初次髋膝关节置换术中不留置尿管的可行性和安全性研究

目的探讨单侧初次髋或膝关节置换术中不常规留置尿管的可行性及安全性,以减少不必要的导尿,提高患者就医舒适度和满意度。 方法本文回顾性分析中日友好医院骨关节外科2015年11月至2016年10月期间109例无明显尿潴留高危因素、无术前尿路感染、无尿路刺激征及重度肝肾功能不全、且接受单侧初次髋或膝关节置换术、术中不留置尿管(NIC)患者的资料。根据配对条件,与同期行常规术前留置尿管(IC)的单侧初次髋或膝关节置换患者按照1 ∶1进行配对研究,应用SPSS 19.0统计学软件对正态分布计量资料采用配对t检验,非正态分布计量资料采用Wilcoxon符号秩和检验,计数资料采用χ²检验分析比较两组患者术后的尿潴留、二次尿潴留、尿管相关膀胱不适、尿路刺激症、尿路感染、不良事件发生率,以及术后住院时间及患者满意度,分析并评价不留置尿管在单侧初次髋、膝关节置换术中的可行性及安全性。 结果两组患者术后尿潴留、二次尿潴留、尿路感染发生率比较,差异无统计学意义(P>0.05),NIC组术后尿管相关膀胱不适、尿路刺激征、不良事件发生率及术后住院时间均明显低于IC组,而患者满意度高于IC组,两组比较差异有统计学意义(χ²＝10.844,P<0.05),单侧初次髋或膝关节置换术中不必要的导尿高达81.7%。 结论初次髋或膝关节置换术中不常规留置尿管安全可靠,能有效减少尿管相关膀胱不适、尿路刺激征及不良事件的发生,同时可缩短术后住院时间,提高患者早期满意度。     

排尿训练与限制性输液在全膝置换术的应用

[目的]评价初次单侧全膝关节置换术通过术前排尿训练联合围术期限制性输液,不留置尿管的临床效果。[方法]回顾比较2017年07月～2019年01月190例行术前排尿训练、手术当日限制性输液、不留置尿管的初次单侧全膝关节置换患者(不置管组)与2016年01月～2017年05月190例手术当日自由性输液、留置尿管的患者(置管组)的临床早期结果。[结果]两组患者均顺利手术,无严重术中并发症。两组患者在手术时间、术中失血量、24 h引流量的差异无统计学意义(P0.05);不置管组患者手术当日术前、术中、术后输液量及总输液量均低于置管组,差异有统计学意义(P0.05);两组手术当日尿量比较,差异无统计学意义(P0.05)。术后1个月内,两组尿潴留发生率比较,差异无统计学意义(P0.05);不置管组在尿路感染、尿路刺激征、膀胱不适发生率方面均显著低于置管组,差异均有统计学意义(P0.05)。不置管组住院时间显著小于置管组,且患者满意度优于置管组,差异有统计学意义(P0.05)。[结论]通过术前排尿训练联合围术期限制性输液,初次单侧全膝关节置换术不留置尿管不增加术后尿潴留风险,且降低术后早期尿路感染、尿路刺激征、尿管相关膀胱不适的发生率,缩短住院时间,提高患者满意度。     

加速康复流程下人工全膝关节置换术后留置尿管的危险因素分析

目的探讨加速康复流程下人工全膝关节置换术(total knee arthroplasty,TKA)患者术后留置尿管的危险因素。方法以2017年1月-2018年8月全麻下初次单侧TKA患者为研究对象,其中205例符合选择标准纳入研究。收集患者临床资料,包括年龄、性别、体质量指数,术前关节活动度、美国特种外科医院(HSS)评分、美国麻醉医师协会(ASA)评分、疾病类型、合并症、血红蛋白、血细胞比容、血容量,手术时间及时刻、术后是否留置引流管、术中失血量、总失血量,术前、术中、术后补液量以及手术当天总补液量,手术当天小便量。采用单因素及logistic回归分析术后留置尿管的危险因素。同时,比较留置或未留置尿管患者术后住院时间以及围术期并发症发生情况,包括肌间静脉血栓、下肢深静脉血栓、肺栓塞形成,切口红肿渗出,电解质紊乱,恶心呕吐,尿路感染。结果205例患者中41例术后留置尿管,发生率为20.0%。单因素分析显示,年龄、性别、术后留置引流管、手术当天总补液量和小便量是初次单侧TKA术后留置尿管的影响因素(P<0.05)。多因素分析显示,男性和手术当天小便量多是初次单侧TKA术后留置尿管的危险因素(P<0.05)。与留置尿管组相比,未留置尿管组患者术后住院时间明显缩短、尿路感染发生率明显降低,差异有统计学意义(P<0.05);两组其他围术期并发症发生率差异均无统计学意义(P>0.05)。结论加速康复流程下,男性和手术当天小便量更多的患者在全麻初次单侧TKA后需留置尿管的风险更高。     

