Abstract
Study Objective:
Surgeons employ various methods for evaluating what is considered a common occurrence after gynecologic operations, postoperative urinary retention (POUR). Few have reported the incidence of POUR with a liberal voiding protocol (no requirement to void prior to discharge). The primary objective of this study is to evaluate the risk of POUR after benign gynecologic surgery, comparing a liberal voiding protocol to more strict voiding protocols. Secondary outcomes include length of hospital stay and urinary tract infection (UTI).
Design:
Retrospective cohort study.
Setting:
Quaternary-care academic hospital in the United States.
Patients:
Patients undergoing hysterectomy or myomectomy at Cedars-Sinai Medical Center from August 2017 through July 2018 (n=652). Cases involving incontinence operations, correction of pelvic organ prolapse, malignancy, or peripartum hysterectomy were excluded.
Interventions:
Hysterectomy, myomectomy
Measurements and Main Results:
POUR, defined as the need for re-catheterization within 24 hours of catheter removal, along with UTI and length of stay, were compared between liberal and strict voiding protocols. Sub-group analysis was performed for those undergoing minimally invasive surgery (MIS). 303 (46.5%) women underwent surgery with a liberal postoperative voiding protocol and 349 (53.5%) with a strict voiding protocol. Overall, the incidence of POUR was low at 3.8% and not different among groups (2.6% liberal vs. 4.9% strict, p = 0.14). UTI also occurred infrequently (2.8% overall, 2.6% liberal vs. 2.9% strict, p= 0.86). Similar results were seen specifically among those that underwent MIS: POUR (3.7% overall, 2.8% liberal vs. 5.3% strict, p= 0.17) and UTI (3.3% overall, 2.4% liberal vs. 4.7% strict, p= 0.28). Median length of stay (IQR) was much shorter for MIS patients with a liberal voiding protocol (median 15 hours overall (IQR 15 hours), 9 (4) liberal vs. 36 (34) strict, p<0.01). Among those discharged same-day (72.6% of MIS cases), patients with a liberal voiding protocol had a significantly shorter LOS than those with strict (mean (SD) 9.4 (2.5) hours vs. 10.6 (35) hours, p<0.01). Postoperative complications occurred less frequently among those with MIS procedures (11.8% in MIS vs 20.2% in laparotomies, p<0.01), as well as those with liberal voiding protocols (11.2% liberal vs 16.9% strict p=0.04).
Conclusion:
Overall, POUR occurs infrequently after major benign gynecologic surgery and does not differ among those with a liberal and a strict voiding protocol. Our data suggest same-day discharge after MIS hysterectomy and myomectomy without a requirement to void does not increase the risk of POUR and shortens LOS. Eliminating voiding protocols after these procedures may facilitate greater efficiency in the post-anesthesia recovery unit (PACU) and may contribute to Enhanced Recovery After Surgery (ERAS) protocols.
Keywords: Urinary retention, Hysterectomy, Myomectomy, Laparoscopy, Same-day discharge, Minimally Invasive Surgery
Precis
Postoperative urinary retention is infrequent after benign gynecologic surgery and similar among those with a strict voiding protocol and those discharged with no voiding requirement.
Introduction
Postoperative urinary retention (POUR) occurs when patients are unable to void after surgery. The reasons for this complication are multifactorial, including the effects of general anesthesia on detrusor activity (1) and medications used perioperatively, including opioids (2). Patients undergoing pelvic surgery are at particular risk for POUR, likely due to manipulation of tissue and nerves near the genitourinary system (3–5). Although the treatment for POUR is relatively benign (re-catheterization and bladder rest) re-placing a foley catheter is uncomfortable, inconvenient, increases the risk of urinary tract infection (UTI), and slows recovery through decreased mobility.
With increased use of minimally invasive surgery (MIS) for gynecologic operations (6, 7) and implementation of enhanced recovery after surgery (ERAS) protocols (8), same-day dischargeis becoming common, even for what are considered major operations such as hysterectomy and myomectomy (7, 9–11). Same-day discharge has multiple benefits for patients and health care systems, but concerns around re-admission remain an impediment to implementation (12). POUR is of particular concern because the emergent problem (a full bladder with inability to void) may not be apparent for many hours following surgery. Rates of POUR following MIS in the gynecology literature vary considerably, from less than 1% to more than 20% (1, 13–17), partly due to variation in definition, protocol, and type of procedure.
