Int Urogynecol J (2009) 20:295–300
DOI 10.1007/s00192-008-0769-6
ORIGINAL ARTICLE
Postoperative urinary outcomes in catheterized
and non-catheterized patients undergoing
laparoscopic-assisted vaginal hysterectomy—a randomized
controlled trial
Ching-Chung Liang & Chyi-Long Lee &
Ting-Chang Chang & Yao-Lung Chang &
Chin-Jung Wang & Yung-Kuei Soong
Received: 29 July 2008 / Accepted: 28 October 2008 / Published online: 14 November 2008
# The International Urogynecological Association 2008
Abstract The objective of this study is to assess the impact
of bladder catheterization on the incidence of postoperative
urinary tract infection (UTI) and urinary retention (PUR)
following laparoscopic-assisted vaginal hysterectomy
(LAVH). One hundred fifty patients undergoing LAVH were
randomly assigned to no catheter use, 1-day, and 2-day
catheter groups. The relationship between preoperative,
intraoperative, and postoperative factors and the rates of
UTI and PUR were determined. The incidences of UTI and
PUR were 9.3% and 18.7%, respectively. The highest rate of
UTI occurred in the 2-day catheter group; the highest rate of
PUR occurred in no-catheter-use group. Multivariable
logistical regression showed the duration of catheterization
was the single predictor of UTI; duration of catheterization
and diabetes mellitus were predictors for PUR. While short-
term indwelling catheterization resulted in decreased rate of
PUR, UTI rate increased among patients undergoing LAVH.
Nonetheless, most patients resumed normal urination shortly
after surgery.
Keywords Catheterization . Hysterectomy . Laparoscopy .
Urinary retention . Urinary tract infection
C.-C. Liang : C.-L. Lee : T.-C. Chang : Y.-L. Chang :
C.-J. Wang : Y.-K. Soong (*)
Department of Obstetrics and Gynecology,
Chang Gung Memorial Hospital, Linkou Medical Center,
5, Fu-Shin Street, Kweishan,
Taoyuan, Taiwan, 333
e-mail: ccjoliang@cgmh.org.tw
C.-C. Liang : C.-L. Lee : T.-C. Chang : Y.-L. Chang :
C.-J. Wang : Y.-K. Soong
College of Medicine, Chang Gung University,
Taoyuan, Taiwan
Introduction
Hysterectomy for non-malignant conditions is the most
common major gynecological surgery performed in women
less than the age of 50 years [1]. For preventing increased risk
of postoperative urinary retention (PUR) due to bladder over-
distention and atony, most gynecologists use continuous
bladder drainage in women undergoing hysterectomy [2].
However, whether indwelling bladder catheterization has
benefits over no catheter use at the time of routine abdominal
or vaginal hysterectomy remains controversial. Previous
reports demonstrated that prolonged indwelling bladder
catheterization at the time of pelvic laparotomy is associated
with increased risk of urinary tract infection (UTI) and
potential development of chronic renal disease [3, 4]. With
the advent of minimally invasive surgery, laparoscopic
hysterectomy is currently advocated as an alternative to
abdominal hysterectomy. To date, no randomized studies
have been conducted to examine bladder catheterization in
association with PUR and UTI incidence following laparo-
scopic-assisted vaginal hysterectomy (LAVH) and to ascertain
whether patients diagnosed with PUR or UTI in the
immediate postoperative period subsequently developed per-
sistent urinary problems. The purposes of this study were to
determine whether bladder catheterization affected the preva-
lence of UTI and PUR following LAVH and to investigate
risk factors that could contribute to their occurrence.
Materials and methods
From July 2007 to January 2008, patients with benign
gynecologic disease who were scheduled for inpatient
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LAVH at our institution, a tertiary hospital, were invited to
join this randomized, controlled trial. The ethics committee
of the hospital approved the study protocol (No. 95-1179B).
Indications for LAVH included uterine myoma, adenomyo-
sis, tubo-ovarian abscess, intra-epithelial neoplasia of the
cervix, grade 3, and intractable menorrhagia. Patients were
excluded if they had had pelvic reconstructive surgery for
pelvic organ prolapse or urodynamic stress incontinence;
they were also not included if found with bacteriuria from
preoperative urinalysis or clinically adverse urinary symp-
toms such as dysuria, frequency of micturition, urgency,
stress incontinence, or obstructive voiding symptoms as
detected through detailed history-taking and bladder scan-
ning before surgery. All the patients with adverse urinary
symptoms received assessment of their postvoid residual
bladder volume (PVRBV) by a bladder portable scan (BVI
3000, Diagnostic Ultrasound Corporation, Ijsselstein, Neth-
erlands). Based on history, we assumed the study group had
