Urinary Catheter Utility in Laparoscopic Appendectomy: Risk Benefit Analysis of Post-Operative Urinary Tract Complications

Abstract

Background:

Catheter-associated urinary tract infections (CAUTIs) account for 1 million nosocomial infections annually and 75% of all hospital-acquired UTIs. A risk factor for CAUTI is prolonged urinary catheterization (UC); therefore, transitory UC during laparoscopic appendectomy (LA), a common practice justified to avoid iatrogenic bladder injury, is believed to be safe. However, data on the incidence of post-operative UC-related complications, including CAUTI, following LA or their avoidance are limited.

Hypothesis:

Patients who underwent UC for LA developed more post-operative UTIs than patients without UC (noUC), without effect on the incidence of bladder injury.

Patients and Methods:

Retrospective analysis of patients ≥21 years who underwent LA (2016–2023) at an academic hospital. The primary outcome was post-operative UTI in UC versus noUC patients, defined as symptoms or urinalysis findings compatible with UTI within 21 days from LA. Secondary outcomes included bladder injury, catheter-related complications, time until UTI diagnosis, and antibiotic exposure. Statistics: Mann–Whitney U and Fisher exact tests; p < 0.05.

Results:

Among 981 LA, there were 678 UC and 303 noUC. A majority was male (56%) and young [38 years, inter-quartile range (IQR) 28–50]. Duration of catheterization was 102 min (IQR 85–123), whereas duration of the procedure was 58 min (IQR 44–80). There were more catheter-related complications in the UC versus noUC group (10 [1.5%] vs. 0; p = 0.04). The incidence of UTI was 0.5%, with five cases (0.7%) after UC and zero for noUC (p = 0.34). UTIs were detected at 11 post-operative days (IQR 6–17) and treated with antibiotic agents for 5 days (IQR 5–13). Four UC patients had urinary retention (two required re-catheterization and discharge with an indwelling catheter). One UC urinary “retainer” developed a post-operative UTI and required hospital re-admission. There was no urinary retention in the noUC group. There were no bladder injuries.

Conclusions:

The incidence of UTI was low following LA; bladder injuries were non-existent. UC-related complications were greater among UC patients, but there was neither urinary retention and post-operative catheterization nor bladder injury in the noUC group; we suggest the omission of UC for LA.

Introduction

Catheter-associated urinary tract infections (CAUTIs) are one of the most common nosocomial infections and account for 1 million cases annually worldwide and more than 75% of all hospital-acquired UTIs in the United States.^1–2 CAUTIs can result in cystitis, pyelonephritis, bacteremia, prolonged hospital stay, and mortality (>13,000 deaths/year).^3–6 CAUTIs also pose a financial burden of an estimated $115 million to $1.82 billion annually.^7–8 As fewer antibiotic agents are being developed and resistance leads to reduced effectiveness of existing antibiotic agents, the prevention of infections that necessitate antimicrobial therapy is of upmost importance.^1,9–11

Urinary catheterization (UC) is often performed prior to laparoscopic appendectomy (LA) to decompress the bladder to minimize the risk of iatrogenic bladder injury during port placement.^12–13 As the risk of CAUTI increases 3–7% with each day, the catheter remains in place,¹⁴ and transitory UC use for the duration of the surgical procedure is believed to be safe and low risk.¹⁵ However, there are few data on the incidence of post-operative UC complications or bladder injury following LA with UC.¹⁶

The study evaluated the safety and risk of routine UC during LA and classified the rate of post-operative UTI after LA. We hypothesized that patients who underwent UC for LA developed more post-operative UTIs than patients without UC (noUC), without effect on the incidence of bladder injury.

Patients and Methods

This was a single-center retrospective cohort study at an urban academic level 1 trauma center from 2016 to 2023. All patients who underwent LA were identified using operating room data. Patients aged 21 years and older who underwent LA were included in the study. Patients were excluded if they had a UTI on presentation, the primary indication for procedure was unrelated to the appendix (for example, laparoscopic hernia repair and incidental appendectomy), or the appendectomy was performed open by primary intent without prior laparoscopic approach.

