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Postoperative Urinary Retention After Bariatric Surgery: An Institutional Analysis
j o u r n a l o f s u r g i c a l r e s e a r c h n o v e m b e r 2 0 1 9 ( 2 4 3 ) 8 3 e8 9
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Association for Academic Surgery
Postoperative Urinary Retention After Bariatric Surgery: An Institutional Analysis Daniel Roadman, BS, Melissa Helm, MS, Matthew I. Goldblatt, MD, Tammy L. Kindel, MD, PhD, Jon C. Gould, MD, and Rana M. Higgins, MD* Division of General Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
article info
abstract
Article history:
Background: Postoperative urinary retention (POUR) can impact quality outcomes, leading to
Received 14 February 2019
urinary tract infections, longer lengths of stay, and increased healthcare costs. The inci-
Received in revised form
dence of POUR in bariatric patients is unknown. Our primary objective was to determine
23 April 2019
the incidence and risk factors contributing to POUR in primary bariatric surgery.
Accepted 1 May 2019
Methods: A retrospective review was conducted on patients who underwent a laparoscopic
Available online xxx
sleeve gastrectomy (LSG) or laparoscopic Roux-en-Y gastric bypass (LRYGB) from 2013 to 2017. POUR was defined as the inability to urinate postoperatively, requiring urinary
Keywords:
catheterization. Univariate and multivariate analyses were performed on perioperative
Urinary retention
variables and their correlation with POUR.
Bariatric surgery
Results: During the study period, 603 patients underwent surgery: 317 (52.6%) LSG and 286
Laparoscopy
(47.4%) LRYGB. Overall, 49 (8.1%) patients developed POUR. There were no significant differences in preoperative demographics between patients with and without POUR. Patients who underwent an LSG had an increased incidence of POUR compared with LRYGB (P ¼ 0.002). In both procedures, POUR was associated with decreased neostigmine, isolated nondepolarizing muscle relaxant, and reduced intraoperative fluid. LSG and congestive heart failure, as well as LSG and body weight, were independently associated with POUR. Female patients who experienced POUR had significantly increased length of stay. Conclusions: Risk factors associated with POUR after primary bariatric surgery include LSG, less intraoperative neostigmine and intravenous fluids, and isolated nondepolarizing muscle relaxants. These risk factors can help educate patients and providers, as well as identify quality initiatives that focus on perioperative and anesthetic management to reduce POUR and length of hospital stay. ª 2019 Elsevier Inc. All rights reserved.
Introduction Approximately 40% of the US population is obese.1,2 Obesity is a known risk factor for the development of multiple
comorbidities that are responsible for more than 2.8 million deaths per year globally.3-7 To date, only bariatric surgery results in substantial and long-term weight loss for obese patients, improving comorbidities, quality of life, and reducing
This study was presented as a QuickShot oral presentation at the 2019 Academic Surgical Congress, Houston, Tx, February 5-7, 2019. * Corresponding author. Division of General Surgery, Medical College of Wisconsin, 8701 W Watertown Plank Road, Milwaukee, WI 53226. Tel.: þ1 414 955-1775; fax: þ1 414 955-0085. E-mail address: [email protected] (R.M. Higgins). 0022-4804/$ e see front matter ª 2019 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jss.2019.05.005
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mortality.3,8-11 In 2010, the estimated healthcare cost of obesity in the United States was $168.4 billion per year, with the most significant driver of cost being age- and obesityrelated comorbid conditions.3,6,9,12 The two most commonly performed bariatric procedures in the United States are the laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB). Postoperative urinary retention (POUR) is a well-known complication of laparoscopic procedures, and the incidence and specific risk factors of this complication within the primary bariatric surgery population are unknown. POUR has been associated with urinary tract infections and longer length of hospital stay, which could significantly increase overall costs.13,14 POUR is defined as the inability to void in the postoperative period, and the need for urinary straight or indwelling catheterization. The primary objective of this study was to determine risk factors contributing to POUR in bariatric surgery patients.
Materials and methods An institutional review boardeapproved retrospective chart review was performed of patients who underwent a primary LSG or LRYGB at a single institution from 2013 to 2017. Informed consent was waived per institutional policy because the review did not have direct contact with patients. The procedures were performed by five fellowship-trained minimally invasive general surgeons. All surgeons performed the procedure in a similar fashion. Intraoperative catheter usage was initially at the discretion of the surgeon; however, midway in the study, urinary catheters were no longer routinely placed. Within this cohort of patients, those who developed POUR were identified. POUR was defined as the inability to urinate postoperatively, requiring urinary straight or indwelling catheterization before discharge. All patients were required to void within 8-10 h postoperatively, post straight
catheterization or removal of an indwelling catheter. If they were unable to void, a straight catheterization was performed. If they were subsequently unable to void, an indwelling catheter was placed that was removed the following morning. If patients were unable to void on subsequent attempts, they were discharged with an indwelling catheter and scheduled to follow-up with a urologist within 1 wk for a voiding trial. Demographic information, preoperative comorbidities, perioperative events, and postoperative variables were identified to determine risk factors that contributed to the incidence of POUR. Statistical analysis was completed using IBM SPSS Statistics version 24. A P value of <0.05 was considered significant. Univariate analyses were performed on perioperative variables and their correlation with POUR. All proportional data are presented as percentages and were analyzed using chisquare tests. All continuous data are presented as mean standard deviation and were compared using twotailed, unpaired Student’s t-tests. Predictive variables in univariate analysis were input into a binary logistic regression model in a stepwise fashion and were presented with odds ratio and 95% confidence interval.
