Postoperative urinary retention following benign gynecologic surgery with a liberal vs. strict voiding protocol

Study objective: Surgeons employ various methods for evaluating what is considered a common occurrence after gynecologic operations, postoperative urinary retention (POUR). Few have reported the incidence of POUR with a liberal voiding protocol (no requirement to void prior to discharge). The primary objective of this study is to evaluate the risk of POUR after benign gynecologic surgery, comparing a liberal voiding protocol to more strict voiding protocols. Secondary outcomes include length of hospital stay and urinary tract infection (UTI).

Design: Retrospective cohort study.

Setting: Quaternary-care academic hospital in the United States.

Patients: Patients undergoing hysterectomy or myomectomy at Cedars-Sinai Medical Center from August 2017 through July 2018 (n=652). Cases involving incontinence operations, correction of pelvic organ prolapse, malignancy, or peripartum hysterectomy were excluded.

Interventions: Hysterectomy, myomectomy MEASUREMENTS AND MAIN RESULTS: POUR, defined as the need for re-catheterization within 24 hours of catheter removal, along with UTI and length of stay, were compared between liberal and strict voiding protocols. Sub-group analysis was performed for those undergoing minimally invasive surgery (MIS). 303 (46.5%) women underwent surgery with a liberal postoperative voiding protocol and 349 (53.5%) with a strict voiding protocol. Overall, the incidence of POUR was low at 3.8% and not different among groups (2.6% liberal vs. 4.9% strict, p = 0.14). UTI also occurred infrequently (2.8% overall, 2.6% liberal vs. 2.9% strict, p= 0.86). Similar results were seen specifically among those that underwent MIS: POUR (3.7% overall, 2.8% liberal vs. 5.3% strict, p= 0.17) and UTI (3.3% overall, 2.4% liberal vs. 4.7% strict, p= 0.28). Median length of stay (IQR) was much shorter for MIS patients with a liberal voiding protocol (median 15 hours overall (IQR 15 hours), 9 (4) liberal vs. 36 (34) strict, p<0.01). Among those discharged same-day (72.6% of MIS cases), patients with a liberal voiding protocol had a significantly shorter LOS than those with strict (mean (SD) 9.4 (2.5) hours vs. 10.6 (35) hours, p<0.01). Postoperative complications occurred less frequently among those with MIS procedures (11.8% in MIS vs 20.2% in laparotomies, p<0.01), as well as those with liberal voiding protocols (11.2% liberal vs 16.9% strict p=0.04).

Conclusion: Overall, POUR occurs infrequently after major benign gynecologic surgery and does not differ among those with a liberal and a strict voiding protocol. Our data suggest same-day discharge after MIS hysterectomy and myomectomy without a requirement to void does not increase the risk of POUR and shortens LOS. Eliminating voiding protocols after these procedures may facilitate greater efficiency in the post-anesthesia recovery unit (PACU) and may contribute to Enhanced Recovery After Surgery (ERAS) protocols.

Keywords: Hysterectomy; Laparoscopy; Minimally Invasive Surgery; Myomectomy; Same-day discharge; Urinary retention.