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Jasinski J, Tong D, Yoon E, Claus C, Lytle E, Houseman C, Bono P, Soo TM. Preventing Postoperative Urinary Retention (POUR) in Patients Undergoing Elective Lumbar Surgery: A Quality Improvement Project. Qual Manag Health Care 2023; 32:270-277. [PMID: 36913773 DOI: 10.1097/qmh.0000000000000394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
BACKGROUND AND OBJECTIVES Postoperative urinary retention (POUR) is associated with significant morbidity. Our institution's POUR rate was elevated among patients undergoing elective lumbar spinal surgery. We sought to demonstrate that our quality improvement (QI) intervention would significantly lower our POUR rate and length of stay (LOS). METHODS A resident-led QI intervention was implemented from October 2017 to 2018 on 422 patients in an academically affiliated community teaching hospital. This consisted of standardized intraoperative indwelling catheter utilization, postoperative catheterization protocol, prophylactic tamsulosin, and early ambulation after surgery. Baseline data on 277 patients were collected retrospectively from October 2015 to September 2016. Primary outcomes were POUR and LOS. The focus, analyze, develop, execute, and evaluate (FADE) model was used. Multivariable analyses were used. P value <.05 was considered significant. RESULTS We analyzed 699 patients (277 pre-intervention vs 422 post-intervention). The POUR rate (6.9% vs 2.6%, Δ confidence interval [CI] 1.15-8.08, P = .007) and mean LOS (2.94 ± 1.87 days vs 2.56 ± 2.2 days, Δ CI 0.066-0.68, P = .017) were significantly improved following our intervention. Logistic regression demonstrated that the intervention was independently associated with significantly decreased odds for developing POUR (odds ratio [OR] = 0.38, CI 0.17-0.83, P = .015). Diabetes (OR = 2.25, CI 1.03-4.92, P = .04) and longer surgery duration (OR = 1.006, CI 1.002-1.01, P = .002) were independently associated with increased odds of developing POUR. CONCLUSIONS After implementing our POUR QI project for patients undergoing elective lumbar spine surgery, the institutional POUR rate significantly decreased by 4.3% (62% reduction) and LOS, by 0.37 days. We demonstrated that a standardized POUR care bundle was independently associated with a significant decrease in the odds of developing POUR.
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Affiliation(s)
- Jacob Jasinski
- Division of Neurosurgery, Ascension Providence Hospital, College of Human Medicine, Michigan State University, Southfield
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Rughani A, Cushing D, Lary CW, Cox S, Jumper B, Johnson N, Florman J. Does tamsulosin decrease postoperative urinary retention in spine surgery? A double-blind, randomized controlled trial. J Neurosurg 2022; 137:1172-1179. [PMID: 35148516 DOI: 10.3171/2021.10.jns212393] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 10/29/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The authors' objective was to determine whether preoperative administration of tamsulosin decreases postoperative urinary retention after spine surgery. METHODS In this randomized, double-blind, placebo-controlled clinical trial performed at a single institution between 2016 and 2019, eligible males aged 50 to 85 years were administered tamsulosin or placebo for 5 days prior to elective spine surgery. Patients were excluded if they were taking alpha adrenergic blocking drugs; were allergic to tamsulosin, lactose, or sulfa drugs; had a preexisting indwelling urinary catheter, orthostatic hypotension, history of urological surgery, or renal failure; or were scheduled for cataract surgery within 2 weeks. Screening identified 1051 eligible patients (140 declined participation, 150 did not meet the inclusion criteria, and 151 did not enroll for other reasons). A total of 610 patients were randomly assigned to receive 0.4 mg oral tamsulosin or an identical placebo capsule for 5 days preoperatively and 2 days postoperatively. RESULTS A total of 497 patients were included in the final statistical analysis. The overall rate of postoperative urinary retention was 9.7%, and tamsulosin had no observed effect on reducing the rate of postoperative urinary retention as compared with placebo (9.4% vs 9.9%, p = 0.96). There were no significant differences in the reported adverse events between groups. Multivariate logistic regression was performed to model the effects of patient, surgical, and anesthetic factors on postoperative urinary retention, and the study drug remained an insignificant factor. CONCLUSIONS This study did not detect an effect of perioperative tamsulosin on reducing the rate of postoperative urinary retention in male patients aged 50 to 85 years who underwent elective spine surgery. This study does not support the routine use of tamsulosin to reduce postoperative urinary retention in patients without a previous prescription. It is unknown if subpopulations exist for which prophylactic tamsulosin may reduce postoperative urinary retention.
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Affiliation(s)
- Anand Rughani
- 1Neuroscience Institute, Maine Medical Center, Portland, Maine
- 2Department of Neurosurgery, Tufts University Medical Center, Boston, Massachusetts
| | - Deborah Cushing
- 1Neuroscience Institute, Maine Medical Center, Portland, Maine
| | - Christine W Lary
- 3Center for Outcomes Research and Education, Maine Medical Center Research Institute, Portland, Maine
| | - Sara Cox
- 1Neuroscience Institute, Maine Medical Center, Portland, Maine
| | - Brian Jumper
- 4Department of Urology, Maine Medical Center, Portland, Maine; and
| | - Nathaniel Johnson
- 5Department of Urology, University of Vermont Medical Center, Burlington, Vermont
| | - Jeffrey Florman
- 1Neuroscience Institute, Maine Medical Center, Portland, Maine
- 2Department of Neurosurgery, Tufts University Medical Center, Boston, Massachusetts
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3
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Elsamadicy AA, Koo AB, Reeves BC, Freedman IG, David WB, Ehresman J, Pennington Z, Laurans M, Kolb L, Sciubba DM. Octogenarians Are Independently Associated With Extended LOS and Non-Routine Discharge After Elective ACDF for CSM. Global Spine J 2022; 12:1792-1803. [PMID: 33511889 PMCID: PMC9609534 DOI: 10.1177/2192568221989293] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE The aim of this study was to determine the impact age has on LOS and discharge disposition following elective ACDF for cervical spondylotic myelopathy (CSM). METHODS A retrospective cohort study was performed using the National Inpatient Sample (NIS) database from 2016 and 2017. All adult patients >50 years old undergoing ACDF for CSM were identified using the ICD-10-CM diagnosis and procedural coding system. Patients were then stratified by age: 50 to 64 years-old, 65 to 79 years-old, and greater than or equal to 80 years-old. Weighted patient demographics, comorbidities, perioperative complications, LOS, discharge disposition, and total cost of admission were assessed. RESULTS A total of 14 865 patients were identified. Compared to the 50-64 and 65-79 year-old cohorts, the 80+ years cohort had a significantly higher rate of postoperative complication (50-64 yo:10.2% vs. 65-79 yo:12.6% vs. 80+ yo:18.9%, P = 0.048). The 80+ years cohort experienced significantly longer hospital stays (50-64 yo: 2.0 ± 2.4 days vs. 65-79 yo: 2.2 ± 2.8 days vs. 80+ yo: 2.3 ± 2.1 days, P = 0.028), higher proportion of patients with extended LOS (50-64 yo:18.3% vs. 65-79 yo:21.9% vs. 80+ yo:28.4%, P = 0.009), and increased rates of non-routine discharges (50-64 yo:15.1% vs. 65-79 yo:23.0% vs. 80+ yo:35.8%, P < 0.001). On multivariate analysis, age 80+ years was found to be a significant independent predictor of extended LOS [OR:1.97, 95% CI:(1.10,3.55), P = 0.023] and non-routine discharge [OR:2.46, 95% CI:(1.44,4.21), P = 0.001]. CONCLUSIONS Our study demonstrates that octogenarian age status is a significant independent risk factor for extended LOS and non-routine discharge after elective ACDF for CSM.