Results A total of 603 patients underwent primary bariatric surgery during our study period. The mean body mass index (BMI) was 48.58 13.23 kg/m2, with 474 (78.6%) female and 129 (21.4%) male patients. Patient preoperative and intraoperative variables are included in Table 1. Overall, 49 (8.1%) of patients developed POUR with a mean urinary volume at time of intervention of 682.5 319.7 mL. There were no significant differences in preoperative demographics in relation to the development of POUR (Table 1). Analysis of perioperative variables identified POUR as significantly associated with LSG, with an incidence of 11.4% compared with 4.5% after LRYGB (P ¼ 0.002). Additional factors associated with POUR included
Table 1 e Univariate analysis of patient demographics as predictors of POUR. Variable
Age (y) 2
POUR (n ¼ 49)
No POUR (n ¼ 554)
n (%) or mean (SD)
n (%) or mean (SD)
46.20 13.04
44.30 11.97
0.29
P value
46.34 8.05
48.77 13.58
0.22
294.89 60.08
299.54 65.91
0.63
Gender, female
35 (71.4)
439 (79.2)
0.20
Diabetes
22 (44.9)
177 (31.9)
0.07
Smoker
5 (10.2)
46 (8.3)
0.65
Body mass index (kg/m ) Weight (lbs)
Congestive heart failure
3 (6.1)
23 (4.2)
0.52
Obstructive sleep apnea
20 (40.8)
222 (40.1)
0.92
Gastroesophageal reflux disease
20 (40.8)
196 (35.4)
0.45
Hypertension
31 (63.3)
304 (54.9)
0.26
HLD
17 (34.7)
189 (34.1)
0.94
1 (0.2)
0.08
13 (2.3)
0.28
Benign prostatic hyperplasia Chronic obstructive pulmonary disease
1 (2.0) 0 (0.0)
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roadman et al urinary retention in bariatric surgery
Table 2 e Univariate analysis of perioperative outcomes as predictors of POUR. Variable
POUR (n ¼ 49)
No POUR (n ¼ 554)
n (%) or mean (SD)
n (%) or mean (SD)
P value
0.002*
Procedure type Laparoscopic Sleeve Gastrectomy
36 (11.4)
281 (88.6)
Laparoscopic Roux-en-Y Gastric bypass
13 (4.5)
273 (95.5)
Scopolamine patch
14 (28.6)
183 (33.0)
0.52
Regional anesthesia
7 (14.3)
58 (10.5)
0.41
11 (22.4)
187 (33.8)
0.11
Intraoperative indwelling catheter Intraoperative fluids (mL) Glycopyrrolate (mg)
y
y
Neostigmine (mg)y Nondepolarizing muscle relaxant
z
Urinary tract infection within 30 d
1111.63 522.57
1354.76 623.14
0.01*
0.77 0.20
0.79 0.24
0.64
5.0 0.70
5.24 1.14
0.04*
45 (91.8%)
432 (78.0%)
0.02*
4 (0.7)
0.32
1 (2.1)
Urinary catheter removal (d)
0.89 0.33
0.95 0.31
0.57
Length of stay (d)
1.96 1.08
1.67 1.17
0.09
Males (d)
1.5 0.65
1.52 0.77
0.92
Females (d)
2.14 1.17
1.71 1.25
0.046*
*
Statistical significance (P < 0.05). Analysis includes only patients who received medication and/or fluids in the operating room: intraoperative fluid (n ¼ 528), glycopyrrolate (n ¼ 575), neostigmine (n ¼ 573). z Nondepolarizing muscle relaxant analysis excludes patients who also had a depolarizing muscle relaxant (n ¼ 477). y
decreased neostigmine usage, isolated nondepolarizing muscle relaxant usage, and reduced intraoperative fluid (IVF) administration. Female patients with POUR had a significantly longer length of stay (LOS) at 2.14 1.17 d compared with those without POUR at 1.71 1.25 d (P ¼ 0.046). There was no significant difference in LOS for male patients. Additional perioperative variables that were not statistically significant determinants of POUR are also listed (Table 2). In patients who developed POUR, urinary intervention methods by gender were evaluated (Table 3). No significant differences were found in regard to intraoperative urinary catheter usage or urinary tract infection. Per protocol, if an indwelling catheter is placed, it is removed on postoperative day 1, with 167 patients (90.7%) having their indwelling catheter removed on postoperative day 1 in this
Table 3 e Univariate analysis of POUR interventions by gender. Variable
Females (n ¼ 35)
Males (n ¼ 14)
n (%)
n (%)
Indwelling catheter
23 (65.7)
11 (78.6)
0.378
Straight catheter
19 (54.3)
4 (28.6)
0.103
Successive intervention*
7 (20.0)
1 (7.1)
0.271
Discharged with indwelling
1 (2.9)
2 (14.3)
0.082
Urinary tract infection
1 (2.9)
0 (0.0)
0.517
*
P value
Successive intervention indicates an initial straight catheter was used, followed by an indwelling catheter after the patient remained unable to void.
