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. 2022 Dec 23;13(6):1658–1670. doi: 10.1177/21925682221146493

Risk Factors for Postoperative Urinary Retention Following Lumbar Spine Surgery: A Review of Current Literature and Meta-Analysis

Logan A Reed 1,✉, Alexander K Mihas 1, Travis A Fortin 1, Connor J Donley 1, Guna Pratheep 2, Sakthivel Rajaram Manoharan 1, Steven M Theiss 1, Vibhu Krishnan Viswanathan 2
PMCID: PMC10448081  PMID: 36562179

Abstract

Study Design

Systematic Review and Meta-analysis

Objective

Postoperative urinary retention (POUR) is a common complication following lumbar spine surgery (LSS) and timely recognition is imperative to avoid long-term consequences. The aim of the current meta-analysis was to systematically review the literature in order to identify risk factors associated with POUR after LSS.

Methods

In accordance with PRISMA guidelines, a systematic review of the literature was performed using Pubmed, EMBASE, and MEDLINE database for articles on POUR following LSS. A meta-analysis was performed comparing patients with and without POUR; and the factors associated with this adverse event were analyzed. The pooled data were reported as mean differences with 95% confidence intervals (CI; P < .05). Heterogeneity among the studies was evaluated using the I2 statistic.

Results

The meta-analysis included 10 studies compromised of 30,300 patients. Based on our analysis, patients who were male, were older in age, underwent instrumented fusion, had diabetes mellitus, coronary artery disease, or benign prostatic hypertrophy had significantly higher risk of developing POUR. Additionally, patients in who developed POUR had significantly longer surgical times and higher volumes of intra-operative fluid administration, as compared with non-POUR patients. The POUR patients also had a significantly higher association with urinary tract infection. Prior surgery, BMI, length of stay, and smoking status did not reveal any statistical association with POUR.

Conclusions

Risk factors associated with POUR following LSS include male gender, older age, longer surgical times, fusion procedures, larger volumes of intraoperative infusions, and associated comorbidities like DM, CAD, and BPH.

Keywords: urinary retention, lumbar, risk factors, spine

Introduction

Postoperative urinary retention (POUR) is a relatively common minor adverse event (AE) reported in patients undergoing lumbar spine surgery (LSS).1,2 It can be defined as the inability to urinate after a surgical procedure despite retaining a full bladder. 3 Prior studies on POUR have shown an incidence rate varying from 5% to 70% following diverse surgical interventions.4,5 Although considered a minor AE, this condition can be quite distressing for patients; and may result in the need for catheterization in the post-operative unit which further increases the risk of infection. 6 Such unplanned catheterization, especially in the elderly population, can lead to other complications including delirium, urethral trauma or strictures, and infection. 7 POUR also leads to increased length of inpatient hospital stay and associated augmented costs.7,8 Wang et al reported annual cost savings of 7 million dollars, if POUR was prevented with prophylactic catherization. 9

Given the significant costs and patient morbidity associated with POUR, various studies have attempted to identify the risk factors for this AE. Recently, Chang et al conducted a meta-analysis to study the factors associated with POUR in patients undergoing spinal surgeries. 10 It is well-acknowledged that this complication is more commonly anticipated following lumbar procedures than pathologies involving other spinal regions. Nevertheless, to the best of our knowledge, no systematic review evaluating the prevalence of POUR following LSS has hitherto been published. In this context, the current meta-analysis was planned to specifically evaluate the risk factors for POUR in patients undergoing LSS; so as to identify solutions to mitigate this often under-emphasized but significant post-operative AE.

