Development Of Postoperative Urinary Retention Research Articles

Risk Factors for Postoperative Urinary Retention After Lumbar Fusion Surgery: Anesthetics and Surgical Approach.

Postoperative urinary retention (POUR) after lumbar fusion surgery can lead to longer hospital stays and thus increased risk of developing other postoperative complications. Therefore, we aimed to determine the relationship between POUR and (1) surgical approach and (2) anesthetic agents, including sugammadex and glycopyrrolate. After institutional review board approval, L4-S1 single-level lumbar fusion surgeries between 2018 and 2021 were identified. A 3:1 propensity match of patients with POUR to those without was conducted, controlling for patient age, sex, diabetes status, body mass index, smoking status, history of benign prostatic hyperplasia, and the number of levels decompressed. POUR was defined as documented straight catheterization yielding >400 mL. We compared patient demographic, surgical, anesthetic, and postoperative characteristics. A bivariant analysis and backward multivariable stepwise logistic regression analysis ( P -value < 0.200) were performed. Significance was set to P < 0.05. Of the 899 patients identified, 51 met the criteria for POUR and were matched to 153 patients. No notable differences were observed between groups based on demographic or surgical characteristics. On bivariant analysis, patients who developed POUR were more likely to have been given succinylcholine (13.7% vs. 3.92%, P = 0.020) as an induction agent. The independent predictors of POUR identified by multivariable analysis included the use of succinylcholine {odds ratio (OR), 4.37 (confidence interval [CI], 1.26 to 16.46), P = 0.022} and reduced postoperative activity (OR, 0.99 [CI, 0.993 to 0.999], P = 0.049). Factors protective against POUR included using sugammadex as a reversal agent (OR, 0.38 [CI, 0.17 to 0.82], P = 0.017). The stepwise regression did not identify an anterior surgical approach as a notable predictor of POUR. We demonstrate that sugammadex for anesthesia reversal was protective against POUR while succinylcholine and reduced postoperative activity were associated with the development of POUR. In addition, we found no difference between the anterior or posterior approach to spinal fusion in the development of POUR.

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 35years of age undergoing primary unilateral TJA were recruited. Patients received doxazosin (4mg once) or placebo 2h before surgery. The primary outcome of interest was the development of POUR, which was diagnosed when patients with a urine volume over 400ml 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 ± 13.7years, range 36-88years) and Placebo group (mean age 54.6 ± 13.9years, range 38-81years). 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 ± 1.1days compared to 3.6 ± 1.7days 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 Following Thoracolumbosacral Spinal Fusion: Prevalence, Risk Factors, and Outcomes.

ObjectivePostoperative 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.MethodsElectronic 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.ResultsOne 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.ConclusionPOUR 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.

Prophylactic Administration of Alpha Blocker for the Prevention of Urinary Retention in Males Undergoing Inguinal Hernia Repair Under Spinal Anesthesia: Interim Analysis of a Randomized Controlled Trial.

Introduction: This randomized controlled study aims to investigate the prophylactic effect of tamsulosin on the development of postoperative urinary retention (POUR) in men undergoing elective open inguinal hernia (IH) repair under spinal anesthesia. The study also focused on potentially predisposing factors for POUR.Methods: 100 eligible patients were randomized into two groups. Patients in the experimental group were given two doses of tamsulosin 0.4 mg orally 24 hours and 6 hours before surgery. In the control group, two doses of placebo were administered, in the same manner as the study group. The following parameters were also recorded: the International Prostate Symptom Score (IPSS) questionnaire scores, the presence of scrotal hernia, operation duration, perioperative administration of IV opioids and/or atropine, postoperative pain, and preoperative anxiety.Results: Overall, the incidence of POUR was 37% (37/100) with no difference between the two groups. Among patients receiving tamsulosin, 39.2% (20/51) developed POUR, compared to 34.7% (17/49) in the control group. Preoperative patients’ high anxiety visual analog scale (VAS) score (>51mm) (P=0.007) and the intraoperative use of atropine (P=0.02) were detected as risk factors for POUR.Conclusion: This interim analysis of our prospective randomized trial showed no benefit from the prophylactic use of tamsulosin in preventing POUR after IH repair under spinal anesthesia. This type of anesthesia was also correlated with an overall high incidence of POUR. Preoperative anxiety and administration of atropine were identified as statistically significant factors for POUR. In patients with preoperative high anxiety, VAS score a different type of anesthesia may be used.