no problem emptying the bladder and, therefore, chose not
to perform a preoperative bladder scan in this group. After a
signed informed consent was obtained, all enrolled patients
undergoing LAVH were randomly assigned to three groups:
group 1, no catheter use, group 2, indwelling bladder
catheter use for 1 day after LAVH, and group 3, and
indwelling bladder-catheter-use after LAVH for 2 days.
Randomization was achieved by selection of sealed
envelopes, which were opened just before surgery. When
patients’ number in each group reached 50, we ended the
patient collection.
All patients received general anesthesia and intravenous
prophylactic antibiotics consisting of cefazolin 500 mg after
induction of general anesthesia. After preparation of the
vagina and perineum with dilute povidone–iodine solution,
the bladder was emptied by means of in-and-out catheteri-
zation with a rubber catheter. LAVH was performed by an
attending faculty member or fourth-year gynecology resident
with an attending faculty member as the first assistant,
following procedures as described by Wang et al. [5]. Type II
or III laparoscopic hysterectomy, according to the American
Association of Gynecologic Laparoscopists’ classification
system [6], was performed in this study. The vaginal cuff
was closed in all cases, and no vaginal packing was used.
Patients were considered dropouts from the protocol if an
intraoperative bladder or rectal injury occurred, vaginal
packing was required, severe hemorrhage necessitating
postoperative monitoring of urinary output occurred, and if
conversion to an abdominal hysterectomy was required.
Those patients assigned to have postoperative bladder
catheterization had an indwelling Foley catheter inserted.
All indwelling catheters were removed from 7 AM to
8 AM on postoperative day 1 or day 2, as specified by
randomization. The patient’s PVRBV was estimated by a
bladder scan. Senior nurses took two measurements of
Int Urogynecol J (2009) 20:295–300
PVRBV for each patient within 5 min after first micturition
or at 6 h after removal of the indwelling catheter in patients
who did not spontaneously micturate, and the largest
volume was recorded. PUR was defined as PVRBV>
150 ml. If the patient was unable to void within 6 h after
surgery or after two attempts to void, a sterile in-and-out
catheterization was done every 6 h. When a patient
underwent two in-and-out catheterizations, an indwelling
catheter was inserted for 24 h and in-and-out catheterization
was performed again on the ensuing day.
To spare patients the discomfort of catheterization, clean
voided midstream urine specimens were obtained from
patients in the no-catheter group and urine specimens from
catheterization were obtained from those in the catheter
groups 48 h after surgery for urine analysis and culture. A
second urine specimen from catheterization for analysis and
culture was obtained in patients with UTI and postvoid
bladder scan volume was measured in patients with PUR at
the 2-week postoperative outpatient visit. UTI was defined
as a positive urine culture with colonies of bacteria >105
organisms/µl. However, treatment was instituted for posi-
tive urine cultures only if the patient had adverse urinary
symptoms or postoperative pyrexia (>38°C).
To demonstrate quality of life following LAVH, a
generic instrument (MOS 36-Item Short-Form) [7] and
two specific instruments for urinary problems (Incontinence
Impact Questionnaire, IIQ-7 and the Urinary Distress
Inventory, UDI-6 short form) [8] were administered to all
patients before surgery and 3 and 6 months, postoperative-
ly. The IIQ-7 and UDI-6 scores were calculated as
previously described by Hung et al. [9].
Continuous data were analyzed using one-way analysis
of variance or the Kruskal–Wallis H test, depending on the
homogeneity of the variance. Proportions were compared
using the Chi-squared test. Multivariable logistic regression
(including age, parity, body mass index, hypertension,
diabetes mellitus, operating time, blood loss, postoperative
analgesia, and duration of catheterization) was conducted to
determine independent predictors of UTI and PUR. A P
value of <0.05 was considered statistically significant.
Statistical analyses were performed using SPSS 12.0 for
Windows (SPSS, Inc, Chicago, IL, USA).
Results
One hundred fifty patients were randomly assigned to no
catheter use (n=50), indwelling bladder catheter use for
1 day (n=50), or indwelling bladder catheter use for 2 days
(n=50) after surgery (Fig. 1). Patient characteristics are
shown Table 1. Patient age, postoperative analgesia, and
duration of catheterization differed significantly between
the groups.
Int Urogynecol J (2009) 20:295–300 297