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Affiliation(s)
- Aladine A. Elsamadicy
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
- Aladine A. Elsamadicy, Department of
Neurosurgery, Yale University School of Medicine, 333 Cedar Street, New Haven,
CT 06520, USA.
| | - Andrew B. Koo
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Benjamin C. Reeves
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Isaac G. Freedman
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Wyatt B. David
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Jeff Ehresman
- Department of Neurosurgery, John Hopkins School of Medicine, Baltimore, MD, USA
| | - Zach Pennington
- Department of Neurosurgery, John Hopkins School of Medicine, Baltimore, MD, USA
| | - Maxwell Laurans
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Luis Kolb
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Daniel M. Sciubba
- Department of Neurosurgery, John Hopkins School of Medicine, Baltimore, MD, USA
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Brant JE, Smith S, Radoslovich SS, Wyland A, Walker JR, Lieberman EG, Yoo JU. Effects of delayed postoperative void and preoperative urologic symptoms on delay in time of discharge for elective lumbar decompression surgery. Spine J 2022; 22:810-818. [PMID: 34963631 DOI: 10.1016/j.spinee.2021.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 11/19/2021] [Accepted: 12/20/2021] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Jason E Brant
- Department of Orthopaedics & Rehabilitation, Oregon Health & Science University, Sam Jackson Hall, Suite 2360, 3181 S.W. Sam Jackson Park Rd, Portland, OR 97239, USA
| | - Spencer Smith
- Department of Orthopaedics & Rehabilitation, Oregon Health & Science University, Sam Jackson Hall, Suite 2360, 3181 S.W. Sam Jackson Park Rd, Portland, OR 97239, USA
| | - Stephanie S Radoslovich
- Department of Orthopaedics & Rehabilitation, Oregon Health & Science University, Sam Jackson Hall, Suite 2360, 3181 S.W. Sam Jackson Park Rd, Portland, OR 97239, USA
| | - Alden Wyland
- Department of Orthopaedics & Rehabilitation, Oregon Health & Science University, Sam Jackson Hall, Suite 2360, 3181 S.W. Sam Jackson Park Rd, Portland, OR 97239, USA
| | - Jorge R Walker
- Department of Orthopaedics & Rehabilitation, Oregon Health & Science University, Sam Jackson Hall, Suite 2360, 3181 S.W. Sam Jackson Park Rd, Portland, OR 97239, USA
| | - Elizabeth G Lieberman
- Department of Orthopaedics & Rehabilitation, Oregon Health & Science University, Sam Jackson Hall, Suite 2360, 3181 S.W. Sam Jackson Park Rd, Portland, OR 97239, USA
| | - Jung U Yoo
- Department of Orthopaedics & Rehabilitation, Oregon Health & Science University, Sam Jackson Hall, Suite 2360, 3181 S.W. Sam Jackson Park Rd, Portland, OR 97239, USA.
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Tan CMP, Kaliya-Perumal AK, Ho GWK, Oh JYL. Postoperative Urinary Retention Following Thoracolumbosacral Spinal Fusion: Prevalence, Risk Factors, and Outcomes. Cureus 2021; 13:e19724. [PMID: 34934587 PMCID: PMC8684364 DOI: 10.7759/cureus.19724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2021] [Indexed: 11/18/2022] Open
Abstract
Objective Postoperative urinary retention (POUR) is an often-underestimated common complication following spine surgery, and it is essential to avoid its untoward long-term consequences. Besides, a dilemma exists regarding the appropriate timing for the postoperative removal of indwelling catheter (IDC). Hence, we aim to describe the prevalence, risk factors, and outcomes of POUR and also come up with recommendations for the removal of IDC. Methods Electronic records of patients who underwent elective thoracolumbosacral spinal fusion surgery from January 2017 to December 2019 were retrospectively reviewed. Excluded were those who underwent fusion for indications such as trauma, cauda equina syndrome, infection, and malignancy. Both surgery-related and patient-related risk factors were tabulated, and their association with the likely development of POUR was assessed by univariate and multivariate analysis. Results One hundred sixty-eight patients (median age=64.1 years; 58.9% female) were included, with the incidence of POUR being 7.8%. Our findings suggest surgery-related factors, both intra- and postoperative, including operating time (p=0.008), anesthetic time (p=0.005), number of fusion levels (p<0.001), mobilization status prior to trial off catheter (TOC; p=0.021), and TOC timing (p=0.029) may have an association with POUR. In addition, patient-related factors, including the use of beta-blockers (p=0.020) and pre-operative mobility status (p<0.001), may also be associated with the likely development of POUR. Conclusion POUR seems to be a frequent complication following thoracolumbosacral spinal fusion surgery, which was found to have an association with some surgery-related and patient-related factors. While most of these factors are non-modifiable, certain modifiable risk factors provide the surgeon an opportunity to prevent POUR. Considering these factors, we recommend appropriate and timely mobilization of the patient prior to removal of IDC, which is to be performed preferably in the daytime.