Materials and Methods

Study Design and Characteristics

We conducted a comprehensive, systematic review of the literature in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) algorithm and checklist. 11 Following registration of the systematic review in the Prospective Register of Systematic Reviews (PROSPERO) database (CITE), a systematic review of the literature was performed using Pubmed, EMBASE, and MEDLINE. Eligible studies were identified (date of search - February 5th, 2022) with the search criteria and terms: (urine retention OR ischuria OR POUR OR retention OR retain OR impaired bladder emptying OR impair OR incomplete bladder-emptying) AND (arthrodesis OR spine fusion OR anterior spine fusion OR posterior lumbar interbody fusion OR posterior spine fusion OR spine OR vertebra OR anterior-interbody OR lumbar fusion). Titles and abstracts were independently reviewed by 2 authors (GP, VKV). Duplicates were removed and full texts were checked for suitability. Additional inclusion criteria consisted of studies that were written in the English language, had at least one or more of the target variables comparing POUR and non-POUR in adult (age>18 years) patients undergoing LSS. All the randomized control trials (RCTs), non-randomized prospective trials, retrospective case-control studies, observational cohort studies, and case series, which focused on the risk factors contributing to POUR in LSS, were included. Manuscripts involving non-comparative studies, review articles, case reports, and letters to the editor were excluded. Consensus decision was used to resolve any discrepancies. Following title and abstract screening, the same 2 researchers independently reviewed the full-text articles; and the articles were selected using the aforementioned inclusion and exclusion criteria. Included studies are expressed in Table 1.1,2,5,12-18

Table 1.

Study Characteristics.

Study Type of Study/Country Sample Size Definition of POUR Patients with POUR Surgery  Approach MINORS Score
Gandhi 2014 Retro-spective/USA 647 Need for post-operative catheterization due to inability to void, PVR>300 mL, available documentation for the need for post-operative urology consultation 36 Lumbar decompression [291 (44.9%)]/Fusion [356 (55.1%)] Posterior 20
Lee 2017 Retrospective/S.Korea 284 Inability to void > 2 days, PVR≥100 mL > 2 days 77 Decompression [152 (53.5%)]/Fusion [132 (46.5%)] Anterior (3)/Posterior [198 (69.7%)]/Combined [83(29.3%)] 20
Aiyer 2018 Prospective/India 370 Clinical criteria: Inability to void urine postoperatively, with suprapubic discomfort on palpation or palpable full bladder 61 Decompression [226 (61.1%)]/Fusion [134 (38.9)] Posterior 22
Golubov-sky 2018 Retrospective/USA 1592 Insertion or reinsertion of Foley catheter postoperatively due to: Failure to void, bladder distension, and discomfort in the setting of a clinically significant bladder scan volume > 400-500 mL 273 Decompression [753 (47.3%)]/Fusion [839 (52.7%)] Posterior 20
Issac 2019 Prospective 123 Clinical criteria: Supra pubic pain and discomfort, difficulty or inability to void, presence of supra pubic dullness and palpable bladder
Radiological criteria: Significant PVR on bedside ultrasound		 20 Decompression/Fusion 22
Cremins 2020 Retrospective/USA 333 Clinical criteria: Low urine volume of <180 mL 6 hours after surgery, inability to void post-operatively
Radiological criteria: Significant PVR		 58 Decompression Posterior 20
Zakaria 2020 Prospective/USA 25,769 Three straight catheterizations, with one beyond 48 hours post-operatively, insertion of indwelling catheter at any time after the patient left OR, discharge from the hospital with indwelling catheter, physician documentation of POUR (from medical record) 1899 Decompression [13,496 (52.4%)]/Fusion [12,273 (47.6%)] Posterior 19
Bowman 2021 Prospective/USA 200 PVR≥300 mL (determined by USG<90 minutes of voiding) 19 Fusion — 22
Mormol 2021 Retrospective/USA 814 Defined when straight catheterization was required for PVR >400 mL 138 Fusion Posterior 20
Tan 2021 Retrospective/Singapore 168 Clinical criteria: Requirement of foley’s catheter re-insertion after trial of removal, bladder distention, discomfort, or failure to void
Radiological criteria: PVR >300 mL (USG)		 13 Fusion Posterior [135 (80.4%)]/Lateral + posterior [31 (18.5%)]/Anterior + posterior (2) 20
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Abbreviations: POUR, Post-operative urinary retention; MINORS, methodological index for non-randomized studies.

