The Journal of Arthroplasty 30 (2015) 502–506
Contents lists available at ScienceDirect
The Journal of Arthroplasty journal homepage: www.arthroplastyjournal.org
General Anesthesia: To catheterize or Not? A Prospective Randomized Controlled Study of Patients Undergoing Total Knee Arthroplasty ZeYu Huang, MD, PhD, Jun Ma, MD 1, Bin Shen, MD, PhD, FuXing Pei, MD Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu, People’s Republic of China
a r t i c l e
i n f o
Article history: Received 11 June 2014 Accepted 23 September 2014 Keywords: postoperative urinary retention total knee arthroplasty general analgesia urinary tract infection risk factors
a b s t r a c t This study was to investigate whether urinary catheterization could be avoided for patients undergoing total knee arthroplasty (TKA) under general anesthesia with saphenous nerve block. 314 patients from a single surgical team were randomized to receive either an indwelling urinary catheter or no urinary catheter before the surgery. The results revealed that the prevalence of postoperative urinary retention (POUR) was quite low in both groups (5.7% vs 6.4%, P = 1). Additionally, the prevalence of urinary tract infection was significantly higher in patients using an indwelling catheter (5.1% vs 0.6%, P = 0.036). We also identified age, male gender, ASA grade, benign prostatic hypertrophy, intraoperative intravenous fluid and duration of surgery as the risk factors for POUR in these patients. © 2014 Elsevier Inc. All righs reserved.
Postoperative urinary retention (POUR) is a common complication following many surgical procedures, especially total joint arthroplasty [1]. Though some researchers developed different pharmacological approaches to avoiding POUR, the results seem inconclusive or controversial [2], which leaves indwelling or intermittent urinary catheterization as the only option for prevention and treatment of POUR. However, both POUR and bladder catheterization can increase the risk of urinary tract infection (UTI), which can lead to hematogenous bacteremia [3–5], seeding of the implant, and subsequent joint infection following total knee arthroplasty (TKA). In addition, POUR and its sequelae may prevent early mobilization, prolong the hospitalization and increase readmission rates [6]. Urinary catheters are usually used for longer surgical procedures to allow monitoring urinary output and guiding fluid resuscitation. And also they are widely used in the surgeries performed under neuraxial anesthesia, which is considered to result in loss of the ability to sense bladder distention and subsequent to neurogenic bladder problems [1]. However, with the development of blood saving and anesthetic techniques, the intraoperative blood loss in TKA is extremely reduced, making the intraoperative fluid control less important [7]. In addition, the introduction of fast-track clinical pathways and the need to accelerate hospital discharges have also cast questions on the preoperative urinary catheterization.
Source of Funding: This research was funded by the China Health Ministry Program (201302007). The Conflict of Interest statement associated with this article can be found at http://dx. doi.org/10.1016/j.arth.2014.09.028. Reprint requests: FuXing Pei, M.D., Department of Orthopaedics, West China hospital, Sichuan University, 37# Wainan Guoxue Road, Chengdu, 610041, People’s Republic of China. 1 Jun Ma contributed equally to this work. http://dx.doi.org/10.1016/j.arth.2014.09.028 0883-5403/© 2014 Elsevier Inc. All righs reserved.
Currently, there is no standard protocol for the implementation and maintenance of indwelling catheters for total knee arthroplasty. At many centers, including ours, preoperative indwelling catheterization is a routine practice for patients undergoing TKA. The aim of this study was therefore to investigate whether urinary catheterization could be avoided for all patients undergoing TKA under general anesthesia with saphenous nerve block. The hypothesis of the current prospective study was that rates of POUR would be low for patients with and without a urinary catheter. Materials and Methods This prospective, randomized controlled study was approved by the Institutional Review Board of our center (No. 201302009). Enrollment and Screening All patients, aged 18 years and older, who were scheduled for a primary TKA for end-stage osteoarthritis were approached for participation in the study. Exclusion criteria included revisions, bilateral procedures, surgical history of urinary system, UTI and systematical conditions (renal disease, renal failure, chronic renal insufficiency, or an indwelling catheter at the time of surgery) needing intraoperative monitoring urine output. Patients taking medication for a diagnosis of benign prostatic hypertrophy were included in the study. All patients followed a uniform preoperative food and liquid intake protocol. Solid food intake was forbidden after 10:00 P.M. on the day prior to surgery. No liquid was taken in after 12:00 A.M. on the evening prior to surgery. No patient was permitted to consume any food or liquid on the surgical day until the completion of the procedure. Before the
Z. Huang et al. / The Journal of Arthroplasty 30 (2015) 502–506
surgery, patients were given intravenous crystal liquid of 500 mL– 1000 mL based on the operation sequence. Recruited patients were randomized to receive either an indwelling urinary catheter (control group) or no urinary catheter (study group) before the surgery. Randomization was performed under the sole knowledge of research personnel with the use of sealed envelopes in a 1:1 ratio opened just prior to surgery. The patients and the surgeons were blinded to the selection group until anesthesia or sedation. All the surgeries were performed by one surgical team, composed of four senior orthopedic surgeons, and conducted under general anesthesia with saphenous nerve block (20 mL of ropivacaine 0.5%). TKA was performed in the standard way, using a midline skin incision, a standard medial parapatellar approach and a measured resection technique. A tourniquet was applied to all the patients from both groups with a strategy of inflating before the incision and deflating after the closure of the incision controlled at 100 mmHg above systolic pressure. Intraoperative intravenous liquid was controlled under 1500 mL. Cement knee system was used in all patients.
