Introduction

Each year, >500,000 women in the United States undergo pelvic reconstructive surgery to treat pelvic organ prolapse, urinary incontinence, and other conditions. ^, Postoperative urinary retention occurs when patients do not pass their postoperative voiding trial (VT) or are unable to empty their bladder appropriately and affects between 2.5% and 43% of patients. Most cases are transient and are managed with temporary drainage of the bladder using urinary catheters. Moreover, women undergoing surgery for other benign conditions and gynecologic malignancy may experience postoperative urinary retention. The rates of postoperative urinary retention vary considerably by type of surgery, in different patient populations, and by the method of diagnosis. Once patients are diagnosed with urinary retention and require postoperative catheterization, several approaches to manage short-term catheterization are available. Our work focused on the cost associated with different methods of management of urinary catheterization during the postoperative period.

Several methods for catheter management are available, and the selection of 1 method over another is often based on the surgeon’s preference or facility policies. According to a recent survey in 2017 of physicians practicing at Accreditation Council for Graduate Medical Education–accredited residencies and fellowships in obstetrics and gynecology, urology, and female pelvic medicine and reconstructive surgery, clean intermittent catheterization (CIC) was the most popular method among 105 physicians surveyed and the most popular among urologists. Indwelling catheterization is the most commonly described in the methodology of randomized controlled trials (RCTs). Indwelling catheters can be managed and discontinued in several ways. The catheter can be drained by gravity into the bag or by using a “plug-unplug” method, similar to using a valved catheter, where the catheter is inserted and the patient intermittently drains the bladder. The patient may come in to the office for a repeat VT, or they can be instructed to remove the catheter themselves.

Several studies have compared short-term catheterization approaches and have demonstrated no difference in patient satisfaction among them. Therefore, it is important to evaluate the overall cost of these methods, as understanding cost differences from the societal perspective, which includes both the patients and healthcare system, may help clinicians make informed decisions about the management of postoperative urinary retention. Moreover, the choice among each method may be guided by the provider accessibility based on the distance between the patient and provider, which may influence the overall cost. This study aimed to compare the costs of 3 postoperative pathways for short-term catheter management following pelvic surgery.

Materials and Methods

We constructed a Markov model to analyze the comparative costs of 3 management strategies for postoperative urinary retention. Markov modeling was used as patients have some probability of staying in their current health state vs moving to another health state (ie, continuing to have urinary retention vs recovering spontaneous voiding) at certain times in the model. Postoperative urinary retention is defined as the inability to void adequately according to evaluations by methods, including retrograde VTs and passive VTs but not including patients discharged without any evaluation of voiding function. Patients enter this model only after being identified as having postoperative urinary retention ( Figure 1 ). Therefore, regardless of the varying rates of postoperative urinary retention in the literature, our model dealt only with the subsequent management of urinary retention and was not affected by the rates of postoperative urinary retention or methods of voiding assessment to make the diagnosis. Given no difference in the patients’ satisfaction among these management strategies, a cost analysis rather than a cost-effectiveness analysis was appropriate. In pathway 1, the patients were managed with an indwelling catheter for several days and returned to the office for a VT. They either pass the VT and have spontaneous voiding or fail the VT and are taught how to perform CIC if able. In pathway 2, patients with postoperative urinary retention were managed with an indwelling catheter and instructed to discontinue the catheters themselves at home. At this point, they can either spontaneously void or not. If they are unable to void, then they must present to the office or, if it is not accessible, to an urgent care center or emergency department (ED) for assessment and treatment at which point they are managed with an indwelling catheter. In pathway 3, patients who fail the VT were taught CIC during their hospitalization postoperatively. For all patients who were taught CIC at any point in this model, we accounted for a proportion of patients who would be unable to learn CIC. In this model, we used the Markov chains to model the recovery of spontaneous voiding in each period, which was 1 week. In other words, at the end of each week, there was a chance of staying in the state of needing catheterization or moving to spontaneous voiding. The wavy arrows in Figure 1 denote these transitions. The primary analysis time frame was 6 weeks as most short-term postoperative urinary retentions resolve during this time.

Decision tree model

Different management strategies after a patient is identified as having postoperative urinary retention were compared. The wavy arrows denote Markov transition between states (in each period, there is a chance of staying or moving to the next state). Each time a patient is taught CIC, there is a chance that the patient is unable to learn CIC.

CIC , clean intermittent catherization; ED , emergency department.

Wang et al. Catheter management cost analysis. Am J Obstet Gynecol 2022.

Model base case estimates were taken from the published literature at the highest level of evidence whenever possible and varied the estimates across wide ranges for sensitivity analyses when the evidence was limited. The probabilities of passing an office VT or spontaneous voiding after self-removal of a catheter were estimated at 80%. ^, Patients who failed the office VTs were taught CIC, if capable. Among patients managed with self-removal of indwelling catheters, 12% (or 64% of the 20% who failed to void after self-removal) presented to the ED with acute urinary retention, and the remaining patients presented to the office. For patients performing CIC, we estimated the rate of returning to spontaneous voiding during each period at 80%. We based these rates on RCTs in the urogynecologic population but varied this probability of spontaneous voiding following bladder drainage between 50% and 100% for the sensitivity analysis to account for other patient populations. The probabilities of spontaneous voiding in each arm of the model were linked such that they varied together during the sensitivity analyses. This simulates scenarios where specific patient populations have overall higher or lower risks of spontaneous voiding following short-term catheterization. We estimated that in the base case scenario, 25% of patients who are taught CIC would be unable to perform CIC. ^, We varied this estimate between 0% and 100% for the sensitivity analysis. We estimated appropriate rates of urinary tract infection (UTI) testing and treatment based on a catheter method with each of the 3 management strategies based on available literature ( Table 1 ).

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