study. Provider preference early in the study and patientspecific variables accounted for variations from protocol, 14 patients (7.6%) had their catheter removed at the end of their case, 4 patients (2.2%) had their catheter removed on postoperative day 2 due to decreased urine output, concern for upper gastrointestinal leak, and/or cardiac complication that required cardioversion. An additional 13 patients had straight urinary catheterization during their procedure. Overall, 198 of the 603 patients (32.8%) included in the study had an intraoperative urinary catheter. In the earliest year of our study, 56.0% of patients had an intraoperative catheter, which declined each year and by the final year of our study; only 3.1% of patients had an intraoperative catheter. There were no significant differences in the incidence of POUR over time while the protocol changed (Figure). Patient demographics and perioperative outcomes of all patients were further analyzed by procedure type. It was found that those undergoing LSG had an increased weight of 306.19 68.30 lbs compared with 291.38 61.27 lbs for LRYGB (P ¼ 0.005) and were more likely to have congestive heart failure (CHF; 6.0% LSG versus 2.4% LRYGB, P ¼ 0.032). In addition, LSG patients had shorter operative times of 108.77 43.12 min compared with 182.91 47.48 min for LRYGB (P < 0.001). On the contrary, those who underwent LRYGB were more likely to have diabetes (38.1% versus 28.4%, P ¼ 0.011), gastroesophageal reflux disease (GERD; 48.3% versus 24.6%, P < 0.001), and hyperlipidemia (HLD; 39.2% versus 29.7%, P ¼ 0.014; Table 4). Multivariate logistic regression revealed procedure type (P ¼ 0.003) and nondepolarizing muscle relaxant (P ¼ 0.030) were all independent in predicting the development of POUR. Specifically, the risk of developing POUR increased 2.69-fold with LSG (95% confidence interval [CI] 1.40-5.18), and 3.18fold with isolated nondepolarizing muscle relaxant use (95%
86
j o u r n a l o f s u r g i c a l r e s e a r c h n o v e m b e r 2 0 1 9 ( 2 4 3 ) 8 3 e8 9
Fig e Trend of postoperative urinary retention incidence and intraoperative catheterization use over study period (20132017).
CI 1.12-9.01; Table 5). In contrast, neostigmine (P ¼ 0.259) and female LOS (P ¼ 0.056) were not significant on multivariate regression. Multivariate logistic regression controlling for procedure type in patients who developed POUR revealed CHF, GERD, HLD, diabetes, weight (in logarithmic units), and operative time (in logarithmic units) were statistically different between the two procedure types. Specifically, patients undergoing LSG were 1.53-fold more likely to be heavier, 1.64-fold more likely to have CHF (95% CI 1.19-2.27), and 1.54-fold more likely to have shorter operative time (95% CI 1.14-2.08). Whereas patients undergoing LRYGB were 1.80-fold more likely to have diabetes (95% CI 1.19-2.74), 2.02-fold more likely to have GERD (95% CI 1.34-3.05), and 1.75-fold more likely to have HLD (95% CI 1.20-2.53; Table 6).
Discussion Obesity is a chronic disease, and prior research has demonstrated that bariatric surgery is the most effective intervention for inducing long-term weight loss, improved quality of life,
and comorbidities.8,9,15,16 In this high-risk patient population, it is important to identify complications that could impact quality outcomes. POUR is a known complication of other laparoscopic procedures and leads to patient discomfort, prolonged LOS, and potential infectious complications.13 This is the first study to identify the incidence and risk factors associated with POUR in primary laparoscopic bariatric surgery. At our institution, we found an overall incidence of 8.1% in primary LSG and LRYGB patients. The incidence of POUR in LSG patients was increased 2.69fold compared with LRYGB patients. This difference could be secondary to patient selection. Higher risk patients, such as those with BMI >65 kg/m2 or cardiopulmonary comorbidities that place them at higher risk of general anesthesia complications, are typically recommended to undergo an LSG over LRYGB. Through a multivariate analysis and controlling for procedure type, significance was identified between POUR and CHF as well as weight. Presumably, diuretic dependence of patients with CHF could explain the higher incidence of POUR in LSG compared with LRYGB patients. At our institution, the protocol is to hold the diuretics the morning of surgery, as well as immediately postoperatively. Diuretics are only restarted
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roadman et al urinary retention in bariatric surgery
Table 4 e Univariate analysis of patient demographics and perioperative outcomes by procedure type. Variable
LSG (n ¼ 317)
LRYGB (n ¼ 286)
n (%) or mean (SD)
n (%) or mean (SD)
P value
Age (y)
43.77 12.05
45.21 12.04
0.14
BMI (kg/m2)
49.22 9.62
47.87 16.31
0.21
Weight (lbs)
306.19 68.30
291.38 61.27
0.005*
Sex
248 (78.2)
226 (79.0)
0.81
Diabetes
90 (28.4)
109 (38.1)
0.011*
Smoker
26 (8.2)
25 (8.7)
Congestive heart failure
19 (6.0)
7 (2.4)
Obstructive sleep apnea
123 (38.8)
119 (41.6)
0.48
78 (24.6)
138 (48.3)
<0.001*
Gastroesophageal reflux disease Hypertension HLD
0.81 0.032*
172 (54.3)
163 (57.0)
0.50
94 (29.7)
112 (39.2)
0.014*
Benign prostatic hyperplasia
2 (2.9)
Chronic obstructive pulmonary disease
7 (2.2)
6 (2.1)
Hispanic ethnicity
13 (4.1)
24 (8.4)
0.029*
POUR
36 (11.4)
13 (4.5)
0.002*
108.77 43.12
182.91 47.48
<0.001*
1119.10 489.61
1575.00 658.53
<0.001*
Operative time (min) Intraoperative fluids (mL) *
0 (0.0)
0.93
Statistical significance (P < 0.05).
when needed in patients with CHF on postoperative day 1 if the patient is euvolemic, and the medical necessity for the diuretic to control CHF symptoms outweighs the potential risk of dehydration. Given the retrospective nature of this study, we are unable to control for diuretic administration. However, this could be considered a future quality initiative to closely document the volume status of patients, when diuretics were restarted, and the development of POUR, as this has not previously been studied. In addition, the role of increased weight in these patients and development of POUR was evaluated. In a recent study, the association between obesity and lower urinary tract symptoms was evaluated using propensity score matching on validated questionnaires. They found marked differences in lower urinary tract symptoms between obese and nonobese patients, including in voiding and storage symptoms.17 Additional studies found obesity plays a role in bladder filling dysfunction with increased symptoms such as in urgency and urinary incontinence.18 The exact mechanism between obesity and bladder pathophysiology is unknown. A previous study identified risk factors of urinary incontinence and
retention after LRYGB without intraoperative catheterization. Although they identified a reduction in postoperative incontinence from 43% to 15%, they did not find any preoperative risk factors of POUR, as none of their 60 patients developed this complication.19 Given the retrospective nature of our study, we were unable to identify symptoms of urinary incontinence and if this was associated with POUR. In our patients, we did not identify preoperative voiding dysfunction, and it is possible that as a result of their increased weight, the heavier patients had more difficulty with voiding at baseline. Identifying the preoperative voiding capacity of our patients through mechanisms such as validated questionnaires and/or urologic consultation for urodynamics in symptomatic patients could be pursued prospectively to further understand and reduce the risk of POUR.