Periopeative Course After the surgery, patients were first transferred to the anesthesia recovery unit for a 1-h period of postoperative care, then to the in-patients unit. All patients were evaluated and began walking on the day of the surgery. A knee brace was used in all patients to protect the surgical side. Partial weight bear was permitted. Physical therapy three times per day supervised by a physiotherapist was initiated on the surgical day and lasted until hospital discharge. Fluid therapy was discontinued on the postoperative day 1. Perioperative pain management was the same between the two groups; all patients started to receive Celebrex (200 mg every twelve hours) on the day of admission, then changed to Diclofenac (50 mg
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every twelve hours) after the surgery and continued throughout the hospital stay. No postoperative narcotic analgesia was utilized. The control group was managed following the standard postoperative TKA protocol at our center, which involves removing the indwelling catheter within 24 h postoperatively. Once the catheter was removed, patients were encouraged to drink water and void. Also, symptoms of POUR and UTI were monitored. In the study group, patients were monitored for POUR based on the symptoms and bladder ultrasound scans performed by senior nursing staff. Patients who didn’t void within four hours and had a urinary volume N400 mL confirmed by ultrasound were managed with a one-time catheterization. If the urinary volume was less than 400 mL measured by ultrasound, the bladder scan was repeated in two hours. Straight catheterization was tolerated for up to two times prior to the placement of an indwelling catheter (Fig. 1). In the control group, bladder scanning was started at six hours after removing the catheter if no spontaneous voiding happened. A one-time catheterization was managed for the patients with a urine volume of more than 400 mL. Patients requiring catheterization were considered to have POUR. Also, a one-time catheterization was repeated twice before an indwelling catheter was placed. In both groups, bladder ultrasound scanning was also performed in patients with suprapubic discomfort and the inability to void. A urine sample for urinalysis and culture was routinely obtained from the patients with symptoms suggesting UTI and patients experiencing POUR. UTI was diagnosed based on the international guidelines [8] as follows: pyrexia or body temperature of 38 °C, urinary tract symptoms (dysuria, increased frequency of urination, urinary urgency, suprapubic pain and burning on micturition) and positive urine culture (N107 bacterial colonies of microorganism forming units per liter). Data Analysis All detailed data were collected and recorded by an independent secretary for later analysis. The data we used to analyze included
Fig. 1. Flowchart of the urinary retention protocol for both groups.
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demographic characteristics, the duration of surgery, the prevalence of straight catheterization, the prevalence of indwelling catheterization after the surgery, the volume of urine following catheterization, the prevalence of UTI, the amount of perioperative fluid given to the patients, the length of hospitalization and any complications. All data management and statistical analysis were performed with SPSS version 18.0 software (SPSS Inc., Chicago, IL, USA). Independent t-tests were used for continuous variables. Person chi-square test or Fisher exact test was used to analyze the categorical variables. Logistic regression analysis was also performed. Results During the recruitment period from June 2013 to December 2013, 367 patients were scheduled to have a primary unilateral TKA because of osteoarthritis in our center. Of them all, twenty-eight patients were ineligible and twenty-five patients declined participation. The remaining 314 eligible patients were recruited and formed the study cohort; 157 were randomized to the control group and the other 157 to the study group (Fig. 2). The two groups were comparable at baseline (Table 1). Nine patients (5.7%) in the control group developed POUR following removal of the indwelling catheter. The mean volume of urine at the time of one time catheterization in these patients was 798 ± 65 mL. One underwent a single, straight catheterization and the other eight patients required an indwelling catheterization after receiving one-time catheterization for twice, whereas ten patients (6.4%) in the study group developed POUR. The mean volume of urine in these patients was 732 ± 47 mL. Six of them had a single catheterization. An indwelling catheter was required in the other four patients. All the indwelling catheters were discontinued prior to discharge. No statistical differences
Table 1 Demographics and Outcomes. Control Group (n = 157) Agea (yr) Male gender BMIa (kg/m2) ASA (%) I II III Surgical site (right/left) Benign prostatic hypertrophy Intraoperative intravenous fluida (mL) Duration of the surgerya (min) Postoperative urinary retention Postoperative urinary tract infection Length of staya (d)
Study Group (n = 157)
P Value
66.9 ± 8.5 33 (21%) 24.4 ± 3.6
67.4 ± 8.2 38 (24.2%) 24.5 ± 3.4
0.633 0.590 0.676
27 (17.2%) 123 (78.3%) 7 (4.5%) 84/73 8 (5.1%) 816.9 ± 131.1
31 (19.7%) 117 (74.5%) 9 (5.8%) 75/82 12 (7.6%) 810.8 ± 125.9
0.736
74.6 ± 10.0 9 (5.7%)
74.8 ± 9.4 10 (6.4%)
0.829 1
8 (5.1%)
1 (0.6%)
0.036b
6.5 ± 1.4
6.3 ± 1.9
0.386
0.367 0.489 0.677
P values calculated using independent t-test, Person chi-square or Fisher exact test. Abbreviations: BMI, body mass index; ASA, American Society of Anesthesiologists. a The values are given as mean ± standard deviation. b Significantly different.
were observed in terms of the rate POUR (P = 1) and length of stay (P = 0.386) between the two groups (Table 1). However, the rate of UTI was significantly lower in the study group than the control group (0.6% vs 5.1%, P = 0.036) (Table 1). A history of benign prostatic hypertrophy was reported for five (26.3%) of the nineteen patients who developed POUR, compared with fifteen (5.1%) of the 295 patients who didn’t develop POUR. The difference reached significance level (P = 0.004). Also significant differences were observed in terms of age (P b 0.001), gender (P = 0,019), American Society of Anesthesiologists (ASA) grade (P = 0.013), intraoperative intravenous fluid (P b 0.001), duration of the surgery (P = 0.03) and the length of stay (P b 0.001) between patients who developed POUR and those who didn’t. There was no significant difference between the two groups of patients in terms of body mass index (BMI) (P = 0.510) and postoperative urinary tract infection (P = 0.097) (Table 2). The correlation analysis failed to detect the correlation between patients with UTI and patients with POUR (P = 0.175). Multivariate logistical regression with POUR as the dependent outcome variable showed that age, male gender, ASA grade, benign prostatic hypertrophy, intraoperative intravenous fluid and duration of the surgery could be considered as independent risk factors for POUR (Table 3). Eight patients in the control group developed UTI while only one patient in the study group developed UTI during the hospital stay. The one patient in the study group with a UTI was also a POUR patient. All these patients were treated with intravenous antibiotics and received consecutive urine analysis and culture for twice to confirm the cure of the UTI. Discussion
Fig. 2. Flow diagram of patients involved.
