TUGAS KEPERAWATAN DASAR PROFESI

LAMPIRAN ARTIKEL JURNAL PADA GANGGUAN PEMENUHAN

ELIMINASI URINE

DOSEN PEMBIMBING
ABBASIAH, SKM, M.Kep

DISUSUN OLEH

YULIAWATI YUSRI

PO 71.20.22.000.26

PROGRAM STUDI PROFESI NERS JURUSAN KEPERAWATAN

POLITEKNIK KESEHATAN KEMENKES JAMBI
TAHUN 2020
 Nursing Arts
Vol XIII,
Nursing Arts,No 02, Desember
Vol.XIII, 2019
No 02, Desember
ISSN: 1978-6298 (Print), 2686-133X (Online)

PERBEDAAN PEMASANGAN KATETER DENGAN MENGGUNAKAN

JELLY YANG DIMASUKKAN URETRA DAN JELLY YANG
DIOLESKAN DI KATETER TERHADAP TINGKAT NYERI PASIEN
1
Oktovina Mobalen, 2Tansar, 3Yehud Maryen
1,2,3
Politeknik Kesehatan Kemenkes Sorong
email:omobalen@gmail.com

Artikel History
Dikirim, Desember 13th, 2019
Ditinjau, Desember 16th, 2019
Diterima, Desember 19th, 2019

ABSTRACT
Elimination is one of the fulfillment of human physiological needs. Disruption of elimination indicates
the occurrence of interference on the part of the urinary system, causing an inconvenience in daily life
and can interfere the activity. Urinary catheter is an invasive procedure that putting a tube into the
bladder which aims to help out the urine. This action can save lives, especially when the urinary tract is
blocked or the patient is unable to urinate. This study was conducted to determine the comparison of
pain response in male urinary catheterization procedures with applicating the jelly on the catheter
technique and spraying directly into the urethra. This study is a kind of experiment using quasi-
experimental design. Total sample of 30 respondents conducted by kuota sampling. The analysis of this
study used the mann-whitney test, the results of the study showed that there was a significant difference
between the jelly that was inserted with the dilethra and the jelly applied to the catheter to the level of
the patient's pain.
Keywords: Catheterization, Jelly, Pain Response

ABSTRAK
Eliminasi merupakan salah satu pemenuhan kebutuhan fisologis manusia. Terganggunya
eliminasi menandakan terjadinya gangguan pada bagian sistem perkemihan sehingga
menimbulkan ketidaknyamanan dalam kehidupan sehari – hari dan dapat mengganggu
aktivitas.Pemasangan kateter urin merupakan suatu tindakan invasif dengan memasukkan
selang ke dalam kandung kemih yang mana bertujuan untuk membantu dalam mengeluarkan
urin.Tindakan ini dapat menyelamatkan kehidupan, khususnya bila saluran kemih tersumbat
atau pasien tidak dapat melakukan pengeluaran urin. Penelitian ini dilakukan untuk
mengetahui perbandingan respon nyeri pada prosedur kateterisasi urin pria dengan teknik
pengolesan jelly pada kateter dan penyemprotan jelly langsung ke dalam urethra. Jenis
penelitian adalah eksperimen dengan desain quasi eksperimen. Jumlah sampel 30 responden
yang dilakukan dengan kuota sampling. Analisa penelitian ini menggunakan uji mann-whitney,
hasil penelitian menunjukkan ada perbedaan yang bermakna antara jelly yang dimasukan
diuretra dan jelly yang dioleskan di kateter terhadap tingkat nyeri pasien.
Kata Kunci: Kateterisasi, Jelly, Respon Nyeri
Nursing Arts, Vol.XIII, No 02, Desember 2019

PENDAHULUAN
Eliminasi merupakan salah satu mencapai 13 juta dengan 85 persen diantaranya
pemenuhan kebutuhan fisologis laki-laki. Jumlah ini sebenarnya masih sangat
manusia.Terganggunya eliminasi menandakan sedikit dari kondisi sebenarnya, sebab masih
terjadinya gangguan pada bagian sistem banyak kasus yang tidak dilaporkan 3.
perkemihan baik karena cidera ataupun penyakit Lebih dari 30 juta kateterisasi urin
seperti retensi urin, batu ginjal, inkonentsia urin, dilakukan setiap tahun di Amerika Serikat, yaitu
atau BPH (benigna prostat hipertropi) sehingga berkisar 10% pada pasien akut dan 7,5% sampai
menimbulkan ketidaknyamanan dalam kehidupan dengan 10% pada pasien yang memerlukan
sehari – hari dan dapat mengganggu fasilitas perawatan jangka panjang, angka ini
aktivitas.Pentingnya eliminasi atau pengeluaran diperkirakan akan meningkat hingga mencapai
urin dengan lancar, salah satu tindakan 25%. Banyak alasan yang membuat peningkatan
keperawatan kolaborasi yang sering dilakukan tindakan kateterisasi urin, mencakup kompleksitas
perawat di rumah sakit yang berkaitan dengan perawatan dan tingkat keparahan penyakit 4.
pemenuhan kebutuhan eliminasi adalah Di Indonesia sekitar 5,8 persen penduduk
pemasangan kateter1. Indonesia menderita inkontinensia urin. Jika
Dalam prosedur tetap tindakan dibandingkan dengan negara-negara Eropa, angka
pemasangan kateter dapat dilakukan oleh petugas ini termasuk kecil. Hasil survey yang dilakukan di
kesehatan yaitu Dokter dan Perawat. Sebagai rumah sakit-rumah sakit menunjukkan, penderita
seorang Petugas Kesehatan khususnya Perawat inkontinesia di seluruh Indonesia mencapai 4,7
diharapkan dalam melakukan suatu tindakan dapat persen atau sekitar 5-7 juta penduduk dan enam
memahami dan mengerti betul tentang anatomi, puluh persen diantaranya adalah laki-laki. Meski
teknik komplikasi / risiko dari suatu tindakan tidak berbahaya, namun gangguan ini tentu sangat
termasuk2. mengganggu dan atau depresi pada sehingga
Kateterisasi urin merupakan salah satu menimbulkan rasa rendah diri membuat malu,
tindakan untuk membantu eliminasi urin maupun penderitanya 5.
ketidakmampuan melakukan urinasi. Banyak klien Pada survei pendahuluan yang dilakukan oleh
merasakan cemas, takut akan rasa nyeri dan penulis pada tanggal 05 mey 2017 di dapatkan
ketidaknyamanan dalam menghadapi kateterisasi pasien yang mengunakan kateter di RSUD Sele Be
urin. Mereka terlihat emosional menghadapi Solu Kota Sorong sebesar 90 orang per 3 bulan,
tindakan-tindakan pengobatan maupun perawatan, dari Bulan Januari, Ferbuari dan Maret 2017.
terlebih yang berhubungan dengan daerah Untuk mengurangi nyeri saat pemasangan
urogenital yaitu saat kateter menembus masuk ke kateter urin adalah dengan menggunakan jelly
dalam tubuh2. pelumas. Ada dua alternatif dalam penggunaan
Menurut data dari WHO, 200 juta jelly pelumas, yang pertama dengan mengolesi
penduduk dunia mengalami inkontinensia urin. Di jelly pada selang kateter di sepanjang selang yang
Amerika Serikat, jumlah penderita inkontinensia akan dimasukkan ke dalam urethra setelah diukur,
111 Nursing Arts, Vol. XIV, Nomor 1, Juni 2019, hlm:

dan yang kedua dengan memasukkan jelly pada

uretra di Instalasi Gawat Darurat RSU Prif. R.D
urethra dengan menggunakan spuit5.
kandou Manado sebagai besar mengalami nyeri
Dari kedua alternatif tersebut, tampaknya
berat 86,7 % dan sisa dalam kategori berat (13,3).
alternatif pertama masih menjadi primadona dalam
Sedangkan tingkat nyeri pasien yang di pasangan
prosedur pemasangan kateter di rumah sakit.
kateter dengan jelly yang di oleskan pada kateter
Berbeda dengan Ferdinan .dkk (2003)6, bahwa cara
di Instalasi Gawat Darurat RSU Prif. R.D kandou
memasukkan jelly langsung ke dalam uretra dapat
Manadosebagaia besar mengalami nyeri sedang
memengaruhi kecepatan dalam pemasangan selang
66,7 % dan sisanya dalam kategori sedang.
kateter sehingga dapat mengurangi iritasi pada
Garbutt, David, Victor, & Michael
dinding uretra akibat dari pergesekan dengan
(2012)9, kateterisasi urin termasuk dalam empat
selang kateter dibandingkan dengan cara
besar sebagai prosedur yang paling menimbulkan
pelumasan jelly pada kateter.
nyeri selama masa perawatan di rumah sakit.
Berdasarkan hasil studi mengenai dampak
Sekitar 32% dari kateterisasi urin menyebabkan
kateterisasi urin pada laki-laki terhadap respon
trauma iatrogenik, dari jumlah tersebut 52%
nyeri yang dialami, diketahui bahwa 86,7% dari 15
mempengaruhi uretra bulbar dan atau prostatik
pasien yang menjalani kateterisasi urin dengan
(Djakovic, Plas, Martínez, & Lynch, 2012).
jelly biasa yang dimasukkan ke uretra mengalami
Komplikasi dari kateterisasi urin menyebabkan
nyeri dengan kategori sedang dan 13,3%
ketidak- mampuan melakukan perawatan diri dan
mengalami nyeri kategori berat, sementara dari 15
mempengaruhi kualitas hidup individu.
pasien yang menjalani kateterisasi urin dengan
Melihat fenomena tersebut, peneliti
jelly yang dioleskan ke selang kateter 66,7%
tertarik untuk mengetahui apakah ada
diantaranya mengalami nyeri kategori berat dan
perbandingan respon nyeri pada prosedur
33,3% mengalami nyeri kategori sangat berat
kateterisasi urin pria dengan teknik pengolesan
(Riadiono, Handoyo, & Dina, 2008). Pada studi
jelly pada kateter dan penyemprotan jelly langsung
lain dari 25 pasien laki-laki yang menjalani
ke dalam uretra1.
tindakan kateterisasi urin 52% mengalami nyeri
METODE
kategori sedang dan 12% mengalami nyeri
Desain penelitian ini adalah quasi
kategori berat7.
eksperiment, jumlah sampel sebanyak 30
Berbeda dengan penelitian (Frenky Tahun
menggunakan tekniksampel accidental sampling.
2012)8 dengan judul yang sama meneliti di kota
Data dianilis menggunakan uji independent T-
Manado di RSU Prof. Dr. R.D kandou Manado
Test. Lokasi penelitian dilakukan di RSUD Sele
mengatakan tingkat nyeri pasien yang di
Be Solu Kota Sorong Pada bulan agustus Tahun
pasangkan kateter dengan jelly yang di masukan
2017.
112 Nursing Arts, Vol. XIV, Nomor 1, Juni 2019, hlm:

