Abstracting and Indexing

  • Google Scholar
  • CrossRef
  • WorldCat
  • ResearchGate
  • Academic Keys
  • DRJI
  • Microsoft Academic
  • Index Copernicus
  • Academia.edu
  • OpenAIRE

Can Early First Trial of Void after Elective Spine Surgery Reduce the Incidence of Post-Operative Urinary Retention? - Results from a Cross-Sectional Study of 195 Patients

Article Information

Shin-Jae Kim1, Sang-Ho Lee1, Sang Soo Eun2*, Sourabh Chachan3

1Department of Neurosurgery, Chungdam Wooridul Spine Hospital, Seoul, Korea

2Department of Orthopaedic surgery, Chungdam Wooridul Spine Hospital, Seoul, Korea

3Department of Spine Surgery, Chungdam Wooridul Spine Hospital, Seoul, South Korea

*Corresponding Author: Sang Soo Eun, Department of Orthopaedic surgery, Chungdam Wooridul Spine Hospital, Seoul, Korea

Received: 28 April 2020; Accepted: 09 May 2020; Published: 25 May 2020

Citation:

Shin-Jae Kim, Sang-Ho Lee, Sang Soo Eun, Sourabh Chachan. Can Early First Trial of Void after Elective Spine Surgery Reduce the Incidence of Post-Operative Urinary Retention? - Results from a Cross-Sectional Study of 195 Patients. Journal of Spine Research and Surgery 2 (2020): 037-043.

View / Download Pdf Share at Facebook

Abstract

Study design: Retrospective study Object: To find the risk factors for post-operative urinary retention (POUR) and identify the controllable factors that can reduce it.

Background: Post-operative urinary retention (POUR) is one of the common postoperative complications and affects the recovery period after surgery. Authors hypothesize that early encouragement of first voiding trial after spine surgery may reduce incidence of POUR. The purpose of this study is to confirm the significance of the previously known risk factors and to evaluate the incidence of POUR according to the management of postoperative foley catheter.

Patients and methods: From June 2014 to August 2014, 215 patients who diagnosed with spinal stenosis and had under 3 levels of surgery under general anesthesia were consecutively extracted and divided as POUR group and non-POUR group. The data includes gender, age, duration of hospital stay, hypertension, diabetes mellitus, preoperative prostate disease, number of operative level, surgical method, operative time, amount of perioperative fluid, usage of patient controlled analgesia, presence of preoperative foley catheterization, foley removal time, and timing of first trial of void (TOV).

Results: Incidence of POUR is 33 out of 195 (16.9%). The risk factors that showed a significant correlation with POUR were male gender, duration of hospital stay, preoperative prostate disease, operative time, amount of perioperative fluid, long operative level (3 level), and delay of TOV.

Conclusion: This study confirmed the significance of POUR with the previously known risk factors and identified the importance of peri-operative fluid management and shortening of TOV after surgery.

