Abstract
Background
Postoperative urinary retention (POUR), a known complication following total joint arthroplasty (TJA), remains inconsistent in its diagnostic criteria, prevalence, and risk factors. This study aims to quantify POUR rates, identify risk factors, and assess complications associated with catheterization in TJA.
Methods
A single-center cohort undergoing TJA between January 2015 and December 2022 was retrospectively reviewed. POUR rates were quantified using 3 different diagnostic criteria. Variables analyzed included age, sex, alpha-blocker prescription, operative joint, body mass index, American Society of Anesthesiologists score, Charlson Comorbidity Index classification, and anesthesia type. Complication rates between POUR and non-POUR patients were compared. Among POUR patients, 90-day postoperative renal and infectious complications were evaluated based on catheterization type and frequency.
Results
Among the 17,220 TJA patients identified, POUR incidence rates varied from 20% (catheterization), 25% (postoperative bladder scan > 500 mL), to 29% (catheterization and/or bladder scan). Advanced age, male gender, lower body mass index, moderate Charlson Comorbidity Index scores, total knee arthroplasty, spinal anesthesia, and alpha-blocker use were significantly more prevalent among POUR patients. The development of postoperative complications, including renal/infectious complications, was not significant between POUR and non-POUR patients. Among POUR patients, there was a significant increase in renal/infectious complications among patients who received 4+ catheters (odds ratio = 10.17, 2.75, 37.59).
Conclusions
Diagnostic variability in POUR after TJA persists. For POUR management, patients receiving 4+ catheters were at a 10-fold risk for renal/infectious complications compared to those without catheterization. Reducing catheterization frequency and employing risk stratification for susceptible patients may help mitigate these risks effectively.
Keywords: Total joint arthroplasty, Postoperative complications, Postoperative urinary retention, Urinary tract infection, Catheterization
Introduction
Total joint arthroplasty (TJA) continues to be one of the most frequently performed elective surgeries in the United States, with expectations for continued growth [1]. With this, the occurrence of perioperative complications is presumed to grow proportionately. Postoperative urinary retention (POUR) is a well-documented complication in both total hip arthroplasty (THA) and total knee arthroplasty (TKA), with a reported incidence that spans from 0% to 75% [[2], [3], [4], [5], [6]]. Previously understood etiologies are multifactorial and include age, medical comorbidities, anesthesia type, and operative time [3,7,8]. Clinically, the presence of POUR and its treatment of catheterization have been associated with increased patient morbidity, duration of hospital stay, and associated hospital costs [9,10]. The impact of POUR generates an opportunity to risk stratify and elucidate prevention strategies in patients undergoing TJA.
The diagnosis of POUR is driven clinically; however, there is no current consensus regarding quantitative criteria for diagnostic purposes. The primary aim of this study is to compare the rate of 3 distinct definitions of POUR in a large cohort who underwent TJA. Furthermore, the goal is to identify POUR risk factors and quantify 90-day postoperative renal and infectious complication rates based on the type of urinary catheterization. We hypothesized that male sex would be the most prominent risk factor for the development of POUR and those who received multiple catheters or both straight and foley urinary catheterization would be at the highest risk for renal and infectious complications in a 90-day postoperative period.
Material and methods
This study was submitted to our institutional review board and subsequently approved before the data collection process was initiated. Using the prospectively collected institutional database from a high-volume, single-center acute care hospital, a retrospective review was carried out comprising 35 fellowship-trained arthroplasty surgeons from January 1, 2015 to December 31, 2022.
Patients aged 18-89 years with associated Current Procedural Terminology codes 27447 (primary TKA) and 27310 and 27132 (primary THA) were included in the study. Subsequent surgeries after the first TKA or THA, any revisional TKA/THA, and traumatic injuries that were subsequently managed with TKA or THA were omitted from the analysis (Fig. 1). Patient data that met inclusion criteria were stratified against several variables of interest including age, sex, operative joint (THA or TKA), body mass index (BMI), alpha-blocker prescription, American Society of Anesthesiologists (ASA) score, Charlson Comorbidity Index (CCI) classification, anesthesia type (spinal, nonspinal, unknown), and postoperative complications. Complications of special interest included urinary tract infections (UTIs) and other potentially catheter-associated complications including acute kidney injury (AKI), acute renal failure (ARF), periprosthetic joint infection (PJI), and surgical site infection (SSI) within 90-day postoperative period which were grouped together as renal/infectious complications.
