POUR Management: Optimizing Care for Postoperative Urinary Retention

Abstract

Post-Operative Urinary Retention (POUR) is a common and well-known postoperative complication and can be defined as the inability to void spontaneously after surgery, despite having a ‘full bladder’. POUR can happen after any type of surgery under general or spinal anesthesia. Next to lacking a general consensus on the specific thresholds to define POUR, the care and responsibility for POUR are still debatable. In this thesis we critically evaluate current standards and provide solutions to optimize care for POUR, with specific focus on effective management of the complication and determining appropriate bladder volume thresholds to justify catheterization. For this, we performed a randomized controlled trial (RCT) comparing the maximum bladder capacity (MBC, determined by the patient) versus a fixed standard cut-off volume of 500 mL, with the aim to lower the incidence of POUR and to reduce unnecessary postoperative urinary catheterizations. Out of the 4500 patients asked to participate, 1844 were included and randomized. We found a large variation in the individual MBC independent of gender, age and BMI. Using the MBC limit significantly reduced the incidence of catheterization from 11.8% to 8.6% (p=0.025). Based on these findings we propose that catheterization following POUR should only be performed ‘when a postoperative surgical patient is unable to void and presents with a scanned bladder volume that exceeds his/her individual MBC’. This result validated routine assessment and evaluation of the preoperative MBC in patients. If the MBC is unknown, we suggest that the average maximum bladder volume of 600 ml should be used as a bladder volume limit to prevent bladder damage. Further we concluded that the accuracy of ultrasound devices measuring postoperative bladder volumes still need improvement and their accuracy should be within a 5% range. Significant risk factors for POUR were spinal anesthesia, MBC <500 mL, duration of surgery ≥60 minutes, first scan at the PACU ≥250 mL and age ≥60 years. One month after surgery, close to 5% of the enrolled patients had a clinically relevant LUT dysfunction, expressed an increase in IPSS ≥6 points. We also demonstrated that implementing a hospital-wide MBC-POUR protocol is feasible, but its success crucially depends on cooperation of the nursing staff and the willingness of anesthesiologists to be responsible. Still, we have come to the realization that it is still difficult to give POUR the platform it warrants. Raising awareness among health care providers should be the primary objective in order to reduce unnecessary catheterizations and avoid adverse events. POUR deserves more attention! To facilitate follow-up with patients and promote general awareness we need to develop an (inter)national electronic database, in which all cases of POUR followed by bladder distention and associated damage are registered (as a Clavien-Dindo complication). Ultrasound devices for the accurate measurement of bladder volumes should be readily available and routinely used in every hospital. Ultimately, the final and most important question remains: “Are we, as health care providers, willing to change our established routines in favor of a well-developed protocol to prevent bladder damage and benefit patient care?”