original study started 19 May 2008, and ended 30 April 2009, when the last patient was included.

Urinary retention after total joint arthroplasty of hip and knee: Systematic review

PURPOSE

Postoperative urinary retention (POUR) is a common complication after total joint arthroplasties (TJAs). The POUR is managed with urinary catheterization, which is associated with a risk of urinary tract infection and subsequent periprosthetic joint infection. The purpose of this review was to afford a comprehensive understanding of POUR and its management.

METHODS

We identified 15 original articles concerning POUR after TJA, which were published from January 2010 to February 2019. The diagnostic method, incidence, risk factors, and management of POUR of the 15 studies were reviewed.

RESULTS

The incidence of POUR was ranged from 4.1% to 46.3%. Ultrasound was used for the detection of POUR among the total of the 15 studies. The following factors of old age, male gender, benign prostatic hypertrophy, history of urinary retention, spinal/epidural anesthesia, excessive fluid administration, patient-controlled analgesia, the use of opiates, underlying comorbidities, and poor American Society of Anesthesiologists (ASA) grade were risk factors for POUR. Most of the studies did not use indwelling catheterization during surgery. The POUR patients were managed with intermittent catheterization. The most common volume criterion for bladder catheterization was 400 mL. In inevitable use of an indwelling catheter, it should be removed within 48 h.

CONCLUSIONS

This review provided an up-to-date guide for the detection and management of POUR.

LEVEL OF EVIDENCE

Level III.

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

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

Controversial Topics in Total Knee Arthroplasty: A 5-Year Update (Part 1)

This review article examines updates to the literature during the past 5 years on numerous topics related to total knee arthroplasty which were felt to have ongoing controversy. These include the use of peripheral nerve blocks and local infiltrative analgesia, intrathecal morphine, patellar resurfacing, and bearing designs.

Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations

Background and purpose - There is a large volume of heterogeneous studies across all Enhanced Recovery After Surgery (ERAS®) components within total hip and total knee replacement surgery. This multidisciplinary consensus review summarizes the literature, and proposes recommendations for the perioperative care of patients undergoing total hip replacement and total knee replacement with an ERAS program.Methods - Studies were selected with particular attention being paid to meta-analyses, randomized controlled trials, and large prospective cohort studies that evaluated the efficacy of individual items of the perioperative treatment pathway to expedite the achievement of discharge criteria. A consensus recommendation was reached by the group after critical appraisal of the literature.Results - This consensus statement includes 17 topic areas. Best practice includes optimizing preoperative patient education, anesthetic technique, and transfusion strategy, in combination with an opioid-sparing multimodal analgesic approach and early mobilization. There is insufficient evidence to recommend that one surgical technique (type of approach, use of a minimally invasive technique, prosthesis choice, or use of computer-assisted surgery) over another will independently effect achievement of discharge criteria.Interpretation - Based on the evidence available for each element of perioperative care pathways, the ERAS® Society presents a comprehensive consensus review, for the perioperative care of patients undergoing total hip replacement and total knee replacement surgery within an ERAS® program. This unified protocol should now be further evaluated in order to refine the protocol and verify the strength of these recommendations.

The effect of intrathecal bupivacaine/morphine on quality of recovery in robot-assisted radical prostatectomy: a randomised controlled trial

Robot‐assisted radical prostatectomy causes discomfort in the immediate postoperative period. This randomised controlled trial investigated if intrathecal bupivacaine/morphine, in addition to general anaesthesia, could be beneficial for the postoperative quality of recovery. One hundred and fifty‐five patients were randomly allocated to an intervention group that received intrathecal 12.5 mg bupivacaine/300 μg morphine (20% dose reduction in patients > 75 years) or a control group receiving a subcutaneous sham injection and an intravenous loading dose of 0.1 mg.kg⁻¹ morphine. Both groups received standardised general anaesthesia and the same postoperative analgesic regimen. The primary outcome was a decrease in the Quality of Recovery‐15 (QoR‐15) questionnaire score on postoperative day 1. The intervention group (n = 76) had less reduction in QoR‐15 on postoperative day 1; median (IQR [range]) 10% (1–8 [−60% to 50%]) vs. 13% (5–24 [−6% to 50%]), p = 0.019, and used less morphine during the admission; 2 mg (1–7 [0–41 mg]) vs. 15 mg (12–20 [8–61 mg]), p < 0.001. Furthermore, they perceived lower pain scores during exertion; numeric rating scale (NRS) 3 (1–6 [0–9]) vs. 5 (3–7 [0–9]), p = 0.001; less bladder spasms (NRS 1 (0–2 [0–10]) vs. 2 (0–5 [0–10]), p = 0.001 and less sedation; NRS 2 (0–3 [0–10]) vs. 3 (2–6 [0–10]), p = 0.005. Moreover, the intervention group used less rescue medication. Pruritus was more severe in the intervention group; NRS 4 (1–7 [0–10]) vs. 0 (0–1 [0–10]), p = 0.000. We conclude that despite a modest increase in the incidence of pruritus, multimodal pain management with intrathecal bupivacaine/morphine remains a viable option for robot‐assisted radical prostatectomy.