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Affiliation(s)
| | | | - Glen Wen Kiat Ho
- Orthopaedic Surgery, Yong Loo Lin School of Medicine, Singapore, SGP
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Risk factors for postoperative urinary retention following elective spine surgery: a meta-analysis. Spine J 2021; 21:1802-1811. [PMID: 34015508 DOI: 10.1016/j.spinee.2021.05.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 04/18/2021] [Accepted: 05/07/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Limited studies have investigated risk factors for postoperative urinary retention (POUR) following elective spine surgery. Furthermore, some discrepancies have been found in the results of existing observational studies. PURPOSE This study aimed to review the available literature on risk factors associated with POUR following elective spine surgery. STUDY DESIGN A systematic review with meta-analysis was performed. PATIENT SAMPLE A total of 31,251 patients (POUR=2,858, no POUR=28,393) were included in the meta-analysis. OUTCOME MEASURES Demographics, type of elective spine surgery, country, definition of POUR, and potential risk factors for POUR were evaluated. METHODS The Cochrane Library, Embase, and Medline electronic databases were searched to identify relevant studies. Binary outcomes were reported as odds ratio (OR). Weighted mean differences (WMD) or standardized mean differences (SMD), with 95% confidence intervals (CI), were used for meta-analysis of continuous outcomes. RESULTS Eleven studies (2 prospective and 9 retrospective) were included in the analysis. Patients with POUR were older than those without POUR (WMD, 7.13; 95% CI, 4.50-9.76). Male patients were found to have an increased risk of POUR (OR, 1.31; 95% CI, 1.04-1.64). The following variables were also identified as significant risk factors for POUR: benign prostatic hyperplasia (BPH; OR, 3.79; 95% CI, 1.89-7.62), diabetes mellitus (DM; OR, 1.50; 95% CI, 1.17-1.93), and previous urinary tract infection (UTI; OR, 1.70; 95% CI, 1.28-2.24). Moreover, longer operative time (WMD, 19.88; 95% CI, 5.01-34.75) and increased intraoperative fluid support (SMD, 0.37; 95% CI, 0.23-0.52) were observed in patients with POUR. In contrast, spine surgical procedures involving fewer levels (OR, 0.75; 95% CI, 0.65-0.86), and ambulation on the same day as surgery (OR, 0.65; 95% CI, 0.52-0.81) were associated with a decreased risk of POUR. CONCLUSIONS Based on our meta-analysis, older age, male gender, BPH, DM, and a history of UTI are risk factors for POUR following elective spine surgery. We also found that longer operative time and increased intravenous fluid support would increase the risk of POUR. Additionally, multi-level spine surgery may have a negative effect on postoperative voiding.
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Key Words
- CAD, coronary artery disease
- CI, confidence Interval
- DM, diabetes mellitus
- Elective surgery
- IAP, intra-abdominal pressure
- IQR, interquartile range
- Meta-analysis Abbreviations: BPH, benign prostatic hyperplasia
- OR, odds ratio
- POUR, postoperative urinary retention
- PVR, post-void residual
- Postoperative urinary retention
- Risk factor
- SD, standard deviation
- SMD, standardized mean differences
- Spine surgery
- Systematic review
- UTI, urinary tract infection
- WMD, weighted mean difference
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Bowman JJ, Edwards CC, Dean C, Park J, Edwards CC. Incidence and Risk Factors for Postoperative Urinary Retention Following Lumbar Spine Fusion. Clin Spine Surg 2021; 34:E397-E402. [PMID: 34050045 DOI: 10.1097/bsd.0000000000001202] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 04/07/2021] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN This was a prospective cohort study (observational-retrospective chart review). OBJECTIVE The objective of this study was to determine clinical rates and correlations of postoperative urinary retention (POUR) in elective spine decompression and fusion procedures. SUMMARY OF BACKGROUND DATA POUR is a common postoperative complication that often has a major adverse impact on a patient's recovery from elective lumbar spine surgery. The etiology of POUR in most cases is unknown. Patients undergoing lumbar spine surgery are considered to be at increased risk for POUR due to prone positioning during surgery and intraoperative cauda equina nerve root manipulation. Current studies reporting on POUR after elective spine surgery provide limited insight regarding risk factors and effective prevention strategies for this at-risk population. The purpose of this study is to identify risk factors for POUR after elective lumbar spine surgery and strategies for reducing its incidence. MATERIALS AND METHODS Two hundred consecutive patients aged 50 years or older undergoing combined lumbar decompression and fusion procedures over a 5-month period at a single institution were prospectively observed. Demographic and clinical data were prospectively recorded, including: medical history, surgical data, medications administered, complications, and postoperative hospital course. Factors correlating with POUR through a univariate analysis with P≤0.20 were considered for multivariate analysis. RESULTS POUR occurred in 19 of 200 patients. Those with POUR were more likely to be male (20% vs. 4%, odds ratio=6.2). Administration of scopolamine (P=0.02), neostigmine (P=0.01), and the total number of levels operated on (P=0.02) were found to be independent risk factors for the development of POUR. Length of surgery, surgical level, the performance of an interbody fusion did not have a bearing on the development of POUR (P>0.05). DISCUSSION We describe a single institution's experience of POUR incidence in 200 consecutive patients aged 50 years or older undergoing single or multilevel lumbar spine fusion procedures by 1 of 4 surgeons. Specific demographic and clinical risk factors were identified and a codified classification for POUR in a surgical population is presented.The results of this study will help clinicians appropriately counsel patients undergoing elective lumbar fusion about the potential development of POUR. The perioperative administration of scopolamine and neostigmine should be cautiously considered in men over 50 years of age due to the increased POUR risk. CONCLUSIONS Perioperative scopolamine and neostigmine administration in men over 50 should be avoided when possible to minimize the risk of POUR. LEVEL OF EVIDENCE Level III.
