Abdel-Aleem Hany, Aboelnasr Mohamad Fathallah, Jayousi Tameem M, Habib Fawzia A
Department of Obstetrics and Gynecology, Faculty of Medicine, Assiut University Hospital, Assiut, Assiut, Egypt, 71511.
Cochrane Database Syst Rev. 2014 Apr 11;2014(4):CD010322. doi: 10.1002/14651858.CD010322.pub2.
Caesarean section (CS) is the most common obstetric surgical procedure, with more than one-third of pregnant women having lower-segment CS. Bladder evacuation is carried out as a preoperative procedure prior to CS. Emerging evidence suggests that omitting the use of urinary catheters during and after CS could reduce the associated increased risk of urinary tract infections (UTIs), catheter-associated pain/discomfort to the woman, and could lead to earlier ambulation and a shorter stay in hospital.
To assess the effectiveness and safety of indwelling bladder catheterisation for intraoperative and postoperative care in women undergoing CS.
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 December 2013) and reference lists of retrieved studies.
Randomised controlled trials (RCTs) comparing indwelling bladder catheter versus no catheter or bladder drainage in women undergoing CS (planned or emergency), regardless of the type of anaesthesia used. Quasi-randomised trials, cluster-randomised trials were not eligible for inclusion. Studies presented as abstracts were eligible for inclusion providing there was sufficient information to assess the study design and outcomes.
Two review authors independently assessed studies for eligibility and trial quality, and extracted data. Data were checked for accuracy.
The search retrieved 16 studies (from 17 reports). Ten studies were excluded and one study is awaiting assessment. We included five studies involving 1065 women (1090 recruited). The five included studies were at moderate risk of bias.Data relating to one of our primary outcomes (UTI) was reported in four studies but did not meet our definition of UTI (as prespecified in our protocol). The included studies did not report on our other primary outcome - intraoperative bladder injury (this outcome was not prespecified in our protocol). Two secondary outcomes were not reported in the included studies: need for postoperative analgesia and women's satisfaction. The included studies did provide limited data relating to this review's secondary outcomes. Indwelling bladder catheter versus no catheter - three studies (840 women) Indwelling bladder catheterisation was associated with a reduced incidence of bladder distension (non-prespecified outcome) at the end of the operation (risk ratio (RR) 0.02, 95% confidence interval (CI) 0.00 to 0.35; one study, 420 women) and fewer cases of retention of urine (RR 0.06, 95% CI 0.01 to 0.47; two studies, 420 women) or need for catheterisation (RR 0.03, 95% CI 0.01 to 0.16; three studies 840 participants). In contrast, indwelling bladder catheterisation was associated with a longer time to first voiding (mean difference (MD) 16.81 hours, 95% CI 16.32 to 17.30; one study, 420 women) and more pain or discomfort due to catheterisation (and/or at first voiding) (average RR 10.47, 95% CI 4.71 to 23.25, two studies, 420 women) although high levels of heterogeneity were observed. Similarly, compared to women in the 'no catheter' group, indwelling bladder catheterisation was associated with a longer time to ambulation (MD 4.34 hours, 95% CI 1.37 to 7.31, three studies, 840 women) and a longer stay in hospital (MD 0.62 days, 95% CI 0.15 to 1.10, three studies, 840 women). However, high levels of heterogeneity were observed for these two outcomes and the results should be interpreted with caution.There was no difference in postpartum haemorrhage (PPH) due to uterine atony. There was also no difference in the incidence of UTI (as defined by trialists) between the indwelling bladder catheterisation and no catheterisation groups (two studies, 570 women). However, high levels of heterogeneity were observed for this non-prespecified outcome and results should be considered in this context. Indwelling bladder catheter versus bladder drainage - two studies (225 women)Two studies (225 women) compared the use of an indwelling bladder catheter versus bladder drainage. There was no difference between groups in terms of retention of urine following CS, length of hospital stay or the non-prespecified outcome of UTI (as defined by the trialist).There is some evidence (from one small study involving 50 women), that the need for catheterisation was reduced in the group of women with an indwelling bladder catheter (RR 0.04, 95% CI 0.00 to 0.70) compared to women in the bladder drainage group. Evidence from another small study (involving 175 women) suggests that women who had an indwelling bladder catheter had a longer time to ambulation (MD 0.90, 95% CI 0.25 to 1.55) compared to women who received bladder drainage.