肺叶切除术后患者无尿管留置的前瞻性队列研究

目的探讨肺叶切除术后无尿管留置的临床应用效果和不足。方法前瞻性纳入2014年4~12月在四川大学华西医院胸外科单个医疗组行肺癌肺叶切除术的患者100例。将患者分为两组:无尿管留置组,麻醉后置入尿管和术后清醒前拔除导尿管,50例,男女各25例,年龄(53.94±10.91)岁;尿管留置组,麻醉后置入尿管和术后24~72 h拔除尿管,50例,男22例、女28例,年龄(50.62±12.31)岁。比较两组患者康复情况。结果两组患者尿潴留(P=0.433)和尿路感染发生率(P=0.050)差异均无统计学意义。无尿管留置组患者术后舒适度0度高于尿管留置组,且差异有统计学意义(P=0.002)。而尿管留置组有尿道症状(Ⅰ度、Ⅱ度和Ⅲ度)高于无尿管留置组(P=0.023),且差异有统计学意义。无尿管留置组术后平均住院时间短于尿管留置组(P=0.004)。前列腺增生症是肺部术后发生尿潴留的高危因素(P=0.056)。结论肺部手术患者术后无尿管留置未增加尿潴留,且能提高患者术后舒适度和快速康复。     

胸腔镜肺叶切除术患者围手术期无尿管留置导致尿潴留的危险因素分析

目的探讨全身麻醉下电视胸腔镜手术(video-assisted thoracoscopic surgery,VATS)肺叶切除患者不留置尿管导致术后尿潴留(postoperative urinary retention,POUR)的高危因素。方法分析2015年7~12月在四川大学华西医院胸外科单个医疗组行肺癌肺叶切除术患者148例的临床资料。将患者分为尿管留置组(尿管组,74例)和无尿管留置组(无尿管组,74例),分析病史,临床体征及麻醉过程和国际前列腺症状评分(IPSS)与术后尿潴留的关系。结果无尿管组和尿管组术后尿潴留发生率(9.46%vs.6.76%)差异无统计学意义(P=0.087)。男性和腹部手术史患者所占比例在尿潴留患者(83.33%,33.33%)中高于无尿潴留患者(56.62%,0.00%,P=0.017,P=0.000);尿潴留患者IPSS评分(26.55±7.00)高于无尿潴留患者(15.31±8.31),差异有统计学意义(P=0.031);而年龄、手术时间、术中输液量均与尿潴留是否无关。术后尿道感染率在尿管组和尿潴留患者中(4.05%,25.00%)显著高于无尿管组和无尿潴留患者(1.35%,0.74%,P=0.049,P=0.048)。结论男性、前列腺中-重度增生和腹部手术史是胸腔镜肺癌肺叶切除术患者发生尿潴留的危险因素。     

加速康复外科模式下全膝关节置换术围术期限制性输液的临床研究

[目的]探讨加速康复外科模式下全膝关节置换术围术期限制性输液的安全性和有效性。[方法]回顾分析2015年7月~2016年1月行初次单侧全膝关节置换术手术当日自由性输液患者90例(对照组)和2016年2月~8月手术当日限制性输液患者70例(限制组)的临床资料。记录并比较两组患者围术期出入量情况、生命体征及不良事件发生情况。[结果]限制组手术当日平均输液量显著低于对照组[(1 532.76±296.51)ml vs(2 303.13±313.35)ml,P<0.001]。两组在手术时间、总失血量、术后每小时尿量、围术期血压及心率、术后住院时间方面差异无统计学意义(P>0.05)。限制组利尿剂及尿管使用率均低于对照组(11.40%vs 24.40%,P=0.036;15.70%vs 30.00%,P=0.035),但两组术后低血压、低钾血症、恶心呕吐、便秘发生率差异并无统计学意义(P>0.05)。[结论]加速康复外科模式下全膝关节置换术围术期采用限制性输液方案(手术当日输液量控制在1 500 ml左右)是安全有效的,但该结论仍需大样本前瞻性研究进一步证实。     