HASIL
Univariat
Tabel 1. Distriusi Responden Berdasarkan Waktu Yang Di Rasakan Nyeri

No Waktu rasa nyeri Frekwensi Presentasi

1 Saat di masukan 28 93.33 %
2 Setelah di masukan 2 6.67 %

Berdasarkan tabel 1 maka dapat yang dirasakan nyeri saat di masukan yaitu
diketahui bahwa responden penelitian sebanyak 28 orang atau 93.33 %.
didominasi oleh responden dengan waktu

Tabel 2. Distriusi Responden Berdasarkan Waktu Yang Di Rasakan Nyeri

No Waktu rasa nyeri Frekwensi Presentasi

1 Saat di masukan 28 93.33 %

2 Setelah di masukan 2 6.67 %

Berdasarkan tabel 2, maka dapat yang dirasakan nyeri saat di masukan yaitu
diketahui bahwa responden penelitian sebanyak 28 orang atau 93.33 %.
didominasi oleh responden dengan waktu

Tabel 3.Distribusi Responden Berdasarkan Durasi Nyeri

No Durasi Frekwensi Presentasi

1 < 5 menit 27 90 %
2 ≥ 5 menit 3 10 %
Berdasarkan tabel 3 maka dapat nyeri kurang dari 5 menit yaitu sebanyak 27
diketahui bahwa responden penelitian orang atau 90 %.
didominasi oleh responden dengan durasi

Tabel 4. Distribusi Responden Berdasarkan kualitas Nyeri

No Kualitas nyeri Frekwensi Presentasi
1 Hilang Timbul 28 93.33
2 Terus Menerus 2 6.67
Nursing Arts, Vol.XIII, No 02, Desember 2019

Berdasarkan tabel 4 maka dapat nyeri hilang timbul yaitu sebanyak 28 orang
diketahui bahwa responden penelitian atau 93.33 %.
didominasi oleh responden dengan kualitas
Bivariat
Tabel 5. Hasil Analsis Bivariat
NO Teknik pemasngan n Mean Rank Sun of Ranks

1 Jelly yang dimasukan diuretra 15 12.00 180.00

2 Jelly yangdioleskan 15 19.00 285.00
Total 30
Asymp. Sig (2-tailed) .027
Berdasarkan hasil uji statistik dengan
Untuk mengetahui perbedaan
tingkat kepercayaan 95%, df:3, a = 0,05
pemasangan kateter dengan mengunakan
didapatkan hasil r = 0,027. Ini berarti, r < a
jelly yang dimasukkan diuretra dan jelly
(0,27<0,05). Jika r < a, maka Ha diterima
yang di oleskan di kateter terhadap respon
dan Ho ditolak. Kesimpulan yang didapat
nyeri dilakukan uji statistik mann-whitney
yaitu ada perbedaan yang bermakna antara
dengan bantuan komputer program SPSS
jelly yang dimasukan diuretra dan jelly
for windows versi 16.
yang dioleskan di kateter terhadap tingkat
nyeri pasien.
PEMBAHASAN perbedaan antara kateter mengunakan jelly yang
Hasil penelitian menunjukan bahwa ada
di masukan diuretra dan jelly yang di oleskan di
perbedaan antara pemasangan kateter
kateter terhadap tingkat nyeri pasien.
mengunakan jelly yang di masukan diuretra dan
Penelitian ini berbeda disebabkan
jelly yang di oleskan di kateter terhadap tingkat
riadiono mengunakan jelly dengan jumlah 2 cc
nyeri pasien di RSUD Sele Be Solu Kota
Dari jelly yang di gunaka peneliti mengunakan
Sorong. Penelitian ini sama dengan hasil
3- 3,5 cc jelly yang di ukur di dispo ini untuk
penelitian Franky R, (2014)10 bahwa ada
mencegah terjadinya pada saat diseprotkan pada
perbedaan antara pemasangan kateter kateter
uretra akan mengalami kerfluk keluar
mengunakan jelly yang di masukan diuretra dan
sedangkan peneliti Riadiono mengunakan jelly
jelly yang di oleskan di kateter terhadap tingkat
lebih sedikit yaitu 2 cc, jika jelly yang di
nyeri pasien, dan berbeda dengan hasil
masukan sedikit akan merasang nyeri11.
penelitian oleh Riadiono bahwa tidak ada
Nyeri merupakan pengalaman sensorik kerusakan jaringan, baik aktual maupun
dan emosional yang tidak menyenangkan akibat potensial, atau yang digambarkan dalam bentuk
114 Nursing Arts, Vol. XIV, Nomor 1, Juni 2019, hlm:

kerusakan tersebut. Sedangkan The

diasumsikan bahwa seluruh dinding uretra pada
International Association for the Study of Pain
pria sepanjang 12-17 cm telah telumuri jeli
(IASP) mendefinisikan nyeri sebagai
sebelum kateter dimasukkan. Sehingga
pengalaman sensorik dan emosional yang tidak
meminimalkan terjadinya pergesekan antara
menyenangkan terkait dengan kerusakan
dinding uretra dengan kateter yang akan
jaringan baik aktual maupun potensial atau yang
meminimalkan efek nyeri. Selain itu jumlah jeli
digambarkan dalam kerusakan tersebut. Kedua
yang masuk dalam uretra juga terukur untuk
pengertian ini memperjelas bahwa nyeri adalah
semua responden. Sedangkan bila menggunakan
bagian dari proses patologis2.
jeli yang dilumurkan pada kateter yang akan
Tindakan kateterisasai merupakan
dipasang, kemungkinan jumlah jeli yang
tindakan invasif dan dapat menimbulkan rasa
digunakan dan panjang kateter yang dilumuri
nyeri sehingga jika dikerjakan secara keliru
jeli antar sesama perawat yang akan memasang
akan menimbulkan kerusakan urethra. Nyeri
kateter relative tidak sama, hal ini akan
merupakan keluhan utama yang sering dialami
mengakibatkan respon nyeri klien yang
oleh pasien dengan kateterisasi urin karena
berbeda-beda.
tindakan memasukkan selang kateter dalam
Ini dapat dilihat dari banyak factor yang
kandung kemih mempunyai resiko terjadinya
mengakibatkan nyeri salah satunya adalah usia
infeksi atau trauma pada urethra12.
dapat dilihat saat peneliti meneliti usia 56
Risiko trauma berupa iritasi pada
sampai 65 sedikit yang mengalami nyeri hal ini
dinding urethra lebih sering terjadi pada pria
sesuai dengan teori yang dikemukakan Zatzick
karena keadaan urethranya yang lebih panjang
& Dimsdale (2010)13 bahwa dewasa tua akan
dan berliku-liku dari pada wanita serta
memiliki intensitas nyeri lebih rendah
membran mukosa yang melapisi dinding uretra
dibandingkan dengan usia sebelumnya. Hal ini
sangat mudah rusak oleh pergesekan akibat
terjadi karena dewasa memiliki pengalaman
dimasukkannya selang kateter Pada pasien pria,
lebih banyak terhadap berbagai rasa nyeri yang
teradapat dua alternatif penggunaan jelly
pernah dialaminya, selain itu dewasa tua sudah
pelumas. Yang pertama dengan mengolesi jelly
lebih baik dalam mengungkapkan perasaan
pada selang kateter di sepanjang selang yang
nyeri yang dialaminya secara verbal.
akan dimasukkan ke dalam urethra setelah
Cara memasukkan jeli langsung ke
diukur, dan yang kedua dengan memasukkan
dalam uretra dapat mempengaruhi kecepatan
jelly pada meatus urethra dengan menggunakan
pemasangan kateter sehingga mengurangi
spuit12.
tingkat iritasi pada dinding uretra akibat
Terkadang saat selang kateter
pergesekan dengan kateter bila dibandingkan
dimasukkan, banyak jeli yang tertinggal atau
dengan cara pelumasan dengan melumuri jeli
bahkan keluar sebelum selang kateter tersebut
pada ujung kateter (Ferdinan, Pahria, 2003) 14.
tuntas dimasukkan. Upaya memasukkan jeli 3-
Iritasi jaringan atau nekrosis dapat juga
3,5 cc terlebih dahulu ke dalam uretra
diakibatkan oleh pemakaian kateter yang
115 Nursing Arts, Vol. XIV, Nomor 1, Juni 2019, hlm:
ukurannya tidak sesuai besarnya orifisium
uretra, kurangnya pemakaian jeli, penekanan
yang berlebihan, misalnya memfiksasi terlalu
SIMPULAN
Bedasarkan hasil penelitian dan
pembahasan tentang perbedaan pemasangan
kateter mengunakan jelly yang yang di masukan
diuretra dan jelly yang dioleskan dikateter
terhadap tingkat nyeri, maka penulis dapat
UCAPAN TERIMA KASIH
Terimakasih peneliti ucapkan kepada
direktur RSUD Sele Be Solu Kota Sorong yang
DAFTAR RUJUKAN
1. Dorhorty, (2006). Hubungan Pemasangan
Kateter Dengan Kejadian Infeksi
Saluran Kemih Dan Terjadinya
Bakteri Di urin. Skripsi
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36.
2. Esho, (2014). teknik pemasangan kateter
mengunakan jelly yang dimasuk di
uretra dan yang di oleskan di kateter
terhadap respon nyeri pasien.
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metode manajemen nyeri.
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terlalu sering dapat merusak jaringan kulit.
simpulkan ada perbedaan antara pemsangan
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masukan diuretra dan jelly yang dioleskan
dikateter terhadap tingkat nyeri di RSUD Sele
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www.joannabriggs.edu.au pada
tanggal 10 mei 2014. Respon, P.,
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Studi Keperawatan.
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J., Universitas, F., & Soedirman, J.
(2008). Jurnal Keperawatan
Soedirman (The Soedirman Journal
of Nursing), Volume 3 No.2 Juli
2008, 3(2), 95–100.
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manajemen nyeri. Keperawatan
Gawat Darurat Dan Menajen Nyeri,
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116 Nursing Arts, Vol. XIV, Nomor 1, Juni 2019, hlm:

10. Risnawati (2014) buku saku 18. Sari, M. (2015). buku saku eliminasi
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 Open Access Original
Article DOI: 10.7759/cureus.5494

Prevalence of Catheter-Associated Urinary Tract

Infections in Neurosurgical Intensive
Care Patients – The Overdiagnosis of
Urinary Tract Infections
Stacey Podkovik 1 , Harjyot Toor 1 , Maya Gattupalli 2 , Samir Kashyap 1 , James Brazdzionis 1 , Tye
Patchana 1
, Sruthi Bonda 2 , Serena Wong 3 , Christine Kang 2 , Kevin Mo 4 , Margaret Rose Wacker 5 , Dan E. Miulli 1 ,
Sharon Wang 6

1. Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA 2.
Neurosurgery, Touro University College of Osteopathic Medicine California, Vallejo, USA 3.
Neurosurgery, St. George's University School of Medicine, St. George's, GRD 4. Neurosurgery, Western
University of Health Sciences, Pomona, USA 5. Neurosurgery, Arrowhead Regional Medical Center,
Colton, USA 6. Infectious Disease, Arrowhead Regional Medical Center, Colton, USA

 Corresponding author: Stacey Podkovik,

s.podkovik@ruhealth.org Disclosures can be found in Additional
Information at the end of the article

Abstract
Background: Hospital-acquired infections (HAIs) are profound
causes of prolonged hospital stay and worse patient outcomes.
HAIs pose serious risks, particularly in neurosurgical patients in
the intensive care unit, as these patients are seldom able to
express symptoms of infection, with only elevated temperatures
as the initial symptom. Data from Center for Disease Control
(CDC) and the Infectious Disease Society of America (IDSA)
have shown that of all HAIs, urinary tract infections (UTIs) have
been grossly over-reported,
resulting in excessive and unnecessary antibiotic usage.

Methods: We conducted a retrospective analysis of 686 adult

patients that were evaluated by the neurosurgery service at
Arrowhead Regional Medical Center between July 2018 and
March 2019. Inclusion criteria were adults greater than 18 years
of age with neurosurgical pathology requiring a minimum of one
full day admission to the intensive care unit (ICU), and an
indwelling urinary catheter. Exclusion criteria were patients
under the age of 18, those who did not spend any time in the
ICU, or with renal pathologies such as renal failure.

Received 06/25/2019 Review began 08/06/2019 Review ended 08/07/2019 Published 08/26/2019
© Copyright 2019
Podkovik et al. This is an open access
Majority of the patients with an elevated temperature had an infectious
article distributed under the terms of the
Creative Commons Attribution License
source other than urine, such as sputum (22 out of 42, 52.38%), blood
CC- BY 3.0., which permits unrestricted
use, distribution, and reproduction in
(three out of 42, 7.14%) or CSF (one out of 42, 2.38%). We were able
any medium, provided the original
author and source are credited.
to find only two individuals (4.76%) with a positive urine culture and
Results: We no evidence of other positive cultures or deep vein thrombosis.
reviewed 686
Conclusions: Our analysis shows evidence to support the newest
patients from the
IDSA guidelines that patients with elevated temperatures should
neurosurgical
have a clinical workup of all alternative etiologies prior to
census. In total, 146 testing for a urinary source unless the clinical suspicion is high.
adult patients with This will help reduce the rate of unnecessary urine cultures, the
indwelling urinary over- diagnosis of asymptomatic bacteriuria, and the overuse of
catheters were antibiotics. Based on our current findings, all potential sources
selected into the of fever should be ruled out prior to obtaining urinalysis, and
catheters should be removed as soon as they are not needed.
statistical analysis.
Most individuals Urinalysis with reflex to urine culture should be reserved for
spent an average of those cases where there remains a high index of clinical
suspicion for a urinary source.
8.91 ± 9.70 days in
the ICU and had an
Categories: Infectious Disease, Preventive Medicine, Neurosurgery
indwelling catheter Keywords: urinary catheters, urinalysis, neurosurgery, urinary tract infections, intensive care units, fever,
catheters, indwelling, temperature
for approximately
8.14 ± 7.95 days.
Introduction
Forty-two out of
Catheter-associated urinary tract infections (CAUTI) continue
the 146 individuals
to be among the most common healthcare- associated
were found to have infections in the United States. In 2011, there were an
a temperature of estimated two cases of CAUTIs per 1000 hospital indwelling
100.4°F or higher. catheter days in US acute care hospitals [1]. CAUTIs can lead
to more serious

How to cite this article

Podkovik S, Toor H, Gattupalli M, et al. (August 26, 2019) Prevalence of Catheter-Associated
Urinary Tract Infections in Neurosurgical Intensive Care Patients – The Overdiagnosis of Urinary
Tract Infections .
Cureus 11(8): e5494. DOI 10.7759/cureus.5494
 complications such as sepsis and endocarditis; it is estimated that over
13,000 deaths each year are associated with healthcare-associated
urinary tract infections (UTIs) [2]. Per the Infectious Disease Society
of America (IDSA), a CAUTI is defined by the following criteria:1)
indwelling urinary catheter for more than two days after insertion. 2)
one sign or symptom including fever, suprapubic tenderness,
costovertebral angle tenderness, urinary frequency or urgency or
dysuria and 3) urine culture with more than 105 colony forming units
(CFU)/mL of one bacterial species [2,3]. Patients with symptomatic
UTIs generally present with fever, chills, urinary urgency, suprapubic
tenderness, costovertebral angle tenderness, flank pain, altered mental
status (in those older than 65 years of age), hypotension, and
potentially, evidence of systemic inflammatory response syndrome
(SIRS) [2].

These infections and their resultant fevers can be especially

detrimental in patients with severe head and spine injury, who already
face high rates of morbidity and mortality. Diringer et al. evaluated
nearly 4300 patients in neurologic intensive care units (ICUs) and
found that elevated body temperatures were independently associated
with longer ICU and hospital stays, higher mortality rates, and worse
outcomes. This was second only to complications from patients’
primary reason for admission [4]. Many neurosurgical patients suffer
from systemic dysfunction due to their neurological injury that makes
them susceptible to infections. Many cannot provide an adequate
history to guide clinical decision making. Most patients require
indwelling urinary catheters for a prolonged time, fostering bacterial
colonization. Some may be on prophylactic antibiotics for other
reasons such as standard perioperative antibiotics, drain prophylaxis,
or other concurrent infection sources such as pneumonia. Such
antimicrobial drug therapy can be protective for a short duration but
can lead to the growth of multi-drug resistant organisms (MDRO)
including Pseudomonas species, yeast, and resistant gram-negative
bacilli. In addition, antibiotic use can lead to Clostridium difficile (C.
diff) infections. Our goal was to determine if the cases that were being
marked as CAUTIs at our hospital were due to true UTIs, or whether
they were due to non-indicated urine cultures. This would allow for
more accurate tailoring of infectious workup instead of culturing all
possible sources, leading to unnecessary antibiotic use.

Materials And Methods

Study design and population
We conducted a retrospective analysis of 686 adult patients evaluated by
the neurosurgery service at Arrowhead Regional Medical Center
(ARMC) (an academic, 450-bed, Level 2 trauma center) between July
2018 and March 2019, with approval of the Institutional Review Board
2019 Podkovik et al. Cureus 11(8): e5494. DOI 2 of
10.7759/cureus.5494
 (IRB). Definitions for determining UTI were based on the IDSA
guidelines. These guidelines state that for a patient to be diagnosed with
CAUTI, they must have had a catheter placed at minimum 48 hours prior
to the fever and have no alternative source of infection [3].

Inclusion criteria for the study were adults greater than 18 years of age
with a neurosurgical pathology requiring a minimum of one full day
admission to the ARMC ICU, and an indwelling urinary catheter for a
minimum of two days. Exclusion criteria for the study were patients
under the age of 18, those who did not spend any time in the ICU, or
with renal pathologies such as renal failure. Certain renal pathologies
can increase infectious risk or predispose to colonization, leading to
abnormal results when assessing infection due to indwelling catheters.