AUTHORS' CONCLUSIONS: This review includes limited evidence from five RCTs of moderate quality. The review's primary outcomes (bladder injury during operation and UTI), were either not reported or reported in a way not suitable for our analysis. The evidence in this review is based on some secondary outcomes, with heterogeneity present in some of the analyses. There is insufficient evidence to assess the routine use of indwelling bladder catheters in women undergoing CS. There is a need for more rigorous RCTs, with adequate sample sizes, standardised criteria for the diagnosis of UTI and other common outcomes.
剖宫产术是最常见的产科外科手术，超过三分之一的孕妇接受下段剖宫产。在剖宫产术前需进行膀胱排空。新出现的证据表明，剖宫产术中及术后不使用导尿管可降低相关的尿路感染（UTI）风险增加、导尿管相关的女性疼痛/不适，并可导致更早下床活动和缩短住院时间。
评估留置导尿管用于剖宫产女性术中及术后护理的有效性和安全性。
我们检索了Cochrane妊娠与分娩组试验注册库（2013年12月31日）以及检索到的研究的参考文献列表。
比较剖宫产（计划或急诊）女性留置导尿管与不使用导尿管或膀胱引流的随机对照试验（RCT），无论使用何种麻醉方式。半随机试验、整群随机试验不符合纳入标准。以摘要形式呈现的研究，只要有足够信息评估研究设计和结果，就符合纳入标准。
两位综述作者独立评估研究的纳入资格和试验质量，并提取数据。对数据进行准确性检查。
检索到16项研究（来自17份报告）。排除10项研究，1项研究等待评估。我们纳入了5项研究，涉及1065名女性（招募了1090名）。纳入的5项研究存在中度偏倚风险。4项研究报告了与我们的一项主要结局（UTI）相关的数据，但不符合我们对UTI的定义（如我们方案中预先规定的）。纳入的研究未报告我们的另一主要结局——术中膀胱损伤（该结局未在我们的方案中预先规定）。纳入的研究未报告两项次要结局：术后镇痛需求和女性满意度。纳入的研究确实提供了与本综述次要结局相关的有限数据。留置导尿管与不使用导尿管——3项研究（840名女性） 留置导尿管与术后膀胱扩张发生率降低相关（未预先规定的结局）（风险比（RR）0.02，95%置信区间（CI）0.00至0.35；1项研究，420名女性），尿潴留病例数减少（RR 0.06，95%CI 0.01至0.47；2项研究，420名女性）或导尿需求减少（RR 0.03，95%CI 0.01至0.16；3项研究840名参与者）。相比之下，留置导尿管与首次排尿时间延长相关（平均差（MD）16.81小时，95%CI 16.32至17.30；1项研究，420名女性），且导尿（和/或首次排尿时）导致的疼痛或不适更多（平均RR 10.47，95%CI 4.71至23.25，2项研究，420名女性），尽管观察到高度异质性。同样，与“不使用导尿管”组的女性相比，留置导尿管与下床活动时间延长相关（MD 4.34小时，95%CI 1.37至7.31，3项研究，840名女性）以及住院时间延长相关（MD 0.62天，95%CI 0.15至1.10，3项研究，840名女性）。然而，这两个结局观察到高度异质性，结果应谨慎解释。因子宫收缩乏力导致的产后出血（PPH）无差异。留置导尿管组和不使用导尿管组之间UTI的发生率（如试验者所定义）也无差异（2项研究，570名女性）。然而，对于这个未预先规定的结局观察到高度异质性，结果应在此背景下考虑。留置导尿管与膀胱引流——2项研究（225名女性） 2项研究（225名女性）比较了留置导尿管与膀胱引流的使用。剖宫产术后尿潴留、住院时间或UTI的未预先规定结局（如试验者所定义）在两组之间无差异。有一些证据（来自1项涉及50名女性的小型研究）表明，与膀胱引流组的女性相比，留置导尿管组的女性导尿需求减少（RR 0.04，95%CI 0.00至0.70）。另一项小型研究（涉及175名女性）的证据表明，与接受膀胱引流的女性相比，留置导尿管的女性下床活动时间更长（MD 0.90，95%CI 0.25至1.55）。
本综述纳入了来自5项中等质量RCT的有限证据。综述的主要结局（术中膀胱损伤和UTI）要么未报告，要么报告方式不适合我们的分析。本综述中的证据基于一些次要结局，部分分析存在异质性。没有足够的证据评估剖宫产女性常规使用留置导尿管的情况。需要进行更严格的RCT，样本量充足，UTI及其他常见结局的诊断标准标准化。
