High rates of postoperative urinary retention following primary total hip replacement performed under combined general and spinal anaesthesia with intrathecal opiate

doi:10.1016/j.jor.2015.10.020

Journal of Orthopaedics

Volume 12, Supplement 2, December 2015, Pages S157-S160

https://doi.org/10.1016/j.jor.2015.10.020 Get rights and content

Abstract

Background

Postoperative urinary retention (POUR) occurs frequently following hip replacement.

Methods

94 consecutive primary hip arthroplasty patients were assessed prospectively for POUR. 80 patients followed our anaesthesia protocol with combined general and spinal anaesthesia using bupivacaine and intrathecal diamorphine.

Results

29 instances of POUR with higher rates in men and younger patients (under-50s), independent of either pre-existing renal impairment or opiate strength. POUR was observed to increase length of stay by 1.6 days.

Conclusions

We report a 36% overall rate of POUR. Males demonstrated a 3-fold increased risk. Patients should be counselled pre-operatively on the risk of urinary retention.

Introduction

Postoperative urinary retention (POUR) is a common problem with overall rates looking at the entire surgical population quoted between 4% and 6%.1, 2 Lower limb arthroplasty patients are described as having a 20-fold greater risk³ with much variation in the literature on the account of differences in anaesthesia and postoperative analgesia regimes. Published incidence rates thus vary widely from 0% to 75%,4, 5 with little overall difference on meta-analysis.³

Increasing age and male gender have already been identified as independent risk factors.⁶ In men, there is evidence both for and against a link between POUR and either obstructive uropathic symptoms or the International Prostate Symptom Score (IPSS).7, 8, 9 Propofol along with volatile anaesthesia agents used during a general anaesthesia impair the micturition reflex and reduce detrusor contractility.10, 11 Intrathecal bupivacaine used for spinal and epidural anaesthesia abolishes detrusor control within 5 min and can last up to eight hours.12, 13 High quality postoperative analgesia is believed to positively impact functional rehabilitation and in-patient hospital stay. Baldieri has summarised that all analgesia modalities have been linked with POUR, with a systematic review showing rates of 33% with postoperative systemic opiates and epidural analgesia, but only 9% with continuous peripheral nerve blocks³; however their quoted summary statistic could not control for anaesthesia modality.

Urinary catheterisation is traditionally advised for bladder volumes distended over 600 ml, to avoid long-term detrusor muscle damage and bladder atony.² Most studies use this as a cut-off to define postoperative urinary retention. Prolonged over-distension leads to ischaemic detrusor muscle injury and impaired function. Subsequent increased post-void residual volumes of static urine predispose to urinary tract infection (UTI) independent of urethral instrumentation.³ Either intermittent in-and-out catheterisation or an in-dwelling urinary catheter with early removal, once a patient is mobile following hip arthroplasty, is used to treat POUR and decompress the bladder. Early removal is important, as a risk of UTI is reported to rise 5% for each day a urinary catheter remains in situ,¹⁴ and associated bacteraemia is linked with deep prosthetic joint infection.15, 16, 17 Intermittent catheterisation is less favoured in the United Kingdom, as repeated urethral instrumentation has a greater financial burden,¹⁸ and is imagined to increase infection risk despite evidence to the contrary.¹⁹

Our institution is a dedicated tertiary-referral orthopaedic unit with a high volume arthroplasty department comprising six surgeons. Average annual primary hip arthroplasty procedures performed exceeds 850 cases per year,^d with established patient pathways that standardise rehabilitation, anaesthesia, and perioperative surgical care regimes. Our aim was to evaluate the burden of POUR, which is an attempt to identify risk factors and establish if POUR impacts on length of hospital stay, as the unit endeavours to devise and roll-out an effective enhanced recovery protocol.

Section snippets

Methods

Any patient undergoing primary total hip replacement during a 6-week consecutive period between October and November 2013, under the care of the six surgeons comprising the arthroplasty department, was included. Data were collected prospectively regarding their demographics, type of anaesthesia, strength of intrathecal opiate administered, pre-operative laboratory-calculated estimated glomerular filtration rate (eGFR), incidence of urinary retention within 24-hours of surgery. According to the

Results

94 consecutive primary hip replacements were performed during the six-week timeframe selected. Primary hip replacements designated as complex-primary for the purposes of National Joint Registry audit forms were not included. 14 patients received a planned variation from the protocol anaesthesia regime and were excluded from the main analysis, as the small numbers within this group for each anaesthesia variant precluded any meaningful statistical analysis. This left us with a sample size of 80

Discussion

Our data add to the limited evidence available and corroborate surprisingly high rates of postoperative urinary retention following primary hip arthroplasty. While published rates vary broadly, our finding of a 36% incidence of POUR following a unique combined general anaesthesia and spinal anaesthesia using intrathecal opiate is comparable with the 33% rate encountered in patients receiving systemic or epidural opiate analgesia, quoted in the systematic review by Baldieri.³ Men in our series

Conflicts of interest

The authors have none to declare.

