Author's Accepted Manuscript

Comparison of urinary tract infection rates associated with transurethral

catheterization, suprapubic tube and clean intermittent catheterization in the
postoperative setting: a network meta-analysis

Christopher S. Han , Sinae Kim , Kushan D. Radadia , Philip T. Zhao , Sammy E.

Elsamra , Ephrem O. Olweny , Robert E. Weiss

PII: S0022-5347(17)77185-6
DOI: 10.1016/j.juro.2017.07.069
Reference: JURO 14879

To appear in: The Journal of Urology

Accepted Date: 16 July 2017

Please cite this article as: Han CS, Kim S, Radadia KD, Zhao PT, Elsamra SE, Olweny EO, Weiss RE,
Comparison of urinary tract infection rates associated with transurethral catheterization, suprapubic tube
and clean intermittent catheterization in the postoperative setting: a network meta-analysis, The Journal
of Urology® (2017), doi: 10.1016/j.juro.2017.07.069.

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 ACCEPTED MANUSCRIPT
1

Comparison of urinary tract infection rates associated with transurethral

catheterization, suprapubic tube and clean intermittent catheterization in the
postoperative setting: a network meta-analysis.

PT
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Christopher S. Han1,2, Sinae Kim3, Kushan D. Radadia1,2, Philip T. Zhao1,2, Sammy E.
Elsamra1,2, Ephrem O. Olweny1,2, and Robert E. Weiss1,2

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1
Rutgers–Robert Wood Johnson Medical School, New Brunswick, NJ 08901
2
Rutgers–Cancer Institute of New Jersey, New Brunswick, NJ 08903

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3
Rutgers–School of Public Health, Piscataway, NJ 08854
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Key Words: Genitourinary, infection, catheter, postoperative, meta-analysis

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Funding: None
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Corresponding Author:
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Kushan Radadia, MD
1 Robert Wood Johnson Place
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MEB 584
New Brunswick, NJ 08901
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Phone: (610)-639-2002
kradadia@gmail.com
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Abstract:

Purpose

A network meta-analysis was performed of available randomized controlled trials (RCT) to

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elucidate the risks of urinary tract infection (UTI) associated with transurethral catheterization

(TUC), suprapubic tube (SPT) and intermittent catheterization (IC) in the postoperative setting.

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Materials and Methods

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PubMed, EMBASE and Google Scholar searches were performed for eligible RCTs from

January 1980 to July 2015 that included patients who had TUC, SPT, or IC at the time of surgery

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and catheterization lasting up to postoperative day 30. The primary outcome of comparison was
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rates of UTI via a network meta-analysis with random effects model using a package netmeta in

R 3.2.
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Results
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Fourteen RCTs were included in the analysis (n=1,391 patients). IC and SPT showed no
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evidence of decreased UTI rates compared to TUC. SPT and IC had comparable UTI rates

(OR=0.903, 95% CI 0.479-2.555). In a subgroup analysis on 10 RCTs with available mean

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duration of catheterization (DOC) data (n=928 patients), IC and SPT were associated with

significantly decreased risks of UTI compared to TUC when DOC > 5 days (OR=0.173, 95% CI
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0.073-0.412 and OR=0.142, 95% CI 0.073-0.276, respectively).

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Conclusions

TUC is not associated with increased UTI risks compared to SPT and IC if DOC is ≤ 5 days.

However, SPT or IC are associated with lower rates of UTI if longer term catheterization is

expected in postoperative periods.

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Introduction:

Catheter-associated urinary tract infection (CAUTI) has received a great deal of attention

over the past few years. UTI is catheter-related in 80% of times accounting for up to 40% of

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hospital-acquired infection (1). Proper bladder drainage, however, remains a necessity and is a

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routine postoperative care in surgical patients due to high rates of urinary retention during this

period (2). Catheter-associated complications, however, can be major hurdles to recovery.