下肢骨折拔管后尿潴留患者护理干预效果观察

目的:观察下肢骨折术后尿潴留患者护理干预效果。方法:将335例下肢骨折术后留置尿管患者随机分为两组,观察组173例进行护理干预,对照组162例进行常规基础护理及术后专科护理。比较两组拔除尿管后排尿情况。结果:观察组拔出尿管后出现尿潴留而重新置管发生率低于对照组(P<0.05)。结论:下肢骨折术后留置尿管患者采取护理干预措施可降低拔出尿管后出现尿潴留而重新置管发生率。     

人工膝关节置换术后留置引流与否的对比研究

目的 对比人工膝关节置换术后留置引流与否的临床结果.方法 将2008年9月至2010年3月56例单侧初次人工膝关节置换术患者分为2组,一组留置引流(27例),一组不留置引流(29例),采用相同的手术技术和术后处理,比较两组患者的失血量、隐性失血量、输血量、输血率、疼痛评分、出院时关节活动度、肢体周径增加、下肢深静脉血栓发生率、感染、血肿形成、伤口愈合不良等临床结果.结果 术后失血量有引流组为(1250±487) ml,无引流组为(932±332)ml,两组差异有统计学意义(t =2.877,P=0.006).人均异体血输血量有引流组为(933±487)ml,明显高于无引流组的(510±443)ml(t=3.406,P=0.001).输血率有引流组为88.9％,无引流组为62.1％,明显低于有引流组(x2 =5.364,P=0.021).隐性失血量、肢体周径增加、下肢深静脉血栓发生率、疼痛评分、出院时关节活动度两组无明显差异.两组病例均未出现术后感染、血肿形成、伤口愈合不良等并发症.结论 无引流组术后失血量小于有引流组,输血量及输血率也相应降低,且在疼痛评分、出院时关节活动度、肢体肿胀、下肢深静脉血栓发生率等方面,两组病例临床结果相似,膝关节置换术后不常规留置引流可能是更好的选择.本结论尚需大样本随机对照的临床研究进行验证.     

单侧全膝人工关节置换术后引流选择的随机对照研究

目的 比较单侧全膝人工关节置换术后引流与否的差异.方法 2006年2月至2007年2月100例单侧全膝人工关节置换术患者随机分为未引流组和引流组(对照组),每组50例,进行前瞻性研究.通过Gross方程推算,对术后总失血量(显性失血量+隐性失血量)和输血量进行分析;并对两组术后并发症及功能恢复状况进行比较.结果 引流组患者总失血量为(535±295)ml,隐性失血量为(513±290)ml;对照组患者总失血量为(853±331)ml,隐性失血量(689±324)ml;未引流组总失血量明显少于对照组(t=5.4611,P<0.05).未引流组患者术后输血量为(112±226)ml,对照组(316±283)ml,未引流组明显少于对照组(t=3.9852,P<0.05).术后输血人次未引流组为11例,对照组为32例,未引流组输血率明显低于对照组(未校正χ~2=18,P<0.05).两组间术后并发症的发生率及功能恢复差异无统计学意义(P>0.05).结论 单侧全膝人工全膝关节置换术术后不放引流组无论总失血量,还是术后输血量均少于对照组,且输血率低.两组术后并发症的发生率及术后膝关节功能恢复无明显差异.     

