Voiding Trial Research Articles

Bupivacaine Use After Posterior Colporrhaphy to Reduce Postoperative Pain: A Multicenter, Double-Blinded, Placebo-Controlled, Randomized Clinical Trial.

The aim of this study was to determine if injection of bupivacaine into levator muscles after posterior colporrhaphy reduces postoperative pain. This study was a multicenter, double-blinded, placebo-controlled, randomized clinical trial of 130 participants, comparing bilateral infiltration of puborectalis and iliococcygeus muscles with 0.5% bupivacaine without epinephrine or normal saline after vaginal prolapse repair that included a posterior colporrhaphy. Primary outcome was the 24-hour cumulative Visual Analog Scale (VAS) pain score (measured as a sum of VAS pain scores at postoperative hours 0, 4, 8, 16, and 24) across intervention allocations. Secondary outcomes include the individual VAS pain scores per postoperative times 0, 4, 8, 16, and 24 hours and at 1 and 2 weeks, morphine equivalent use, postoperative void trial success, and time to first bowel movement. Sixty-eight participants received bupivacaine, and 62 participants received normal saline. No significant differences were identified in the 24-hour postoperative cumulative VAS pain scores for the bupivacaine and normal saline arms, 19 and 18 (P = 0.71); individual pain scores per each postoperative assessment time; opiate use (24-hour use was 42 vs 48, P = 0.39; 48-hour use was 75 vs 37, P = 0.09); length of hospital stay (26 hours vs 22 hours, P = 0.069); hours to passing void trial (10 hours vs 12 hours, P = 0.17); or hours to first postoperative bowel movement (18 hours vs 12 hours, P = 0.78). Use of bupivacaine for muscle block after posterior colporrhaphy does not reduce postoperative pain, opiate use, and time to first bowel movement, or increase void trial success.

16 Postoperative clinical assessment of voiding function using force of stream in women with acute postoperative urinary retention following pelvic reconstructive surgery

The primary objective of this study was to evaluate and compare in-office retrograde fill voiding trial pass rates to the subjective scores on the urinary Force of Stream visual analog scale in the clinical setting in women with acute postoperative urinary retention managed with transurethral catheterization following pelvic reconstructive surgery. This was a prospective cohort study conducted across two fellowship clinical training sites between October 2017 and April 2019. Women with acute postoperative urinary retention managed with transurethral catheterization following pelvic reconstructive surgery who had been consented and randomized to the parent study were included. Women presented for an in-office retrograde fill voiding trial 1-7 days postoperatively after failure of voiding trial prior to hospital discharge. Immediately following a timed voiding attempt, each participant completed a urinary Force of Stream visual analog scale (Figure 1), with a score of “100” equivalent to voiding function prior to surgery. Following subjective assessment with the Force of Stream visual analog scale, the voided amount was measured and post-void residual was obtained by a portable bladder scanner. The primary outcome was urinary Force of Stream score. Secondary outcomes included postoperative urinary tract infections. Descriptive statistics were utilized. Data was collected on 156 women during the study period. Study participants were divided into two groups: scores >100 (n = 81) and scores ≤100 (n = 75). No demographic differences were observed. The median duration of catheterization was 3 days in each group (P = 0.11). There were no differences in types of surgical procedure between groups, except for mid urethral slings (3 vs 10, P = 0.03). There were significant differences in the median scores between the >100 score group and ≤100 score group (120 vs 100, P = < 0.001). Women in the >100 score group had significantly lower post-void residual volumes compared to women in the ≤100 score group (0 mL vs 15 mL, P = 0.003). There was no difference in time to void between groups (7.4 ± 8.4 versus 9.9 ± 10.1 minutes, P = 0.10). No participants returned with postoperative urinary retention. There was no difference in urinary tract infections between groups postoperatively at 30 days (14.8% versus 22.7%, P = 0.21). Subjective assessment of the urinary Force of Stream, especially with scores >100, correlated well with objective voiding trials, and demonstrated low post-void residuals. Urinary Force of Stream may be considered as an alternative assessment in the clinical setting in women with acute postoperative voiding dysfunction.