Data Extraction and Study Quality Assessment

Two investigators (LAR, GP) independently extracted data and assessed the quality of the included studies as described below. The data extracted included study design, sample size, demographic details, and any of the aforementioned outcome variables. The study methodology was examined using the revised Methodological Index for Non-Randomized Studies (MINORS) tool. 19 The MINORS tool assesses eight items for non-comparative studies and twelve items for comparative studies. Each item is scored from 0 to 2, with 0 being not reported, 1 if reported but inadequate, and 2 if reported and adequate. The highest possible total score is 16 for non-comparative studies and 24 for comparative studies. All comparative studies with a score less than 16 were excluded from analysis to minimize bias and increase the quality of data.

Statistical Analysis

A meta-analysis was performed comparing LSS patients who developed POUR against those who did not. Measurements for the outcomes of interests were analyzed using Review Manager 5.4 (Cochrane Collaboration, Copenhagen, Denmark). Studies, which did not report means with standard deviations or raw data for computation of these values, were not included. Pooled differences were reported as mean differences with 95% confidence intervals (CIs). Heterogeneity among studies was evaluated using the I2 statistic. When statistically significant heterogeneity was identified (as defined by an I2 >50%), studies were excluded one at a time and the sensitivity analysis was repeated until the heterogeneity was lowered below 50%. Such a strategy (also termed as “one-out” sensitivity analysis) could potentially eliminate heterogeneity, unfairly contributed by a particular study. A random-effects and fixed-effects models were utilized for the included studies showing high and low heterogeneity, respectively. The P-values of <.05 were considered as statistically significant. The point estimate I2 should be interpreted cautiously when a meta-analysis has few studies. In small meta-analyses, confidence intervals should supplement or replace the biased point estimate I2.

Results

Search Results and Study Demographics

Following the application of our search criteria, a total of 265 studies were identified. After the exclusion of 255 manuscripts which did not meet our inclusion criteria, 10 studies were finally included. Figure 1 presents the flow chart of our literature search; and our selection strategy with the final studies included for the review has been shown in Table 1. A total of 30,300 patients were identified in these included studies, among which 2594 developed POUR. MINORS scores were included for bias measurement with an average of 20.5 for comparative studies. Only comparative studies were included for our meta-analysis and none of the included studies required exclusion based on the MINORS score.

Figure 1.

Figure 1.

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PRISMA Flow Sheet.

Risk Factors for Postoperative Urinary Retention

Nine studies (N = 29,553) comparing POUR in patients undergoing LSS reported on gender. Male patients were associated with a statistically significant increased odds of POUR (odds ratio [OR]: 1.38; 95% CI: 1.13 to 1.70, P = .01), as compared to the female counterparts. There was moderate heterogeneity among the studies with an I2 of 49% (Figure 2).

Figure 2.

Figure 2.

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Forrest Plot of Male Gender and Association with Developing Postoperative Urinary Retention.

Seven of the included studies (N = 29,201) reported on age. The pooled mean difference (MD) in age between those with and without POUR was 5.58 years (Mean age: 64.84 and 59.51 years in POUR+ and POUR- groups, respectively; 95% confidence interval [CI]: 3.36 to 7.81). Patients with POUR were relatively older and this difference was statistically significant (P < .0001). There was substantial heterogeneity between the studies with an I2 of 87% (Figure 3). Sensitivity analysis was performed with two studies excluded, decreasing the heterogeneity to a I2 of 37%. The results remained statistically significant with a pooled mean difference in age between those with and without POUR of 5.37 years (95% CI: 3.21 to 7.53, P < .001) (Figure 3).

Figure 3.

Figure 3.

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Forrest Plot with Sensitivity Analysis of Age and Association with Developing Postoperative Urinary Retention.