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While the most common type of bladder drainage is a transurethral catheterization

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(TUC), suprapubic tube (SPT) and intermittent catheterization (IC) are alternative approaches.
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Each method has a unique rationale behind its utilization, though a paucity of evidence supports

each practice. SPT has been suggested to have lower rate of UTI compared to TUC (3). More
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significant adverse events associated with SPT along with its invasiveness, however, have

discouraged routine use of SPT (4). IC has also been suggested to have lower rates of bacteriuria,
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asymptomatic and symptomatic, compared to TUC in the postoperative settings (5). One study,
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however, has reported six-fold increase in the estimated costs of IC per patient, as compared to

that of TUC, for the first 48 hours after surgery questioning its cost-effectiveness (6). TUC is
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also simple and familiar to most hospital staff in the postoperative setting, therefore, has been the

most utilized method of bladder drainage (3). However, with conventional wisdom suggesting
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higher rates of UTI with TUC compared to the other approaches, it is often difficult to choose the
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best treatment option for the patients. We have therefore performed a systematic review and

network meta-analysis to elucidate the UTI rates between TUC, SPT and IC in the postoperative

period in an attempt to better answer this question.

Methods:
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PubMed, EMBASE, Google Scholar and the Cochrane Library searches were performed

identifying studies from January 1980 to July 2015 with keywords “suprapubic”, “transurethral”,

“intermittent”, “catheter” and “urinary tract infection.” Search results were further narrowed to

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patients who had TUC, SPT, or IC at the time of surgery and catheterization lasting only up to

postoperative day 30. The rest of the inclusion criteria includes: randomized clinical trials

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(RCT), patients undergoing elective surgery for benign or malignant conditions and at least one

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outcome measure reported. No other restrictions were placed on the searches. Two authors

reviewed the potentially relevant articles independently. The primary outcome of comparison

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was the rates of UTI. UTI was defined as a urine culture of >105 colonies/mL urine with or
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without symptoms. A subgroup analysis based on the duration of catheterization (DOC) was also

performed (DOC ≤ five days, DOC > five days).

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There are no published RCT comparing all three types of catheterization. As standard
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meta-analyses could not utilize the information about a treatment which was not directly
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compared within a study, network meta-analysis with random effects model was performed

using a package netmeta in R 3.2. Network meta-analysis, a novel concept of meta-analysis, aims
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to combine information from all randomized comparisons among a set of treatments for a given

condition. Furthermore, it allows to rank the treatments in order to identify the best and/or worst
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treatment among them. Cochran’s Q test and I2 index were used to test for the study
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heterogeneity. The risk of bias within trials was evaluated using the Jadad score by assessing the

description of randomization, blinding, and withdrawals/dropouts. The statistical analyses were

performed on an intention-to-treat basis. Ranking of catheterization was determined by P-Scores

based on network estimates and corresponding standard errors.

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Results:

Literature search identified 14 RCT applicable to our search criteria with a total of 1,391

patients (Figure 1). Four, three, and seven studies were identified comparing IC versus TUC,

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SPT versus IC, and TUC versus SPT, respectively, after orthopedic, urogynecologic,

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gynecologic, and general surgery procedures. Jadad score was calculated with a mean score of

2.85 (Table 1). Basic characteristics of patients are described in Table 2. Each study was

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reviewed for mean DOC and UTI rate.

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IC and SPT showed no evidence of decreased UTI rates compared to TUC (OR=0.565,
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95% CI 0.252-1.267 and OR=0.51, 95% CI 0.255-1.023, respectively) (Table 3). IC and SPT

also showed no significant differences in their risks of UTI (OR=1.107, 95% CI 0.479-2.555).
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Using TUC as a reference, a forest plot was generated (Figure 2). The catheterization modality

was ranked by the likelihood of developing a postoperative UTI using a P-scores which are
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based solely on point estimates and standard errors of the network estimate. Ranking showed
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SPT>IC>TUC. I2 of 69% and Q of 38.69 were reported.

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A subgroup analysis based on mean DOC was then performed. Group 1 included those

with mean DOC of five days or less whereas Group 2 included those with mean DOC of longer
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than five days. A total number of 10 studies were identified with mean DOC records (Table 4).
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No statistically significant differences in UTI rates were seen between TUC, SPT and IC when

mean DOC was five days or less (OR=1.021, 95% CI 0.346-3.014 for IC versus TUC,

OR=1.537, 95% CI 0.34-6.943 for SPT versus TUC, and OR=0.664, 95% CI 0.145-3.037 for IC

versus SPT) (Table 5). The ranking showed that TUC was associated with the lowest risk of UTI

in Group 1, but the differences did not meet statistical significance. With mean DOC longer than
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five days, IC and SPT were associated with significantly decreased risks of UTI compared to

TUC (OR=0.173, 95% CI 0.073-0.412 and OR=0.142, 95% CI 0.073-0.276, respectively). Using

TUC as a reference, a forest plot was generated (Figure 3).