Risk factors for urinary retention after urogynecologic surgery: A retrospective cohort study and prediction model.

Postoperative urinary retention (POUR) is a common complication of urogynecological surgery. Our study aimed to identify demographic and perioperative risk factors to construct a prediction model for POUR in urogynecology. Our retrospective cohort study reviewed all patients undergoing pelvic reconstructive surgeries at our tertiary care center (Jan 1, 2013-May 1, 2019). Demographic, pre-, intra- and postoperative variables were collected from medical records. The primary outcome, POUR, was defined as (1) early POUR (E-POUR), failing initial trial of void or; (2) late POUR (L-POUR), requiring an indwelling catheter or intermittent catheterization on discharge. Risk factors were identified through univariate and multivariate logistic regression analyses. A clinical prediction model was constructed with the most significant and clinically relevant risk factors. In 501 women, 182 (36.3%) had E-POUR and 61 of these women (12.2% of the entire cohort) had L-POUR. Multivariate logistic regression revealed preoperative postvoid residual (PVR) over 200 ml (odds ratio [OR]: 3.17; p = 0.026), voiding dysfunction symptoms extracted from validated questionnaires (OR: 3.00; p = 0.030), and number of concomitant procedures (OR: 1.30 per procedure; p = 0.021) as significant predictors of E-POUR; preoperative PVR more than 200 ml (OR: 4.07; p = 0.011) and antiincontinence procedure with (OR: 3.34; p = 0.023) and without (OR: 2.64; p = 0.019) concomitant prolapse repair as significant predictors of L-POUR. A prediction model (area under the curve: 0.70) was developed for E-POUR. Elevated preoperative PVR is the most significant risk factor for POUR. Alongside other risk factors, our prediction model for POUR can be used for patient counseling and surgical planning in urogynecologic surgery.

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.

Postoperative Pain and Urinary Retention After Vaginal Reconstructive Surgery.

The objective of this study was to evaluate the effect of patients' immediate prevoiding pain level after vaginal pelvic reconstructive surgery on their ability to void. We conducted a retrospective cohort study of women with and without urinary retention after urogynecologic procedures. Postoperative pain, measured by a visual analog scale, was recorded for each patient before a voiding trial. Demographic, surgical characteristics, prevoiding trial pain, and rate of postoperative urinary retention were compared. Multiple-logistic regression analysis was used with all analyses controlled for univariate variables with a P value of ≤0.1 to estimate adjusted odds ratios (aORs) with 95% confidence intervals (CIs). Two-tailed tests were used, with P < 0.05. A total of 458 patients were identified, of which 21% (97/458) failed their voiding trial. In our study, 62% (284/458) of women had a voiding trial on postoperative day 1, and 38% (174/458) underwent a same-day voiding trial. No differences were noted between groups comparing race, ethnicity, hysterectomy, urinary sling, estimated surgical blood loss, utilization of intraoperative or postoperative narcotics, or the proportion of same-day voiding trials. Women with postoperative urinary retention had higher mean prevoiding pain when compared with women without urinary retention (pain visual analog scale, 25 mm vs 12 mm [P < 0.001], respectively). After multiple-logistic regression analysis, a significant association between postoperative urinary retention persisted for prevoiding trial pain score (aOR, 1.02; 95% CI, 1.01-1.03), age (aOR, 1.05; 95% CI, 1.02-1.02), and anterior colporrhaphy (aOR, 2.13; 95% CI, 1.18-3.8). Prevoiding pain after pelvic surgery is significantly associated with increased rates of postoperative urinary retention.

The effect of preoperative phenazopyridine on short-term urinary retention following urogynecologic surgery.

