Optimal timing of urinary catheter removal after cesarean section; Randomized controlled trial
Nancy Ahmed1, Hesham Torad2, Omar Nagy3, Ali Elsayed Khayal4, Kareem El-Nahhas3,
Basma farouk Hussein mohamed3, Ahmed Samir Hamid Shaaban5,
Nawal Hamdy Ahmed Keshta6, Hanan Barakat Abu Elyazid Shatat6, Rehab Abdelkhalek Ahmed Abdelkader6, Mahmoud Sedki Yassin Ali6, Maged Salah eldien elkady8,
Marwa Yahia Mahmoud1.
1Department of Obstetrics and Gynecology, Faculty of Medicine, Beni-suef University, Beni-suef, Egypt.
2Department of Urology, Faculty of Medicine, Cairo University, Cairo, Egypt.
3Department of Reproductive Health and Family Planning, Medical Research and Clinical Studies Institute, National Research Centre, Egypt.
4Department of Obstetrics and Gynecology at General Organization for Teaching Hospitals and Institutes, Matareya Teaching hospital, Cairo, Egypt.
5Department of Obstetrics and Gynecology, Faculty of Medicine, Al Azhar University, Cairo, Egypt.
6Department of Obstetrics and Gynecology, Faculty of Medicine,
Al Azhar University, Girls Branch, Cairo, Egypt.
7Department of Obstetrics and Gynecology at General Organization for Teaching Hospitals and Institutes,
Banha Teaching Hospital, Banha, Egypt.
8Lecturer of Obstetrics and Gynecology, At Misr University for Science and Technology Must University, Egypt.
*Corresponding Author E-mail: omarnagy72@proton.me
ABSTRACT:
Background: Urethral catheterization plays a major role for reducing the likelihood of bladder damage and avoiding urinary retention before and after cesarean section, we aim to investigate the optimal time of removal catheter after cesarean section. Material And Method: A total of 250 eligible women, who were eligible for either primary or repeat elective cesarean section, were randomly assigned to two equal groups in a prospective randomized controlled study. In group A, the catheter was removed two hours after the surgery, whereas in group B, the catheter was extracted after 12 hours. Result: our study found that group of early catheter removal (2h) associated with lower events than delayed catheter removal (12h), early catheter removal (2h) associated with less bacteriuria, urinary retention, urgency, dysuria, burning on micturition and urinary frequency. We also found that early catheter removal (2h) over delayed catheter removal (12h) in postoperative outcomes as Postoperative mobilization, Postoperative oral rehydration, First postoperative voiding and Hospital stays. Conclusion: Early removal of the catheter is associated with less bacteriuria, urinary retention, urgency, dysuria, burning on micturition, and urinary frequency and did not enhance the urinary tract infection.
KEYWORDS: Earlycatheter, Delayed Catheter, Cesarean Section.
INTRODUCTION:
Cesarean delivery is a frequently performed surgical operation in the field of obstetrics1. The incidence of maternal death related to the surgery has significantly decreased due to advancements in anesthetic procedures, thromboprophylaxis, and the availability of more effective antibiotics2. Nevertheless, women who have had cesarean births may still encounter some avoidable complications such as urinary tract infections and issues with voiding3. Greater efforts should be made to decrease the frequency of these illnesses in order to guarantee a complication-free postoperative recovery period4.
Urethral catheterization plays a major role for reducing the likelihood of bladder damage and avoiding urinary retention before and after surgery. However, urethral catheters have drawbacks such as a high occurrence of urinary tract infections, urethral discomfort, urine retention, as well as longer postoperative recovery time and hospital stay5.
The optimal period of urethral catheterization following cesarean section remains uncertain. The majority of knowledge is derived from traditional practices rather than empirical research. Hence, the therapeutic applicability differs for every doctor. Certain physicians choose to promptly remove catheters immediately after surgery, while others choose to delay removal for a period of 12-24 hours in order to prevent the occurrence of urine retention6.
