Early versus Delayed Removal of Urinary Catheter after Laparoscopic Hysterectomy: Insights from a Prospective Observational Study

Urinary catheterization is routinely employed during and after laparoscopic hysterectomy to monitor urine output, prevent bladder overdistension, and reduce intraoperative injury.[ 1 2 ] However, the optimal timing for catheter removal in the postoperative period remains a subject of ongoing debate.[ 3 4 ] While delayed removal is thought to reduce the risk of urinary retention, it may simultaneously increase the risk of catheter-associated urinary tract infections,[ 5 6 ] patient discomfort, delayed ambulation, and prolonged hospital stay. A catheter located in the bladder can cause discomfort postoperatively, a condition known as catheter-related bladder discomfort (CRBD). The incidence of CRBD has been increasing, ranging from 47% to 90% postoperatively.[ 7 ] The Visual Analog Scale (VAS) and the 10-point numerical rating scale are the most commonly used scales to measure bladder discomfort or pain.[ 8 ] Early removal of the catheter, on the other hand, is associated with enhanced patient mobility, lower infection risk, and improved patient comfort.[ 9 10 ] Nonetheless, concerns regarding postoperative urinary retention (POUR) and the potential need for re-catheterization often prompt clinicians to adopt a more conservative approach. Several randomized and observational studies have attempted to compare early versus delayed catheter removal (DCR) strategies, but results remain inconclusive and vary depending on the type of surgery, patient population, and perioperative protocols. Laparoscopic hysterectomy has become increasingly preferred due to its minimally invasive nature and faster recovery time.[ 11 12 ] As surgical recovery pathways evolve toward enhanced recovery after surgery protocols, optimizing perioperative interventions, including urinary catheter management, becomes essential. Despite existing literature, there is limited evidence from Indian healthcare settings that balances both safety and patient-centered outcomes, like comfort and length of hospital stay.[ 13 14 15 ] A trial comparing quality of life (QoL) after LAVH or TAH found that the laparoscopic group had significantly better QoL values after surgery.[ 16 ] In this prospective observational study, we aimed to compare early versus delayed urinary catheter removal following laparoscopic hysterectomy with respect to POUR, urinary tract infection (UTI), and hospital stay duration. The findings are intended to inform perioperative protocols and support individualized, evidence-based decisions in gynecologic surgical practice.

This prospective observational study was conducted in the Department of Obstetrics and Gynecology at a Tertiary Referral Centre in Western Rajasthan from September 2019 to January 2022. The Institutional Ethics Committee approved the study protocol. This study commenced during the early phase of the COVID-19 pandemic, during which elective laparoscopic cases were limited and randomized allocation was not feasible due to frequent disruptions in OT scheduling and patient flow. Therefore, alternate allocation was used for group assignment. While this introduces potential bias, we ensured uniform surgical protocols and postoperative care across both groups to minimize confounding. All women scheduled for total laparoscopic hysterectomy (TLH) for benign gynecological conditions and who consented to participate in the study were approached for enrollment. The patients were assigned to either Group A - Early Catheter Removal (ECR) or Group B - DCR in a 1:1 ratio. Since this was a nonrandomized observational study, group assignment was made alternately based on the previous case allotted. Women scheduled for surgery for uterovaginal prolapse, extensive endometriosis, or advanced oncological dissection, including nodal dissection, were excluded from the study. In addition, Women undergoing concomitant procedures for stress or urge incontinence, those with systemic diseases affecting their ability to void, such as multiple sclerosis, and those with a UTI prior to surgery were also excluded. Furthermore, any intraoperative complications requiring prolonged catheterization led to the exclusion from the study. Assuming the risk difference between ECR and DCR as 13.0% in the previous study by Sandberg et al .,[ 3 ] taking alpha error of 0.05, power of 80%, and attrition rate of 10%, a minimum of 132 sample size was calculated by G*Power v.3.1.9.4 (G* Power version 3.1.9.7; Heinrich-Heine University, Düsseldorf, Germany), with 66 subjects in each group. Participants were assigned to one of two groups based on the timing of catheter removal: ECR Group: Catheter removed immediately after the surgery DCR Group: Catheter removed 18–24 h post-surgery. ECR Group: Catheter removed immediately after the surgery DCR Group: Catheter removed 18–24 h post-surgery. The primary outcome was urinary retention, defined as the inability to void completely within 6 h postcatheter removal. Secondary outcomes included pain score, length of hospital stay, and UTI at discharge and 2 weeks later. The CRBD or pain was assessed via VAS. Surgical outcomes such as intraoperative blood loss, operative time, and uterine weight were noted to eliminate any confounding factors. Patient satisfaction was evaluated using a 5-point Likert scale at discharge, ranging from 1 (very dissatisfied) to 5 (very satisfied). All laparoscopic hysterectomies were performed using standardized techniques by experienced laparoscopic surgeons. Before inserting the manipulator, a Foley catheter (French size 16) was inserted under sterile precautions on the operating table. Uniform techniques were followed for patient positioning, uterine manipulator placement, peritoneal cavity entry, CO2 