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Postoperative Urinary Retention and UTI After LAVH for Benign Disease

34 Years
68 Years
Not Enrolling
Hysterectomy, Urinary Retention, Urinary Tract Infection

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Trial Information

Postoperative Urinary Retention and UTI After LAVH for Benign Disease

Hysterectomy is the most common major gynecological operation performed; in previous study,
20% of women will have undergone a hysterectomy by the age of 50 years, mostly for
nonmalignant conditions such as uterine fibroids, endometriosis, abnormal bleeding, uterine
prolapse and intra-epithelial neoplasia of the cervix grade 3. (1) Fever is the most common
perioperative complication of hysterectomy, arising in about 25%. (2) The other early
complications associated with hysterectomy including hemorrhage, infection, and injury to
adjacent organs, femoral neuropathy, and thromboembolic disease. (3) However, whether
hysterectomy is linked to the development of urinary symptoms remains controversial. Some
groups observed no effect or improved urinary dysfunction after hysterectomy, (4-7) others
reported that hysterectomy is the cause of a variety of urinary symptoms including the
urethral syndrome, stress incontinence, detrusor overactivity and voiding difficulty. (8, 9)
Voiding difficulty in the female is a condition in which the bladder fails to empty
completely and easily after micturition. Failure to detect voiding difficulties after
surgery may lead to bladder overdistention and irreversible damage of the detrusor muscle.
(10) Postoperative urinary retention (PUR) is defined as the inability to void with a full
bladder during the postoperative period. The etiology of PUR involves a combination of many
factors, including sedation, type of anesthesia, increased sympathetic stimulation,
overdistension of bladder by large quantities of fluids given intravenously, pain and
anxiety. (11) In the literature, incidence of postoperative urinary retention (PUR) has
ranged from 3.8% to 80%, depending on the definition used and the type of surgery performed.
(12-15) There is no consensus on how to diagnose PUR and various criteria, such as clinical
symptoms, bladder palpation and a fixed time interval or drainage by catheterization of more
than 500 ml of urine, have been used. (16) Traditionally gynecologists have used an
indwelling catheter for abdominal surgical procedures for several reasons, including the
beliefs that women would be unable to void satisfactorily in the immediate postoperative
period, that the indwelling catheter provided the only reliable method of assuring adequate
exposure, and that a catheter would be necessary in the recording of intake-output. In fact,
prompted by women's dislike of the catheter as well as an increased incidence of
postoperative urinary tract infection (UTI). (17) The potential sequelae of UTI include
gram-negative bacteremia, antimicrobial toxicity, chronic bacteriuria and chronic renal
disease. (18) In most cases the infection is mild and easily treated, but UTI is the
commonest nosocomial infection and leads to increased morbidity and treatment costs. (18-20)
Some North American studies addressing postoperative UTI have been confounded by the use of
perioperative antibiotics, (17, 21) suggesting UTI rates of 3-10%, whereas British work has
suggested a rate of 35% in control patients receiving no antibiotics. (22) It has been
estimated that the risk of UTI associated with indwelling catheterization is 5-10% per day
of catheterization (18) and that the commonest cause of UTI in hospital is urinary
catheterization (23). Short-term catheterization has been associated with subsequent
bacterial colony counts of > 105/ml of urine in 21% of women undergoing minor surgery, (24)
and the incidence of positive urine cultures rises with the length of time catheterization
is continued. (17, 18) In a randomized trial study for the effect of prophylactic
antibiotics on the postoperative UTI in patients undergoing abdominal hysterectomy, Ireland
et al found single dose cotrimoxazole is effective in reducing the incidence of
postoperative UTI from 35% in the control group to 4% in the treated group. (25) Hakvoort et
al studied whether prolonged urinary bladder catheterization after vaginal prolapse surgery
is advantageous. (26) They found that residual volumes > 200 ml and need for
recatheterization occurred in 9% in the 4 days catheterization group versus 40% of patients
in the one day catheterization group (OR 0.15, 95% CI 0.045-0.47). Positive urine cultures
were found in 40% of cases in the 4 days catheterization group versus 4% of patients in the
one day catheterization group (OR 15, 95% CI 3.2-68.6). By contrast, in a prospective study
of postoperative infection after abdominal and vaginal gynecological surgery, Kingdom et al
reported 40% of 115 patients receiving no prophylactic antibiotics developed a UTI in the
postoperative period and this was not clearly related to the need for postoperative
catheterization. (25) Since prolonged indwelling urinary catheterization may be associated
with an increased risk of UTI, increasing patient morbidity and potentially prolonging the
hospital stay (18), prophylactic antibiotics and a reduction in catheter time or no catheter
after surgery might be expected to reduce this risk.