全髋关节置换术后患者院内感染的多因素分析

[目的]调查全髋关节置换术患者院内感染情况,分析该类患者院内感染的易感因素及可能的预防措施.[方法]回顾性分析2006年1月～2008年1月本院骨科住院行全髋关节置换术且资料完整的病例206例(206髋),按照有无院内感染分为院内感染组(A组)、无院内感染组(B组),统计两组患者的年龄、基础疾病情况、血红蛋白含量、血清白蛋白、手术时间、输血量、尿管留置时间、抗生素使用时间,同时对发生院内感染的患者统计院内感染的部位、病原菌及转归情况.[结果]206例患者发生院内感染20例,感染部位依次为呼吸道10例,泌尿系9例,皮肤感染1例,发生率为9.7%,院内感染组患者的年龄、输血量、手术时间及术后尿管留置时间明显高于无院内感染组,贫血、低蛋白血症与院内感染的发生具有相关性,两组患者在基础疾病、抗生素使用时间无明显差异.[结论]全髋关节置换术患者院内感染发生是多因素所致,年龄、低蛋白血症、贫血、手术时间以及尿管的长期留置与院内感染密切相关.     

Hip dysfunction‐related urinary incontinence: A prospective analysis of 189 female patients undergoing total hip arthroplasty

Patients reporting that their symptoms of urinary incontinence have decreased after total hip arthroplasty can be encountered in orthopedic practice. In this questionnaire‐based study, we prospectively evaluated the symptoms of urinary incontinence before and after total hip arthroplasty. The International Consultation on Incontinence Questionnaire‐Short Form was used to prospectively evaluate these symptoms in 189 consecutive female patients undergoing total hip arthroplasty. The patients were asked to fill in a questionnaire before and 3 months after surgery. A decrease in the International Consultation on Incontinence Questionnaire‐Short Form score of ≥1 point was defined as an improvement, whereas an increase of ≥1 point was defined as worsening. A total of 81 (43%) patients reported urinary incontinence before total hip arthroplasty. At 3 months after surgery, symptoms of urinary incontinence were improved in 64% of these patients, remained unchanged in 32% and worsened in 4%. Mean International Consultation on Incontinence Questionnaire‐Short Form score in patients with urinary incontinence before surgery significantly improved from 6.0 to 3.5 (P = 0.0002). These findings suggest a relationship between hip joint function and pelvic floor function, and consequently a hip dysfunction‐related urinary incontinence.     

A Retrospective Study of Anticholinergic Use and Later Mobilization as Risk Factors for Urinary Retention After Major Lower Extremity Joint Arthroplasty

BackgroundPostoperative urinary retention (POUR) is a common surgical complication of major joint arthroplasty and is associated with increased lengths of stay and urinary tract infections. Studies have found that certain anticholinergic medications and reduced mobility are associated with POUR. This study assessed the effect of anticholinergic burden and later postoperative ambulation on POUR.MethodsIn this retrospective cohort study, we included subjects who had undergone elective primary or revision hip or knee arthroplasty (total hip arthroplasty [THA] or total knee arthroplasty [TKA]) between March 2015 and December 2017 in a single health system. Anticholinergic burden was measured using the Anticholinergic Drug Scale (ADS). We performed bivariate and multivariable logistic regression with POUR as the dependent variable. Of the 1,397 study subjects, 622 (45%) underwent THA and 775 (55%) underwent TKA. Their mean age was 65 years (range, 21 to 98), and 841 (60%) were women. POUR developed in 183 (13%) subjects.ResultsIn multivariable analyses, ADS was associated with POUR after THA (P < .05), but not TKA (P = .08), while later ambulation was not associated with POUR after either procedure (P > .3 for both).ConclusionAnticholinergic burden after THA was independently associated with POUR. Strategies to reduce anticholinergic burden may help reduce POUR after THA.     

Preoperative Risk Factors for Postoperative Urinary Tract Infection After Primary Total Hip and Knee Arthroplasties