Six included studies (N = 3432) reported on the BMI data of patients. The pooled MD in BMI between the two groups was .01 kg/m2 (95% CI: −1.03 to 1.06), which was not statistically significant (P = .98). There was substantial heterogeneity among the studies with an I2 of 82% (Figure 4). Given the high heterogeneity, sensitivity analysis was performed. This led to one study being excluded with a statistically significant pooled MD in BMI between those with and without POUR of 1.00 (95% CI: -.25 to 2.24, P = .07). However, a moderate heterogeneity of I2 = 62% remained (Figure 4).

Figure 4.

Figure 4.

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Forrest Plot with Sensitivity Analysis of Body Mass Index and Association with Developing Postoperative.

A total of three studies (N = 26,783) reported data on patients who had undergone previous spine surgery. Patients who had previous spine surgery had decreased odds of POUR (odds ratio [OR]: .84; 95% CI: .53 to 1.32) compared to those who did not, although this difference was not statistically significant (P = .45). There was a substantial heterogeneity among the studies (I2 = 67%; Figure 5). Given this, sensitivity analysis was performed and a heterogeneity of I2 = 0% was obtained. This did not significantly change the results, but increased the odds ratio to 1.05 ([OR]: .84; 95% CI: .96 to 1.16) (Figure 5).

Figure 5.

Figure 5.

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Forrest Plot with Sensitivity Analysis of Patients with Previous Surgery and the Association with Developing.

Six included studies (N = 3391) reported data on patients’ smoking status. Smoking was associated with decreased odds of POUR (odds ratio [OR]: .84; 95% CI: .67 to 1.05) compared to controls, although this difference was not statistically significant (P = .13). These studies had low heterogeneity with an I2 of 27% (Figure 6).

Figure 6.

Figure 6.

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Forrest Plot of Smokers and Association with Developing Postoperative Urinary Retention.

A total of nine studies (N = 29,653) reported data on POUR in diabetic patients undergoing lumbar surgery. Patients with DM were associated with a significantly increased odds of POUR (OR: 1.53; 95% CI: 1.39 to 1.69; P < .0001). These studies had a low statistical heterogeneity with an I2 = 35% (Figure 7).

Figure 7.

Figure 7.

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Forrest Plot of Diabetes and Association with Developing Postoperative Urinary Retention.

Three studies (N = 3476) reported on patients with CAD. Patients with CAD were associated with significantly increased odds of POUR (OR: 1.87; 95% CI: 1.67 to 2.08; P < .0001) when compared to those patients. These studies had a moderate statistical heterogeneity (I2 = 47%; Figure 8).

Figure 8.

Figure 8.

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Forrest Plot of Coronary Artery Disease and Association with Developing Postoperative Urinary.

The presence of BPH was reported in five studies (N = 3191). Patients with BPH were associated with significantly increased odds of POUR (OR: 2.48; 95% CI: 1.94 to 3.17; P < .0001). These studies had low heterogeneity (I2 = 7%; Figure 9).

Figure 9.

Figure 9.

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Forrest Plot of Benign Prostatic Hyperplasia and Association with Developing Postoperative Urinary.

Four of the included studies (N = 1026) reported on the operative time. Based on our analysis, the patients developing POUR had relatively longer operative time in comparison with those who did not [pooled MD between those with and without POUR of 26.44 minutes ([CI]: 7.99 to 44.89, P = .005)]. The studies had a high statistical heterogeneity of I2 = 83% (Figure 10). Following sensitivity analysis and the removal of one study, the heterogeneity decreased to I2 = 46%. The pooled MD in operative time was still significantly higher in POUR patients at 18.61 minutes (95% CI: 4.66 to 32.56, P = .009) (Figure 10).

Figure 10.

Figure 10.

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Forrest Plot with Sensitivity Analysis of Operative Time and Association with Developing Postoperative Urinary Retention.

