From the Department of Upper GI Surgery, North Cumbria Hospital.
Department of Obstetrics and Gynaecology, North Cumbria Hospital, Cumbria.
J Patient Saf. 2019 Dec;15(4):e21-e23. doi: 10.1097/PTS.0000000000000612.
Expert opinion remains divided regarding whether routine urethral catheterization is required before nononcological laparoscopic pelvic surgery. Catheterization is thought to reduce the incidence of bladder injury when inserting a suprapubic laparoscopic port and prevent obstruction of the view of the pelvis because of bladder filling. However, catheterization comes with a risk of nosocomial infection and harbors financial cost. Moreover, indwelling catheters inhibit early mobilization and increase postoperative discomfort.
A systematic review was undertaken using the Meta-Analysis of Observational Studies guidelines to identify eligible publications. End points included bladder injury, positive postoperative urinary microbiology, and postoperative urinary symptoms.
The reported incidence rates of laparoscopic bladder injury in included publications ranges from 0% to 1.3%. Importantly, bladder injury has occurred during both catheterized and noncatheterized operations. Our meta-analysis also shows that patients who are catheterized have a 2.33 times relative risk of developing postoperative positive microbiology in their urine (P = 0.01) and a 2.41 times relative risk of postoperative urinary symptoms (P = 0.005), when compared with noncatheterized patients.
This meta-analysis indicates that omitting a catheter in emergency and elective nononcological laparoscopic pelvic surgery may be a safe option. Catheterization does not remove the risk of bladder injury but results in more urinary tract infections and symptoms. It may be reasonable to ask a patient to void immediately before anesthesia, after which an on-table bladder scan should be performed. If there is minimal residual volume, a urinary catheter may not be necessary, unless operative time is estimated to be greater than 90 minutes.
在进行非肿瘤腹腔镜盆腔手术前，是否需要常规进行尿道插管，专家意见仍存在分歧。人们认为，在插入耻骨上腹腔镜端口时，插管可以降低膀胱损伤的发生率，并防止因膀胱充盈而妨碍盆腔视野。然而，插管存在医院感染的风险，并且需要花费。此外，留置导尿管会抑制早期活动并增加术后不适。
我们采用观察性研究荟萃分析指南进行了系统评价，以确定符合条件的出版物。终点包括膀胱损伤、术后尿液微生物阳性和术后尿症状。
纳入研究报告的腹腔镜膀胱损伤发生率为 0%至 1.3%。重要的是，在插管和非插管手术中均发生了膀胱损伤。我们的荟萃分析还表明，与非插管患者相比，插管患者发生术后尿液微生物阳性的相对风险增加 2.33 倍（P = 0.01），发生术后尿症状的相对风险增加 2.41 倍（P = 0.005）。
这项荟萃分析表明，在紧急和择期非肿瘤性腹腔镜盆腔手术中，不插入导尿管可能是一种安全的选择。插管并不能消除膀胱损伤的风险，但会导致更多的尿路感染和症状。在麻醉前要求患者立即排尿，然后在手术台上进行膀胱扫描可能是合理的。如果残余尿量很少，则可能不需要导尿管，除非手术时间估计超过 90 分钟。