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Discussions:

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Early reviews and meta-analyses have reported higher infection rates with TUC

compared to SPT and/or IC in the surgical population with short-term bladder drainage (≤ 14

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days) (3). This population includes the general surgical, orthopedic, gynecological, and

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urological patients. The recently updated 2015 Cochran review for the hospitalized adults,
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however, concludes that the current evidences are insufficient to draw any conclusion on the

comparative risks of symptomatic UTI associated with TUC, SPT and IC (20). This indicates
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that the evidence is still lacking to formulate a general consensus on this topic. Interestingly, SPT

is found to be associated with reduced risk of asymptomatic bacteriuria (ASB) in this review.
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The clinical significance of this reduced risk of ASB, however, is unclear. As a general
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consensus, recommendations are against the treatment of ASB due to its low clinical significance

and increased risk of the development of resistant bacterial strains (21,22). The confusion
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between the symptomatic UTI and ASB, however, is still prevalent in the community.
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This confusion is largely due to the variations in the current UTI criteria. Although
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generally similar, UTI criteria vary by organizations, medical specialties and even within

hospitals. The criteria of a postoperative UTI by the National Surgical Quality Improvement

Program (NSQIP), one of the largest national program measuring the surgical outcomes, include

one of the symptoms (fever >38ºC, urgency, frequency, dysuria, or suprapubic tenderness) and

urine culture of >105 colonies/mL urine (with no more than two species of organisms) (23).
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However, the NSQIP, American Urological Association (AUA), EAU and National Healthcare

Safety Network (NHSN), the CDC’s patient safety surveillance system, all have variations in

both the method of diagnosis and definition of UTI (21,22). To further compound the problem,

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the CAUTI data often do not exclude those who were treated for urinary symptoms, but

subsequently found to have negative urine cultures (22). CAUTI definitions also do not

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distinguish between the urinary symptoms secondary to the bladder irritation from the

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catheterization itself and infection. Furthermore, postoperative CAUTI is a unique entity where

the indication and/or duration of the catheterization is different from other hospitalized patients

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and prophylactic antibiotic use may have altered the culture data and/or UTI symptomatology.
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The recent change in the definition of CAUTI by NHSN in 2009 has also contributed to

this confusion. The main change was the removal of ASB from its criteria (24). As a result, care
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should be taken when pooling the pre-change data for an analysis with the post-change data as

some of the pre-change studies include both UTI and ASB patients. Nonetheless, meta-analysis
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is still the preferred method in answering this longstanding controversy on postoperative CAUTI
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as performing an RCT to compare all three modalities of bladder drainage is difficult, if not
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impossible, due to the large number of patient needed with the innate heterogeneity of the

surgical population. As it is nearly impossible to sort out the included patients with ASB in some
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of the pre-change studies, some of the patients included in our analysis have ASB limiting the
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significance of our results.

The inclusion of pre-change data into analysis, however, warrants a discussion as the rate

of treatment of ASB has not declined significantly in tertiary care hospitals (25). Although a

significant decline in CAUTI has been seen since the NHSH definition change, likely due to the

removal of ASB from its criteria, the above finding suggest that the definition change itself does
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not affect the clinical practice (24). By including RCTs with varying definitions of UTI, which

lead to actual treatments, attempts can be made to capture the “true” rate of UTI that leads to an

actual treatment in the current clinical practice. Although such broad inclusion is certainly a

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limitation, it may also allow increased generalizability of the data. It should be clear, however,

that the antibiotic treatment is only warrantied in those with symptomatic bacteriuria. The

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postoperative patient population is also unique in that many of them have baseline and/or

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transient bladder dysfunction from the operation itself that, along with the catheter-related

irritative symptoms, interfere with the accurate diagnosis of UTI. For this reason, many of the

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RCTs have incorporated multiple precatheter and postcatheter cultures for improved accuracy. In
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order to further maximize the statistical power, a network-analysis, where multiple treatments

can be compared using both direct comparisons of intervention within RCT as well as indirect
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comparisons across trials based on a common comparator, has been performed (26).