POUR is a well-known complication in total joint arthroplasty. Previously, few studies investigated the prevalence of this complication after total joint arthroplasty [9–12]. In the study by Macdowell et al [12], they reported a POUR rate of 13.9% in 173 patients undergoing THA with epidural anesthesia. In another study [11], 119 patients undergoing total joint arthroplasty were randomized either to receive or not receive a urinary catheter during surgery. In this study, researchers reported a POUR rate of 35% for patients without an indwelling urinary catheter compared with a POUR rate of 19% for patients with an indwelling urinary catheter. Most of the patients in this study also received indwelling epidural catheters, retained to provide analgesia during the first postoperative two days. Many studies [9,10] have proved that the type of anesthesia is a risk factor for POUR. Davis et al [9] reported that the incidence
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Table 2 Demographic Differences Between Patients With and Without POUR.
Agea (yr) Male gender BMIa (kg/m2) ASA I II III Benign prostatic hypertrophy (%) Intraoperative intravenous fluida (mL) Duration of the surgerya (min) Postoperative urinary tract infection Length of staya (d)
Postoperative Urinary Retention (n = 19)
No Postoperative Urinary Retention (n = 295)
P Value
75.2 ± 7.0 9 (47.4%) 23.9 ± 3.2
66.6 ± 8.2 62 (21.0%) 24.5 ± 3.5
b0.001b 0.019b 0.510
4 (21.1%) 11 (57.8%) 4 (21.1%) 5 (26.3%) 944.7 ± 144.2 79.2 ± 12.4 2 (10.5%) 7.7 ± 1.5
54 (18.3%) 229 (77.6%) 12 (4.1%) 15 (5.1%) 805.4 ± 122.8 74.2 ± 9.5 7 (2.4%) 6.3 ± 1.6
0.013b
0.004b b0.001b 0.030b 0.097 b0.001b
P values calculated using independent t-test, Person chi-square or Fisher exact test. Abbreviations: POUR, postoperative urinary retention; BMI, body mass index; ASA, American Society of Anesthesiologists. a The values are given as mean ± standard deviation. b Significantly different.
of POUR following spinal anesthesia was significantly lower than that after epidural anesthesia (21.8% vs 46.7%, P b 0.05). In another retrospective study which included 1440 patients undergoing TKA or THA, Donald et al reported a lower rate of POUR in patients following general anesthesia than those after spinal anesthesia [10]. With the development of surgical techniques, surgical care and the introduction of fast-track clinical pathways, epidural anesthesia is less commonly used for patients undergoing TKA. Thus, we conducted this prospective randomized study to investigate whether urinary catheterization could be avoided for patients undergoing TKA under general anesthesia with saphenous nerve block, a common practice in our center. According to the previous studies [1,2,6,13], factors associated with increased risk of POUR are age, male gender, ASA grade, type of surgery, type of anesthesia and analgesia, previous history from the urinary tract and neurologic comorbidities, duration of surgery, and intraoperative intravenous fluid. Several animal studies [14,15] have reported that sedative, hypnotic agents and volatile anesthetics can impair the micturition reflex in varying degrees, leading to the decreased detrusor contractions. Many clinical studies [6,7] have illustrated that the general anesthesia has lower incidence of POUR than epidural and spinal anesthesia. In addition, there has been ample evidence that systemic opioids impair bladder function by spate central and peripheral mechanisms, resulting in relaxation of the detrusor and contraction of the bladder sphincter. Combrisson et al [15] reported a POUR incidence of 18.3% in patients whose analgesia protocol after lower limb arthroplasty was provided by systemic opioids. A recent study identified the use of intrathecal morphine as a risk factor for POUR (odds ratio, 1.4; 95% confidence interval, 1.1 to 1.9) [10]. In our study, we used the combination of general anesthesia and saphenous nerve block as the anesthesia protocol. Cumulative evidence has proved that by using multimodal anesthesia patients can have less postoperative knee pain and decreased consumption of opiates, thus facilitating patients’ functional rehabilitation [16]. Also, we used the oral Celebrex and Diclofenac as the analgesia Table 3 Multivariate Logistic Regression for POUR. Predictor
P Value
Odds Ratio
95% Confidence Interval
Age Male gender BMI ASA grade Benign prostatic hypertrophy Indwelling catheter Intraoperative intravenous fluid Duration of the surgery
b0.001a 0.028a 0.870 0.037a 0.048a 0.282 0.006a 0.013a
1.330 3.558 0.984 5.418 4.038 2.019 1.008 1.083
1.158 to 1.529 1.149 to 11.021 0.808 to 1.197 1.107 to 26.517 1.012 to 34.113 0.866 to 12.904 1.002 to 1.013 1.017 to 1.153
Abbreviations: POUR, postoperative urinary retention; BMI, body mass index; ASA, American Society of Anesthesiologists. a Significantly different.