insufflation, and laparoscopic port placement. The Ligasure™ device was used to coagulate and transect the adnexal structures, whereas the Harmonic™ scalpel shears (ETHICON; Johnson and Johnson, USA) were used to mobilize the bladder flap. Ligasure™ was again used to desicate the uterine arteries. Colpotomy was performed by Harmonic™ and vaginal cuff closure was done either with polyglactin (1-0, Ethicon) or barbed sutures (V-LOC™). Women in the ECR group had their catheters removed immediately after the procedure, while those in the DCR group had theirs removed 18–24 h later. If prolonged catheterization was deemed necessary, those women were classified as dropouts. Participants could also opt out at any time. Demographic data collected included age, body mass index (BMI), parity, reasons for surgery, associated health conditions, and prior abdominal surgeries. If a patient from the ECR group did not urinate within 6 h post-catheter removal, a bladder scan was performed. If retention was not indicated, an extra 3 h was allowed for spontaneous urination. If retention was indicated, re-catheterization was performed. For urine volumes between 500 and 1000 ml, bladder emptying was done once, followed by observation for spontaneous voiding. Volumes exceeding 1000 ml necessitated the use of an indwelling catheter. Post-operative pain was assessed using a VAS score from 0 to 10 after 6 h. UTI was defined as a microbiologically proven UTI. The workflow is shown in Figure 1 . Work flow of the study Statistical analysis was conducted using the Statistical Package for the Social Sciences (SPSS) software, version 23.0 (IBM Corp., Armonk, NY, USA). A one-sample Kolmogorov–Smirnov test was used to assess the normality of the quantitative data. For normally distributed data, a Student’s t -test was used, whereas Chi-square and Fisher’s exact tests were applied for categorical variables at a two-sided significance level of 0.05 to compare two groups. This study adhered to the STROBE guidelines for observational studies.

During the study period, a total of 183 laparoscopic hysterectomies were performed. Out of these 183 cases, 37 were excluded as they involved operations for malignancy and deep infiltrating endometriosis. Fourteen women declined to participate in the study. Therefore, a total of 132 cases were enrolled for the study, with 65 in the ECR group and 67 in the DCR group. Of the 132 enrolled, 128 participants (ECR: 62, DCR: 66) were analyzed for urinary retention. The flow chart of the recruited women is presented in Figure 2a and b . The two groups were well matched, with no statistically significant differences in baseline characteristics such as age, BMI, parity, prevalence of comorbidities, and previous surgeries, as shown in Table 1 . The most common indication for hysterectomy was a fibroid uterus in both groups. Flow chart of recruited women Graphical abstract Baseline characteristics in both early catheter removal and delayed catheter removal groups ECR: Early catheter removal, DCR: Delayed catheter removal, SD: Standard deviation, BMI: Body mass index There were 4 dropouts, three in the ECR group and one in the DCR group. One patient was dropped from Group A for suspected bladder injury. Two requested recatheterization within 3 and 4 h, so we could not analyze retention in them. Another patient dropped out for conversion to TAH in the DCR group. Hence, 128 cases were analyzed for the primary outcome. The median time taken for surgery in both groups was 104.0 min, with an interquartile range (IQR) of 90–120 min, and 112.0 min (IQR: 90–130), respectively. It was observed that, out of 65 patients in the ECR group, after excluding the 3 dropouts, 6 patients were unable to pass urine within the first 6 h. Hence, the risk difference was 9.7% (95% confidence interval [CI] [2.3–17.0]); P = 0.028. This difference was statistically significant. These six cases underwent a bladder scan to see residual urine. Two patients passed urine subsequently within 3 h without any intervention, whereas 4 cases required re-catheterization with an indwelling catheter for retention of urine [ Table 2 ]. The detailed description of the six cases is shown in Table 3 . Comparison of outcomes between the early catheter removal and delayed catheter removal groups *2 had UTI within a week of surgery, while 3 had UTI on day 14, 19, and 20. ECR: Early catheter removal, DCR: Delayed catheter removal, SD: Standard deviation, UTI: Urinary tract infection, VAS: Visual Analogue Scale, CI: Confidence interval Descriptive analysis of the women with temporary retention Three patients requested re-catheterization due to post-operative pain and inability to move around for urination. Out of these three, one had passed urine within 6 h, whereas two requested catheterization at 4 h and 3 h after surgery in anticipation that they will not be able to move out of bed. The difference in the overall rate of recatheterization was 10.9% (95% CI 3.23–18.30); P = 0.01, which was statistically significant. The median VAS score in both groups was 7.0. Two patients in the DCR group developed a UTI during the hospital stay, and three developed a UTI during follow-up. Overall, there were 5 cases of UTI in the DCR group. Whereas only one developed UTI in the ECR group, who was recatheterized. However, this difference was not statistically significant ( P = 0.2; Fisher’s exact test). Patients in the ECR group had a significantly shorter hospital stay (2.91 ± 0.9 days vs. 2.97 ± 0.6 days, P = 0.05). This difference was statistically significant. The mean satisfaction score in the ECR group was 4.3 ± 0.6, compared to 3.8 ± 0.9 in the DCR group ( P = 0.01), suggesting higher satisfaction with ECR. A higher proportion of patients in the ECR group reported satisfaction scores of 4 or higher (82.2% vs. 63.6%).