Historically, patients after MIS were admitted overnight and given a voiding trial in the morning. With same-day discharge, many surgeons remove the catheter in the operating room or post-anesthesia recovery unit (PACU) and require successful void prior to discharge. Bedside ultrasounds (bladder scans) are often employed to evaluate bladder volume, either to determine if there is sufficient volume to prompt an urge to void, or to evaluate post-void residual volume. Lastly, some advocate active voiding trials when a set volume of sterile fluid (e.g. 300mL normal saline) is instilled retrograde through a catheter into the bladder and the catheter removed. The patient then voids into a graduated hat and is considered to have passed the trial if the majority of instilled fluid (e.g. 200mL) is evacuated. Active voiding trials, compared to passive trials, are more accurate and preferred by patients (18, 19).
These voiding protocols are meant to mitigate the risks associated with prolonged POUR, including detrusor dysfunction and, in severe cases, bladder rupture. Our practice, however, includes no requirement to void prior to discharge after MIS and no set time limit before further evaluation; we simply let patients urinate when the urge arises and instruct them to call or represent if they sense the bladder feels completely full but can’t empty. Using this liberal voiding protocol, our impression has been that POUR happens infrequently and abandoning a requirement to void prior to discharge shortens and simplifies PACU care. This presumption, however, has not been formally investigated. A recent comprehensive review, in fact, specifically recommends against the use of a liberal voiding protocol because of the risk of POUR (20). We hypothesized that the risk of POUR is acceptably low with the liberal voiding protocol and has similar outcomes to more strict protocols.
Materials and Methods
In a retrospective study, we assessed the risk of POUR after major MIS benign gynecologic surgery (hysterectomy and myomectomy), comparing a liberal voiding protocol (no requirement to void prior to discharge) to more strict voiding protocols. Although our primary focus was on MIS procedures, we included laparotomies as a comparison group to better define the risk of POUR in our population overall. Secondary outcomes included length of hospital stay (LOS) and UTI. Approval was obtained from the Institutional Review Board at Cedars-Sinai (Protocol 54192).
All hysterectomies and myomectomies performed for benign indications at Cedars-Sinai from August 2017 through July 2018 were reviewed. Cases involving incontinence operations, correction of pelvic organ prolapse, malignancy, or peripartum hysterectomy were excluded. POUR, defined as the need for re-catheterization within 24 hours of catheter removal, along with UTI and LOS, were compared between liberal and strict voiding protocols. A patient was considered to have UTI if she had symptoms and was treated with antibiotics. “Strict” protocols included any requirement to void prior to discharge, including active and passive voiding trials. Patients in the liberal voiding group were not actively called for assessment of voiding at home nor were given a specific time limit for voiding but were instructed to call the office or answering service if they experienced a full bladder or urge to void but were unable. Sub-group analysis was performed for those undergoing MIS. All patients had general anesthesia for their operations.
Variables collected through direct abstraction from the electronic medical record included basic demographic information, including age, body mass index (BMI), race, smoking status, diabetes, immunosuppression, history of vaginal delivery, number of prior abdominal surgeries, menopausal status, indication for the index surgery (e.g. uterine fibroids, abnormal uterine bleeding, pelvic pain, etc.). Operative variables included surgery type (hysterectomy vs. myomectomy, laparotomy vs. laparoscopy), surgeon, specimen weight, number of myomas removed (myomectomy cases only), need for significant adhesiolysis (enterolysis, ureterolysis), presence of deeply infiltrating endometriosis, whether cystoscopy was performed, estimated blood loss (EBL), total OR time (wheels in to wheels out), surgery time (skin incision to close), intraoperative complications, and day of catheter removal. Postoperative variables collected included POUR, UTI, postoperative complications as measured by the Dindo-Clavien classification (21), and 30-day re-admission.
