Key Points
Question
What is the effect of intraoperative urinary catheters on urinary retention after laparoscopic inguinal hernia repair?
Findings
In this randomized clinical trial, there were no stastistically significant differences in postoperative urinary retention rates between the catheter and no-catheter groups.
Meaning
Intraoperative urinary catheters did not reduce the risk of postoperative urinary retention during laparoscopic inguinal hernia repair and thus their use may be reconsidered.
This randomized clinical trial evaluates the effect of intraoperative catheter use on urinary retention following laparoscopic inguinal hernia repair.
Abstract
Importance
Urinary catheters are commonly placed during laparoscopic inguinal hernia repair as a presumed protection against postoperative urinary retention (PUR), one of the most common complications following this operation. Data from randomized clinical trials evaluating the effect of catheters on PUR are lacking.
Objective
To investigate the effect of intraoperative catheters on PUR after laparoscopic inguinal hernia repair.
Design, Setting, and Participants
This 2-arm registry-based single-blinded randomized clinical trial was conducted at 6 academic and community hospitals in the US from March 2019 to March 2021 with a 30-day follow-up period following surgery. All patients who presented with inguinal hernias were assessed for eligibility, 534 in total. Inclusion criteria were adult patients undergoing laparoscopic, elective, unilateral, or bilateral inguinal hernia repair. Exclusion criteria were inability to tolerate general anesthesia and failure to understand and sign the written consent form. A total of 43 patients were excluded prior to intervention.
Interventions
Patients in the treatment arm had placement of a urinary catheter after induction of general anesthesia and removal at the end of procedure. Those in the control arm had no urinary catheter placement.
Main Outcomes and Measures
PUR rate.
Results
Of the 491 patients enrolled, 241 were randomized to catheter placement, and 250 were randomized to no catheter placement. The median (IQR) age was 61 (51-68) years, and 465 participants (94.7%) were male. Overall, 44 patients (9.1%) developed PUR. There was no difference in the rate of PUR between the catheter and no-catheter groups (23 patients [9.6%] vs 21 patients [8.5%], respectively; P = .79). There were no intraoperative bladder injuries. In the catheter group, there was 1 incident of postoperative urethral trauma in a patient who presented to the emergency department with PUR leading to a suprapubic catheter placement.
Conclusions and Relevance
Intraoperative urinary catheters did not reduce the risk of PUR after laparoscopic inguinal hernia repair. While their use did not appear to be associated with a high rate of iatrogenic complications, there may be a low rate of catastrophic complications. In patients who voided urine preoperatively, catheter placement did not appear to confer any advantage and thus their use may be reconsidered.
Trial Registration
ClinicalTrials.gov Identifier: NCT03835351
Introduction
Urinary catheters are commonly used intraoperatively during laparoscopic inguinal hernia repair and are thought to be protective against postoperative urinary retention (PUR) and perhaps bladder injury as well. However, this intervention is not entirely benign and may cause catheter-related infections, urethral trauma, prostatitis, and patient discomfort.1,2 This practice seems to be based on surgical dogma rather than evidence and, to our knowledge, no prospective study has been performed to determine if catheters confer any clinical benefit intraoperatively or postoperatively. This is an important question with broad implications given the commonality of inguinal hernia repairs, with over 20 million procedures performed worldwide each year.3
PUR is a well-known complication after laparoscopic inguinal hernia repair, with a reported incidence ranging from 1% to 22%.2,4,5 Defined as the failure of spontaneous voiding of urine after surgery requiring urinary catheterization, PUR has been associated with increased length of stay, cost, urinary tract infections, and decreased patient satisfaction.6 This study investigated the effect of intraoperative catheters on PUR, which is one of the most common complications after laparoscopic inguinal hernia repair. We hypothesized that catheter use would significantly reduce the rate of PUR compared with no catheter use. Intraoperative complications and complications associated with catheterization were also studied.