Urinary catheterization is done in many gynecological surgeries to assess the output and to prevent POUR; however, it may be a source of infection and pain. UTI affects 75% of the patients who get catheterized.[ 17 ] In addition, it increases the length of hospital stay and the associated healthcare costs. Early removal of the urinary catheter is associated with significantly less pain and a lower chance of UTI.[ 16 18 ] In our study, the ECR group experienced higher rates of temporary retention (9.7%) and recatheterization (10.9%) compared to no occurrences in the DCR group. This difference was statistically significant ( P : 0.02 and 0.01, respectively). These results are consistent with studies demonstrating that earlier catheter removal can increase the likelihood of POUR due to incomplete bladder recovery from anesthesia or surgical manipulation.[ 3 17 19 20 ] In the most recent study on laparoscopic hysterectomy, the POUR rate observed was 13.5%.[ 3 ] Numerous studies have compared early versus DCR in cesarean sections, typically performed under regional anesthesia, while TLH is done under general anesthesia. Factors such as duration and type of anesthesia, operative time, and postoperative pain can influence urinary retention. Lamonerie et al .,[ 21 ] in their prospective study, identified spinal anesthesia as a risk factor for urinary retention, with bladder function recovery taking 4–5 h.[ 22 23 ] Consequently, many studies advocate for ECR after 6 h postsurgery instead of immediate removal.[ 1 24 25 26 27 ] UTI is an important complication of indwelling urethral catheters. In our study, patients whose catheters were removed immediately after the procedure did not develop UTI during the hospital stay or follow-up, as confirmed microbiologically. In contrast, two patients in the DCR group developed UTI during hospital stay and three during follow-up. Similar results, showing a lower positive urine culture rate with early removal of urethral catheters post-surgery, have been observed in various studies.[ 3 17 28 29 ] A randomized trial by Sekhavat et al .[ 30 ] involving 90 women undergoing anterior colporrhaphy found that UTI rates were significantly lower in the ECR group. This group also experienced shorter ambulation time and reduced hospital stay by nearly 19 h (36.2 h for early removal versus 55.2 h for delayed removal). Furthermore, urinary retention may elevate the risk of infection. Research shows that prolonged catheterization heightens bacterial colonization and subsequently increases the risk of infection. The hospital stay was shorter in the ECR group than in the DCR group ( P = 0.001), consistent with other studies, which reported durations of 36.2 ± 2.3 versus 50.4 ± 4.2 h, and 36.2 versus 55.2 h for ECR and DCR, respectively. Basbug et al . found that ECR reduces mobilization time and length of stay.[ 24 ] In addition, a systematic review indicates that faster voiding after ECR can facilitate earlier patient discharge.[ 31 ] The Infectious Diseases Society of America,[ 32 ] the Centers for Disease Control and Prevention,[ 18 ] and the Cochrane review[ 33 ] recommend that catheters should not remain in place longer than necessary after surgery. Patients have reported discomfort with indwelling catheters in some studies.[ 10 ] However, none in the DCR group complained or requested early removal, possibly due to cultural norms in India, where women receive meticulous care after surgeries like cesarean sections or hysterectomies. Furthermore, ECR has the additional advantage of reducing the risk of deep venous thrombosis, while also decreasing pulmonary complications such as atelectasis, insulin resistance, and loss of muscle mass, as well as shortening the interval to the return of bowel function.[ 34 ] Pain perception varies among individuals. The 10 cm VAS score measures pain intensity postprocedure, yet the minimal clinically important difference is still unknown, despite common usage. In our study, VAS scores were similar for both groups. Patients in the ECR group reported higher satisfaction than those in the DCR group, supporting findings that ECR improves comfort and recovery.[ 3 4 30 ] However, some ECR patients experiencing urinary retention expressed dissatisfaction, indicating a need for tailored protocols. The study’s prospective design ensures accurate data collection, and its focus on a specific surgical cohort enhances applicability. However, this was a nonrandomized, single-center study, and selection bias may exist due to surgeon-dependent allocation. Long-term UTI data beyond 2 weeks were not collected. Despite multiple international studies, evidence from Indian centers in real-world, resource-constrained settings is scarce. This study provides data from a high-volume center during peri-pandemic challenges, offering insights into catheter protocols in LMICs. ECR may reduce UTI risk and hospital stay for low-risk patients, but retention risk in older or comorbid patients must be considered. A risk-based protocol or randomized trial could guide future practice. There are no conflicts of interest.