protocol instead of PCA, oral opioids and intrathecal morphine. This might explain why the POUR rate is lower than the studies mentioned before. To make the two groups comparable at the baseline, we excluded the patients who had previous history of the urinary tract and neurologic comorbidities. Still, our multivariate logistic regression for POUR identified age, male gender, ASA grade, duration of surgery, intraoperative intravenous fluid as the risk factors. Among them, age, male gender and ASA grade were considered as the unmodifiable risk factors for development of POUR and well discussed [17]. As to the duration of surgery and intraoperative intravenous fluid, with the development of surgical techniques and the emphasis of optimal perioperative management these risk factors can be well controlled. For example, by applying the tourniquet [7], tranexamic acid [18], and blood retransfusion in TKA [19], which are routine practices in our center, the intraoperative blood loss can be significantly reduced, thus the requirement for intraoperative fluid control is less essential. Previously, the impact of intraoperative intravenous fluids on POUR has been studied and there is strong evidence that excessive administration of crystalloids can lead to overdistension of bladder [1,6,20–23]. Wynd et al [24] found that patients with POUR, undergoing lower limb arthroplasty, received more intravenous fluids throughout the whole perioperative period than those without POUR. In our study, we discontinued intravenous fluid on the first postoperative day. But still, we found a similar phenomenon which proved that intraoperative intravenous fluid is a risk factor for POUR. All these consequences are not in accordance with the requirements of fast-track clinical pathways. Our study suggests that the indwelling catheters aren’t necessary for the majority of the patients undergoing TKA. Without the indwelling catheter, the incidence of UTI can be effectively lowered. Except for the randomized, prospective nature of our study, some limitations of the current study warrant further discussion. First, we included the patients with benign prostatic hypertrophy, which is considered as a risk factor for POUR in our study. And our multivariate logistic regression has confirmed that. Second, to make the baselines of both groups comparable, we have to exclude the patients with surgical history of urinary system, UTI and systematical conditions intraoperative monitoring urine output. We also didn’t use oral or systemic opioids as postoperative analgesia protocol. Thus, we could not identify more risk factors for POUR. The results of this high-quality randomized controlled trial revealed several important findings as follows: first, the prevalence of POUR is relatively low (6.4%) without using an indwelling catheter in patients undergoing TKA with combination use of general anesthesia and saphenous nerve block. This finding has encouraged us to reconsider whether we should use an indwelling catheter as a routine practice in TKA, especially considering that we also include patients with benign prostatic
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hypertrophy. Second, we found that the prevalence of UTI was significantly higher in patients using an indwelling catheter compared with those who didn’t (5.1% vs 0.6%, P = 0.036). Third, we proved that older age, male gender, higher ASA grade, benign prostatic hypertrophy, intraoperative intravenous fluid and longer duration of surgery tend to be the risk factors for POUR in patients undergoing TKA. Conclusion In conclusion, our study has found that indwelling catheter during surgery, which can increase the postoperative UTI, is not routinely necessary for the majority of the patients undergoing TKA under general anesthesia with saphenous nerve block. We also identified age, male gender, higher ASA grade, benign prostatic hypertrophy, intraoperative intravenous fluid and longer duration of surgery as the risk factors of POUR. Acknowledgments No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. References 1. Balderi T, Carli F. Urinary retention after total hip and knee arthroplasty. Minerva Anestesiol 2010;76(2):120. 2. Baldini G, Bagry H, Aprikian A, et al. Postoperative urinary retention: anesthetic and perioperative considerations. Anesthesiology 2009;110(5):1139. 3. Madersbacher H, Cardozo L, Chapple C, et al. What are the causes and consequences of bladder overdistension? ICI-RS 2011. Neurourol Urodyn 2012;31(3):317. 4. Pulido L, Ghanem E, Joshi A, et al. Periprosthetic joint infection: the incidence, timing, and predisposing factors. Clin Orthop Relat Res 2008;466(7):1710. 5. Berbari EF, Hanssen AD, Duffy MC, et al. Risk factors for prosthetic joint infection: case–control study. Clin Infect Dis 1998;27(5):1247. 6. Karason S, Olafsson TA. Avoiding bladder catheterisation in total knee arthroplasty: patient selection criteria and low-dose spinal anaesthesia. Acta Anaesthesiol Scand 2013;57(5):639.
7. Huang ZY, Pei FX, Ma J, et al. Comparison of three different tourniquet application strategies for minimally invasive total knee arthroplasty: a prospective nonrandomized clinical trial. Arch Orthop Trauma Surg 2014;134(4):561. 8. Balderi T, Mistraletti G, D'Angelo E, et al. Incidence of postoperative urinary retention (POUR) after joint arthroplasty and management using ultrasound-guided bladder catheterization. Minerva Anestesiol 2011;77(11):1050. 9. Davis S, Erskine R, James MF. A comparison of spinal and epidural anaesthesia for hip arthroplasty. Can J Anaesth 1992;39(6):551. 10. Griesdale DE, Neufeld J, Dhillon D, et al. Risk factors for urinary retention after hip or knee replacement: a cohort study. Can J Anaesth 2011;58(12):1097. 11. Knight RM, Pellegrini Jr VD. Bladder management after total joint arthroplasty. J Arthroplasty 1996;11(8):882. 12. Macdowell AD, Robinson AH, Hill DJ, et al. Is epidural anaesthesia acceptable at total hip arthroplasty? A study of the rates of urinary catheterisation. J Bone Joint Surg (Br) 2004;86(8):1115. 13. Kerr DR, Kohan L. Local infiltration analgesia: a technique for the control of acute postoperative pain following knee and hip surgery: a case study of 325 patients. Acta Orthop 2008;79(2):174. 14. Matsuura S, Downie JW. Effect of anesthetics on reflex micturition in the chronic cannula-implanted rat. Neurourol Urodyn 2000;19(1):87. 15. Combrisson H, Robain G, Cotard JP. Comparative effects of xylazine and propofol on the urethral pressure profile of healthy dogs. Am J Vet Res 1993;54(12):1986. 16. Parvizi J, Miller AG, Gandhi K. Multimodal pain management after total joint arthroplasty. J Bone Joint Surg Am 2011;93(11):1075. 17. Bjerregaard LS, Bagi P, Kehlet H. Postoperative urinary retention (POUR) in fast-track total hip and knee arthroplasty. Acta Orthop 2014;85(1):8. 18. Huang Z, Ma J, Shen B, et al. Combination of intravenous and topical application of tranexamic acid in primary total knee arthroplasty: a prospective randomized controlled trial. J Arthroplast 2014. http://dx.doi.org/10.1016/j.arth.2014.05.026. 19. Friederichs MG, Mariani EM, Bourne MH. Perioperative blood salvage as an alternative to predonating blood for primary total knee and hip arthroplasty. J Arthroplasty 2000; 17(3):298. 20. Petros JG, Rimm EB, Robillard RJ, et al. Factors influencing postoperative urinary retention in patients undergoing elective inguinal herniorrhaphy. Am J Surg 1991;161 (4):431. 21. Gerstenberg TC, Nielsen ML, Clausen S, et al. Bladder function after abdominoperineal resection of the rectum for anorectal cancer. Urodynamic investigation before and after operative in a consecutive series. Ann Surg 1980;191(1):81. 22. Kemp D, Tabaka N. Postoperative urinary retention: part II—a retrospective study. J Post Anesth Nurs 1990;5(6):397. 23. Tammela T, Kontturi M, Lukkarinen O. Postoperative urinary retention. II. Micturition problems after the first catheterization. Scand J Urol Nephrol 1986;20(4):257. 24. Wynd CA, Wallace M, Smith KM. Factors influencing postoperative urinary retention following orthopaedic surgical procedures. Orthop Nurs 1996;15(1):43.
