Feasibility and safety of a non-indwelling urinary catheter after flexible ureteroscopy with intelligent control of renal pelvis pressure: A retrospective study

doi:10.21203/rs.3.rs-4474896/v1

Download PDF

Research Article

Feasibility and safety of a non-indwelling urinary catheter after flexible ureteroscopy with intelligent control of renal pelvis pressure: A retrospective study

https://doi.org/10.21203/rs.3.rs-4474896/v1

This work is licensed under a CC BY 4.0 License

Journal Publication

published 24 Oct, 2024

Read the published version in BMC Urology →

You are reading this latest preprint version

Background

To explore the feasibility and safety of a non-indwelling urinary catheter after flexible ureteroscopy with intelligent control of renal pelvic pressure (FUS-ICP).

Methods

In this retrospective study, we assessed patients with upper urinary tract stones who were treated with FUS-ICP at the Ganzhou People's Hospital from February 2022 to December 2023. Patients were divided into the non-urinary catheter (non-UC) and urinary catheter (UC) groups according to whether an indwelling catheter was used after surgery.

Results

In total, 142 patients were included in the study. There was no significant difference in the preoperative general data between the two groups. Patients in the non-UC group performed better than those in the UC group in terms of catheter-related bladder irritation (P = 0.001), the Sedation-Agitation Scale score (P = 0.012), and the numerical rating scale (P = 0.003). The incidences of urinary retention (P = 0.620), urinary tract infection (P = 0.529), and re-indwelling urinary catheters (P = 0.438) in the UC group were inferior to those in the non-UC group, but there was no statistical significance.

Conclusions

Non-indwelling urinary catheters are safe and feasible for patients undergoing FUS-ICP.

urinary catheter

flexible ureteroscopy

renal pelvic pressure

A perioperative indwelling urinary catheter is a common practice because it prevents bladder expansion and incontinence in anesthetized patients and facilitates the measurement of urine volume [1].In urological surgery, the indwelling urinary catheter is convenient for draining urine and blood clots, maintaining low bladder pressure, preventing infection, and promoting postoperative recovery. With the advancement of minimally invasive technology and the promotion of enhanced recovery after surgery (ERAS), the operation time and hospital stay have been further shortened, and the routine use of an indwelling urinary catheter after surgery has brought a lot of discomfort to patients [2]. It is safe and feasible for gynecology and thoracic surgery patients who have undergone general anesthesia to not undergo placement of an indwelling urinary catheter after surgery. This greatly reduces the negative experience of patients, such as urethral pain or urinary tract discomfort, and also reduces the incidence of urinary tract infection and the length of hospital stay [3, 4]. At present, there is a lack of reports pertaining to the removal of the urinary catheter after urology surgery.

Flexible ureteroscopy is associated with less trauma and a faster recovery, with most procedures performed as a day surgery [5]. The indwelling urinary catheter is still routinely placed after surgery, which can result in urethral pain or urinary tract discomfort, burning sensation and confusion, trembling limbs, and other restless behaviors during recovery from anesthesia; this can seriously affect the rapid recovery of patients [6]. In recent years, with the improvement of the sheath, laser, and ureteroscope, particularly flexible ureteroscopy with intelligent control of renal pelvis pressure (FUS-ICP), the surgical safety and effectiveness have been greatly improved, the operation time is shorter, the stress on patients is less, and the recovery of patients is promoted [7–9].

This study reviewed and analyzed cases of non-indwelling ureteral catheters in our hospital and discussed the feasibility and safety of non-urinary catheters after FUS-ICP to further accelerate patient recovery.

Patient data

This study was approved by the Ethics Committee of the Ganzhou People's Hospital and included patients who underwent FUS-ICP under general anesthesia in the Department of Urology from February 2022 to December 2023. The inclusion criteria were as follows: 1) aged 18–70 years; 2) upper urinary tract stones, where the diameter of a single stone is ≤ 2 cm or the maximum diameter of multiple stones is ≤ 2 cm; 3) American Society of Anesthesiologists (ASA) score I/II; and 4) operation time < 60 min. All patients voluntarily participated in this study and signed informed consent. They were informed before surgery whether a urinary catheter would be placed or not, and in some cases, no urinary catheter was placed during the operation according to the preoperative wishes of the patients.