Tamsulosin vs placebo to prevent postoperative urinary retention following female pelvic reconstructive surgery: a multicenter randomized controlled trial

Postoperative urinary retention is common after female pelvic reconstructive surgery. Alpha receptor antagonists can improve dysfunctional voiding by relaxing the bladder outlet and may be effective in reducing the risk of postoperative urinary retention. This study aimed to determine whether tamsulosin is effective in preventing postoperative urinary retention in women undergoing surgery for pelvic organ prolapse. This was a multicenter, double-blind, randomized controlled trial between August 2018 and June 2020, including women undergoing surgery for pelvic organ prolapse. Patients were excluded from recruitment if they had elevated preoperative postvoid residual volume, history of postoperative urinary retention, or a contraindication to tamsulosin. Those who experienced cystotomy were excluded from analysis. Participants were randomized to a 10-day perioperative course of tamsulosin 0.4 mg vs placebo, beginning 3 days before surgery. A standardized voiding trial was performed on postoperative day 1. The primary outcome was the development of postoperative urinary retention, as defined by the failure of the voiding trial or subsequent need for catheterization to empty the bladder. Secondary outcomes included the rate of urinary tract infection and the impact on lower urinary tract symptoms as measured by the American Urological Association Symptom Index. Of 119 patients, 57 received tamsulosin and 62 received placebo. Groups were similar in regard to demographics, preoperative prolapse and voiding characteristics, and surgical details. Tamsulosin was associated with a lower rate of postoperative urinary retention than placebo (5 patients [8.8%] vs 16 patients [25.8%]; odds ratio, 0.28; 95% confidence interval, 0.09-81; P=.02). The number needed to treat to prevent 1 case of postoperative urinary retention was 5.9 patients. The rate of urinary tract infection did not differ between groups. American Urological Association Symptom Index scores significantly improved after surgery in both groups (median total score, 14 vs 7; P<.01). Scores related to urinary stream improved more in the tamsulosin group than in placebo (P=.03). In this placebo-controlled trial, tamsulosin use was associated with a reduced risk of postoperative urinary retention in women undergoing surgery for pelvic organ prolapse.

AB075. SOH21AS027. Prophylactic alpha-blockade as a strategy to reduce acute urinary retention post inguinal hernia repair in male patients: a retrospective and prospective analysis

Background: Post-operative urinary retention (POUR) is a common complication following inguinal hernia repair (IHR). The aim of this study was to assess the incidence of POUR following IHR and to investigate the benefit of prophylactic alpha-blockade (alpha-1 antagonist) on the development of POUR in a small cohort of high-risk male patients.

The Effectiveness of Caudal Block with Low Doses of Dexmedetomidine and Pethidine in Transrectal Prostate Biopsy: Preliminary Results

Purpose To evaluate the effectiveness of caudal block (CB) using dexmedetomidine and pethidine instead of local anesthesia (LA) for prostate needle biopsy and the effect of CB on urinary retention. Material and Methods A transrectal ultrasound-guided prostate needle biopsy (TRUS-Bx) was performed on 68 patients with a mean age of 65 ± 2.18 years. CB with a combination of dexmedetomidine and pethidine without LA was administered to the patients. The pain levels of the patients were determined using numeric rating scale (NRS) scores to evaluate the effectiveness of CB. Preoperative and postoperative postvoid residual urine volumes (PRUV) were also calculated. Results The CB success rate was 93.15%. The NRS scores were 0.79 ± 0.19 and 0.89 ± 0.22 during probe entry and manipulation and biopsy, respectively, without any significant differences between them (p = 0.382). The mean PRUVs before and after biopsy did not differ significantly (41 ± 15.6 vs. 71.93 ± 22.3, p = 0.379). The degree of sedation, as assessed using the Ramsay scale, was 2 or 3 in all patients. Conclusion The combination of dexmedetomidine and pethidine for CB in TRUS-Bx provided quality analgesia for the patient and prevented the development of postoperative urinary retention.