However, it is unclear if the time of removing the urethral catheter following cesarean birth has a substantial impact on the likelihood of developing urinary tract infections.the aim of our study to investigate the optimal time for catheter removal after CS.
MATERIAL AND METHOD:
A prospective randomized controlled trial conducted in tertiary referral hospital between January 2023 to October 2023. Our study focused on women between the ages of 18 and 45 who were receiving elective cesarean sections. We excluded women from our research who had urinary tract infections (confirmed by urine analysis), significant vaginal hemorrhage, severe preeclampsia, eclampsia, or any other disorders that necessitated postoperative monitoring of urinary output.
Participants were divided into two groups in a 1:1 ratio utilizing block randomization, using computer-generated random numbers. A Foley urethral catheter (French size 16) was placed into all subjects using sterile techniques on the operating table just before the operation. In group A, the catheter was extracted two hours after the surgery, whereas in group B, the catheter was withdrawn 12 hours after the operation. The cesarean sections were conducted using the conventional approach, with the patient under general anesthesia. The abdominal incisions used were Pfannenstiel incisions. The loose fold of peritoneum that covers the top edge of the bladder was carefully separated from the underlying myometrium using either blunt or sharp dissection, without going deeper than 5 cm. A transverse incision was made in the bottom part of the uterus. Generally, all patients were given a uniform treatment plan consisting of intravenous fluids (a sterile saline solution of 2000 ml over a period of 24 hours), preventive antibiotics (a single dose of 2 g of Cefazolin administered intravenously 30 minutes before surgery), and postoperative pain relief (75 mg of Diclofenac sodium administered intramuscularly as required). Participants in group A were instructed to only urinate when they felt the need to do so. If they had the desire to urinate at a time when they were unable to move, they were provided with a bedpan. If the need to urinate was noted at a later time, when movement was feasible, individuals were assisted to a nearby restroom. If the patient continues to have difficulties in urinating after 6 hours and/or if the abdominal examination reveals a palpable urinary bladder, recatheterization is performed.
The primary measures of interest were the presence of a large amount of bacteria in the urine (100,000 bacteria per ml) in a sample obtained 24 hours after the surgery, as well as the occurrence of urinary symptoms such as urinary retention, dysuria, burning sensation during urination, increased frequency of urination, and urgency. Additional outcome measures included the duration until initiation of oral rehydration and the resumption of intestinal sounds after the surgery, the timing of the first urination, the duration of postoperative walking, and the length of hospitalization.
To test our hypothesis that removing the urethral catheter immediately after elective cesarean section is equally safe as keeping it for 12 hours, we needed a sample size of at least 117 women in each group. This would give us 80% power and a type I error of 0.05 in a two-sided test7. The continuous data were represented as the mean ± standard deviation (SD) and were compared using the Student t-test. The categorical data were presented as a percentage and were compared using the Fisher exact test. A p-value represents the probability associated with a two-tailed test.
RESULT:
Two hundred-fifty patients included in the final recruitment of our study figure1.
Figure 1: Consort flow chart
Table 1: Demographic data of the included studies.
|
Variable |
Early (125) |
Delayed (125) |
p-value |
|
Age |
29.1±3.8 |
29.5±3.4 |
0.3 |
|
BMI |
33.9±4.9 |
34.7±4.2 |
0.1 |
|
Gestational age |
38.1±1.2 |
38.2±1.1 |
0.4 |
|
Parity 0 1 2 >3 |
43 36 27 19 |
49 29 30 17 |
0.7 |
|
Previous CS |
77 |
60 |
0.06 |
There was no statistically significant difference in the term of age, BMI, gestational age, parity and Previous CS and p-value leas more 0.05.
Table 2: urinary complications after CS
|
Early (125) |
Delayed (125) |
p-value |
|
|
bacteriuria |
13 |
21 |
0.07 |
|
Urinary retention |
14 |
19 |
0.04 |
|
Urgency |
22 |
23 |
0.007 |
|
Dysuria |
16 |
22 |
0.03 |
|
burning on micturition |
11 |
17 |
0.06 |
|
Urinary frequency |
13 |
16 |
0.03 |
According to urinary complication; there was a statistically significant difference in bacteriuria, urinary retention, urgency, dysuria, burning on micturition and urinary frequency p-value>0.05.