Previous studies have found that administration of phenazopyridine decreased short-term urinary retention following surgery but other more recent trials have shown mixed results. This study sought to investigate the potential benefit of preoperative administration of oral phenazopyridine in relation to the prevention of short-term urinary retention following urogynecologic surgery. This is a retrospective cohort study of a convenience sample of women undergoing urogynecologic surgery from June 2016 to March 2019. Following surgery, subjects underwent a standardized retrograde voiding trial. The data had previously been gathered from a prior prospective trial at our institution (Kesty et al. Int Urogynecol J 31(9):1899-1905, 11). Chart review was performed to determine whether patients that received 200mg of preoperative oral phenazopyridine to better visualize ureteral efflux during cystourethroscopy were more or less likely to pass their postoperative voiding trial. Bivariate statistical analysis was performed as well as a multivariate logistic regression model. A total of 165 subjects were included in the final analysis; 100 who did not receive preoperative phenazopyridine and 65 who did receive phenazopyridine. There was no statistical difference between voiding trial pass rates following urogynecologic surgery between those who did not receive preoperative phenazopyridine compared to those who did [77% (77/100) and 82% (53/65), respectively, p = 0.37)]. The multivariate logistic regression model demonstrated no difference in postoperative voiding trial pass rates among those who received preoperative phenazopyridine compared to those who did not (OR 1.7, 95% CI: 0.53, 5.8). Preoperative administration of oral phenazopyridine does not decrease short-term urinary retention following urogynecologic surgery.

The impact of post-operative voiding trial on length of stay following laparoscopic hysterectomy: a prospective, randomized control trial

Objective: Same day discharge (SDD) is feasible following laparoscopic hysterectomy (TLH) in gynecologic oncology patients resulting in low complication and re-admission rates. Following vaginal surgery, backfill or active voiding trials have been shown to reduce hospital discharge with a catheter. The aim of this study is to determine if performing an active backfill voiding trial (AVT) vs. passive voiding trial (PVT) leads to expedited discharge following TLH. Methods: Subjects scheduled for SDD TLH were enrolled and randomized to an AVT or a PVT. The primary outcome was length of stay. Secondary outcomes include time to void, catheter replacement, admission to the extended recovery unity (ERU), post-operative pain, and complications. Results: 121 patients were randomized: 60 to an AVT and 61 to a PVT. There was a statistically significant reduction in median length of stay for patients undergoing an AVT vs. PVT (271.5 minutes vs. 329 minutes, P = 0.015). Median time to void was also decreased with an AVT vs. PVT (30 minutes vs. 289 minutes, P &lt; 0.001). There was no difference in median pain score (2), catheter replacement, peri-operative complications, or overnight admissions between the two groups. Conclusion: There is a significant reduction in time to void and total length of stay in patients randomized to a backfill voiding trial following TLH with no increased patient discomfort. While the numbers of post-operative admissions were low and underpowered to detect a difference in admission rate, these data will help to streamline post-operative care for SDD gynecologic oncology patients.

Urinary retention after AdVance™ Sling: A multi-institutional retrospective study.

To identify risk factors for urinary retention following AdVance™ Sling placement using preoperative urodynamic studies to evaluate bladder contractility. A multi-institutional retrospective review of patients who underwent an AdVance Sling for post-prostatectomy stress urinary incontinence from 2007 to 2019 was performed. Acute urinary retention (AUR) was defined as the complete inability to void or elevated post-void residual (PVR) leading to catheter placement or the initiation of intermittent catheterization at the first void trial postoperatively. Bladder contractility was evaluated based on preoperative urodynamics. Of the 391 patients in this study, 55 (14.1%) experienced AUR, and 6 patients (1.5%) had chronic urinary retention with a median follow-up of 18.1 months. In total, 303 patients (77.5%) underwent preoperative urodynamics, and there was no significant difference between average PdetQmax (26.4 vs. 27.4 cmH2 O), Qmax (16.6 vs. 16.2 ml/s), PVR (19.9 vs. 28.1 ml), bladder contractility index (108 vs. 103) for patients with or without AUR following AdVance Sling. Impaired bladder contractility preoperatively was not predictive of AUR. Time to postoperative urethral catheter removal was predictive of AUR (odds ratio, 0.83; 95% confidence interval, 0.73-0.94; p = .003). Chronic urinary retention after AdVance Sling placement is uncommon and acute retention is generally self-limiting. No demographic or urodynamic factors were predictive of AUR. Patients who developed AUR were more likely to have their void trials within 2 days following AdVance Sling placement versus longer initial catheterization periods, suggesting that a longer duration of postoperative catheterization may reduce the occurrence of AUR.