Indwelling Urinary Catheter for Total Joint Arthroplasty Using Epidural Anesthesia

BACKGROUND

The objective of this study was to evaluate if not placing an indwelling urinary catheter leads to a higher potential for adverse genitourinary (GU) issues after total joint arthroplasty (TJA) under epidural anesthesia.

METHODS

Three hundred thirty-five consecutive patients who underwent primary TJA using epidural anesthesia were retrospectively reviewed. The initial 103 patients received a preoperative urinary catheter, which was maintained until the morning of postoperative day 1. The subsequent 232 patients did not receive a preoperative urinary catheter. Demographics, medical complications, GU complications, and length of stay were compared between groups.

RESULTS

Compared between catheter and noncatheter groups, there were no differences in demographics including age, gender, or laterality of surgery. There was a difference in type of surgery (total knee arthroplasty vs total hip arthroplasty) (P = .008). There was no difference in American Society of Anesthesiologists score, but with a difference in body mass index (P = .01). There were no differences in GU complications among patients with benign prostatic hyperplasia or prostate cancer. However, among patients with a history of prostate disorders (benign prostatic hyperplasia or prostate cancer), urinary tract infection rate was higher in catheter group (P = .023). Postoperative GU complications were associated with increased median age in years and increased average length of stay in days.

CONCLUSION

Patients undergoing TJA under epidural anesthesia demonstrate no increased risk of postoperative urological complications without the placement of preoperative indwelling urinary catheter. The routine use of preoperative catheters can be reconsidered for this mode of anesthesia.

LEVEL OF EVIDENCE

Level II, retrospective comparative study.

Identifiable Risk Factors to Minimize Postoperative Urinary Retention in Modern Outpatient Rapid Recovery Total Joint Arthroplasty

BACKGROUND

Postoperative urinary retention (POUR) following total joint arthroplasty (TJA) presents a significant barrier to outpatient and early discharge TJA. This study examined the incidence and risk factors for acute POUR in a modern, evidence-based, outpatient, and early discharge TJA program.

METHODS

Prospectively recorded data on 685 consecutive primary unilateral TJAs discharged the day of or day after surgery were retrospectively reviewed. POUR was diagnosed by a perioperative internal medicine specialist. Univariate analysis of potential predictors was performed, followed by binary logistic regression (BLR) testing of predictors with P ≤ .25.

RESULTS

After exclusions for confounds, the final analysis sample consisted of 633 procedures. The overall incidence of POUR was 5.5% (3.9% for same day discharges). Male gender, history of urinary retention, use of rocuronium, use of glycopryrrolate, use of neostigmine, fentanyl spinals, and the absence of an indwelling urethral catheter were associated with acute POUR and met criteria for entry into multivariate BLR. Seventeen additional predictors, including kidney disease and outpatient surgery were unrelated to POUR. In the final BLR model (P = .001), male patients who received glycopyrrolate with neostigmine had a 34% probability of developing POUR, which declined to 2.8% in the absence of these risk factors.

CONCLUSION

Despite a relatively low incidence of 5.5%, avoidance of anticholinergics and cholinesterase inhibitors during anesthesia should be carefully considered in outpatient TJA, particularly in stand-alone ambulatory surgery centers.

The AAHKS Clinical Research Award: Prophylactic Tamsulosin Does Not Reduce the Risk of Urinary Retention Following Lower Extremity Arthroplasty: A Double-Blinded Randomized Controlled Trial

BACKGROUND

Postoperative urinary retention (POUR) is common. Selective alpha-1 adrenergic antagonists, such as tamsulosin, are effective for treating urinary retention. The purpose of this study is to determine whether perioperative prophylactic tamsulosin reduces the incidence of POUR following total hip and knee arthroplasty.