Standard descriptive summaries were used to describe baseline and demographic characteristics (e.g. means and standard deviations for continuous variables such as age, and frequencies and percentages for categorical variables such as smoking status). Unadjusted outcomes were compared using parametric and non-parametric tests for categorical (e.g. POUR, UTI) and continuous (e.g. LOS) outcomes as appropriate. Regression analysis was used to control for potential confounders. Variables were considered confounders if they were different between groups and associated with the outcome.
A previous study conducted with analysis of patients undergoing laparoscopic hysterectomy at Cedars-Sinai demonstrated a baseline risk of 10% for POUR (22). Assuming beta of 80%, alpha of 5%, 400 subjects would be needed to detect a 10% difference in POUR (either increase or decrease) between the liberal voiding protocol group and the strict voiding protocol group.
Results
303 (46.5%) women underwent surgery with a liberal postoperative voiding protocol and 349 (53.5%) with a strict voiding protocol. Women in the strict voiding protocol group were older and more likely to be menopausal; otherwise baseline characteristics were similar (Table 1). Of the 652 procedures, 439 were hysterectomies and 213 myomectomies (Table 2). Seventy-eight percent of hysterectomies and 45% of myomectomies were performed minimally invasive (laparoscopic, robotic, or vaginal). Uterine fibroids, abnormal uterine bleeding, and pelvic pain were the most common indications for surgery.
Table 1.
Demographic/Patient Characteristics by Voiding Protocol
| Liberal Voiding Protocol | Strict Voiding Protocol | p-value | |
|---|---|---|---|
| N = 303 (46.5%) | N = 349 (53.5%) | ||
| Age, Mean (SD) | 43.0 (8.3) | 46.2 (10.4) | <0.001 |
| BMI (kg/m2), Mean (SD) | 26.8 (6.5) | 26.9 (6.4) | 0.87 |
| Race/Ethnicity | |||
| White | 151 (49.8%) | 148 (42.4%) | 0.27 |
| Black | 63 (20.8%) | 91 (26.1%) | |
| Asian | 33 (10.9%) | 45 (12.9%) | |
| Latina | 46 (15.2%) | 57 (16.3%) | |
| Other | 10 (3.3%) | 8 (2.3%) | |
| Ever smoker | 17 (5.6%) | 15 (4.3%) | 0.44 |
| Diabetes | 6 (2.0%) | 14 (4.0%) | 0.13 |
| Immunosuppression | 10 (3.3%) | 7 (2.0%) | 0.30 |
| No. vaginal deliveries, Median (IQR) | 0 (1) | 0 (1) | 0.60 |
| No. previous abdominal surgeries, Median (IQR) | 0 (1) | 0 (1) | 0.87 |
| Postmenopausal | |||
| Not menopausal | 269 (88.8%) | 277 (79.4%) | <0.01 |
| Menopausal, no HRT | 26 (8.6%) | 54 (15.5%) | |
| Menopausal, uses HRT | 8 (2.6%) | 18 (4.2%) |
Table 2.