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Leitner L, Wanivenhaus F, Bachmann LM, Liechti MD, Aguirre JA, Farshad M, Kessler TM. Bladder management in patients undergoing spine surgery: An assessment of care delivery. NORTH AMERICAN SPINE SOCIETY JOURNAL 2021; 6:100059. [PMID: 35141624 PMCID: PMC8820009 DOI: 10.1016/j.xnsj.2021.100059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 03/30/2021] [Accepted: 03/30/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND Lower urinary tract dysfunction is common in the early postoperative phase after spine surgery. Although it is essential for an optimal patient management to balance benefits and harms, it is not known which patient benefit from a perioperative indwelling catheter. We therefore evaluated urological parameters prior and after spine surgery performing a quality assessment of our current clinical practice in bladder management. METHODS Preoperatively, all patients completed the International Prostate Symptom Score and were interviewed for urological history. Decision for preoperative urethral catheter placement was individually made by the responsible anesthesiologist according to an in-house protocol. Within and between group analyses using univariate and probability matching statistics were performed for patients with intraoperative urethral catheter-free management (n = 54) and those with a preoperatively placed catheter (n = 46). Post void residual (PVR) was measured prior and after surgery or after removal of the urethral catheter, respectively. The outcome measures consisted of postoperative urinary retention (POUR) and postoperative urological complications (PUC), defined as POUR and any catheter-related adverse events. RESULTS Hundred patients undergoing spine surgery were prospectively evaluated. Sixteen of the 54 (30%) patients with urethral catheter-free management developed POUR. Length of surgery and volume of intravenous infusion were associated with POUR (p < 0.05). In the 46 preoperatively catheterized patients, re-catheterization was required in 6 (13%). In a fairly homogenous subgroup of 72 patients with a probability of PUC between 15 and 40%, no significant association between intraoperative urethral catheter-free management and the occurrence of PUC was found (odds ratio 2.09, 95% confidence interval 0.69 to 6.33; p = 0.193). CONCLUSIONS In case of postoperative PVR monitoring allowing de novo catheterization as appropriate, urethral catheter-free management seems to be a valuable option in spine surgery since it does not to increase PUC but minimizes unnecessary catheterizations with their related complications.
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Affiliation(s)
- Lorenz Leitner
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Florian Wanivenhaus
- Spine Division, Department of Orthopedics, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | | | - Martina D. Liechti
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - José A. Aguirre
- Department of Anesthesia, Intensive Care and Pain Therapy, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Mazda Farshad
- Spine Division, Department of Orthopedics, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Thomas M. Kessler
- Department of Neuro-Urology, Balgrist University Hospital, University of Zürich, Zürich, Switzerland
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Shuai M, Li Y. Indwelling catheter increases the risk of urinary tract infection in total knee arthroplasty: A meta-analysis of randomized controlled trials. Medicine (Baltimore) 2021; 100:e25490. [PMID: 33847659 PMCID: PMC8052073 DOI: 10.1097/md.0000000000025490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 03/23/2021] [Indexed: 01/04/2023] Open
Abstract
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.
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Affiliation(s)
- Mingying Shuai
- Department of Obstetric Nursing, West China Second University Hospital, Sichuan University/West China School of Nursing, Sichuan University
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
| | - Yueping Li
- Department of Obstetric Nursing, West China Second University Hospital, Sichuan University/West China School of Nursing, Sichuan University
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan, China
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10
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Doherty RJ, Wahood W, Yolcu YU, Zreik J, Goyal A, Gazelka HM, Habermann EB, Sebastian A, Bydon M. Chronic opioid use is associated with increased postoperative urinary retention, length of stay and non-routine discharge following lumbar fusion surgery. Clin Neurol Neurosurg 2020; 197:106161. [PMID: 32854090 DOI: 10.1016/j.clineuro.2020.106161] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 08/13/2020] [Accepted: 08/16/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND The incidence of chronic opioid use (COU) is increasing with health related complications impacting both patients and healthcare services. OBJECTIVE The aim of this study was to identify the impact of COU on postoperative urinary retention (PUR) in patients following lumbar fusion surgery as well as its impact on length of stay (LOS) and non-routine discharges (NRD). MATERIALS & METHODS The State Inpatient Databases were utilised to identify patients undergoing elective lumbar fusion procedures. Patients with and without COU were separated into groups and matched using 3:1 propensity score matching. PUR, LOS in the upper quartile and discharge to a location other than home were the outcomes of interest. Multivariable logistic regression was used to examine the impact of COU on the above outcomes and Wald chi-square tests were used to determine the factors with the most significant associations. RESULTS COU was significant for PUR (p = 0.037), prolonged LOS (p < 0.001), and NRD (p < 0.001). Factors most significantly associated with PUR were Elixhauser Mortality Index and COU both with p < 0.05. Factors associated with prolonged LOS and NRD were Elixhauser Mortality Index, COU, and insurance status. CONCLUSION COU has a notable impact on PUR, LOS, and NRD. The Elixhauser Mortality Index and insurance status of patients also showed predictive utility for these outcomes. This knowledge enables us to identify sources of pressure for health services and approach them strategically through increased awareness.
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Affiliation(s)
- Ronan J Doherty
- School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland; Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA; Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Waseem Wahood
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA; Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA; Dr. Kiran C. Patel College of Allopathic Medicine, Nova Southeastern University, Davie, FL, USA
| | - Yagiz U Yolcu
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA; Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Jad Zreik
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA; Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Anshit Goyal
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA; Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Halena M Gazelka
- Division of Pain Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Elizabeth B Habermann
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery Surgical Outcomes Program, Mayo Clinic, Rochester, MN, USA
| | - Arjun Sebastian
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Mohamad Bydon
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA; Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA.
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Karani R, Mahdy A, Asghar F. Postoperative Urinary Retention in Patients Who Undergo Joint Arthroplasty or Spine Surgery. JBJS Rev 2020; 8:e18.00040. [PMID: 32759614 DOI: 10.2106/jbjs.rvw.18.00040] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
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.
