BMC Women's Health Volume 21, Article Number: 195 (2021) Cite this article
Transient postoperative urinary retention (POUR) is common after pelvic floor surgery. Our goal is to determine the association between perioperative variables and POUR, and to determine the number of cavities required to normalize postoperative voiding (PVR).
We conducted a retrospective cohort study of 992 patients who underwent pelvic floor surgery in a tertiary referral center from January 2015 to October 2017. The variables evaluated include age, BMI, ASA score, type of anesthesia, type of surgery, postoperative hospital stay, surgeon, bladder protocol used, and the number of PVRs required to "pass" the protocol.
Important risk factors for POUR include: placement of MUS during POP surgery, anterior repair, and hysterectomy, accompanied by sacral vault suspension. A total of 25.1% of patients require catheterization when discharged from the hospital. Patients who also received a midsection urethral sling (MUS) had an increased probability of PVR after the second TOV and the third TOV were 2.2 (95% CI 1.6–2.9) and 2.3 (95% CI 1.8–3.1), respectively Times (p <0.0001), respectively, compared with those without MUS. Allowing a third TOV allows an additional 10% of women to pass the urination protocol before discharge. The median number of holes passing the plan is 2. The placement of ASA> 2 and MUS is related to the increase in the number of holes required to pass the plan.
Although many women passed the protocol on the second urination, using the third urination as an entry point to determine success will result in fewer women requiring catheterization after discharge. Before pelvic floor surgery, women should be informed of the possibility of POUR in order to manage postoperative expectations.
Transient postoperative urinary retention (POUR) is common after pelvic floor surgery and occurs in 15-45% of women [1,2,3]. If POUR is not found, it may cause serious complications, including continuous bladder inflation with detrusor injury, renal dysfunction secondary to ureteral reflux and urinary tract infection [4,5,6]. Undiagnosed POUR can also lead to a painful emergency presentation for catheterization in the emergency room after discharge from the hospital.
Women have a higher risk of POUR after pelvic floor reconstruction surgery. This may be due to tissue edema, changes in the urethra-bladder junction, and hematoma formation [7]. The small peripheral nerve endings needed for bladder sensation may be temporarily interrupted, leading to temporary neuropathy and bladder dysfunction [4]. POUR risk factors previously assessed include: lower body mass index (BMI), advanced age, higher prolapse stage, anterior vaginal reconstruction, previous incontinence surgery, and residual urine volume (PVR) before and after surgery [8,9,10,11,12]. Intravenous infusion> 750 mL or bladder volume ≥ 270 mL in the recovery area after anesthesia has also been shown to increase the risk of POUR [13]. In addition, the increase in opioid administration is associated with a 1.5 times higher risk of POUR (OR 1.3) [14]. Interestingly, a study by Bracken et al. [15] showed that the use of vaginal bupivacaine when placing a midsection urethral sling (MUS) increased the incidence of POUR, but did not reduce the level of pain or the use of analgesics [15].
The optimal pattern of bladder filling before the post-operative voiding (TOV) test is unclear. There are two main methods of voiding test: (1) retrograde filling of the bladder with a Foley catheter left in place, and (2) spontaneous bladder filling (16-20). The sensitivity of retrograde voiding test to detect urinary retention was 94.4%, and the specificity was 58.1% [16]. The sensitivity of spontaneous filling is 100% and the specificity is 25.8%; however, due to the time required for natural and passive filling of the bladder, this method may take longer than the retrograde method to complete [16]. A study by Pulvino et al. [17] A 300 ml retrograde filling and spontaneous filling using a Foley catheter were compared to determine the success of TOV. Compared with spontaneous filling, retrograde filling technique results in a statistically significantly more complete bladder emptying. It also showed less heterogeneity of bladder volume during TOV, and less over-distension when bladder volume exceeds 450 ml [17]. Another study by Dolgun et al. [18] Shows that the TOV success rate is equal between the spontaneous filling group and the retrograde group. The spontaneous urination group requires women to urinate ≥ 150 ml to pass, while the retrograde urination group has stricter standards, requiring 200 ml urination and PVR <100 ml. The proportion of women who had urinary retention and needed catheterization was similar in the two groups [18].