Figure 1.
Flow diagram showing patient selection, POUR definitions, and type and number of catheterization and renal complications associated with catheterization by type and number.
Postoperative patients followed a standardized protocol that consisted of a bladder scan after their first postoperative void or within 4-6 hours after surgery if they had not voided, or if they had a complaint of bladder fullness. Subsequent bladder scans were taken at similar time frames if the patient was still retaining. The diagnosis of POUR was obtained when patients met the criteria for one of the following diagnostic definitions:
-
(1)
POUR1: A patient with a postoperative bladder scan of > 500 mL.
-
(2)
POUR2: A patient with any documentation of postoperative catheterization (ie, straight or foley).
-
(3)
POUR3: A patient with a postoperative bladder scan of > 500 mL or a documented postoperative catheterization.
Patients identified with POUR were subjected to urinary catheterization per institutional guidelines. Protocols for the type of catheter varied over the course of the study. For analyses, we examined total number of catheters as well as type of catheter, which was categorized as none, straight only, foley only, or both straight and foley.
Statistical analysis
A Chi-square analysis was performed to compare the significance of risk factors and complication rates among POUR3 and non-POUR patients. Age was compared using a 2-sample t-test. Three multivariable logistic regression models examined the relationship of POUR3 (Y/N) with outcomes (1) ‘any’ complication, (2) renal/infectious complications, and (3) UTI within 90 days of surgery. Potential covariates included demographics, risk factors and operative joint. Two separate multivariable logistic regression models examined the relationships of (1) catheter type and (2) total number of catheters with renal/infectious complications among POUR patients. Subanalyses among male patients examined the relationship of alpha-blockers and benign prostatic yperplasia (BPH) with renal or infectious complications and a multivariable logistic regression was used. Multivariable logistic regressions like those above were used with BPH/alpha-blocker as an additional covariate. All analyses were performed using SAS 9.4 (SAS Institute, Cary, NC). Two-sided P values < .05 were determined to be statistically significant.
Results
Rates of POUR using our 3 defined designations are compared in Figure 2. There were 25.4% (4368/17,220 patients) of patients who met POUR1 diagnostic criteria. However, a substantial portion of patients (6414/17,220; 37.3%) did not have a documented postoperative bladder scan. The rate of POUR2 was 19.7% (3392/17,220), while POUR3 demonstrated the highest rate of the 3 criteria at 28.7% (4941/17,220). All subsequent analyses used the POUR3 definition.
Figure 2.
Percentage rates of POUR development in TJA patients by definition.
Table 1 compares POUR3 vs non-POUR patients by risk factors and the development of complications. Advanced age, male gender, lower BMI, moderate CCI scores, TKA, spinal anesthesia, and being prescribed an alpha-blocker were significantly more prevalent among POUR patients (P < .01). In contrast, there was no difference by POUR vs non-POUR in the development of complications, including POUR-focused complications such as SSI, PJI, AKI/ARF, and UTI within 90 days from the initial surgery date.
Table 1.
Number of patients (POUR3 vs non-POUR) by risk factor and overall complication.