Table 3: postoperative outcomes of included patients
|
Variable |
Early (125) |
Delayed (125) |
p-value |
|
Passage of flatus (hours) |
12.3±4.5 |
13.0±5.4 |
0.2 |
|
Postoperative mobilization (hours) |
5.8±1.8 |
6.0±1.7 |
0.3 |
|
Postoperative oral rehydration (hours) |
5.7±1.7 |
7.2±2.3 |
< 0.001 |
|
First postoperative voiding (hours) |
6±1.5 |
6.8±1.2 |
< 0.001 |
|
Hospital stays (hours) |
44.6±10.6 |
50.8±8.4 |
< 0.001 |
There was no statistically significant difference in passage of flatus and Postoperative mobilization between the two groups p-value=0.2. on the other hand, there was a statistically significant difference in the term of Postoperative oral rehydration, First postoperative voiding and Hospital stays with p-value>0.05.
DISCUSSION:
our study found that group of early catheter removal (2h) associated with lower events than delayed catheter removal (12h), early catheter removal (2h) associated with less bacteriuria, urinary retention, urgency, dysuria, burning on micturition and urinary frequency. We also found that early catheter removal (2h) over delayed catheter removal (12h) in postoperative outcomes as Postoperative mobilization, Postoperative oral rehydration, First postoperative voiding and Hospital stays. several studies investigates the comparison between early and delayed catheter removal after CS section and found that a significant results for early removal over delayed removal in agreement of our study, Onile et al. conducted a study to examine the removal of urethral catheters immediately after surgery and 24 hours after surgery for elective cesarean birth. The immediate removal group of women showed a much-decreased occurrence of positive urine culture after the operation compared to those who had a catheter for 24 hours8. Tambyah and Maki conducted a study that revealed that the introduction of a catheter may introduce bacteria from the urethra into the bladder. The length of time the catheter is in place is the most significant determinant in the development of catheter-associated bacteriuria. After the insertion of a urethral catheter, the rate of bacteriuria increases by 3-10% every day9,10. Ghoreishi et al11 reported that women who did not get an indwelling urinary catheter had a reduced duration of hospital stay and a shorter period of time required for walking. In Senanayake's trial, 344 women had surgery without the use of a urethral catheter. Two women (0.58%) had distress catheterization. The remaining urine was emptied on average after 8.76 hours, which is the time it takes for a catheter to potentially introduce bacteria from the urethra into the bladder. The length of time the catheter remains in place is the most significant determinant in the likelihood of developing catheter-associated bacteriuria12.Elmazny et al found that The removal of a urine catheter immediately after an elective cesarean section has been related to a decreased probability of urinary infection and earlier postoperative mobility. Therefore, it is advisable to remove the catheter promptly in women undergoing elective cesarean surgery, unless there is another specific reason for keeping the catheter in place for an extended period7. basbug et al13 declared that Early removal of an indwelling urinary catheter can lead to a lower occurrence of microscopic hematuria, increased urine frequency, and shorter times of postoperative mobilization and hospital stay, as compared to delayed catheter removal. the timing of catheter removal after a C-section does not appear to have a substantial impact on the occurrence of major complications, we believe that a shorter removal time decreases the probability of gathering infections during hospitalization. Additionally, it enhances patient comfort and contributes to emotional well-being after childbirth by allowing for early discharge from the hospital.
CONCLUSION:
In conclusion, we advised that the quick removal of
the catheter is associated with less bacteriuria, urinary retention, urgency,
dysuria, burning on micturition, and urinary frequency and did not enhance the
urinary tract infection.
CONFLICT OF INTEREST:
None.
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Received on 26.12.2023 Modified on 18.05.2024
Accepted on 08.08.2024 © RJPT All right reserved
Research J. Pharm. and Tech 2024; 17(9):4597-4600.