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Affiliation(s)
- Rajiv Karani
- University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Ayman Mahdy
- Departments of Urology (A.M.) and Orthopaedic Surgery (F.A.), University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Ferhan Asghar
- Departments of Urology (A.M.) and Orthopaedic Surgery (F.A.), University of Cincinnati Medical Center, Cincinnati, Ohio
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12
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Knight BA, Bayne AP, Zusman N, Barney N, Yang S. Postoperative management factors affect urinary retention following posterior spinal fusion for adolescent idiopathic scoliosis. Spine Deform 2020; 8:703-709. [PMID: 32077085 DOI: 10.1007/s43390-020-00090-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 01/03/2020] [Indexed: 12/31/2022]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES This study investigates postoperative urinary retention (POUR) following posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) and the effects of postoperative analgesia and mobility on retention. High opioid use and decreased postoperative mobility are proposed risk factors for retention in adults. There is a paucity of literature on POUR in the adolescent population undergoing surgery for AIS. The impact of pain control and mobility on POUR in these patients is unknown. METHODS A retrospective cohort study was conducted of adolescents (11-18 years) undergoing elective PSF for AIS at a single institution (2012-2018). POUR was defined as the inability to void > 8 h after catheter removal. Possible risk factors for retention including opioid usage and ambulatory status at the time of catheter removal were assessed on univariate and binomial logistic regression analyses. RESULTS One hundred and thirty-six patients were included, with 21 (15.4%) experiencing POUR. On the day of catheter removal, 24 patients had not attempted ambulation; these patients had 2.5 times higher rate of POUR than those who were walking (30% vs. 12%, p = 0.04). Patients who developed retention ambulated a mean threefold shorter distance than those without POUR (45 vs. 136 feet, p = 0.04). On binomial logistic regression, decreased ambulation distance was associated with retention (p = 0.038). While opioid use was not significant on univariate analysis, higher opioid use on the day of catheter removal predicted retention on logistic regression (p = 0.001). POUR resolved in all patients (median duration 0.5 days, range 0-12 days). CONCLUSIONS The development of POUR after PSF for AIS affects one in six patients but resolves quickly. Non-ambulatory patients and patients who received large doses of opioids on the day of catheter removal were more likely to develop POUR. LEVEL OF EVIDENCE III.
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Affiliation(s)
- B Alexander Knight
- Department of Urology, Doernbecher Children's Hospital, Oregon Health and Science University, Portland, OR, USA
| | - Aaron P Bayne
- Department of Urology, Doernbecher Children's Hospital, Oregon Health and Science University, Portland, OR, USA
| | - Natalie Zusman
- Department of Orthopaedics, Doernbecher Children's Hospital, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Mail Code CDW6, Portland, OR, 97239, USA
| | - Nicole Barney
- Department of Orthopaedics, Doernbecher Children's Hospital, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Mail Code CDW6, Portland, OR, 97239, USA
| | - Scott Yang
- Department of Orthopaedics, Doernbecher Children's Hospital, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Mail Code CDW6, Portland, OR, 97239, USA.
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13
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Cremins M, Vellanky S, McCann G, Mancini M, Sanzari L, Yannopoulos A. Considering healthcare value and associated risk factors with postoperative urinary retention after elective laminectomy. Spine J 2020; 20:701-707. [PMID: 32006710 DOI: 10.1016/j.spinee.2020.01.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 01/10/2020] [Accepted: 01/27/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND Mitigating common complications such as postoperative urinary retention (POUR) following elective spine surgery is prudent. Identifying patients at risk for POUR and recognizing associated factors, to avoid a more complicated postoperative episode should be a priority and easily achievable. Understanding the financial burden of complications, such as POUR, is also important for value-based healthcare, not only for providers, but for employers and payors as well. PURPOSE The purpose of this study is to examine patient and surgical factors that may lead to increased risk for POUR and its associated cost following elective lumbar laminectomies. STUDY DESIGN/SETTING This is a retrospective study of the incidence of postoperative urinary retention after elective one- and two-level primary lumbar laminectomies. PATIENT SAMPLE We followed patients undergoing one- and two-level primary elective lumbar laminectomies performed between April 2014 and December 2016. OUTCOME MEASURES Patient factors included age, gender, body-mass index, and comorbidities. Surgical factors included surgical time, intraoperative fluid volume requirements, anesthesia type, and surgical levels involved. Other outcome variables included length of stay, discharge disposition, 30-day all-cause readmissions and emergency department visits, 90-day complications, and variable direct costs. METHODS The incidence of POUR was evaluated and compared with patient and surgical factors and cost-specific variables to identify correlations and potential risk for POUR after one- and two-level primary lumbar laminectomies. RESULTS Analysis included 333 patients - 203 one-level laminectomies and 130 two-level laminectomies. The overall incidence of POUR was 17.4%. Age, male gender, and history of urinary retention were significantly associated with POUR. There was a significantly increased risk of POUR with increased surgical time, but not with anesthesia type. There were also no significant differences in body-mass index, other study comorbidities, intraoperative fluid requirements, readmission, emergency department visit, and complication rates between groups. On average, patients with POUR had a significantly longer length of stay than patients without POUR. In addition, more POUR patients were discharged to acute rehabilitation facilities and had higher average variable direct cost compared tonon-POUR patients. CONCLUSIONS POUR is a significant risk after elective laminectomy. This study supports several widely accepted beliefs regarding POUR risk, while challenging others. It also highlights the burden of POUR development after surgery. At our institution, we developed a protocol supported by these findings.
