Postoperative Urinary Retention and Urinary Track Infection (UTI) After Laparoscopic Assisted Vaginal Hysterectomy (LAVH) for Benign Disease
Condition: Hysterectomy; Urinary Retention; Urinary Tract Infection
MeSH terms: Infections; Urinary Tract Infections; Urinary Retention
Study type: Interventional

Summary: 
      With the advent of minimally invasive surgery, laparoscopic assisted vaginal hysterectomy
      (LAVH) is currently advocated as an alternative to abdominal hysterectomy. Reported benefits
      of LAVH in short-term study, when compared with the abdominal hysterectomy, include shorter
      hospital stays and convalescence, less postoperative pain, lower morbidity. To our best
      knowledge, no study has been conducted to examine bladder catheterization is associated with
      PUR and UTI after LAVH. No study has been performed to evaluate the long-term sequelae of PUR
      after LAVH.

      In this study, 150 patients undergoing LAVH are randomly assigned to have an indwelling Foley
      catheter for 0 (n = 50), at 7AM-8AM in the morning of postoperative day 1 (n = 50), at
      7AM-8AM in the morning of postoperative day 2 (n = 50) after the procedure by selecting a
      sealed envelope, which is opened before the operation. The inclusion criteria are uterine
      fibroids, endometriosis, abnormal bleeding, uterine prolapse and intra-epithelial neoplasia
      of the cervix grade 3. Patients are excluded if they experienced pelvic reconstructive
      surgery for pelvic organ prolapse or stress urinary incontinence; if they have bacteriuria
      and clinical urinary tract symptoms, e.g. dysuria, frequency, urgency and stress incontinence
      before surgery. After surgery, all patients stay at least 2 days in the hospital. The
      incidences of febrile morbidity and other postoperative complications are recorded. The
      outcome is assessed as immediate postoperative urinary tract symptoms, urinary tract
      bacteriuria (defined as a positive culture > 105 organisms/µl), postoperative fever > 38°C
      and urinary retention or the inability to pass urine 6 hours after catheter remove. All
      patients are followed up at 3 months and one year after surgery. To demonstrate quality of
      life of women after undergo LAVH, a generic instrument of MOS Short Form 36 (SF-36) and two
      specific instruments for urinary problems, Incontinence Impact Questionnaire (IIQ7) and
      Urinary Distress Inventory (UDI) are asked to answer in all patients before surgery and
      postoperative follow-up. All data are analyzed by the two-tailed Fisher exact test when
      appropriate. Correlation coefficients are calculated to determine the associations of
      preoperative, intraoperative, and postoperative factors with the incidence of postoperative
      urinary retention and positive urine cultures. A value of p < 0.05 is considered
      statistically significant.
    

Detailed description: 
      Hysterectomy is the most common major gynecological operation performed; in previous study,
      20% of women will have undergone a hysterectomy by the age of 50 years, mostly for
      nonmalignant conditions such as uterine fibroids, endometriosis, abnormal bleeding, uterine
      prolapse and intra-epithelial neoplasia of the cervix grade 3. (1) Fever is the most common
      perioperative complication of hysterectomy, arising in about 25%. (2) The other early
      complications associated with hysterectomy including hemorrhage, infection, and injury to
      adjacent organs, femoral neuropathy, and thromboembolic disease. (3) However, whether
      hysterectomy is linked to the development of urinary symptoms remains controversial. Some
      groups observed no effect or improved urinary dysfunction after hysterectomy, (4-7) others
      reported that hysterectomy is the cause of a variety of urinary symptoms including the
      urethral syndrome, stress incontinence, detrusor overactivity and voiding difficulty. (8, 9)
      Voiding difficulty in the female is a condition in which the bladder fails to empty
      completely and easily after micturition. Failure to detect voiding difficulties after surgery
      may lead to bladder overdistention and irreversible damage of the detrusor muscle. (10)
      Postoperative urinary retention (PUR) is defined as the inability to void with a full bladder
      during the postoperative period. The etiology of PUR involves a combination of many factors,
      including sedation, type of anesthesia, increased sympathetic stimulation, overdistension of
      bladder by large quantities of fluids given intravenously, pain and anxiety. (11) In the
      literature, incidence of postoperative urinary retention (PUR) has ranged from 3.8% to 80%,
      depending on the definition used and the type of surgery performed. (12-15) There is no
      consensus on how to diagnose PUR and various criteria, such as clinical symptoms, bladder
      palpation and a fixed time interval or drainage by catheterization of more than 500 ml of
      urine, have been used. (16) Traditionally gynecologists have used an indwelling catheter for
      abdominal surgical procedures for several reasons, including the beliefs that women would be
      unable to void satisfactorily in the immediate postoperative period, that the indwelling
      catheter provided the only reliable method of assuring adequate exposure, and that a catheter
      would be necessary in the recording of intake-output. In fact, prompted by women's dislike of
      the catheter as well as an increased incidence of postoperative urinary tract infection
      (UTI). (17) The potential sequelae of UTI include gram-negative bacteremia, antimicrobial
      toxicity, chronic bacteriuria and chronic renal disease. (18) In most cases the infection is
      mild and easily treated, but UTI is the commonest nosocomial infection and leads to increased
      morbidity and treatment costs. (18-20) Some North American studies addressing postoperative
      UTI have been confounded by the use of perioperative antibiotics, (17, 21) suggesting UTI
      rates of 3-10%, whereas British work has suggested a rate of 35% in control patients
      receiving no antibiotics. (22) It has been estimated that the risk of UTI associated with
      indwelling catheterization is 5-10% per day of catheterization (18) and that the commonest
      cause of UTI in hospital is urinary catheterization (23). Short-term catheterization has been
      associated with subsequent bacterial colony counts of > 105/ml of urine in 21% of women
      undergoing minor surgery, (24) and the incidence of positive urine cultures rises with the
      length of time catheterization is continued. (17, 18) In a randomized trial study for the
      effect of prophylactic antibiotics on the postoperative UTI in patients undergoing abdominal
      hysterectomy, Ireland et al found single dose cotrimoxazole is effective in reducing the
      incidence of postoperative UTI from 35% in the control group to 4% in the treated group. (25)
      Hakvoort et al studied whether prolonged urinary bladder catheterization after vaginal
      prolapse surgery is advantageous. (26) They found that residual volumes > 200 ml and need for
      recatheterization occurred in 9% in the 4 days catheterization group versus 40% of patients
      in the one day catheterization group (OR 0.15, 95% CI 0.045-0.47). Positive urine cultures
      were found in 40% of cases in the 4 days catheterization group versus 4% of patients in the
      one day catheterization group (OR 15, 95% CI 3.2-68.6). By contrast, in a prospective study
      of postoperative infection after abdominal and vaginal gynecological surgery, Kingdom et al
      reported 40% of 115 patients receiving no prophylactic antibiotics developed a UTI in the
      postoperative period and this was not clearly related to the need for postoperative
      catheterization. (25) Since prolonged indwelling urinary catheterization may be associated
      with an increased risk of UTI, increasing patient morbidity and potentially prolonging the
      hospital stay (18), prophylactic antibiotics and a reduction in catheter time or no catheter
      after surgery might be expected to reduce this risk.