Keywords

Post-operative urinary retention, Timing of first trial of void

Post-operative urinary retention articles Post-operative urinary retention Research articles Post-operative urinary retention review articles Post-operative urinary retention PubMed articles Post-operative urinary retention PubMed Central articles Post-operative urinary retention 2023 articles Post-operative urinary retention 2024 articles Post-operative urinary retention Scopus articles Post-operative urinary retention impact factor journals Post-operative urinary retention Scopus journals Post-operative urinary retention PubMed journals Post-operative urinary retention medical journals Post-operative urinary retention free journals Post-operative urinary retention best journals Post-operative urinary retention top journals Post-operative urinary retention free medical journals Post-operative urinary retention famous journals Post-operative urinary retention Google Scholar indexed journals Timing of first trial of void articles Timing of first trial of void Research articles Timing of first trial of void review articles Timing of first trial of void PubMed articles Timing of first trial of void PubMed Central articles Timing of first trial of void 2023 articles Timing of first trial of void 2024 articles Timing of first trial of void Scopus articles Timing of first trial of void impact factor journals Timing of first trial of void Scopus journals Timing of first trial of void PubMed journals Timing of first trial of void medical journals Timing of first trial of void free journals Timing of first trial of void best journals Timing of first trial of void top journals Timing of first trial of void free medical journals Timing of first trial of void famous journals Timing of first trial of void Google Scholar indexed journals Elective Spine Surgery articles Elective Spine Surgery Research articles Elective Spine Surgery review articles Elective Spine Surgery PubMed articles Elective Spine Surgery PubMed Central articles Elective Spine Surgery 2023 articles Elective Spine Surgery 2024 articles Elective Spine Surgery Scopus articles Elective Spine Surgery impact factor journals Elective Spine Surgery Scopus journals Elective Spine Surgery PubMed journals Elective Spine Surgery medical journals Elective Spine Surgery free journals Elective Spine Surgery best journals Elective Spine Surgery top journals Elective Spine Surgery free medical journals Elective Spine Surgery famous journals Elective Spine Surgery Google Scholar indexed journals iatrogenic nerve injuries  articles iatrogenic nerve injuries  Research articles iatrogenic nerve injuries  review articles iatrogenic nerve injuries  PubMed articles iatrogenic nerve injuries  PubMed Central articles iatrogenic nerve injuries  2023 articles iatrogenic nerve injuries  2024 articles iatrogenic nerve injuries  Scopus articles iatrogenic nerve injuries  impact factor journals iatrogenic nerve injuries  Scopus journals iatrogenic nerve injuries  PubMed journals iatrogenic nerve injuries  medical journals iatrogenic nerve injuries  free journals iatrogenic nerve injuries  best journals iatrogenic nerve injuries  top journals iatrogenic nerve injuries  free medical journals iatrogenic nerve injuries  famous journals iatrogenic nerve injuries  Google Scholar indexed journals urogenital disorders articles urogenital disorders Research articles urogenital disorders review articles urogenital disorders PubMed articles urogenital disorders PubMed Central articles urogenital disorders 2023 articles urogenital disorders 2024 articles urogenital disorders Scopus articles urogenital disorders impact factor journals urogenital disorders Scopus journals urogenital disorders PubMed journals urogenital disorders medical journals urogenital disorders free journals urogenital disorders best journals urogenital disorders top journals urogenital disorders free medical journals urogenital disorders famous journals urogenital disorders Google Scholar indexed journals patient-controlled analgesia articles patient-controlled analgesia Research articles patient-controlled analgesia review articles patient-controlled analgesia PubMed articles patient-controlled analgesia PubMed Central articles patient-controlled analgesia 2023 articles patient-controlled analgesia 2024 articles patient-controlled analgesia Scopus articles patient-controlled analgesia impact factor journals patient-controlled analgesia Scopus journals patient-controlled analgesia PubMed journals patient-controlled analgesia medical journals patient-controlled analgesia free journals patient-controlled analgesia best journals patient-controlled analgesia top journals patient-controlled analgesia free medical journals patient-controlled analgesia famous journals patient-controlled analgesia Google Scholar indexed journals open lumbar microscopic discectomy articles open lumbar microscopic discectomy Research articles open lumbar microscopic discectomy review articles open lumbar microscopic discectomy PubMed articles open lumbar microscopic discectomy PubMed Central articles open lumbar microscopic discectomy 2023 articles open lumbar microscopic discectomy 2024 articles open lumbar microscopic discectomy Scopus articles open lumbar microscopic discectomy impact factor journals open lumbar microscopic discectomy Scopus journals open lumbar microscopic discectomy PubMed journals open lumbar microscopic discectomy medical journals open lumbar microscopic discectomy free journals open lumbar microscopic discectomy best journals open lumbar microscopic discectomy top journals open lumbar microscopic discectomy free medical journals open lumbar microscopic discectomy famous journals open lumbar microscopic discectomy Google Scholar indexed journals transforaminal lumbar interbody fusion articles transforaminal lumbar interbody fusion Research articles transforaminal lumbar interbody fusion review articles transforaminal lumbar interbody fusion PubMed articles transforaminal lumbar interbody fusion PubMed Central articles transforaminal lumbar interbody fusion 2023 articles transforaminal lumbar interbody fusion 2024 articles transforaminal lumbar interbody fusion Scopus articles transforaminal lumbar interbody fusion impact factor journals transforaminal lumbar interbody fusion Scopus journals transforaminal lumbar interbody fusion PubMed journals transforaminal lumbar interbody fusion medical journals transforaminal lumbar interbody fusion free journals transforaminal lumbar interbody fusion best journals transforaminal lumbar interbody fusion top journals transforaminal lumbar interbody fusion free medical journals transforaminal lumbar interbody fusion famous journals transforaminal lumbar interbody fusion Google Scholar indexed journals anterior lumbar interbody fusion articles anterior lumbar interbody fusion Research articles anterior lumbar interbody fusion review articles anterior lumbar interbody fusion PubMed articles anterior lumbar interbody fusion PubMed Central articles anterior lumbar interbody fusion 2023 articles anterior lumbar interbody fusion 2024 articles anterior lumbar interbody fusion Scopus articles anterior lumbar interbody fusion impact factor journals anterior lumbar interbody fusion Scopus journals anterior lumbar interbody fusion PubMed journals anterior lumbar interbody fusion medical journals anterior lumbar interbody fusion free journals anterior lumbar interbody fusion best journals anterior lumbar interbody fusion top journals anterior lumbar interbody fusion free medical journals anterior lumbar interbody fusion famous journals anterior lumbar interbody fusion Google Scholar indexed journals

