JOURNAL
OF SURGICAL
52,111-112
RESEARCH
(19%)
Post-Herniorrhaphy Urinary Retention: A Randomized Prospective Study ROBERT VA Medical Presented
at the Annual
A. KOZOL, M.D., KIM MASON, CRNA, AND KAREN MCGEE, R.N.
Center, Allen Park, Michigan
Symposium
of the Association
48101; and Wayne State University, of Veterans
Administration
risk Academic
age over 60 years approached
factor Press,
for
pOStOperatiVe
urinary
significance IWtentiOn.
Michigan
Surgeons, Milwaukee,
48201
Wisconsin,
May 9-11, 1991
stricted to 500 mls or less of iv crystalloid solution containing in meq/liter Na 140, K 5, Cl 98, Mg 3, acetate 27, and gluconate 23. All intravenous lines were discontinued in the recovery room. Urinary retention was defined as the requirement of bladder catheterization. Patients having a spontaneous urine output of less than 100 ml within the first 8 hr were catheterized. In addition, any patients with lower abdominal discomfort and a palpable bladder were catheterized. Void volumes were recorded along with the patients age, urological history, and type of anesthetic. Statistical analysis was accomplished utilizing the x2 test with a P value of less than 0.05 considered significant. This study was approved by the Human Investigations Committee of Wayne State University and the Allen Park VA Medical Center.
Urinary retention is a known complication of inguinal herniorrhaphy. Bladder distension due to vigorous fluid administration is believed to contribute to this problem. Our hypothesis is that fluid restriction will lower the incidence of urinary retention, post-herniorrhaphy. From January 1989 through March 199 1, 113 male patients entered the study. Sixty patients (Group I) received unlimited iv fluids (1294 + 58 ml) and 9 patients (15%) developed urinary retention. Fifty-three patients (Group II) received 500 ml or less by protocol (485 + 2 ml) and 5 of these patients developed retention (9%). Thus, fluid restriction lowered the incidence of urinary retention post-herniorrhaphy but the difference did not reach statistical significance. In
addition
Detroit,
as a 0 1992
Inc.
RESULTS Urinary retention is a known complication of inguinal herniorrhaphy. This complication can result in an overnight hospital stay of an otherwise planned same day surgery patient. It is therefore, timely to investigate methods to avoid this complication. This randomized prospective study was designed to examine the effect of intravenous fluid restriction on the development of urinary retention in patients undergoing inguinal herniorrhaphy. MATERIALS
There were 60 patients in group I and 53 patients in group II. Patient characteristics are listed in Table 1. In group I (controls) 9 patients required catheterization with a mean urine volume of 800 ml at catheterization. In group 2 (500 ml limit) 5 patients required catheterization with a 600 ml mean urine volume. Thus 15% of patients in group 1 and 9% patients in group 2 had urinary retention P = NS. The influence of age and positive urologic history are displayed in Table 2. As noted, age over 60 years approached significance as a risk factor (P = 0.1) for the development of postoperative urinary retention. Too few patients had general or local anesthesia, precluding meaningful evaluation of type of anesthetic.
AND METHODS
From January 1989 through March 1991, 113 male patients undergoing inguinal herniorrhaphy entered the study. Patients with a history of congestive heart failure, renal failure, serum creatinine greater than 1.6, and those with an indwelling Foley catheter were excluded from the study. After obtaining informed consent, patients were randomized to one of two groups by the selection of an envelope in the preoperative holding area. No preoperative intravenous lines were instituted until this point. Group I was the control group (no intravenous fluid restriction) and group II patients were re-
DISCUSSION Urinary retention is a known complication of inguinal herniorrhaphy with a reported incidence of 3 to 25% [ 1, 21. In a series of 961 hernia repairs, 70 required catheterization for an incidence of 7% [3]. Factors believed to contribute to the development of postoperative urinary retention include pelvic dissection, postoperative pain, 111
0022.4804/92 $1.50 Copyright 0 1992 by Academic Press, Inc. All rights of reproduction in any form reserved.