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Cited by (17)

Post-operative urinary retention is impacted by neuromuscular block reversal agent choice: A retrospective cohort study in US hospital setting
2024, Journal of Clinical Anesthesia
Perioperative neuromuscular blocking agents are pharmacologically reversed to minimize complications associated with residual neuromuscular block. Neuromuscular block reversal with anticholinesterases (e.g., neostigmine) require coadministration of an anticholinergic agent (e.g., glycopyrrolate) to mitigate muscarinic activity; however, sugammadex, devoid of cholinergic activity, does not require anticholinergic coadministration. Single-institution studies have found decreased incidence of post-operative urinary retention associated with sugammadex reversal. This study used a multicenter database to better understand the association between neuromuscular block reversal technique and post-operative urinary retention.
Retrospective cohort study utilizing large healthcare database.
Non-profit, non-governmental and community and teaching hospitals and health systems from rural and urban areas.
61,898 matched adult inpatients and 95,500 matched adult outpatients.
Neuromuscular block reversal with sugammadex or neostigmine plus glycopyrrolate.
Incidence of post-operative urinary retention by neuromuscular block reversal agent and the independent association of neuromuscular block reversal technique and risk of post-operative urinary retention.
The incidence of post-operative urinary retention was 2-fold greater among neostigmine with glycopyrrolate compared to sugammadex patients (5.0% vs 2.4% inpatients; 0.9% vs 0.4% outpatients; both p < 0.0001). Multivariable logistic regression identified reversal with neostigmine to be independently associated with greater risk of post-operative urinary retention (inpatients: odds ratio, 2.20; 95% confidence interval, 2.00 to 2.41; p < 0.001; outpatients: odds ratio, 2.57; 95% confidence interval, 2.13 to 3.10; p < 0.001). Post-operative urinary retention-related visits within 2 days following discharge were five-fold higher among those reversed with neostigmine than sugammadex among inpatients (0.05% vs. 0.01%, respectively; p = 0.018) and outpatients (0.5% vs. 0.1%; p < 0.0001).
Though this study suggests that neuromuscular block reversal with neostigmine can increase post-operative urinary retention risk, additional studies are needed to fully understand the association.
A Retrospective Study of Anticholinergic Use and Later Mobilization as Risk Factors for Urinary Retention After Major Lower Extremity Joint Arthroplasty
2023, Journal of Arthroplasty
Postoperative urinary retention (POUR) is a common surgical complication of major joint arthroplasty and is associated with increased lengths of stay and urinary tract infections. Studies have found that certain anticholinergic medications and reduced mobility are associated with POUR. This study assessed the effect of anticholinergic burden and later postoperative ambulation on POUR.
In this retrospective cohort study, we included subjects who had undergone elective primary or revision hip or knee arthroplasty (total hip arthroplasty [THA] or total knee arthroplasty [TKA]) between March 2015 and December 2017 in a single health system. Anticholinergic burden was measured using the Anticholinergic Drug Scale (ADS). We performed bivariate and multivariable logistic regression with POUR as the dependent variable. Of the 1,397 study subjects, 622 (45%) underwent THA and 775 (55%) underwent TKA. Their mean age was 65 years (range, 21 to 98), and 841 (60%) were women. POUR developed in 183 (13%) subjects.
In multivariable analyses, ADS was associated with POUR after THA (P < .05), but not TKA (P = .08), while later ambulation was not associated with POUR after either procedure (P > .3 for both).
Anticholinergic burden after THA was independently associated with POUR. Strategies to reduce anticholinergic burden may help reduce POUR after THA.
Perioperative Medical Optimization of Symptomatic Benign Prostatic Hyperplasia Is an Economically Justified Infection Prevention Strategy in Total Joint Arthroplasty
2021, Journal of Arthroplasty
Abnormal voiding dynamics may be a modifiable risk factor for prosthetic joint infection (PJI) after total joint arthroplasty (TJA), but the cost-effectiveness of their optimization in the perioperative setting is unknown. Using a break-even analysis, we calculated the economic viability of perioperative voiding optimization for infection prevention after TJA in patients with symptomatic benign prostatic hyperplasia (BPH).