Article Details

1. Introduction

Post-operative urinary retention (POUR), defined as impaired voiding after surgery, is one of the common complications after surgery [1]. The incidence of POUR has been reported to vary from 5 to 70% [2-6]. The strong association between post-op urinary retention (POUR) and spine surgery has long been established by various studies. This postoperative complication prolongs hospital stay after surgery and increases pain, anxiety, bladder distension, renal failure, and morbidity [2, 7], which is a stumbling block to successful surgical treatment, and results in significant anxiety both for the patient and treating surgeon. Especially, spine surgery requires more accurate evaluation, because unlike other general anesthesia operations, iatrogenic nerve injuries that can be occurred during the neurosurgery itself may causes POUR [8]. This has also prompted the development of various peri-operative protocols for prevention and management of POUR. Currently known risk factors associated with POUR include male gender, old age, past history of prostate disease, and amount of perioperative fluid [4, 9]. The purpose of current study is to evaluate the modifiable and non-modifiable risk factors affecting occurrence of POUR after elective spine surgery.

2. Materials and Methods

2.1 Study design

Retrospective study.

2.2 Patient selection and parameters

From June 2014 to August 2014, authors performed a retrospective analysis of prospectively maintained data from 215 patients who underwent three or less level elective spine surgery at a specialist spine center. The analysis specifically included surgeries performed under general anesthesia. Cases of revision surgeries, multi-staged surgical procedures, history of previous urogenital surgery and cauda equine syndrome were specifically excluded. As a result, 195 patients were enrolled in this study. Data analyzed included patient demographics, previous medical/surgical history (hypertension (HTN), diabetes mellitus (DM), urogenital disorders including prostate disease), pre-operative diagnosis, type/level/duration of surgery, perioperative fluid management, timing of insertion/removal of foley’s catheter, timing of first trial of void (TOV) after surgery, use of patient-controlled analgesia (PCA), and duration of hospital stay (Table 1).

2.3 POUR

Normally, residual urine is measured by ultrasound in patients with urinary retention [10]. But in many clinical papers, POUR is defined as the use of a straight catheterization or foley postoperatively [6, 9, 11]. In this study POUR was defined as patients who failed to pass urine voluntarily after surgery and required therapeutic measures (catheterization/medication/both) for the same. The medications included Doxazocin mesylate (Alpha-1 blocker), Tamsulosin HCl (Alpha-1 blocker), and Bethanechol chloride (Para-sympathomimetic choline carbamate).

2.4 Statistical analysis

Statistical analysis was performed using SPSS statistics 24 (IBM® SPSS® Statistics 24) and employed Student's t-test and Chi-square test. P value <0.05 was considered significant. 

3. Results

3.1 Demographic data

The final analysis included 195 patients (M=105, F=90) with average of 54 years who underwent either of the following surgical procedures: anterior cervical discectomy and fusion (ACDF), open lumbar microscopic discectomy (OLM), unilateral laminectomy bilateral decompression (ULBD), transforaminal lumbar interbody fusion (TLIF) and anterior lumbar interbody fusion (ALIF). The overall incidence of POUR was 16.9% with 24 males and 9 females. Male percentage of the POUR group (69.7%) was significantly higher than the non-POUR group (50%) (p = 0.017). The duration of hospital stay was also significantly longer in the POUR group (p=0.008). In-terms of pre-morbid medical conditions, prevalence of HTN (p= 0.076) and DM (p= 0.1) was identical in both the groups, whereas prostate disease (p=.000) was significantly more prevalent in the POUR group (Table 1).