RETention of urine After INguinal hernia Elective Repair (RETAINER study I and II).

Purpose:Post-operative urinary retention (POUR) is a well-recognised complication of inguinal hernia repair (IHR). The magnitude of the problem is unclear, and contradictory evidence surrounds postulated risk factors. POUR risks patient distress, catheter-complications and a financial and logistical burden to services. Separately, in the field of IHR, there has been a lack of research into patients’ perceptions of surgical ‘success’. Our aim is to perform a two-phase, multi-centre prospective study to:Assess the rate, risk factors and impact related to POUR post IH repair.Develop and validate a patient reported outcome measure (PROM) for inguinal hernia repair.Methods:RETAINER I: We propose a 24-week prospective study with voluntary international participation in 4 week blocks. All patients undergoing elective IH repair (minimally-invasive/open) will be eligible. Standardised data collection will include patient and perioperative factors. Primary outcome will be development of POUR, defined as the need for insertion of a urinary catheter as determined by the treating clinician. Secondary outcomes will be identification of factors predisposing to POUR and the impact of POUR.RETAINER II: A patient reported outcome measure will be developed using representative patient focus groups for item generation, from which an initial questionnaire will be developed and piloted. Validity, reliability, sensitivity and reproducibility will be assessed using the QQ-10 and standard psychometric methodology.Conclusions:Using an international multicentre collaborative approach will produce the necessary volume of patients, whilst capturing inter-centre variability, to accurately reflect POUR rates and allow analysis of risk factors. This patient pool will provide an excellent opportunity to develop a PROM using appropriate qualitative methodology.Highlights: RETAINER I & II ProtocolsRETAINER (RETention of urine After INguinal hernia Elective Repair) I is a prospective, multicentre, international observational study.RETAINER I aims to explore the incidence of and risk factors for urinary retention following elective inguinal hernia repair.Urinary retention following inguinal hernia repair has a marked impact on patients and creates a significant financial and logistical burden for hospital services.RETAINER II is a prospective, qualitative study, recruiting patients to guide the creation of a patient-reported outcome measure (PROM) for elective inguinal hernia repair.

This Month in Adult Urology

This Month in Adult Urology

Tamsulosin to Prevent Urinary Retention Following Female Pelvic Reconstructive Surgery: A Multicenter Randomized Controlled Trial

Study Objective To determine if tamsulosin is effective in reducing the risk of postoperative urinary retention in women undergoing pelvic reconstructive surgery. Design We performed a multicenter double-blind randomized controlled trial. Setting Surgery for pelvic organ prolapse with or without a concomitant incontinence procedure. Patients or Participants All patients undergoing surgery for pelvic organ prolapse from August 2018 to March 2020 at two academic institutions were screened. Patients with a history of urinary retention requiring catheterization, sulfa allergy, or a preoperative post-void residual volume of greater than 100ml were not eligible. Participants who experienced cystotomy were excluded from analysis. A total of 132 patients were enrolled. Interventions Using permuted block randomization, participants were allocated to receive a 10-day course of either tamsulosin 0.4mg or placebo, beginning 3 days prior to surgery. Both patients and providers were blinded to treatment group. A standardized voiding trial was performed on postoperative day one. Measurements and Main Results An intention-to-treat analysis of 118 patients was performed. Patients received either tamsulosin (n=57) or placebo (n=61). Mean age was 61.2 ± 10.2 years, 86.4% were Caucasian, and 71.2% had stage 2 or 3 prolapse. Procedures included vaginal prolapse repair in 85.6%, abdominal prolapse repair in 49.2%, hysterectomy in 66.9%, and midurethral sling in 60.2%. Groups were similar in regards to demographics, pelvic organ prolapse quantification scores, baseline urinary symptoms, urodynamic parameters, and surgical details. Tamsulosin users had a significantly lower rate of urinary retention compared to placebo (8.7% vs 24.6%, p=0.03). Postoperative urinary tract infection and prolonged urinary retention requiring reoperation did not differ between groups. Variables associated with the development of postoperative urinary retention included tamsulosin use (OR 0.29, 95%CI 0.10-0.85) and American Urological Association Symptom Index score (OR 0.90, 95%CI 0.82-0.98). Conclusion This study supports the prophylactic use of tamsulosin to reduce the risk of postoperative urinary retention following female pelvic reconstructive surgery.

