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Table of Contents
ORIGINAL ARTICLE
Year : 2018  |  Volume : 29  |  Issue : 6  |  Page : 288-292

Early versus late trail of catheter removal in patients with urinary retention secondary to benign prostatic hyperplasia under tamsulosin treatment


Department of Urology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt

Date of Web Publication22-Nov-2018

Correspondence Address:
Salem Hassan Salem Mohamed
Building 2, 3rd Floor, 2nd Stage, Becho American City, Zahraa Al Maadi, Cairo
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/UROS.UROS_12_18

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  Abstract 

Objective: The main objective of this study is to evaluate the impact of early and late removal of urinary catheter after acute urine retention (AUR) in patients with benign prostatic hyperplasia (BPH) under tamsulosin treatment on the success of trial without catheter (TWOC). Materials and Methods: This is a prospective randomized study, 60 men with AUR secondary to BPH, after fulfilling the inclusion criteria in the absence of the exclusion criteria of the study were catheterized and then were randomly assigned to receive 0.4 mg tamsulosin hydrochloride for 3 days or 7 days, after that the catheter was removed and the ability to void unaided assessed. Results: Eighteen men taking tamsulosin for 3 days and 21 patients taking tamsulosin for 7 days did not require recatheterization on the day of the TWOC (60% and 70%, respectively, P = 0.417). Complication as urinary tract infection, urine leakage, hematuria, or catheter obstruction occurred in five (16.7%) men who received tamsulosin for 3 days and 13 (43.3%) men who received tamsulosin for 7 days (P = 0.024). Conclusions: Men catheterized for AUR can void successfully after catheter removal if treated with alpha-1 blockade, and success rate of TWOC is controversial regarding the duration of catheterization. However, the complications were increased with period of catheterization.

Keywords: Acute urinary retention, benign prostatic hyperplasia, tamsulosin, trial without catheter


How to cite this article:
Salem Mohamed SH, El Ebiary MF, Badr MM. Early versus late trail of catheter removal in patients with urinary retention secondary to benign prostatic hyperplasia under tamsulosin treatment. Urol Sci 2018;29:288-92

How to cite this URL:
Salem Mohamed SH, El Ebiary MF, Badr MM. Early versus late trail of catheter removal in patients with urinary retention secondary to benign prostatic hyperplasia under tamsulosin treatment. Urol Sci [serial online] 2018 [cited 2018 Dec 13];29:288-92. Available from: http://www.e-urol-sci.com/text.asp?2018/29/6/288/240950


  Introduction Top


Benign prostatic hyperplasia (BPH), a histologic diagnosis, is a condition that occurs with aging; the prevalence increases from 25% among men 40–49 years of age to >80% among men 70–79 years of age.[1]

Many complications may be developed from BPH such as increased postvoiding residual, bladder diverticula or calculi, vesicoureteral reflux, hydronephrosis, renal insufficiency, and urine retention.[2]

Acute urine retention (AUR) is a common urological emergency that is characterized by sudden and painful inability to pass urine. The incidence of AUR in patients with BPH varies widely from 0.4% to 25%.[3] Management of AUR consists of immediate bladder decompression by catheterization usually followed by BPH-related surgery.[4]

A trial without catheter (TWOC) is considered preferable to leaving a catheter in place[5] alpha-1 (α-1) blockers decrease smooth muscle tone in the prostate, thereby rapidly improving urinary symptoms and flow.[6] Tamsulosin has a rapid onset of action and is effective in patients with moderate or severe symptoms. The drug is, therefore, a valuable therapeutic option, with both demonstrated and potential advantages over older nonselective agents, in the management of patients with lower urinary tract symptoms (LUTS) associated with BPH.[7]

The duration of catheterization before TWOC is controversial regarding the length of time a catheter should remain in situ during the initial therapeutic phase.[3],[8]


  Materials and Methods Top


Sixty male patients with acute urinary retention (AUR), secondary to BPH having their first attack, were enrolled in a prospective randomized study. The study protocol had been approved from the local ethical committee at our hospitals.