Methods
Study Design and Participants
This study was a 2-arm registry-based single-blinded randomized clinical trial with a treatment (catheter) to control (no catheter) allocation ratio of 1:1. This was a multi-institution study performed at 6 academic and community hospitals in the US with 11 participating surgeons. Institutional review board approval was obtained before initiating enrollment, and the Consolidated Standards of Reporting Trials (CONSORT) reporting guideline was followed. Written informed consent was obtained from all participants.
All patients who presented with inguinal hernias from March 2019 to March 2021 were screened. Inclusion criteria were adult patients (18 years and older) undergoing laparoscopic, elective, unilateral, or bilateral inguinal hernia repair for primary or recurrent inguinal hernias previously repaired in an open fashion. Patients with benign prostatic hyperplasia (BPH), defined for the purposes of this study as having a diagnosis and undergoing medical treatment, were also included in the study. BPH was initially an exclusion criterion; however, after enrolling the first patient, we amended the protocol to include patients with BPH to improve the generalizability of our results, and the first patient was included in the final analysis. Exclusion criteria were inability to tolerate general anesthesia and failure to understand and sign the written consent form. Consent was acquired by the participating surgeons or the study coordinators. The Abdominal Core Health Quality Collaborative, a hernia-specific nationwide registry, served as the primary platform for data collection. Details regarding the Abdominal Core Health Quality Collaborative and registry structure, governance, and data assurance process have been previously reported.7 Supplemental data not captured by the Abdominal Core Health Quality Collaborative were prospectively recorded in a Research Electronic Data Capture database.
Interventions and Surgical Procedure
This study had 2 arms. Patients in the treatment arm had placement of a urinary catheter after induction of general anesthesia using a standard catheterization kit. Those in the control arm had no urinary catheter placement.
All patients were asked to void urine in the preoperative area before going into the operating room. Antibiotic prophylaxis, hair removal, and skin preparation were performed per Surgical Care Improvement Project protocol guidelines.8 Following induction of general anesthesia, participants were randomized by a study coordinator to the treatment or control arm. Inguinal hernia repairs were performed using the transabdominal preperitoneal technique or totally extraperitoneal technique at the discretion of the operating surgeon. For participants randomized to the intervention arm, the catheter was removed at the end of the procedure before emergence from general anesthesia. All participants remained blinded throughout the study period. Anesthetic management, intraoperative fluids, and postoperative emergence were not standardized and were based on local care pathways and recorded in a Research Electronic Data Capture database.
Outcomes
The primary outcome was postoperative urinary retention, defined as failure to void urine requiring straight catheterization, placement of an indwelling catheter, or return to the emergency department owing to inability to void urine after discharge from the hospital up to 30 days postoperatively.4,5 The decision and timing of the bladder scan and specific criteria for placement of urinary catheters were determined by the standard practices of each institution and the surgeon. Secondary outcomes included bladder injuries, urinary tract infections, and urinary tract injuries at the time of the procedure or postoperatively.
Sample Size and Randomization
Previous publications9 have reported a urinary retention rate of 7.5% when no urinary catheters were used. We surveyed the surgeons at each institution included in the trial to determine which ones routinely used Foley catheters. We analyzed the available data from the Abdominal Core Health Quality Collaborative registry for those surgeons with routine Foley use and determined that the PUR rate for patients receiving catheters was 2%. We powered the study to detect a 5.5–percentage point decrease in the rate of PUR for the Foley group vs the control group. At 80% power while holding type I error at 5%, 444 participants (222 per arm) were required. Accounting for a 10% loss to follow-up at 30 days, the estimated sample size was 488 patients, 244 per arm. Patients were randomized consecutively by a study coordinator using a concealed randomization scheme, which was housed in Research Electronic Data Capture. A random block generator with a 1:1 ratio was used to assign patients to each arm.
Statistical Analysis
Data were described using medians with IQRs or means with SDs for continuous variables and counts with percentages for categorical variables. Pairwise comparisons were made by adjusting the α level with the Bonferroni method. Patients who developed PUR were analyzed using multivariate logistic regression to identify independent predictors, which were identified using the participating surgeons’ clinical judgment. A post hoc exploratory analysis was also performed to determine the rates of urinary retention for those patients identified as high risk based on catheter usage. All analyses were performed with 2-tailed tests using R version 3.5.3 (The R Foundation). P < .05 was considered significant.
