The Utility of Bladder Catheterization in Total Hip Arthroplasty

Abstract

Reply: We thank Drs. Michelson and Lotke for their interest in our retrospective study “The Utility of Bladder Catheterization in Total Hip Arthroplasty”1 in which we evaluated 719 patients who had primary unilateral total hip arthroplasties that were randomized by surgeon into two bladder catheterization protocols. Results of a group of patients who had universal preoperative insertion of an indwelling bladder catheter were compared with results of an observation group that had catheterization as needed. Our conclusions were: there was no difference in the incidence of urinary tract infections between the groups; there was no difference in hospital length of stay; and there was a small increased cost associated with the universal preoperative catheterization group. We suggested that routine preoperative bladder catheterization for patients having total hip arthroplasties may not be necessary. Michelson and Lotke questioned the validity of our conclusions because of potential distribution differences in medical comorbidities among the two treatment groups. We agree that the differences in length of stay and hospital cost might not be fully explained by the catheterization protocol. Charnley class, age, and gender were not significantly different between the treatment groups. We pointed out in the Discussion that there may be the potential of a selection bias toward patients with more comorbidities in the universal catheter placement cohort. This could explain the slightly increased length of stay in the universal catheter cohort. However, these 719 patients were taken from a multispecialty group practice with a relatively homogenous patient population. The patients were randomized by surgeon, but all were treated with the same clinical pathway for total hip arthroplasty. We pointed out in the Abstract that postoperative catheterization as necessary may be more cost effective, and we did not make cost savings a declarative conclusion. One of the major findings of our study was that there was no significant difference in the incidence of urinary tract infection between the two groups. Furthermore, there was a significant difference in incidence of urinary tract infection in females and in patients with increasing age in both groups. Michelson and Lotke question whether our patients had unrecognized or unreported urologic complications attributable to over-distension of the bladder, and they also question the cost of additional catheterizations and the burden on the nursing staff. We respectfully point out that Michelson and Lotke published their data in 1988. The study involved only 100 patients.2 Since that time, routine bladder scan analysis of patients having total joint replacement is done on an every 8-hour basis. Patients with bladder volume residuals of 700 cc or greater are candidates for insertion of a bladder catheter. Our data confirm that only 19 patients (2.6%) required introduction of a catheter for a second time after initial catheterization. We reviewed all of the morbidity and mortality records and the hospital records of the 719 patients for readmissions and potential complications and did not find any in these cohorts. Michelson and Lotke think routine preoperative catheterization is needed based on results their 1988 study of 100 patients. Given the new technology available to scan patients for residual bladder volumes, perhaps it is time to reexamine the routine use of urinary catheterization in patients having total joint replacement. Universal catheterization is not always routine. Issues with prosthetic hypertrophy, urethral stricture, and patients who have had prostate surgery make bladder catheterization of patients while in the operating room by nonurologic personnel, a sometimes nonroutine procedure. These insertions can cause undue operating room delays, urologic tract trauma, and the need for longer-term catheterization than would be necessary if the catheterization were done postoperatively. With the advent of bladder scan technology; we think routine use of bladder catheterization of patients while in the operating room is not necessary at this time. We encourage more study and debate on this topic.