| Patient characteristics | Documented catheter or bladder scan ≥ 500 mL |
||
|---|---|---|---|
| No POUR, n = 12,279 | POUR, n = 4941 | P value | |
| Age group, n (%) | <.01 | ||
| <55 | 1332 (10.9) | 448 (9.1) | |
| 55-64 | 3628 (29.6) | 1397 (28.3) | |
| 65-75 | 4507 (36.7) | 1931 (39.1) | |
| 75+ | 2812 (22.9) | 1165 (23.6) | |
| Sex, n (%) | <.01 | ||
| Female | 7136 (58.12) | 2684 (54.32) | |
| Male | 5143 (41.88) | 2257 (45.68) | |
| Alpha-blocker prescription | <.01 | ||
| Yes | 4432 (28.14) | 504 (34.50) | |
| No | 11,320 (71.86) | 957 (65.50) | |
| Body mass index, n (%) | <.01 | ||
| <25 | 1829 (14.90) | 977 (19.77) | |
| 25-29.99 | 4091 (33.32) | 1766 (35.74) | |
| 30-34.99 | 3451 (28.11) | 1246 (25.22) | |
| 35+ | 2907 (23.68) | 952 (19.27) | |
| ASA class, n (%) | .06 | ||
| I-II | 8215 (66.94) | 3380 (68.43) | |
| III-IV | 4057 (33.06) | 1559 (31.57) | |
| Charlson Comorbidity Index | <.01 | ||
| Mild (0-2) | 5348 (43.55) | 2046 (41.41) | |
| Moderate (3-4) | 5710 (46.50) | 2425 (49.08) | |
| Severe (5+) | 1221 (9.94) | 470 (9.51) | |
| Joint replaced, n (%) | <.01 | ||
| Hip | 5780 (47.07) | 2098 (42.46) | |
| Knee | 6499 (52.93) | 2843 (57.54) | |
| n= 11,754 | n = 4694 | ||
|---|---|---|---|
| Anesthesia typea | <.01 | ||
| Spinal | 7216 (61.39) | 3606 (76.82) | |
| Nonspinal | 4538 (38.61) | 1088 (23.18) | |
| Any complication within 90 days of surgery | .58 | ||
| Yes | 392 (3.19) | 166 (3.36) | |
| No | 11,887 (96.81) | 4775 (96.64) | |
| AKI/ARF | .16 | ||
| Yes | 7 (0.06) | 6 (0.12) | |
| No | 12,272 (99.94) | 4935 (99.89) | |
| PJI | .55 | ||
| 0 | 84 (0.68) | 38 (0.22) | |
| No | 12,195 (99.32) | 4903 (99.23) | |
| SSI | .21 | ||
| Yes | 23 (0.19) | 5 (0.10) | |
| No | 12,256 (99.81) | 4936 (99.90) | |
| UTI | .99 | ||
| Yes | 62 (0.50) | 25 (0.51) | |
| No | 12,217 (99.5) | 4916 (99.49) |
A portion of this cohort (n = 772/4.5%) was missing documentation of anesthesia type.
Table 2 displays the results from 3 multivariable logistic regressions with outcomes of ‘any’complication, renal/infectious complication, and UTI within 90 days postoperatively. There was no significant difference in the postoperative development of complications between POUR and non-POUR patients. Males were 1.4 times more likely to have ‘any’ complication compared to females (P < .01); however, there was no difference in 90-day UTI incidence by sex (P = .21). ASA classes III-IV were 1.4 times more likely to have ‘any’ complication and 1.68 times more likely to develop a UTI compared to ASA class I-II (P < .01). Those who received a spinal anesthetic and patients with no documented anesthesia data had fewer complications and UTIs compared to those who did not receive a spinal anesthetic. Male gender, ASA III-IV, nonspinal anesthesia, and BMI of 35+ increased the likelihood of developing renal/infectious complications. Finally, when evaluating UTI, only age more than 75 years and ASA III-IV were significant for increased risk for developing postoperative UTI (P < .04).
Table 2.
Multivariable logistic regression by overall complication, specific renal and infectious complications, and UTI within 90 days following TJA using POUR3 criteria.