METHODS

Male patients 35 years of age and older undergoing primary total hip or knee arthroplasty at a single center from 2015 to 2018 were eligible for inclusion. Patients were randomized to receive tamsulosin 0.4 mg or placebo daily for 5 days preoperatively, the morning of surgery, and the first postoperative day. The incidence of POUR was determined during the postoperative hospitalization.

RESULTS

A total of 176 patients were enrolled in the study. Two patients were withdrawn prior to randomization. The remaining 174 were randomized to tamsulosin (n = 87) or placebo (n = 87). After an additional 43 patients were withdrawn prior to surgery, 131 patients completed the study (tamsulosin, n = 64; placebo, n = 67). A total of 42 patients (32.1%) developed POUR, with 18 cases (28.1%) in the tamsulosin group and 24 cases (35.8%) in the placebo group (P = .345), resulting in an odds ratio of 0.701 and a risk difference of 7.69%.

CONCLUSION

Prophylactic tamsulosin did not reduce the incidence of POUR after hip and knee arthroplasty compared to placebo. The odds ratio indicates an approximately 30% decreased odds of developing POUR in the tamsulosin group, albeit not statistically significant. Tamsulosin does not appear to be effective as a prophylactic measure for reducing POUR in male hip and knee arthroplasty 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.

Bladder training prior to urinary catheter removal in total joint arthroplasty. A randomized controlled trial

BACKGROUND

Urinary catheters are commonly used in patients undergoing total hip and knee arthroplasty. Bladder training before catheter removal is reported to shorten the time to return to normal bladder function and reduce the incidence of urinary retention.

OBJECTIVE

To evaluate the results of bladder training in patients with total hip and knee arthroplasty.

DESIGN

Randomized controlled trial.

SETTING

Orthopaedic Department of a tertiary Military Hospital.

PARTICIPANTS

We enrolled consecutive patients undergoing total hip or knee arthroplasty during a period of 14 months.

METHODS

We randomly allocated the participants into either a bladder training group, in which clamping was considered prior to catheter removal, or a free drainage removal group, using a computer-generated list and subsequently assessed their need for re-catheterization due to urinary retention. The primary outcome of this study was to evaluate if bladder training in patients with total hip and knee arthroplasty reduces the need for re-catheterization due to urinary retention. Multivariable logistic regression was used to model the association between postoperative urinary retention and independent variables (total hip or total knee arthroplasty, age, gender, and history of diabetes mellitus or prostatism). Secondary outcomes were the incidence of urinary tract infection, and subjective patients' symptoms.

RESULTS

We included 218 patients in the study; 114 in the bladder training group and 104 in the free drainage removal group. All patients were over 50 years old with a mean age of 69.3 (SD = 8) years. We observed three cases of urinary retention in the bladder training and six in free drainage removal group, and the difference was not statistically significant (2.6% and 5.8% respectively, p = 0.316). We also observed increased odds of re-catheterization in patients with prostatism under medication (odds ratio was 26.42, p < 0.001). No infections or major subjective symptoms were noted.

CONCLUSION

This trial shows that bladder training by catheter clamping offers no advantage over free draining removal of short-term urinary catheters in patients with total hip and knee arthroplasty. Therefore, we conclude that the bladder training procedure is not indicated. However, healthcare providers should monitor patients' urination after removal of the catheter.

Determination of the median effective dose (ED50) of bupivacaine and ropivacaine unilateral spinal anesthesia : Prospective, double blinded, randomized dose-response trial

BACKGROUND

Unilateral spinal anesthesia (USpA) has been reported to potentiate spinal anaesthesia and is used in geriatric patients. The purpose of this study was to determine the median effective dose (ED₅₀) of 0.5% hypobaric bupivacaine and 0.5% hypobaric ropivacaine USpA for geriatric patients (age ≥ 70 years) undergoing elective hip replacement surgery.

METHODS

A total of 60 geriatric patients (age ≥ 70 years) undergoing elective hip replacement surgery were enrolled in this study. The patients were randomized into 2 groups to receive either intrathecal 0.5% hypobaric bupivacaine USpA (group B) or 0.5% hypobaric ropivacaine USpA (group R). Effective anesthesia was defined as a T10 sensory blockade level maintained for more than 60 min, and a Bromage score of 3 on the operation side within 10 min after injection with no additional epidural anesthetic required during surgery. The ED₅₀ of 0.5% hypobaric bupivacaine and 0.5% hypobaric ropivacaine was calculated using the Dixon and Massey formula.

RESULTS

No significant differences were found between the two groups in terms of demographic data. The ED₅₀ of 0.5% hypobaric bupivacaine USpA was 4.66 mg (95% confidence interval CI 4.69-4.63 mg) mg and that of 0.5% hypobaric ropivacaine USpA was 6.43 mg (95% CI 6.47-6.39 mg) for geriatric patients undergoing hip replacement surgery.