Results
Of 496 patients enrolled, 5 were lost to follow-up, 2 in the catheter group and 3 in the no-catheter group. Of 491 patients randomized, 241 had urinary catheter placement, and 250 had no catheter placement (Figure). Patient demographic and hernia characteristics are shown in Table 1. The median (IQR) age was 61 (51-68) years, and 465 participants (94.7%) were male. Median (IQR) body mass index was 26.1 (23.6-28.6), and 85 patients (17.3%) had BPH. Most patients had unilateral inguinal hernias (182 [37.1%] right side and 116 [23.6%] left side), and 193 (39.3%) had bilateral inguinal hernias. A scrotal component was present in 58 individuals (11.8%).
Figure. Flow Diagram.
Table 1. Patient Demographic and Hernia Characteristics.
| Characteristic | No. (%) | ||
|---|---|---|---|
| All | Catheter | No catheter | |
| No. | 491 | 241 | 250 |
| Age, median (IQR), y | 61 (51-68) | 61 (52-68) | 62 (49-69) |
| Sex | |||
| Female | 26 (5.3) | 9 (3.7) | 17 (6.8) |
| Male | 465 (94.7) | 232 (96.3) | 233 (93.2) |
| BMI, median (IQR) | 26.1 (23.6-28.6) | 26.2 (23.7-28.6) | 26.0 (23.5-28.5) |
| BPH | 85 (17.3) | 42 (17.4) | 43 (17.2) |
| Use of diuretic medication | 43 (8.8) | 17 (7.1) | 26 (10.4) |
| Prior prostate procedures | 13 (2.7) | 5 (2.1) | 8 (3.2) |
| Prior pelvic operation | 17 (3.5) | 8 (3.3) | 9 (3.6) |
| Diabetes | 24 (4.9) | 11 (4.6) | 13 (5.2) |
| Smoking | 33 (6.7) | 18 (7.5) | 15 (6.0) |
| COPD | 4 (0.8) | 4 (1.7) | 0 |
| Hypertension | 172 (35.0) | 84 (34.9) | 88 (35.2) |
| ASA classification | |||
| 1 | 64 (13.0) | 33 (13.7) | 31 (12.4) |
| 2 | 289 (58.9) | 142 (58.9) | 147 (58.8) |
| 3 | 135 (27.5) | 65 (27.0) | 70 (28.0) |
| 4 | 3 (0.6) | 1 (0.4) | 2 (0.8) |
| Hernia laterality | |||
| Bilateral | 193 (39.3) | 107 (44.4) | 86 (34.4) |
| Left | 116 (23.6) | 53 (22.0) | 63 (25.2) |
| Right | 182 (37.1) | 81 (33.6) | 101 (40.4) |
| Component | |||
| Indirect | 382 (77.8) | 179 (74.3) | 203 (81.2) |
| Direct | 253 (51.6) | 140 (58.3) | 113 (45.2) |
| Femoral | 41 (8.4) | 17 (7.1) | 24 (9.6) |
| Obturator | 4 (0.8) | 2 (0.8) | 2 (0.8) |
| Scrotal | 58 (11.8) | 24 (10.0) | 34 (13.6) |
| Recurrent inguinal hernia | 48 (9.8) | 23 (9.5) | 25 (10) |
Abbreviations: ASA, American Society of Anesthesiologists; BMI, body mass index; BPH, benign prostatic hyperplasia; COPD, chronic obstructive pulmonary disease.
Intraoperative details, length of stay, and intraoperative complications are outlined in Table 2. Total extraperitoneal was the most common technique (352 [71.7%]), with the remainder of the hernias repaired using the transabdominal preperitoneal approach (139 [28.3%]; P = .34). The median (IQR) operative time was 73 (57-94) minutes, and all operations were performed under general anesthesia. Preformed mesh was the most commonly used prosthetic (384 [77.6%]), followed by flat polypropylene mesh (102 [20.4%]). A higher volume of intravenous crystalloids was infused intraoperatively in the catheter group (1100 mL vs 1000 mL; P < .001).