| Patient characteristics | Any complication |
Renal/infectious complication |
UTI within 90 days of surgery |
||||||
|---|---|---|---|---|---|---|---|---|---|
| Estimate (SE) | Odds ratio (95%, CI) | P value | Estimate (SE) | Odds ratio (95%, CI) | P value | Estimate (SE) | Odds ratio (95%, CI) | P value | |
| POUR | .41 | .45 | .91 | ||||||
| Yes | 0.04 (0.05) | 1.08 (0.90, 1.30) | 0.05 (0.07) | 1.12 (0.84, 1.49) | 0.01 (0.12) | 1.03 (0.64, 1.64) | |||
| No | ref | n/a | ref | n/a | ref | n/a | |||
| Age group, n (%) | .43 | .09 | .04 | ||||||
| <55 | −0.15 (0.13) | 0.78 (0.51, 1.18) | −0.46 (0.22) | 0.47 (0.24, 0.92) | −0.99 (0.56) | 0.17 (0.04, 0.80) | |||
| 55-64 | 0.07 (0.08) | 0.97 (0.73, 1.30) | 0.14 (0.12) | 0.86 (0.56, 1.33) | 0.01 (0.27) | 0.46 (0.22, 0.95) | |||
| 65-75 | −0.03 (0.08) | 0.88 (0.70, 1.11) | 0.02 (0.12) | 0.76 (0.53, 1.09) | 0.18 (0.25) | 0.54 (0.32, 0.91) | |||
| 75+ | ref | n/a | ref | n/a | ref | n/a | |||
| Sex, n (%) | <.01 | <.01 | .21 | ||||||
| Male | 0.17 (0.04) | 1.4 (1.19, 1.68) | 0.22 (0.07) | 1.55 (1.19, 2.01) | −0.15 (0.12) | 0.75 (0.48, 1.17) | |||
| Female | ref | n/a | ref | n/a | ref | n/a | |||
| Body mass index, n (%) | .1 | <.01 | .27 | ||||||
| 35+ | 0.12 (0.07) | 1.28 (1.02, 1.61) | 0.29 (0.10) | 1.79 (1.28, 2.51) | 0.27 (0.17) | 1.57 (0.90, 2.72) | |||
| 30-34.99 | 0.01 (0.07) | 1.14 (0.93, 1.40) | 0.01 (0.10) | 1.35 (0.98, 1.86) | −0.09 (0.17) | 1.09 (0.64, 1.86) | |||
| <30 | ref | n/a | ref | n/a | ref | n/a | |||
| ASA class, n (%) | <.01 | <.01 | .03 | ||||||
| III-IV | 0.17 (0.05) | 1.42 (1.17, 1.71) | 0.26 (0.07) | 1.70 (1.28, 2.26) | 0.26 (0.12) | 1.68 (1.06, 2.69) | |||
| I-II | ref | n/a | ref | n/a | ref | n/a | |||
| Charlson Comorbidity Index | <.01 | .86 | .59 | ||||||
| Severe (5+) | 0.38 (0.09) | 1.92 (1.38, 2.68) | 0.07 (0.15) | 1.10 (0.66, 1.84) | 0.16 (0.22) | 1.49 (0.63, 3.51) | |||
| Moderate (3-4) | −0.10 (0.06) | 1.20 (0.95, 1.52) | −0.04 (0.10) | 0.98 (0.69, 1.40) | 0.09 (0.16) | 1.39 (0.72, 2.68) | |||
| Mild (0-2) | ref | n/a | ref | n/a | ref | n/a | |||
| Joint replaced, n (%) | <.01 | .07 | .9 | ||||||
| Hip | 0.21 (0.04) | 1.51 (1.27, 1.80) | 0.12 (0.07) | 1.28 (0.98, 1.68) | 0.01 (0.11) | 1.03 (0.66, 1.6) | |||
| Knee | ref | n/a | ref | n/a | ref | n/a | |||
| Anesthesia type | <.01 | <.01 | .06 | ||||||
| Received spinal (Y) | −0.17 (0.09) | 0.62 (0.52, 0.74) | 0.27 (0.21) | 0.68 (0.52, 0.88) | 0.28 (0.35) | 0.65 (0.42, 1.01) | |||
| No documented anesthesia (U) | −0.14 (0.15) | 0.63 (0.40, 1.00) | −0.92 (0.39) | 0.21 (0.07, 0.65) | −0.99 (0.67) | 0.18 (0.03, 1.33) | |||
| No spinal (N) | ref | n/a | ref | n/a | ref | n/a | |||
| Complications: Cardiac arrest, cardiac arrhythmia (including atrial fibrillation), cerebral vascular event, transient ischemic attack, wound dehiscence, dislocation, periprosthetic fracture, periprosthetic joint infection, tendon rupture (quadriceps and patellar), hematoma, gastrointestinal hemorrhage, mechanical failure, nerve injury, delirium, pneumonia, pneumothorax, surgical site infection, pressure ulcer, venous thromboembolism, vascular, and in-hospital mortality | Complications: Acute kidney injury/acute renal failure, periprosthetic joint infection, and surgical site infection. | ||||||||
CI, confidence interval; n/a, not applicable; ref, reference; SE, standard error.
