Urinary retention after gynecologic surgeries for benign diseases in Egyptian women

doi:10.21203/rs.3.rs-2754184/v1

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Urinary retention after gynecologic surgeries for benign diseases in Egyptian women

https://doi.org/10.21203/rs.3.rs-2754184/v1

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Background: Postoperative urinary retention (POUR) is the inability to void following surgery. It is a common complication of gynecologic surgery, particularly when urine incontinence and pelvic organ prolapse are treated.

Objective: To determine the incidence and factors influencing urinary retention following benign gynecologic surgery in Egyptian women.

Patients and methods: This research was done on a total of 100 patients who all had gynecologic surgeries for benign diseases within the period from November 2021 to November 2022 in Al-Hussein University Hospital.

Results: the void volume was significantly lower 24 hours postoperative than preoperative and one-week postoperative (P <0.001). The post-void residuals volume was significantly higher 24 hours postoperative than preoperative and one-week postoperative (P < 0.001). 13 of the 100 women included in the study had retention. There were statistically non-significant differences between the presence of POUR and demographic data (P > 0.05). There were statistical significance differences in both POUR and CS presence (P = 0.045) and need for indwelling catheter (P < 0.001). The void volume was considerably lesser before 24 hours postoperative in the patients with retention than the patients without retention (P < 0.001). The post-void residuals substantially greater 24 hours postoperative in the patients with retention than the patients without retention (P < 0.001).

Conclusion: The findings of this study suggest that benign gynecologic surgery may have an unanticipated impact on postoperative voiding dysfunction.

Urinary retention

gynecologic surgery

benign diseases.

Postoperative Urinary Retention (POUR) is a prominent postoperative complication characterized as the inability to void despite sustained effort. ¹ Urinary retention and concomitant bladder distension can cause discomfort, irritation, and anxiety in those affected, as well as postoperative discharge delays. ² Incidence rates of urine retention during laparoscopy have been recorded anywhere from 1.2–22.2% .³

The effects of general anesthesia on detrusor activity, as well as drugs used preoperatively (such as opioids), are just two of the many causes of this problem. ⁴ Maybe because of the manipulation of tissue and nerves close to the genitourinary system, patients undergoing pelvic surgery are at increased risk for postoperative urine retention (POUR). ⁵

POUR is more likely to occur in certain patients. Increased incidences of POUR have been linked to the use of tricyclic antidepressants (TCAs), scopolamine patches during surgery, preexisting urine retention or lower urinary tract symptoms, and patient age more than 50 years. POUR is more common in patients whose surgeries last more than 2 hours.⁶

In some cases who are asymptomatic, over-distension of the bladder may cause irreversible alterations in bladder contractility and hence chronic urinary dysfunction. ⁷ Several studies have found that after surgery, 44% of patients have bladder volumes larger than 500 mL, with 52% of those people reporting no symptoms. ²

Patient at high risk for POUR should be counseled before to surgery. Preventive measures during surgery often focus on keeping patients hydrated and stopping excessive bleeding. Managing postoperative pain well is also crucial in avoiding POUR. ¹

Replacement of a Foley catheter is unpleasant, inconvenient, increases the risk of urinary tract infection (UTI), and delays recovery due to limited movement; nevertheless, the treatment for POUR itself is generally benign (re-catheterization and bladder rest). ⁸

This prospective longitudinal study was carried out on a total of 100 patients who underwent gynecologic surgeries for benign diseases within the period from November 2021 to November 2022 in Al-Hussein University Hospital.

The inclusion criteria were women over 18 and Patients undergone gynecologic surgeries for benign disease.

The exclusion criteria were Cases undergone incontinence operations, correction of pelvic organ prolapse, malignancy, or peripartum hysterectomy, Lesions of lumbosacral regions and CNS disorders that affect urinary functions and Diabetes.

Methods

Entire cases were collected:

Demographic data: include age, ethnicity, body mass index, tobacco use, parity and gravidity, mode of previous births, and abdomino-pelvic surgical history. Menopausal status, indication for the index surgery (e.g., uterine myomas). Preperative data: measurement of void volumes and postvoid residuals volumes by Ultrasound, urine analysis and Uroflowmetry. Intraoperative data: include procedure type, disease, surgical sites, operative time, and mode of anesthesia. And intraoperative complications. The pouch of Douglas, uterovesical fold, adnexa, uterosacral ligaments, pelvic side-wall, uterus, and vagina will all be listed as surgical sites. Clinical data: length of admission, time the indwelling catheter will be in situ, and whether dysfunction contributed to extended admission will be recorded. Postoperative data: include urine analysis, postoperative complications and 30-day readmission void volumes and postvoid residuals volumes by Ultrasound at 24h after surgery, 1 week then month and Uroflowmetry.