Timing and Success of Postoperative Voiding Trial After Colpocleisis With and Without Concomitant Midurethral Sling

The aim of this study was to compare failure rates of first voiding trial (VT) within 7 days and on postoperative day (POD) 1 after colpocleisis with versus without concomitant midurethral sling (MUS). Predictors of POD 1 VT failure were also examined. This was a retrospective cohort study of women undergoing colpocleisis from January 2012 to October 2019 comparing VT outcomes with versus without MUS. Primary outcome was first VT failure within 7 days; outcomes of VTs performed on POD 1 were also assessed. Association between MUS and VT failure and predictors of POD 1 VT failure were assessed via logistic regression. Of 119 women, 45.4% had concomitant MUS. First VT was performed on mean POD 3.1 ± 2.2 in the MUS group versus POD 1.8 ± 1.8 in the no MUS group (P < 0.01). The MUS group was less likely to undergo POD 1 VT (50% vs 83%, P < 0.01). Failure of the first VT did not differ (22.2% with MUS vs 32.8% without MUS, P = 0.20); no association between VT failure and MUS was noted (adjusted odds ratio [aOR], 0.6; 95% confidence interval [CI], 0.18-2.1). There were 68.1% (81/119) of participants who underwent POD 1 VT, MUS was performed in 33.3% (27/81). The POD 1 failure did not differ between those with 33.3% versus 40.7% without MUS (P = 0.52). Midurethral sling was not associated with POD 1 VT failure (aOR, 0.93; 95% CI, 0.27-3.23). In women undergoing POD 1 VT, preoperative postvoid residual was associated with VT failure (aOR, 1.39; 95% CI, 1.01-1.92). In women undergoing colpocleisis, MUS was not associated with VT failure within 7 days or on POD 1. Increased preoperative postvoid residual was associated with POD 1 VT failure.

Clinical Protocol for Identifying and Managing Bladder Dysfunction during Acute Care after Traumatic Spinal Cord Injury.

Bladder dysfunction is widespread following traumatic spinal cord injury (TSCI). Early diagnosis of bladder dysfunction is crucial in preventing complications, determining prognosis, and planning rehabilitation. We aim to suggest the first clinical protocol specifically designed to evaluate and manage bladder dysfunction in TSCI patients during acute care. A retrospective cohort study was conducted on 101 patients admitted for an acute TSCI between C1 and T12. Following spinal surgery, presence of voluntary anal contraction (VAC) was used as a criterion for removal of indwelling catheter and initiating trial of void (TOV). Absence of bladder dysfunction was determined from three consecutive post-void bladder scan residuals ≤200 mL without incontinence. All patients were reassessed 3 months post-injury using the Spinal Cord Independence Measure (SCIM). A total of 74.3% were diagnosed with bladder dysfunction during acute care, while 57.4% had a motor-complete TSCI. Three months later, 94.7% of them reported impaired bladder function. None of the patients discharged from acute care after a functional bladder was diagnosed reported impaired bladder function at the 3-month follow-up. A total of 95.7% patients without VAC had persisting impaired bladder function at follow-up. The proposed protocol is specifically adapted to the dynamic nature of neurogenic bladder function following TSCI. The assessment of VAC into the protocol provides major insight on the potential for reaching adequate bladder function during the subacute phase. Conducting TOV using bladder scan residuals in patients with VAC is a non-invasive and easy method to discriminate between a functional and an impaired bladder following acute TSCI.

The Association of Preoperative Medication Administration and Preoperative and Intraoperative Factors With Postoperative Urinary Retention After Urogynecologic Surgery.

