JU INSIGHT Retrospective Multicenter Observational Study of Immediate Voiding at End of Urinary Sphincter Surgery

By: Ridwan Alam, MD, James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland; Thomas Kozar, MD, University of Alabama at Birmingham; Luke Wiegand, MD, University of South Florida Morsani College of Medicine, Tampa; Andrew J. Cohen, MD, James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland | Posted on: 15 Dec 2023

Kozar T, Kaylor JM, Hinderscheid C, et al. Retrospective Multicenter Observational Study of Immediate Voiding at End of Urinary Sphincter Surgery (REMOVE). J Urol. 2023;210(6):865-873.

Study Need and Importance

A long-standing dogma after artificial urinary sphincter (AUS) placement has been the placement of a postoperative urethral catheter. Historically, this was done given concerns for urethral swelling and risk of retention in the setting of a new urethral cuff, where repeated catheterizations may represent unnecessary risk to a fresh surgical site. REMOVE (the Retrospective Multicenter Observational Study of Immediate Voiding at End of Urinary Sphincter Surgery) attempts to address whether catheter omission has any negative impact on outcomes. Specifically, the aim was to address if withholding a catheter would impact retention rates as feared.

What We Found

In 425 virgin AUS implantations, there was no difference in retention rates following different approaches to postoperative catheterization. The rates of urinary retention were 6.6% for the catheter group and 7.3% for the no-catheter group. Controlling for age, cuff size, radiation history, and surgeon, multivariable analysis demonstrated that omission of a catheter was not an independent risk factor for urinary retention (Table). Furthermore, the rates of surgical site infections and erosions were not different between the 2 groups. Finally, Kaplan-Meier analysis revealed similar rates of revision surgery over time between the 2 groups.

Table. Univariable and Multivariable Predictors of Urinary Retention Based on Logistic Regression Models

Factor	Univariable			Multivariable
Factor	OR	95% CI	P value	OR	95% CI	P value
Age	1.05	0.99-1.10	.05	1.01	0.95-1.08	.7
BMI	0.97	0.88-1.08	.6
Cuff size	0.82	0.46-1.46	.5	0.60	0.16-2.30	.5
No-catheter group	1.11	0.49-2.51	.8	0.45	0.13-1.58	.2
CCI score	1.16	0.95-1.43	.1
Prior XRT	1.16	0.38-3.50	.8	1.04	0.32-3.29	1
Smoker	1.40	0.66-3.00	.4
Bladder neck contracture/VUAS	0.70	0.16-3.04	.6
Prior CIC	0.80	0.10-6.20	.8
Prior urethral procedure^a	2.15	0.77-5.98	.1
Intraoperative cystoscopy	1.40	0.63-3.11	.4
Surgeon No.	(Reference)
2	1.69	0.50-5.74	.4	1.20	0.18-8.10	.9
3	0.97	0.26-3.57	1	1.44	0.23-8.89	.7
4	0.30	0.53-1.69	.2	0.74	0.09-5.82	.8
5	1.90	0.55-6.66	.3	2.11	0.30-14.9	.5
Abbreviations: BMI, body mass index; CCI, Charlson Comorbidity Index; CI, confidence interval; CIC, clean intermittent catheterization; OR, odds ratio; VUAS, vesicourethral anastomotic stricture; XRT, radiation therapy. ^aUrethroplasty, bulking procedure, or urethral sling.

Limitations

This study is limited by its retrospective design and that it only addresses first-time AUS placements and includes only high-volume surgeons. The overall rate of urinary retention was low (n=29 [6.8%]); hence, confidence intervals on statistical outputs were quite wide. There was also variability in follow-up length among the cohorts.

Interpretation for Patient Care

The study ultimately is reassuring in that catheter omission is an easy-to-implement strategy that does not negatively impact patient outcomes. As a result, we would encourage implanters to simply remove the catheter after AUS placement.