Ultrasound assessment of postvoid residual volume:

Since delays of up to 10 minutes from bladder might affect the accuracy of post-void residual measurements, taking these measurements as soon as possible after urination is essential.

When a patient is prone, the ultrasound probe (Mindray DC-7) is positioned over the suprapubic area to measure the bladder's capacity from the outside. Both sagittal and transverse views of the bladder are captured during imaging. We also measure the greatest width, depth, and height from side to side, top to bottom, and front to back.

Most ultrasound equipment include a capability that automatically calculates volumes using ultrasonic caliper measurements. If this function is unavailable, it is alternatively possible to calculate the volumes using the prolate ellipsoid formula (Volume = length x width x height x 0.52). Maximum transverse (width), longitudinal (length), and anterior-posterior (height) dimensions are utilized to assess the bladder.

Urinary bladder residuals were measured immediately upon micturition, or four hours after catheter removal if the patient had not emptied.

Post-void residual volume more than 200 mL necessitated an in-out catheter and recording of the residual volume.

Residues of 100 mL on 2 consecutive occasions with a void of at least 150 mL, scanning was ceased, and the patient was discharged if their clinical state was adequate.

Scan without undergoing catheterization because of residuals between 100 and 200 ml.

Patients with 24-hour or longer residuals of 200 mL were evaluated with a midstream urine sample, and self-catheterization instruction was provided prior to release.

Patients who refused self-catheterization or were unable to learn how to do so stayed in the hospital until their bladder function improved to an acceptable level.

Table 1

Demographic characteristics and relevant history of the studied sample.
		Mean & SD	Median	Range	Interquartile range
Age (years)		46.36 ± 9.945	46.00	30.0, 62.0	37.25, 56.00
BMI (kg/m²)		27.27 ± 3.195	27.30	22.0, 33.3	24.36, 29.64
Parity		1.96 ± 1.435	2.00	0.0, 4.0	1.00, 3.00
Gravidity		2.85 ± 1.666	3.00	0.0, 6.0	1.25, 4.00
Operative time (minutes)		66.85 ± 20.359	65.00	30.0, 125.0	50.00, 83.75
Length of admission (days)		2.70 ± 0.959	3.00	1.0, 5.0	2.00, 3.00
Smoking history		15 (15.0%)
Abdomino-pelvic surgical history		71 (71.0%)
Menopausal status	Pre- menopausal	55 (55.0%)
Menopausal status	Post- menopausal	45 (45.0%)
Mode of previous births	VD	49 (49.0%)
Mode of previous births	CS	51 (51.0%)
Surgery	Uterine myomas	20 (20.0%)
	Hysterectomy	34 (34.0%)
	Ovarian Cyst Removal	43 (43.0%)
	Total Laparoscopic Hysterectomy	3 (3.0%)
Need for indwelling catheter		4 (4.0%)
30-day readmission		3 (3.0%)
Data is expressed as mean and standard deviation, median, range and interquartile range or as percentage and frequency.

This table showed that 15% of the studied cases were smokers and 71% had abdomino-pelvic surgical history. 55% of them were premenopausal and 51% had previous CS. The most common surgery was ovarian cyst removal (43%) followed by hysterectomy (34%) while the least common was total laparoscopic hysterectomy (3%). 4% needed indwelling catheter and 3% needed 30-day readmission.

Table 2

Void volume and Postvoid residuals volume of the studied sample.
		Mean & SD	Median	Range	IQR
Void volume (ml)	Preoperative	454.25 ± 55.169	450	350, 550	400, 500	-
	24 hours Postoperative	232.0 ± 94.554	225	50, 400	150, 318.75	˂ 0.001
	One-week Postoperative	454.0 ± 62.130	475	350, 550	400, 500	0.975
Postvoid residuals volume (ml)	Preoperative	31.30 ± 11.160	30.0	15, 50	20, 40	-
	24 hours Postoperative	68.30 ± 43.089	60.0	25, 215	40, 73.75	˂ 0.001
	One-week Postoperative	33.25 ± 9.984	35.0	15, 50	25, 45	0.182
P is significant when ˂ 0.05.

This table showed that the void volume was significantly lower 24 hours postoperative than preoperative and one-week postoperative (P < 0.001). The post-void residuals volume was significantly higher 24 hours postoperative than preoperative and one-week postoperative (P < 0.001).