Surgical Details by Voiding Protocol
| MIS procedures | Laparotomies | |||||
|---|---|---|---|---|---|---|
| Liberal | Strict | p-value | Liberal | Strict | p-value | |
| N = 289 (63%) | N = 170 (37%) | N = 14 (7%) | N = 179 (93%) | |||
| Indication for surgery | ||||||
| Fibroids | 202 (69.9%) | 78 (45.9%) | <0.01 | 12 (85.7%) | 161 (89.9%) | 0.62 |
| Abnormal uterine bleeding | 136 (47.1%) | 85 (50.0%) | 0.54 | 6 (42.9%) | 102 (57.0%) | 0.40 |
| Pelvic pain | 102 (35.3%) | 41 (24.1%) | 0.01 | 5 (35.7%) | 66 (36.9%) | 1.00 |
| Endometriosis | 43 (14.9%) | 14 (8.2%) | 0.04 | 2 (14.3%) | 2 (6.7%) | 0.29 |
| Other | 60 (20.8%) | 72 (42.4%) | <0.01 | 1 (7.1%) | 27 (15.1%) | 0.70 |
| Surgery type | ||||||
| VH | 8 (2.8%) | 3 (1.8%) | ||||
| LAVH | 4 (1.4%) | 12 (7.1%) | ||||
| TLH | 158 (54.7%) | 116 (68.2%) | ||||
| LSH | 14 (4.8%) | 18 (10.6%) | ||||
| R-TLH | 0 (0.0%) | 7 (4.1%) | ||||
| R-LSH | 0 (0.0%) | 1 (0.6%) | ||||
| TAH | 2 (15.4%) | 69 (38.6%) | ||||
| ASH | 0 (0.0%) | 27 (15.1%) | ||||
| LM | 104 (36.0%) | 11 (6.5%) | ||||
| RM | 1 (0.4%) | 2 (1.2%) | ||||
| AM | 12 (85.7%) | 83 (46.4%) | ||||
| High-volume surgeon* | 272 (94.1%) | 131 (77.1%) | <0.01 | 12 (85.7%) | 84 (46.9%) | <0.01 |
| Specimen weight (grams), Median (IQR) | 164 (248) | 162 (264) | 0.48 | 251 (420) | 476 (644) | 0.07 |
| No. myomas removed (myomectomies only), Median (IQR) | 1 (3) | 1 (2) | 0.05 | 12 (22) | 3 (11) | 0.02 |
| Need for significant adhesiolysis | 51 (17.7%) | 32 (18.8) | 0.75 | 4 (28.6%) | 33 (18.4%) | 0.48 |
| Deeply infiltrating endometriosis | 22 (7.6%) | 6 (3.5%) | 0.11 | 1 (7.1%) | 3 (1.7%) | 0.26 |
| Cystoscopy performed | 74 (25.7%) | 45 (26.5%) | 0.86 | 0 (0%) | 5 (2.8%) | 1.00 |
| Estimated blood loss, mL, Mean (SD) | 79(148) | 124 (192) | <0.01 | 234 (201) | 283 (311) | 0.92 |
| Total OR time (min), Mean (SD) | 158 (80) | 179 (95) | <0.01 | 182 (78) | 159 (67) | 0.36 |
| Surgery time (min), Median (IQR) | 109 (73) | 127 (89) | <0.01 | 136 (73) | 112 (63) | 0.26 |
| Intraoperative complications | ||||||
| Grade 0 | 285 (98.6%) | 152 (89.4%) | <0.01 | 13 (92.9%) | 171 (95.5%) | 0.50 |
| Grades1–4 | 4 (1.4%) | 18 (10.6%) | 1 (7.1%) | 8 (4.5%) | ||
| Postoperative complications | ||||||
| Grade 0 | 260 (90.0%) | 145 (85.3%) | 0.13 | 9 (64.3%) | 145 (81.0%) | 0.16 |
| Grades1–5 | 29 (10.0%) | 25 (14.7%) | 5 (35.7%) | 34 (19.0%) | ||
| 30-day readmission | 5 (1.7%) | 5 (2.9%) | 0.51 | 1 (7.1%) | 6 (3.4%) | 0.42 |
high-volume surgeon = more than 10 cases in 12 months
Of the 459 patients who underwent MIS procedures, 289 (63%) had a liberal voiding protocol and 170 (37%) had a strict voiding protocol. High-volume surgeons (more than 10 cases in 12 months) were more likely to employ a liberal voiding protocol.
Overall, the incidence of POUR was low at 3.8% and not different among groups (2.6% liberal vs. 4.9% strict, p = 0.14). UTI also occurred infrequently (2.8% overall, 2.6% liberal vs. 2.9% strict, p= 0.86). Similar results were seen specifically among those that underwent MIS: POUR (3.7% overall, 2.8% liberal vs. 5.3% strict, p= 0.17) and UTI (3.3% overall, 2.4% liberal vs. 4.7% strict, p= 0.28). Median LOS was much shorter for MIS patients with a liberal voiding protocol (median 15 hours overall (IQR 15 hours), 9 (4) liberal vs. 36 (34) strict, p<0.01). Among those discharged same-day (72.6% of MIS cases), patients with a liberal voiding protocol had a significantly shorter LOS than those with strict (mean (SD) 9.4 (2.5) hours vs. 10.6 (35) hours, p<0.01). Postoperative complications occurred less frequently among those with MIS procedures (11.8% in MIS vs 20.2% in laparotomies, p<0.01), as well as those with liberal voiding protocols (11.2% liberal vs 16.9% strict p=0.04). Table 3 summarizes the management of POUR for whom full details were available in the medical record.