Postoperative management factors affect urinary retention following posterior spinal fusion for adolescent idiopathic scoliosis.

Retrospective cohort study. 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. A retrospective cohort study was conducted of adolescents (11-18years) undergoing elective PSF for AIS at a single institution (2012-2018). POUR was defined as the inability to void > 8h 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. 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 0.5days, range 0-12days). 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. III.

Prospective Risk Factor Analysis for the Development of Post-operative Urinary Retention Following Ambulatory General Surgery

AimsPost-operative urinary retention (POUR) is a common cause of unplanned admission following day-case surgery and has negative effects on both patient and surgical institution. We aimed to prospectively evaluate potential risk factors for the development of POUR following day-case general surgical procedures.MethodsOver a 24-week period, consecutive adult patients undergoing elective day-case general surgery at a single institution were prospectively recruited. Data regarding urinary symptoms, comorbidities, drug history, surgery and perioperative anaesthetic drug use were collected. The primary outcome was the incidence of POUR, defined as an impairment of bladder voiding requiring either urethral catheterisation, unplanned overnight admission or both. Potential risk factors for the development of POUR were analysed by logistic regression.ResultsA total of 458 patients met the inclusion criteria during the study period, and data were collected on 382 (83%) patients (74.3% male). Sixteen patients (4.2%) experienced POUR. Unadjusted analysis demonstrated three significant risk factors for the development of POUR: age ≥ 56 years (OR 7.77 [2.18–27.78], p = 0.002), laparoscopic surgery (OR 3.37 [1.03–12.10], p = 0.044) and glycopyrrolate administration (OR 5.56 [2.00–15.46], p = 0.001). Male sex and lower urinary tract symptoms were not significant factors. Multivariate analysis combining type of surgery, age and glycopyrrolate use revealed that only age ≥ 56 years (OR 8.14 [2.18–30.32], p = 0.0018) and glycopyrrolate administration (OR 3.48 [1.08–11.24], p = 0.0370) were independently associated with POUR.ConclusionsPatients aged at least 56 years and/or requiring glycopyrrolate—often administered during laparoscopic procedures—are at increased risk of POUR following ambulatory general surgery.

Urinary Retention After Hysterectomy and Postoperative Analgesic Use.

This study aimed to determine risk factors, including postoperative analgesic use, for the development of postoperative urinary retention (PUR) after hysterectomy for routine gynecologic indications using a case-control study design. Cases of PUR after hysterectomy were identified from billing data. Cases were those patients requiring recatheterization for inability to void. Controls were similarly identified and matched by age and date of surgery in a 3:1 control-to-case ratio. Chart review was performed to obtain demographic, medical, surgical, anesthetic, and medication data. Cumulative and interval doses of postoperative narcotic were recorded and converted into morphine equivalents. Crude odds ratios (ORs) were determined for potential risk factors for PUR using standard statistical analysis. Conditional logistic regression was used on multivariate models, including cumulative postoperative narcotic use, to determine adjusted ORs for risk factors. Twenty-six cases of PUR were matched with 78 controls. The cases had a higher body mass index (32 vs 28 kg/m2, P = 0.02), had a higher preoperative use of tricyclic antidepressants (TCA; 19.2% vs 1.3%, P = 0.004), were more likely to present preoperative urinary retention associated with fibroids (19.2% vs 0%, P < 0.01), and received a higher cumulative narcotic dose in the postoperative period (109 vs 73.6 mg, P < 0.001). In a multivariate model, preoperative TCA use (OR, 30.1; 95% confidence interval, 1.99-456; P = 0.01) and cumulative narcotic dose (OR, 2.54; 95% confidence interval, 1.44-4.56; P < 0.01) were significantly associated with PUR. Postoperative urinary retention after hysterectomy is associated with higher postoperative narcotic dose, preoperative TCA use, and preoperative urinary retention.