Fig. 1 Patient flow chart

Of the 150 patients studied, only four had postoperative
pyrexia (2.7%) and 14 patients (9.3%) were diagnosed with
postoperative UTIs. The incidence of UTI was significantly
higher in the 2-day catheter use group than in the 1-day and
no-catheter-use groups (Table 2). The mean spontaneous
micturition volume at first voiding after surgery was 210 ml
(range, 0–600 ml), but there was no significant difference in
voided volume among the three groups. The mean
postoperative PVRBV was 67 ml (range, 0–780 ml). Of
the 28 (18.7%, 28/150) patients that required in-and-out
catheterization to relieve PUR, 22 (78%, 22/28) patients
resumed spontaneous voiding after one catheterization,
while six (22%, 6/28) others needed indwelling catheters
for 24 h of urinary drainage and then returned to normal
urination after catheter removal. Among all these six
patients, including one in the 1-day catheter group and five
in no-catheter-use group, none developed UTI. The no-
catheter-use group had a higher incidence of PUR when
compared with the 1-day and 2-day catheterization groups
(Table 2).
Multivariable logistic regression showed that the dura-
tion of indwelling catheterization was the single indepen-
dent predictor for UTI (odds ratio, OR=2.512, P=0.023).
Duration of catheterization (OR=0.425, P=0.003) and
diabetes mellitus (OR=10.312, P=0.014) were predictors
of PUR. Of six patients with diabetes mellitus, three
patients (one in the no-catheter and two in the 2-day
catheter use group) had PUR. Figure 2 shows the relation-
ships between the duration of catheterization and the
incidences of adverse urinary events, UTI, and PUR, in
each of the groups. Two patients without adverse urination
problems were readmitted for treatment of ovarian hema-

Table 1 Characteristics of patients

No catheter (n=50) 1-day (n=50) 2-day (n=50) P value

Agea (years) 43.7±3.9 45.7±3.5 45.7±5.8 0.026

Paritya 2.4±1.1 2.5±0.9 2.4±1.0 0.167
BMIb (kg/m2) 25.7±3.5 25.6±3.1 25.3±3.2 0.304
Hypertensionc 6% (3) 6% (3) 6% (3) 1.000
Diabetesc 2% (1) 2% (1) 8% (4) 0.210
Operating timea (min) 142.5±102.2 143.9±81.5 154.2±81.6 0.861
Blood lossa (ml) 279.3±102.2 238.5±81.5 325.1±82.4 0.117
PCEAc 30% (15) 46% (23) 58% (29) 0.018
Duration of cathetera (h) 0 17.3±2.9 40.8±3 <0.001

Data are presented as mean±standard deviation and % (n)