POUR is a common condition after pelvic floor surgery. If a woman uses a catheter or self-catheterization when she is discharged from the hospital, it can cause severe anxiety and pain. The main purpose of this study is to determine which perioperative factors are related to the occurrence of POUR. This information is considered to be valuable for the consultation of preoperative patients regarding postoperative catheterization expectations. Our secondary goal is to determine the average number of cavities required to normalize postoperative voiding (PVR).
We conducted a retrospective cohort study of patients who underwent pelvic floor reconstruction surgery with four surgeons in a tertiary referral center from January 2015 to October 2017. The project was reviewed and approved by the Research Ethics Committee of Shanlu Medical Center (ID# CHREB150706). The operations analyzed include occlusive surgery (with or without MUS) and reconstruction surgery to resolve the vaginal tip (including vaginal hysterectomy with sacral spine or uterosacral vault drape, with or without anterior and posterior vaginoplasty, sacral vault drape) Sling, sacral vaginal fixation (SCP), and or without MUS). Cases are determined in the pelvic medicine and reconstructive surgery reservation database. Perioperative data is entered as part of the city's inpatient EMR (Sunrise Clinical Manager) routine clinical practice, and is extracted by FPMRS/Uogynecology researchers into a database specially designed for research purposes.
The data set does not capture single-point prolapse procedures, such as isolated anterior or posterior repairs. Pelvic organ prolapse (POP) during all MUS operations during surgery use 1% vaginal xylocaine and 1:100,000 epinephrine mixed 1:1 with sterile water, in the range of 10–40 ml for the period of placement Water separation. If the patient has received apical suspension surgery (such as surgery for non-prolapsed indications), solitary incontinence surgery, vesicovaginal and rectovaginal fistula repair, and day surgery cases (such as dilation surgery), the patient Excluded from our study and curettage, laparoscopic endometriosis resection). This data set excludes patients with an increase in urinary residual volume ≥ 150 ml before and after surgery. Extract data from the postoperative electronic chart of the patient. The extracted variables include: age, body mass index (BMI), American Society of Anesthesiologists (ASA) score as a health indicator, previous pelvic floor surgery and the type of surgery performed. The extracted perioperative variables include: length of stay (in days), the number of urination tests in the hospital, and whether the patient went home through a catheter or self-catheterized.
In the tertiary center where the study is conducted, the attending surgeon can decide to implement two bladder options during the postoperative period. The first (retrograde protocol) is performed by filling the bladder with 300 ml of normal saline or sterile water through a Foley catheter that remains in place overnight. The urine output is measured by the nurse in the urine cap, and the post-urinary residual volume (PVR) is determined based on the urine output. The second and subsequent (spontaneous filling protocol) bladder protocol involves removing the Foley catheter and allowing the bladder to fill spontaneously. The patient must urinate within 4 hours after removing the catheter and measure PVR with a bedside bladder scanner. The urine output is measured by the nurse in the urine cap, and the PVR is measured by the bladder scanner. If the patient has two consecutive urinations> 200 ml and PVR ≤ 150 ml, they are considered to have passed the bladder protocol and monitored for urination cessation. If the first TOV fails, the other two consecutive invalids must be "passed" to pass the invalid agreement. If PVR> 250 ml, place an access catheter to confirm PVR and decompress the bladder. With these two schemes, the postoperative indwelling catheter was removed at 6 am on the first day, in line with the guidelines for early postoperative recovery (ERAS), and the duration of catheterization was the shortest [19]. Patients must pass at least two consecutive TOVs to pass the urination regimen. This is based on the unreliability of PVR measurement and the need to repeat to confirm consistency [20]. A study by Dunsmuir et al. Et al. showed that only one-third of patients have an approximately constant PVR (variation range <120 mL), and therefore need to repeat transabdominal bladder ultrasound [21]. If only one PVR is performed as part of the TOV, the patient may have a falsely low PVR and may show urinary retention. The type of bladder protocol implemented and the results are then recorded in the electronic patient chart.