3.2 Operative data

There was no significant relationship between surgical method and POUR, but there was a significant correlation between POUR and long level surgery (3 levels) (p=0.034). The operative time of the POUR group was significantly longer than that of the non-POUR group (p= 0.019). As compared to non-POUR group, significantly higher amount of perioperative fluid administration was observed in the POUR group (p= 0.006). However, use of PCA did not seem to affect the occurrence of POUR (p=0.356) (Table 1).

3.3 Urological data

The time for first post-operative TOV was significantly longer in the POUR group (p= 0.028). First foley removal time was similar in both groups. Of the POUR groups, 24 patients (75%) required ward catheterization, and the average time taken to remove them again was 159 [20 - 420] hours. 31 patients (91.7%) received a medication (Table 1).

 

POUR group (n=33)

non-POUR group (n=162)

Total (n=195)

p-value

Sex (Male/Female)

24/9

81/81

105/90

0.017

Age (yr)

56.9 ± 15.1

53.4 ± 14.3

54.0 ± 14.4

0.21

Duration of hospital stay (Day)

9.5 ± 14.3

7.5 ± 4.0

7.8 ± 4.1

0.008

Hypertension (%)

15 (45.5)

48 (29.6)

63 (32.3)

0.076

Diabetes mellitus (%)

8/25 (24.2)

20 (12.3)

28 (14.4)

0.1

Preoperative prostate disease (%, among male)

12 (50)

8 (9.9)

20 (19.0)

.000

Operative level (%)

1 level

19 (57.6)

116 (71.6)

135 (69.2)

0.111

2 levels

9 (27.3)

39 (24.1)

48 (24.6)

0.697

3 levels

5 (15.1)

7 (4.3)

12 (6.2)

0.034

Surgical method (%)

 1.ACDF

2 (6.1)

16 (9.9)

18 (9.2)

0.743

2.ALIF

3 (9.1)

25 (15.4)

28 (14.3)

0.426

3.OLM

23 (69.6)

100 (61.7)

123 (63.1)

0.387

4.TLIF

2 (6.1)

12 (7.4)

14 (7.2)

0.785

  5.ULBD

3 (9.1)

9 (5.6)

12 (6.2)

0.431

Operative time (min)

191 ± 49.7

164 ± 88.4

169 ± 83.6

0.019

Perioperative fluid, cc

1283 ± 503.3

972 ± 866.0

1025 ± 823.3

0.006

Usage of ?PCA (%)

33 (100)

154 (95.1)

187 (95.9)

0.356

Preoperative foley catheterization (%)

22 (66.7)

80 (49.4)

102 (52.3)

0.07

First foley removal time, hours

31.9 ± 17.1

30.9 ± 18.0

31.1 ± 17.7

0.81

Timing of first trial of void (TOV) (minutes)

460.2 ± 324.5

374.7 ± 167.9

389.2 ± 204.5

0.028

Need for ward catheterization (%)

24 (72.7)

 

 

 

(Ward foley maintain time, hours)

159 [20-420]

 

 

 

§Need for ward medication (%)

31 (93.9)

 

 

 

1.ACDF-Anterior cervical discectomy and fusion

2.ALIF-Anterior lumbar interbody fusion

3.OLM-Open lumbar microscopic discectomy

4.TLIF-Transforaminal lumbar interbody fusion

5.ULBD-Unilateral laminectomy bilateral decompression

PCA-Patient controlled analgesia

§Medication: α-Adrenergic Blockers, Parasympathomimetic choline carbamate 

Pearson's Chi-square test/Student-T test/Fisher test, p-value < 0.05; statistically significant.

Table 1: Patient's parameters, peri-operative and urologic data.

