Same day surgical discharge after vaginal reconstructive surgery is often appropriate but, in those with acute urinary retention, timing for repeat attempt at a voiding trial is not clear. Previously identified risk factors for failure of voiding trial after vaginal reconstruction come from a single retrospective study: age, degree of cystocele, intraoperative blood loss, Levator and Kelly Plication[1]. We present novel data analyzing a cohort of patients with routinely placed suprapubic catheters, providing insight into return of bladder function and risk factors for postoperative voiding dysfunction following vaginal prolapse repair. We aim to improve postoperative care by minimizing clinic visits for voiding trials.

We identified 127 women undergoing native tissue vaginal reconstruction from a single surgeon between 2012 and 2019 who routinely used suprapubic catheters. These patients all followed a specific catheter regimen postoperatively, giving reliable information about postvoid residual volumes (PVR) and thus bladder function. We used a PVR of <150 cc at 4 hours to be a surrogate marker for return of bladder function. Univariate and multivariate logistic regression analyses were used to identify risk factors for return of bladder function >4 days by surrogate marker. Variables included were age, baseline PVR, history of diabetes, stroke and/or smoking, leading edge of prolapse, stage of prolapse, type of apical suspension, estimated surgical blood loss (EBL), operative duration, anesthesia duration, concomitant hysterectomy and/or incontinence procedure. Primary outcome measure was PVR >150 cc measured by suprapubic catheter after 4 hours.

Our cohort (n=127) had a median age of 67 yrs (IQR 61-75), median BMI of 27.3 (IQR 23.9-29.3), were 95.3% (n=121) white and 94.5% (n=120) postmenopausal. Thirteen% (n=16) were diabetic, 3.9% (n=5) had history of stroke and 26.8% (n=34) had smoking history. Prolapse stage was advanced for the majority of patients: 55 patients had Stage 3 and 24 patients had Stage 4. The leading edge of prolapse was anterior in 31.5% (n=40) and apical in 62.2% (n=79). The average time to return of bladder function was 4.1 days. Eighty% of patients with vaginal vault suspension had return of bladder function by the fifth postoperative day whereas 80% of patients with concomitant hysterectomy had return of bladder function by the seventh postoperative day (See figure 1). Eighty% of patients with operative duration ≤ 120 minutes had return of bladder function by day 4 while 80% of patients with operative duration > 120 minutes had return of bladder function by day 7. Univariate and multivariate analyses of risk factors for return of bladder function after the 4th postoperative day can be seen in Table 1.

We present several clinically relevant findings which provide guidance on timing of voiding trials following prolapse repair. First, a concomitant hysterectomy demonstrated a 2.86-fold increased risk of delayed return of bladder function >4 days compared to patients with a vaginal vault suspension. We recommend repeating a void trial after 1 week in these patients given 80% of our cohort met criteria for return of bladder function by day 7. Second, surgical duration >120 minutes resulted in a 9.96-fold increased risk of delayed return of bladder function >4 days even when controlling for all other evaluated risk factors. We recommend considering surgical length along with other risk factors identified such as DM (5.65-fold), sacrospinous fixation (2.59-fold), and estimated blood loss (1.1-fold) when scheduling office visits. Third, in patients with an uncomplicated vaginal vault suspension and no other identified risk factors, we recommend voiding trial on postoperative day 5 as 80% of our cohort had return of bladder function by this time. 

Limitations of the study are in the homogeneity of the cohort which could limit generalizability and in the retrospective design.

Concomitant hysterectomy, operative duration > 2 hours and diabetes were all significantly associated with delayed return of bladder function after pelvic organ prolapse repair. Based on this data, an individualized approach to post-operative voiding trials can be implemented: we recommend removal of Foley catheter on postoperative day 5 after a vaginal vault suspension and day 7 after a hysterectomy with suspension and/or after a case with operative duration>120 minutes. We believe our data allows surgeons to minimize postoperative clinic visits by stratifying patients based on risks for prolonged voiding dysfunction.

Hakvoort, R.A., et al., Predicting short-term urinary retention after vaginal prolapse surgery. Neurourol Urodyn, 2009. 28(3): p. 225-8.