Patients were selected with these exclusion criteria: patients with initial catheterization volume >1000 ml, bladder stones, renal impairment, suspected urethral stricture, neurogenic bladder, cancer prostate, medically induced retention, previous use of alpha-blockers, history of drug hypersensitivity or allergy to tamsulosin, chronic retention.

Afer informed consent was acquired from the patients, all patients were catheterized and the urine volume was assessed and subjected to culture and sensitivity tests. After catheter insertion, the patients received prophylactic dose of levofloxacin 500 mg once and they divided randomly into two groups: Group I: 30 patients received tamsulosin hydrochloride 0.4 mg once daily and the catheter removed after 3 days and Group II: 30 patients received tamsulosin hydrochloride 0.4 mg once daily and the catheter removed after 7 days.

All recruited patients were assessed through the following regimen:

  1. All patients were subjected to complete medical history, with stress on LUTS before AUR using International Prostate Symptom Score (IPSS) and operative history was taken
  2. Complete physical examination was carried out including digital rectal examination
  3. Urine volume and color were recorded after catheterization
  4. Investigations:


    • Laboratory investigations: Complete blood picture, urine analysis and urine culture and sensitivity tests in infected patients, renal function tests, liver function tests, and prostatic-specific antigen (PSA)
    • Radiological investigations: All patients were subjected to pelvi–abdominal ultrasound and estimation of prostate size.


  5. Complications related to catheter such as hematuria, obstruction, urinary leakage, and urinary tract infections (UTIs) were recorded in the two groups
  6. After catheter removal, patients were allowed to void and were discharged home who had a successful void >200 cc of urine. Patients who failed to void were recatheterized and prepared them for prostatectomy


    • Two weeks after catheter removal, all patients were subjected to:


      1. Pelvi–abdominal ultrasound with estimation of postvoiding residual urine
      2. Uroflowmetry
      3. Urine analysis, urine culture, and sensitivity tests
      4. PSA.


  7. Six weeks after catheter removal: The previous investigations were repeated. PSA was repeated only for patients whose first PSA was ≥4 ng/dl.


Data management and analysis were performed using Statistical Package for the Social Sciences (SPSS) version 24 for Windows (SPSS Inc., Chicago, IL, USA) comparisons between numerical variables of two groups were done by Student's unpaired t-test for parametric data and categorical variables were done by Chi-square test or Fisher exact test for small sample size, P value was considered significant when P > 0.05.


  Results Top


Between March 2017 and August 2017, this study was conducted at the Department of Urology, Al-Azhar University Hospitals and Om El-Masryeen General Hospital. The mean patients' age was 59.9 ± 8.9 years; prostatic volume ranged from 30 to 147 cc with mean of 59.7 ± 24 cc. Urine volume collected in the urine bag immediately after catheterization was recorded. Retained volume ranged from (450 to 1000 ml) with mean of 672.6 ± 153.6 ml. Screening serum PSA was done for all patients in the 2nd-week follow-up after catheter removal. median PSA level of the studied cases was 2.65 (interquartile range = 1.7–3.9) ng/ml. The IPSS was assessed for all patients during the first clinical examination. Mean IPSS of the studied cases was 13.25 ± 3.56 (ranged from 6 to −22).

After catheter removal, 65% of patients voided successfully while 35% failed TWOC. the volume of residual urine was assessed in cases who voided by ultrasound and ranged from 0 to 182; median was 50 ml. Qmax was assessed in cases who voided by uroflowmetry and ranged from 10 to 22.6 with mean 17.56 ± 3.02 ml/s. The overall complication was 30%, included obstruction in 6.7%, UTI in 20%, hematuria in 10%, and urinary leakage in 3.3% of cases.