Table 3.
Summary of patients with POUR
| Procedure | Time out of OR | POD* catheter removal | Voiding protocol | Details and management of POUR |
|---|---|---|---|---|
| TLH | 1000 | 0 | Strict | Unable to void 6h after foley removed, bladder scan >400 mL, straight cath 1530 700mL. Foley replaced overnight, removed 0400 POD1, able to void spontaneously after that. |
| TLH | 1630 | 0 | Strict | Unable to void PACU or floor, straight cath at 0000 for 600mL. Could not void 0900 POD1, foley replaced. Removed POD2 and able to void spontaneously after that. |
| TLH | 1000 | 0 | Strict | Unable to void 6h after foley removed, bladder scan 500mL. Foley replaced and removed 0500 POD1, voided spontaneously after that. |
| TLH | 0900 | 0 | Liberal | Patient had severe pain and urge to void but unable at 1230, bladder scan > 1L, foley replaced for 2200mL. Discharged home with leg bag and self-removed POD2, able to void spontaneously after that. |
| LAVH | 1100 | 0 | Strict | Patient with minimal voiding as of 2100, felt fullness, bladder scan 500mL, straight cath for 850mL. Voiding POD1, but with bladder scans >150mL, so discharged home with leg bag. Removed POD6 and voided spontaneously after that. |
| TLH | 1100 | 0 | Strict | Had episode of hypotension after narcotic administration. Bedside ultrasound to look for bleeding noted full bladder. Patient unable to ambulate to void so straight cath for 450mL, able to void spontaneously after that. |
| TLH | 1800 | 0 | Strict | Foley replaced at 0000. Removed 1200 POD1. Able to void spontaneously several times after that with PVR** <100mL. |
| TLH | 1000 | 0 | Strict | Unable to void at 1600 and admitted for retention, foley replaced. Plan was to keep overnight to POD1 but patient wanted foley out evening POD0 and was able to void spontaneously after that. |
| TLH | 1800 | 0 | Strict | Unable to void in PACU and admitted for retention. Straight cath at 0030 for 600mL. Could not void morning POD1, foley replaced. Plan was to send home with leg bag but patient wanted another voiding trial and passed POD2. |
| VH | 1000 | 0 | Strict | Unable to void at 1400, bladder scan 390mL, foley replaced for 400mL and admitted for retention. Foley removed POD2 and voided spontaneously after that. |
| TLH | 1900 | 0 | Liberal | At 0030 had urge to void but unable, bladder scan 371mL, straight cath for 700mL. Voided spontaneously at 0300. |
| TLH | 2000 | 0 | Liberal | Foley removed in OR, Couldn’t get out of bed to void due to vertigo at 0200, foley replaced. Foley removed next day and able to void. |
| LSH | 1930 | 0 | Strict | Foley removed 2000. Unable to void 0400, straight cath for 300mL, able to void spontaneously after that and discharged. |
| TLH | 1800 | 0 | Strict | Failed voiding trial 0000, foley placed for 800mL. Foley out 0600 POD1 and able to void spontaneously with bladder scan PVR<100mL multiple times. |
| TLH | 1400 | 0 | Strict | Foley removed 2000. Failed voiding trial 0200, bladder scan 340mL, foley replaced and then removed 0600. Unable to void 1200, bladder scan 350–400mL, foley replaced again and patient discharged with leg bag with successful voiding trial in three days. |
| TLH | 1030 | 0 | Liberal | Discharged POD0. Felt urge but unable to void and presented to ED 0030. Foley replaced for 600mL. Removed foley at home 48 hours later and able to void spontaneously after that. |
| LSH | 1030 | 0 | Liberal | Patient discharged POD0. Re-presented POD1 with retention, foley replaced and then removed at home 48 hours later and able to void spontaneously after that. |
| AM, converted to TAH | 1400 | 1 | Strict | Unable to void POD1 and straight cath for 550mL. Able to void spontaneously after that. |