BackgroundEstablishing clear risk factors for complications such as urinary tract infection (UTI) after arthroplasty procedures helps guide clinical practice and provides more information to both surgeons and patients. This study aims to assess selected preoperative patient characteristics as risk factors for postoperative UTI after primary total hip and knee arthroplasties (THA and TKA).MethodsThis was a retrospective analysis using current procedural terminology codes to investigate the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database for patients who underwent THA or TKA from 2010 to 2017. Patients were classified for UTI by NSQIP guidelines. Patient samples with all possible covariates were included for multivariate logistic regression analysis and assessed for independent associations.ResultsIn a cohort of 983 identified patients (983 of 119,096; 0.83%): ages 57+ years, preoperative red blood cell (RBC) transfusion, perioperative RBC transfusion, bleeding disorders, operative time 110+ minutes, preoperative steroid use, diabetes, pulmonary comorbidities, body mass index 30+ kg/m² were independent risk factors for postoperative UTI after THA. In a cohort of 1503 identified patients (1503 of 189,327; 0.8%): ages 60+ years, preoperative RBC transfusion, perioperative RBC transfusion, anemia, platelets less than 150k, preoperative steroid use, diabetes, and body mass index 30+ kg/m² were independent risk factors for postoperative UTI after TKA. Male sex was associated with a decreased risk of UTI in both THA and TKA.ConclusionThis study provides novel evidence on risk factors associated with the development of UTI after THA or TKA. Clinicians should be aware of risk factors in the manifestation of postoperative UTI after primary THA or TKA procedures.     

Incidence and Risk Factors of Postoperative Urinary Retention and Bladder Catheterization in Patients Undergoing Fast-Track Total Joint Arthroplasty: A Prospective Observational Study on 371 Patients

Background

Postoperative urinary retention (POUR) appears to be a common complication in lower limb joint arthroplasty; however, reports on its incidence vary. There is no general consensus on its definition and there is no scientific evidence on treatment principles. We performed a prospective observational study to establish the incidence of POUR and its risk factors, including the preoperative postvoid residual urine volume and the perioperative fluid balance, in fast-track total joint arthroplasty (TJA). The preoperative residual urine volume and the perioperative fluid balance have not been studied in previous literature in the context of TJA and POUR.

Perioperative bladder management after primary total hip arthroplasty

A retrospective review of 95 consecutive primary total hip arthroplasty patients was performed to assess the clinical outcome of two postoperative bladder management protocols. The first 49 patients (group 1) were treated with a pro re nata straight catheterization protocol. The next 46 patients (group 2) were treated with an indwelling catheterization protocol. There were no differences between the groups with respect to sex or age. The patients in group 2 had significantly lower incidences of urinary retention (P < .0005) and bladder distention (P < .0005) than those in group 1. Preoperative systemic diseases and urologic symptoms did not correlate with the occurrence of postoperative urinary retention or bladder distention. There were no infections in group 1. In group 2, one patient (2%) had bacteriuria and one patient (2%) had a urinary tract infection (P > .1). This trend of increased contamination in the catheterization group may be related to a mean catheterization duration of 72 hours.     

Preoperative Asymptomatic Leucocyturia and Early Prosthetic Joint Infections in Patients Undergoing Joint Arthroplasty

Prosthetic joint infection (PJI) is associated with a higher mortality, morbidity and economic costs. Although it is well known that the presence of urinary tract infection (UTI) is associated with PJI, few investigations evaluated the preoperative asymptomatic leukocyturia (ASL) and the possible relationship with early PJI. We reviewed the records of 739 patients performed primary joint arthroplasty. A total of 131 patients had preoperative ASL (17.7%) and 7 of 739 patients (0.9%) had early PJI. Preoperative ASL was not confirmed as a risk factor for early PJI on the multivariate regression analysis with an adjusted OR of 1.04 (P > 0.05). Therefore, it should not be considered as a reason for postponement of total joint arthroplasty.     

Does Symptomatic Benign Prostatic Hyperplasia Increase the Risk of Periprosthetic Joint Infection After Primary Total Joint Arthroplasty?

BackgroundPeriprosthetic joint infection (PJI) is among the leading causes of failure in total joint arthroplasty. A recently proposed risk factor for PJI is symptomatic benign prostatic hyperplasia (sBPH). This study aims to determine if sBPH is associated with PJI following primary total hip arthroplasty (THA) and total knee arthroplasty (TKA).MethodsUsing the Mariner all-payer claims database, 1745 patients with sBPH undergoing primary THA were propensity-matched with 3490 controls, and 3053 patients with sBPH undergoing primary TKA were propensity-matched with 6106 controls. Additionally, the same 1745 patients with sBPH undergoing THA were compared to 317,360 prematched controls, and the same 3053 patients with sBPH undergoing TKA were compared to 557,730 prematched controls. Univariate analysis was conducted using chi-squared or ANOVA where appropriate.ResultsAt two years postoperatively, patients with sBPH were not at significantly increased risk for PJI following primary THA (1.54% vs 1.43%; P = .745) and TKA (1.99% vs 2.14%; P = .642) relative to postmatch controls. Compared to matched controls, THA patients with sBPH had an increased 90-day incidence of anemia (P < .001), blood transfusion (P < .001), and urinary tract infection (UTI; P < .001). Total knee arthroplasty patients with sBPH had an increased 90-day incidence of anemia (P < .001), blood transfusion (P < .001), cellulitis (P = .023), renal failure (P = .030), heart failure (P = .029), and UTI (P < .001) relative to matched controls.ConclusionIn primary THA and TKA, sBPH does not appear to be an independent risk factor for PJI within two years postoperatively. However, clinicians should be cognizant of the significantly increased risk for postoperative UTI in this patient population.     