Definitions and outcomes

Complicated appendicitis was defined according to the standards of the U.S. Food and Drug Administration for trials of investigational antibiotic agents in complicated intra-abdominal infections.¹⁷ The U.S. Centers for Disease Control and Prevention (CDC) defines CAUTI as a UTI diagnosis the day UC is discontinued or the following day in patients with a UC in place for ≥2 consecutive days.^8,18 In addition, urine culture cannot have more than two species of organisms and should have at least one with quantitative culture of ≥10⁵ colony-forming units/mL. Because both the duration of UC and hospital length of stay for patients undergoing LA are typically <48 h, and post-operative UTI diagnosis typically requires patient self-reported symptoms by phone call, telehealth, or office visit, urine cultures may not have been collected; therefore, most CAUTI patients do not meet the CDC definition. Therefore, for this study, we defined post-operative UTI as clinical symptoms or urinalysis findings compatible with UTI within 21 days from LA. Consistent with the CDC, symptomatic UTI was defined by at least one of the following: fever (>38°C), dysuria or urinary frequency or urgency, and suprapubic tenderness or costovertebral angle pain or tenderness.¹⁶

The study compared post-operative outcomes between UC and noUC patients. The primary outcome was post-operative UTI, and the secondary outcomes included bladder injury, catheter-associated complications (i.e., traumatic catheter placement, hematuria, ureteral injury, urinary retention, and need for catheter replacement), time until UTI diagnosis, and need for antibiotic management. This study was approved by the Institutional Review Board (Pro2023002435) with an approved waiver of consent in accordance with 45 CFR 46.116.

Data collection

Baseline demographic information, such as age, gender, race, and ethnicity, was collected from electronic medical records for each patient, as well as admission data such as systolic blood pressure, heart rate, temperature, white blood cell count, and lactate concentration. Preoperative comorbidities were collected including smoking history, hypertension, diabetes mellitus, chronic kidney disease, end-stage renal disease, coronary artery disease, chronic obstructive pulmonary disease, benign prostatic hyperplasia, and body mass index. Additional data collected included the diagnostic modality of appendiceal pathology, duration of catheterization and operation, intra-operative findings (uncomplicated appendicitis [phlegmonous changes], complicated appendicitis [abscess and perforation], and appendiceal neoplasm), and operative details such as the need for cecectomy or ileocecectomy and conversion to open appendectomy or open (ileo)cecectomy. Peri-operative antibiotic prophylaxis and treatment data were also collected along with UTI antibiotic treatment duration and antimibrobial(s) used. Other outcomes included 30-day re-admission, hospital length of stay, and mortality. Electronic medical record data were available from the inpatient hospitalization, outpatient post-operative follow-up visit, outpatient visits with other physicians within the health system, notes documenting telephone calls to the surgeons’ clinic, and re-admission visits within the health system.

Statistical analysis

Categorical data were reported using counts and frequencies, and continuous data were reported using medians and inter-quartile ranges (IQRs). Comparative analysis of post-operative outcomes was completed using Fisher exact test for categorical variables and Mann–Whitney U tests for continuous variables. Statistical significance was determined at α = 0.05.

Results

UC vs. noUC

Of 981 patients who had LA, 678 underwent UC and 303 had noUC. A majority of patients were male (56%), young [38 years, IQR 28–50], and hemodynamically sufficient upon arrival (Table 1). Although systolic blood pressure was significantly greater in the noUC group compared with the UC group (134 mmHg [IQR 123–146] vs. 131 [IQR 119–143], p = 0.004), this was not meaningful clinically. There were no differences in comorbidities between the UC and noUC groups (all p > 0.05, Table 1).

Table 1.

Demographics, Admission Data, and Comorbidities of Patients Who Underwent Laparoscopic Appendectomy: Catheterized Versus Non-Catheterized Groups

	All laparoscopic appendectomy (n = 981)	Urinary catheter (UC, n = 678)	No urinary catheter (noUC, n = 303)	p Value
Age, years (median [IQR])	38 [28–50]	38 [29–50]	40 [28–52]	0.359
Male (n [%])	552 (56%)	378 (56%)	174 (57%)	0.676
Body mass index, kg/m²	27.2 [24–31]	27.2 [24–31]	27.4 [24–31]	0.899
Systolic blood pressure, mmHg	131 [120–144]	131 [119–143]	134 [123–146]	0.004
Heart rate, bpm	83 [74–96]	83 [74–96]	86 [74–97]	0.255
Hypertension	153 (15.5%)	101 (14.8%)	52 (17.1%)	0.391
Diabetes mellitus	62 (6.3%)	45 (6.6%)	17 (5.6%)	0.670
Chronic kidney disease	5 (0.5%)	4 (0.6%)	1 (0.3%)	1.000
Coronary artery disease	20 (2.0%)	10 (1.5%)	10 (3.3%)	0.084
Chronic obstructive pulmonary disease	5 (0.5%)	3 (0.4%)	2 (0.7%)	0.647
Benign prostatic hyperplasia	5 (0.5%)	4 (0.6%)	1 (0.3%)	1.000

