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- 1. Urinary catheterization in gynecological surgery: When should it be removed? Adly Nanda A, Budi Iman Santoso Presented at IUGA Regional Symposium Poster Competition Bali 7-9 Nov 2013 Urogynecology and Pelvic Reconstruction Division Department of Obstetrics & Gynecology Faculty of Medicine Univeristas Indonesia/Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia.
- 2. Introduction: Post-operative Urinary Retention (POUR) Incidence • 2,1% -70% • Multifactorial etiology Early detection is important Abdominal hysterectomy: Vaginal hysterectomy: 4% -13.7% 2-15% • To prevent irreversible detrusor injury Laparoscopy : 4% 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. 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.
- 3. POUR consequences Residual Volume> 500 ml 44% Detrusor Injury Bladder Overdistention • Bladder Atony • Recurrent UTI • Persistent Voiding Dysfunction • Kidney Impairment If undetectable Rizvi, R. M., & Rizvi, J. (2006). Reviews in Gynaecological and Perinatal Practice, 6(3-4), 140–144 Joelsson-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. Morbidity • Length of stay • Cost
- 4. Catheterization Duration Policy: EBM Detrussor Injury Pain, length of stay, complicati on Patient Morbidity Urinary Retention UTI Post-operative Urinary Retention Habit Hospital Policy Personal Preferences 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.
- 5. 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
- 6. Clinical Question P (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 infection Does 24 hour postoperative urinary catheters removal superior compared to other duration to prevent postoperative urinary retention and urinary tract infection?
- 7. Methods Clinical Question (PICO) Literature Searching Articles: RCT Critical Appraisal (RCT form) Result & Discussion
- 9. Appraisal Table No Study Type of surgery Sample Cath. Removal 1. Hakvoort, et al (2004) Vaginal prolapse 100 Day-5 VS Morning after surgery 2. Chai, et al (2011) Total abdominal 70 hysterectomy 3. Kamilya, et al (2010) Vaginal prolapse 4. Alessandri, et al (2006) Various type hysterectomy 5. Weemhoff, et al Anterior (2011) Colporrhaphy 6. Glavind, et al vaginal (2007) surgery 200 of 96 246 prolapse 134 Validity Result Applicability Total Score 1 + 2 ?++ 3 +? 4 --- 5 ++ 6 + 7 ++ 8 ++ 11/16 Immediately after VS day 1 + +++ ++ +++ ++ + +- ++ 15/16 Day I VS day 4 + +++ ++ --- ++ + ++ ++ 13/16 Immediately VS 6 + hour VS 12 hour +++ ++ --- ++ + +- ++ 12/16 Day-2 VS Day-5 + +++ +? --+ ++ + +- ++ 12/16 3 hour VS 24 hour + ?+? +? --- -+ + -- ++ 7/16 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
- 10. Critical Appraisal Summary from 6 Clinical Trials Highest Appraisal Score for hysterectomy Highest Appraisal Score for Prolapse Surgery 4 RCTs for vaginal prolapse surgery 2 RCTs for hysterectomy surgery
- 11. POUR & UTI Incidence in Hysterectomy & Prolapse Surgery Chai, et al Kamilya, et al 28.60% 30.00% 25.00% 19.40% 15.60% 20.00% 13.30% 15.00% 7.50% 10.00% 5.00% 0% 0% 0% 0.00% Re-catheterization UTI 38% 40.00% 34.30% 35.00% 28% 30.00% 22% 25.00% 19% 20.00% 14.30% 15.00% 9% 10.00% Hysterectomy 9% 4.50% 5.00% 0.00% 3 hours 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. 828-830 Kamilya, 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. 8.10% day 1 Re catheterization (%) day 2 day 4 day 5 UTI (%) Vaginal Prolapse Surgery
- 12. Earlier or later removal? “Earlier Removal” : • 3 to 4 times more likely to have recatheterization (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).
- 13. Discussion • Since the result from several trials remains inconstant, Cochrane can be counted as the primary consideration to create the policy in the hospital Clinical Experiences High Level of Evidence Research Patient Preferences EBM
- 14. 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.
- 15. dr Adly Nanda Al Fattah 081222206663 adlynanda@yahoo.com
Hinweis der Redaktion
- Good afternoon. In this era of quality of life, patient safety and high-quality of care should become our priority. Therefore, I and dr Budi ImanSantoso performed a critical appraisal titled:
- the incidence of POUR is ranging widely from 2.1-70%. The incidence would be affected by definition used, procedures and catheterization duration. We will put the patient at risk for irreversible dertusor muscle injury if we fail to detect the POUR earlier.
- 44 percent of woman with residual volume of > 500 ml, will be faced with bladder over-distension. It possibly lead to the dertrusor injury and other complication. All of these consequences will increase patient’s morbidity then affect the quality of life, So that urinary retention is an important issue.
- 2 important aspects in determining the duration are urinary retention AND UTI. Both of them will increase the patient morbidity. The duration usually based on providers’s habit, hospital policy, and surgeon preferences. Ideally it should be based on the highest level of evidence.
- Cochrane Review had stated that fewer Urinary Tract Infection (UTI) reported when catheters were removed earlier in seven out of 11 trials.Catheter - associated UTI is an important factor to be considered in determining the duration because it accounts for 80% of hospital-acquired infections.16,17
- We use appraisal questions developed by Makela, et al to appraise these trials. Eight questions for each trials have been answered to determine the total score.
- We found 4articles of prolapse surgery and 4 articles of hysterectomy surgery. Trial conducted by Chai has the highest score for hysterectomy. While Kamilya, has the highest score for prolapse surgery.
- The red box indicate the study conducted by Chai and colleagues. While the blue box indicate Kamilya’s study. There is no urinary retention in 24 hr group, however the UTI incidence is significantly higher compared to early removal groupIn vaginal prolapse surgery, 24 hr group has the lowest incidence of UTI. However, they are still at risk for re-catheterization.