Medical and non-medical interventions for post-operative urinary retention prevention: network meta-analysis and risk–benefit analysis

Abstract

Aims: To assess the efficacy in lowering post-operative urinary retention, urinary tract infection and lower urinary tract symptoms and the incidence of adverse events among 12 interventions and to perform risk–benefit analysis. Methods: Previous randomized controlled trials were identified from MEDLINE, Scopus and CENTRAL database up to January 2020. The interventions of interest included early ambulation, fluid adjustment, neuromodulation, acupuncture, cholinergic drugs, benzodiazepine, antispasmodic agents, opioid antagonist agents, alpha-adrenergic antagonists, non-steroidal anti-inflammatory drugs (NSAIDs) and combination of any interventions. The comparators were placebo or standard care or any of these interventions. Network meta-analysis was performed. The probability of being the best intervention was estimated and ranked using rankogram and surface under the cumulative ranking curve. Risk–benefit analysis was done. Incremental risk–benefit ratio (IRBR) was calculated and risk–benefit acceptability curve was constructed. Results: A total of 45 randomized controlled trials with 5387 patients was included in the study. Network meta-analysis showed that early ambulation, acupuncture, alpha-blockers and NSAIDs significantly reduced the post-operative urinary retention. Regarding urinary tract infection and lower urinary tract symptoms, no statistical significance was found among interventions. Regarding the side effects, only alpha-adrenergic antagonists significantly increased the adverse events compared with acupuncture and opioid antagonist agents from the indirect comparison. According to the cluster ranking plot, acupuncture and early ambulation were considered high efficacy with low adverse events, corresponding to the IRBR. Conclusion: Early ambulation, acupuncture, opioid antagonist agents, alpha-adrenergic antagonists and NSAIDs significantly reduce the incidence of post-operative urinary retention with no difference in adverse events. Regarding the risk–benefit analysis of the medical treatment, alpha-adrenergic antagonists have the highest probability of net benefit at the acceptable threshold of side effect of 15%, followed by opioid antagonist agents, NSAIDs and cholinergic drugs.

Summary of evidence on prevention and management of bladder dysfunction in patients after radical hysterectomy

“…One of these studies (i.e. Sirisreetreerux et al., 2021 ), had all entries ‘yes’ except for 11 (‘Whether appropriate suggestions were made for the specific direction of further research?’). The literature was included after an overall independent valuation by two researchers.…”

“…The pharmacological intervention mainly involves improving the contraction of the detrusor muscle and reducing urethral resistance, which may have a preventive effect on postoperative bladder dysfunction. Recently, some system reviews (Aue‐Aungkul et al., 2021 ; Jackson et al., 2019 ; Sirisreetreerux et al., 2021 ) explored the usefulness and safety of pharmacological interventions such as antispasmodic agents, non‐steroidal anti‐inflammatory drugs suppository, alpha‐adrenergic antagonist (Ghuman et al., 2018 ), cholinergic drug and opioid antagonist agents in preventing urinary retention. Past research (Aue‐Aungkul et al., 2021 ) has indicated that bethanechol, a type of cholinergic preparation, may reduce the chance of bladder dysfunction by lowering the volume of post‐void residual assessed 1 month after the surgery and may show better urodynamic assessment results.…”

“…However, the certainty of this evidence is relatively low, warranting further research to confirm this outcome. A network meta‐analysis (Sirisreetreerux et al., 2021 ) revealed that opioid antagonist agents and alpha‐adrenergic antagonists can significantly reduce the incidence of postoperative urinary retention, with no difference in adverse events. In addition, regarding the risk–benefit analysis of the medical treatment, alpha‐adrenergic antagonists show the highest probability of net benefit at the acceptable threshold of a side effect of 15%, followed by opioid antagonist agents and cholinergic drugs (Sirisreetreerux et al., 2021 ).…”

Neostigmine for postoperative surgical urine retention: A systematic review and meta-analysis

“…Prior meta-analyses carried out by Sirisreetreerux et al 46 and Jackson et al 47 demonstrated neostigmine efficacy, a medication classified as either a parasympathomimetic or a reversible cholinesterase inhibitor, in the management and prevention of POUR. Nonetheless, it is imperative to subject these medications to RCTs with substantial sample sizes to determine their clinical efficacy and patient acceptability.…”

Postoperative urinary retention (POUR): A narrative review

“…According to Sirisreetreerux et al ,[ 71 ] early ambulation, acupuncture, opioid antagonist agents, alpha-adrenergic antagonists, and non-steroidal anti-inflammatory drugs (NSAIDs) significantly reduce the incidence of POUR with no difference in adverse events.…”