Contents lists available at ScienceDirect
The Journal of Arthroplasty journal homepage: www.arthroplastyjournal.org
General Anesthesia: To catheterize or Not? A Prospective Randomized Controlled Study of Patients Undergoing Total Knee Arthroplasty ZeYu Huang, MD, PhD, Jun Ma, MD 1, Bin Shen, MD, PhD, FuXing Pei, MD Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu, People’s Republic of China
a r t i c l e
i n f o
Article history: Received 11 June 2014 Accepted 23 September 2014 Keywords: postoperative urinary retention total knee arthroplasty general analgesia urinary tract infection risk factors
a b s t r a c t This study was to investigate whether urinary catheterization could be avoided for patients undergoing total knee arthroplasty (TKA) under general anesthesia with saphenous nerve block. 314 patients from a single surgical team were randomized to receive either an indwelling urinary catheter or no urinary catheter before the surgery. The results revealed that the prevalence of postoperative urinary retention (POUR) was quite low in both groups (5.7% vs 6.4%, P = 1). Additionally, the prevalence of urinary tract infection was significantly higher in patients using an indwelling catheter (5.1% vs 0.6%, P = 0.036). We also identified age, male gender, ASA grade, benign prostatic hypertrophy, intraoperative intravenous fluid and duration of surgery as the risk factors for POUR in these patients. © 2014 Elsevier Inc. All righs reserved.
Postoperative urinary retention (POUR) is a common complication following many surgical procedures, especially total joint arthroplasty [1]. Though some researchers developed different pharmacological approaches to avoiding POUR, the results seem inconclusive or controversial [2], which leaves indwelling or intermittent urinary catheterization as the only option for prevention and treatment of POUR. However, both POUR and bladder catheterization can increase the risk of urinary tract infection (UTI), which can lead to hematogenous bacteremia [3–5], seeding of the implant, and subsequent joint infection following total knee arthroplasty (TKA). In addition, POUR and its sequelae may prevent early mobilization, prolong the hospitalization and increase readmission rates [6]. Urinary catheters are usually used for longer surgical procedures to allow monitoring urinary output and guiding fluid resuscitation. And also they are widely used in the surgeries performed under neuraxial anesthesia, which is considered to result in loss of the ability to sense bladder distention and subsequent to neurogenic bladder problems [1]. However, with the development of blood saving and anesthetic techniques, the intraoperative blood loss in TKA is extremely reduced, making the intraoperative fluid control less important [7]. In addition, the introduction of fast-track clinical pathways and the need to accelerate hospital discharges have also cast questions on the preoperative urinary catheterization.
Source of Funding: This research was funded by the China Health Ministry Program (201302007). The Conflict of Interest statement associated with this article can be found at http://dx. doi.org/10.1016/j.arth.2014.09.028. Reprint requests: FuXing Pei, M.D., Department of Orthopaedics, West China hospital, Sichuan University, 37# Wainan Guoxue Road, Chengdu, 610041, People’s Republic of China. 1 Jun Ma contributed equally to this work. http://dx.doi.org/10.1016/j.arth.2014.09.028 0883-5403/© 2014 Elsevier Inc. All righs reserved.
Currently, there is no standard protocol for the implementation and maintenance of indwelling catheters for total knee arthroplasty. At many centers, including ours, preoperative indwelling catheterization is a routine practice for patients undergoing TKA. The aim of this study was therefore to investigate whether urinary catheterization could be avoided for all patients undergoing TKA under general anesthesia with saphenous nerve block. The hypothesis of the current prospective study was that rates of POUR would be low for patients with and without a urinary catheter. Materials and Methods This prospective, randomized controlled study was approved by the Institutional Review Board of our center (No. 201302009). Enrollment and Screening All patients, aged 18 years and older, who were scheduled for a primary TKA for end-stage osteoarthritis were approached for participation in the study. Exclusion criteria included revisions, bilateral procedures, surgical history of urinary system, UTI and systematical conditions (renal disease, renal failure, chronic renal insufficiency, or an indwelling catheter at the time of surgery) needing intraoperative monitoring urine output. Patients taking medication for a diagnosis of benign prostatic hypertrophy were included in the study. All patients followed a uniform preoperative food and liquid intake protocol. Solid food intake was forbidden after 10:00 P.M. on the day prior to surgery. No liquid was taken in after 12:00 A.M. on the evening prior to surgery. No patient was permitted to consume any food or liquid on the surgical day until the completion of the procedure. Before the
Z. Huang et al. / The Journal of Arthroplasty 30 (2015) 502–506
surgery, patients were given intravenous crystal liquid of 500 mL– 1000 mL based on the operation sequence. Recruited patients were randomized to receive either an indwelling urinary catheter (control group) or no urinary catheter (study group) before the surgery. Randomization was performed under the sole knowledge of research personnel with the use of sealed envelopes in a 1:1 ratio opened just prior to surgery. The patients and the surgeons were blinded to the selection group until anesthesia or sedation. All the surgeries were performed by one surgical team, composed of four senior orthopedic surgeons, and conducted under general anesthesia with saphenous nerve block (20 mL of ropivacaine 0.5%). TKA was performed in the standard way, using a midline skin incision, a standard medial parapatellar approach and a measured resection technique. A tourniquet was applied to all the patients from both groups with a strategy of inflating before the incision and deflating after the closure of the incision controlled at 100 mmHg above systolic pressure. Intraoperative intravenous liquid was controlled under 1500 mL. Cement knee system was used in all patients.