The exclusion criteria were as follows: 1) uncontrolled urinary tract infections (UTIs); 2) patients in which pyonephrosis was identified during the operation; 3) patients with structural abnormalities (ectopic kidney, horseshoe kidney, kidney transplant patients and duplicate kidney), ureteral stenosis, and urine flow diversion; 4) severe hydronephrosis; 5) preoperative mental illness or cognitive dysfunction; 6) severe systemic hemorrhagic disease; 7) patients undergoing simultaneous bilateral surgery; 8) severe hip deformity and difficulty in positioning; 9) urinary disorders caused by nervous system disorders, such as prostatic hyperplasia, urethral stenosis, etc.; and 10) pregnant women.

Surgical Methods

The surgery was performed by two doctors experienced in flexible ureteroscopy with intelligent control of RPP for more than 3 years, with 200 cases each year. The patient was positioned at an angle 60° oblique to the supine lithotomy position with the diseased side positioned upward. Initially, ureteroscopy was performed with a semirigid 7/8.4 Fr ureteroscope (KARL Storz, Germany) guided by a zebra guide wire. A Zebra guide wire was placed under a ureteroscope. A 12/14 or 11/13Fr patented ureteral access sheath with pressure-measuring suctioning was inserted under a guidewire according to the ureter conditions without fluoroscopic guidance. The platform selection mode was set to fully automatic. The pressure sensory and suctioning channels of the ureteral access sheath were connected to the irrigation and suctioning platform. After the sensor is injected with normal saline using a syringe, the normal saline and urine in the renal pelvis are drained through the sheath to completely empty the air in the pressure sensor pipe for accurate pressure measurement. After that, zero calibration was performed at the platform. The actual pressure in the renal pelvis displayed on the platform was 0 mmHg. The perfusion flow was initially set at 100 mL/min. The pressure control values were set at -5. The 8.5Fr flexible ureteroscope (Hawk, China) was connected by a peristaltic tube and inserted after the platform was activated to confirm the location of the sheath. First, 276 µm holmium laser fiber (Chunhui, China) was used with a power of 2.0 ~ 3.0 J/20 ~ 30 Hz. 5 Fr ureteral stents were indwelled after the operation, and the stents were removed, extracorporeal lithotripsy or re-operation were performed 2–4 weeks after the operation according to Kidney-Ureter-Bladder or Computed Tomography examination of residual calculi.

Urinary catheter management

Patients were divided into the non-urinary catheter (non-UC) and urinary catheter (UC) groups according to whether an indwelling catheter was used after surgery. FUS-ICP was performed under general anesthesia in both groups. In the non-UC group, a 14Fr disposable urinary catheter was removed immediately after thorough postoperative urinary drainage. After the patients were awakened from anesthesia, patients in the non-UC group were instructed to use physical stimulation methods (hot compressing the bladder area, listening to the sound of running water, etc.) to achieve self-urination; patients were instructed to get out of bed to urinate and pay attention to prevent accidents such as falls. In the UC group, a 14Fr disposable urinary catheter was placed and fixed to an airbag after the operation, which was subsequently removed 1–2 days after the operation.

The training staff recorded the observation indicators according to the scoring criteria and compared them between the two groups of patients. The signs of urinary duct-related bladder irritation include suprapubic discomfort, burning, urgency, and pain, which can lead to agitation in severe cases. The occurrence of urinary catheter-associated bladder irritation was assessed and recorded by nurses in the anesthesia and resuscitation rooms. The scoring criteria were as follows: 1) no complaints; 2) tolerable mild discomfort; 3) moderate discomfort without behavioral reaction; and 4) severe discomfort accompanied by behavioral reactions such as fidgeting limbs and scratching [10].

②The Sedation-Agitation Scale (SAS; range 1–7, unarousable to dangerous agitation) was used to assess patients [11].③ pain refers to pain caused by irritation of the bladder wall, bladder triangle, or urethra by the urinary tube. Urinary duct-related pain was evaluated using a numerical rating scale (NRS) [12].