IQR = inter-quartile range; UC = catheterized; noUC = non-catheterized.

Table 2 compares LA patients categorized by the use of UC versus noUC. Uncomplicated appendicitis was the most common (82.8%) indication for LA and was similar between groups (UC 83.6% vs. noUC 80.9%, p = 0.314). Complicated appendicitis was not only less common but also similar between groups (15.6% vs. 17.8%, p = 0.401); appendiceal neoplasm was rare (0.4%). LA was performed for 96.3% of patients. The conversion rate to open surgical procedure was low and similar between UC versus noUC groups (1.5% vs. 2.6%, p = 0.208). A small number of patients required cecectomy or ileocecectomy, but this did not differ (p > 0.05).

Table 2.

Diagnosis, Operative Procedures, and Post-Operative Outcomes of Patients Who Underwent Laparoscopic Appendectomy: Catheterized Versus Non-Catheterized Groups

	All laparoscopic appendectomy (n = 981)	Urinary catheter (UC, n = 678)	No urinary catheter (noUC, n = 303)	p Value
Diagnosis (n [%])
Uncomplicated appendicitis	812 (82.8%)	567 (83.6%)	245 (80.9%)	0.314
Complicated appendicitis	160 (16.3%)	106 (15.6%)	54 (17.8%)	0.401
Appendiceal neoplasm	4 (0.4%)	2 (0.3%)	2 (0.7%)	0.591
Normal	5 (0.5%)	3 (0.4%)	2 (0.7%)	0.647
Procedure performed
Lap appendectomy (LA)	945 (96.3%)	654 (96.4%)	291 (96%)	0.717
LA + lap cecectomy/ileocolectomy	6 (0.6%)	4 (0.6%)	2 (0.7%)	1.000
LA converted to open	18 (1.8%)	10 (1.5%)	8 (2.6%)	0.208
LA converted to open cecectomy/ileocolectomy	11 (1.1%)	9 (1.3%)	2 (0.7%)	0.518
Interval appendectomy	14 (1.4%)	9 (1.3%)	4 (1.3%)	1.000
Peri-operative antibiotic prophylaxis	885 (90.2%)	613 (90.4%)	272 (89.7%)	0.816
Duration of surgical procedure, min (median, IQR)	58 [44–82]	58 [44–80]	60 [45–86]	0.310
Duration of urinary catheterization, min	102 [85–123]	102 [85–123]
Catheter-related complications	10 (1.0%)	10 (1.5%)	0	0.04
Urinary retention	4 (0.4%)	4 (0.6%)
Hematuria	1 (0.1%)	1 (0.1%)
Urethral damage or injury	0
Incidence of post-operative UTI	5 (0.5%)	5 (0.7%)	0	0.331
Iatrogenic bladder injury	0	0	0
Post-operative follow-up visit	696 (71%)	473 (69.7%)	223 (73.5%)	0.253
Length of stay, d	1 [1–2]	1 [1–2]	1 [1–2]	0.076
Mortality	1 (0.1%)	1 (0.1%)	0	1.000
30-d re-admission	60 (6.1%)	42 (6.2%)	18 (5.9%)	1.000
Length of stay for re-admission (days)	2 [1–4]	1.5 [1–4]	2 [1–4]	0.486

IQR = inter-quartile range; UTI = urinary tract infection.