| TAH | 1000 | 0 | Strict | Per patient request, foley removed POD0 1400. Straight cath at 2130 but oliguric rather than retention. Foley replaced POD1 for better monitoring of ins and outs. Foley removed POD2 and able to void spontaneously after that. |
| AM | 1600 | 0 | Strict | Foley out 2200, initially voided but then felt pressure at 0200 and unable to void. Bladder scan 300mL, straight cath for 875mL, voided spontaneously after that. |
| AM | 0900 | 0 | Strict | Foley removed 2200. Complained of fullness 0200, bladder scan 700mL, straight cath for 1100mL. Couldn’t void 0600, bladder scan 400mL, new foley 450mL. Foley removed again later POD1 and able to void spontaneously after that. |
| AM | 0900 | 1 | Strict | Foley out 0600 POD1. Unable to void, straight cath at 1200. 1800 unable to void, bladder scan 400mL, foley replaced. Foley out 0600 POD2, replaced 1200. Discharged home with leg bag POD3. Presented to ED with UTI POD4, had active voiding trial (200mL instilled and 120mL voided) and able to void spontaneously after that. |
| TAH | 1830 | 1 | Strict | Foley removed AM POD1, initially voided spontaneously, had straight cath middle of the day, then able to void spontaneously after that. |
| ASH | 1000 | 0 | Strict | Unable to void 1500, straight cath. Unable to void at 2300, foley replaced. Foley removed POD1 and able to void spontaneously after that. |
| ASH | 1430 | 1 | Strict | Foley removed 0600 POD1. Required straight cath later POD1 and able to void spontaneously after that. |
| AM | 1600 | 0 | Liberal | Foley removed 2100 and voided initially. At 0200 felt pressure, bladder scan 300mL, straight cath 875mL. Voided spontaneously after that. |
| ASH | 1800 | 1 | Strict | Unable to void 6h after foley removed, bladder scan 500mL, foley replaced. Removed 1530 POD2, failed TOV again, foley replaced again. Patient remained in hospital and foley removed again POD5, able to void spontaneously after that. |
POD = postoperative day;
PVR = post-void residual
After adjusting for potential confounders (age, postoperative complications, menopause), there remained no difference in the incidence of POUR between liberal and strict protocols for all patients, as well as those who underwent MIS. Among MIS patients, LOS was associated with surgery time—for every one-minute increase in surgery time, there was a corresponding minute increase in LOS. A liberal voiding protocol remained independently associated, with an average 1.6 hours reduction in LOS after adjusting for surgery time.
Discussion
POUR was uncommon in this cohort of women who underwent hysterectomy and myomectomy, and not different among patients who were required to void before discharge and those who were sent home with no requirement to void. A liberal voiding protocol resulted in a shorter LOS, including in those discharged same-day after MIS.
Our results demonstrate a significantly lower rate of POUR after gynecologic surgery than others (13–16), though all of these differ in standards for defining POUR, including strict time cut-offs and measurement of bladder volume after voiding. Few data exist on the rate of POUR with no voiding protocol at all, although a recent manuscript examining immediate versus delayed catheter removal after laparoscopic hysterectomy demonstrated that the majority of women who are unable to void at six hours postop are able to do so by nine hours without additional intervention (23). A previous study from our institution examined voiding protocols, but was limited by only assessing re-admission. Also, we separated patients by whether there was an electronic order to void before discharge, not necessarily reflective of actual practice (24). The data presented here add to the literature on the risk of urinary retention, including the addition that simply allowing patients to void on their own schedule rarely leads to representation.