Urination was scored as follows: 1) smooth urination; 2) induced urination: the patient has difficulty urinating and can discharge urine after induction; 3) urinary catheter reset: no urination and abdominal distension within 4–6 h after surgery were defined as urinary retention. In cases of urinary retention, a physical examination revealed swelling of the lower abdomen and a full bladder. Urination induction was ineffective, and an indwelling urinary catheter was required. Smooth and induced urination were defined as the absence of urinary retention. A UTI was diagnosed if there was 10³ CFU/mL on culture in the setting of a positive urinalysis result.

In total, 142 patients were included in the study. There were no significant differences in the preoperative general data between the two groups (Table 1). Patients in the non-UC group significant improvements compared to those in the UC group in terms of catheter-related bladder irritation, SAS and NRS scores (P < 0.05). Postoperative hospital stay in the UC group was longer than that in the non-UC group (P = 0.731). In the non-UC group, a lower rate of UTI was observed (P = 0.620).Furthermore, the incidence of urinary retention and re-insertion urinary catheters in the UC group was lower than that in the non-UC group; however, the difference was not statistically significant (P > 0.05).

Table 1

General data and perioperative data of two groups of patients
Item	Non-UC group (N = 70)	UC group (N = 72)	P value
Age	42.6 ± 8.2	43.6 ± 9.3	0.716
BMI(kg/m²)	22.3 ± 3.2	21.8 ± 2.4	0.424
Sex(Male)(n%)	26 (37.1%)	31(43.1%)	0.472
Diabetes	5 (7.1%)	4(5.6%)	0.743
History of urinary retention	3(4.3%)	6(8.3%)	0.494
Stone size (mm)	19.8 ± 5.2	18.4 ± 4.6	0.531
Operation time(min)	46.5 ± 14.1	51.2 ± 13.3	0.546
Postoperative hospital stay(d)	1.3 ± 0.3	1.8 ± 0.5	0.731
Urinary catheter-related bladder irritation	1.8 ± 2.1	4.8 ± 4.2	0.001
SAS	3.5 ± 2.7	5.8 ± 5.2	0.012
NRS	4.6 ± 2.4	7.1 ± 4.6	0.003
UTI	1(1.4%)	3(4.2%)	0.620
Urinary retention	6(8.6%)	4(5.6%)	0.529
Re-insertion of urinary catheter	4(5.7%)	2(2.8%)	0.438

With the advancement of minimally invasive technology and the promotion of the ERAS concept, increasing evidence supports the expedient removal of catheters and the absence of urinary indentations after surgery [13, 14]. Due to problems such as high renal pelvic pressure and low lithotripsy efficiency, traditional ureteroscopy is prone to postoperative complications such as infection and bleeding. To facilitate observations of the urine volume and prevent high bladder pressure, urinary catheters are routinely placed after surgery, which results in urethral pain or urinary discomfort, burning sensation and confusion, limb shaking, and other restless behaviors during recovery from anesthesia. Agitation immediately after general anesthesia is common and can lead to serious adverse events, including injury, increased pain, bleeding, or catheterization [15]. Agitation during recovery from general anesthesia carries great safety risks, which may lead to inaccurate patient monitoring data, accidental extubation, accidental bed fall, surgical site bleeding, decreased patient satisfaction, prolonged hospital stay, and even secondary surgery [16]. A postoperative indwelling urinary catheter is the main cause of agitation after general anesthesia. Therefore, avoiding the use of postoperative indwelling urinary catheters can reduce the risk of agitation after general anesthesia. Furthermore, the longer the catheter retention time, especially > 2 days, the greater the probability of patients developing catheter-associated UTIs [17, 18]. Early removal of unnecessary urinary catheters, either immediately or after 1–2 days, does not result in higher recatheterization rates, whereas immediate removal leads to earlier activity and a shorter hospital stay [13, 19, 20].