      Regarding the relationship of bladder catheterization with PUR, in published data of
      prospective or retrospective studies on PUR after abdominal or vaginal hysterectomy, we found
      that several factors of postoperative care affect the result of PUR including type of
      surgery, use of catheter, duration of catheterization, and postoperative analgesia. (16, 17,
      25, 27-30) During 4-year period, Summitt et al have not used postoperative bladder catheter
      drainage after routine vaginal hysterectomy. (28) To assess the potential differences in
      postoperative outcome, they prospectively compared the use of indwelling bladder catheter
      drainage with no catheter use after standard vaginal hysterectomy. Their data showed 2
      patients in the catheterized group required recatheterization after the catheters were
      removed; none in the no-catheter group required a catheter. The results inferred that
      indwelling catheterization appears unnecessary after routine vaginal hysterectomy. In a
      prospective randomized trial study, Dobbs et al compared the infection rate and postoperative
      morbidity between indwelling catheterization and in-out catheterization at the time of
      abdominal hysterectomy. (27) Of the 95 patients in their study, 36% of that undergoing in-out
      catheterization had PUR, requiring bladder emptying, compared with 4% of those receiving an
      indwelling catheter. In addition, 29% of the catheterized group had urinary tract bacteriuria
      compared with 13% of the uncatheterized group. They concluded that in-out urinary
      catheterization at the time of routine abdominal hysterectomy was associated with a
      significantly higher incidence of PUR compared with indwelling catheterization, and may have
      implications for long-term bladder function. (27) Dobbs et al also pointed out that abdominal
      muscular pain when the intra-abdominal pressure is increased during voiding coupled with the
      decreased sensation for voiding due to analgesia, suggests that an indwelling catheter in the
      immediate postoperative period will help to prevent long-term morbidity from bladder atony.
      Bodker and Lose presented the prevalence of PUR was 9.2% in their patients receiving
      gynecological surgery. (16) Of 124 patients undergoing abdominal hysterectomy, 13.7% had PUR.
      Of 24 patients undergoing laparoscopic assisted vaginal hysterectomy (LAVH), 8.7% had PUR.
      They concluded patients at risk of PUR are difficult to predict. The risk is higher after
      laparotomy than after laparoscopy. A retention rate of 13.7% after abdominal hysterectomy is
      fairly similar to that of 11.8% after gynecologic laparotomies reported by Schiotz, (29) Who
      used an indwelling Foley catheter routinely for 20-24 hours to ascertain the risks of UTI and
      aymptomatic bacteriuria. Based on 949 gynecologic laparotomies without the use of catheters
      but with bladder needling at the end of surgery, Bartzen and Halferty found that 26% needed
      catheterization. (17) They suggested that abstaining from the use of an indwelling catheter
      was also associated with lower cost and greater patient satisfaction.

      With the advent of minimally invasive surgery, LAVH is currently advocated as an alternative
      to abdominal hysterectomy. Reported benefits of LAVH in short-term study, when compared with
      the abdominal hysterectomy, include shorter hospital stays and convalescence, less
      postoperative pain, lower morbidity, and, in some series, greater cost-effectiveness. (31-35)
      Whereas benefits of LAVH in long-term follow-up, only few studies have appeared in the
      literature. A report from Taiwan, Shen et al compared 1-month and 8-year follow-up of LAVH
      and abdominal hysterectomy. In their 8-year follow-up showed no statistically significant
      differences in vaginal vault prolapse, cystocele, rectocele, enterocele, postcoital bleeding,
      and cuff granulation between LAVH and abdominal hysterectomy procedures. (36) However, with
      regard to the consequences of PUR and UTI after LAVH, to our best knowledge, no study has
      been conducted to examine bladder catheterization is associated with this problem.
      Furthermore, no study has been performed to evaluate the long-term sequelae of PUR after
      LAVH.
    

Intervention name(s): on Foley time
Intervention type(s): Procedure
Intervention description(s): A-no Foley B-remove Foley at 7AM in the morning of postoperative day 1 C-remove Foley at 7AM in the morning of postoperative day 2
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: hysterectomy; laparoscopy; urinary retention; urinary tract infection; catheterization