Four studies (N = 1026) reported on the volume of intraoperative fluid infusion. The pooled MD in milliliters (ml) of fluid infused was 171.70 mL (95% CI: 89.75 to 253.65; P < .0001). No statistical heterogeneity existed between the included studies (I2 = 0%; Figure 11).

Figure 11.

Figure 11.

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Forrest Plot of Fluids and Association with Developing Postoperative Urinary Retention.

Five studies (N = 1673) reported on the length of inpatient hospital stay (LOS). The pooled MD in LOS between the two groups was .56 days (95% CI: −.31 to 1.42), which was not statistically significant (P = .21). There was substantial heterogeneity between the studies with an I2 of 94% (Figure 12). Sensitivity analysis did not significantly alter the heterogeneity.

Figure 12.

Figure 12.

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Forrest Plot of Length of Stay and Association with Postoperative Urinary Retention.

Four studies (N = 262,356) comparing POUR in patients undergoing LSS reported on its association with the type of procedure (fusion vs non-fusion surgeries). Fusion surgeries were associated with significantly increased odds of POUR (odds ratio [OR]: 1.43; 95% CI: .98 to 2.09), as compared to non-fusion strategies. However, there was a substantial heterogeneity between the studies (I2 = 60%; Figure 13). Sensitivity analysis was performed and one study was removed which reduced the heterogeneity to I2 = 29%. The results increased the odds ratio to 1.61 ([OR]: .84; 95% CI: 1.29 to 2.02, P < .0001; Figure 13).

Figure 13.

Figure 13.

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Forrest Plot with Sensitivity Analysis of Patients Undergoing Fusion and the Association with Developing Postoperative Urinary Retention.

Patients, who developed POUR following LSS, were associated with higher odds of developing UTI (odds ratio [OR]: 7.27; 95% CI: 6.19 to 8.54, P < .001). The studies did not show any statistical heterogeneity (I2 = 0%; Figure 14)(Table 2).

Figure 14.

Figure 14.

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Forrest Plot of Patients who Developed a Urinary Tract Infection Following Postoperative Urinary Retention.

Table 2.

Significant Results Summary.

Variables Sample Size Result Odds Ratio/Confidence Interval
Gender Nine studies (N = 29,553) Increased odds of POUR OR: 1.38; 95% CI: 1.13 to 1.70, P = .01
Age Five studies (N = 1544) Mean difference in age between those with and without POUR of 5.37 years 95% CI: 3.21 to 7.53, P < .001
BMI Four studies (N = 595) Mean difference in BMI between those with and without POUR of 1.00 95% CI: -.25 to 2.24, P = .07
Diabetes Nine studies (N = 29,653) Diabetic patients had significantly increased odds of POUR OR: 1.53; 95% CI: 1.39 to 1.69; P < .0001
CAD Three studies (N = 3476) CAD was associated with significantly increased odds of POUR OR: 1.87; 95% CI: 1.67 to 2.08; P < .0001
BPH Five studies (N = 3191) BPH was associated with a significantly increased odds of POUR OR: 2.48; 95% CI: 1.94 to 3.17; P < .0001
Operative time Three studies (N = 593) Mean difference in operative time was higher in POUR patients at 18.61 minutes 95% CI: 4.66 to 32.56, P = .009
Fluids infused Four studies (N = 1026) Mean difference in milliliters of fluid infused between those with and without POUR was 171.70 mL 95% CI: 89.75 to 253.65, P < .0001
Fusion Six studies (N = 25,854) Statistically significant increased odds of POUR of 1.61 OR: .84; 95% CI: 1.29 to 2.02, P < .0001
UTI Four studies (N = 24,882) POUR was associated with higher odds of developing UTI OR: 7.27; 95% CI: 6.19 to 8.54, P < .0001
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Discussion