FUS-ICP can be used to effectively monitor and control the intrapelvic pressure, resulting in large intraoperative flow, clear vision, continuous and rapid lithotripsy, and stone removal, shortening of the operation time and postoperative recovery time, great improvements in surgical safety and stone removal rate, and a reduction in postoperative complications, such as fluid absorption, vomiting, and lower back pain [8]. In this study, patients in the non-UC group showed better outcomes than those in the UC group in terms of postoperative hospital stay, catheter-related bladder irritation signs, SAS score, NRS score, and UTs. The differences were considered statistically significant. Furthermore, the incidence of urinary retention and re-retention was higher in the non-UC group than in the UC group; however, the difference was not statistically significant. In contrast to the traditional belief that non-indwelling catheters increase the risk of infection and urinary retention, non-indwelling catheters improved patient satisfaction with surgery. The length of hospital stay was shortened; ERAS programs have been reported to reduce the length of hospital stay by 30–50%, with a corresponding reduction in costs and complications [2]. Urinary catheter placement is a common area of dissatisfaction when assessing patient satisfaction with the surgical experience [10]. For many years, concerns have been raised regarding the safety and feasibility of not placing urinary catheters in urological patients; however, it is believed that patients undergoing flexible ureteroscopy without indwelling urinary catheters can avoid urinary catheter-related problems such as catheter-associated urinary tract infections and catheter-associated bladder discomfort.

This study has some limitations. First, this was a single-center, retrospective study with a small sample size. Second, there were no strict criteria to determine the non-placement of indwelling catheters, and the selection was mainly based on the preoperative wishes of the patients, which may have affected the conclusion. Therefore, in future, we will refine the indications for non-indwelling urinary catheters and exclude factors that may affect the conclusion.

Non-indwelling urinary catheters are safe and feasible for patients undergoing FUS-ICP.

FUS-ICP

flexible ureteroscopy with intelligent control of renal pelvic pressure

urinary catheter

ERAS

enhanced recovery after surgery

UTIs

urinary tract infections

SAS

Sedation-Agitation Scale

NRS

numerical rating scale

Ethics approval and consent to participate

The study was approved by institutional ethics committee of Ganzhou People's Hospital(TY-HKY2021-012). All patients provided written informed consent.

Consent for publication

Not applicable.

Data availability statement

The datasets used or analyzed in the current study are available from the corresponding author upon reasonable request.

Competing Interests

The authors declare that this study was conducted in the absence of any commercial or financial relationships that could be construed as potential conflicts of interest.

Funding

This study was funded by the Ganzhou Science and Technology Bureau Science and Technology Plan project 2022-2023.

Authors’ Contributions

DXL and SLM: design; HM and YBH: data acquisition; LYY and LXH：data analysis and interpretation; YBH and DXL: manuscript drafting and statistical analysis; HM and SLM: Critical revision. All the authors have read and approved the final version of this manuscript.

Acknowledgments

The authors sincerely thank all the medical workers who contributed to this treatment. We would like to thank Editage (www.editage.cn) for the English language editing.