We only screened ICU patients because that is where the majority of

neurosurgical patients that have altered mentation preside. The initial
search was for patients with an indwelling urinary catheter, and then the
eligible patients were evaluated for their maximum temperatures (Tmax)
during their stay. We recorded the results of any cultures, including
blood, urine, sputum, and/or cerebrospinal fluid (CSF). The patient’s
urinalysis (UA) and any evidence of pyuria were also obtained. The
presenting pathologies were recorded for stratification purposes. Urinary
catheter infection was determined based upon a positive urine culture,
positive urinalysis, and no other coinciding positive cultures.

Statistical analysis
The data were gathered in the form of an excel spreadsheet with all
protected health information (PHI) removed prior to any statistical
analysis. A separate data key was kept on a separate secure internal
Arrowhead server in order to be able to match the data points to particular
patients if further analysis or research was indicated. Data analysis was
accomplished through IBM SPSS Statistics, Version 23.0. Pearson
correlation matrices were done to evaluate for any relationships within the
data. A Kaplan-Meier curve estimate was created to assess the chance of
neurosurgical ICU patients contracting a positive urine culture. A p-value
of ≤0.05 was used for determining statistical significance.

Results

2019 Podkovik et al. Cureus 11(8): e5494. DOI 3 of

10.7759/cureus.5494
We reviewed 686 patients from the neurosurgical census. In total, 146
adult patients with indwelling urinary catheters were selected for
statistical analyses, contributing to 1301 hospital ICU and 1189 catheter
days (Figure 1). There were 87 (59.6%) males and 59 (40.4%) females,
with an overall average age of 55.48 ± 21.65 years of age (Table 1).
There appeared to be a bimodal distribution in patients’ ages, with peaks
at approximately 25 and 65 years of age.

FIGURE 1: Pictorial representation of the patient selection process

Characteristic All Patients (n=146) Males (n=87) Females (n=59) p-value

Age (years)
Mean 55.48 ± 21.65 53.64 ± 22.18 58.19 ± 20.73 0.215

Days in ICU 0.955

Mean 8.91 ± 9.70 8.87 ± 9.44 8.97 ± 10.14

Median 5 7 5
Days of Indwelling Urinary Catheter 0.824

Mean 8.14 ± 7.95 8.02 ± 7.64 8.32 ± 8.44

Median 5 5 5

T-Max (ºF) 0.05

Mean 99.69 ± 1.42 99.87 ± 1.51 99.42 ± 1.26

Number of patients with T-Max ≥ 100ºF 42 (28.8%) 30 (34.5%) 12 (20.3%)

Presenting Pathology

IPH 27 (18.5%) 12 (13.8%) 15 (25.4%)

SDH 24 (16.4%) 17 (19.5%) 7 (11.9%)

Spine Fracture 18 (12.3%) 8 (9.2%) 10 (16.9%)

Intracranial Tumor 18 (12.3%) 10 (11.5%) 8 (13.6%)

Head Trauma 15 (10.3%) 10 (11.5%) 5 (8.5%)

Other 44 (30.1%) 30 (34.5%) 14 (23.7%)

TABLE 1: Demographics
ICU: intensive care unit; IPH: intraparenchymal hemorrhage; SDH: subdural hematomas

Most individuals spent an average of 8.91 ± 9.70 days in the ICU and had
an indwelling catheter for approximately 8.14 ± 7.95 days, with a median
of five days (Table 1). The most prevalent admitting diagnoses were
intraparenchymal hemorrhage (27 patients, 18.5%), subdural hematomas
(24 patients, 16.4%), and intracranial tumors (18 patients, 12.3%) (Table
1). The overall breakdown regarding the types of positive cultures within
the population is demonstrated in Table 2, with sputum as being the most
common source.
Characteristic All Patients (n=146) Males (n=87) Females (n=59)

Number of Positive Cultures

Urine 34 (23.3%) 14 (16.1%) 20 (33.9%)

Sputum 44 (30.1%) 26 (29.9%) 18 (30.5%)

Blood 10 (6.9%) 6 (6.9%) 4 (6.8%)

CSF 3 (2.1%) 1 (1.2%) 2 (3.4%)

Wound 1 (0.7%) -- 1 (1.7%)

TABLE 2: Frequencies of all positive cultures within the entire sample population

Forty -two out of 146 individuals were found to have a temperature of

100.4°F or greater (mean 99.69 ± 1.421ºF) (Figure 1). The majority of the
patients with an elevated temperature had an infectious source other than
urine, such as sputum (22 out of 42, 52.38%), blood (three out of 42,
7.14%) or CSF (one out of 42, 2.38%) (Table 3).

Characteristic All Patients (n=42) Males (n=30) Females (n=12)

Number of Positive Cultures in Febrile Patients

Urine 12 (28.6%) 6 (20.0%) 6 (50.0%)

Sputum 22 (52.4%) 15 (50.0%) 7 (58.3%)

Blood 3 (7.1%) 1 (3.3%) 2 (16.7%)

CSF 1 (2.4%) -- 1 (8.3%)

Wound -- -- --

TABLE 3: Frequencies of all positive cultures within only the febrile patients

Of these, we were able to find only two individuals (4.76%) with a

positive urine culture, and possible UTI, with no evidence of other
positive cultures or deep vein thrombosis (DVTs). However, these two
positive urine cultures were not true CAUTIs, as explained below. There
was a moderate correlation (r=.399, p- value<0.001) between the number
of days a urinary catheter was in place, and the maximum temperature
recorded for a patient. The Kaplan-Meier estimate indicates the chance
that an individual, of the total population of 146, will be free from a
positive urine culture at a certain number of indwelling catheter days;
with a 30-day infection-free rate of approximately 20% (Figure 2).
 FIGURE 2: Kaplan-Meier estimate depicting the cumulative proportion of negative urine

Discussion
Hospital-acquired infections, especially CAUTIs, are a significant
morbidity and mortality risk to the general inpatient hospital population.
This risk is increased by almost five to ten-fold in those admitted to the
ICU [5,6]. Risk factors found to be associated with CAUTIs are younger
adults (ages 0-17) and females when accounting for variations in their
underlying disease process [7]. Abulhasan et al. conducted a six-year
prospective analysis of neurologic and neurosurgical ICU patients and
found that they had documented CAUTIs at a rate of 3 to 5.3 infections
per 1000 urinary catheter-days [8]. Klevens et al. estimated that
approximately 13,000 deaths could be attributed to catheter-associated
UTIs yearly [2,7,9]. Every episode of a CAUTI has been estimated to cost
nearly $600 to diagnose and treat, contributing to nearly 131 million
dollars in annual nationwide costs [10].

Studies such as Puri et al. and Patel et al. demonstrated that the
prevalence of CAUTIs in neurosurgical and neurology patients is around
8-10%, with a mean of 8.5 to 12.5 infections per 1000 catheter days [11-
13].
O’Shea et al. analyzed the prevalence of different infections in
neurosurgical patients with prophylactic antibiotics in 2004 at the
University Hospital of West Indies. Out of 73 patients, seven presented
with urinary tract infections (about 9.5%), which is very similar to the
Puri et al. study [11,14]. In a prospective study analyzing the CAUTIs in
patients with indwelling catheters (> 48 hours) for 18 months, 68 out of
800 patients (8.5%) acquired a UTI. The most common organisms were:
Escherichia coli (32.9%), Pseudomonas sp. (15.1%), Staphylococcus
aureus (12.3%), and Candida albicans (13.7%). All gram-positive
organisms were sensitive to vancomycin, while gram-negative organisms
were sensitive to amikacin (sensitivity of 42%) [11]. The majority of
microorganisms that cause CAUTIs are from the gastrointestinal tract;
however, approximately 15% of these infections occur due to patient-to-
patient transmission [10].

In our study, we evaluated 146 patients that had urine cultures

obtained in the presence of an indwelling urinary catheter. We
attribute our bimodal age distribution to the fact that we are a trauma
center and commonly receive young patients involved in accidents or
elderly people after a mechanical fall. We found two out of 42 febrile
patients that had a positive urine culture, which may have attributed to
a UTI; however, these individuals did not meet CAUTI criteria. We
only recorded the first episode of a hospital-acquired infection, and all
cultures were sent within 24 hours of the documented infection. One
of the patients was an 18-year-old male after a trauma who had a fever
on postoperative day (POD) 1, indicating that he did not
have a urinary catheter in place for greater than 48 hours. The second
patient was a 76-year-old female who presented as a Glasgow Coma
Scale (GCS) 4T after an intraparenchymal hemorrhage; the family
elected to pursue comfort measures. Urinalysis and urine culture were
ordered upon admission for altered mental status. Therefore, this was
not a CAUTI either. These findings are significantly better as
compared to the national averages.

The correlation (r=0.343, p-value<0.001) between the number of days

an indwelling catheter was in place, and patient temperatures is an
expected finding. This number of catheter days had a higher
statistically significant correlation to patient temperatures than the
number of days in the ICU. This is similar to findings by Al-Hazmi et
al. that demonstrated the percentage of patients that had a CAUTI
between three and eight days of catheterization increased from 15%
to 68% [15].

Urine cultures were considered a nominal variable, indicated by either

presence or absence of a positive culture, which necessitates the use
of a special (Eta) correlation statistic. There was a weak Eta
correlation of 0.021 between urine culture positivity and patient
temperatures. A weak correlation is expected because the vast
majority of urine cultures that were found within the patient
population were determined to be either asymptomatic bacteriuria
(ASB). The IDSA 2019 guidelines for asymptomatic bacteriuria indicate
that patients with short-term indwelling catheters have nearly a 3 to
5% cumulative daily risk of developing ASB, whereas patients with
long-term catheter use have nearly a 100% chance [3,16,17]. Stickler
et al. also demonstrated that 10 to 50% of patients with an indwelling
urinary catheter in place for seven days would likely develop
bacteriuria due to biofilm formation [18,19]. The Kaplan-Meier curve
depicted in Figure 2 demonstrates that, based on the ARMC data,
80% of patients with an indwelling catheter had bacteria in their urine
at 30 catheter days, increasing to 100% by 40 days, regardless of
whether they were febrile or had any alternative positive cultures.