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Affiliation(s)
- Michael Cremins
- Frank H. Netter M.D. School of Medicine at Quinnipiac University, 370 Bassett Rd, North Haven, CT 06473, USA
| | - Smitha Vellanky
- Frank H. Netter M.D. School of Medicine at Quinnipiac University, 370 Bassett Rd, North Haven, CT 06473, USA
| | - Grace McCann
- Frank H. Netter M.D. School of Medicine at Quinnipiac University, 370 Bassett Rd, North Haven, CT 06473, USA.
| | - Michael Mancini
- Spine Institute of Connecticut, Saint Francis Hospital and Medical Center, 114 Woodland St, Hartford, CT 06105, USA
| | - Laura Sanzari
- Frank H. Netter M.D. School of Medicine at Quinnipiac University, 370 Bassett Rd, North Haven, CT 06473, USA
| | - Aris Yannopoulos
- Musculoskeletal Outcomes Institute, Saint Francis Hospital and Medical Center, 114 Woodland St, Hartford, CT 06105, USA
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Lower Urinary Tract Symptoms and Urinary Bother Are Common in Patients Undergoing Elective Cervical Spine Surgery. Clin Orthop Relat Res 2019; 477:872-878. [PMID: 30844824 PMCID: PMC6437367 DOI: 10.1097/corr.0000000000000666] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Lower urinary tract symptoms (LUTS) and urinary bother have been reported in adults undergoing surgery and have been associated with urinary tract infections, longer hospital stays, increased surgical costs, and decreased patient satisfaction. Previous reports indicate that up to one in two patients with lumbar spine pathology have moderate-to-severe LUTS, but little is known about LUTS in patients with cervical spine conditions. QUESTIONS/PURPOSES (1) What is the prevalence of moderate-to-severe LUTS and clinically relevant urinary bother among patients undergoing elective cervical spine surgery? (2) Does the presence of myelopathy affect frequency of moderate-to-severe LUTS or clinically relevant urinary bother among patients undergoing elective cervical spine surgery? (3) Do MRI findings of spinal cord injury or compression correlate with presence and severity of LUTS? METHODS We performed a cross-sectional study using clinical data collected from adult patients undergoing elective cervical spine surgery. Over an approximately 30-month period, we approached all patients who were evaluated in the preoperative clinic before undergoing elective cervical spine surgery. Of the 257 approached, 242 participated (94%). Study participants ranged in age from 34 to 83 years with a mean age of 58 years (SD 12). There were 108 males (45%) and 134 females (55%). A validated questionnaire, the International Prostate Symptom Score (IPSS), was used to identify LUTS. The IPSS score ranges from 0 to 35 points with LUTS presence defined as a score of ≥ 8 and LUTS severity categorized as mild (IPSS 0-7), moderate (IPSS 8-19), or severe (IPSS 20-35). Quality of life resulting from urinary bother is scored 0 to 6 with scores ≥ 4 considered clinically relevant urinary bother. Patients were grouped into a myelopathy group and a nonmyelopathy group based on diagnosis as assigned by the operating surgeon. MRIs were analyzed by one spine surgeon to identify the presence of cord signal, number of levels with cord compression (mm), and a calculated compression ratio score with cord compression and with compression ratio among patients with myelopathy. RESULTS The prevalence of moderate LUTS in our patient sample was 40% (97 of 242; 95% confidence interval [CI], 34%-47%). The prevalence of severe LUTS in our patient sample was 8% (19 of 242; 95% CI, 5%-12%). Clinically relevant urinary bother was reported in 18% of patients (41 of 228; 95% CI, 13%-24%). After adjustment for age and sex, the odds of moderate-to-severe LUTS among patients with myelopathy was greater than that observed in patients without myelopathy (adjusted odds ratio, 2.0; p = 0.015). The prevalence of clinically relevant urinary bother was higher in patients with myelopathy (30% [26 of 88]) compared with those with no myelopathy (11% [15 of 140]; p < 0.001). With the numbers available, among patients with myelopathy, there was no difference in distribution of LUTS symptom severity or IPSS score according to cord signal presence (50% [23 of 46]) and absence (65% [31 of 48]; p = 0.153), number of levels with compression (70% [seven of 10 with four levels]; 59% [13 of 22 with three levels]; 51% [19 of 37] with two levels; and 60% [15 of 25] with one level; p = 0.730), millimeters of cord compression (r = 0.02; p = 0.854), or compression ratio (r = 0.09; p = 0.413). CONCLUSIONS Nearly half of all patients undergoing elective cervical spine surgery had moderate-to-severe LUTS. This is more than double the prevalence that has been reported in a community-dwelling adult population. These symptoms can impair quality of life, lead to surgical complications (urinary retention or incontinence), and may be mistaken for cauda equina, prompting potentially unnecessary imaging and studies. Given that urinary bother is reported less frequently than LUTS, patients may be less likely to seek care for urinary symptoms before undergoing surgery. Therefore, it is important to increase provider awareness of the high prevalence of LUTS. LEVEL OF EVIDENCE Level III, prognostic study.
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15
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Aiyer SN, Kumar A, Shetty AP, Kanna RM, Rajasekaran S. Factors Influencing Postoperative Urinary Retention Following Elective Posterior Lumbar Spine Surgery: A Prospective Study. Asian Spine J 2018; 12:1100-1105. [PMID: 30322244 PMCID: PMC6284120 DOI: 10.31616/asj.2018.12.6.1100] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 04/17/2018] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
| | - Ajit Kumar
- Department of Spine Surgery, Ganga Hospital, Coimbatore, India
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16