Contrary to the prior RCTs and/or meta-analyses, our results demonstrated that TUC is
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not associated with increased risk of UTI compared to SPT and IC. However, a difference was
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delineated during the subgroup analysis based on the DOC of five days. DOC ≤ five days
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represented an immediate postoperative bladder drainage and DOC > five days represented

prolonged bladder drainage possibly due to a failure to void and/or the nature of the surgery.
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Five days is chosen based off various surgical and gynecological literatures (28, 29). Studies
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reported average DOC of approximately five days, and UTI rates peak at 6th day of

catheterization. These studies also did not remove catheters early in the postoperative setting due

to the risk of urinary retention (27,28).

RCTs evaluated in this trial only reported mean DOC of their cohorts. While absolute

DOC was not available, subgroup analysis was performed with given values. TUC is shown to
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be associated with different risk profiles based on mean DOC when compared to SPT and IC. If

mean DOC ≤ five days, TUC is still found to have similar risk of UTI compared to SPT and IC.

In fact, TUC was ranked the lowest with regard to the risk of UTI in this group, though not

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statistically significant. This result could prevent unnecessary initiation of SPT or IC, which

could potentially increase the complications and/or cost, when mean DOC is expected to be five

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days or less.

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If mean DOC > five days, TUC is shown to be associated with higher risk of UTI. This

result is in congruence with the previous studies and suggests that the method of postoperative

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bladder drainage should be tailored in regards to the expected DOC to reduce the postoperative
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CAUTI. Therefore, IC or SPT can be the preferred means of bladder drainage in this group. SPT

in particular can be beneficial if prolonged catheterization is expected at the time of surgery as

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lower re-catheterization rates are seen with SPT likely due to the trial of spontaneous void that
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could be given in SPT without having to remove the catheter (3). The placement of SPT in the
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operating room with the patient under anesthesia is relatively easy and ensures safe insertion as

well. IC can be taught to the patient and/or the caregiver prior to discharge in these settings and
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potentially minimize the increased cost which are mainly associated with the increased nursing

care (6).
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Nonetheless, our study has some limitations. As discussed above, the varying definitions
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of postoperative UTI in our study may limit its clinical applicability. However, its broad

inclusion criteria more accurately represent the current clinical practice patterns for varying

definitions of UTI. Secondly, analysis of this kind is often associated with statistical

heterogeneity. Even with the high quality RCTs (most studies have Jadad score of 3 or higher)
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included in the analysis, the significant differences among the trials including the types of

surgeries, gender and DOC may make such pooling of data less ideal. Nevertheless, surgical

populations are inherently heterogeneous with different levels of complexities and types of

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operations. This is seen by the reported Q statistic implying that the individual studies do not

provide consistent result. However, as Q statistic has low power when the number of studies are

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low, I2, a more intuitive measure of inconsistency, is also calculated and showed that 69% of

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variability may be due to the between-study variation. To further address this, random-effects

model was used as recommended for the meta-analysis of surgical trials (29). Such

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heterogeneity, therefore, could further support the generalizability of this data. However, a
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relatively low proportion of male patients included in our analysis may limit generalization of

our data. The large female population in our cohort may overestimate the actual UTI as females
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are more likely to experience a UTI than males due to anatomic differences (30). To our

knowledge, our study is the first network meta-analysis comparing all three types of
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postoperative catheterization with more contemporary data exclusively from RCTs.