The most recent standardized infection ratio (SIR) from 2017,

determined by the National Healthcare Safety Network (NHSN) was
0.850 [20]. These standardized infection ratios evaluate the number of
confirmed infections relative to the number of predicted infections.
The SIR at our institution was 0.734 in 2018 and 0.819 in 2017, both
of which are better than the national average [21]. Significant efforts
have been put in place to help reduce the number of CAUTIs within
our hospital such as the Houdini Protocol, which is a nursing driven
catheter removal protocol which allows nurses to remove indwelling
urinary catheters if certain criteria are met. Other efforts include
resident education, staff education regarding appropriate use of
urinalysis and urine culture, and nurse training on proper sterile
insertion techniques and maintenance.

In addition to the 146 patients included in this study, we examined the

charts of the seven neurosurgical patients that were flagged as CAUTIs
at our institution in 2018 to delineate a common risk factor. Of the seven
patients that were noted to have CAUTIs by Medicare, four patients had
concurrent pneumonia, one had multiple negative urine cultures before
the final positive culture, and two were true CAUTIs. The patients all
had their urinary catheters in for a minimum of five days before their
positive culture result. They were all febrile above 101.0ºF with
associated leukocytosis. All patients with pneumonia had exhibited signs
of consolidation on chest x-ray or an increasing oxygen requirement. The
argument could be made that, given this clinical picture, a urine culture
was not indicated and was aberrantly ordered. The patient who had
multiple negative urine cultures prior to the positive one was also an
avoidable CAUTI. Once the patient had their initial fever with no
suspected infectious source, and the initial urine culture had returned
negative, there was no indication for nearly daily repeat urine cultures.
The majority of these seven patients did not present as CAUTIs upon our
analysis because they either had alternative positive cultures or were
originally flagged as CAUTIs prior to the beginning timeframe of our
data collection.

Neurosurgical patients are an inherently difficult population in which to

diagnose UTIs due to their altered mentation. The most common reasons
for urinalysis in these patients are fevers and leukocytosis. As stated
earlier, there is a cumulative daily risk of developing ASB, which could
lead to an errant classification of CAUTI. The diagnosis and unnecessary
treatment of ASB leads to increased antibiotic resistance, unintended
antibiotic side effects, exposure to more harmful infections, such as C.
diff, and increased hospital costs.
IDSA 2019 guidelines demonstrate strong recommendations against
screening and treating ASB in cognitively impaired individuals, and to
evaluate for all other possible sources prior to evaluating for a urinary
source [3]. The difference between IDSA and Centers for Medicare
and Medicaid Services (CMS) assessment for CAUTIs is that CMS
does not factor in whether there are alternative concurrent infections
besides UTI that are more likely to be the causative pathology for
elevated temperatures. Our data support a stricter indication for
obtaining urinalysis and urine culture in neurosurgical patients that
become febrile. We recommend a diagnosis of UTI in a febrile patient
with an indwelling catheter for at least five days when other diagnoses
such as pneumonia, line infection, venous thrombi, or medication
reactions have been ruled out through the appropriate tests.
Limitations
There were several limitations within this study. Firstly, not all of the
patients had appropriate documentation. ARMC currently has a system
that is transitioning from paper to electronic charting, which can
contribute to loss of information. There is a certain level of human
error inherently embedded in progress notes, making it difficult to
analyze the clinical reasoning behind treatment plans for any given
patient.

Secondly, patient outcomes were not recorded within this study despite
having been shown to significantly impact elevated temperatures in the
neurosurgical ICU. It may be prudent to conduct a prospective study
monitoring patient temperatures and their neurologic status before and
after the onset of the fevers and the outcomes after treatment.

Thirdly, we used fever as a presenting symptom for a possible UTI in

this study. This was done as most neurosurgical patients have altered
mentation and are not able to express alternative symptoms.
Additionally, the retrospective nature of this study is limited by the
thoroughness of the medical records, which may not include small
subjective complaints, but commonly include objective findings such as
fevers. However, this practice inherently excludes the individuals who
would be able to express signs such a suprapubic tenderness and provide a
higher clinical index of suspicion for urinary etiology of their fevers.

Fourthly, surgical patients are commonly placed on peri-operative

antibiotics, usually either cefazolin or vancomycin, which could
potentially interfere with certain culture speciation. We do not believe
this to be a large limitation, as this would likely prevent from a fever
occurring for a UTI if the organism were being adequately treated.

Lastly, our proposal to increase the threshold of obtaining urine studies in

the setting of a new-onset fever comes from a small sample size. An
analysis of a significantly larger population of neurosurgical patients with
CAUTIs would better inform the validity of our proposal.

Conclusions
Analysis of our patient population shows evidence to support the
newest IDSA guidelines that patients who develop elevated
temperatures should have a clinical workup of all alternative etiologies
before testing for a urinary source unless the clinical suspicion is high.
Further research is needed to evaluate for possible predictive
characteristics of neurosurgical patients that have true CAUTIs. This
will help reduce the rate of unnecessary urine cultures, the over-
diagnosis of asymptomatic bacteriuria, the overuse of antibiotics
leading to the development of MDROs and C. diff colitis. Based on
 our current findings, all potential sources of fever should be ruled out
before obtaining urinalysis, and catheters should be removed as soon
as they are not needed. Urinalysis with reflex to urine culture should
be reserved for those cases where there remains a high index of
clinical suspicion for a urinary source.

Additional Information
Disclosures
Human subjects: All authors have confirmed that this study did not
involve human participants or tissue.
Animal subjects: All authors have confirmed that this study did not
involve animal subjects or tissue. Conflicts of interest: In compliance
with the ICMJE uniform disclosure form, all authors declare the
following: Payment/services info: All authors have declared that no
financial support was received from any organization for the submitted
work. Financial relationships: All authors have declared that they
have no financial relationships at present or within the previous three
years with any organizations that might have an interest in the submitted
work. Other relationships: All authors have declared that there are no
other relationships or activities that could appear to have influenced the
submitted work.

Acknowledgements
We would like to give special thanks to Brain R. Hu, MD at Loma
Linda University Medical Center for his review and edits towards the
final manuscript.

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International Journal of Colorectal Disease
https://doi.org/10.1007/s00384-019-03333-y

ORIGINAL ARTICLE

Prediction of urinary retention after surgery for rectal cancer using

voiding efficiency in the 24 h following Foley catheter removal
Ken Imaizumi1,2 & Yuichiro Tsukada1 & Yoshinobu Komai3 & Shogo Nomura4 & Koji Ikeda1 & Yuji Nishizawa 1 &
Takeshi Sasaki1 & Akinobu Taketomi2 & Masaaki Ito1

Accepted: 12 June 2019

# Springer-Verlag GmbH Germany, part of Springer Nature 2019

Abstract
Purpose Postoperative urinary retention is a common adverse effect after rectal surgery. Current methods for assessing
postop- erative urinary retention (residual urine volume) are inaccurate and unable to predict long-term retention.
Voiding efficiency is an effective indicator of postoperative urinary retention in urological and gynaecological fields, but
not in colorectal surgery. We aimed to determine whether voiding efficiency in the initial 24 h after urinary catheter
removal was more effective in predicting the incidence of postoperative urinary retention than residual urine volume.
Methods In this retrospective, observational study using prospectively collected data from patients who visited the
colorectal department of a single institution, 549 patients who underwent rectal cancer surgery between April 2012 and
May 2016 were initially enrolled, of which 46 were excluded and 503 finally included.
Results The incidence of postoperative urinary retention was 18.5% (93/503). Multivariable logistic regression analyses
revealed that the association of postoperative urinary retention with voiding efficiency < 50% was stronger than that
with residual urine volume > 100 mL (odds ratio, 38.30 (residual urine volume) and 138.0 (voiding efficiency)). Voiding
efficiency was significantly lower in patients with long-term than in those with short-term postoperative urinary retention
(adjusted p value = 0.02), whereas residual urine volume was not different between the two groups. Multivariable
logistic regression analysis for long-term post- operative urinary retention showed the strongest association with voiding
efficiency < 20% (odds ratio, 25.70).
Conclusions Voiding efficiency is a more effective predictor of postoperative urinary retention than residual urine
volume in rectal cancer patients.