Meddings J, Skolarus TA, Fowler KE, et al. Michigan Appropriate Perioperative (MAP) criteria for urinary catheter use in common general and orthopaedic surgeries: Results obtained using the rand/UCLA Appropriateness Method. BMJ Qual Saf 2019; 28: 56–66.
Ljungqvist O, Scott M, and Fearon KC. Enhanced recovery after surgery: A review. JAMA Surg 2017; 152: 292–298.
Deng J, Chen J, Yang T, et al. The safety and feasibility of no-placement of urinary catheter after single-port laparoscopic surgery in patients with benign ovarian tumor: A retrospective cohort study. Taiwan J Obstet Gynecol 2023; 62: 50–54.
Lai Y, Wang X, Zhou K, et al. The feasibility and safety of no placement of urinary catheter following lung cancer surgery: A retrospective cohort study with 2,495 cases. J Invest Surg 2021; 34: 568–574.
Zeng G, Traxer O, Zhong W, et al. International Alliance of Urolithiasis guideline on retrograde intrarenal surgery. BJU Int 2023; 131: 153–164.
Mitobe Y, Yoshioka T, Baba Y, et al. Predictors of catheter-related bladder discomfort after surgery: A literature review. J Clin Med Res 2023; 15: 208–215.
Deng X, Xie D, Huang X, et al. Suctioning Flexible ureteroscopy with Automatic Control of Renal Pelvic Pressure versus Mini PCNL for the Treatment of 2–3-cm Kidney Stones in Patients with a Solitary Kidney. Urol Int 2022; 106: 1293–1297.
Chen YJ, Liu SW, Deng XL, et al. The effect and safety assessment of monitoring ethanol concentration in exhaled breath combined with intelligent control of renal pelvic pressure on the absorption of perfusion fluid during flexible ureteroscopic lithotripsy. Int Urol Nephrol 2024; 56: 45–53.
Yu Y, Chen Y, Zhou X, et al. Comparison of novel flexible and traditional ureteral access sheath in retrograde intrarenal surgery. World J Urol 2024; 42: 7.
Lim N and Yoon H. Factors predicting catheter-related bladder discomfort in surgical patients. J Perianesth Nurs 2017; 32: 400–408.
Riker RR, Picard JT, and Fraser GL. Prospective evaluation of the Sedation-Agitation Scale for adult critically ill patients. Crit Care Med 1999; 27: 1325–1329.
Zugail AS, Pinar U, and Irani J. Evaluation of pain and catheter-related bladder discomfort relative to balloon volumes of indwelling urinary catheters: A prospective study. Investig Clin Urol 2019; 60: 35–39.
Nollen JM, Pijnappel L, Schoones JW, et al. Impact of early postoperative indwelling urinary catheter removal: A systematic review. J Clin Nurs 2023; 32: 2155–2177.
Fu CY, Wan L, Shen PY, et al. Feasibility of immediate removal of urinary catheter after laparoscopic gynecological surgery for benign diseases: A meta-analysis of randomized controlled trials. Int J Gynaecol Obstet 2022; 159: 622–629.
Yu D, Chai W, Sun X, et al. Emergence agitation in adults: Risk factors in 2,000 patients. Can J Anaesth 2010; 57: 843–848.
Lee SJ and Sung TY. Emergence agitation: Current knowledge and unresolved questions. Korean J Anesthesiol 2020; 73: 471–485.
Moreno CEL, Velandia OMM, Sánchez CAB, et al. Impact of urinary catheter on resistance patterns and clinical outcomes on complicated urinary tract infection. Int Urogynecol J 2023; 34: 1195–1201.
Wald HL, Ma A, Bratzler DW, et al. Indwelling urinary catheter use in the postoperative period: Analysis of the national surgical infection prevention project data. Arch Surg 2008; 143: 551–557.
Chen HJ, Chang CP, and Wang PH. Is it possible to no placement of indwelling urethra catheter during the surgery? Taiwan J Obstet Gynecol 2023; 62: 623–624.
Kim IK, Lee CS, Bae JH, et al. Immediate urinary catheter removal after colorectal surgery with the enhanced recovery after surgery protocol. Int J Colorectal Dis 2023; 38: 162-165.

No competing interests reported.

Download PDF

Journal Publication

published 24 Oct, 2024

Read the published version in BMC Urology →

Editorial decision: Revision requested
27 Aug, 2024
Reviews received at journal
19 Aug, 2024
Reviews received at journal
16 Aug, 2024
Reviewers agreed at journal
11 Aug, 2024
Reviewers agreed at journal
10 Aug, 2024
Reviewers agreed at journal
10 Jul, 2024
Reviewers invited by journal
30 May, 2024
Editor invited by journal
28 May, 2024
Submission checks completed at journal
28 May, 2024
Editor assigned by journal
28 May, 2024
First submitted to journal
24 May, 2024

You are reading this latest preprint version

Feasibility and safety of a non-indwelling urinary catheter after flexible ureteroscopy with intelligent control of renal pelvis pressure: A retrospective study

Status:

Journal Publication

Version 1

Abstract

Background

Methods

Results

Conclusions

Introduction

Methods

Patient data

Surgical Methods

Urinary catheter management

Results

Discussion

Conclusion

Abbreviations

Declarations

References

Additional Declarations

Status:

Journal Publication

Version 1