Periopeative Course After the surgery, patients were first transferred to the anesthesia recovery unit for a 1-h period of postoperative care, then to the in-patients unit. All patients were evaluated and began walking on the day of the surgery. A knee brace was used in all patients to protect the surgical side. Partial weight bear was permitted. Physical therapy three times per day supervised by a physiotherapist was initiated on the surgical day and lasted until hospital discharge. Fluid therapy was discontinued on the postoperative day 1. Perioperative pain management was the same between the two groups; all patients started to receive Celebrex (200 mg every twelve hours) on the day of admission, then changed to Diclofenac (50 mg
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every twelve hours) after the surgery and continued throughout the hospital stay. No postoperative narcotic analgesia was utilized. The control group was managed following the standard postoperative TKA protocol at our center, which involves removing the indwelling catheter within 24 h postoperatively. Once the catheter was removed, patients were encouraged to drink water and void. Also, symptoms of POUR and UTI were monitored. In the study group, patients were monitored for POUR based on the symptoms and bladder ultrasound scans performed by senior nursing staff. Patients who didn’t void within four hours and had a urinary volume N400 mL confirmed by ultrasound were managed with a one-time catheterization. If the urinary volume was less than 400 mL measured by ultrasound, the bladder scan was repeated in two hours. Straight catheterization was tolerated for up to two times prior to the placement of an indwelling catheter (Fig. 1). In the control group, bladder scanning was started at six hours after removing the catheter if no spontaneous voiding happened. A one-time catheterization was managed for the patients with a urine volume of more than 400 mL. Patients requiring catheterization were considered to have POUR. Also, a one-time catheterization was repeated twice before an indwelling catheter was placed. In both groups, bladder ultrasound scanning was also performed in patients with suprapubic discomfort and the inability to void. A urine sample for urinalysis and culture was routinely obtained from the patients with symptoms suggesting UTI and patients experiencing POUR. UTI was diagnosed based on the international guidelines [8] as follows: pyrexia or body temperature of 38 °C, urinary tract symptoms (dysuria, increased frequency of urination, urinary urgency, suprapubic pain and burning on micturition) and positive urine culture (N107 bacterial colonies of microorganism forming units per liter). Data Analysis All detailed data were collected and recorded by an independent secretary for later analysis. The data we used to analyze included
Fig. 1. Flowchart of the urinary retention protocol for both groups.
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demographic characteristics, the duration of surgery, the prevalence of straight catheterization, the prevalence of indwelling catheterization after the surgery, the volume of urine following catheterization, the prevalence of UTI, the amount of perioperative fluid given to the patients, the length of hospitalization and any complications. All data management and statistical analysis were performed with SPSS version 18.0 software (SPSS Inc., Chicago, IL, USA). Independent t-tests were used for continuous variables. Person chi-square test or Fisher exact test was used to analyze the categorical variables. Logistic regression analysis was also performed. Results During the recruitment period from June 2013 to December 2013, 367 patients were scheduled to have a primary unilateral TKA because of osteoarthritis in our center. Of them all, twenty-eight patients were ineligible and twenty-five patients declined participation. The remaining 314 eligible patients were recruited and formed the study cohort; 157 were randomized to the control group and the other 157 to the study group (Fig. 2). The two groups were comparable at baseline (Table 1). Nine patients (5.7%) in the control group developed POUR following removal of the indwelling catheter. The mean volume of urine at the time of one time catheterization in these patients was 798 ± 65 mL. One underwent a single, straight catheterization and the other eight patients required an indwelling catheterization after receiving one-time catheterization for twice, whereas ten patients (6.4%) in the study group developed POUR. The mean volume of urine in these patients was 732 ± 47 mL. Six of them had a single catheterization. An indwelling catheter was required in the other four patients. All the indwelling catheters were discontinued prior to discharge. No statistical differences
Table 1 Demographics and Outcomes. Control Group (n = 157) Agea (yr) Male gender BMIa (kg/m2) ASA (%) I II III Surgical site (right/left) Benign prostatic hypertrophy Intraoperative intravenous fluida (mL) Duration of the surgerya (min) Postoperative urinary retention Postoperative urinary tract infection Length of staya (d)
Study Group (n = 157)
P Value
66.9 ± 8.5 33 (21%) 24.4 ± 3.6
67.4 ± 8.2 38 (24.2%) 24.5 ± 3.4
0.633 0.590 0.676
27 (17.2%) 123 (78.3%) 7 (4.5%) 84/73 8 (5.1%) 816.9 ± 131.1
31 (19.7%) 117 (74.5%) 9 (5.8%) 75/82 12 (7.6%) 810.8 ± 125.9
0.736
74.6 ± 10.0 9 (5.7%)
74.8 ± 9.4 10 (6.4%)
0.829 1
8 (5.1%)
1 (0.6%)
0.036b
6.5 ± 1.4
6.3 ± 1.9
0.386
0.367 0.489 0.677
P values calculated using independent t-test, Person chi-square or Fisher exact test. Abbreviations: BMI, body mass index; ASA, American Society of Anesthesiologists. a The values are given as mean ± standard deviation. b Significantly different.
were observed in terms of the rate POUR (P = 1) and length of stay (P = 0.386) between the two groups (Table 1). However, the rate of UTI was significantly lower in the study group than the control group (0.6% vs 5.1%, P = 0.036) (Table 1). A history of benign prostatic hypertrophy was reported for five (26.3%) of the nineteen patients who developed POUR, compared with fifteen (5.1%) of the 295 patients who didn’t develop POUR. The difference reached significance level (P = 0.004). Also significant differences were observed in terms of age (P b 0.001), gender (P = 0,019), American Society of Anesthesiologists (ASA) grade (P = 0.013), intraoperative intravenous fluid (P b 0.001), duration of the surgery (P = 0.03) and the length of stay (P b 0.001) between patients who developed POUR and those who didn’t. There was no significant difference between the two groups of patients in terms of body mass index (BMI) (P = 0.510) and postoperative urinary tract infection (P = 0.097) (Table 2). The correlation analysis failed to detect the correlation between patients with UTI and patients with POUR (P = 0.175). Multivariate logistical regression with POUR as the dependent outcome variable showed that age, male gender, ASA grade, benign prostatic hypertrophy, intraoperative intravenous fluid and duration of the surgery could be considered as independent risk factors for POUR (Table 3). Eight patients in the control group developed UTI while only one patient in the study group developed UTI during the hospital stay. The one patient in the study group with a UTI was also a POUR patient. All these patients were treated with intravenous antibiotics and received consecutive urine analysis and culture for twice to confirm the cure of the UTI. Discussion
Fig. 2. Flow diagram of patients involved.