Keywords Rectal cancer . Postoperative urinary retention . Long-term postoperative urinary retention . Voiding
efficiency . Residual urine volume

Introduction rectal surgery is reported to range from 4 to 29%, and

many factors are proposed to be associated with PUR,
Postoperative urinary retention (PUR) is a common including old age, male sex, low rectal tumours, longer
adverse effect of rectal surgery [1–4]. The incidence of operative time, ag- gressive fluid resuscitation, early
PUR after urinary catheter removal and
pelvic autonomic nerve resection [5–10].
Generally, PUR is characterised by the need for urethral
* Masaaki Ito
maito@east.ncc.go.jp
catheterisation for postoperative self-voiding difficulty
[8–12]. If patients need urethral catheterisation after dis-
1
Department of Colorectal Surgery, National Cancer Centre Hospital charge, they are required to master self-management of
East, 6-5-1, Kashiwanoha, Kashiwa, Chiba 277-8577, Japan clean intermittent self-catheterisation (CIC) or indwelling
2
Department of Gastroenterological Surgery I, Graduate School of Foley catheter during hospitalisation. Residual urine
Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
3
volume (RUV) is routinely used to assess PUR at
Department of Genitourinary Oncology, Cancer Institute Hospital of
Japanese Foundation for Cancer Research, Tokyo, Japan
discharge; however, the accuracy of predicting PUR using
4
RUV is not sufficient. Chaudhri et al. reported that even
Biostatistics Division, Centre for Research Administration and
Support, National Cancer Centre, Chiba, Japan when a patient’s RUV was high after catheter removal,
voiding difficulties were im- proved by the tenth postoperative day in 80% of cases [13].
 Int J Colorectal Dis

Moreover, according to previous studies, the cut-off using questionnaires on medication, CIC and
value of RUV for estimating PUR is not fixed and indwelling Foley catheter.
ranges from 50 to 400 mL [6, 7, 9, 13–15]. In our We conducted a retrospective review of the
department, we use an RUVof 100 mL as the database and patients’ medical records. Data on the
standard cut-off value because this value had been following clinical fac- tors were collected:
used commonly in various fields [14, 16–19]. demographics, history of diabetes mellitus or benign
In contrast, voiding efficiency (VE), which is the prostatic hyperplasia, preoperative RUV (pre- RUV),
ratio of self-voiding volume to the total voiding distance of the tumour from the anal verge, clinical T
volume, has been reported to be a good indicator for
evaluating PUR in urologi- cal [20–22] and
gynaecological fields [23–26]. We have con- sidered
that VE may be also a useful tool to assess PUR after
colorectal surgery. Moreover, some patients with
long-term PUR require prolonged catheterisation.
Changichien et al. re- ported that 32.6%, 19.4% and
7.8% of colorectal cancer pa- tients had PUR 1, 3 and
6 months after surgery, respectively [2]. Sterk et al.
reported that 46.7% of rectal cancer patients with
PUR needed catheterisation for more than 3 months
after the surgery [5]. However, there have been no
reports investi- gating the predictors for long-term
PUR. Therefore, in this study, we examined whether
VE in the initial 24 h after urinary catheter removal
was more effective than RUV of more than 100 mL
in predicting PUR after rectal surgery. We also eval-
uated the predictability of long-term PUR (PUR
lasting over 3 months) using VE.

Methods
Study design and patients

This study was a retrospective, observational study

using pro- spectively collected data and it was
approved by the Institutional Review Board of the
National Cancer Centre Hospital in Chiba, Japan (No.
2017-089). The study and man- uscript adhere to the
STROBE guidelines for observational studies.
In the department of colorectal surgery of our
institution (National Cancer Centre Hospital East),
clinical and patholog- ical information is
prospectively recorded in a single database. From this
database, we first extracted the data of patients with
middle and low rectal cancer who had undergone
rectal sur- gery between April 2012 and May 2016.
The exclusion criteria were patients who underwent
concurrent cystectomy or prostatectomy and local
excision only, had urinary system injury during
surgery or severe postoperative complications and
urinary tract fistula after surgery and had lack of
declara- tion of self-voiding. Patients’ urinary status
was evaluated at 1, 3, 6 and 12 months after surgery
stage, preoperative therapy, surgical approach,
surgical meth- od, lateral lymph node dissection
(LLND), pelvic autonomic nerve preservation,
operative time, bleeding and postoperative
hospitalisation day.
Postoperative urinary management
and definition of PUR
To define the incidence of PUR, the standard clinical
flow of postoperative urinary management at our
institution is shown in Fig. 1. For most patients, the
Foley catheter was removed 5 days after surgery
(day 5), as recommended in previous reports [27,
28]. At day 5, the self-voiding urinary volume and
RUV were measured at each self-voiding time in pa-
tients who had self-voiding after Foley catheter
removal. If the patients could not urinate by
themselves, RUV was mea- sured every 5–6 h using
bladder ultrasonography (BVI-6100 BladderScan,
Verathon Inc., Bothell, WA, USA). When RUV was
≥ 100 mL on measurement using BladderScan in
both patients who could and could not urinate, we
confirmed the actual RUV by bladder-emptying
catheterisation. When we confirmed that the RUV
was 100 mL or higher in three or more consecutive
measurements, treatment with oral med- ication,
such as alpha-blockers and/or cholinergic was started
[29]. When the patient’s RUV did not reach the
criterion for RUV (< 100 mL after oral medications),
we suspected the incidence of PUR and offered
patients a choice between CIC and Foley catheter re-
insertion (RUV ≥ 100 mL flow in Fig. 1). When RUV
was less than 100 mL in three consecutive
measurements, with a self-voiding volume of 100 mL
or higher, the patient was regarded as ‘non-PUR’, and
then the RUV measurements were stopped (RUV <
100 mL flow in Fig. 1). When RUV was 100 mL or
higher, we monitored the patient’s RUV
continuously, and if it de- creased to less than 100 mL
over three consecutive measure- ments, with a self-
voiding volume of 100 mL or higher, the patient was
regarded as ‘non-PUR’, and then the RUV mea-
surements were stopped (the patients’ RUV changed
to < 100 mL flow in Fig. 1). However, in patients
whose RUV was less than 100 mL but increased and
in whom RUV increased to 100 mL or higher in three
or more consecutive measurements, treatment with
oral medication was started as mentioned above
(patients’ RUV changed to ≥ 100 mL flow in Fig. 1).
A patient was regarded as ‘PUR’ when CIC or
indwelling Foley catheter was needed at the day of
hospital discharge. In patients with PUR, long-term
PUR (long PUR) was defined as the necessity for
catheterisation more than 3 months after sur- gery [5,
10], and short-term PUR (short PUR) was defined as
the necessity for catheterisation within 3 months after
surgery. Self-voiding volume and RUV within 24 h
after Foley cathe- ter removal were recorded in our
database.
Int J Colorectal Dis
Fig. 1 Algorithm of the postoperative urinary management protocol RUV = residual urine volume, CIC = clean intermittent self-catheterisation,
PUR = postoperative urinary retention
Calculation of 24-h VE
VE was calculated using the following formula:
voiding effi- ciency (VE) = [total self-voiding
volume/(total self-voiding volume + total RUV)] ×
100 (%). Total self-voiding volume and total RUV
were the sums of the volumes recorded within 24 h
after Foley catheter removal [30].
Statistical analysis
Receiver operating characteristics (ROC) curves of
continuous VE and RUV were drawn using a
univariable logistic model and
compared by bootstrapping the original dataset. The
cut-off values of VE for predicting PUR or long PUR
were determined from the ROC curves. For RUV, a cut-
off value of 100 mL (standard cut-off point in our
institution) was used. Potential predictive factors for
PUR or long PUR were selected on the basis of
significant associations (p < 0.05) in the univariable lo-
gistic regression model. For multivariable regression
analysis, RUV and VE were independently assessed by
adjusting the se- lected potential predictive factors,
considering a correlation be- tween RUV and VE. The
distributions of RUV and VE were compared using a
Steel-Dwass test for multiple comparisons among the
three groups (non-PUR, short PUR and long PUR).

P values less than 0.05 were considered
statistically signif- icant. All statistical analyses were
performed using EZR ver 2.2–5 (Saitama Medical
Centre, Jichi Medical University, Saitama, Japan), a
modified version of R Commander that is designed to
add statistical functions, which are frequently used in
biostatistics [31], and R ver 3.3.1 (The R Foundation
for Statistical Computing, Vienna, Austria).
Results
Patient characteristics and frequency of
PUR
In this study, 549 patients with middle and low rectal
cancer were identified. However, 9 patients who
underwent concur- rent cystectomy or prostatectomy
and local excision only, 17 patients who had urinary
system injury during surgery or se- vere postoperative
complications and urinary tract fistula after surgery
because they did not fit our standard flow of postop-
erative urinary management for long-term indwelling
Foley catheter and 20 patients with missed
measurements of RUV because of lack of declaration
of self-voiding were excluded. Finally, 503 patients
were included in the study (Fig. 2).
Fig. 2 Flowchart of included and
excluded patients RUV =
residual urine volume, TME =
total mesorectal excision, TSME
= tumour-specific mesorectal
excision
Int J Colorectal Dis
Patient characteristics are shown in Table 1. Among
the 503 patients, the median value of RUV
(interquartile range [IR]) was 64.0 mL (25.0, 184.0)
and that of VE (IR) was 83.7% (53.8, 93.2) within 24
h after Foley removal. PUR was ob- served in 93
(18.5%) patients. PUR was managed by CIC in 75
patients and by Foley catheter re-insertion in the
remaining 18 patients. All patients completed
evaluation of their urinary status at 1, 3 and 6 months
after surgery; however, the evalu- ation was
discontinued in two patients at 12 months because of
loss to follow-up and mortality, respectively.
Effectiveness and cut-off value of VE for
predicting PUR
ROC analysis revealed that VE predicts PUR more
accurately than RUV (area under the curve [AOC],
0.971 vs. 0.932, p < 0.001, calculated by
bootstrapping the original dataset for 2000
replications) (Fig. 3). The best cut-off value of VE for
predicting PUR was determined to be 50% because it
was closest to the top-left corner in the ROC plot (the
cut-off values of VE for PUR in male or female cases
were similar at values close to 50%). Classification
with RUVs (cut-off value, 100 mL) showed a
sensitivity, specificity and accuracy
 Int J Colorectal Dis

Table 1 Patient characteristics

Characteristics (n = 503) n %

Age (years), median (range) 63 (27-86)