Table 3

Demographic characteristics and relevant history of the studied sample according to presence of POUR.
		No retention (n= 87)	Retention (n= 13)	95% CI	P
Age (years)		46.20 ± 10.072	47.46 ± 9.351	- 7.2, 4.6	0.758
BMI (kg/m²)		27.36 ± 3.318	26.66 ± 2.201	-1.2, 2.6	0.499
Parity		1.91 ± 1.403	2.31 ± 1.653	-1.2, 0.4	0.328
Gravidity		2.75 ± 1.608	3.54 ± 1.941	-1.8, 0.2	0.121
Operative time (minutes)		65.80 ± 19.378	73.85 ± 25.832	- 20.0, 3.9	0.368
Length of admission (days)		2.68 ± 0.946	2.85 ± 1.068	-0.7, 0.4	0.584
Smoking history		13 (14.9%)	2 (15.4%)	-	0.967
Abdomino-pelvic surgical history		60 (69.0%)	11 (84.6%)	-	0.246
Menopausal status	Pre- menopausal	48 (55.2%)	7 (53.8%)	-	0.929
Menopausal status	Post- menopausal	39 (44.8%)	6 (46.2%)	-	0.929
Mode of previous births	VD	46 (52.9%)	3 (23.1%)	-	0.045
Mode of previous births	CS	41 (47.1%)	10 (76.9%)	-	0.045
Surgery	Uterine myomas	18 (20.7%)	2 (15.4%)	-	0.134
	Hysterectomy	30 (34.5%)	4 (30.8%)
	Ovarian Cyst Removal	38 (43.7%)	5 (38.5%)
	Total Laparoscopic Hysterectomy	1 (1.1%)	2 (15.4%)
Need for indwelling catheter		0 (0.0%)	4 (30.8%)	-	˂ 0.001
30-day readmission		2 (2.3%)	1 (7.7%)	-	0.344
95% CI: 95% confidence interval of the mean difference between both readings.

Thirteen of the one hundred women in the research had retention, as seen in the table. POUR prevalence and demographic characteristics of the study population were not significantly different as: age, BMI, parity, gravidity, operative time, length of admission, smoking history, abdomino-pelvic surgical history, menopausal status, type of surgery, and 30-day readmission (P > 0.05). Distinct variations existed statistically between the No retention and Retention groups regarding Mode of previous births. CS incidence in the Retention group was higher than No retention group (47.1% vs. 76.9%, P = 0.045). Differences were discernible on a statistical level between the No retention and Retention groups regarding need for indwelling catheter (P < 0.001).

Table 4

Void volume and Postvoid residuals volume of the studied sample according to presence of POUR.
		No retention (n= 87)	Retention (n= 13)	95% CI	P
Void volume (ml)	Preoperative	455.75 ± 54.145	444.23 ± 63.043	- 21.1, 44.2	0.549
	24 hours Postoperative	247.99 ± 89.184	125.00 ± 50.000	72.6, 173.4	˂ 0.001
	One-week Postoperative	454.31 ± 60.905	451.92 ± 72.501	-34.5, 39.2	0.914
Postvoid residuals volume (ml)	Preoperative	31.03 ± 11.158	33.08 ± 11.463	-8.6, 4.6	0.488
	24 hours Postoperative	53.79 ± 16.030	165.38 ± 41.706	-123.9, -99.2	˂ 0.001
	One-week Postoperative	33.45 ± 10.295	31.92 ± 7.783	-4.4, 7.4	0.600

This table showed that the void volume was significantly lower 24 hours postoperative in the patients with retention than the patients without retention (P < 0.001). The post-void residuals volume was significantly higher 24 hours postoperative in the patients with retention than the patients without retention (P < 0.001).

Our results supported with Won et al. ² estimated the incidence of bladder dysfunction after gynecological surgery, 20 of the 102 women included in the study (19.61%) were found to have bladder dysfunction with median post-void residual volume 210.

Also, Sandberg et al. ⁹ compared the retention outcomes of immediate catheter removal (ICR) and delayed removal (DCR) following laparoscopic hysterectomy and found that while 10 women in the ICR group were unable to urinate spontaneously within 6 hours, none of the women in the DCR group had this problem (risk difference 13.5%, 5.6–24.8, P = 0.88). Nonetheless, within 9 hours, 7 of these women were able to urinate normally without any help.

Similarly, after a hysterectomy, Ghezzi et al. ¹⁰ found that 21 percent of patients experienced postoperative voiding dysfunction, with 32 percent of those patients experiencing complete urine retention and 17 percent experiencing a postvoid residual volume more than 150 mL. Within 48 hours, all of these patients' voiding problem resolved.

In contrast to our study and previous studies, Risk assessments for POUR following benign gynecologic surgery were conducted by Siedhoff et al. ⁸ and revealed an extremely low incidence of 3.8%.

The void volume was significantly lower 24 hours postoperative than preoperative and one-week postoperative (P < 0.001). The post-void residuals volume was significantly higher 24 hours postoperative than preoperative and one-week postoperative (P < 0.001).