The aim of this study was to determine if preoperative medication administration is associated with postoperative urinary retention (PUR) after urogynecologic procedures and identify preoperative and intraoperative factors that are predictive of PUR. A retrospective review of patients who underwent prolapse and/or incontinence surgery was performed. The primary outcome was PUR, defined as postoperative retrograde void trial with postvoid residuals of greater than 100 mL. Bivariate analysis was performed to compare demographics and preoperative and intraoperative characteristics of women with and without PUR, and multivariable logistic regression modeling was used to identify independent predictors of PUR. Of women in this cohort, 44.8% (364/813) had PUR. There were no significant differences in preoperative medication administration in women with and without PUR. Age older than 60 years (adjusted odds ratio [aOR], 1.48; 95% confidence interval [CI], 1.09-2.02), combined prolapse and incontinence surgery (aOR, 1.84; 95% CI, 1.29-2.62), vaginal hysterectomy (aOR, 1.66; 95% CI, 1.66-2.38), and procedure time (aOR, 1.01; 95% CI, 1.00-1.01) were associated with increased odds of PUR, whereas laparoscopic sacrocolpopexy was associated with lower odds (aOR, 0.22; 95% CI, 0.10-0.46). Although preoperative medication administration was not associated with PUR, other clinically important variables were age older than 60 years, vaginal hysterectomy, incontinence and prolapse surgery, or longer procedure time. Sacrocolpopexy reduced the odds of PUR by approximately 80%. These factors may be useful in preoperative and postoperative counseling regarding PUR after urogynecologic surgery.

Active Versus Passive Discharge Voiding Protocols and Urinary Retention Rates after Same-Day Minimally Invasive Hysterectomy

Study Objective The primary objective was to determine proportion of patients discharged with a urinary catheter after undergoing a same-day minimally invasive hysterectomy (MIH) for a benign gynecological condition according to active versus passive discharge voiding protocol. Secondary objectives included assessing post anesthesia care unit (PACU) duration and postoperative urinary retention (PUR) rate ≤2 weeks of discharge. Design Retrospective observational data-only cohort study. Setting A large integrated healthcare system serving over one-million reproductive-aged women annually. Patients or Participants Patients ≥18 years old, undergoing a same-day MIH for benign gynecological conditions without urogynecology procedures 2015-2018, were categorized into active or passive voiding trial groups. An active voiding trial was defined as a patient arriving in PACU with a catheter, retrograde filling the bladder with 300ml, then allowing for voiding ≥50% within 30 minutes. If unable to void this volume, then discharged with a catheter to be removed within 24 hours. A passive voiding trial involved filling or not filling the bladder prior to arriving in PACU without a catheter, then allowing for voiding or performing a straight catheterization in PACU if unable to void. Interventions N/A. Measurements and Main Results We found 1644 (83.2%) patients underwent passive voiding trials and 333 (16.8%) active voiding trials. Proportion of patients discharged with a catheter was lower in the passive voiding group than the active voiding group (5.4% versus 10.5%, P=0.001). Passive group had shorter mean PACU time than active group (218±86 versus 240±93 minutes, P Conclusion Within a large integrated healthcare system, passive voiding trials were associated with a smaller proportion of patients discharged with a catheter, shorter PACU duration, and lower PUR rate. This suggests that passive voiding trials can be safely utilized after a benign MIH to reduce hospital duration, optimize healthcare resources, and ultimately improve patient experience.

Nitrofurantoin Prophylaxis Following Short-Term Transurethral Catheterization: A Randomized Controlled Trial