Bivariate analysis was carried out to identify factors that may affect the TWOC failure [Table 1]. The difference between mean age among failed and succeeded cases are significantly different (P = 0.04). Furthermore, the IPSS was P = 0.039. Age among cases with complications and those without were significantly different (P = 0.003) also was IPSS (P = 0.021).
Table 1: Bivariate analysis of factors related to trial without catheter outcome

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Comparision between the groups was carried out [Table 2], Group I: 18 cases (60%) had a successful voiding compared to 21 cases (70%) in Group II. The difference was not statistically significant (P = 0.4).
Table 2: Comparison between the studied groups

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Group I had a complication rate (16.7%) and it was statistically significant when compared to Group II (43.3%) (P = 0.0.02) [Table 3].
Table 3: Catheter complications

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  Discussion Top


Clinical BPH is one of the most common diseases in aging men which can lead to LUTS.[9] The prevalence of BPH rises markedly with increased age. Autopsy studies have observed a histological prevalence of 8%, 50%, and 80% in the fourth, sixth, and ninth decades of life, respectively.[10]

As regarding age of the cases, our study demonstrated that there was significantly different in TWOC outcome with age as the mean age among succeeded cases was 58.03 ± 8.02, while among failed cases was 63.23 ± 9.55 (P = 0.03).

A retrospective study conducted by Bansal and Aditi Arora[11] of 2188 patients presenting with first episode of AUR between January 2009 and July 2016 showed that age was an independent predicting factor of successful TWOC for AUR and that patients older than 65 years were at a 1.84 times higher risk of failure of TWOC than were those younger than 65 years.

However, Lucas et al.[5] in 2005 and Mariappan et al.[12] in 2007 found that the efficacy was similar across the age range and no association between TWOC outcome and age.

Our results showed that prostate volume is an insignificant predicting factor of successful TWOC for AUR where mean prostate size among succeeded cases was 56.10 ± 19.05 while mean size in failed cases was 66.29 ± 30.54 (P = 0.175), this may be due to the small number of patients in our study (n = 60). Our study statistically showed that patients with prostate volume ≥50 cc were at 1.62 times higher risk of failure of TWOC than those with >50 cc (61.9% vs. 38.1) and those with volume ≥60 cc were at 1.1 times (52.4% vs 47.6%).

Previous studies by Kumar et al.[13] in 2000 and Zeif et al. in 2010[14] also demonstrated that failure of TWOC was associated with larger prostate size. However, studies by Tan and Foo in 2003[15] and Djavan et al. in 1997[16] showed contradictory negative results.

Bivariate analysis was carried out in our study to identify factors related to TWOC outcome, we found that retained urinary volume at time of catheterization among succeeded was 656.41 ± 162.69 ml and among failed cases was 702.76 ± 133.53 ml, but the difference was statistically insignificant (P > 0.1). Several studies have shown that retained volume has no prognostic significance for the prediction of success of TWOC. On the contrary, various studies have proved that if residual volume at catheterization is 1 L or more, it could be a risk factor for failed TWOC, which suggests a correlation between RV and outcome of TWOC.[11]

Taube and Gajraj in 1989[17] found that the successful outcome of TWOC is associated with retained volume >900 ml. Similarly, our data showed that retained volume of ≥650 ml is associated with increased failure rate of TWOC but it was statistically insignificant (P = 0. 09). This may be because of prolonged bladder distension due to large volume of residual urine which may result in ischemia and axonal degeneration leading to loss of bladder tone.[14]

The relationship of baseline AUA symptom score IPSS with the success of TWOC is poorly understood in literature. In this study, men with successful TWOC had significantly lesser AUA score than those with failed TWOC (12.56 ± 3.5 vs. 14.52 ± 3.3, P < 0.04).

Our results are consistent with those of Bhomi and Bhattachan in 2011[18] who also confirmed that patients with low AUA score had significantly higher chances of successful TWOC. However, Djavan et al. in 1997 showed no correlation of AUA score with outcome of TWOC. Lim et al. in 1999[19] studied the association of serum PSA with outcome of TWOC and showed that serum PSA is significantly higher in patients in whom TWOC failed and assumed that it is due to prostatic infarction or infection giving rise to AUR. However, Zeif et al. in 2010[14] found no impact of serum PSA level on the outcome of TWOC.