112
JOURNAL
OF SURGICAL
RESEARCH:
use of narcotics for analgesia, and overzealous intravenous hydration resulting in bladder distension. In a prospective study of patients having anorectal surgery Prasad and Abcarian restricted fluids to 50 ml/ hr intraoperatively. This resulted in a 1.17% incidence of urinary retention compared to a 52% incidence in historic controls in their hospital [4]. In a randomized prospective study of perioperative fluid restriction in anorectal surgery, Baily and Ferguson were able to reduce urinary retention from 14.9% to 3.5% [5]. It should be noted that their study focused on oral fluids, while intravenous fluids were also controlled. Petros et al. retrospectively reviewed 295 inguinal herniorrhaphies in men 161. They found age less than 53 years, spinal anesthesia, and perioperative fluids less than 1200 ml all significantly reduced the incidence of postoperative urinary retention. In another retrospective review the intraoperative iv fluid volume was found to have a statistically significant effect on the incidence of postoperative urinary retention post-anorectal surgery [7]. In that study patients with less than 1000 ml of iv fluid had a 0% incidence of urinary retention while patients receiving greater than 1000 ml had a 36% occurrence of urinary retention (P < 0.0001). Some investigators have addressed this problem by using alpha adrenergic blockade postoperatively. In a prospective study, Goldman et al. demonstrated remarkable success in reducing post herniorrhaphy urinary retention using CYadrenergic blockade with phenoxybenzamine. It should be noted that their control group had an extraordinary incidence of 26144 patients with postoperative urinary retention [2]! In a retrospective review of patients having cola-rectal surgery, the same group reported successful reduction in urinary retention using phenoxybenzamine. Again, the incidence of urinary retention in this study was high with 54.7% in the control group and 19.2% in the phenoxybenzamine group [a].
VOL.
TABLE Influence Development
Patient Group I (controls) 60 54 1294 f 58 47 11 2
and Age on the Urinary Retention % Retention
P
7.3% 20%
0.1
Pos. Urol. Hx. Neg. Urol. Hx.
31 82
19% 10%
0.4
The current study is the only prospective evaluation of intravenous fluid restriction as a means of avoiding bladder distension and subsequent urinary retention after inguinal herniorrhaphy. This protocol resulted in the reduction of urinary retention from 15% in the controls to 9% in the restricted group. Although this difference did not achieve statistical significance there is a chance of a type II statistical error. In addition, our restriction of 500 ml iv may not be restrictive enough to demonstrate a benefit. We found that age over 60 years approached significance as a risk factor for the development of postoperative urinary retention. We recommend intra-operative iv fluid restriction to otherwise healthy males undergoing inguinal herniorrhaphy. REFERENCES 1. 2.
3. 4.
6.
53 54 485 * 2 43 8 2
of urologic History of Postoperative
68 45
Group II (fluid restriction) N Mean age Mean iv fluid (*SE) Spinal anesth. General anesth. Local anesth.
2
Age ~60 Age >60
1
Characteristics
1992
n
5.
TABLE
52, NO. 2, FEBRUARY
7.
8.
Stallard, S., and Prescott, S. Post-operative urinary retention in general surgical patients. Br. J. Surg. 75: 1141, 1988. Goldman, G., Leviav, A., Mazor, A., Kashtan, H., Aladgem, D., Greenstein, A., and Wiznitzer, T. Alpha-adrenergic blocker for post-hernioplasty urinary retention. Arch. Surg. 123: 35, 1988. Rydell, W. B. Inguinal and femoral hernias. Arch. Surg. 87: 151, 1963. Prasad, M. L., and Abcarian, H. Urinary retention following operations for benign anorectal diseases. Dig. Dis. Sci. 21: 490, 1978. Bailey, H. R., and Ferguson, J. A. Prevention of urinary retention by fluid restriction following anorectal operations. Dis. Cd. Rect. 19: 250, 1976. Petros, J. G., Rimm, E. B., Robillard, R. J., and Argy, 0. Factors influencing post-operative urinary retention in patients undergoing elective inguinal herniorrhaphy. Am. J. Surg. 161: 431, 1991. Petros, J. G., and Bradley, T. M. Factors influencing post-operative urinary retention in patients undergoing surgery for benign anorectal disease. Am. J. Surg. 159: 374, 1990. Goldman, G., Kahn, P. J., Kashtan, H., Stadler, J., and Wiznitzer, T. Prevention and treatment of urinary retention and infection after surgical treatment of the colon and rectum with alpha adrenergic blockers. Surg. Gynecol. O&et. 166: 447,198s.