If the patient meets all other discharge criteria but fails the TOV, they can choose to self-cathenize at home after every urine measurement or use an indwelling Foley catheter to be discharged. Patients who choose self-catheterization at discharge can stop self-catheterization as soon as the urination mode shows that the urine output is> 200 ml and the PVR is ≤ 150 ml for 3 consecutive urinations. Those patients who choose to use catheters to be discharged from the hospital undergo retrograde TOV clinical examination 4-7 days after discharge. This is consistent with a prospective randomized controlled trial by Schachar et al. This shows that compared with the 7th day after the operation, if the women with POUR undergoing prolapse surgery on the 4th day after the operation, the risk of failure to follow-up TOV is 7 times higher [22].
Use Stata 16 (University of Texas Station) for statistics. Descriptive statistics are used to describe research samples and calculate the proportions, averages, and medians of demographic characteristics. An elevated PVR is defined as a PVR greater than 150 cc. We calculated the descriptive statistics, chi-square test, and crude odds ratio of the increase in PVR during the second cavity, and stratified the results according to the type of POP surgery (reconstruction and occlusion) and the presence of MUS surgery. Then, the concomitant hysterectomy and the previous hysterectomy were used to further stratify the reconstructive surgery to explore the impact of hysterectomy on the risk factors of POUR.
The sample size based on regression analysis is difficult to calculate a priori. However, logistic regression accepts the general rule of 10 cases/events per regression variable. Our original model includes more than 10 variables and multiple interaction terms. For this reason, we estimate that our logistic regression model requires 200 events. Recognizing that some cases may lose information due to chart errors, we increased the sample size by 20% to 240 events. The prevalence of postoperative urinary retention is estimated to be 40%, which will be a sample size of 600 women. However, due to multiple group comparisons, other forms of regression analysis require a larger sample than logistic regression, so the same size increases again by 50% to 900. Based on our average operation volume, it is estimated that a review of all cases for more than 34 months will provide this number (January 2015 to October 2017).
We conducted several regression analyses and realized that the concept of POUR can be defined in many ways. Binary logistic regression assesses the impact of patient age, BMI, ASA score, type of bladder protocol, type of anesthesia (general and local), surgeon, concomitant hysterectomy, and vaginal anterior and posterior wall repair on the results of the second TOV pass-operation invalid. Explore age and BMI in linear and non-linear ways. The interaction items between age and BMI and the combination of surgery are discussed. We also explored the potential impact of surgeons on urination results using mixed-effect logistic regression and McFadden's R-squared reported variance value (not reported).
A zero-cut Poisson regression is used to explore the association with the absolute number of variables through the bladder protocol and perioperative period, where the dependent variable is the observed non-zero count, assuming a Poisson distribution. The Poisson regression model checks whether any measured clinical variables (including age, BMI, MUS, ASA score, type of anesthesia, hysterectomy, uterosacral or sacrospinous process suspension, and laparoscopic SCP) predict whether the number of urinations through the bladder protocol is predicted. The crude odds ratio and the adjusted odds ratio are calculated.
Drawing a histogram of the number of holes required to pass the TOV allows us to determine where the natural clustering of the data occurs, and to classify the pattern groups of the number of holes required to pass the TOV, which are essentially ordered. We used the Brant test to evaluate the proportional advantage hypothesis. The results of the Brant test show that the proportional advantage assumption is not violated. We can assume that the relationship between each pair of result groups is the same (that is, compared with 1, being in category 2 or 3 is the same as being in the group 3 and 2 and 1 compared). We calculated the original model (using the results of a single predictor and the empty class) and the adjusted model (using the results of all the predictors and the empty class).
For all regression modeling, we evaluated the significance at the p <0.05 level. For the binary result of passing TOV on the second hole, a sensitivity analysis was also performed using the boundary point of the third hole. Use multiple regression methods as sensitivity analysis to ensure that our results are consistent across different POUR classification methods.
Overall, our study examined the association of 992 women undergoing pelvic floor reconstruction surgery at tertiary medical centers with surgery and demographic characteristics and POUR. Table 1 describes the demographic characteristics of our study sample. A total of 25.1% of people had a catheter indwelled or self-catheterized when they returned home from the hospital.