These data suggest that we may intervene for potential urinary retention too quickly after gynecologic surgery. There were too few patients in the laparotomy group who were provided a liberal voiding protocol to make conclusions, but the low risk of POUR in open procedures suggests we may be unnecessarily providing bladder scans or re-catheterizing inpatients at six hours, even after open surgery. More importantly, patients undergoing gynecologic MIS can be safely discharged the day of surgery with the simple instruction to call if they feel the bladder is full and cannot be spontaneously emptied. This practice shortens time in recovery, eliminating unnecessary testing and work for surgeons and recovery staff. The safety of same-day discharge after gynecologic laparoscopy is well-established, but assessing voiding status can bottle-neck the PACU and urinary retention is the most common reason for admission after planned outpatient gynecologic procedures when strict protocols are used (12). Other strategies, such as actively filling the bladder at the end of surgery, reduces the time to void, but not LOS (25). Removing a requirement to void could increase both OR efficiency and patient satisfaction.
Our findings on the safety of liberal voiding protocol after gynecologic surgery would be bolstered by a prospective study examining more completely time spent and subjective patient experience in recovery through a randomized trial. If safety data were replicated and a trial supported the observation that no requirement to void decreased time in recovery without a reduction in patient satisfaction, it would strengthen the suggestion that a liberal voiding protocol should be incorporated into ERAS protocols after gynecologic surgery. As an iterative process, ERAS is continually examined for refinements in its protocols, and our data suggest a simpler evaluation of voiding may be helpful for gynecologic surgery. Investigating other populations in gynecology and other surgical services would be valuable as well. In addition, providing a longer duration for a trial of void after laparotomy may be another avenue worthy of investigation.
A strength of the study is its large size, adequately powered to detect a difference in our primary outcome. The diversity of patients and surgeons of various backgrounds and experience add to the generalizability of our findings. We chose to limit our sample to only those undergoing hysterectomies and myomectomies, suspecting out of clinical experience that the risk of POUR after more minor gynecologic procedures would be similar or lower. By excluding prolapse, incontinence, and cancer operations, we are unable to extrapolate the risk of POUR among patients undergoing these gynecologic procedures. Perhaps because the incidence of POUR was so low, we were unable to identify any specific risk factors (e.g. blood loss, duration of surgery) that would suggest certain patients would benefit from stricter assessment of voiding before discharge. Our findings may underestimate the risk of POUR by not including a more objective measure such as a time cut-off of six hours or precise measurement of post-void residual. We chose to define POUR as the need for re-catheterization, however, because it seemed to be the most clinically meaningful measure. In addition, although most patients have all of their care documented in a system-wide electronic health record, some patients could have presented to private offices and been managed outpatient, and thus some outcome events could have been missed in data abstraction. Lastly, we chose to compare no voiding protocol to all other methods of assessing voiding, including active and passive voiding trials. We chose this comparison because practice patterns are so diverse. There could be differences among the various more “strict” protocols, but, regardless, our data clearly show the safety of discharging patients without formally assessing voiding.
Conclusions
The risk of urinary retention may be lower than previously reported if defined as the need to re-catheterize. Particularly in MIS patients, a liberal voiding protocol seems to facilitate the efficiency of same-day discharge with a low risk for re-presentation for POUR.
Funding:
This research was supported by NIH National Center for Advancing Translational Science (NCATS) UCLA CTSI Grant Number UL1TR001881. The sponsor assisted in design of the study and abstraction of data.
Footnotes
Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Disclosure statement: Dr. Siedhoff has served as a consultant for Applied Medical, Eximis Surgical, Hologic, Caldera Medical, Cooper Surgical, and Olympus. Dr. Wright has served as a consultant for Applied Medical, Caldera Medical, Hologic, and Karl Storz. The authors report no relevant conflict of interest.
These data were accepted for presentation at the Society of Gynecologic Surgeons 46th Annual Scientific Meeting which was to be held March 29-Apr 1, 2020, in Jacksonville FL. This meeting has been postponed to July 6–9 due to the COVID-19 pandemic, but SGS is currently reviewing whether it will be postponed again, moved online, or canceled.
Approval was obtained 11/17/2018 from the Institutional Review Board at Cedars-Sinai (Protocol 54192).
The data generated and analyzed during the current study are available from the corresponding author upon reasonable request.
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