Urinary catheterization in gynecological surgery: When should it be removed?

Adly Nanda A, Budi Iman SantosoPresented at IUGA Regional Symposium

Poster Competition Bali 7-9 Nov 2013

Urogynecology and Pelvic Reconstruction DivisionDepartment of Obstetrics & GynecologyFaculty of Medicine Univeristas Indonesia/Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia.

Introduction: Post-operative Urinary Retention (POUR)

Incidence• 2,1% -70% • Multifactorial etiology

Early detection is important

• To prevent irreversible detrusor injury

UTI incidence• In women with POUR :

9,7%,• Women without POUR :

4,1%

Terry Feliciano BSN, R., Jo Montero BSN, R., Mary McCarthy RN, P. C., & BSN, M. P. (2008). Journal of PeriAnesthesia Nursing, 23(6), 394–400.Rizvi, R. M., & Rizvi, J. (2006). Reviews in Gynaecological and Perinatal Practice, 6(3-4), 140–144.

Abdominal hysterectomy:4% -13.7%

Vaginal hysterectomy:2-15%

Laparoscopy : 4%

Robotic : 10,3% Radical : 30% -85% .

Smorgick, N., et al.,. Obstetrics & Gynecology, 2012. 120(3): p. 581-586.Turnbull, H., et al.,. Archives of Gynecology and Obstetrics, 2012. 286(4): p. 1007-1010.

POUR consequences

Bladder Over-distention

Detrusor Injury• Bladder Atony• Recurrent UTI• Persistent Voiding

Dysfunction• Kidney Impairment

Morbidity• Length of stay• Cost

Rizvi, R. M., & Rizvi, J. (2006). Reviews in Gynaecological and Perinatal Practice, 6(3-4), 140–144Joelsson-Alm, E., Ulfvarson, J., Nyman, C. R., Divander, M.-B., & Svensén, C. (2012). Scandinavian Journal of Urology and Nephrology, 46(2), 84–90.Tammela, T., et al.,. British journal of urology, 1987. 60(1): p. 43-46.Darrah, D.M., T.L. Griebling, and J.H. Silverstein,, 2009. 27(3): p. 465-484.Petros, J.G., et al.. American journal of surgery, 1991. 161(4): p. 431-3; discussion 434.

If undetectable

Residual Volume> 500 ml

44%

Quality of life

Catheterization Duration Policy: EBM

Post-operative Urinary Retention

Urinary Retention UTI

Detrussor Injury Patient

Morbidity

Pain, length of stay,

complication

Personal Preferences

Hospital PolicyHabit

Dobbs, S.P., et al.,. Brit J of Urol, 1997: p. 554-556.Wu, A.K., A.D. Auerbach, and D.S. Aaronson American journal of surgery, 2012. 204(2): p. 167-171.

Shorter VS Longer duration regarding UTI rate

7 out of 11 trials Fewer UTI reported in earlier removal groups. UTI accounts for 40% of nosocomial infection

Phipps, S., et al(2006). Cochrane database of systematic reviews CD004374

Clinical QuestionP (patients)• Women underwent gynecology (hysterectomy & prolapse) surgery

I (intervention)• Urinary catheters removal at 24 hour Postoperative

C (comparison)• Urinary catheters removal on day-5, day-4, day-2, 12 hours, 6 hours, 3

hours, and immediately after surgery.

O (objective)• Postoperative urinary retention and urinary tract infectionDoes 24 hour postoperative urinary catheters removal superior compared to other duration to prevent postoperative urinary retention and urinary tract infection?

Methods

Clinical Question (PICO)

Literature Searching

Articles: RCT

Critical Appraisal (RCT form)

Result & Discussion

Searching Flow

Appraisal Table

1. research question, 2. randomization, 3. blinding, 4. follow-up, 5.intervention & co-intervention, 6. selection of outcomes, 7. effect size, 8.Using result in your own setting,

Makela, M. Sing med j, 2005. 46(3): p. 108-14

Critical Appraisal Summary from 6 Clinical Trials

Highest Appraisal Score for hysterectomy

Highest Appraisal Score for Prolapse Surgery

4 RCTs for vaginal prolapse surgery2 RCTs for hysterectomy surgery

POUR & UTI Incidence in Hysterectomy & Prolapse Surgery

Im-medi-ately

6 hr 12 hr day 10.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

19%

0% 0% 0%

7.50%

13.30%15.60%

28.60%

Chai, J. and T.-C. Pun,. Acta Obstet Gynecol Scand, 2011. 90(5): p. 478-482.Alessandri, F., et al.. Acta Obstet Gynecol Scand, 2006. 85(6): p. 716-720.Hakvoort, R.A., et al.,. BJOG, 2004. 111(8): p. 828-830Kamilya, G., et al.. J of Obstet Gynaecol Res, 2010. 36(1): p. 154-158.Weemhoff, M., et al., Int Urogynecol J, 2010. 22(4): p. 477-483.Glavind, K., et al., A. Acta Obstet Gynecol Scand, 2007. 86(9): p. 1122-1125.

3 hours day 1 day 2 day 4 day 50.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

5%

19%

28%

8% 9%

14%

9%

22%

34%38%

Re catheterization (%) UTI (%)

Vaginal Prolapse Surgery

Hysterectomy

Re-catheterizationUTI

Chai, et al

Kamilya, et al

Earlier or later removal?

“Earlier Removal” :• 3 to 4 times more likely to have re-

catheterization (OR = 3.10-4.0) compared to later-removal groups

“later removal”• They who have it removed on 5th day were

14 times more likely to develop UTI compared with immediate group (OR = 14.786, 95% CI 3.187- 68.595).

Discussion• Since the result from several trials remains inconstant,

Cochrane can be counted as the primary consideration to create the policy in the hospital

EBM

High Level of Evidence Research

Clinical ExperiencesPatient

Preferences

Conclusion

24 hour catheterization policy in hysterectomy and vaginal prolapse surgery remains most appropriate although associated with an increased risk of re-catheterization.

The removal of catheter before 24 hour (6 or 12 hour) could be considered to be used as one of interventions in further RCT(s) to find out the best duration which would result in lowest incidence in both of UTI and POUR.

Thank You

dr Adly Nanda Al Fattah081222206663adlynanda@yahoo.com