POUR is a well-known complication in total joint arthroplasty. Previously, few studies investigated the prevalence of this complication after total joint arthroplasty [9–12]. In the study by Macdowell et al [12], they reported a POUR rate of 13.9% in 173 patients undergoing THA with epidural anesthesia. In another study [11], 119 patients undergoing total joint arthroplasty were randomized either to receive or not receive a urinary catheter during surgery. In this study, researchers reported a POUR rate of 35% for patients without an indwelling urinary catheter compared with a POUR rate of 19% for patients with an indwelling urinary catheter. Most of the patients in this study also received indwelling epidural catheters, retained to provide analgesia during the first postoperative two days. Many studies [9,10] have proved that the type of anesthesia is a risk factor for POUR. Davis et al [9] reported that the incidence
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Table 2 Demographic Differences Between Patients With and Without POUR.
Agea (yr) Male gender BMIa (kg/m2) ASA I II III Benign prostatic hypertrophy (%) Intraoperative intravenous fluida (mL) Duration of the surgerya (min) Postoperative urinary tract infection Length of staya (d)
Postoperative Urinary Retention (n = 19)
No Postoperative Urinary Retention (n = 295)
P Value
75.2 ± 7.0 9 (47.4%) 23.9 ± 3.2
66.6 ± 8.2 62 (21.0%) 24.5 ± 3.5
b0.001b 0.019b 0.510
4 (21.1%) 11 (57.8%) 4 (21.1%) 5 (26.3%) 944.7 ± 144.2 79.2 ± 12.4 2 (10.5%) 7.7 ± 1.5
54 (18.3%) 229 (77.6%) 12 (4.1%) 15 (5.1%) 805.4 ± 122.8 74.2 ± 9.5 7 (2.4%) 6.3 ± 1.6
0.013b
0.004b b0.001b 0.030b 0.097 b0.001b
P values calculated using independent t-test, Person chi-square or Fisher exact test. Abbreviations: POUR, postoperative urinary retention; BMI, body mass index; ASA, American Society of Anesthesiologists. a The values are given as mean ± standard deviation. b Significantly different.
of POUR following spinal anesthesia was significantly lower than that after epidural anesthesia (21.8% vs 46.7%, P b 0.05). In another retrospective study which included 1440 patients undergoing TKA or THA, Donald et al reported a lower rate of POUR in patients following general anesthesia than those after spinal anesthesia [10]. With the development of surgical techniques, surgical care and the introduction of fast-track clinical pathways, epidural anesthesia is less commonly used for patients undergoing TKA. Thus, we conducted this prospective randomized study to investigate whether urinary catheterization could be avoided for patients undergoing TKA under general anesthesia with saphenous nerve block, a common practice in our center. According to the previous studies [1,2,6,13], factors associated with increased risk of POUR are age, male gender, ASA grade, type of surgery, type of anesthesia and analgesia, previous history from the urinary tract and neurologic comorbidities, duration of surgery, and intraoperative intravenous fluid. Several animal studies [14,15] have reported that sedative, hypnotic agents and volatile anesthetics can impair the micturition reflex in varying degrees, leading to the decreased detrusor contractions. Many clinical studies [6,7] have illustrated that the general anesthesia has lower incidence of POUR than epidural and spinal anesthesia. In addition, there has been ample evidence that systemic opioids impair bladder function by spate central and peripheral mechanisms, resulting in relaxation of the detrusor and contraction of the bladder sphincter. Combrisson et al [15] reported a POUR incidence of 18.3% in patients whose analgesia protocol after lower limb arthroplasty was provided by systemic opioids. A recent study identified the use of intrathecal morphine as a risk factor for POUR (odds ratio, 1.4; 95% confidence interval, 1.1 to 1.9) [10]. In our study, we used the combination of general anesthesia and saphenous nerve block as the anesthesia protocol. Cumulative evidence has proved that by using multimodal anesthesia patients can have less postoperative knee pain and decreased consumption of opiates, thus facilitating patients’ functional rehabilitation [16]. Also, we used the oral Celebrex and Diclofenac as the analgesia Table 3 Multivariate Logistic Regression for POUR. Predictor
P Value
Odds Ratio
95% Confidence Interval
Age Male gender BMI ASA grade Benign prostatic hypertrophy Indwelling catheter Intraoperative intravenous fluid Duration of the surgery
b0.001a 0.028a 0.870 0.037a 0.048a 0.282 0.006a 0.013a
1.330 3.558 0.984 5.418 4.038 2.019 1.008 1.083
1.158 to 1.529 1.149 to 11.021 0.808 to 1.197 1.107 to 26.517 1.012 to 34.113 0.866 to 12.904 1.002 to 1.013 1.017 to 1.153
Abbreviations: POUR, postoperative urinary retention; BMI, body mass index; ASA, American Society of Anesthesiologists. a Significantly different.
