Intraoperative catheter disappoints for urinary retention after hernia repair
Intraoperative catheter use did not protect against the development of postoperative urinary retention (PUR) in patients who underwent laparoscopic inguinal hernia repair surgery, according to a randomized trial.
Among more than 450 of these patients, no significant difference was observed in the rate of PUR for those who received intraoperative catheter placement compared to those who did not (9.6% versus 8. 5%, respectively, P=0.79), reported Aldo Fafaj, MD, of the Cleveland Clinic Center for Abdominal Core Health in Ohio, and colleagues.
“The lack of apparent immediate clinical benefit accompanied by the potential for rare but devastating complications offers a compelling argument for abandoning the routine use of catheters during laparoscopic inguinal hernia repair in patients who urinate before the procedure. operation,” the band wrote in JAMA Surgery.
During laparoscopic inguinal repair surgery, urinary catheters are often placed to protect against PUR and bladder damage, Fafaj’s group noted. PUR is the most common complication of the procedure, with an incidence of up to 22%.
However, the required use of intraoperative catheters can also lead to catheter-related infections, prostatitis, and complications of urethral trauma, aside from patient discomfort alone. PUR was previously linked to higher healthcare costs, urinary tract infections, longer hospital stays and lower patient satisfaction.
“Low-value services are ubiquitous in healthcare,” noted Martin Almquist, MD, PhD, of Skåne University Hospital in Malmö, Sweden, in an accompanying editorial. “The United States alone is estimated to spend more than $100 billion a year on unnecessary medical tests, treatments, and procedures that expose patients to harm with no apparent benefit. Deimplementation has proven difficult, despite campaigns such as Choosing Wisely Canada.
He noted that “although no evidence of effect does not equal evidence of no effect”, the current study “provides a strong argument for abandoning routine urinary catheter placement during repair. elective endoscopic examination of an inguinal hernia”.
For their study, Fafaj and colleagues recruited 491 patients with primary or recurrent inguinal hernias and randomized them to receive an intraoperative catheter after induction of general anesthesia (n=241) or no catheter placement (control; n=250) at six centers from 2019 to 2021. Catheters were removed after the procedure. Follow-up was for 30 days after surgery and PUR, the primary outcome, was defined “as inability to urinate requiring direct catheterization, placement of an indwelling catheter, or return to emergencies due to inability to urinate after discharge from hospital”. hospital for up to 30 days after the operation.”
Participants underwent laparoscopic, elective, unilateral or bilateral primary (90%) or recurrent (10%) inguinal hernia repair. The study was single-blind and patients were excluded if they were intolerant to general anesthesia. Preoperative voiding was required, along with other standard surgical procedures.
The median patient age was 61 years, almost all were male (95%), the median body mass index was 26%, and 17% had benign prostatic hyperplasia (BPH). Common comorbidities were hypertension (35%) and diabetes (5%).
Just under a quarter had unilateral left-sided inguinal hernias, 37% had unilateral right-sided inguinal hernias, and 39% had bilateral inguinal hernias; 12% had a scrotal component.
With a median operating time of 73 minutes, 72% of surgeries were performed using the total extraperitoneal technique and 28% using the transabdominal preperitoneal approach. More than two-thirds were treated with an indwelling catheter for urinary retention and were discharged from hospital the same day.
An exploratory multivariate analysis revealed that certain risk factors were associated with the development of PUR: age greater than 65 years, BPH, inoperative use of anticholinergic drugs, and volume of intraoperative crystalloid infusion. But a post hoc analysis found that placement of a urinary catheter did not reduce PUR in these groups.
Among the catheter group, one patient with PUR resulting in suprapubic catheter placement suffered postoperative urethral trauma. No intraoperative bladder injury occurred. No difference was observed in the timing of diagnosis and treatment of PUR between the two groups.
Limitations of the study included that the criteria for the timing of bladder scans and the decision to catheterize patients were not standardized across centers. Patients with BPH were also underrepresented. Finally, the sample size was small and unmeasured confounders could have impacted the results.
Fafaj revealed support from the Abdominal Core Health Quality Collaborative. The co-authors disclosed relationships with Abdominal Core Health Quality Collaborative, Dickinson, Intuitive Surgical, Medtronic, Becton, and Pacira.
Almquist revealed Ipsen’s support.