Sex Male 329 65.4
Female 174 34.6
History of DM 66 13.1
History of BPH* 20 6.1
Preoperative residual urine volume (mL) < 50 394 78.3
≤ 50, < 100 53 10.5
≤ 100 21 4.2
No data 35 7.0
Distance of the tumour from the ≤5 200 39.8
anal verge (cm)
< 5, ≤ 10 246 48.9
10 < 57 11.3
Clinical T stage T1 105 20.9
T2 93 18.5
T3 273 54.3
T4 32 6.4
Preoperative therapy Chemotherapy 90 17.9
Chemoradiotherapy 9 1.8
Surgical approach Open 64 12.7
Laparoscopic 422 83.9
Robotic-assisted 17 3.4
Surgical method High anterior resection 27 5.4
Low anterior resection 250 49.7
Intershincteric resection 189 37.6
Abdominoperineal resection 27 5.4
Others 10 2.0
Lateral lymph node dissection 208 41.4
Autonomic nerve partial/total resection** Total preservation 311 61.8
Hypogastric nerve 38 7.6
median (range) Pelvic plexus/splanchnic nerve 98 19.5
DM diabetes mellitus, BPH benign prostatic hyperplasia
*Only male patients were included
**There is some duplication

of 94.6%, 75.1% and 78.7%, respectively. In contrast,
classi- fication with VE (cut-off value, 50%) showed
a sensitivity, specificity and accuracy of 93.5%,
92.7% and 92.8%, respectively.
The univariable logistic regression analysis
demonstrated that the following could be potential
predictive factors of PUR: male sex, pre-RUVof ≥ 50
mL, clinical T3 or T4 stages, preoperative
chemotherapy or chemoradiotherapy, open sur- gery,
LLND, no hypogastric nerve preservation (no-HNP),
no pelvic plexus/splanchnic nerve preservation (no-
PSP), no
neurovascular bundle preservation (no-NVBP),
operative time more than 300 min, bleeding more
than 100 mL, post- operative hospitalisation day more
than 14 days, RUV more than 100 mL and VE less
than 50%. Multivariate logistic regression analysis
adjusting the potential predictive factors showed that
classification according to VE (cut-off, 50%) per-
formed far better than that according to RUV (odds
ratio (OR) and its 95% CI: RUV, 38.30, 14.40–102.0;
VE, 138.0, 51.70–
367.0), as shown in Table 2. When all patients had
been di- vided into male or female groups, VE less
than 50% was the
 Int J Colorectal Dis

Fig. 3 Receiver operating

characteristics (ROC) curves for
voiding efficiency (VE) and re-
sidual urine volume (RUV) in the
prediction of postoperative uri-
nary retention (PUR). The accu-
racy in distinguishing patients
with and without PUR was
assessed by calculating the area
under the curve (AUC). ROC
curves were compared by
bootstrapping the original dataset

independent significant predictive factor for PUR in (adjusted p value = 0.02 by Steel-Dwass test) (Fig. 5).
the mul- tivariate logistic analyses that included male The ROC analysis revealed that VE predicts long PUR
or female patients (data not shown). more accurately than RUV (AOC, 0.950 vs. 0.903, p =
A difference in the distribution between RUV and
VE is shown in Fig. 4. The cut-off line of RUV was
set to 100 mL and that of VE was set to 50%, as
previously mentioned. In 190 patients with RUV
more than 100 mL, 74.3% (84/113) of patients with
VE less than 50% had PUR. However, only 5.2%
(4/77) of patients with VE and more than 50% had
PUR (indicated as Zone A in Fig. 4).

Long course of PUR

Patients recovered from PUR gradually after surgery.

At the time of discharge, the number of patients who
had PUR was
93. However, it decreased to 64 patients (69%) 1
month after, 35 patients (38%) 3 months after, 19
patients (20%) 6 months after and 9 patients (10%)
12 months after the operation day. Of the 93 patients
with PUR, 58 had short PUR and 35 long PUR. RUV
within 24 h after Foley removal was not different
between short PUR patients and long PUR patients
(adjusted p value = 0.23 by Steel-Dwass test). On the
contrary, the VE of long PUR patients was
significantly lower than that of short PUR patients
 , calculated by bootstrapping the original dataset
for 2000 replications) (Fig. 6). The best cut-off value
of VE to predict long PUR was defined as less than
20%, which was closest to the top-left corner of the
ROC (the cut-off values of VE for long PUR in male
or female cases were similar at values close to 20%).
RUV was not analysed for the cut-off value because
it was not considered a useful indicator of long PUR,
as shown in Fig. 5. Classification with VE (cut-off
value, 20%) showed a sensitivity, specificity and
accuracy of 82.9%, 91.0% and 90.5%, respectively.
The univariate logistic regression analysis
demonstrated that the following can be potential
predictive factors of long PUR: age ≥ 70 years,
clinical T3 or T4, preoperative chemo- therapy or
chemoradiotherapy, open surgery, LLND, no- HNP,
no-PSP, no-NVBP, operative time more than 300 min,
bleeding more than 100 mL, postoperative
hospitalisation day more than 14 days and VE less
than 20%. Multivariate logis- tic regression analysis
after adjusting for the potential predic- tive factors
showed that the independent predictive factors were
as follows: age ≥ 70 years, no-NVBP and VE < 20%.
VE < 20% had the strongest association (OR, 95%
CI: 25.70, 8.770–75.10) (Table 3). When all patients
had been divided into male or female group, VE less
than 20% was the independent significant predictive
factor for long PUR in the multivariate logistic
analyses that included male or female patients (data
not shown).
 Int
Table 2 Predictive factors for PUR after rectal surgery in univariate and multivariate analyses J
Col
Predictive factors n PUR, n (%) Univariate analysis Multivariate analysis Multivariate analysis or
(included RUV) (included VE) ect
al
OR (95% CI) p value OR (95% CI) p value OR (95% CI) p value

Age ≥ 70 years 194 42 (21.6) 1.400 (0.887–2.200) 0.149 – –

< 70 years 309 51 (16.5) Reference
Sex Male 329 73 (22.2) 2.200 (1.290–3.740) 0.004 1.690 (0.824–3.450) 0.153 1.560 (0.612–3.980) 0.352
Female 174 20 (11.5) Reference Reference Reference
History of DM Yes 66 17 (25.8) 1.650 (0.900–3.020) 0.105 – –
No 437 76 (17.4) Reference
History of BPH* Yes
No 309
20 4 (20.0)
69 (22.3)
0.870 (0.281–2.690)
Reference
0.808 – –
A
Preoperative residual
urine volume
≥ 50 mL
< 50 mL or no data 429
74 20 (27.0)
73 (17.0)
1.810 (1.020–3.200)
Reference
0.043 1.230 (0.551–2.750)
Reference
0.613 1.550 (0.541–4.460)
Reference
0.414
ut
Distance of the tumour
from the anal verge
≤ 5 cm
> 5 cm
200
303
42 (21.0)
51 (16.8)
1.310 (0.834–2.070)
Reference
0.239 – –
h
Clinical T stage T3 or T4
T1 or T2
305
198
78 (25.6)
15 (7.6)
4.190 (2.330–7.530)
Reference
< 0.001 1.820 (0.758–4.370)
Reference
0.180 1.920 (0.648–5.670)
Reference
0.240
or
Preoperative therapy Chemotherapy or
chemoradiotherapy
99 34 (34.3) 3.060 (1.860–5.030) < 0.001 0.612 (0.276–1.360) 0.227 0.607 (0.211–1.750) 0.356
's
Surgical approach
No
Open
404
64
59 (14.6)
35 (54.7)
Reference
7.930 (4.510–13.90) < 0.001
Reference
1.780 (0.756–4.190) 0.187
Reference
1.280 (0.406–4.030) 0.673
c
Laparoscopic or 439 58 (13.2) Reference Reference Reference
robotic-assisted

Lateral lymph node Yes 208 63 (30.3) 3.840 (2.380–6.200) < 0.001 0.640 (0.221–1.850) 0.410 0.503 (0.124–2.040) 0.336
dissection No 295 30 (10.2) Reference Reference Reference
Hypogastric nerve No 38 19 (50.0) 5.280 (2.670–10.50) < 0.001 2.230 (0.810–6.120) 0.121 1.840 (0.479–7.060) 0.375
preservation Yes 465 74 (15.9) Reference Reference Reference
Pelvic plexus/splanchnic No 98 43 (43.9) 5.550 (3.380–9.120) < 0.001 1.480 (0.694–3.150) 0.311 1.500 (0.557–4.040) 0.422
nerve preservation Yes 466 50 (12.3) Reference Reference Reference
Neurovascular bundle No 152 59 (38.8) 5.910 (3.660–9.570) < 0.001 1.990 (0.973–4.060) 0.060 2.400 (0.972–5.920) 0.058
preservation Yes 351 34 (9.7) Reference Reference Reference
Operative time ≥ 300 min 242 67 (27.7) 3.460 (2.110–5.670) < 0.001 1.340 (0.486–3.720) 0.568 1.160 (0.340–3.990) 0.809
< 300 min 261 26 (10.0) Reference Reference Reference
Bleeding ≥ 100 mL 206 67 (32.5) 5.020 (3.060–8.260) < 0.001 2.150 (0.923–4.980) 0.076 3.000 (0.999–9.000) 0.050
< 100 mL 297 26 (8.8) Reference Reference Reference
Multivariate analysis (included VE)

OR (95% CI) p value

1.130 (0.480–2.660)0.780

138.0 (51.70–367.0)
< 0.001
Discussion
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Int J Colorectal Dis