A perioperative voiding optimization algorithm was created to represent a common approach to treating symptomatic BPH before TJA. Treatment is initiated with a 6-week trial of tamsulosin (pathway 1), followed by 6 months of combination tamsulosin/finasteride therapy (pathway 2) if symptoms persist. Patients with unremitting symptoms after medical management undergo surgical correction with transurethral resection of the prostate (pathway 3). Costs associated with each pathway were derived from the literature and institutional purchasing records. A break-even economic model was constructed to calculate the absolute risk reduction (ARR) in the infection rate and number needed to treat necessary for cost-effectiveness.
Pathway 1 was cost-effective if it prevented 1 infection of 113 (ARR = 0.883%) TKAs or 140 (ARR = 0.714%) THAs. Pathway 2 was cost-effective if it obviated infection in 1 of 69 TKAs (ARR = 1.445%) or 86 THAs (ARR = 1.169%). Pathway 3 was only deemed cost-effective assuming a cost of $400,000 to treat a PJI (number needed to treat = 71, ARR = 1.406%). Cost-effectiveness for pathways 1 and 2 was maintained with varying voiding optimization costs, infection rates, and PJI costs.
Perioperative medical management of symptomatic BPH is an economically justified PJI prevention strategy, whereas surgical interventions appear to be financially substantiated only when considering the long-term societal costs of a PJI.
Incidence and Predictive Risk Factors of Postoperative Urinary Retention After Primary Total Knee Arthroplasty
2021, Journal of Arthroplasty
Citation Excerpt :
We found that higher PACU bladder scan volumes, longer operative duration, NSAID use, glycopyrrolate use, and less narcotic use were all associated with development of POUR. In contrast to previous studies, we did not find that male gender [1,2,8,10,11,17,18], perioperative IV fluid volume [9,16,17], or poor ASA classification [17] increased the risk POUR. To our knowledge, this is the first study to prospectively follow patients with serial bladder scans to identify a volume threshold predictive of POUR after TKA.
Postoperative urinary retention (POUR) after total knee arthroplasty (TKA) may cause urologic injury and delay patient discharge. This study measures the incidence of POUR and identifies predictive risk factors.
Two-hundred seventy-one consecutive patients undergoing primary unilateral TKA were prospectively enrolled. Bladder scans were performed in the postanesthesia care unit (PACU) and every four hours thereafter. POUR was defined as >400cc with inability to void and was treated with catheterization. Patient demographics, urologic history, operative data, perioperative medications, and bladder scanner volumes were investigated with the univariate and multivariate logistic regression analysis.
Fifty-five patients (20%) developed POUR. Compared with non-POUR patients, PACU bladder scan volumes were greater in patients who developed POUR (344cc vs 120cc, P < .001). POUR patients had lower BMI (27.8 vs 29.4, P = .03), longer operative duration (83.9 vs 76.0 minutes, P = .002), and lower ASA scores (2.2 vs 2.4, P = .02). Total intravenous fluid was equivalent between groups (1134cc vs 1185cc, P = .41). POUR patients received less narcotics measured by morphine milligram equivalents (16.1 vs 23.9, P < .001). Fifteen variables including spinal type (bupivacaine and ropivacaine) and paralytic use were not predictive of POUR. Potentially predictive variables included anesthetic types administered (spinal, general, regional, and combination) and perioperative administration of nonsteroidal anti-inflammatory drugs (NSAIDs), glycopyrrolate, and muscle relaxants. The multivariate analysis showed that NSAIDs (P = .05) and glycopyrrolate (P = .04) were significant predictors.
A significant percentage of patients develop POUR after TKA. Select patient demographics and PACU bladder scanning may identify those at risk. Appropriate pain control and judicious use of perioperative NSAIDs and glycopyrrolate may help minimize the risk of POUR.
A Comparison in Outcomes of Preoperative Single-shot versus Continuous Catheter Fascia Iliaca Regional Anesthesia in Geriatric Hip Fracture Patients
2020, Injury
Citation Excerpt :
Our rates of urinary retention did not differ between the two groups, with a combined incidence of 13.1%. The incidence of urinary retention has not been clearly described in the literature in regards to fascia iliaca blocks for hip fractures but is reported to be 9.3-36% for THA patients undergoing regional anesthesia [33,34]. There are several limitations to our study.