4. Discussion

POUR is a well established complication of spinal surgery with significant clinical implications. The current study showed significant improvements in incidence of POUR if the time for first TOV was reduced. This can be implemented by encouraging ambulation and use of general toilet facilities as soon as possible after surgery and discouraging the use of bed pans and similar facilities. These results are thought to be related to the mechanism of POUR development after general anesthesia. The exact patho-physiological mechanism behind the development of POUR is not well understood, yet it is assumed that general anesthetic agents cause bladder atony by interfering with the autonomic nervous system. Diazepam, pentobarbital, propofol, isoflurane, methoxyflurane, and halothane known to have an effect of suppressing detrusor contractions [12]. The effect of these drugs is found to increase the incidence of POUR as the administration dose increased as the operation time prolonged [13]. The reason for the need for an early ambulation and first TOV after surgery is supposed to help with early recovery of this deteriorated bladder function. Medically unnecessary prolongation of post-op bed rest will delay recovery of bowel movement and rectal distension and increase sympathetic tone and stimulation of the α-receptors in the internal urethral sphincter, which will leads to increased pressure on the bladder neck and potentially to POUR [2]. There is currently no standard protocol for optimal foley removal time after surgery. However, many studies have reported that there is no significant difference in the incidence of POUR after removal of foley within 1 day after surgery [14]. However, long-term ambulation with foley insertion state after surgery may lead to urethral stricture, edema due to friction, which may lead to iatrogenic urinary retention after foley removal [15]. In previous studies, male gender, old age, past history of prostate disease, excess amount of perioperative fluid administration, and use of PCA have been found to be associated with higher incidence of POUR [4, 16, 17]. The reason for the higher prevalence of POUR in male patients has mostly been attributed to gender-specific pathologies [13, 18]. Presence of prostate issues (benign prostatic hyperplasia (BPH), prostatitis, and prostate cancer) can result in acute urinary retention and can also affect the recovery of urinary function after non-urological surgery [19]. Incidence of POUR also increases with aging process because of age-related progressive neuronal degeneration leading to bladder dysfunction [16]. Contrary to various studies which related POUR to age, the current study could not find age as contributing factor to the occurrence of POUR.

The probable reason could be non-normal age distribution of study subjects as most of them were above 50 years. If the data of the POUR patient group is more scaled, it is expected that similar will be obtained as in the existing papers. Although DM is known to cause urinary retention due to diabetic neuropathy [20], the current study could not elicit any such association. This could be because only the presence or absence of DM was recorded and no attempt was made to assess the severity of diabetes mellitus. Use of opioids based PCA is also known to make post-surgical spontaneous urination difficult by increasing urinary sphincter’s tone while diminishing urethral contractions [21]. However, PCA was used in more than 95% of cases in current study, which makes it difficult to gauge its true contribution to POUR. ULBD has been known to induce iatrogenic compression of the dural sac by use of kerrison punch during contralateral decompression [22]. Authors wanted to investigate whether such complications which vary from operation method, have relation with occurrence of POUR. The results showed no significant difference in POUR according to the operation method, but the number of cases was not sufficient compared to OLM in other operations. If the number of cases of ULBD or other fusion operations is sufficiently cumulative, consider carefully that further studies may yield different results. Increased surgical levels and prolonged operative time cause peri-operative fluid gain. Significant relation between POUR and 3 levels’ long surgery seems to be caused by this reason. Shortening the operative time by surgeon may help lower the incidence of POUR.

The current study identified two significant factors affecting development of POUR in patients undergoing elective spine surgery: timing of first TOV and peri-operative fluid management. They are modifiable and explicit control of these can be the key to management of POUR. Furthermore, pre-operative anticipation and identification of high risk patients (e.g. elderly males with prostate issues) by the surgical team can possibly result in better management of POUR. Despite the inherent design-based (cross sectional and retrospective) and data-dependent (small volume) short-comings of current study, the positive outcomes extracted can guide and encourage better designed, large volume, multi-center futures trials concerning management of POUR in the cohort of spine surgery patients.

5. Conclusion

Male gender, pre-operative prostate disorder, poor peri-operative fluid management, and prolonged timing of first trial of void can be detrimental to the return of voluntary urinary function. Expert fluid management, shortening of operation time and early first trial of void can significantly prevent post-op urinary retention and facilitate post-op rehabilitation.

