Assessing Health Care Utilization and Feasibility of Transurethral Catheter Self-Discontinuation

Abstract

ABSTRACT Common issues after pelvic reconstructive surgery are incomplete bladder emptying and urinary retention, often resulting in placement of an indwelling transurethral Foley catheter, which then remains until a patient returns to the office. Catheterization is significantly distressing for women undergoing these procedures and burdensome due to travel to the office during the postoperative period. In addition, in-office voiding trials add to the workload of health care professionals and staff. A potential alternative is at-home self-discontinuation of the Foley catheter. This study's primary aim was the comparison of the rates of health care utilization (calls, messages, office visits, and emergency department [ED] visits) and postoperative complications within 30 days of surgery among patients with voiding trials on the day of surgery, versus those with Foley placement and void trials on postoperative day 1. Secondary objectives included identifying risk factors for unsuccessful voiding trials and exploring any complications associated with catheter self-discontinuation. This study was designed as a prospective observational cohort study at 1 academic institution and included outpatient women undergoing outpatient urogynecologic or minimally invasive gynecological surgery for benign indications between August 2021 and January 2022. Qualifying patients included cisgendered English-speaking women of at least 18 years of age who exhibited postoperative urinary retention on the day of surgery. Excluded were patients with any preoperative degree of urinary retention (defined as any observation of a postvoid residual more than 200 mL), known upper motor neuron disease, and patients undergoing surgeries with concomitant extra pelvic procedures or minor procedures not requiring a postoperative voiding trial. Based on the exploratory nature of this study, primarily for determining safety and feasibility, the convenience sample size of 50 was set, and patients were recruited at the time of their unsuccessful voiding trials on the day of surgery. On the day of surgery, medical staff performed voiding trials in the postoperative anesthesia care unit, backfilling the bladder with 200 mL of sterile fluid. The void trial was successful if this was followed by a patient void of at least 150–200 mL, otherwise the voiding trial was marked as unsuccessful. Unsuccessful trials resulted in the insertion of an indwelling Foley catheter, followed by verbal and written instruction for performing a home-based, patient-led catheter self-discontinuation at 6:00 am on postoperative day 1. Instructions for catheter removal included pictures and written information. After removal, if the patient failed to void 150 mL within 6 hours, they were instructed to return to the office for additional care. Perioperative data collected from charts included age, parity, body mass index, self-reported race, surgical location, smoking status, periprocedural antibiotics, operative indication, procedures performed, operative time, surgeon type, anesthesia type, estimated blood loss, and intraoperative complications. Results of the study demonstrated 140 patients eligible for day 0 postoperative voiding trials. Of these, most patients were postmenopausal, White, and one third were obese. A majority (82.8%) had a urogynecologist perform their surgery, and the overall rate of voiding trial failure on the day of surgery was 35.7%. The majority of patients (48/50) proceeded with at-home voiding trials according to protocol. Of these, 39 had no further voiding difficulty. Of the 9/50 (18.8%) requiring additional assessment, 6 had a repeat void trial in the office of which 4 were successful, 1 voided spontaneously in the office, 1 required prolonged clean intermittent self-catheterization, and 1 was successful with repeat Foley self-discontinuation on day 3 postoperatively. Only 2 of the 39 patients with successful self-discontinuation on postoperative day 1 had retention later, with 1 presenting to an ED and 1 presenting to the office. Patients with unsuccessful postoperative day 0 void trials had an average of 1 additional call or message to the office, and patients with unsuccessful postoperative day 1 void trials had an average of 1 additional office visit. Although both of these comparisons to those with successful day of surgery void trials were statistically significant, they did not indicate excessive care requirements. Risk factors for failure of day of surgery void trial included older age (also a risk factor for failure on the following day), smoking history, and vaginal hysterectomy. Strengths of the study include its diverse population of women undergoing a wide array of minimally invasive gynecological and urogynecologic surgeries, as well as its prospective nature. Limitations of the study include a lack of control groups, the singular institution in which the study was performed, and the small sample size that limited the potential identification of rare complications. These factors also limit the generalizability of the findings to other settings. Ultimately, catheter self-discontinuation was largely straightforward and efficient for patients and office staff, with low subsequent retention rates. Although further research is required, data currently point to catheter self-discontinuation as a safe and feasible option for women undergoing advanced gynecological surgery, providing a valuable management option for acute postoperative voiding dysfunction.