Table 2. Intraoperative Outcomes.
| Outcome | No. (%) | P value | ||
|---|---|---|---|---|
| All | Catheter | No catheter | ||
| No. | 491 | 241 | 250 | NA |
| Operative approach | ||||
| TAPP | 139 (28.3) | 63 (26.1) | 76 (30.4) | .34 |
| TEP | 352 (71.7) | 177 (73.9) | 174 (69.6) | |
| Converted to open | 3 (0.6) | 2 (0.8) | 1 (0.4) | .62 |
| Operative time, median (IQR), min | 73.0 (57.0-94.0) | 74.0 (59.0-94.0) | 72.0 (54.0-94.8) | .38 |
| General anesthesia | 491 (100) | 241 (100) | 250 (100) | NA |
| TAP block, yes | 2 (0.4) | 2 (0.8) | 0 | NA |
| Local anesthesia | 181 (36.9) | 89 (36.9) | 92 (36.8) | NA |
| Type of mesha | ||||
| Preformed | 384 (77.6) | 192 (78.8) | 192 (76.4) | .52 |
| Polypropylene | 102 (20.4) | 47 (19.2) | 55 (21.6) | |
| Other | 4 (0.8) | 1 (0.4) | 3 (1.2) | |
| Tack typeb | ||||
| Absorbable | 239 (49.5) | 119 (50.0) | 120 (49.0) | .89 |
| Permanent | 244 (50.5) | 119 (50.0) | 125 (51.0) | |
| No. of mesh tacks, median (IQR) | 4.0 (3.0-8.0) | 5.0 (3.0-8.0) | 4.0 (3.0-6.0) | .14 |
| No. of peritoneum tacks, TAPP, median (IQR) | 6.0 (6.0-8.0) | 6.0 (6.0-8.0) | 6.0 (6.0-8.0) | .23 |
| Volume of crystalloids, median (IQR), mL | 1000 (800-1300) | 1100 (900-1400) | 1000 (800-1200) | <.001 |
| Anticholinergic medication | 397 (81.0) | 196 (81.7) | 201 (80.4) | .81 |
| Wound status | ||||
| Clean | 490 (99.8) | 240 (99.6) | 250 (100) | .49 |
| Contaminated | 1 (0.2) | 1 (0.4) | 0 | |
| Intraoperative complication | 5 (1.0) | 4 (1.7) | 1 (0.4) | .21 |
| Bladder injury | 0 | 0 | 0 | NA |
| Urethral trauma | 1 (0.2) | 1 (0.4) | 0 | .49 |
| Hematuria | 4 (0.8) | 4 (1.7) | 0 | .06 |
| Intraoperative bleeding | 1 (0.2) | 0 | 1 (0.4) | .49 |
| Length of hospital stay, median (IQR), h | 4.0 (3.1-5.1) | 4.0 (3.2-5.2) | 3.9 (3.1-5.1) | .54 |
Abbreviations: NA, not applicable; TAP, transversus abdominis plane; TAPP, transabdominal preperitoneal; TEP, totally extraperitoneal.
Data missing for 1 patient.
Data missing for 8 patients.