We examined the characteristics of women with PVR> 150 ml through occlusive and reconstructive surgery (Table 2). Overall, 51.2% (95%CI 48.0-54.3%) of the women in our study increased their PVR after the second urination, and 40.8% (95%CI 37.7-43.9%) increased their PVR after the third urination . Overall, those patients who also underwent MUS surgery were 2.2 (95% CI 1.6-2.9) times (p <0.0001) and 2.3 (95% CI 1.8-3.1) more likely to have an increased PVR after the second TOV. Double the PVR after the third TOV (p <0.0001). The increase in PVR after the second and third emptying is significantly different due to the presence of MUS in reconstructive surgery. However, there is no significant difference in the probability of increased PVR caused by the presence of MUS in occlusive surgery, which may be Women undergoing occlusion surgery and MUS surgery due to the relatively small sample size. For occlusive surgery, there are no variables related to the probability of failure of the bladder protocol, which makes it difficult to predict the results of this group before surgery.
We also examined the characteristics of women with PVR> 150 ml through hysterectomy, and compared those who had had a hysterectomy and therefore only had a fornix sling with those who had a hysterectomy and accompanying apical sling Women. This stratification is shown in Table 3.
In the reconstruction group that did not undergo hysterectomy at the same time, logistic regression was used to check the outcome of the bladder protocol failure after the second and third TOV. The performance accompanying MUS is related to the probability of failure of the bladder protocol during the second TOV (aOR 3.08, 95%CI 1.67–5.68) and the third TOV (aOR 2.96, 95%CI 1.65–5.33). In the absence of hysterectomy, the adjusted odds ratio (aOR) of TOV failure after sacral vault suspension and laparoscopic SCP was not significant (aOR 1.18, 95%CI 0.71-1.97 and aOR 1.02, 95, respectively) %CI 0.621-1.69). There is also no comparison of the rough OR of the second and third TOV, as shown in Table 3. For reconstructive surgery accompanying hysterectomy, MUS and anterior repair are important predictors of bladder protocol failure after the second and third TOV. After adjusting the MUS status and anterior restoration, the odds ratio of the sacral vault suspension compared with the uterosacral vault suspension was not significant (aOR 1.10, 95% CI 0.70–1.72, and aOR 0.87, 95%, respectively) CI 0.56–1.36), which is not significantly the crude OR shown in Table 3.
In our rough logistic regression model, the OR of retrograde filling TOV is significant compared with spontaneous filling TOV. The possibility of retrograde TOV failure in the second gap is 1.35 times (95% CI 1.04-1.75) of natural filling TOV. And1.45 times (95% CI 1.12–1.89) the probability of the third invalid failure. However, in the adjusted model, these values are not significant for the second time (aOR 1.16, 95%CI 0.89-1.52) or the third time (aOR 1.23, 95%CI 0.94-1.62), indicating the TOV type Does not affect the probability of passing TOV on the 2nd and 3rd TOV. In the adjusted zero-cut Poisson regression model, the incidence ratio of this variable (compare retrograde filling and spontaneous filling) is 1.01 (95% CI 0.70–1.46), again showing that it does not affect the absolute number of holes required to pass . Then delete the variable from the logistic regression model.
It was found that the three surgical procedures were consistently associated with a higher probability of PVR> 150 ml at the second and third postoperative emptying (results not shown in the table). They are: (1) Accompanying the execution of the MUS program (after the second invalidation: adjusted OR 2.22, 95%CI 1.62-3.05; after the third invalidation: adjusted OR 2.27; 95%CI 1.67-3.08) ; (2) Anterior repair (after the second invalidation: adjusted OR 1.55, 95%CI 1.18-2.06; after the third invalidation: adjusted OR 1.49, 95%CI 1.12-1.99); (3) hysterectomy The performance of surgery (after the second emptying, adjusted OR 1.56, 95%CI 1.18-2.05 and after the third emptying, adjusted OR 1.71, 95%CI 1.29-2.25). It was found that the increase in BMI was related to the decrease in the probability of bladder protocol failure at the third TOV (adjusted OR 0.97, 95%CI 0.95–0.99), but not related to the second TOV.
The results of the mixed-effect logistic regression showed that the surgeon variable only explained 3.9% of the variance in the model that predicted the increase in PVR at the second hole, and 7.5% of the variance in the model that predicted the increase in PVR at the third hole. This shows that individual differences in the skills of each surgeon will not have a great impact on the results of POUR.