Antibiotic prophylaxis was administered pre-operatively in 90.2% of patients in both the UC (613 [90.4%]) and noUC (272 [89.7%]) groups (p = 0.816, Table 2). There was no difference in the duration of surgical procedure among UC versus noUC patients (58 min [44–80] vs. 60 [45–86], p = 0.310). There were more catheter-related complications in the UC group compared with the noUC group [10 (1.5%) vs. 0%, p = 0.04]; this included the five patients with UTIs, four with urinary retention, and one with hematuria. The incidence of post-operative UTI was 0.5%, with five cases (0.7%) identified in the UC group and none in the noUC group (p = 0.331, Table 2). Of the four UC patients with urinary retention, two required re-catheterization and hospital discharge with an indwelling catheter, and one required re-admission for a post-operative UTI. There were no patients who developed urinary retention in the noUC group. There were no bladder injuries in either group.

The median length of hospitalization was 1 day (IQR 1–2), 71% of LA patients returned for outpatient follow-up, and the re-admission rate was 6.1% overall. There were no differences in the length of stay, follow-up, re-admission, re-admission length of stay, or mortality between groups (all p > 0.05).

UTIs versus no-UTIs among UC patients

Patients who developed post-operative UTIs tended to be older compared with those without UTIs (48 yrs [39–69] vs. 38 [28–50], p = 0.064) and more likely to have BPH (20% vs. 0.4%, p = 0.029, Table 3). UTIs were detected at a median of 11 post-operative days (IQR 6–17) and treated with antibiotic agents for 5 days (IQR 5–13; Table 4). The antimicrobial agents used were nitrofurantoin, penicillin, trimethoprim-sulfamethoxazole, or a cephalosporin. Among the five UTI patients, three (60%) had uncomplicated appendicitis and two (40%) had complicated appendicitis (Table 4). All five underwent LA only. The duration of catheterization did not differ between the UTI versus no-UTI groups (145 min [IQR 90–159] vs. 102 [85–123], p = 0.168). UTI patients had a greater frequency of catheter-related complications than no-UTI patients (1 [20%] vs. 4 [0.6%], p = 0.036), and one UTI patient was re-admitted for 5 days because of urinary retention. There were no differences in the length of stay, re-admissions, or mortality between UTI and no-UTI patients (all p > 0.05).

Table 3.

Demographics, Admission Data, and Comorbidities of Patients Who Underwent Laparoscopic Appendectomy: Stratified by Post-Operative UTI Versus No-UTI in Patients Who Underwent Urinary Catheterization

	UTI (n = 5)	No-UTI (n = 673)	p Value
Age (median [IQR])	48 [39–69]	38 [28–50]	0.064
Male (n [%])	2 (40%)	376 (55.8%)	0.659
Body mass index, kg/m²	23.8 [21–31]	27.2 [24–31]	0.154
Systolic blood pressure, mmHg	136 [106–165]	131 [119–143]	0.971
Heart rate, bpm	78 [69–101]	83 [74–95]	0.791
Hypertension	2 (40%)	99 (14.7%)	0.162
Diabetes mellitus	1 (20%)	44 (6.5%)	0.291
Chronic kidney disease	0	4 (0.6%)	1.000
Coronary artery disease	0	10 (1.5%)	1.000
Chronic obstructive pulmonary disease	0	3 (0.4%)	1.000
Benign prostatic hyperplasia	1 (20%)	3 (0.4%)	0.029

IQR = inter-quartile range; UTI = urinary tract infection.

Table 4.

Diagnosis, Operative Procedures, and Post-Operative Outcomes Following Laparoscopic Appendectomy: Stratified by Post-Operative UTI Versus No-UTI in Patients Who Underwent Urinary Catheterization

	UTI (n = 5)	No-UTI (n = 673)	p Value
Uncomplicated appendicitis	3 (60%)	564 (83.8%)	0.190
Complicated appendicitis	2 (40%)	104 (15.5%)	0.176
Appendiceal neoplasm	0	2 (0.3%)	1.000
Normal	0	3 (0.4%)	1.000
Procedure performed
Lap appendectomy (LA)	5 (100%)	649 (96.4%)	1.000
LA + lap cecectomy/ileocolectomy	0	4 (0.6%)	1.000
LA converted to open	0	10 (1.4%)	1.000
LA converted to open cecectomy/ileocolectomy	0	9 (1.3%)	1.000
Interval appendectomy	0	9 (1.3%)	1.000
Peri-operative antibiotic prophylaxis given	4 (80%)	609 (90.4)	0.396
Duration of surgery, min	80 [42–102]	58 [44–80]	0.442
Duration of catheterization, min	145 [90–159]	102 [85–123]	0.168
Catheter-related complications	1 (20%)	4 (0.6%)	0.036
Urinary retention	1 (20%)	3 (0.4%)	0.029
Hematuria	0	1 (0.1%)	1.000
Urethral damage or injury	0	0
Time to UTI diagnosis, d	11 [6–17]
Use of antibiotic agents for UTI	5 (100%)	0
Nitrofurantoin	2 (40%)
Penicillin	1 (20%)
TMP-SMX	1 (20%)
Cephalosporins	1 (20%)
Duration of antibiotic agents for UTI (days)	5 [5–13]
Post-operative follow-up visit	5 (100%)	468 (69.5%)	0.329
30-d re-admission	1 (20%)	41 (6%)	0.274
Length of stay for re-admission	5	1 [1–3.5]
Mortality	0	1 (0.1%)	1.000