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Golubovsky JL, Ilyas H, Chen J, Tanenbaum JE, Mroz TE, Steinmetz MP. Risk factors and associated complications for postoperative urinary retention after lumbar surgery for lumbar spinal stenosis. Spine J 2018; 18:1533-1539. [PMID: 29447854 DOI: 10.1016/j.spinee.2018.01.022] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 01/02/2018] [Accepted: 01/19/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Postoperative urinary retention (POUR) is a very common postoperative complication of all surgeries (5%-70%) that may lead to complications such as urinary tract infection (UTI), bladder overdistension, autonomic dysregulation, and increased postoperative length of stay (LOS). Within the field of spine surgery, the reported incidence rate of POUR is highly variable (5.6%-38%). Lack of clear stratification of surgical level, spinal pathology, and inadequate sample size are major limitations of available studies concerning POUR following spine surgery, which may lead to inconsistency in the incidence of POUR and the ability to model its occurrence and consequences. PURPOSE This study examines the incidence, predictive factors, and complications of POUR in patients undergoing elective posterior lumbar decompression with or without fusion for lumbar stenosis to eliminate bias from studying procedures done in different anatomical regions and with different approaches. Additionally, this study intends to identify the consequences of POUR. STUDY DESIGN AND SETTING A retrospective consecutive cohort analysis was performed to examine patients undergoing posterior lumbar decompression who did and did not develop POUR. PATIENT SAMPLE All patients undergoing posterior lumbar decompression with or without fusion for lumbar stenosis with claudication from January 2014 through December 2015 at our institution were evaluated. Patients under the age of 18 and patients with spinal malignancies or infections were excluded. OUTCOME MEASURES Physiological measures included identification of POUR by evidence of reinsertion of a Foley catheter, use of straight catheterization postoperatively, or by a clear medical diagnosis with pharmacologic treatment. Other physiological measures included identification of development of UTI, sepsis, acute kidney injury (AKI), surgical site infection (SSI), or readmission within 90 days after surgery, as well as LOS and discharge disposition. METHODS The electronic medical record was searched for all patients meeting inclusion and exclusion criteria. Postoperative urinary retention was defined as reinsertion of a Foley catheter, use of straight catheterization postoperatively, or a clear medical diagnosis with pharmacologic treatment. Statistical analysis was performed in R statistical software package version 3.3.2. Multiple variable selection techniques were used to determine appropriate variables for regression models, and logistic models were fit to the development of POUR and postoperative complications, whereas a linear regression model was used for LOS. RESULTS Data were collected on 1,592 consecutive patients. Among the sample population, the mean age at surgery was 67 (standard deviation 10.1) and 45% of patients were women. The incidence rate of POUR was 17.1% (273/1592). Increased age (odds ratio [OR]=1.04; 95% confidence interval [CI], 1.02-1.06; p<.001), benign prostatic hyperplasia (BPH) (OR=1.92; 95% CI, 1.32-2.78); p<.001), previous AKI (OR=3.29; 95% CI, 1.11-9.29; p=.025), and previous UTI (OR=1.69; 95% CI, 1.24-2.24; p<.001) significantly increased the probability of developing POUR. Factors including increased body mass index, coronary artery disease, congestive heart failure, diabetes mellitus, chronic obstructive pulmonary disease, tobacco use, and fusion were found to be non-significant and were excluded from the model. With respect to complications, POUR was found to be associated with development of UTI (OR=4.50; 95% CI, 3.14-6.45; p<.001), sepsis (OR=4.05; 95% CI, 1.16-13.55; p=.022), increased LOS (p<.001), increased likelihood to be discharged to a skilled nursing facility (SNF) (OR of discharge to home=0.44; 95% CI, 0.32-0.62; p<.001), and increased risk of readmission within 90 days of the index surgery (OR=1.60; 95% CI, 1.11-2.26; p=.009). Development of POUR did not increase the risk of developing AKI (OR=2.45; 95% CI, 0.93-6.30; p=.063) or a SSI (OR=1.09; 95% CI, 0.56-2.02; p=.79). CONCLUSIONS Overall, POUR was a significant risk factor for the development of UTI, sepsis, increased LOS, discharge to a SNF, and readmission within 90 days. Surgeons and anesthesiologists should take preventative measures against POUR in individuals with increased age, BPH, AKI, and UTI within 90 days before surgery, as these factors were found to significantly increase the risk of POUR.
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Affiliation(s)
- Joshua L Golubovsky
- Center for Spine Health, Cleveland Clinic, Cleveland Clinic Lerner College of Medicine, 9980 Carnegie Ave, Cleveland, OH 44195, USA.
| | - Haariss Ilyas
- Department of Orthopaedic Surgery, Center for Spine Health, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Jinxiao Chen
- Department of Epidemiology and Biostatistics, Case Western Reserve University, 2109 Adelbert Rd, Cleveland, OH 44106, USA
| | - Joseph E Tanenbaum
- Department of Epidemiology and Biostatistics, Center for Spine Health, Cleveland Clinic, Case Western Reserve University School of Medicine, 2109 Adelbert Rd, Cleveland, OH 44106, USA
| | - Thomas E Mroz
- Department of Orthopaedic Surgery, Center for Spine Health, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Michael P Steinmetz
- Department of Neurological Surgery, Center for Spine Health, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
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Blackwell RH, Vedachalam S, Shah AS, Kothari AN, Kuo PC, Gupta GN, Turk TMT. Postoperative Urinary Retention is an Independent Predictor of Short-Term and Long-Term Future Bladder Outlet Procedure in Men. J Urol 2017. [PMID: 28624526 DOI: 10.1016/j.juro.2017.06.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Robert H Blackwell
- Department of Urology, Loyola University Medical Center, Maywood, Illinois; One:MAP Division of Clinical Informatics and Analytics, Loyola University Medical Center, Maywood, Illinois; Surgical Services, Edward Hines Jr. Veterans Administration Medical Center, Hines, Illinois.