Among POUR patients, we examined renal/infectious complications (AKI/ARF, SSI, PJI, and UTI) by urinary catheterization type and by total number of catheterizations, since there was variability in protocol over the study period. The percentage of POUR patients who developed renal/infectious complications is displayed by catheter type (Fig. 3a) and by number of catheters (Fig. 3b). There was a statistically significant (P = .01) difference in both analyses. Patients receiving both a straight and foley catheter (9/232, 3.9%) and patients who received 4 or more catheters had higher complication rates.
Figure 3.
Percentage of POUR patients with postoperative renal/infectious complications (a) by catheter type and (b) by total catheter number. (a) Results from chi-square test (P = .01). (b) Results from trend test (P < .01).
Table 3 displays the results of 2 multivariable logistic regressions predicting renal/infectious complications associated with the (1) type of catheterization and with (2) total number of catheters among POUR patients. When analyzing postoperative complications by catheter type, there was no significance. However, CCI was found to be significant (P < .05). Patients in the severe (5+) CCI class were more than 2 times as likely to have a renal or infectious complication during the postoperative period. The second regression model, which included the number of catheters used, found that patients who received a total of 3 catheters were more than 5 times more likely to develop a renal or infectious postoperative complication, while those who received 4+ catheters were more than 10 times more likely to develop complications compared to patients who received no catheters (P < .01).
Table 3.
Multivariable logistic regression by renal and infectious complications, including UTI, associated with catheter type, total catheter number, and risk factors among POUR patients.
| Outcome renal (AKI/ARF) and infectious (SSI, PJI, UTI) postoperative complications | |||||||
|---|---|---|---|---|---|---|---|
| Characteristics | Estimate (SE) | Odds ratio (95% CI) | P value | Characteristics | Estimate (SE) | Odds ratio (95% CI) | P value |
| Catheter type | .1 | # of catheters | <.01 | ||||
| Both | 0.68 (0.28) | 2.45 (1.05, 5.76) | 4+ | 1.51 (0.50) | 10.17 (2.75, 37.59) | ||
| Foley only | −0.25 (0.28) | 0.97 (0.43, 2.19) | 3 | 0.84 (0.33) | 5.19 (2.12, 12.73) | ||
| Straight only | −0.20 (0.19) | 1.02 (0.57, 1.81) | 2 | −0.62 (0.33) | 1.21 (0.50, 2.96) | ||
| No catheter | ref | ref | 1 | −0.91 (0.22) | 0.91 (0.51, 1.62) | ||
| CCI class | .05 | 0 | ref | ref | |||
| Severe (5+) | 0.39 (0.22) | 2.34 (1.12, 4.89) | CCI class | .08 | |||
| Moderate (3-4) | 0.08 (0.16) | 1.72 (1.00, 2.96) | Severe (5+) | 0.34 (0.22) | 2.16 (1.03, 4.53) | ||
| Mild (0-2) | ref | ref | Moderate (3-4) | 0.09 (0.16) | 1.68 (0.98, 2.89) | ||
| Sex | .16 | Mild (0-2) | ref | ref | |||
| Male | 0.16 (0.12) | 1.39 (0.86, 2.23) | Sex | .26 | |||
| Female | ref | ref | Male | 0.14 (0.12) | 1.32 (0.81, 2.13) | ||
| Surgery | .31 | Female | ref | ref | |||
| Hip | 0.12 (0.12) | 1.27 (0.80, 2.04) | Surgery | .28 | |||
| Knee | ref | ref | Hip | 0.13 (0.12) | 1.30 (0.81, 2.10) | ||
| Anesthesia type | .2 | Knee | ref | ref | |||
| Spinal | 0.53 (0.48) | 0.74 (0.43, 1.26) | Anesthesia type | .15 | |||
| No documented anesthesia | −1.37 (0.93) | 0.11 (0.01, 1.74) | Spinal | 0.56 (0.48) | 0.72 (0.43, 1.22) | ||
| No spinal | ref | ref | No documented anesthesia | −1.44 (0.92) | 0.10 (0.01, 1.52) | ||
| No spinal | ref | ref | |||||
CI, confidence interval; ref, reference; SE, standard error.