Study Objective To evaluate if nitrofurantoin prophylaxis following discontinuation of transurethral catheterization decreases the rate of urinary tract infection. Design Double-blind, Placebo controlled, Randomized trial. Setting Academic. Patients or Participants Women with postoperative urinary retention following pelvic reconstructive surgery managed with transurethral catheterization. Interventions Twice daily dosing of nitrofurantoin or placebo for five days following transurethral catheter removal. Measurements and Main Results This trial was conducted across two clinical sites between October 2017 and April 2019. Once participants passed the postoperative in-office voiding trial, they were randomized to receive oral nitrofurantoin 100mg or placebo twice daily for five days and keep a medication diary to evaluate medication compliance. The primary outcome was clinically suspected urinary tract infection (defined as dysuria, frequency, and irritation in the absence of vaginal discharge) and/or culture-proven urinary tract infection (defined as greater than 105 colony forming units of a single organism) within 30 days of surgery. Secondary outcomes included evaluation of adverse events related to study medication and study medication compliance. Data from 164 consented participants were eligible for analysis (nitrofurantoin, n=82; placebo, n=82). There were no significant demographic and intraoperative differences between groups except for body mass index (27.1±4.7 vs 28.6±5.0 kg/m2, p=0.05) and race ([96.3% vs 87.8% Caucasian, p=0.04] vs [1.2% vs 9.8%, p=0.03]). Median duration of postoperative transurethral catheterization was 3 days (IQR 2-5 days, p=0.12). Fifteen women in the nitrofurantoin group and 14 women in the placebo group experienced urinary tract infections within 30 days (18.3% vs 17.1%, p=0.84, odds ratio [95% CI] 1.09 [0.49-2.43]). There were no study medication allergies, however, nausea was the most common intolerance. Most women in each group completed the study drug treatment (91.5% vs 86.4%, p=0.30). Conclusion Nitrofurantoin prophylaxis following removal of the transurethral catheter did not reduce risk of urinary tract infection in women with postoperative urinary retention following pelvic reconstructive surgery.

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.

Effect of Pudendal Blockade on Bladder Emptying After Midurethral Sling: A Randomized Controlled Trial.

To evaluate the effect of bilateral pudendal nerve blockade on immediate postoperative bladder emptying after midurethral sling. We performed a double-blinded, randomized, placebo-controlled trial of women undergoing a midurethral sling procedure between October 2017 and February of 2019. Women older than 18 years were eligible if they were undergoing a midurethral sling with no concomitant procedures and had no preoperative urinary retention. Participant demographics and medical conditions that may affect bladder emptying were recorded preoperatively. Participants were randomized to a bilateral pudendal injection of either bupivacaine or normal saline. After induction of anesthesia, the pudendal injection was administered before any incisions. No other local anesthesia was used. The primary outcome was the rate of passing a standardized void trial. Secondary outcomes included perioperative pain scores, analgesia use, and complications. Ninety-one participants were enrolled in the study. One patient had a delayed void trial on postoperative day 1, leaving 90 participants for the final analysis. Demographic and perioperative characteristics were similar between the groups. Adjusted logistic regression showed that the administration of a bupivacaine pudendal block led to a higher rate of void trial failure (43% vs 20%, odds ratio = 0.32, P = 0.02 adjusted for age, body mass index, and comorbidities). Postoperative pain scores and analgesia use were similar between the groups. Postoperative complications, including urinary tract infection, mesh erosion, pelvic hematoma, or urinary retention within 6 weeks were similar between the groups. Our prospective trial demonstrates that a bilateral pudendal blockade before midurethral sling procedure worsens postoperative bladder emptying.

Successfully Sustaining Infection Reductions: A Catheter–Associated Urinary Tract Infection (CAUTI) Prevention Initiative Five Years In