BMI Body mass index, PCEA 1-day patient-controlled epidural analgesia
a
Kruskal–Wallis H test
b
One-way ANOVA
c
Chi-square test
298 Int Urogynecol J (2009) 20:295–300

Table 2 Postoperative adverse urination problems in patients under- between patients with UTI or PUR and those without UTI
going laparoscopic-assisted vaginal hysterectomy
and PUR at 3 months and 6 months of follow-up.
Percentage (%) P
value
No catheter 1-day 2-day
Discussion
(n=50) (n=50) (n=50)

Urinary tract 2 (4) 3 (6) 9 (18) 0.034 Ultrasound imaging provides an alternative for estimating
infectiona bladder volume non-invasively. We assessed residual
Urinary retentiona 17 (34) 6 (12) 5 (10) 0.003 volume by bladder scanning rather than by catheterization
Urinary symptom 3 (6) 3 (6) 7 (14) 0.260 because the latter involves the passage of a urethral catheter
at 3 monthsa
to empty the bladder, which may cause discomfort for the
Urinary symptom 1 (2) 1 (2) 2 (4) 0.773
patient and carry a risk of urinary infection or even urethral
at 6 monthsa
trauma [10].
Data are presented as n (%) In the literature, the incidence of PUR following pelvic
a
Chi-square test. surgery ranges from 0% to 60%, depending on the PUR
definition used and the type of surgery performed [11–13].
tomas. Because the diameters of the ovarian hematomas Defining PUR as exceeding the preoperatively determined
were <5 cm and fever and abdominal pain were controlled bladder capacity, Bodker and Lose [14] reported of 124
by medical treatment, both patients were discharged 4 and patients undergoing abdominal hysterectomy, 13.7% (17/
6 days later, respectively. 124) had PUR; of 24 patients undergoing LAVH, 8% (2/24)
All patients recruited had complete follow-up data. Of had PUR [13]. Ghezzi et al. [15] reported that 21% (49/
the 150 patients studied, 13 (8.7%) had lower urinary tract 233) of patients undergoing vaginal hysterectomy or total
symptoms at 3 months of follow-up, including incomplete laparoscopic hysterectomy failed the first voiding trial or
bladder emptying in five, suprapubic pain during voiding in PVRBV was greater than 150 ml. In their report, the
three, strain necessary to void in two, hesitancy in two, and incidence of PUR was 14.1% (20/142) in the laparoscopic
nocturia in one (Table 2). Most patients resumed normal hysterectomy group and 31.9% (29/91) in the vaginal
urination by the 6-month postoperative follow-up visit. hysterectomy group. In the current study, we defined PUR
Analyses of the quality-of-life questionnaires revealed no as PVRBV greater than 150 ml. Our results showed that the
significant differences in SF-36, IIQ-7, and UDI-6 scores incidence of PUR following LAVH was 18.7% (28/150)
and the predictors for PUR were duration of catheterization
and diabetes mellitus. Previous study demonstrated that
57.5% of patients receiving postoperative epidural mor-
phine needed bladder catheterization, but postoperative
analgesia was not a risk factor associated with PUR in this
study [16].
In published data on PUR following abdominal or
vaginal hysterectomy, we found that catheterization and
duration of catheterization affected the incidence of PUR
[4, 14, 17–21]. Summitt et al. [18] prospectively compared
the use of indwelling catheterization for 1 day with no
catheter use after vaginal hysterectomy. Their data showed
that two patients (4%, 2/49) in the catheterized group
required recatheterization after the initial catheters were
removed. No patient in the no-catheter-use group required
catheterization. Dobbs et al. [19] compared the PUR rate
between in-and-out catheterization and indwelling catheter-
ization at the time of abdominal hysterectomy. Of the 95
patients in their randomized study, 36% (17/47) of those
undergoing in-and-out catheterization had PUR, compared
Fig. 2 The relationships between the duration of indwelling catheter- with 4% (2/48) of those receiving indwelling catheters. In
ization and the incidences of adverse urinary events, postoperative
urinary tract infection, and urinary retention, in the no-catheter, 1-day
our study, the no-catheter-use group had a higher incidence