To account for the additional risk of complications for patients on alpha-blockers/history of BPH, a subanalysis was conducted for male patients only. Three outcomes, development of (1) ‘any’ complication, (2) UTI within 90 days of surgery, and (3) renal/infectious complications, were examined. Among all male patients (n = 7400), only anesthesia type was related to developing a UTI postoperatively, although having POUR neared significance (P = .06). Similar results were found in the model predicting ‘any’ complication. In this model, more comorbidities and THA were significant predictors of a complication. History of BPH or a prescription for an alpha-blocker was not related to either ‘any’ complication or UTI development. In contrast, male patients with BPH/alpha-blocker and those with ASA III-IV were 1.5 times more likely to develop a renal/infectious complication, while male patients who received spinal anesthesia were less likely to develop this complication. Among male patients with POUR (n = 2257), BPH/alpha-blocker was not significantly related to development of any of the 3 outcomes.
Discussion
The study explored 3 distinct definitions of POUR, reporting the highest incidence rate of 29% in a large cohort of TJA patients across an 8-year study period. Increasing age, male sex, lower BMI, moderate CCI score, preoperative alpha-blocker utilization, spinal anesthesia, and undergoing a TKA were proportionally higher among patients who developed POUR. The number of patients diagnosed with POUR who developed complications, including renal/infectious complications, and UTI did not differ significantly from non-POUR patients. However, POUR patients who received 4+ catheters had a significantly higher rate of developing postoperative renal or infectious complications (P < .01).
Our study demonstrated an incidence of POUR ranging from 20% to 29% using 3 separate diagnostic definitions. These findings exist within the range of incidence rates from 0% to 75% reported from more recent literature [[2], [3], [4], [5], [6],11,12]. The wide variability in incidence rates between these studies may be due to the differing definitions of POUR and its diagnostic features. Scholten et al. defined POUR as the inability to void with a bladder volume exceeding 400 mL or a postvoid residual urine volume more than 150 mL3. Similarly, a notable number of studies rely on objective measures such as bladder scan volume or postvoid residual volume to diagnose POUR [3,5,[12], [13], [14]]. Tischler et al. relied on more subjective parameters described as a patient’s inability to void [6]. Despite a lack of consensus on the definition and standardization of POUR, our results support that POUR remains a substantial challenge in postoperative TJA patients with further opportunities for improvement.
Increasing age, history of BPH or alpha-blocker prescription, and male sex have previously been identified as risk factors in multiple studies on developing POUR [4,13,15,16]. Our study also found these to be significant risk factors for POUR. While 2 recent studies showed there was no association between increasing BMI and the occurrence of POUR, our analysis found an inverse relationship [2,4]. That is, a significant trend toward decreasing rates of POUR with increasing BMI. There were high rates of moderate CCI among POUR patients. Patients receiving TKA represented a higher proportion of POUR patients compared to THA despite previous studies showing no significant association in TJA surgery type [5,17]. There was significance among patients receiving spinal anesthesia and developing POUR. The majority of these patients received ropivacaine 0.5% or bupivacaine 0.5% as an anesthetic. However, these results may be impacted by other perioperative factors such as intravenous fluids amount and postoperative pain control regimens not assessed in our study [13,14,18,19].