Understanding the risk factors associated with POUR is important, given the increased inpatient length of stay, hospital costs, and overall morbidity observed in patients developing this complication. 20 With rates as high as 70%, POUR represents a common post-operative problem across all elective surgeries.2,5,21 More specifically, patients undergoing spine surgery have reported POUR rates between 5 to 30%.5,12,21 The systematic reviews heretofore published in the literature have evaluated the prevalence of this complication in all spinal surgery patients (irrespective of the level of spinal pathology). Previous studies have clearly demonstrated greater prevalence of POUR following lumbar spinal surgeries (LSS).5,14,15 In this context, the current meta-analysis was planned to evaluate the risk factors for POUR specifically in patients undergoing LSS; so as to identify solutions to mitigate this often under-emphasized but significant post-operative AE.

Several studies have explored the association between various demographic parameters of patients and the development of POUR following LSS. Based on our analysis, we could observe a significantly higher prevalence of POUR in male patients, although there was considerable heterogeneity among the included studies. This observation is in accordance with a majority of published studies in the literature, where male gender has been associated with higher prevalence of POUR across all surgical specialties. 22 Among the literature on POUR following LSS, with the exception of two all other studies identified male gender as a significant predisposing factor. Higher prevalence of BPH and longer length of urethra have been postulated as possible reasons for relatively higher association of POUR with male sex. 2 We also observed a statistically significant difference in the mean age of patients with and without POUR, with the AE being more prevalent in a relatively older population.1,5,13,15-17 Although both these observations were initially attributed to the higher prevalence of BPH in both these patient groups (older age and male gender), more recent studies have demonstrated a significant association between POUR and both these parameters, irrespective of the confounding variable.22-25 Based on the available evidence, we were unable to clearly identify any cut-off age limit beyond which the need for prophylactic measures against POUR could be advocated.

Among the other demographic variable studied in the literature, we did not observe any significant association between POUR and smoking status, BMI or previous surgical history. Although tobacco use was purported to enhance the rate of endothelial sclerosis leading to higher incidence of bladder ischemia and lower urinary tract complications,26-28 such an association was not supported by our meta-analysis. Based on our meta-analysis, three co-morbidities were significantly associated with increased incidence of POUR, namely BPH, DM and CAD. Based on evident literature and anatomical reasoning, it stands to reason that BPH has a higher association with POUR due to mechanical obstruction of urine across the bladder.23,29 Previous studies have also demonstrated substantial association between DM and POUR following diverse general and orthopedic surgical procedures.26,30,31 The pathophysiology underlying bladder dysfunction in patients with DM is multi-factorial; and may be attributed to neuropathy, poly-pharmacy, dehydration, and older age. 32 Based on our analysis; there was nevertheless, considerable heterogeneity among the studies reporting DM in POUR patients. Previous studies have also reported that the same indirect confounding factors for DM may also be the reason underlying the association between POUR and CAD. Lin et al observed that urinary retention in patients with CAD might be attributed to chronic bladder ischemia secondary to associated atherosclerosis. 33 Overall, the evidence regarding the association between these three comorbidities and POUR is reasonably incontrovertible. A majority of the included studies excluded patients with underlying neuro-deficit or cauda-equina syndrome; and therefore, we could not analyze whether there was any association between neurological deficiencies and development of POUR.

On the basis of our meta-analysis, three peri-operative factors could be associated with the development of POUR, namely prolonged operative time, higher volume of fluids infused, and fusion procedures (as compared to non-fusion strategies). Prolonged surgical time has been substantially associated with POUR in previous studies involving patients undergoing non-orthopedic surgeries.31,34,35 Hansen et al reported that operative time longer than two hours significantly predisposed the patients undergoing orthopaedic, abdominal, gynecological or plastic procedures to the development of POUR. 35 Another study revealed that for every additional 15 minutes spent in the operating room, there was a 25% enhanced risk of developing POUR in patients undergoing total joint arthroplasty (TJA). 36 Similarly, based on our meta-analysis, the patients who developed POUR had substantially higher volume of fluid infusion, as compared to the control population. The study by Petros et al involving 111 patients reported that administration of peri-operative fluids of volume greater than 1,000 mL was associated with higher chances of developing POUR. 37 Nevertheless, based on the current evidence, we were unable to identify any clear cut-off limits for the two variables (length of surgical time and volume of fluid infusion) beyond which the need for prophylactic measures against POUR might be necessary. We observed low heterogeneity among the studies which evaluated the association between volume of fluid infusion and POUR.