Patient and surgical factors associated with postoperative urinary retention after lumbar spine surgery.

Retrospective case series. The objectives of this study were to (1) determine the rate of postoperative urinary retention (POUR) in a series of patients undergoing lumbar spine surgery, (2) compare length of hospital stay between patients who developed POUR and patients who did not, and (3) identify the patient and surgical factors associated with the development of POUR. Although POUR is a common complication in many surgical subspecialties, sparse literature is present regarding development of POUR after posterior lumbar surgical procedures. A retrospective review was conducted of all posterior lumbar surgery cases performed at single institute from July 2008 to July 2012. Data collected included demographic variables (age, sex, body mass index), length of stay, comorbid medical conditions, and surgical data. The Wilcoxon rank sum test with continuity correction was used to compare length of hospital stay between patients who developed POUR and patients who did not. A multivariate logistic regression model was created using all patient and surgical factors and systematically pruned of variables not improving overall predictive power. A total of 647 patients (291 decompression, 356 decompression and fusion) were included in the study. Of 647 patients, 36 had urinary retention after lumbar spine surgery (5.6%). Patients who developed POUR had a longer length of stay than patients who did not develop POUR (3.94 d vs. 2.34 d; P=0.005). Male sex, benign prostatic hyperplasia, age, diabetes, and depression were significantly associated with development of POUR (odds ratio=3.05, 9.82, 1.04, 3.32, and 2.51, respectively). Smoking was inversely associated with the development of POUR (odds ratio=0.45). The risk of developing POUR after posterior lumbar spine surgery is approximately 5%. Male sex, benign prostatic hyperplasia, age, diabetes, and depression were significantly associated with the POUR group. Patients who developed POUR had a greater length of hospital stay. 4.

Incidence and risk factors for urinary retention following laparoscopic inguinal hernia repair

BackgroundThe incidence of postoperative urinary retention (PUR) has been reported to range from 1% to 22% in patients who have undergone laparoscopic inguinal hernia procedures. The objectives of this study were to determine the incidence of PUR and examine different risk factors that may be associated with the development of PUR in patients who have undergone laparoscopic inguinal hernia procedures. MethodsA retrospective chart review was performed on 350 patients. Demographics, comorbidities, and operative and postoperative information were collected in patients undergoing laparoscopic inguinal hernia repair by 3 general surgeons from 2007 to 2011. Statistical analysis was done on patient demographics, medical histories, anesthesia notes, and postoperative notes to identify risk factors for the development of urinary retention after laparoscopic inguinal hernia repair. ResultsThree hundred fifty consecutive patients who underwent laparoscopic inguinal hernia repairs were reviewed. Twenty-nine patients developed PUR, an incidence of 8.3%. Age ≥60 years and history of benign prostatic hyperplasia showed significance on multivariate analysis, with odds ratios of 3.0 and 11.0 respectively (P < .05). Anesthesia time ≥2 hours (odds ratio, .75) was a contributing perioperative risk factor but only as an independent risk factor (P < .05). ConclusionsHistory of benign prostatic hyperplasia, age ≥60 years, and anesthesia time ≥2 hours were significant independent risk factors for urinary retention after laparoscopic inguinal hernia repair. On multivariate analysis, only history of group and age ≥60 years showed significance. This is 1 of the largest studies to show that the development of PUR in laparoscopic inguinal hernia repair patients is a multifactorial process. Further studies should be conducted to corroborate our findings.