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Int J Colorectal Dis
Fig. 4 Scatter plot of distribution between voiding efficiency (VE) and
residual urine volume (RUV). Vertical and horizontal lines denote
100 mL RUV and 50% VE, respectively. Red circles and blue
triangles
by catheterisation or oral medication. However, they
would have received treatment for voiding difficulty
in this study, according to our previous protocol using
RUV. If we use VE as a prediction tool for PUR,
patients with high RUV but good VE (such as
patients in Zone A) could avoid unnecessary
medications or catheterisation that might be
administered if
Fig. 5 Correlation of residual urine volume (RUV) and voiding
efficien- cy (VE) among patients with or without postoperative
urinary retention RUV and VE were compared using the Steel-Dwass
test for multiple comparisons among the three groups (patients
without postoperative
represent patients with postoperative urinary retention (PUR) and
non- PUR, respectively. Zone A indicates patients who have an RUV
of more than 100 mL and VE of less than 50%
RUV is used as the predicting tool of PUR. Another
advantage of using VE as a predictor is its potential to
decrease medical resources. Medical staff could omit
the catheterisation proce- dure, which we now realise
is often unnecessary for such Zone A patients.
However, the benefits of VE should be confirmed in a
prospective study in the future.
urinary retention (non-PUR), with short-term postoperative urinary reten-
tion (short PUR) and with long-term postoperative urinary retention
(long PUR))
 Int J Colorectal Dis

Fig. 6 Receiver operating

characteristics curves (ROC) for
voiding efficiency (VE) and re-
sidual urine volume (RUV) in the
prediction of long-term postoper-
ative urinary retention (long
PUR). The accuracy in
distinguishing patients with and
without long PUR was assessed
by calculating the area under the
curve (AUC). ROC curves were
compared by bootstrapping the
original dataset

Moreover, the use of VE allows medical personnel of the neurovascular bundle was a significant predictive factor of
to iden- tify patients who need prolonged long-term PUR. Combined resection of the neurovascular
catheterisation for long-term PUR. Published studies
have reported the frequency of long- term PUR [2, 5],
but none have reported on predictive factors for long-
term PUR in the early period following surgery. Our
results showed that VE < 20% had a strong
association with long PUR. However, RUV was not
significantly different be- tween short PUR and long
PUR. Using VE, we can identify patients with long-
term PUR and better explain what to expect during
recovery as well as provide instructions about
catheter management of CIC or Foley catheters in the
early period following surgery.
Our study identified that no-NVBP and bleeding
tended to be predictive factors for PUR, and older age
and no-NVBP were independent predictive factors
for long-term PUR. Although there has been no
report of bleeding as a risk factor for PUR, we
consider that occult injury to the pelvic nerves would
occur when there is massive bleeding in the pelvis.
We also thought that bleeding would be another result
of intraop- erative fluid volume loss. High
intraoperative fluid resuscita- tion has been reported
to be a risk factor of PUR because it causes urethral
oedema and increased frequency of urination, which
may lead to decreased bladder sensation and contrac-
tility [7, 8, 10]. Furthermore, the preservation status
bundle causes frequent development of
PUR and delayed re- covery from PUR
because the neurovascular bundle is
located at the periphery of the pelvic
nerves. On the contrary, in the univariate
analysis, male patients developed PUR
more sig- nificantly than female patients.
The anatomical differences between male
and female patients influence the technical
dif- ficulties of TME because male
patients generally have narrow pelvic
cavity and the pelvic plexus is closer to
the lower rec- tum because of the absence
of the vagina [33]. Furthermore, the long
urethra may be the cause of PUR in male
patients. However, in this study, we think
that male sex was not an independent
predictive factor because there would be
con- founding between sex and RUV or VE in the
multivariate analyses. On LLND, the rate of PUR in
the TME with LLND was equal to the TME without
LLND in the Japanese randomised controlled trial
[34]. Another report demonstrated that LLND has
little influence on PUR, when bilateral pelvic nerves
were preserved [6]. In our study, LLND was not an
independent risk factor in the multivariate analysis;
therefore, pelvic nerve preservation was considered
more important than LLND for PUR.
In the conservative treatment of PUR, 5-alpha-
reductase inhibitor (dutasteride) and 5-
phosphodiesterase inhibitor (tadalafil), which has
been reported to be useful in the treat- ment of
urinary dysfunction related to BPH, may be effective
apart from the drugs used in this study. These drugs
may be
 Int
J
Table 3 Predictive factors for long-term PUR after rectal surgery in univariate and multivariate analyses
Col
Predictive factors n Long-term Univariate analysis Multivariate analysis or
ect
PUR, n (%)
al
OR (95% CI) p value OR (95% CI) p value

Age ≥ 70 years 194 20 (10.3) 2.250 (1.120–4.510) 0.022 3.320 (1.220–9.060) 0.019
< 70 years 309 15 (4.9) Reference Reference
Sex Male 329 26 (7.9) 1.570 (0.720–3.440) 0.256 –
Female 174 9 (5.2) Reference
History of DM Yes 66 5 (7.6) 1.110 (0.416–2.980) 0.833 –
No 437 30 (6.9) Reference
History of BPH* Yes 20 1 (5.0) 0.598 (0.208–4.650) 0.623 –

Preoperative residual
No
≥ 50 mL
309

74
25 (8.1)

9 (12.2)
Reference

2.150 (0.962–4.790) 0.062 –

A
urine volume

Distance of the tumour

< 50 mL or no data
≤ 5 cm
429

200
26 (6.1)

16 (8.0)
Reference

1.300 (0.652–2.590) 0.457 –

ut
from the anal verge
Clinical T stage
> 5 cm
T3 or T4
303
305
19 (6.3)
33 (10.8)
Reference
11.90 (2.820–50.10) < 0.001 3.110 (0.541–17.90) 0.203
h
Preoperative therapy
T1 or T2
Chemotherapy or
198
99
2 (1.0)
17 (17.2)
Reference
4.450 (2.200–8.990) < 0.001
Reference
2.470 (0.798–7.620) 0.117 or
's
chemoradiotherapy
No 404 18 (4.5) Reference Reference

c
Surgical approach Open 64 19 (29.7) 11.20 (5.370–23.20) < 0.001 2.740 (0.860–8.750) 0.088
Laparoscopic or 439 16 (3.6) Reference Reference
robotic-assisted
Lateral lymph node Yes 208 26 (12.5) 4.540 (2.080–9.910) < 0.001 0.371 (0.065–2.130) 0.267
dissection No 295 9 (3.1) Reference Reference
Hypogastric nerve No 38 8 (21.1) 4.330 (1.810–10.30) 0.001 0.848 (0.224–3.220) 0.808
preservation Yes 465 27 (5.8) Reference Reference
Pelvic plexus/splanchnic No 98 21 (21.4) 7.620 (3.710–15.60) < 0.001 2.240 (0.747–6.730) 0.150
nerve preservation Yes 466 14 (3.5) Reference Reference
Neurovascular bundle No 152 30 (19.7) 17.00 (6.460–44.80) < 0.001 6.230 (1.840–21.10) 0.003
preservation Yes 351 5 (1.4) Reference Reference

Operative time ≥ 300 min 242 27 (11.2) 3.970 (1.770–8.920) < 0.001 1.030 (0.174–6.110) 0.973
< 300 min 261 8 (3.1) Reference Reference

Bleeding ≥ 100 mL 206 28 (13.6) 6.520 (2.790–15.20) < 0.001 0.744 (0.150–3.690) 0.717
< 100 mL 297 7 (2.4) Reference Reference

Postoperative ≥ 14 days 171 22 (12.9) 3.620 (1.780–7.390) < 0.001 1.540 (0.555–4.280) 0.407
hospitalisation day < 13 days 332 13 (3.9) Reference Reference
Voiding efficiency < 20% 71 29 (40.8) 49.00 (19.30–125.0) < 0.001 25.70 (8.770–75.10) < 0.001
≥ 20% 432 6 (1.4) Reference Reference

PUR postoperative urinary retention, OR odds ratio, CI confidence interval, DM diabetes mellitus, BPH benign prostatic hyperplasia
*Only male patients were included
 Author's copy
Int J Colorectal Dis

useful in patients with preserved pelvic nerve because of 2,355 consec- utive patients. Dis Colon Rectum 50:1688–1696
3. Lange MM, Maas CP, Marijnen CAM, Wiggers T, Rutten HJ,
of the decrease in the urethral resistance. Pelvic floor Kranenbarg EK, van de Velde CJH, cooperative clinical
muscle training is a low-risk and low-cost treatment investiga- tors of the Dutch Total Mesorectal Excision trial
strategy for urinary dys- function patients. These (2008) Urinary dysfunction after rectal cancer treatment is
mainly caused by sur- gery. Br J Surg 95:1020–1028
conservative treatments should be considered in the
early postoperative period for patients at high risk for
PUR with poor VE. As a surgical approach, sacral
neuromodulation (SNM) was proved to be an
effective treatment for an overactive bladder.
However, there have been few reports of patients with
an underlying neurological disor- der including PUR
[35]. Furthermore, in patients with no pre- serving
pelvic nerves, the efficacy of SNM would not be ex-
pected. For such cases, regenerative treatment may
be expected.
This study has some notable limitations. First, this
was a retrospective review and a single-centre study.
Second, the timing to define the PUR was different in
each patient because of the variation in the length of
postoperative hospitalisation. However, only one patient
showed an improvement in PUR during the long
hospitalisation, so the wide range of hospitalisation
days had little influence on our results. Finally, our
results require further validation; therefore, a
multicentre study with a large cohort is required to
validate our findings.

Conclusion
VE was a more effective tool than RUV in predicting
the occurrence of PUR in rectal cancer patients. In
addition, the use of VE allowed clinicians to predict
which patients would require catheterisation for long-
term PUR.

Acknowledgements The authors thank all surgeons for appropriate

care and management of the patients in this study.

Compliance with ethical standards

Conflict of interest The authors declare that they have no conflict of
interest.

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