Table 6 e Multivariate logistic regression predictors of POUR, controlling for procedure type. Variable
Odds ratio
95% CI
P value
Operative time (min)
1.54
1.14-2.08
0.005*
Gastroesophageal reflux disease
2.02
1.34-3.05
<0.001*
HLD
1.75
1.20-2.53
0.003*
y
Table 5 e Independent predictors on multivariate logistic regression of the risk to develop POUR after primary bariatric surgery. Variable
Odds ratio
95% CI
P value
Procedure type
2.69
1.40-5.18
0.003
Nondepolarizing muscle relaxant
3.18
1.12-9.01
0.03*
*
0.19
Statistical significance (P < 0.05).
*
1.80
1.19-2.74
0.006*
y
1.53
1.18-1.98
0.001*
Congestive heart failure
1.64
1.19-2.27
0.003*
Diabetes Weight (lbs)
*
Statistical significance (P < 0.05). Odds ratio and 95% CI for weight and operative time expressed as log-based 10 increments. y
88
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The correlation between decreased IVF and POUR is contradictory to a previous study, where Keita et al. found that increased IVF, age, and bladder volume on entry to the postanesthesia care unit independently increased the risk of urinary retention in a variety of different surgical procedures.20 The correlation of decreased IVF and POUR in our study was most likely related to the operative time differences between LSG and LRYGB. LSG had both a significantly shorter operative time 108.77 43.12 min (versus 182.91 47.48 min) and IVF 1119.10 489.61 mL (versus 1575.00 658.53 mL) than that of LRYGB. Thus, the relationship of decreased IVF and POUR in our study was likely confounded by the differences in operative time, as well as the stronger correlation of LSG with POUR. The study finding that decreased neostigmine dosage is correlated with POUR highlights a potential future analysis of its use. Neostigmine is an acetylcholinesterase inhibitor and leads to the accumulation of acetylcholine. Acetylcholine stimulates parasympathetic muscarinic receptors on detrusor smooth muscle cells of the bladder and promotes voiding.21 Therefore, patients who receive lower overall doses of neostigmine have a decreased amount of available acetylcholine, therefore contributing to urinary retention. Furthermore, the association of isolated nondepolarizing muscle relaxants and POUR is likely through a similar mechanism, given that they competitively block cholinergic receptors and are overcome by neostigmine.22 Together, the correlation of decreased neostigmine and the use of isolated nondepolarizing muscle relaxants with POUR emphasizes an opportunity for a future evaluation of neostigmine dosing for neuromuscular blockade reversal and muscle relaxant usage within the bariatric population. In our study, female patients who developed POUR had a longer LOS at 2.14 1.17 d versus 1.71 1.25 d (P ¼ 0.046). In contrast, for male patient, there was no difference in LOS with development of POUR. Although no statistical significance was found in the type of urinary intervention based on gender, this was likely due to the small sample size population who developed POUR. Overall, 14.3% of male patients were discharged home with an indwelling catheter versus 2.9% of female patients, a factor that could account for an increased LOS in females. In addition, 20.0% of female patients received a successive urinary intervention with a straight catheter before indwelling catheter placement versus 7.1% of men, which could also lengthen LOS. Given that the majority (78.6%) of our bariatric surgery patients are female, this highlights an important quality initiative to address the impact of POUR on LOS. Identifying patients who are at risk for developing POUR can help determine quality initiatives to decrease its incidence. Our institution does not have a standard volume at which urinary catheterization is performed, and it is determined at the discretion of the provider. Although catheterization can increase the risk of urinary tract infection, delay in treatment can also be harmful and result in upper urinary tract damage. Thus, a standard volume and/or time frame for intervention would be an important guideline to establish.23,24 In association with our findings, a preoperative assessment to identify baseline bladder capacity, postvoid residual, and urgency to void volume could help personalize and clarify when an intervention is necessary.
Limitations of this study include the retrospective nature of this single-center chart review and thus is subject to errors within the electronic medical record and the information collected during pre- and post-operative visits. In addition, there is no consensus at our institution regarding bladder volume and the threshold for using urinary catheterization.
Conclusions The incidence of POUR in primary LSG and LRYGB at our institution was 8.1%. Patients who had an LSG, reduced IVF, intraoperative isolated non-depolarizing muscle relaxant, and decreased neostigmine usage were more likely to develop POUR. The exact mechanism behind LSG patients developing POUR is unclear but could be secondary to patient differences, identifying specifically CHF and increased weight as associated factors. Female patients who experienced POUR had a significantly longer LOS. These findings highlight an opportunity to counsel patients of the risk of POUR after these procedures, as well as identify quality initiatives that focus on perioperative and anesthetic management to reduce the incidence of POUR.
Acknowledgment This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Authors’ contributions: R.M.H., M.I.G., T.L.K., and J.C.G. conceived of the study. M.H. and D.R. provided statistical analysis. D.R. and M.H. were responsible for clinical data collection and sorting. D.R. and R.M.H. wrote the article; M.I.G., T.L.K., and J.C.G. provided editorial support. All authors read and approved the final article.