In line with our results, Catheterized volumes in individuals unable to void ranged from 464 to 255 milliliters, according to a study by Ghezzi et al. ¹⁰. Among patients where the estimated residual was larger than 150 mL on bladder ultrasonography, the mean PVRV was 444 ± 176 mL. In the study population, the median time to first void was 5 hours, excluding patients who had indwelling catheterization (range: 1–10 hours). The average number of catheterizations for patients with voiding dysfunction was 1.3 ± 0.5 (95%), with 29 women (12.4%) requiring multiple procedures. 14 patients (6.0%) required the insertion of an indwelling catheter. The majority of women had regular urination after 48 hours.

None of the demographic variables of the study's sample differed from chance based on whether or not POUR was present as: age, BMI, parity, gravidity, operative time, length of admission, smoking history, abdomino-pelvic surgical history, menopausal status, type of surgery, and 30-day readmission (P > 0.05). There were statistically significant differences between the presence of POUR and CS (P = 0.045) and need for indwelling catheter (P < 0.001).

Similarly, Won et al. ² found that the number of surgical sites (p = 0.31) or the duration of surgery (p = 0.54) were not associated with a higher risk of postoperative bladder dysfunction (p = 0.58). Those with postoperative bladder dysfunction did not have a higher rate of intraoperative complications than those without (p = 0.20). Opioid use during and after surgery did not differ significantly between patients with and without bladder impairment. Neither group had a significantly higher rate of patients requiring dissection of the pouch of Douglas, uterosacral ligaments, pelvic sidewall, or uterovesical folds than the other. Postoperative bladder dysfunction was more common in patients who used ADEPT anti-adhesion solution intraoperatively (p = 0.001).

Also, Ghezzi et al. ¹⁰ found that no demographic, historical, preoperative, or postoperative characteristics were found to have a statistically significant relationship with the onset of voiding dysfunction following surgery. (eg: operating time, narcotic use, estimated blood loss). The type of hysterectomy procedure performed was the only element identified to significantly affect the occurrence of voiding issues after the procedure. VH patients were more likely to experience complications related to voiding than TLH individuals, with an OR of 2.8 (95% CI 1.5–5.4).

This study's findings suggest that benign gynecologic surgery can have considerable and variable effects on voiding function after surgery. Long-term effects on bladder function and the underlying mechanisms of these alterations are unknown. The lack of an agreed-upon definition, the impact even at greater rates of leftover urine volume, and the possibility for long-term difficulties may be viewed as limitations to external validity, but these findings and definitions should not be overlooked.

This research suggests that even seemingly innocuous gynecological procedures can have considerable and variable effects on postoperative voiding problems. Long-term effects on bladder function and the complexity of their underlying mechanisms make definitive conclusions difficult to draw. Although the lack of a universally accepted definition, the significant impact even at higher rates of remaining urine volume, and the possibility for long-term difficulties may be viewed as limitations to external validity, these results and definitions should not be overlooked.

Ethics approval and consent to participate: The ethics committee of the faculty of medicine at Al-Azhar University approved the study, and all participants provided written consent to participate.

Consent for publication: All participants provided written consent for their data to be used in this publication.

Availability of data and materials: The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Competing interests: The authors declare that they have no competing interests.

Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Authors' contributions: The current research was executed with equitable contributions from all authors, comprising Mahmoud Atef Elsaid Mohamed Zayed, Mohamed Mohamed Ibrahim Gabriel and Muhamed Ahmed Abdelmoaty who conducted Gynecological surgeries, formulated the study design, gathered data, and composed the manuscript, and Mohamed Abd-elrahim Elsalhy who diagnosed urinary retention, administered its management, collected data, and devised the study design. The manuscript was subsequently revised by all authors to ensure its scientific rigor and accuracy.

Acknowledgements: The authors express their sincere gratitude to the Department of Obstetrics and Gynecology and the Department of Urology, Faculty of Medicine, Al-Azhar University for their invaluable contributions towards the successful completion of this research endeavor. The authors acknowledge the unwavering support and guidance provided by these departments throughout the study, which has significantly enhanced the quality and reliability of the findings. The authors recognize the efforts made by these departments in facilitating access to necessary resources, equipment, and facilities required for conducting this study. The authors extend their heartfelt appreciation to these departments for their unwavering commitment towards advancing scientific knowledge in the field of obstetrics and gynecology and urology.

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No competing interests reported.

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Urinary retention after gynecologic surgeries for benign diseases in Egyptian women

Status:

Version 1

Abstract

Introduction

Patients And Methods

Methods

Entire cases were collected:

Ultrasound assessment of postvoid residual volume:

Results

Discussion

Conclusion

Declarations

References

Additional Declarations

Status:

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