protocol instead of PCA, oral opioids and intrathecal morphine. This might explain why the POUR rate is lower than the studies mentioned before. To make the two groups comparable at the baseline, we excluded the patients who had previous history of the urinary tract and neurologic comorbidities. Still, our multivariate logistic regression for POUR identified age, male gender, ASA grade, duration of surgery, intraoperative intravenous fluid as the risk factors. Among them, age, male gender and ASA grade were considered as the unmodifiable risk factors for development of POUR and well discussed [17]. As to the duration of surgery and intraoperative intravenous fluid, with the development of surgical techniques and the emphasis of optimal perioperative management these risk factors can be well controlled. For example, by applying the tourniquet [7], tranexamic acid [18], and blood retransfusion in TKA [19], which are routine practices in our center, the intraoperative blood loss can be significantly reduced, thus the requirement for intraoperative fluid control is less essential. Previously, the impact of intraoperative intravenous fluids on POUR has been studied and there is strong evidence that excessive administration of crystalloids can lead to overdistension of bladder [1,6,20–23]. Wynd et al [24] found that patients with POUR, undergoing lower limb arthroplasty, received more intravenous fluids throughout the whole perioperative period than those without POUR. In our study, we discontinued intravenous fluid on the first postoperative day. But still, we found a similar phenomenon which proved that intraoperative intravenous fluid is a risk factor for POUR. All these consequences are not in accordance with the requirements of fast-track clinical pathways. Our study suggests that the indwelling catheters aren’t necessary for the majority of the patients undergoing TKA. Without the indwelling catheter, the incidence of UTI can be effectively lowered. Except for the randomized, prospective nature of our study, some limitations of the current study warrant further discussion. First, we included the patients with benign prostatic hypertrophy, which is considered as a risk factor for POUR in our study. And our multivariate logistic regression has confirmed that. Second, to make the baselines of both groups comparable, we have to exclude the patients with surgical history of urinary system, UTI and systematical conditions intraoperative monitoring urine output. We also didn’t use oral or systemic opioids as postoperative analgesia protocol. Thus, we could not identify more risk factors for POUR. The results of this high-quality randomized controlled trial revealed several important findings as follows: first, the prevalence of POUR is relatively low (6.4%) without using an indwelling catheter in patients undergoing TKA with combination use of general anesthesia and saphenous nerve block. This finding has encouraged us to reconsider whether we should use an indwelling catheter as a routine practice in TKA, especially considering that we also include patients with benign prostatic
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hypertrophy. Second, we found that the prevalence of UTI was significantly higher in patients using an indwelling catheter compared with those who didn’t (5.1% vs 0.6%, P = 0.036). Third, we proved that older age, male gender, higher ASA grade, benign prostatic hypertrophy, intraoperative intravenous fluid and longer duration of surgery tend to be the risk factors for POUR in patients undergoing TKA. Conclusion In conclusion, our study has found that indwelling catheter during surgery, which can increase the postoperative UTI, is not routinely necessary for the majority of the patients undergoing TKA under general anesthesia with saphenous nerve block. We also identified age, male gender, higher ASA grade, benign prostatic hypertrophy, intraoperative intravenous fluid and longer duration of surgery as the risk factors of POUR. Acknowledgments No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. References 1. Balderi T, Carli F. Urinary retention after total hip and knee arthroplasty. Minerva Anestesiol 2010;76(2):120. 2. Baldini G, Bagry H, Aprikian A, et al. Postoperative urinary retention: anesthetic and perioperative considerations. Anesthesiology 2009;110(5):1139. 3. Madersbacher H, Cardozo L, Chapple C, et al. What are the causes and consequences of bladder overdistension? ICI-RS 2011. Neurourol Urodyn 2012;31(3):317. 4. Pulido L, Ghanem E, Joshi A, et al. Periprosthetic joint infection: the incidence, timing, and predisposing factors. Clin Orthop Relat Res 2008;466(7):1710. 5. Berbari EF, Hanssen AD, Duffy MC, et al. Risk factors for prosthetic joint infection: case–control study. Clin Infect Dis 1998;27(5):1247. 6. Karason S, Olafsson TA. Avoiding bladder catheterisation in total knee arthroplasty: patient selection criteria and low-dose spinal anaesthesia. Acta Anaesthesiol Scand 2013;57(5):639.
7. Huang ZY, Pei FX, Ma J, et al. Comparison of three different tourniquet application strategies for minimally invasive total knee arthroplasty: a prospective nonrandomized clinical trial. Arch Orthop Trauma Surg 2014;134(4):561. 8. Balderi T, Mistraletti G, D'Angelo E, et al. Incidence of postoperative urinary retention (POUR) after joint arthroplasty and management using ultrasound-guided bladder catheterization. Minerva Anestesiol 2011;77(11):1050. 9. Davis S, Erskine R, James MF. A comparison of spinal and epidural anaesthesia for hip arthroplasty. Can J Anaesth 1992;39(6):551. 10. Griesdale DE, Neufeld J, Dhillon D, et al. Risk factors for urinary retention after hip or knee replacement: a cohort study. Can J Anaesth 2011;58(12):1097. 11. Knight RM, Pellegrini Jr VD. Bladder management after total joint arthroplasty. J Arthroplasty 1996;11(8):882. 12. Macdowell AD, Robinson AH, Hill DJ, et al. Is epidural anaesthesia acceptable at total hip arthroplasty? A study of the rates of urinary catheterisation. J Bone Joint Surg (Br) 2004;86(8):1115. 13. Kerr DR, Kohan L. Local infiltration analgesia: a technique for the control of acute postoperative pain following knee and hip surgery: a case study of 325 patients. Acta Orthop 2008;79(2):174. 14. Matsuura S, Downie JW. Effect of anesthetics on reflex micturition in the chronic cannula-implanted rat. Neurourol Urodyn 2000;19(1):87. 15. Combrisson H, Robain G, Cotard JP. Comparative effects of xylazine and propofol on the urethral pressure profile of healthy dogs. Am J Vet Res 1993;54(12):1986. 16. Parvizi J, Miller AG, Gandhi K. Multimodal pain management after total joint arthroplasty. J Bone Joint Surg Am 2011;93(11):1075. 17. Bjerregaard LS, Bagi P, Kehlet H. Postoperative urinary retention (POUR) in fast-track total hip and knee arthroplasty. Acta Orthop 2014;85(1):8. 18. Huang Z, Ma J, Shen B, et al. Combination of intravenous and topical application of tranexamic acid in primary total knee arthroplasty: a prospective randomized controlled trial. J Arthroplast 2014. http://dx.doi.org/10.1016/j.arth.2014.05.026. 19. Friederichs MG, Mariani EM, Bourne MH. Perioperative blood salvage as an alternative to predonating blood for primary total knee and hip arthroplasty. J Arthroplasty 2000; 17(3):298. 20. Petros JG, Rimm EB, Robillard RJ, et al. Factors influencing postoperative urinary retention in patients undergoing elective inguinal herniorrhaphy. Am J Surg 1991;161 (4):431. 21. Gerstenberg TC, Nielsen ML, Clausen S, et al. Bladder function after abdominoperineal resection of the rectum for anorectal cancer. Urodynamic investigation before and after operative in a consecutive series. Ann Surg 1980;191(1):81. 22. Kemp D, Tabaka N. Postoperative urinary retention: part II—a retrospective study. J Post Anesth Nurs 1990;5(6):397. 23. Tammela T, Kontturi M, Lukkarinen O. Postoperative urinary retention. II. Micturition problems after the first catheterization. Scand J Urol Nephrol 1986;20(4):257. 24. Wynd CA, Wallace M, Smith KM. Factors influencing postoperative urinary retention following orthopaedic surgical procedures. Orthop Nurs 1996;15(1):43.