In the adjusted Poisson regression model, we found that the presence of MUS and an ASA score of 2 or higher will significantly increase the number of holes until the agreement passes 1.27 (95% CI 1.13–1.42) and 1.15 times (95% CI 1.03) –1.27), respectively. Finally, although vaginal hysterectomy or sacral spine sling before the passage of the bladder test is not significantly associated with the increase in urination frequency, simultaneous vaginal hysterectomy and sacral spine sling make the frequency of urination significantly An increase of 1.53 times (95 %CI 1.18–1.97). Before the agreement was passed, there was no significant correlation between other predictors and the number of holes (Table 4).
Using visual inspection of the data, we used the natural interruption of the number of voids after surgery to define the pattern of voids after surgery. This defines three groups of patients who need 1-3 cavities, 4-8 cavities, or> 8 cavities to pass the protocol. Using ordered regression (Table 5), we found that MUS, ASA score, and hysterectomy with sacral spine suspension were important predictors of urination grade. If MUS is performed, assuming all other factors in the model remain the same, the adjusted probability of taking longer (rising to the invalid level) to invalid will be 2.27 times higher (95% CI 1.52–3.40). An ASA score of 2 or higher increases the chance of urinating longer by 1.47 times (95% CI 1.01–2.14).
This rigorous analysis of POUR after pelvic floor reconstruction surgery provides clinicians with valuable information that can help women provide consultation before surgery and manage their postoperative expectations if postoperative catheterization may be required. In our analysis of all pelvic floor surgeries, 51.2% passed TOV after the third TOV, and 40.8% after the second TOV, which is equivalent to an additional 10.4% passed TOV. If the third TOV is performed, No intubation is required. This difference is similar when considering surgery with or without MUS.
Previous studies have shown that lower BMI, older women, and anterior vaginal surgery are associated with a higher risk of POUR [8,9,10,11,12]. In our analysis, we found that there is only a modest difference between the reconstruction method and the occlusion method. This difference is mainly caused by the reconstructive surgery of hysterectomy. In the regression model that includes all cases, it does not lose effectiveness like the stratified method, and the effect of hysterectomy is only in the case of concomitant sacrospinous process suspension. This may be due to longer operation time, higher intraoperative blood loss [3] or possible irritation of the pudendal nerve in the overhang area of the sacral spine [23]. Interestingly, in the regression model we used, age and BMI were not very predictive. In the truncated Poisson and ordered regression models, an ASA score greater than 2 (a marker of medical comorbidities) is related to the increase in the number of holes required to pass the agreement. This shows that it is not the parameters such as age and BMI that affect the ability to urinate after surgery, but the overall health of women. We also did not find that female attending surgeons can predict the risk of POUR. The contribution of different surgeons to the model is small, indicating that these associations are common to all four surgeons and are not affected by individual differences in technology.
In our research, placement of MUS is always the most important risk factor for POUR. This is probably because incontinence surgery aims to correct urethral hyperactivity, and its inherent design purpose is to cause a certain degree of urethral obstruction [4]. Women who are afraid or unable to deal with elevated residues after surgery (such as those experiencing dexterity, obesity, or anxiety) may need to consider incontinence surgery after POP surgery, because the sling that accompanies POP surgery increases the risk of pouring [ twenty four].
In our institution, the failure rate of the second and third TOV is very high, from 36.1% (for POP procedures without MUS) to 56.2% (for POP procedures with MUS) after the third TOV . This may be due to the catheter being removed early at 6 am in accordance with the ERAS guidelines. This is consistent with previous studies, that is, TOV with longer intubation time has a higher success rate [25]. Although early catheter removal complies with the ERAS guidelines, it may cause a large proportion of women to require intermittent catheterization due to POUR, leading to an increase in UTI. Indwelling a catheter or self-intubation when discharged from the hospital may cause anxiety and may increase the risk of infection, which may affect the patient's satisfaction with the surgical experience [26]. This is especially important for women who are planning to undergo day surgery and do not want to be discharged from the hospital through a catheter or self-catheter. Such information should be communicated to day care staff, and if resources are available, an additional third TOV should be attempted. Based on the risk factors mentioned earlier, women at higher risk of POUR may benefit from being placed at the beginning of the day and thus benefit from a longer period of time for TOV in PACU. Future research can examine the impact of catheterization on POUR and its relationship with women's perception of surgical experience.