Disclosure The authors reported no proprietary or commercial interest in any product mentioned or concept discussed in this article.
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Association for Academic Surgery
Postoperative Urinary Retention After Bariatric Surgery: An Institutional Analysis Daniel Roadman, BS, Melissa Helm, MS, Matthew I. Goldblatt, MD, Tammy L. Kindel, MD, PhD, Jon C. Gould, MD, and Rana M. Higgins, MD* Division of General Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
article info
abstract
Article history:
Background: Postoperative urinary retention (POUR) can impact quality outcomes, leading to
Received 14 February 2019
urinary tract infections, longer lengths of stay, and increased healthcare costs. The inci-
Received in revised form
dence of POUR in bariatric patients is unknown. Our primary objective was to determine
23 April 2019
the incidence and risk factors contributing to POUR in primary bariatric surgery.
Accepted 1 May 2019
Methods: A retrospective review was conducted on patients who underwent a laparoscopic
Available online xxx
sleeve gastrectomy (LSG) or laparoscopic Roux-en-Y gastric bypass (LRYGB) from 2013 to 2017. POUR was defined as the inability to urinate postoperatively, requiring urinary
Keywords:
catheterization. Univariate and multivariate analyses were performed on perioperative
Urinary retention
variables and their correlation with POUR.
Bariatric surgery
Results: During the study period, 603 patients underwent surgery: 317 (52.6%) LSG and 286
Laparoscopy
(47.4%) LRYGB. Overall, 49 (8.1%) patients developed POUR. There were no significant differences in preoperative demographics between patients with and without POUR. Patients who underwent an LSG had an increased incidence of POUR compared with LRYGB (P ¼ 0.002). In both procedures, POUR was associated with decreased neostigmine, isolated nondepolarizing muscle relaxant, and reduced intraoperative fluid. LSG and congestive heart failure, as well as LSG and body weight, were independently associated with POUR. Female patients who experienced POUR had significantly increased length of stay. Conclusions: Risk factors associated with POUR after primary bariatric surgery include LSG, less intraoperative neostigmine and intravenous fluids, and isolated nondepolarizing muscle relaxants. These risk factors can help educate patients and providers, as well as identify quality initiatives that focus on perioperative and anesthetic management to reduce POUR and length of hospital stay. ª 2019 Elsevier Inc. All rights reserved.
Introduction Approximately 40% of the US population is obese.1,2 Obesity is a known risk factor for the development of multiple
comorbidities that are responsible for more than 2.8 million deaths per year globally.3-7 To date, only bariatric surgery results in substantial and long-term weight loss for obese patients, improving comorbidities, quality of life, and reducing
This study was presented as a QuickShot oral presentation at the 2019 Academic Surgical Congress, Houston, Tx, February 5-7, 2019. * Corresponding author. Division of General Surgery, Medical College of Wisconsin, 8701 W Watertown Plank Road, Milwaukee, WI 53226. Tel.: þ1 414 955-1775; fax: þ1 414 955-0085. E-mail address: [email protected] (R.M. Higgins). 0022-4804/$ e see front matter ª 2019 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jss.2019.05.005
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mortality.3,8-11 In 2010, the estimated healthcare cost of obesity in the United States was $168.4 billion per year, with the most significant driver of cost being age- and obesityrelated comorbid conditions.3,6,9,12 The two most commonly performed bariatric procedures in the United States are the laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB). Postoperative urinary retention (POUR) is a well-known complication of laparoscopic procedures, and the incidence and specific risk factors of this complication within the primary bariatric surgery population are unknown. POUR has been associated with urinary tract infections and longer length of hospital stay, which could significantly increase overall costs.13,14 POUR is defined as the inability to void in the postoperative period, and the need for urinary straight or indwelling catheterization. The primary objective of this study was to determine risk factors contributing to POUR in bariatric surgery patients.
Materials and methods An institutional review boardeapproved retrospective chart review was performed of patients who underwent a primary LSG or LRYGB at a single institution from 2013 to 2017. Informed consent was waived per institutional policy because the review did not have direct contact with patients. The procedures were performed by five fellowship-trained minimally invasive general surgeons. All surgeons performed the procedure in a similar fashion. Intraoperative catheter usage was initially at the discretion of the surgeon; however, midway in the study, urinary catheters were no longer routinely placed. Within this cohort of patients, those who developed POUR were identified. POUR was defined as the inability to urinate postoperatively, requiring urinary straight or indwelling catheterization before discharge. All patients were required to void within 8-10 h postoperatively, post straight
catheterization or removal of an indwelling catheter. If they were unable to void, a straight catheterization was performed. If they were subsequently unable to void, an indwelling catheter was placed that was removed the following morning. If patients were unable to void on subsequent attempts, they were discharged with an indwelling catheter and scheduled to follow-up with a urologist within 1 wk for a voiding trial. Demographic information, preoperative comorbidities, perioperative events, and postoperative variables were identified to determine risk factors that contributed to the incidence of POUR. Statistical analysis was completed using IBM SPSS Statistics version 24. A P value of <0.05 was considered significant. Univariate analyses were performed on perioperative variables and their correlation with POUR. All proportional data are presented as percentages and were analyzed using chisquare tests. All continuous data are presented as mean standard deviation and were compared using twotailed, unpaired Student’s t-tests. Predictive variables in univariate analysis were input into a binary logistic regression model in a stepwise fashion and were presented with odds ratio and 95% confidence interval.