Risk of postoperative urinary retention after laparoscopic (TAPP) or endoscopic (TEP) inguinal hernia repair

To the Editor, I praise Bittner and colleagues for offering this important updated version of guidelines for laparoscopic transabdominal preperitoneal (TAPP) and endoscopic total extraperitoneal (TEP) treatment of inguinal hernia [1]. However, I think the topic of the potential risk for postoperative urinary retention (POUR) after inguinal herniorrhaphy requires further discussion. In Chap. 2, J. F. Kukleta recommends that for TAPP inguinal hernia repair ‘‘grade D: the patient empty his/her bladder before the operation’’ and that preoperative urine catheterization should be considered if for ‘‘grade D: you expect technical difficulties or an extended operating time’’ (p. 2782). Furthermore, he also mentions that for ‘‘grade D: restrictive perand postoperative intravenous fluid administration reduces the risk of postoperative urinary retention.’’ These recommendations are the same as those stated for TEP repairs by P. Chowbey et al. in Chap. 3, p. 2790. In Chap. 11, specifically dedicated to urogenital complications, R. J. Fitzgibbons proposes only that for ‘‘grade C: intraand postoperative intravenous fluid administration should be restricted to no more than 500 cc’’ (p. 2827). Finally, the authors briefly mention other accepted contributing factors for the development of POUR including male gender, age older than 50 years, preexisting benign prostatic hyperplasia, type of surgery, type of anesthesia, and use of opiates for analgesia. Regrettably, they do not mention certain risk factors specifically related to the surgical technique that should warrant further consideration and possibly additional recommendation. This is even more relevant because these guidelines are aimed at helping general surgeons who do not necessarily have a sufficient level of expertise to achieve the outstanding results with the very low incidence rates of POUR experienced by Bittner et al. [2] in a large series of 8,050 TAPP repairs. For instance, tacks, still commonly used for mesh fixation by most general surgeons, seem to be associated with a significant risk of POUR, with incidences reaching 8–27.3%, as suggested in two recent retrospective studies [3, 4]. Interestingly, a look at the ‘‘no mesh fixation’’ cases in the series of Garg et al. [4] shows that although the mean age of the patients was 10 years younger than in the ‘‘mesh fixation’’ group, age difference alone cannot explain the considerable drop in the POUR risk to 4.6%. These results are consistent with the findings of a previous small prospective study that demonstrated a significant discrepancy in POUR risks between no mesh fixation (5 %) and the use of tacks (35 %) [5]. In this series, five to eight tacks were commonly used, and the most likely explanation is that the more tacks used to anchor the prosthesis, the more likely the level of postoperative pain is to increase [6] and thus also the use of opiates, leading to urinary retention [7]. In comparison, when specifically examining fibrin glue for mesh fixation, Olmi et al. [8] denied any occurrence of POUR after 320 TAPP inguinal hernia repairs in 230 patients, as did Topart et al. [9] after the TEP approach used for 66 patients. In a personal case series of 640 TEP inguinal hernia repairs and recently accepted for publication, we encountered only one case of POUR among 472 patients with a median age exceeding 46 years (0.2 %). The fact that this human biologic product (Tisseel/Tissucol) is absolutely nontraumatic for the abdominal wall is the main reason for C. R. Berney (&) Department of Surgery, Bankstown-Lidcombe Hospital, University of New South Wales, 68 Eldridge Road, Bankstown, NSW 2200, Australia e-mail: berneycr@hotmail.com

Bethanechol Chloride for the Prevention of Postoperative Urinary Retention After Anal Surgery Under Spinal Anesthesia

Background: Postoperative urinary retention is a commonly encountered problem after anal surgery particularly under spinal anesthesia. Bethanechol chloride, a muscarinic cholinergic receptor agonist was used to determine whether it could prevent this problem. Methods: One hundred six patients with mean age of 37 ± 9 who underwent anal surgery under spinal anesthesia from January to August 2007 were included in this nonblinded randomized prospective experimental study. Forty-six patients were given bethanechol chloride 25mg/tab 1 hour post-op then another dose after 4-6 hours. Intravenous fluid was limited to &lt;750 ml perioperatively and patients were asked to void within 6-8 hours post-op. Those with the urge to void but unable to do so within the hour or had hypogastric pain (VAS &gt; 8) were immediately catheterized and the amount drained recorded. Results: The study showed that the number of patients catheterized in the bethanechol group was significantly lower (6.52% vs 23.33%, P=0.038) and the mean amount of urine drained was less than the control (&lt;400cc, P=0.001). Using Z test, the proportion of patients catheterized in the bethanechol group was significantly lower than the control (P=0.0097). No significant relationship was noted between the patient's age (&lt;50 or &gt;50) and gender with regards to urinary retention (P=0.254 and P=0.187, respectively). The number needed to treat (NNT) showed that six patients treated with bethanechol are needed to prevent one patient from experiencing urinary retention. Conclusion: Although bethanechol chloride did not completely prevent the development of postoperative urinary retention, its use was associated with reduced need for catheterization. Key words: Bethanechol chloride, postoperative urinary retention, spinal anesthesia

Is It Useful and Safe to Maintain the Sitting Position During Only One Minute before Position Change to the Jack-knife Position?