OF SURGICAL
52,111-112
RESEARCH
(19%)
Post-Herniorrhaphy Urinary Retention: A Randomized Prospective Study ROBERT VA Medical Presented
at the Annual
A. KOZOL, M.D., KIM MASON, CRNA, AND KAREN MCGEE, R.N.
Center, Allen Park, Michigan
Symposium
of the Association
48101; and Wayne State University, of Veterans
Administration
risk Academic
age over 60 years approached
factor Press,
for
pOStOperatiVe
urinary
significance IWtentiOn.
Michigan
Surgeons, Milwaukee,
48201
Wisconsin,
May 9-11, 1991
stricted to 500 mls or less of iv crystalloid solution containing in meq/liter Na 140, K 5, Cl 98, Mg 3, acetate 27, and gluconate 23. All intravenous lines were discontinued in the recovery room. Urinary retention was defined as the requirement of bladder catheterization. Patients having a spontaneous urine output of less than 100 ml within the first 8 hr were catheterized. In addition, any patients with lower abdominal discomfort and a palpable bladder were catheterized. Void volumes were recorded along with the patients age, urological history, and type of anesthetic. Statistical analysis was accomplished utilizing the x2 test with a P value of less than 0.05 considered significant. This study was approved by the Human Investigations Committee of Wayne State University and the Allen Park VA Medical Center.
Urinary retention is a known complication of inguinal herniorrhaphy. Bladder distension due to vigorous fluid administration is believed to contribute to this problem. Our hypothesis is that fluid restriction will lower the incidence of urinary retention, post-herniorrhaphy. From January 1989 through March 199 1, 113 male patients entered the study. Sixty patients (Group I) received unlimited iv fluids (1294 + 58 ml) and 9 patients (15%) developed urinary retention. Fifty-three patients (Group II) received 500 ml or less by protocol (485 + 2 ml) and 5 of these patients developed retention (9%). Thus, fluid restriction lowered the incidence of urinary retention post-herniorrhaphy but the difference did not reach statistical significance. In
addition
Detroit,
as a 0 1992
Inc.
RESULTS Urinary retention is a known complication of inguinal herniorrhaphy. This complication can result in an overnight hospital stay of an otherwise planned same day surgery patient. It is therefore, timely to investigate methods to avoid this complication. This randomized prospective study was designed to examine the effect of intravenous fluid restriction on the development of urinary retention in patients undergoing inguinal herniorrhaphy. MATERIALS
There were 60 patients in group I and 53 patients in group II. Patient characteristics are listed in Table 1. In group I (controls) 9 patients required catheterization with a mean urine volume of 800 ml at catheterization. In group 2 (500 ml limit) 5 patients required catheterization with a 600 ml mean urine volume. Thus 15% of patients in group 1 and 9% patients in group 2 had urinary retention P = NS. The influence of age and positive urologic history are displayed in Table 2. As noted, age over 60 years approached significance as a risk factor (P = 0.1) for the development of postoperative urinary retention. Too few patients had general or local anesthesia, precluding meaningful evaluation of type of anesthetic.
AND METHODS
From January 1989 through March 1991, 113 male patients undergoing inguinal herniorrhaphy entered the study. Patients with a history of congestive heart failure, renal failure, serum creatinine greater than 1.6, and those with an indwelling Foley catheter were excluded from the study. After obtaining informed consent, patients were randomized to one of two groups by the selection of an envelope in the preoperative holding area. No preoperative intravenous lines were instituted until this point. Group I was the control group (no intravenous fluid restriction) and group II patients were re-
DISCUSSION Urinary retention is a known complication of inguinal herniorrhaphy with a reported incidence of 3 to 25% [ 1, 21. In a series of 961 hernia repairs, 70 required catheterization for an incidence of 7% [3]. Factors believed to contribute to the development of postoperative urinary retention include pelvic dissection, postoperative pain, 111
0022.4804/92 $1.50 Copyright 0 1992 by Academic Press, Inc. All rights of reproduction in any form reserved.