Results A total of 603 patients underwent primary bariatric surgery during our study period. The mean body mass index (BMI) was 48.58 13.23 kg/m2, with 474 (78.6%) female and 129 (21.4%) male patients. Patient preoperative and intraoperative variables are included in Table 1. Overall, 49 (8.1%) of patients developed POUR with a mean urinary volume at time of intervention of 682.5 319.7 mL. There were no significant differences in preoperative demographics in relation to the development of POUR (Table 1). Analysis of perioperative variables identified POUR as significantly associated with LSG, with an incidence of 11.4% compared with 4.5% after LRYGB (P ¼ 0.002). Additional factors associated with POUR included
Table 1 e Univariate analysis of patient demographics as predictors of POUR. Variable
Age (y) 2
POUR (n ¼ 49)
No POUR (n ¼ 554)
n (%) or mean (SD)
n (%) or mean (SD)
46.20 13.04
44.30 11.97
0.29
P value
46.34 8.05
48.77 13.58
0.22
294.89 60.08
299.54 65.91
0.63
Gender, female
35 (71.4)
439 (79.2)
0.20
Diabetes
22 (44.9)
177 (31.9)
0.07
Smoker
5 (10.2)
46 (8.3)
0.65
Body mass index (kg/m ) Weight (lbs)
Congestive heart failure
3 (6.1)
23 (4.2)
0.52
Obstructive sleep apnea
20 (40.8)
222 (40.1)
0.92
Gastroesophageal reflux disease
20 (40.8)
196 (35.4)
0.45
Hypertension
31 (63.3)
304 (54.9)
0.26
HLD
17 (34.7)
189 (34.1)
0.94
1 (0.2)
0.08
13 (2.3)
0.28
Benign prostatic hyperplasia Chronic obstructive pulmonary disease
1 (2.0) 0 (0.0)
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roadman et al urinary retention in bariatric surgery
Table 2 e Univariate analysis of perioperative outcomes as predictors of POUR. Variable
POUR (n ¼ 49)
No POUR (n ¼ 554)
n (%) or mean (SD)
n (%) or mean (SD)
P value
0.002*
Procedure type Laparoscopic Sleeve Gastrectomy
36 (11.4)
281 (88.6)
Laparoscopic Roux-en-Y Gastric bypass
13 (4.5)
273 (95.5)
Scopolamine patch
14 (28.6)
183 (33.0)
0.52
Regional anesthesia
7 (14.3)
58 (10.5)
0.41
11 (22.4)
187 (33.8)
0.11
Intraoperative indwelling catheter Intraoperative fluids (mL) Glycopyrrolate (mg)
y
y
Neostigmine (mg)y Nondepolarizing muscle relaxant
z
Urinary tract infection within 30 d
1111.63 522.57
1354.76 623.14
0.01*
0.77 0.20
0.79 0.24
0.64
5.0 0.70
5.24 1.14
0.04*
45 (91.8%)
432 (78.0%)
0.02*
4 (0.7)
0.32
1 (2.1)
Urinary catheter removal (d)
0.89 0.33
0.95 0.31
0.57
Length of stay (d)
1.96 1.08
1.67 1.17
0.09
Males (d)
1.5 0.65
1.52 0.77
0.92
Females (d)
2.14 1.17
1.71 1.25
0.046*
*
Statistical significance (P < 0.05). Analysis includes only patients who received medication and/or fluids in the operating room: intraoperative fluid (n ¼ 528), glycopyrrolate (n ¼ 575), neostigmine (n ¼ 573). z Nondepolarizing muscle relaxant analysis excludes patients who also had a depolarizing muscle relaxant (n ¼ 477). y
decreased neostigmine usage, isolated nondepolarizing muscle relaxant usage, and reduced intraoperative fluid (IVF) administration. Female patients with POUR had a significantly longer length of stay (LOS) at 2.14 1.17 d compared with those without POUR at 1.71 1.25 d (P ¼ 0.046). There was no significant difference in LOS for male patients. Additional perioperative variables that were not statistically significant determinants of POUR are also listed (Table 2). In patients who developed POUR, urinary intervention methods by gender were evaluated (Table 3). No significant differences were found in regard to intraoperative urinary catheter usage or urinary tract infection. Per protocol, if an indwelling catheter is placed, it is removed on postoperative day 1, with 167 patients (90.7%) having their indwelling catheter removed on postoperative day 1 in this
Table 3 e Univariate analysis of POUR interventions by gender. Variable
Females (n ¼ 35)
Males (n ¼ 14)
n (%)
n (%)
Indwelling catheter
23 (65.7)
11 (78.6)
0.378
Straight catheter
19 (54.3)
4 (28.6)
0.103
Successive intervention*
7 (20.0)
1 (7.1)
0.271
Discharged with indwelling
1 (2.9)
2 (14.3)
0.082
Urinary tract infection
1 (2.9)
0 (0.0)
0.517
*
P value
Successive intervention indicates an initial straight catheter was used, followed by an indwelling catheter after the patient remained unable to void.