Finally, our study provides normative data on the number of voids required for normalization after PVR. Previous work has shown that an average of 2-3 TOV is performed during the postoperative period, whether in the ward or in the day care ward/post-anesthesia care ward [15, 16]. Our study found that the median number of passes for reconstruction and occlusion surgery was 2, and the natural urination pattern (1-3, 4-8 or> 8 holes passing TOV) identified in our analysis corresponds to the 75th percentile The number of digits, the 75th-95th percentile, and the greater than the 95th percentile. This suggests that the need for> 3 urinations to pass the bladder plan should be the definition of POUR, and patients who need 8 or more urinations are truly outliers. Patients and nurses who provide them with postoperative cases should be taught that it is completely normal to require 3 urinations to normalize postoperative urinary residues.
The strengths of our study include the large sample size (n = 992) and the level of detail available during the perioperative period. The number and detailed information of urination tests are accessed on the electronic surgery patient chart, so that the number of TOVs used and urination parameters can be analyzed in detail. Limitations include the inability to consider intraoperative infusions in our model, because it has been suggested that a volume ≥ 750 ml will increase the risk of POUR [13, 14]. However, our center adheres to the ERAS principles, including the judicious use of perioperative intravenous fluids, and TOV does not begin until the first day after surgery, which means that most intraoperative intravenous fluids could have been treated with diuresis overnight. Although women with a preexisting PVR> 150 ml were not included in the cohort, it did not include information about other urination parameters, such as urine flow velocity and the shape of the urine flow measurement curve, to assess its value as a predictor. Another limitation is that our results cannot be generalized to patients who were discharged on the day of surgery, and more of them were proven to fail the urination protocol and require catheterization [27]. Finally, our sample size may not be sufficient to detect differences in certain measured variables (for example, differences between types of surgery).
POUR is common after pelvic floor surgery. Our research has identified some risk factors for POUR, including MUS placement and concomitant hysterectomy and sacral vault suspension. However, POUR still occurs in women without these risk factors, which makes it difficult to predict before surgery. Normalization of PVR usually requires two holes, but a third hole may be required. For women who are at higher risk of POUR and plan to undergo day surgery, surgeons should consider placing them at the beginning of the surgery list to allow time for postoperative urination. Women should be informed of the high incidence of POUR before surgery so that they can manage postoperative expectations.
The data set used and/or analyzed during the current research period can be obtained from the corresponding author upon reasonable request.
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Members of the Calgary Women’s Pelvic Health Research Group: Erin A. Brennand, Shunaha Kim-Fine, Magali Robert, Colin Birch, Magnus Murphy, Kaylee Ramage, Emily Sandwith.
Department of Women's Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Foothill Medical Center, University of Calgary School of Medicine, 1403 29 Street Northwest, Calgary, AB, T2N 2T9, Canada
BC Anglim, K. Ramage, E. Sandwith and EA Brennand
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BA: Manuscript project development and editing, KR: Manuscript project development, statistical analysis and editing, ES: Manuscript data entry, project development and editing, EB: Manuscript project development, statistical analysis, data entry and editing. All authors read and approved the final manuscript.
Correspondence with BC Anglim.
The project was reviewed and approved by the Research Ethics Committee of Shanlu Medical Center (IDs# CHREB150706). All methods are carried out in accordance with relevant guidelines and regulations. Since this is a retrospective review, the Research Ethics Committee of the Foothills Medical Center believes that everyone’s informed consent is not required.
The author agrees to publish.
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Anglim, BC, Ramage, K., Sandwith, E. etc. Urinary retention after pelvic organ prolapse surgery: the influence of perioperative factors and a trial of ineffective protocols. BMC Women's Health 21, 195 (2021). https://doi.org/10.1186/s12905-021-01330-4
DOI: https://doi.org/10.1186/s12905-021-01330-4
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