CONCLUSION

We find the ED₅₀ were lower, and the ED50 of 0.5% hypobaric bupivacaine and ropivacaine was 4.66 mg (95% CI 4.69-4.63 mg) and 6.43 mg (95% CI 6.47-6.39 mg), respectively, for USpA in geriatric patients (age ≥ 70 years) undergoing elective hip replacement surgery.

Comorbidities Have a Greater Impact Than Age Alone in the Outcomes of Octogenarian Total Knee Arthroplasty

BACKGROUND

Increasing age and various comorbidities are known risk factors for complications after total knee arthroplasty (TKA), but data on the impact of total comorbidity burden is scarce. We investigated the effect of age and total comorbidity burden on outcomes after primary TKA in octogenarians (OGs).

METHODS

A matched-pair comparison study was conducted using prospectively collected TKA registry data in a large tertiary institution. Between 2006 and 2011, consecutive OGs undergoing primary unilateral TKA, with minimum 2-year follow-up, were matched 1:1 with younger controls based on demographic and surgical variables. We compared the Charlson comorbidity index (CCI), complication rate, length of stay (LOS), 30-day readmission, and 2-year reoperation rate. Multivariate analysis was performed to determine the effects of age and CCI on each outcome.

RESULTS

There were 209 OGs and 209 controls. OGs were significantly older (mean age 82.1 vs 66.1 years, P < .001) and had higher CCI. OGs had longer mean LOS (6.3 vs 5.4 days, P = .001), and a trend for more complications and readmissions. The complication rate increased from 7.5% for CCI = 0, to 33.3% for CCI ≥3 (P = .005). The LOS increased from 5.4 days for CCI = 0, to 9.6 days for CCI ≥3 (P < .001). Multivariate analysis showed that higher CCI was an independent risk factor for complications and longer LOS, whereas age was not.

CONCLUSION

Comorbidity burden has a greater impact than age alone on TKA outcomes in OGs. Well-selected OGs remain good candidates for TKA.

History of Nocturia May Guide Urinary Catheterization for Total Joint Arthroplasty

Urinary tract infection is a common complication after total knee arthroplasty (TKA) and can be related to urethral catheterization. This study attempted to determine whether nocturia could be used as an indicator of risk for postoperative urinary retention to limit the need for prophylactic catheterization in men undergoing TKA. A retrospective study was performed in a consecutive series of men undergoing TKA at a single Veterans Affairs medical center. Patients reporting 0 episodes or 1 episode of nocturia per night were not catheterized prophylactically, and patients reporting 2 or more episodes of nocturia each night were catheterized preoperatively. Of 100 consecutive patients, 51 reported no more than 1 episode of nocturia and did not undergo preoperative catheterization. Of these patients, 10 required 1 postoperative straight catheterization for urinary retention. In the 49 patients who were catheterized prophylactically, all catheters were removed on postoperative day 1. Only 1 of these patients required reinsertion of a catheter. No patient in either group was discharged with a catheter or had a urinary tract infection. Previously, the authors' standard protocol was to use a prophylactic urinary catheter for all men after TKA. In this 100-patient cohort, with this new protocol, 41 patients were not catheterized at all and 10 patients had only 1 straight catheterization. In this study, the frequency of nocturia in men undergoing TKA was an effective screening tool that safely reduced the need for an indwelling catheter in 51% of patients. [Orthopedics. 2016; 39(4):e749-e752.].

Regional or general anesthesia for fast-track hip and knee replacement - what is the evidence?

Regional anesthesia for knee and hip arthroplasty may have favorable outcome effects compared with general anesthesia by effectively blocking afferent input, providing initial postoperative analgesia, reducing endocrine metabolic responses, and providing sympathetic blockade with reduced bleeding and less risk of thromboembolic complications but with undesirable effects on lower limb motor and urinary bladder function. Old randomized studies supported the use of regional anesthesia with fewer postoperative pulmonary and thromboembolic complications, and this has been supported by recent large non-randomized epidemiological database cohort studies. In contrast, the data from newer randomized trials are conflicting, and recent studies using modern general anesthetic techniques may potentially support the use of general versus spinal anesthesia. In summary, the lack of properly designed large randomized controlled trials comparing modern general anesthesia and spinal anesthesia for knee and hip arthroplasty prevents final recommendations and calls for prospective detailed studies in this clinically important field.