study. Provider preference early in the study and patientspecific variables accounted for variations from protocol, 14 patients (7.6%) had their catheter removed at the end of their case, 4 patients (2.2%) had their catheter removed on postoperative day 2 due to decreased urine output, concern for upper gastrointestinal leak, and/or cardiac complication that required cardioversion. An additional 13 patients had straight urinary catheterization during their procedure. Overall, 198 of the 603 patients (32.8%) included in the study had an intraoperative urinary catheter. In the earliest year of our study, 56.0% of patients had an intraoperative catheter, which declined each year and by the final year of our study; only 3.1% of patients had an intraoperative catheter. There were no significant differences in the incidence of POUR over time while the protocol changed (Figure). Patient demographics and perioperative outcomes of all patients were further analyzed by procedure type. It was found that those undergoing LSG had an increased weight of 306.19 68.30 lbs compared with 291.38 61.27 lbs for LRYGB (P ¼ 0.005) and were more likely to have congestive heart failure (CHF; 6.0% LSG versus 2.4% LRYGB, P ¼ 0.032). In addition, LSG patients had shorter operative times of 108.77 43.12 min compared with 182.91 47.48 min for LRYGB (P < 0.001). On the contrary, those who underwent LRYGB were more likely to have diabetes (38.1% versus 28.4%, P ¼ 0.011), gastroesophageal reflux disease (GERD; 48.3% versus 24.6%, P < 0.001), and hyperlipidemia (HLD; 39.2% versus 29.7%, P ¼ 0.014; Table 4). Multivariate logistic regression revealed procedure type (P ¼ 0.003) and nondepolarizing muscle relaxant (P ¼ 0.030) were all independent in predicting the development of POUR. Specifically, the risk of developing POUR increased 2.69-fold with LSG (95% confidence interval [CI] 1.40-5.18), and 3.18fold with isolated nondepolarizing muscle relaxant use (95%
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Fig e Trend of postoperative urinary retention incidence and intraoperative catheterization use over study period (20132017).
CI 1.12-9.01; Table 5). In contrast, neostigmine (P ¼ 0.259) and female LOS (P ¼ 0.056) were not significant on multivariate regression. Multivariate logistic regression controlling for procedure type in patients who developed POUR revealed CHF, GERD, HLD, diabetes, weight (in logarithmic units), and operative time (in logarithmic units) were statistically different between the two procedure types. Specifically, patients undergoing LSG were 1.53-fold more likely to be heavier, 1.64-fold more likely to have CHF (95% CI 1.19-2.27), and 1.54-fold more likely to have shorter operative time (95% CI 1.14-2.08). Whereas patients undergoing LRYGB were 1.80-fold more likely to have diabetes (95% CI 1.19-2.74), 2.02-fold more likely to have GERD (95% CI 1.34-3.05), and 1.75-fold more likely to have HLD (95% CI 1.20-2.53; Table 6).
Discussion Obesity is a chronic disease, and prior research has demonstrated that bariatric surgery is the most effective intervention for inducing long-term weight loss, improved quality of life,
and comorbidities.8,9,15,16 In this high-risk patient population, it is important to identify complications that could impact quality outcomes. POUR is a known complication of other laparoscopic procedures and leads to patient discomfort, prolonged LOS, and potential infectious complications.13 This is the first study to identify the incidence and risk factors associated with POUR in primary laparoscopic bariatric surgery. At our institution, we found an overall incidence of 8.1% in primary LSG and LRYGB patients. The incidence of POUR in LSG patients was increased 2.69fold compared with LRYGB patients. This difference could be secondary to patient selection. Higher risk patients, such as those with BMI >65 kg/m2 or cardiopulmonary comorbidities that place them at higher risk of general anesthesia complications, are typically recommended to undergo an LSG over LRYGB. Through a multivariate analysis and controlling for procedure type, significance was identified between POUR and CHF as well as weight. Presumably, diuretic dependence of patients with CHF could explain the higher incidence of POUR in LSG compared with LRYGB patients. At our institution, the protocol is to hold the diuretics the morning of surgery, as well as immediately postoperatively. Diuretics are only restarted
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roadman et al urinary retention in bariatric surgery
Table 4 e Univariate analysis of patient demographics and perioperative outcomes by procedure type. Variable
LSG (n ¼ 317)
LRYGB (n ¼ 286)
n (%) or mean (SD)
n (%) or mean (SD)
P value
Age (y)
43.77 12.05
45.21 12.04
0.14
BMI (kg/m2)
49.22 9.62
47.87 16.31
0.21
Weight (lbs)
306.19 68.30
291.38 61.27
0.005*
Sex
248 (78.2)
226 (79.0)
0.81
Diabetes
90 (28.4)
109 (38.1)
0.011*
Smoker
26 (8.2)
25 (8.7)
Congestive heart failure
19 (6.0)
7 (2.4)
Obstructive sleep apnea
123 (38.8)
119 (41.6)
0.48
78 (24.6)
138 (48.3)
<0.001*
Gastroesophageal reflux disease Hypertension HLD
0.81 0.032*
172 (54.3)
163 (57.0)
0.50
94 (29.7)
112 (39.2)
0.014*
Benign prostatic hyperplasia
2 (2.9)
Chronic obstructive pulmonary disease
7 (2.2)
6 (2.1)
Hispanic ethnicity
13 (4.1)
24 (8.4)
0.029*
POUR
36 (11.4)
13 (4.5)
0.002*
108.77 43.12
182.91 47.48
<0.001*
1119.10 489.61
1575.00 658.53
<0.001*
Operative time (min) Intraoperative fluids (mL) *
0 (0.0)
0.93
Statistical significance (P < 0.05).
when needed in patients with CHF on postoperative day 1 if the patient is euvolemic, and the medical necessity for the diuretic to control CHF symptoms outweighs the potential risk of dehydration. Given the retrospective nature of this study, we are unable to control for diuretic administration. However, this could be considered a future quality initiative to closely document the volume status of patients, when diuretics were restarted, and the development of POUR, as this has not previously been studied. In addition, the role of increased weight in these patients and development of POUR was evaluated. In a recent study, the association between obesity and lower urinary tract symptoms was evaluated using propensity score matching on validated questionnaires. They found marked differences in lower urinary tract symptoms between obese and nonobese patients, including in voiding and storage symptoms.17 Additional studies found obesity plays a role in bladder filling dysfunction with increased symptoms such as in urgency and urinary incontinence.18 The exact mechanism between obesity and bladder pathophysiology is unknown. A previous study identified risk factors of urinary incontinence and
retention after LRYGB without intraoperative catheterization. Although they identified a reduction in postoperative incontinence from 43% to 15%, they did not find any preoperative risk factors of POUR, as none of their 60 patients developed this complication.19 Given the retrospective nature of our study, we were unable to identify symptoms of urinary incontinence and if this was associated with POUR. In our patients, we did not identify preoperative voiding dysfunction, and it is possible that as a result of their increased weight, the heavier patients had more difficulty with voiding at baseline. Identifying the preoperative voiding capacity of our patients through mechanisms such as validated questionnaires and/or urologic consultation for urodynamics in symptomatic patients could be pursued prospectively to further understand and reduce the risk of POUR.