Our study demonstrated that 65% of cases who received tamsulosin before catheter removal succeeded TWOC while 35% failed. McNeill et al. in 2004 found in their study that the use of α-blockers increases the TWOC success rate compared to placebo, 61.9% versus 47.9%, which approximate our study success rate. Similar findings are reported by Reten-World Study Group where the prevalent use of α-blockers (86%) worldwide is noted with the result doubling success rate of TWOC.[20]

In controversy, Desgrandchamps et al. in 2006[21] found that the success rate of a TWOC was also higher when the catheter was removed after 1–3 days than for a longer duration of catheterization. In their survey, the TWOC success rates were greater for short catheter duration (63.2%, 52.7%, and 52.5% after 1, 2, and 3 days, respectively) than longer catheter duration (41.5% and 46.9% for 4–7 and >7 days, respectively). The study was not randomized and this may reflect differences in the clinical profile of patients.

As regarding complications of catheterization, our study showed that the overall complications rate was 30% and the complication rate was statistically significantly higher in the group who catheterized for 7 days (43.3%) (more than one complication occurred in one patient) than the group who catheterized for 3 days (16.7%) (P = 0.024).

In 2011, Fitzpatrick et al.[22] found that catheterization for >3 days was associated with a significantly higher rate of adverse events compared with those catheterized for 3 days or less (33.8% vs. 19.7%, P < 0.001) which was in agreement with our study.

Our study showed that people with catheter for 7 days had UTI significantly higher than those with catheter for 3 days (33.3% vs. 6.7%, P = 010). Furthermore, Stensballe et al. in 2007[23] found that people with catheters acquire bacteriuria at different rates. Incidence of conversion from sterile urine to bacteriuria occurs at the rate of 3%–10% per day in agreement with our study that showed increases the risk of UTI 6.65% per day with prolonged duration of the catheter.


  Conclusions Top


Urethral catheterization followed by a TWOC is the standard practice worldwide and that alpha-1 blockade before TWOC increase the chances of success, success rate of TWOC was controversial regarding early catheter removal compared to late catheter removal. Late catheter removal was observed to be accompanied by significant increased prevalence of adverse effects such as catheter blockage, hematuria, UTI, and urinary leakage. Finally, to get more data and more valuable statistics, more studies on a larger number of cases should be done.

Acknowledgment

First and foremost, I would like to thank “ALLAH” for everything. This would not be achieved without the support of “Allah.” I would like to express my sincere gratitude and appreciation to Prof. Dr. Mohamed Mabrouk Badr Professor of Urology, faculty of medicine, Al-Azhar University, for his constant help and valuable instructions through this work. It was pleasure and privilege to work under his guide and supervision. I owe special gratefulness and much regard to Dr. Mohamed Fathy El Saeed El Ebiary, Lecturer of Urology, Faculty of Medicine, Al-Azhar University for his helpful and close experienced supervision. His guidance and valuable advice was behind the accomplishment of this work. He provided me with the knowledge and facilities without which I would never be able to complete this work. I would be remiss if failed to acknowledge my family for their tolerance and their emotional support pushing me to finish this work. Finally, thanks to all patients included in our study and to everyone who helped me in the Urology Department, Al-Azhar University.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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Mariappan P, Brown DJ, McNeill AS. Intravesical prostatic protrusion is better than prostate volume in predicting the outcome of trial without catheter in white men presenting with acute urinary retention: A prospective clinical study. J Urol 2007;178:573-7.  Back to cited text no. 12
    
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Tan YH, Foo KT. Intravesical prostatic protrusion predicts the outcome of a trial without catheter following acute urine retention. J Urol 2003;170:2339-41.  Back to cited text no. 15
    
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