TMP-SMX = trimethoprim-sulfamethoxazole; UTI = urinary tract infection.

Discussion

This study investigated the incidence of post-operative UTI as well as iatrogenic bladder injuries following LA in patients who underwent UC compared with those with noUC. We observed a low overall rate (0.7%, n = 5) of post-operative UTI, observed exclusively in the UC group. Notably, there were no bladder injuries in either UC or noUC groups.

The low UTI rate in our study aligns with previous reports suggesting minimal risk with short-term UC for LA.^1,19 However, it is important to acknowledge the consequences of UC, even with a low UTI rate. Five UC patients developed symptomatic post-operative UTIs, requiring a median of 5 d of oral antibiotic therapy. Unnecessary and prolonged antibiotic usages are known drivers of antimicrobial resistance (AMR), which, over time, may render even simple infections difficult to treat.^20–21

AMR can also be abetted by biofilm formation by various uropathogens after UC. Biofilms harbor pathogens that are sequestered from antibiotic penetrance, promoting or potentiating AMR.²² Considering the growing concern about AMR and the limited recent development of new antimicrobial agents, every instance of preventable and unnecessary antibiotic use should be minimized to preserve the utility of existing antibiotic agents.^23–24

The incidence of catheter-related complications was significantly greater in the UC group (zero in the noUC group). Notably, four patients in the UC group experienced post-operative urinary retention that required interventions. This aligns with prior research highlighting the potential risks of even short-term use of UC.²⁵ Importantly, there were no bladder injuries identified in either group, and therefore, we could not determine if UC is protective. However, given the lack of bladder injuries, this raises the question of the potential lack of benefit from routine UC placement during LA, especially considering the potential burden of post-operative antibiotic use for UTI and urinary retention.

Our study has several limitations, including its retrospective nature. The low event rate precluded multi-variable analysis and limits the conclusions that can be drawn. There were no institutional protocols for UC use, thereby creating potential selection bias. As post-operative UTI was defined by this study as clinical symptoms or urinalysis findings compatible with UTI, patients with catheter-related dysuria may have been falsely perceived to have an infection. The follow-up rate for LA patients with UC was only 69.7%, so post-operative complications including UTIs could have been under-reported. We also recognize study patients may have presented to healthcare providers other than their surgeons post-operatively for UTI symptoms, possibly leading to decreased UTI identification. We have neither culture nor susceptibility data for the putative UTIs.

Conclusion

The incidence of post-operative urinary complications, including UTI, was low following LA; bladder injuries were non-existent. As catheter-related complications were greater among the UC group and there were neither episodes of urinary retention and post-operative UC nor bladder injury in the noUC group, we suggest the omission of UC for LA.

Footnotes

Acknowledgments

The authors would like to acknowledge Marie Macor for her invaluable work ethic and dedication to the research process. Her expertise and commitment have enabled this project.

Authors’ Contributions

C.P.: Conceptualization, methodology, investigation, data curation, analysis, and writing—original draft preparation; J.E.G.: Investigation, data curation, analysis, and writing—reviewing and editing; S.N.: Investigation and writing—reviewing and editing; G.A.H.: Investigation and writing—reviewing and editing; A.L.T.: Methodology and writing—reviewing and editing; P.S.B.: Methodology and writing—reviewing and editing; M.N.: Writing—reviewing and editing; R.L.C.: Conceptualization, methodology, data curation, writing—original draft preparation, and reviewing and editing.

Author Disclosure Statement

The authors do not have anything to disclose.

Funding Information

No funding was obtained for this study.

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