Table 6 e Multivariate logistic regression predictors of POUR, controlling for procedure type. Variable
Odds ratio
95% CI
P value
Operative time (min)
1.54
1.14-2.08
0.005*
Gastroesophageal reflux disease
2.02
1.34-3.05
<0.001*
HLD
1.75
1.20-2.53
0.003*
y
Table 5 e Independent predictors on multivariate logistic regression of the risk to develop POUR after primary bariatric surgery. Variable
Odds ratio
95% CI
P value
Procedure type
2.69
1.40-5.18
0.003
Nondepolarizing muscle relaxant
3.18
1.12-9.01
0.03*
*
0.19
Statistical significance (P < 0.05).
*
1.80
1.19-2.74
0.006*
y
1.53
1.18-1.98
0.001*
Congestive heart failure
1.64
1.19-2.27
0.003*
Diabetes Weight (lbs)
*
Statistical significance (P < 0.05). Odds ratio and 95% CI for weight and operative time expressed as log-based 10 increments. y
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The correlation between decreased IVF and POUR is contradictory to a previous study, where Keita et al. found that increased IVF, age, and bladder volume on entry to the postanesthesia care unit independently increased the risk of urinary retention in a variety of different surgical procedures.20 The correlation of decreased IVF and POUR in our study was most likely related to the operative time differences between LSG and LRYGB. LSG had both a significantly shorter operative time 108.77 43.12 min (versus 182.91 47.48 min) and IVF 1119.10 489.61 mL (versus 1575.00 658.53 mL) than that of LRYGB. Thus, the relationship of decreased IVF and POUR in our study was likely confounded by the differences in operative time, as well as the stronger correlation of LSG with POUR. The study finding that decreased neostigmine dosage is correlated with POUR highlights a potential future analysis of its use. Neostigmine is an acetylcholinesterase inhibitor and leads to the accumulation of acetylcholine. Acetylcholine stimulates parasympathetic muscarinic receptors on detrusor smooth muscle cells of the bladder and promotes voiding.21 Therefore, patients who receive lower overall doses of neostigmine have a decreased amount of available acetylcholine, therefore contributing to urinary retention. Furthermore, the association of isolated nondepolarizing muscle relaxants and POUR is likely through a similar mechanism, given that they competitively block cholinergic receptors and are overcome by neostigmine.22 Together, the correlation of decreased neostigmine and the use of isolated nondepolarizing muscle relaxants with POUR emphasizes an opportunity for a future evaluation of neostigmine dosing for neuromuscular blockade reversal and muscle relaxant usage within the bariatric population. In our study, female patients who developed POUR had a longer LOS at 2.14 1.17 d versus 1.71 1.25 d (P ¼ 0.046). In contrast, for male patient, there was no difference in LOS with development of POUR. Although no statistical significance was found in the type of urinary intervention based on gender, this was likely due to the small sample size population who developed POUR. Overall, 14.3% of male patients were discharged home with an indwelling catheter versus 2.9% of female patients, a factor that could account for an increased LOS in females. In addition, 20.0% of female patients received a successive urinary intervention with a straight catheter before indwelling catheter placement versus 7.1% of men, which could also lengthen LOS. Given that the majority (78.6%) of our bariatric surgery patients are female, this highlights an important quality initiative to address the impact of POUR on LOS. Identifying patients who are at risk for developing POUR can help determine quality initiatives to decrease its incidence. Our institution does not have a standard volume at which urinary catheterization is performed, and it is determined at the discretion of the provider. Although catheterization can increase the risk of urinary tract infection, delay in treatment can also be harmful and result in upper urinary tract damage. Thus, a standard volume and/or time frame for intervention would be an important guideline to establish.23,24 In association with our findings, a preoperative assessment to identify baseline bladder capacity, postvoid residual, and urgency to void volume could help personalize and clarify when an intervention is necessary.
Limitations of this study include the retrospective nature of this single-center chart review and thus is subject to errors within the electronic medical record and the information collected during pre- and post-operative visits. In addition, there is no consensus at our institution regarding bladder volume and the threshold for using urinary catheterization.
Conclusions The incidence of POUR in primary LSG and LRYGB at our institution was 8.1%. Patients who had an LSG, reduced IVF, intraoperative isolated non-depolarizing muscle relaxant, and decreased neostigmine usage were more likely to develop POUR. The exact mechanism behind LSG patients developing POUR is unclear but could be secondary to patient differences, identifying specifically CHF and increased weight as associated factors. Female patients who experienced POUR had a significantly longer LOS. These findings highlight an opportunity to counsel patients of the risk of POUR after these procedures, as well as identify quality initiatives that focus on perioperative and anesthetic management to reduce the incidence of POUR.
Acknowledgment This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Authors’ contributions: R.M.H., M.I.G., T.L.K., and J.C.G. conceived of the study. M.H. and D.R. provided statistical analysis. D.R. and M.H. were responsible for clinical data collection and sorting. D.R. and R.M.H. wrote the article; M.I.G., T.L.K., and J.C.G. provided editorial support. All authors read and approved the final article.
Disclosure The authors reported no proprietary or commercial interest in any product mentioned or concept discussed in this article.
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