Of 486 patients who completed follow-up, 44 (9.1%) developed PUR. There was no difference in the PUR rate between the catheter and no-catheter groups (23 patients [9.6%] vs 21 patients [8.5%], respectively, P = .79). PUR was most commonly diagnosed on the day of surgery before the patient was discharged from the hospital (27 patients [61.4%]), and it was most commonly treated with an indwelling catheter with discharge on the same day (30 patients [68.2%]) (Table 3). There was no difference in the timing of PUR diagnosis and treatment between the 2 groups. There were 4 unplanned reoperations in the no-catheter group, 2 for evacuation of hematoma, 1 to repair a port-site hernia, 1 for small-bowel obstruction. There were no intraoperative bladder injuries in this cohort. In the catheter group, there was 1 patient who presented with PUR to an emergency department where multiple attempts to place a urinary catheter were unsuccessful, ultimately requiring placement of a suprapubic catheter (1 vs 0; P = .49). For patients who developed PUR, an exploratory multivariate logistic regression analysis was performed (Table 4). Factors associated with developing PUR included intraoperative anticholinergic medications (odds ratio [OR], 3.53; 95% CI, 1.23-15.57; P = .04), presence of BPH (OR, 3.44; 95% CI, 1.66-7.10; P < .001), age older than 65 years (OR, 1.05; 95% CI, 1.02-1.09; P = .005), and lower volumes of crystalloids infused intraoperatively (OR, 0.90; 95% CI, 0.82-0.99: P = .03). A post hoc analysis of patients older than 65 years with BPH, those who received anticholinergic medications, and those who received more than 1100 mL of intraoperative fluids was also performed (eTable in Supplement 2). Urinary catheter use was not associated with decreased PUR in these groups.
Table 3. Postoperative Outcomes.
| Outcome | No. (%) | P value | ||
|---|---|---|---|---|
| All | Catheter | No catheter | ||
| No. | 486 | 239 | 247 | NA |
| Urinary retention | 44 (9.1) | 23 (9.6) | 21 (8.5) | .79 |
| Timing of urinary retention diagnosis | ||||
| Same day, before discharge | 27 (61.4) | 14 (60.9) | 13 (61.9) | .56 |
| Same day, after discharge | 6 (13.6) | 2 (8.7) | 4 (19.0) | |
| Any other day | 11 (25.0) | 7 (30.4) | 4 (19.0) | |
| Treatment of urinary retention | ||||
| Indwelling catheter and same day discharge | 30 (68.2) | 17 (73.9) | 13 (61.9) | .33 |
| Straight catheterization and same day discharge | 9 (20.5) | 3 (13.0) | 6 (28.6) | |
| Straight catheterization and admitted | 3 (6.8) | 1 (4.4) | 2 (9.5) | |
| Indwelling catheter and admission | 2 (4.6) | 2 (8.7) | 0 | |
| SSI | 1 (0.2) | 0 | 1 (0.4) | >.99 |
| SSOPI | 4 (0.8) | 1 (0.4) | 3 (1.2) | .62 |
| Unplanned readmission | 4 (0.8) | 1 (0.4) | 3 (1.2) | .62 |
| Unplanned reoperation | 4 (0.8) | 0 | 4 (1.6) | |
| Evacuation of hematoma | 2 (4.6) | 0 | 2 (9.5) | .12 |
| Repair of port site hernia | 1 (0.2) | 0 | 1 (0.4) | |
| Bowel obstruction | 1 (0.2) | 0 | 1 (0.4) | |
| Anemia requiring transfusion | 1 (0.2) | 1 (0.4) | 0 | .49 |
| Bowel obstruction | 2 (0.4) | 0 | 2 (0.8) | .49 |
| DVT | 1 (0.2) | 0 | 1 (0.4) | >.99 |
| Ileus | 1 (0.2) | 0 | 1 (0.4) | >.99 |
| Renal failure | 1 (0.2) | 0 | 1 (0.4) | >.99 |
| UTI | 8 (1.7) | 2 (0.8) | 6 (2.4) | .29 |
Abbreviations: DVT, deep vein thrombosis; NA, not applicable; SSI, surgical site infection; SSOPI, surgical site occurrence requiring procedural intervention; UTI, urinary tract infection.
Table 4. Multivariate Logistic Regression With Patients Who Developed Urinary Retention.
| Parameter | Odds ratio (95% CI) | P value |
|---|---|---|
| Age > 65 y | 1.05 (1.02-1.09) | .005 |
| BPH, yes | 3.44 (1.66-7.10) | <.001 |
| Hernia laterality, left | 1.52 (0.59-3.86) | .37 |
| Hernia laterality, right | 1.20 (0.50-2.87) | .84 |
| Operative time, min | 1.01 (0.99-1.02) | .68 |
| Volume of crystalloids, mL | 0.90 (0.82-0.99) | .03 |
| Use of diuretic medication | 0.98 (0.27-2.83) | .98 |
| Operative approach, TEP | 1.47 (0.64-3.56) | .38 |
| Use of anticholinergic medication | 3.62 (1.23-15.57) | .04 |
| Age >65 y and BPH | 1.23 (0.12-29.60) | .87 |
| Use of urinary catheter | 1.33 (0.68-2.64) | .40 |
Abbreviations: BPH, benign prostatic hyperplasia; TEP, totally extraperitoneal.