From our analysis, the proportion of patients with POUR who developed any postoperative complications, specific renal and local infectious (AKI/ARF, SSI, and PJI) complications, or UTIs within 90 days from surgery did not vary significantly from non-POUR patients. Similarly, Weintraub et al. did not illustrate a significant association between the diagnosis of POUR and UTI within a 3-week interval [20]. Male gender, BMI > 30, ASA class III-IV, and nonspinal anesthesia were associated with development of postoperative renal/infectious complications. Patients who develop POUR after TJA should be counseled and reassured that the complication rate is relatively low in the postoperative period. In a recent meta-analysis of randomized controlled trials, Ma et al. demonstrated patients who received foley catheterization were 3 times more likely to develop a UTI against no catheterization [21].
In our study, POUR patients who received 4+ catheters were at a significantly higher risk for developing postoperative renal and infectious complications compared to POUR patients who received no catheter. When solely looking at renal and infectious complications, catheter type was not found to be significant. Patients eligible for multiple catheters may demonstrate prolonged retention due to a multitude of irreversible factors (chronic renal disease, age, etc.) that may increase their risk of complications at baseline. The evidence from this study along with prior studies suggest that the threshold to catheterize postoperative patients should be weighed heavily in the setting of increased morbidity and duration of hospital stays [9,10]. Given the variability in POUR diagnosis, using stricter more clinically relevant diagnostic criteria, such as inability to void, may help reduce rates of catheterization and subsequent complications.
There were several notable limitations to our study and its subsequent results. Retrospective reviews often face limitations due to a lack of control over variables and the presence of inherent confounders, although the present study did strive to mitigate these limitations by way of the statistical analysis used. In addition, due to limitations of the data source, the present analysis did not assess some previously identified POUR risk factors, including amount of intravenous fluid administration and postoperative pain control regimens [5,6,13,14,18,19]. Using the POUR1 diagnostic criteria, approximately one-fourth (25.4%) of patients did not receive a bladder scan, which may result in underestimating POUR rates. Furthermore, we did not analyze the amount of time foley catheters were maintained concerning the rate and development of complications.
Conclusions
POUR remains a substantial challenge in TJA patients, affecting almost one-third of individuals in a large cohort over an 8-year period. Increasing age, male sex, decreasing BMI, moderate CCI score, and knee surgery were found to be proportionally higher factors among patients who developed POUR. However, the number of POUR patients who developed any complications, including renal/infectious complications, or UTIs within a 90-day postoperative window was insignificant when compared to non-POUR patients. Patients with POUR who received 4+ catheters demonstrated a significantly higher risk of developing postoperative renal and infectious complications. Bladder scanning may artificially increase rates of POUR diagnosis and subsequent catheterization. The decision to catheterize postoperative TJA patients with POUR should rely on clinical criteria of a patient’s inability to void and engage a multidisciplinary discussion among members of the providing team and patient. Our findings from this study illustrate an opportunity for further development of risk stratification tools and protocols that aim to identify patients with significant predisposing risk factors of POUR and to decrease the number of catheterizations used to reduce associated renal and infectious complications in POUR patients undergoing TJA.
Conflicts of interest
Matthew J. Grosso is a paid consultant for Stryker and is an AAHKS EBM committee member and AAOS EBVQ committee member. Dorothy B. Wakefield is a statistical consultant for St. Francis Hospital. The other authors declare no potential conflicts of interest.
For full disclosure statements refer to https://doi.org/10.1016/j.artd.2024.101600.
CRediT authorship contribution statement
Madeleine J.F. Powers: Writing – review & editing, Writing – original draft, Visualization, Resources, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Zachary T. Grace: Writing – review & editing, Writing – original draft. Barrett B. Torre: Writing – review & editing, Writing – original draft. Dorothy B. Wakefield: Writing – review & editing, Writing – original draft, Software, Formal analysis, Data curation. Laura Sanzari: Data curation. Matthew J. Grosso: Writing – review & editing, Writing – original draft, Supervision, Investigation, Conceptualization.
Appendix A. Supplementary data
References
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