Based on our meta-analysis, lumbar fusion procedures substantially enhanced the risk of POUR, as compared to non-fusion surgeries. The possible explanations for such an association may include: longer operative time in this patient cohort, increased requirement for narcotics, and greater degree of tissue manipulations.1,2,5,12,13,16,17 We however could not obtain any substantial evidence regarding the association between the levels of fusion performed and the occurrence of POUR. On a similar note, a majority of the studies published on this subject only included patients undergoing posterior approaches for LSS; and therefore, we could not compare the relative incidence of POUR among the diverse spinal approaches. Based on these aforementioned observations, we would recommend the need for future studies to identify the cut-off values for these parameters, namely length of surgical time, volume of fluid infusion and number of fusion levels beyond which the risk of developing POUR might be substantially enhanced.

Among the complications, we could observe a clear increase in the rates of UTIs in the patients who developed POUR. Notably, this association had the highest odds of all variables examined with seven times higher odds of association when compared to controls; and the evidence in this regard were quite clear based on our analysis. UTIs can occur in this cohort of post-operative patients either as a predisposing cause or as a consequence to POUR.38,39 UTIs can develop as a complication of POUR due to direct (due to poor bladder emptying) or indirect (due to indwelling or intermittent catheterization) inoculation.20,40 Studies have demonstrated enhanced morbidity as well as mortality in patients developing post-surgical UTIs.41,42 Our analysis also showed that the patients who developed POUR had significantly prolonged hospital stay, in comparison with those who did not (although there was substantial heterogeneity among the studies which reported on this parameter). This observation is in concordance with the previous large-scale reports in the literature, which have demonstrated prolonged hospital stay in patients developing POUR following elective general surgical interventions. 43 Certain other complications of POUR including abnormal autonomic response of bladder over-distension (leading to vomiting, hypo- or hypertension, or cardiac dysrhythmias) and chronic myogenic bladder changes have been reported in the literature.44,45

As previously highlighted, our meta-analysis was limited by the quality (6 retrospective studies) as well as the numbers of the available studies. There was substantial heterogeneity among the included articles with regard to the reporting of a majority of parameters. There was lack of standardization of definition, documentation and presentation of POUR; as well as the peri-operative prophylactic or management approaches for this AE across the included studies. Given the multifactorial nature of POUR, the data regarding the anesthetic and analgesic medications used peri-operatively were inconsistent in various studies, making it hard to draw any useful conclusions regarding them. With the available data, our meta-analysis could not yield any specific cutoff values for certain important variables like age of patient, volume of fluids infused, levels of fusion, and length of hospital stay. The included manuscripts did not clearly identify what proportion of POUR was observed as a consequence of surgery-related complications (such as hematoma or nerve damage); and therefore, we could not perform any specific analysis on this subject. Additionally, due to the lack of individual data points, multivariate regression analysis could not be performed in our study.

Based on our analysis, the risk factors associated with POUR following LSS include male gender, older age, longer surgical times, fusion procedures, larger volumes of intraoperative infusions, and associated comorbidities like DM, CAD, and BPH. We authors believe that patients with several of these underlying risks should be considered for prophylactic catheter placement with future studies assessing the risk benefit analysis. Additionally, our meta-analysis clearly indicates the paucity of high-quality evidence on this subject; and based on these observations, we recommend the need for high-quality, multi-centered, large-scale, prospective, randomized-controlled studies to evaluate this crucial post-operative complication following LSS.

Footnotes

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.

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