Pre-Operative Urodynamic Assessment Has Poor Predictive Value for Developing Post-Operative Urinary Retention

BackgroundPost-operative urinary retention (POUR) following primary total joint arthroplasty (TJA) has a reported prevalence up to 35%. Risk factors for POUR have included surrogate markers such as the presence or absence of urologic disease. Pre-operative dynamic measurement with post-void residual volumes (PVR) has not been investigated as a tool for assessing POUR risk.MethodsAll male TJA patients underwent an institutional pre-operative screen for POUR, including PVR measurements, patient-derived subjective urinary retention scores, and assessment of urologic disease. The prospectively collected data were retrospectively reviewed. Proportions were evaluated with the chi-squared test, while continuous variables were evaluated by logistic regression analysis. Receiver-operator characteristic curves were utilized to determine the efficacy of using urodynamic variables as a predictor of developing POUR.ResultsTwo hundred fifty-two male patients were reviewed who had a mean age of 64.9 years and mean body mass index of 30.8 kg/m². The overall rate of POUR was 5.1%. Patient urinary retention scores were not associated with POUR. Elevated pre-operative PVR (>10 cc) alone and in combination with a history of urologic disease was significantly associated with POUR. However, both had low positive predictive values (10.5% and 18.2%), despite high negative predictive values (99.2% and 97.9%). Utilization of PVR resulted in moderate sensitivity (91.6%) and low specificity (72.1%) with an area under the curve of 0.69.ConclusionUrodynamic measurements and patient urinary retention scores, as part of an institutional pre-operative screening protocol, have limited value in determining which patients are at increased risk of POUR. The utility of obtaining these measurements pre-operatively is questionable.     

Impact of Perioperative Urinary Tract Infection on Surgical Site Infection in Patients Undergoing Primary Hip and Knee Arthroplasty

BackgroundThe literature lacks clear consensus regarding the association between postoperative urinary tract infection (UTI) and surgical site infection (SSI). Additionally, in contrast to preoperative asymptomatic bacteriuria, SSI risk in patients with preoperative UTI has been incompletely studied. Therefore, our goal was to determine the effect of perioperative UTI on SSI in patients undergoing primary hip and knee arthroplasty.MethodsUsing the National Surgical Quality Improvement Program database, all patients undergoing primary hip and knee arthroplasty were identified. Univariate and multivariate regressions, as well as propensity matching, were used to determine the independent risk of preoperative and postoperative UTI on SSI, reported as odds ratios (ORs) with 95% confidence intervals (CIs).ResultsPostoperative UTI significantly increased the risk for superficial wound infection (OR 2.147, 95% CI 1.622-2.842), deep periprosthetic joint infection (PJI) (OR 2.288, 95% CI 1.579-3.316), and all SSIs (superficial and deep) (OR 2.193, 95% CI 1.741-2.763) (all P < .001). Preoperative UTI was not associated with a significantly increased risk of superficial infection (P = .636), PJI (P = .330), or all SSIs (P = .284). Further analysis of UTI present at the time of surgery using propensity matching showed no increased risk of superficial infection (P = 1.000), PJI (P = .624), or SSI (P = .546).ConclusionPostoperative UTI was associated with SSI, reinforcing the need to minimize factors which predispose patients to the risk of UTI after surgery. The lack of association between preoperative UTI and SSI suggests that hip and knee arthroplasty can proceed without delay, although initiating antibiotic treatment is prudent and future prospective investigations are warranted.