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Conclusions:
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Contrary to the conventional wisdom, TUC is not associated with increased UTI risks

compared to SPT and IC if duration of catheterization is less than five days. SPT or IC are
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associated with lower rates of UTI if longer term catheterization is expected in postoperative
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periods.
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2. L. Lamonerie, E. Marret, A. Deleuze, et al. Prevalence of postoperative bladder

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distension and urinary retention detected by ultrasound measurement. British Journal of

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3. Niël-Weise BS, van den Broek PJ. Urinary catheter policies for short-term bladder

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4. Ahluwalia RS, Johal N, Kouriefs C, et al. The surgical risk of suprapubic catheter

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5. van den Brand I, Castelein RM. Total joint arthroplasty and incidence of postoperative
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6. Knight RM, Pellegrini Jr VD. Bladder management after total joint arthroplasty. Journal

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7. Hakvoort RA, Thijs SD, Bouwmeester FW, et al. Comparing clean intermittent
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8. van den Brand IC, Castelein RM. Total join arthroplasty and incidence of postoperative

bacteriuria with an indwelling catheter or intermittent catheterization with one-dose

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antibiotic prophylaxis: a prospective randomized trial. J Arthroplasty. 2001;16(7):850-

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9. Dobbs SP, Jackson SR, Wilson AM, et al. A prospective randomized trial comparing

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continuous bladder drainage with catheterization at abdominal hysterectomy. Br J Urol.

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10. Dixon L, Dolan LM, Brown K, et al. RCT of urethral versus suprapubic catheterization.

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Br J Nurs. 2010;19(18):S7-13.

11. Jannelli ML, Wu JM, Plunkett LW, et al. A randomized controlled trial of clean

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intermittent self-catheterization versus suprapubic catheterization after urogynecologic
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surgery. Am J Obstet Gynecol. 2007;197(1):72 e1-4.

12. Naik R, Maughan K, Nordin A, et al. A prospective randomised controlled trial of

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intermittent self-catheterisation vs. supra-pubic catheterisation for post-operative bladder

care following radical hysterectomy. Gynecol Oncol. 2005;99(2):437-442.

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13. Stekkinger E, van der Linden PJ. A Comparison of suprapubic and transurethral
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catheterization on postoperative urinary retention after vaginal prolapse repair: a

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randomized controlled trial. Gynecol Obstet Invest. 2011;72(2):109-116.

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versus transurethral catheterization after abdominal surgery on urinary tract infection: a

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randomized controlled trial. Dig Surg. 2003;20(4):290-295.

15. Ratnaval CD, Renwick P, Farouk R, et al. Suprapubic versus transurethral catheterisation

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16. Nwabineli NJ, Walsh DJ, Davis JA. Urinary drainage following radical hysterectomy for

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17. Schiotz HA, Malme PA, Tanbo TG. Urinary tract infections and asymptomatic

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18. Anderson JT, Heisterberg L, Hebjorn S, et al. Suprapubic versus transurethral bladder

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1985;64(2):139-143.
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19. Harms E, Christmann U, Klock FK. [Suprapubic urinary diversion following gynecologic

operations]. Geburstshilfe Frauenheilkd. 1985;45(4):254-260.

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20. Kidd EA, Stewart F, Kassis NC, et al. Urethral (indwelling or intermittent) or suprapubic

routes for short-term catheterisation in hospitalised adults. Cochrane Database Syst Rev.
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2015;10:12-CD004203.
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21. Grabe M, R Bartoletti, Bjerklund-Johansen TE, et al. Guidelines on urological infections.

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European Association of Urology Website. 2015. 5/22/2016.

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urinary tract infections: definitions and significance in the urological patient. Urology
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Practice. 2015;2(6):321-328.

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revisions to definitions 9-1-95. In: Managerial I Site Operations Manual St. Louis, MO:

St. Louis Continuing Education Center. 1995.

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24. Press MJ, Metlay JP. Catheter-associated urinary tract infection: does changing the

definition change quality? Infect Control Hosp Epidemiol. 2013;34(3):313-315.

25. Cope M, Cevallos ME, Cadle RM, et al. Inappropriate treatment of catheter-associated

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asymptomatic bacteriuria in a tertiary care hospital. Clin Infect Dis. 2009;48(9):1182–

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26. Li T, Puhan mA, Vedula SS, et al. Network meta-analysis-highly attractive but more

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methodological research is needed. BMC Med. 2011;9:79.

27. Hendren S, Urinary catheter management. Clinics in Colon and Rectal Surgery.

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2013;26(3):178-181.
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28. Crouzet J, Bertrand X, Venier AG, et al. Control of the duration of urinary catheterization:

impact on catheter-associated urinary tract infection. J Hosp Infect. 2007;3:253-257.