Discussion
This randomized clinical trial evaluated the effect of intraoperative urinary catheter use on PUR following laparoscopic inguinal hernia repair. We found that urinary catheters had no apparent effect on PUR. In addition, there were no significant differences in the rates of intraoperative bladder injuries and urinary tract complications associated with catheter use at the time of the procedure.
Catheterization during laparoscopic inguinal hernia repair is a common practice for many surgeons.2 Given the extensive dissection in the retropubic space, catheters are thought to decrease PUR and minimize the potential for bladder injury. In their 2018 international guidelines for groin hernia management, the HerniaSurge group used data from prospective and retrospective studies to conclude that there is no evidence to support routine use of a urinary catheter for open or laparoscopic inguinal hernia repair.3,10,11 Despite these recommendations, 10 of 11 participating surgeons at the institutions included in the trial used urinary catheters routinely, and 1 used them selectively prior to the initiation of this study. Based on the results of our trial and the HerniaSurge guidelines, all participating surgeons have abandoned the use of urinary catheters during laparoscopic inguinal hernia repairs.
Placement of a urinary catheter is an intervention that, although common, is not always benign. In fact, there is evidence that catheter use may worsen early postoperative urinary symptoms and delay the return of normal lower urinary tract function following inguinal hernia repair. In a prospective analysis of the effect of inguinal hernia repair on urinary symptoms, Reed et al12 used the American Urological Association Symptom Score, a validated 7-item survey covering frequency and nocturia, weak urinary stream, hesitancy, intermittence, incomplete emptying, and urgency.13 The use of intraoperative urinary catheters was associated with a significant increase in American Urological Association Symptom scores (indicating worsening of symptoms) from preoperative baseline to 48 hours and 30 days postoperatively. Additionally, in a retrospective review of 684 patients who underwent laparoscopic transabdominal preperitoneal inguinal hernia repair, Oehlenschläger et al10 concluded that patients who had routine placement of urinary catheter had a higher rate of urinary complications (defined as PUR, hematuria, and cystitis) compared with those who did not have a urinary catheter (5% vs 1%, respectively). Of note, the study period including the routine use of urinary catheters contributed to almost three-fourths of the total patient population. Thus, the differences in the rates of urinary complications could be because of the lower number of patients in the no-catheter group. In our study, the severest injury occurred in a patient with postoperative PUR who was assigned to the intraoperative catheter group and who may have sustained the injury during the operation or passing of the catheter or during the emergency department visit, but this patient ultimately required a suprapubic catheter. The current study and the potential risk factors associated with catheterization further support our recommendation against routine use of urinary catheters for patients undergoing laparoscopic inguinal hernia repairs and who void urine in the preoperative area.
Reduction in the risk of intraoperative bladder injury has been discussed as one of the potential benefits of routinely using a urinary catheter during laparoscopic inguinal hernia repair.14,15 In our study, there were no intraoperative bladder injuries in either group; however, this may simply serve to highlight that randomized clinical trials are not designed or positioned to detect rare but catastrophic complications. In one of the largest series, including 8050 consecutive laparoscopic transabdominal preperitoneal inguinal hernia repairs, Bittner et al11 reported a bladder injury rate of 0.1%. Importantly, urinary catheters were not used routinely in this study. A lower rate was reported by Crain et al,16 where there was only one bladder injury in 5017 laparoscopic hernia repairs (0.02%). The current evidence suggests that laparoscopic inguinal hernia repair without the routine use of a urinary catheter is associated with an extremely low risk of bladder injury. Although we asked all of the patients in our study to void urine preoperatively, it is not clear at this time if this could contribute to preventing intraoperative bladder injuries or PUR. Further prospective studies would be needed to primarily investigate the effect of catheters on bladder injury; however, designing a prospective study would be impractical given the low event rate of this complication. It should further be noted that all unplanned reoperations were in the no-catheter group and were related to intraoperative complications. Although this study was not designed to detect such small differences between the 2 groups, we have no reason to believe that the absence of catheter increased the risk of these complications.