| | - Srikanth Vedachalam
- One:MAP Division of Clinical Informatics and Analytics, Loyola University Medical Center, Maywood, Illinois; Chicago College of Osteopathic Medicine, Midwestern University, Downers Grove, Illinois
| | - Arpeet S Shah
- Department of Urology, Loyola University Medical Center, Maywood, Illinois; Surgical Services, Edward Hines Jr. Veterans Administration Medical Center, Hines, Illinois
| | - Anai N Kothari
- Department of Surgery, Loyola University Medical Center, Maywood, Illinois; One:MAP Division of Clinical Informatics and Analytics, Loyola University Medical Center, Maywood, Illinois; Surgical Services, Edward Hines Jr. Veterans Administration Medical Center, Hines, Illinois
| | - Paul C Kuo
- Department of Surgery, Loyola University Medical Center, Maywood, Illinois; One:MAP Division of Clinical Informatics and Analytics, Loyola University Medical Center, Maywood, Illinois; Surgical Services, Edward Hines Jr. Veterans Administration Medical Center, Hines, Illinois
| | - Gopal N Gupta
- Department of Urology, Loyola University Medical Center, Maywood, Illinois; One:MAP Division of Clinical Informatics and Analytics, Loyola University Medical Center, Maywood, Illinois; Surgical Services, Edward Hines Jr. Veterans Administration Medical Center, Hines, Illinois
| | - Thomas M T Turk
- Department of Urology, Loyola University Medical Center, Maywood, Illinois; Surgical Services, Edward Hines Jr. Veterans Administration Medical Center, Hines, Illinois
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18
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Lee S, Kim CH, Chung CK, Park SB, Yang SH, Kim SH, Kang S, Lee JH, Choi Y. Risk factor analysis for postoperative urinary retention after surgery for degenerative lumbar spinal stenosis. Spine J 2017; 17:469-477. [PMID: 27012647 DOI: 10.1016/j.spinee.2016.03.017] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Revised: 01/25/2016] [Accepted: 03/02/2016] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Postoperative urinary retention (POUR) may not be considered a major complication after surgery for degenerative lumbar spinal stenosis. However, improper management of transient POUR leads to bladder overdistension and permanent bladder detrusor damage. Systematic monitoring of POUR may be recommended in vulnerable patients. PURPOSE The aim of the present study was to determine the incidence of and risk factors for POUR. STUDY DESIGN/SETTING This is a retrospective nested case-control study. PATIENT SAMPLE A total of 284 consecutive patients (M : F=125:159; mean age, 63.3 years) who underwent spine surgery for degenerative lumbar spinal stenosis were reviewed. OUTCOME MEASURES A multivariable logistic model was utilized to identify risk factors. METHODS A systematic postoperative voiding care protocol was applied for all patients to monitor them for the development of POUR. An indwelling urethral catheter was inserted intraoperatively and removed in the postanesthesia care unit. The patients were encouraged to void within 6 hours postoperatively and every 4-6 hours thereafter. After each voiding, the postvoid residual urine (PVR) was measured by an ultrasound bladder scan. POUR was defined as the inability to void or having a PVR≥100 mL for more than 2 days after surgery. RESULTS The incidence of POUR was 27.1% (77/284). Older age (odds ratio, 1.062; 95% confidence interval, 1.029-1.095) and a long duration of surgery (odds ratio, 1.003; 95% confidence interval, 1.001-1.005) were significant risk factors. A formula for determining the probability of POUR was developed, and a probability of ≥0.26 was regarded as the cut-off value (sensitivity of 0.75 and specificity of 0.57; C-statics, 0.684). CONCLUSION POUR was a common morbidity after surgery for degenerative lumbar spinal stenosis. We recommend adopting a systematic postoperative voiding care protocol to prevent bladder overdistension and detrusor damage, especially for elderly patients and those who have undergone longer surgeries.
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Affiliation(s)
- Sungjoon Lee
- Department of Neurosurgery, Inje University Haeundae Paik Hospital, 875 haeun-daero, Haeundae-gu, Busan, 612-896, South Korea
| | - Chi Heon Kim
- Department of Neurosurgery, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea; Department of Neurosurgery, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea; Clinical Research Institute, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea.
| | - Chun Kee Chung
- Department of Neurosurgery, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea; Department of Neurosurgery, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea; Clinical Research Institute, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea; Department of Brain and Cognitive Sciences, Seoul National University College of Natural Sciences, 1 Gwanak-ro, Gwanak-gu, Seoul, 08826, South Korea
| | - Sung Bae Park
- Department of Neurosurgery, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea; Department of Neurosurgery, Seoul National University Boramae Hospital, Borame Medical Center 20, Boramae-ro 5-gil, Dongjak-gu, Seoul, 07061, South Korea
| | - Seung Heon Yang
- Department of Neurosurgery, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea; Department of Neurosurgery, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea; Neuroscience Center, Sheikh Khalifa Specialty Hospital, Ras Al Khaimah, UAE
| | - Soo Hyun Kim
- Department of Medicine, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Korea
| | - Soohee Kang
- Medical Research Collaborating Center, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea
| | - Ju Hee Lee
- Medical Research Collaborating Center, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea
| | - Yunhee Choi
- Medical Research Collaborating Center, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea
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Effects of Intraoperative Anesthetic Medications on Postoperative Urinary Retention After Single-Level Lumbar Fusion. Spine (Phila Pa 1976) 2016; 41:1441-1446. [PMID: 26974835 DOI: 10.1097/brs.0000000000001554] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort analysis. OBJECTIVE The aim of the study was to identify medications that may potentially contribute to developing postoperative urinary retention (POUR) after lumbar spinal fusion procedures. SUMMARY OF BACKGROUND DATA POUR is a concerning event that may occur after routine orthopedic surgery. The relation between intraoperative medications and POUR after lumbar spine surgery has not been well characterized. METHODS A prospectively maintained database of patients who underwent a primary single-level, minimally invasive transforaminal lumbar interbody fusion between 2009 and 2013 was reviewed. POUR was defined as a bladder scan of 300 mL or higher, the postoperative necessity of a straight catheterization, or a urology consult for urinary retention. The use and dose-response of intraoperative medications between patients with and without POUR were compared. Potential risk factors for developing POUR were analyzed using multivariate analysis. RESULTS A total of 205 patients were included in the study, 17% of whom experienced POUR (n = 34). Administration of phenylephrine and neostigmine was associated with POUR (phenylephrine: 32.3% vs. 13.8%, P = 0.017; neostigmine: 19.5% vs. 6.5%, P = 0.042). Parametric analysis demonstrated an association of increasing dose of neostigmine with POUR (4.66 vs. 4.22 mg, P = 0.023). Similarly, a nonparametric analysis demonstrated an association of increasing doses of both neostigmine and phenylephrine with POUR (neostigmine: 4.25 vs. 3.16 mg, P = 0.02; phenylephrine: 105.88 vs. 40.64 mg, P = 0.008). CONCLUSION Approximately 20% of patients may develop POUR after routine lumbar spine surgery. The use of certain intraoperative anesthetics such as phenylephrine and neostigmine is strongly associated with the development of POUR postoperatively. This finding suggests that there may be modifiable anesthetic risk factors to prevent the development of POUR in patients undergoing lumbar spine surgery. Future prospective, controlled studies specifically addressing these findings could lead to improved patient care and decreased healthcare costs. LEVEL OF EVIDENCE 4.
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A Clinical Nurse Specialist–Directed Initiative to Reduce Postoperative Urinary Retention in Spinal Surgery Patients. Am J Nurs 2016; 116:47-52. [DOI: 10.1097/01.naj.0000490176.22393.69] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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