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29. Mahid SS, Hornung CA, Minor KS, et al. Systematic reviews and meta-analysis for the

surgeon scientist. Br J Surg. 2006;93:1315-1324.

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30. Magliano E, Grazioli V, Deflorio L, et al. Gender and age-dependant etiology of

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community-acquired urinary tract infections. Scientific World Journal. 2012; Article ID

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Figure 1: The Study Design.

Figure 2: Forest Plot Comparing the Catheterization Types.

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Figure 3: Forest Plot Comparing the Catheterization Types Based on the Duration of Catheterization.

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Table 1: Summary of the Included Studies.

Study Comparison of Surgical Jadad

Study Period catheterization Procedure n Inclusion Criteria Score

Patients >18 years with

Hakvoort vaginal prolapsed and never

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et al. (7) 2011 IC vs TUC POP Repair 87 been catheterized 1

van den
Brand et al. Patients who received

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(8) 2001 IC vs TUC THA/TKA 99 THA/TKA 3

Patients needing

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Dobbs et hysterectomy for non-
al. (9) 1997 IC vs TUC TAH 95 oncologic reasons 4

Knight et Patients who received

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al. (6) 1996 IC vs TUC THA/TKA 119 THA/TKA 3
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Dixon et al. Patients with POP/stress
(10) 2010 SPT vs IC POP Repair 72 incontinence 3

Jannelli et Patients with POP/stress

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al. (11) 2007 SPT vs IC POP Repair 210 incontinence 3

Patients needing
Naik et al. Radical hysterectomy for oncologic
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(12) 2005 SPT vs IC Hysterectomy 36 reasons. 3

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Stekkinger
et al. (13) 2011 TUC vs SPT POP Repair 126 Patients with POP 3

Any patients needing

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hepatobiliary surgery,
esophageal surgery, colon
Baan et al. Elective
2003 TUC vs SPT 146 surgery, gastric surgery, 3
(14) Laparotomy
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central vascular surgery, or

other major abdominal
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surgeries

Ratnaval et Colorectal Patients needing pelvic

al. (15) 1996 TUC vs SPT Surgery 50 colorectal surgery 3

Patients needing
Nwabineli Radical hysterectomy for oncologic
et al. (16) 1993 TUC vs SPT Hysterectomy 24 reasons. 3

1989 TUC vs SPT Vaginal 78 2

Schiotz et Plastic Patients needing vaginal
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al. (17) Surgery plastic surgery

Andersen SUI/POP Patients with POP/stress

et al. (18) 1985 TUC vs SPT Surgery 92 incontinence 3

Patients needing
Harms et Vaginal hysterectomy for non-

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al. (19) 1985 TUC vs SPT Hysterectomy 157 oncologic reasons N/A

IC: intermittent catheterization; TUC: transurethral catheterization; SPT: Suprapubic tube

catheterization; POP: pelvic organ prolapsed; SUI: Stress urinary incontinence; THA: Total hip

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arthroplasty; TKA: Total knee arthroplasty; TAH: Total abdominal hysterectomy.

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Table 2: Urinary Tract Infection Rate and Duration of Catheterization in Each Study.

Average Length of
Catheterization Therapy UTI Rate

Comparison of n Mean TUC SPT IC

Study catheterization (male:female) Age (days) (days) (days) TUC SPT IC

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Hakvoort et
al. (7) IC vs TUC 87 (0:87) 66 3 0.75 13 5

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van den
Brand et al.
(8) IC vs TUC 99 (27:72) 68 46 53 11 3

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Dobbs et al.
(9) IC vs TUC 95 (0:95) 44 2.04 2.51 6 14

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Knight et al.
(6) IC vs TUC 119 (57:62) 66 2.13 2.34 5 7
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Dixon et al.
(10) SPT vs IC 72 (0:72) N/A 5 4 10 6
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Jannelli et al.
(11) SPT vs IC 210 (0:210) 55 5.2 5.3 26 30

Naik et al.
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(12) SPT vs IC 36 (0:36) 45 20 17 4 20