catheterization, and 2-day catheterization groups. UTI Urinary tract (34%, 17/50) of PUR when compared with the 1-day (12%,
infection, PUR postoperative urinary retention 6/50) and 2-day (10%, 5/50) catheterization groups.
Int Urogynecol J (2009) 20:295–300
Fortunately, transient PUR did not cause persistent voiding
problems, and 78% (22/28) of these patients resumed
spontaneous micturition after one catheterization, and all
recovered from urinary retention by the time of hospital
discharge.
Postoperative UTI following gynecological surgery is a
relatively common event, with the reported incidence
ranging from 1.2% to 50% [4, 18–20, 22, 23]. However,
comparing published data of catheter-associated UTI
following hysterectomy becomes difficult due to variations
in catheterization times reported; furthermore, some inves-
tigations are confounded by the use of prophylactic
antibiotics. Among the 94 patients undergoing vaginal
prolapse surgery reported by Hakvoort et al. [22], postop-
erative bacteriuria occurred in 40% (18/46) of patients in
the 4-day catheterization group versus 4% (2/48) of patients
in the 1-day catheterization group. Dobbs et al. [19] found
that 13% (6/47) of the in-and-out catheterization group had
bacteriuria compared with 29% (14/48) of those in the 36-h
catheterization group following abdominal hysterectomy.
Our data showed that 9.3% (14/150) of patients undergoing
LAVH were diagnosed with postoperative UTIs. The
incidence of UTI was significantly higher in the 2-day
catheter group (18%, 9/50) than in the 1-day (6%, 3/50) and
no-catheter (4%, 2/50) groups. After analyzing the relation-
ships between the durations of catheterization and the
incidences of postoperative UTI (Fig. 2), we found that
catheter placement for 24 h did not contribute significantly
to postoperative UTI. In addition, the 1-day group had a
lower incidence of PUR than the no-catheter-use group.
Thus, our result supports short-term indwelling catheteri-
zation for 24 h, among all three groups, best serves as
optimal bladder drainage in patients undergoing LAVH.
In reports where prophylactic antibiotics were not used,
Richardson et al. reported postoperative UTI in 1.2% (2/161)
of hysterectomy patients with no catheter use [23], while
Kingdom et al. reported 40% (46/115) of patients with
catheterized for 24 to 48 h developed postoperative UTIs
following gynecological surgery [4]. Because it is estimated
that the risk of UTI associated with indwelling catheteriza-
tion is 5–10% per day of catheterization [3], for the sake of
ethical consideration and for clinical management in our
institute, prophylactic therapy with cefazolin is used to
reduce the risk of UTI during LAVH. Our results and other
published data show that significant wound infection and
UTI are uncommon in the immediate postoperative period
following hysterectomy [24], indicating that antibiotic
prophylaxis reduces the risk of postoperative UTI in patients
undergoing indwelling catheterization. At the 3-month
postoperative follow-up we found that 8.7% (13/150) of
patients had adverse lower urinary tract symptoms, but that
most had recovered by the 6 months postoperative follow-up
visit.
299
In conclusion, although the incidence of catheter-
associated UTI following LAVH was confounded by the
use of prophylactic antibiotics in our study, the data suggest
that the duration of catheterization was the most important
predictor for postoperative adverse urinary events. Short-
term indwelling catheterization increased the incidence of
UTI, but decreased the incidence of PUR among patients
undergoing LAVH. Despite this, our patients resumed
normal urination within 6 months after surgery.
Acknowledgement This work was supported by Medical Research
Project Grant CMRPG 360291 and BMRP 412 from Chang Gung
Memorial Hospital. We would like to thank the following gynecolo-
gists for their assistance to accomplish this study: SD Chang, HY
Huang, KJ Huang, CW Wang, LH Tseng, and CM Han.
Conflicts of interest None.
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