Background: Infection prevention efforts are complex, and sustaining reductions is even more challenging. At the UNC Medical Center, multidisciplinary hospital-wide work groups implement quality improvement initiatives to prevent healthcare-associated infections. The first and most successful initiative has been our catheter-associated urinary tract infection (CAUTI) prevention effort, which started in 2014. The program led to initial dramatic reductions, with continued reductions in CAUTI rates each year since then. Methods: A multidisciplinary workgroup formed in 2014 developed an evidence-based CAUTI prevention bundle and partnered with the nursing staff in 2015–2016 to implement practice changes as part of our hospital’s quality improvement “Spread of Innovations” model. These changes included (1) creation of a 2-person catheter-insertion checklist; (2) insertion skills validation for all nursing staff and nursing assistants; (3) standardization of a maintenance protocol and subsequent education and skills validation with nurses and nurse assistants; and (4) peer audits of urinary catheter maintenance. Additional initiatives implemented over the past 5 years include (1) routine resident education on CAUTI prevention; (2) annual nurse competencies to reinforce skills around CAUTI prevention; (3) introduction of products (eg, PureWick) as alternatives to indwelling catheters; (4) diagnostic stewardship efforts; (5) revisions to the electronic medical record; and (6) efforts to encourage removal of unnecessary catheters such as the “nurse-driven conversation” and Trial of Void. Results: Our CAUTI rates decreased 65% from 2.94 per 1,000 catheter days in the baseline period of 2014 to 1.02 in 2018. In our ICUs (excluding the neonatal ICU), the rate dropped 75% from 4.30 in 2014 to 1.08 per 1,000 catheter days in 2018. Conclusions: We attribute our continued reductions and successful sustainment of low CAUTI rates to several factors. First, the use of a multidisciplinary team was critical to obtaining buy-in from key stakeholders including nursing, nurse assistants, physicians, pharmacists, performance improvement specialists, and administration. Second, continuation of the maintenance peer audits outside the initial project year has provided an important framework for this project, giving regular opportunities for frontline staff to evaluate patients’ catheter condition and to give feedback to colleagues or “just in time education.” These activities potentially prevent infections in real time. Third, with the many competing priorities demanding clinicians’ attention, it has been important for the CAUTI workgroup to continue to evaluate the problem, to determine where opportunities for improvement remain, and to tailor initiatives to meet those needs. In this way, new work can focus on priorities identified by staff, and CAUTI prevention initiatives remain relevant.Funding: NoneDisclosures: None

The role of perioperative medications in urinary retention following midurethral sling

Postoperative urinary retention (PUR) is a known complication of midurethral sling (MUS) placement. The use of certain perioperative medications may influence the risk of this complication. This study aimed to investigate the association of perioperative medications with urinary retention after MUS. This was a retrospective study of women undergoing MUS placement for stress urinary incontinence by a fellowship-trained urologic surgeon between 2015 and 2018, under approval by the Institutional Review Board. Both retropubic and transobturator approaches were included. All patients underwent an active void trial following surgery. Intraoperative medications given by the anesthesia team were retrospectively noted. The Fisher's exact test was used to compare the association of PUR with categorical variables. A total of 82 patients were included, 17 (21%) of whom failed postoperative void trial due to urinary retention. Of 25 patients receiving perioperative scopolamine, 40% failed the postoperative void trial, compared to 12% of patients not receiving scopolamine (p = .048). Groups were then stratified based on scopolamine use due to the observed independent association with PUR. Subgroup analysis revealed a stronger association of postoperative retention with scopolamine in patients undergoing concomitant prolapse surgery. Notably, retention rate and scopolamine use were similar whether patients underwent sling placement alone or in combination with prolapse surgery. Rate of retention was also higher for retropubic versus transobturator slings (36% vs. 9%; p = .005). Perioperative scopolamine may be associated with an increased risk of postoperative urinary retention following MUS, especially in the setting of a concomitant prolapse surgery.

Preoperative urinary function does not predict postoperative acute urinary retention in men after rectal resection.

Acute urinary retention (AUR) is a well-known complication after rectal surgery. It can be associated with additional morbidity. Causes of postoperative AUR are often multifactorial - involving patient-, pathology- and treatment-related factors. A proportion of men undergoing total mesorectal excision (TME) have preexisting urinary dysfunction and this may predispose to AUR. The aim of this study was to prospectively assess the influence of preoperative urinary function on postoperative AUR in men undergoing TME. A prospective multicentre cohort study was conducted. All adult men undergoing rectal resection between June 2016 and January 2018 were recruited. Combined pelvic resections, inability to void per urethra and emergency surgery were excluded. Preoperative urinary function was assessed with uroflowmetry, prostate ultrasound and the International Prostate Symptom Score (IPSS). The incidence of postoperative AUR, urinary tract infection (UTI) and length of hospital stay (LOS) were measured. Seventy-seven patients (mean age 61years) were recruited. The overall incidence of AUR was 21%. Preoperative urinary function, IPSS and past urological history were not predictive for postoperative AUR. AUR was not associated with UTI and did not affect LOS. Patients with UTI had a higher intravesical protrusion of the prostate. Preoperative urinary dysfunction in men is not predictive of postoperative AUR after TME. It should not preclude early trial of void after TME. AUR did not predispose to UTI, nor did it prolong LOS.