As our study showed, PUR is a relatively common complication after laparoscopic inguinal hernia repair, affecting almost 1 in 10 patients. This is a considerable problem given the frequency and volume with which this operation is performed and that it can contribute to increased length of stay and anxiety for patients.17 In addition, there is an increased cost associated with emergency department or outpatient urologic visits. Thus, determining perioperative risk factors for PUR may decrease patient and health care burdens. In a retrospective review looking at PUR after laparoscopic totally extraperitoneal inguinal hernia repair, Roadman et al6 found that of those who developed PUR, 18.6% had BPH and 5.8% did not have BPH (P < .001). In addition, they identified age older than 60 years as a risk factor. Similarly, Sivasankaran et al17 showed that BPH and age older than 60 years were significant predictive risk factors, with ORs of 11.0 (95% CI, 3.6-13.4; P = .003) and 3.0 (95% CI, 1.8-5.2; P = .02), respectively. In our exploratory multivariate analysis, age older than 65 years, BPH, use of anticholinergic medication intraoperatively, and volume of intraoperative crystalloid infusion were significant risk factors for developing PUR. However, a post hoc analysis of these high-risk patients did not identify an association between catheter use and PUR.
Anticholinergic use and volume of intraoperative fluids were independent risk factors that deserve some attention. Anticholinergic medications, such as glycopyrrolate, are commonly used in the perioperative period at the discretion of the anesthesia team to dry secretions and protect against vagal overactivity.18 However, this class of medications also blocks detrusor contraction, potentially leading to bladder hypotonia and urinary retention.1,6 As for the intraoperative fluid volume, the multivariate analysis showed that higher volume of intraoperative fluids is protective against PUR. Importantly, the difference between the 2 groups was only 100 mL, and although this reached statistical significance, we have to be cautious not to overanalyze the clinical relevance of this finding. Our study was not designed to determine how anticholinergic medication or intraoperative fluids affect PUR. Future investigations are warranted as these are 2 modifiable risk factors that may significantly affect PUR. In summary, while we are moving away from catheter use, attention should be turned toward identifying the factors that affect this complication in future prospective studies.
Limitations
There are some limitations to this study that must be mentioned. First, since this was a multi-institutional study, the criteria for determining the timing of bladder scan and decision when to catheterize each patient were not standardized and ultimately determined by the policies of each institution and the surgeon. Second, the surgeons, the anesthesia team, and the study coordinators were not blinded to the interventions as this was not possible owing to the nature of the intervention. Third, patients with BPH may have been underreported in this study as they were identified only if participants were receiving medical treatment for this condition, and BPH is a well-known risk factor for developing an inguinal hernia but may not have been previously diagnosed in some patients in our cohort. Fourth, most inguinal hernia repairs are performed in male individuals; thus, the findings of this study may not apply to female individuals. Fifth, the lack of difference in PUR rates between the groups in our study could be because of a small sample size and subject to type II error. Sixth, there may have been unmeasured variables that served as confounders that cannot be accounted for by even the best-designed trials.
Conclusions
In this study, intraoperative urinary catheters did not reduce the risk of postoperative urinary retention following laparoscopic inguinal hernia repair. The lack of apparent immediate clinical benefit accompanied by the potential for rare but devastating complications offer a compelling argument in favor of abandoning routine use of catheters during laparoscopic inguinal hernia repair in patients who void urine preoperatively.
Trial protocol
eTable. The effect of catheter use on patients identified as high risk who developed urinary retention
Data sharing statement
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Trial protocol
eTable. The effect of catheter use on patients identified as high risk who developed urinary retention
Data sharing statement