Fascia iliaca nerve blocks relieve pain in geriatric hip fracture patients and can be administered via a single-shot or continuous catheter. We compared perioperative opioid consumption and pain scores between these two blocks.
We performed a prospective, observational cohort study, including geriatric hip fracture patients who received a preoperative block. We compared morphine milligram equivalent (MME) consumption and visual analog scale (VAS) pain scores between single-shot and continuous fascia iliaca blocks at multiple time points: preoperative and on postoperative (POD) day 0, 1, and 2. We compared the change in preoperative total and hourly opioid consumption before and after block placement within and between groups. Secondary outcomes included opioid related adverse events, length of stay, and readmission rates.
107 patients were analyzed, 66 received a single-shot and 41 a continuous block. No significant differences were found between both blocks at any time point for median MME consumption or pain scores. MME [IQR]: preoperative 20.5 [6.0,48.8] vs. 24.0 [8.8,48.0], p=0.95; POD0 6.0 [0.0,18.6] vs. 10.0 [0.0,14.0], p=0.52; POD1 12.0 [0.0,30.0] vs. 18.0 [5.0,24.0], p=0.69; POD2 6.0 [0.0,21.2] vs. 12.0 [0.0,24.0], p=0.54. VAS [IQR]: preoperative 4.0 [2.2,5.3] vs. 4.6 [3.2,5.3], p=0.34; POD0 1.3 [0.0,3.7] vs. 2.5 [0.0,3.6], p=0.73; POD1 2.9 [1.7,4.4] vs. 3.7 [1.5,4.7], p=0.59; POD2 2.4 [1.0,4.4] vs. 3.3 [1.9,4.2], p=0.18. Preoperative MME/hr significantly decreased after the block for both groups: 1.05 [0.0,2.2] to 0.0 [0.0,0.0], p < 0.001; 1.4 [0.6,3.1] to 0.0 [0.0,0.1], p < 0.001. The reduction in MME/hr between groups was not significantly different: 0.9 [0.0,1.9] vs. 1.4 [0.6,3.1], p = 0.067. We found no significant differences in secondary outcomes between groups.
We report no differences in opioid use and pain scores between single-shot and continuous catheter fascia iliaca nerve blocks. Both blocks similarly reduce preoperative opioid consumption.
Identifiable Risk Factors to Minimize Postoperative Urinary Retention in Modern Outpatient Rapid Recovery Total Joint Arthroplasty
2019, Journal of Arthroplasty
Postoperative urinary retention (POUR) following total joint arthroplasty (TJA) presents a significant barrier to outpatient and early discharge TJA. This study examined the incidence and risk factors for acute POUR in a modern, evidence-based, outpatient, and early discharge TJA program.
Prospectively recorded data on 685 consecutive primary unilateral TJAs discharged the day of or day after surgery were retrospectively reviewed. POUR was diagnosed by a perioperative internal medicine specialist. Univariate analysis of potential predictors was performed, followed by binary logistic regression (BLR) testing of predictors with P ≤ .25.
After exclusions for confounds, the final analysis sample consisted of 633 procedures. The overall incidence of POUR was 5.5% (3.9% for same day discharges). Male gender, history of urinary retention, use of rocuronium, use of glycopryrrolate, use of neostigmine, fentanyl spinals, and the absence of an indwelling urethral catheter were associated with acute POUR and met criteria for entry into multivariate BLR. Seventeen additional predictors, including kidney disease and outpatient surgery were unrelated to POUR. In the final BLR model (P = .001), male patients who received glycopyrrolate with neostigmine had a 34% probability of developing POUR, which declined to 2.8% in the absence of these risk factors.
Despite a relatively low incidence of 5.5%, avoidance of anticholinergics and cholinesterase inhibitors during anesthesia should be carefully considered in outpatient TJA, particularly in stand-alone ambulatory surgery centers.

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Original ArticleHigh rates of postoperative urinary retention following primary total hip replacement performed under combined general and spinal anaesthesia with intrathecal opiate

Abstract

Background

Methods

Results

Conclusions

Introduction

Section snippets

Methods

Results

Discussion

Conflicts of interest

J Clin Anesth

Br J Anaesth

Surgeon

Urol Clin North Am

J Arthroplasty

J Arthroplasty

Br J Anaesth

Br J Anaesth

Predictors of postoperative urinary retention

Am Surg

Postoperative urinary retention: anesthetic and perioperative considerations

Anesthesiology

Urinary retention after total hip and knee arthroplasty

Minerva Anestesiol

Patient-controlled analgesia and urinary retention following lower limb joint replacement: prospective audit and logistic regression analysis

Eur J Anaesthesiol

Original Article
High rates of postoperative urinary retention following primary total hip replacement performed under combined general and spinal anaesthesia with intrathecal opiate