Intraoperative Catheter Disappoints for Urinary Retention After Hernia Repair

The use of an intraoperative catheter did not protect against the development of postoperative urinary retention (PUR) for patients who underwent laparoscopic inguinal hernia repair surgery, a randomized trial found.

Among over 450 such patients, no significant difference was observed in the rate of PUR for those who received an intraoperative catheter placement versus those who did not (9.6% vs 8.5%, respectively, P=0.79), reported Aldo Fafaj, MD, of the Cleveland Clinic Center for Abdominal Core Health in Ohio, and colleagues.

“The lack of apparent immediate clinical benefit accompanied by the potential for rare but devastating complications offer a compelling argument in favor of abandoning routine use of catheters during laparoscopic inguinal hernia repair in patients who void urine preoperatively,” the group wrote in JAMA Surgery.

During laparoscopic inguinal repair surgery, urinary catheters are often placed to protect against PUR and bladder injury, Fafaj’s group noted. PUR is the most common complication of the procedure, with incidence reaching up to 22%.

However, the required use of intraoperative catheters can also lead to catheter-related infections, prostatitis, and urethral trauma complications, outside of patient discomfort alone. PUR has been previously linked to higher costs of care, urinary tract infections, longer hospital stays, and less patient satisfaction.

“Low-value services are ubiquitous in health care,” noted Martin Almquist, MD, PhD, of the Skåne University Hospital in Malmö, Sweden, writing in an accompanying editorial. “It is estimated that the U.S. alone spends more than $100 billion annually on unnecessary medical tests, treatments, and procedures that expose patients to harms without apparent benefit. Deimplementation has proven difficult, despite campaigns such as Choosing Wisely.

He noted that “although lack of evidence of effect does not equal evidence of no effect,” the current study “provides a strong argument for abandoning routine urinary catheter placement during elective endoscopic inguinal hernia repair.”

For their study, Fafaj and colleagues enrolled 491 patients with primary or recurrent inguinal hernias and randomized them to receive an intraoperative catheter after the induction of general anesthesia (n=241) or no catheter placement (control; n=250) across six centers from 2019 to 2021. Catheters were removed after the procedure. Follow-up occurred for 30 days after surgery and PUR, the primary outcome, was defined “as failure to void urine requiring straight catheterization, placement of an indwelling catheter, or return to the emergency department owing to inability to void urine after discharge from the hospital up to 30 days postoperatively.”

Participants were undergoing laparoscopic, elective, unilateral or bilateral primary (90%) or recurrent (10%) inguinal hernia repairs. The study was single-blinded, and patients were excluded if they were intolerant to general anesthesia. Preoperative voiding was required, along with other standard surgical procedures.

Median patient age was 61, nearly all were men (95%), the median body mass index was 26, and 17% had benign prostatic hyperplasia (BPH). Common comorbidities were hypertension (35%) and diabetes (5%).

Just under a fourth had left-sided unilateral inguinal hernias, 37% had right-sided unilateral inguinal hernias, and 39% had bilateral inguinal hernias; 12% had a scrotal component.

With a median operative time of 73 minutes, 72% of the surgeries were performed using the total extraperitoneal technique and 28% by the transabdominal preperitoneal approach. Over two-thirds were treated with an indwelling catheter for urinary retention and had same-day discharge from the hospital.

Exploratory multivariate analysis found certain risk factors were associated with the development of PUR: age over 65, BPH, inoperative use of anticholinergic medication, and intraoperative crystalloid infusion volume. But a post hoc analysis found that urinary catheter placement did not reduce PUR in these groups.

Among the catheter group, one patient with PUR resulting in a suprapubic catheter placement experienced postoperative urethral trauma. No intraoperative bladder injuries occurred. No difference was seen in the timing of PUR diagnosis and treatment between the two groups.

Study limitations included the fact that criteria for the timing of bladder scans, and the decision to catheterize patients, were not standardized across centers. BPH patients also were underrepresented. Finally, the sample size was small and unmeasured confounders could have impacted the findings.