References

  1. Darrah DM, Griebling TL, Silverstein JH. Postoperative urinary retention. Anesthesiology clinics 27 (2009): 465-484.
  2. Baldini G, Bagry H, Aprikian A, et al. Postoperative Urinary RetentionAnesthetic and Perioperative Considerations. The Journal of the American Society of Anesthesiologists 110 (2009): 1139-1157.
  3. Stallard S, Prescott S. Postoperative urinary retention in general surgical patients. British journal of surgery 75 (1988): 1141-1143.
  4. Tammela T, Kontturi M, Lukkarinen O. Postoperative urinary retention: I. Incidence and predisposing factors. Scandinavian journal of urology and nephrology 20 (1986): 197-201.
  5. Redfern T, Machin D, Parsons K, et al. Urinary retention in men after total hip arthroplasty. The Journal of bone and joint surgery American volume 68 (1986): 1435-1438.
  6. Jung HJ, Park J-B, Kong C-G, et al. Postoperative urinary retention following anterior cervical spine surgery for degenerative cervical disc diseases. Clinics in orthopedic surgery 5 (2013): 134-137.
  7. Pavlin DJ, Rapp SE, Polissar NL, et al. Factors affecting discharge time in adult outpatients. Anesthesia & Analgesia 87 (1998): 816-826.
  8. Boulis NM, Mian FS, Rodriguez D, et al. Urinary retention following routine neurosurgical spine procedures. Surgical neurology 55 (2001): 23-27.
  9. Golubovsky JL, Ilyas H, Chen J, et al. Risk factors and associated complications for postoperative urinary retention after lumbar surgery for lumbar spinal stenosis. The Spine Journal (2018).
  10. Lamonerie L, Marret E, Deleuze A, et al. Prevalence of postoperative bladder distension and urinary retention detected by ultrasound measurement. British Journal of Anaesthesia 92 (2004): 544-546.
  11. Halawi MJ, Caminiti N, Cote MP, et al. The Most Significant Risk Factors for Urinary Retention in Fast-Track Total Joint Arthroplasty Are Iatrogenic. The Journal of Arthroplasty (2018).
  12. Lee KS, Koo KC, Chung BH. Risk and management of postoperative urinary retention following spinal surgery. International neurourology journal 21 (2017): 320.
  13. Petros J, Rimm E, Robillard R. Factors influencing urinary tract retention after elective open cholecystectomy. Surgery, gynecology & obstetrics 174 (1992): 497-500.
  14. Lau H, Lam B, Patil N. Management of postoperative urinary retention: a randomized trial of in-out versus overnight catheterization. Annals of the College of Surgeons of Hong Kong 8 (2004): A5.
  15. Edwards L, Lock R, Powell C, et al. Post-catheterisation urethral strictures. A clinical and experimental study. British journal of urology 55 (1983): 53-56.
  16. Keita H, Diouf E, Tubach F, et al. Predictive factors of early postoperative urinary retention in the postanesthesia care unit. Anesthesia & Analgesia 101 (2005): 592-596.
  17. Lee S, Kim CH, Chung CK, et al. Risk factor analysis for postoperative urinary retention after surgery for degenerative lumbar spinal stenosis. The Spine Journal 17 (2017): 469-477.
  18. Petros JG, Bradley TM. Factors influencing postoperative urinary retention in patients undergoing surgery for benign anorectal disease. The American Journal of Surgery 159 (1990): 374-376.
  19. Jacobsen SJ, Jacobson DJ, Girman CJ, et al. Natural history of prostatism: risk factors for acute urinary retention. The Journal of urology 158 (1997): 481-487.
  20. Ellenberg M. Development of urinary bladder dysfunction in diabetes mellitus. Annals of internal medicine 92 (1980): 321-323.
  21. Rocha LCdA. Retençäo urinária aguda. AMB Rev Assoc Med Bras 36 (1990): 26-28.
  22. Çavusoglu H, Kaya RA, Türkmenoglu ON, et al. Midterm outcome after unilateral approach for bilateral decompression of lumbar spinal stenosis: 5-year prospective study. European Spine Journal 16 (2007): 2133-2142.

Journal Statistics

Impact Factor: * 3.123

CiteScore: 2.9

Acceptance Rate: 14.90%

Time to first decision: 10.4 days

Time from article received to acceptance: 2-3 weeks

Discover More: Recent Articles

© 2016-2024, Copyrights Fortune Journals. All Rights Reserved!