112
JOURNAL
OF SURGICAL
RESEARCH:
use of narcotics for analgesia, and overzealous intravenous hydration resulting in bladder distension. In a prospective study of patients having anorectal surgery Prasad and Abcarian restricted fluids to 50 ml/ hr intraoperatively. This resulted in a 1.17% incidence of urinary retention compared to a 52% incidence in historic controls in their hospital [4]. In a randomized prospective study of perioperative fluid restriction in anorectal surgery, Baily and Ferguson were able to reduce urinary retention from 14.9% to 3.5% [5]. It should be noted that their study focused on oral fluids, while intravenous fluids were also controlled. Petros et al. retrospectively reviewed 295 inguinal herniorrhaphies in men 161. They found age less than 53 years, spinal anesthesia, and perioperative fluids less than 1200 ml all significantly reduced the incidence of postoperative urinary retention. In another retrospective review the intraoperative iv fluid volume was found to have a statistically significant effect on the incidence of postoperative urinary retention post-anorectal surgery [7]. In that study patients with less than 1000 ml of iv fluid had a 0% incidence of urinary retention while patients receiving greater than 1000 ml had a 36% occurrence of urinary retention (P < 0.0001). Some investigators have addressed this problem by using alpha adrenergic blockade postoperatively. In a prospective study, Goldman et al. demonstrated remarkable success in reducing post herniorrhaphy urinary retention using CYadrenergic blockade with phenoxybenzamine. It should be noted that their control group had an extraordinary incidence of 26144 patients with postoperative urinary retention [2]! In a retrospective review of patients having cola-rectal surgery, the same group reported successful reduction in urinary retention using phenoxybenzamine. Again, the incidence of urinary retention in this study was high with 54.7% in the control group and 19.2% in the phenoxybenzamine group [a].
VOL.
TABLE Influence Development
Patient Group I (controls) 60 54 1294 f 58 47 11 2
and Age on the Urinary Retention % Retention
P
7.3% 20%
0.1
Pos. Urol. Hx. Neg. Urol. Hx.
31 82
19% 10%
0.4
The current study is the only prospective evaluation of intravenous fluid restriction as a means of avoiding bladder distension and subsequent urinary retention after inguinal herniorrhaphy. This protocol resulted in the reduction of urinary retention from 15% in the controls to 9% in the restricted group. Although this difference did not achieve statistical significance there is a chance of a type II statistical error. In addition, our restriction of 500 ml iv may not be restrictive enough to demonstrate a benefit. We found that age over 60 years approached significance as a risk factor for the development of postoperative urinary retention. We recommend intra-operative iv fluid restriction to otherwise healthy males undergoing inguinal herniorrhaphy. REFERENCES 1. 2.
3. 4.
6.
53 54 485 * 2 43 8 2
of urologic History of Postoperative
68 45
Group II (fluid restriction) N Mean age Mean iv fluid (*SE) Spinal anesth. General anesth. Local anesth.
2
Age ~60 Age >60
1
Characteristics
1992
n
5.
TABLE
52, NO. 2, FEBRUARY
7.
8.
Stallard, S., and Prescott, S. Post-operative urinary retention in general surgical patients. Br. J. Surg. 75: 1141, 1988. Goldman, G., Leviav, A., Mazor, A., Kashtan, H., Aladgem, D., Greenstein, A., and Wiznitzer, T. Alpha-adrenergic blocker for post-hernioplasty urinary retention. Arch. Surg. 123: 35, 1988. Rydell, W. B. Inguinal and femoral hernias. Arch. Surg. 87: 151, 1963. Prasad, M. L., and Abcarian, H. Urinary retention following operations for benign anorectal diseases. Dig. Dis. Sci. 21: 490, 1978. Bailey, H. R., and Ferguson, J. A. Prevention of urinary retention by fluid restriction following anorectal operations. Dis. Cd. Rect. 19: 250, 1976. Petros, J. G., Rimm, E. B., Robillard, R. J., and Argy, 0. Factors influencing post-operative urinary retention in patients undergoing elective inguinal herniorrhaphy. Am. J. Surg. 161: 431, 1991. Petros, J. G., and Bradley, T. M. Factors influencing post-operative urinary retention in patients undergoing surgery for benign anorectal disease. Am. J. Surg. 159: 374, 1990. Goldman, G., Kahn, P. J., Kashtan, H., Stadler, J., and Wiznitzer, T. Prevention and treatment of urinary retention and infection after surgical treatment of the colon and rectum with alpha adrenergic blockers. Surg. Gynecol. O&et. 166: 447,198s.