‘Top-Down’ holmium laser enucleation of the prostate. Report of initial cases performed by a single surgeon

ABSTRACT Objectives To present the 12-month outcomes of ‘Top-Down’ holmium laser enucleation of the prostate (HoLEP). Patients and methods We retrospectively reviewed the charts of prospectively collected patients who underwent Top-Down HoLEP between 2017 and 2018. All cases were operated upon by a single urologist (H.E), using a 100-W holmium:YAG laser with a 550-μm laser fibre. We recorded the enucleation time, morcellation time, intraoperative, and postoperative complications. All patients had postoperative follow-up visits at 1, 3, 6 and 12 months. The evaluation included the International Prostate Symptom Score (IPSS), quality-of-life (QoL) assessment, measurement of maximum urinary flow rate (Qmax) and the post-void residual urine volume (PVR). Results A total of 60 consecutive patients were recruited. The median (range) prostatic volume, resected prostatic weight, and percentage of resected prostatic tissue were 124 (70–266) mL, 90 (44–242) g and 76 (46–97)%, respectively. The median (range) enucleation and morcellation times were 80 (25–200) and 14.5 (4–58) min, respectively. One patient had a simple bladder mucosal injury and another developed clot retention. At 3 months, three patients (5%) had stress urinary incontinence (SUI) and eight patients (13.3%) presented with urge UI (UUI). At the last follow-up visit, one patient (1.7%) presented with persistent SUI, while three patients (5%) presented with UUI. The IPSS and QoL significantly improved during the follow-up period (P = 0.045 and P = 0.04, respectively). Conclusion The results of the Top-Down technique are comparable to those of traditional HoLEP. However, the Top-Down technique may reduce the complexity, operating time, and SUI rates. Abbreviations BN: bladder neck; HoLEP: holmium laser enucleation of the prostate; PVR: post-void residual urine volume; Qmax: maximum urinary flow rate; QoL: quality of life; TOV: trial of voiding; (S)(U)UI: (stress) (urge) urinary incontinence

Postoperative Urinary Retention Rates after Autofill versus Backfill Void Trial following Total Laparoscopic Hysterectomy: A Randomized Controlled Trial

To compare the rate of postoperative urinary retention (POUR) after total laparoscopic hysterectomy (TLH) using the autofill vs the backfill void trial. Secondary objectives were to compare the time to discharge from the recovery room, rate of postoperative urinary tract infection (UTI), perceived bladder condition, the effect of bladder function on life, and patient satisfaction. Randomized controlled trial. Single academic medical center. Women who underwent TLH by conventional laparoscopy or robotic-assisted laparoscopy for benign non-urogynecologic indications. After TLH, participants were randomized to have an autofill void trial (group A) or a backfill void trial once they were able to ambulate (group B). Failure rate, time to discharge, and UTI rate were assessed. Participants completed the patient perception of bladder condition and the incontinence impact questionnaire-short form questionnaires. Patient satisfaction was assessed. Multiple regression analysis was performed to determine the predictors of POUR. Eighty-two participants completed the study after randomization, 42 in group A and 40 in group B. There were no statistically significant differences in demographic or perioperative outcomes. Seven participants had POUR in group A (16.7%) and 11 in group B (27.5%) (p = .36), respectively. The median time to discharge was 176 minutes for group A (160.5, 255.5) and 218 minutes for group B (180, 265) (p = .01), respectively. There were no statistically significant differences in rate of postoperative UTI (p >.99), patient perception of bladder condition scores (p = .24), incontinence impact questionnaire-short form scores (p = .23), and patient satisfaction scores (p = .26). A stepwise logistic regression analysis did not demonstrate any predictors of POUR. Backfill void trial once the participant was able to ambulate was not superior to the autofill void trial with respect to the rate of POUR. The autofill void trial resulted in faster same-day discharge.