TE

Stekkinger et
al. (13) TUC vs SPT 126 (0:126) N/A 62 64 6 5

Baan et al.
EP

(14) TUC vs SPT 146 (82:64) 60 5.9 6.5 8 8

Ratnaval et al.
(15) TUC vs SPT 50 (50:0) 66 7.5 7.2 2 1
C

Nwabineli et
AC

al. (16) TUC vs SPT 24 (0:24) 44 16.5 13.1 13 7

Schiotz et al.
(17) TUC vs SPT 78 (0:78) N/A 3.3 4.9 9 11

61
Andersen et (med
al. (18) TUC vs SPT 92 (0:92) ian) 5 3.7 20 10
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Harms et al.
(19) TUC vs SPT 157 (0:157) N/A 7.35 5.2 46 18

IC: intermittent catheterization; TUC: transurethral catheterization; SPT: Suprapubic tube

catheterization

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Table 3: Network Meta-Analysis of the Catheterization Types.

Comparison OR (95% C.I.)

IC vs. TUC 0.565 [0.252, 1.267]

SPT vs. TUC 0.51 [0.255, 1.023]

PT
IC vs. SPT 1.107 [0.479, 2.555]

Variance between 0.685

RI
studies

I2 69%

SC
Q 38.69

Ranking SPT> IC> TUC

U
IC: intermittent catheterization; TUC: transurethral catheterization; SPT: Suprapubic tube catheterization;
OR: Odds ratio; C.I.: Confidence interval; Q: Cochran’s Q test; I2: I2 Index
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Table 4: Duration of Catheterization in the Subgroup Analysis.

DOC ≤ 5 days Mean durations DOC > 5 days Mean durations
(IC, TUC) (IC, TUC)
Hakvoort (2011); IC (0.75, 3) days Jannelli (2007); IC (5.3, 5.2) days
vs. TUC vs. SPT
Dobbs (1997); IC vs. (2.51, 2.04) days Naik (2005); IC vs. (17, 20) days

PT
TUC SPT
Knight (1996); IC vs. (2.34, 2.13) days Ratnaval (1996); (7.2, 7.5) days
TUC SPT vs. TUC
Dixon (2010); IC vs. (4, 5) days Nwabineli (1993); (13.1, 16.5) days

RI
SPT SPT vs. TUC
Schiotz (1989); SPT (4.9, 3.3) days Harms (1985); SPT (5.2, 7.35) days
vs. TUC vs. TUC

SC
DOC: Duration of catheterization; IC: intermittent catheterization; TUC: transurethral catheterization;
SPT: Suprapubic tube catheterization

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Table 5: Network Meta-Analysis of the Catheterization Types Based on the Duration of

Catheterization.
DOC ≤ 5 days DOC > 5 days
OR (95% C.I) OR (95% C.I.)
IC vs. TUC 1.021 [0.346, 3.014] IC vs. TUC 0.173 [0.073, 0.412]
SPT vs. TUC 1.537 [0.34, 6.943] SPT vs. TUC 0.142 [0.073, 0.276]

PT
IC vs. SPT 0.664 [0.145, 3.037] IC vs. SPT 1.218 [0.697, 2.126]
Variance 0.737 Variance <0.0001
between-studies between-studies
I2 69.4% I2 0%

RI
Q 9.8 Q 2.53
Ranking TUC, IC, SPT Ranking SPT, IC, TUC
DOC: Duration of catheterization; IC: intermittent catheterization; TUC: transurethral catheterization;

SC
SPT: Suprapubic tube catheterization; OR: Odds ratio; C.I.: Confidence interval; Q: Cochran’s Q test; I2:
I2 Index

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Abbreviations

RCT: randomized controlled trial

DOC: duration of catheterization
UTI: urinary tract infection
CAUTI: catheter associated urinary tract infection
ASB: asymptomatic bacteriuria

PT
IC: intermittent catheterization
TUC: transurethral catheterization
SPT: suprapubic tube catheterization
POP: pelvic organ prolapsed

RI
SUI: Stress urinary incontinence
THA: Total hip arthroplasty
TKA: Total knee arthroplasty

SC
TAH: Total abdominal hysterectomy
Q: Cochran’s Q test
I2: I2 Index
OR: Odds ratio

U
C.I.: Confidence interval AN
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C EP
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