BackgroundConventional spinal saddle block is performed with the patient in a sitting position, keeping the patient sitting for between 3 to 10 min after injection of a drug. This amount of time, however, is long enough to cause prolonged postoperative urinary retention. The trend in this block is to lower the dose of local anesthetics, providing a selective segmental block; however, an optimal dose and method are needed for adequate anesthesia in variable situations. Therefore, in this study, we evaluated the question of whether only 1 min of sitting after drug injection would be sufficient and safe for minor anorectal surgery.MethodsTwo hundred and sixteen patients undergoing minor anorectal surgery under spinal anesthesia remained sitting for 1 min after completion of subarachnoid administration of 1 ml of a 0.5% hyperbaric bupivacaine solution (5 mg). They were then placed in the jack-knife position. After surgery, analgesia levels were assessed using loss of cold sensation in the supine position. The next day, urination and 11-point numeric rating scale (NRS) for postoperative pain were assessed.ResultsNone of the patients required additional analgesics during surgical manipulation. Postoperative sensory levels were T10 [T8-T12] in patients, and no significant differences were observed between sex (P = 0.857), height (P = 0.065), obesity (P = 0.873), or age (P = 0.138). Urinary retention developed in only 7 patients (3.2%). In this group, NRS was 5.0 ± 2.4 (P = 0.014).ConclusionsThe one-minute sitting position for spinal saddle block before the jack-knife position is a safe method for use with minor anorectal surgery and can reduce development of postoperative urinary retention.

Postoperative Urinary Retention

Urinary retention is common after anesthesia and surgery, reported incidence of between 5% and 70%. Comorbidities, type of surgery, and type of anesthesia influence the development of postoperative urinary retention (POUR). The authors review the overall incidence and mechanisms of POUR associated with surgery, anesthesia and analgesia. Ultrasound has been shown to provide an accurate assessment of urinary bladder volume and a guide to the management of POUR. Recommendations for urinary catheterization in the perioperative setting vary widely, influenced by many factors, including surgical factors, type of anesthesia, comorbidities, local policies, and personal preferences. Inappropriate management of POUR may be responsible for bladder overdistension, urinary tract infection, and catheter-related complications. An evidence-based approach to prevention and management of POUR during the perioperative period is proposed.

Predicting Short‐Term Urinary Retention After Vaginal Prolapse Surgery

Identification of risk factors for urinary retention after vaginal prolapse surgery. The medical records of 345 women undergoing surgical correction for symptomatic pelvic organ prolapse were analyzed. Independent risk factors for the development of post-operative urinary retention were identified by performing univariate and multivariate logistic regression analysis. Variables included in the analysis were age, parity, body mass index, previous prolapse surgery, previous hysterectomy, menopausal status, degree of prolapse, type of anesthesia, type and technique of surgery, operation time, intra-operative blood loss, preoperative urinary stress-incontinence, and other co-morbidities. Main outcome measure was the occurrence of urinary retention defined as a residual volume after voiding higher than 200 ml as measured by bladder scan. High grade cystocele (OR 2.5, CI 1.3-4.7), performing levator plication (OR 4.3, CI 2.0-9.3), performing Kelly plication (OR 5.1, CI 1.7-15.5) and amount of intra-operative blood loss (OR 1.4 per 100 ml, CI 1.1-1.8) were identified as independent risk factors for the occurrence of urinary retention after vaginal prolapse surgery. Urinary retention after vaginal prolapse surgery occurs more frequently in women with larger cystoceles, severe intra-operative blood loss and the application of levator plication and Kelly plication.