Regarding the relationship of bladder catheterization with PUR, in published data of
prospective or retrospective studies on PUR after abdominal or vaginal hysterectomy, we
found that several factors of postoperative care affect the result of PUR including type of
surgery, use of catheter, duration of catheterization, and postoperative analgesia. (16, 17,
25, 27-30) During 4-year period, Summitt et al have not used postoperative bladder catheter
drainage after routine vaginal hysterectomy. (28) To assess the potential differences in
postoperative outcome, they prospectively compared the use of indwelling bladder catheter
drainage with no catheter use after standard vaginal hysterectomy. Their data showed 2
patients in the catheterized group required recatheterization after the catheters were
removed; none in the no-catheter group required a catheter. The results inferred that
indwelling catheterization appears unnecessary after routine vaginal hysterectomy. In a
prospective randomized trial study, Dobbs et al compared the infection rate and
postoperative morbidity between indwelling catheterization and in-out catheterization at the
time of abdominal hysterectomy. (27) Of the 95 patients in their study, 36% of that
undergoing in-out catheterization had PUR, requiring bladder emptying, compared with 4% of
those receiving an indwelling catheter. In addition, 29% of the catheterized group had
urinary tract bacteriuria compared with 13% of the uncatheterized group. They concluded that
in-out urinary catheterization at the time of routine abdominal hysterectomy was associated
with a significantly higher incidence of PUR compared with indwelling catheterization, and
may have implications for long-term bladder function. (27) Dobbs et al also pointed out that
abdominal muscular pain when the intra-abdominal pressure is increased during voiding
coupled with the decreased sensation for voiding due to analgesia, suggests that an
indwelling catheter in the immediate postoperative period will help to prevent long-term
morbidity from bladder atony. Bodker and Lose presented the prevalence of PUR was 9.2% in
their patients receiving gynecological surgery. (16) Of 124 patients undergoing abdominal
hysterectomy, 13.7% had PUR. Of 24 patients undergoing laparoscopic assisted vaginal
hysterectomy (LAVH), 8.7% had PUR. They concluded patients at risk of PUR are difficult to
predict. The risk is higher after laparotomy than after laparoscopy. A retention rate of
13.7% after abdominal hysterectomy is fairly similar to that of 11.8% after gynecologic
laparotomies reported by Schiotz, (29) Who used an indwelling Foley catheter routinely for
20-24 hours to ascertain the risks of UTI and aymptomatic bacteriuria. Based on 949
gynecologic laparotomies without the use of catheters but with bladder needling at the end
of surgery, Bartzen and Halferty found that 26% needed catheterization. (17) They suggested
that abstaining from the use of an indwelling catheter was also associated with lower cost
and greater patient satisfaction.

With the advent of minimally invasive surgery, LAVH is currently advocated as an alternative
to abdominal hysterectomy. Reported benefits of LAVH in short-term study, when compared with
the abdominal hysterectomy, include shorter hospital stays and convalescence, less
postoperative pain, lower morbidity, and, in some series, greater cost-effectiveness.
(31-35) Whereas benefits of LAVH in long-term follow-up, only few studies have appeared in
the literature. A report from Taiwan, Shen et al compared 1-month and 8-year follow-up of
LAVH and abdominal hysterectomy. In their 8-year follow-up showed no statistically
significant differences in vaginal vault prolapse, cystocele, rectocele, enterocele,
postcoital bleeding, and cuff granulation between LAVH and abdominal hysterectomy
procedures. (36) However, with regard to the consequences of PUR and UTI after LAVH, to our
best knowledge, no study has been conducted to examine bladder catheterization is associated
with this problem. Furthermore, no study has been performed to evaluate the long-term
sequelae of PUR after LAVH.

Inclusion Criteria:

- Uterine fibroids

- Endometriosis

- Abnormal bleeding

- Uterine prolapse and intra-epithelial neoplasia of the cervix grade 3

Exclusion Criteria:

- If they experienced pelvic reconstructive surgery for pelvic organ prolapse or stress
urinary incontinence

- If they have bacteriuria and clinical urinary tract symptoms, e.g. dysuria,
frequency, urgency and stress incontinence before surgery

Type of Study:


Study Design:

Allocation: Randomized, Endpoint Classification: Efficacy Study, Intervention Model: Parallel Assignment, Masking: Open Label, Primary Purpose: Treatment

Outcome Measure:

all cause mortality

Outcome Time Frame:

one year

Safety Issue:


Principal Investigator

Ching-Chung Liang, MA

Investigator Role:

Principal Investigator

Investigator Affiliation:



Taiwan: Department of Health

Study ID:




Start Date:

March 2007

Completion Date:

July 2008

Related Keywords:

  • Hysterectomy
  • Urinary Retention
  • Urinary Tract Infection
  • hysterectomy
  • laparoscopy
  • urinary retention
  • urinary tract infection
  • catheterization
  • Urinary Retention
  • Urinary Tract Infections