Karen E. Fowler, MPH

 To formally assess the appropriateness of different timings of urethral catheter removal after transurethral prostate resection or ablation. Although urethral catheter placement is routine after this common treatment for benign prostatic hyperplasia (BPH), no guidelines inform duration of catheter use.

Using a standardized, multiround rating process (ie, the RAND/UCLA Appropriateness Methodology), an 11-member multidisciplinary panel reviewed a literature summary and rated clinical scenarios for urethral catheter duration after transurethral prostate surgery for BPH as appropriate (ie, benefits outweigh risks), inappropriate, or of uncertain appropriateness. We examined appropriateness across 4 clinical scenarios (no preexisting catheter, preexisting catheter [including intermittent], difficult catheter placement, significant perforation) and 5 durations (postoperative day [POD] 0, 1, 2, 3-6, or ≥7).

 Urethral catheter removal and first trial of void on POD 1 was rated appropriate for all scenarios except clinically significant perforations. In this case, waiting until POD 3 was deemed the earliest appropriate timing. Waiting 3 or more days to remove the catheter for patients with or without preexisting catheter needs, or for those with difficult catheter placement in the operating room, was rated as inappropriate.

 We defined clinically relevant guidance statements for the appropriateness of urethral catheter duration after transurethral prostate surgery. Given the lack of guidelines and this robust expert panel approach, these ratings may help clinicians and healthcare systems improve the consistency and quality of care for patients undergoing transurethral surgery for BPH.

Given increasing focus on appropriateness of care for quality, payment, and policy, clarifying appropriate urinary catheter duration after transurethral prostate surgery could help improve consistency and quality of care for healthcare organizations. In particular:

Urethral catheter removal and trial of void on postoperative day 1 after the procedure was rated appropriate for all scenarios except clinically significant perforations.

Waiting 3 or more days to remove a catheter for a first voiding trial after these common procedures was inappropriate for the majority of patients.

Both indwelling catheter placement and intermittent catheterization were acceptable approaches to a failed trial of void.

Benign prostatic hyperplasia (BPH) is a leading diagnosis among male Medicare beneficiaries. Approximately 100,000 men are treated with transurethral prostate surgery each year, making it one of the most common surgical procedures in the United States.

 The procedure is performed using various approaches and routinely involves urinary catheter placement. Given an increasing focus on appropriateness of care for policy,

 clarifying appropriate urinary catheter duration after this common surgery could help improve consistency and quality of care for healthcare organizations and their patients treated surgically for BPH.

However, there are no guidelines for the duration of urinary catheter use after transurethral prostate surgery.

 Some providers recommend overnight urinary catheter placement, whereas others recommend leaving the catheter in place for days afterward. Observational studies indicate that catheter removal and trial of void the day after surgery is safe for most patients,

 relieving them of their 1-point restraint

 and associated discomfort sooner rather than later. Decreasing indwelling urinary catheter duration not only reduces patient discomfort and nursing care during the hospitalization and after discharge, but it also lowers the risks of complications, including catheter-associated urinary tract infections (UTIs).

 Although the former might affect patient satisfaction and postsurgical care utilization, the latter is an important quality-of-care metric, especially when catheter use might be scrutinized as inappropriate by national institutions such as the CDC.

In the absence of evidence-based guidelines, defining the most appropriate duration of urinary catheter use after this procedure may help decrease practice variation, reduce postoperative complication risk, and improve consistency and quality of care for patients with BPH and lower urinary tract symptoms.

For these reasons, we assessed the appropriateness of different timings of urinary catheter removal among patients treated with transurethral resection or ablation of the prostate. Following the RAND/UCLA Appropriateness Method,

 we asked a multidisciplinary panel of experts and practicing urologists to review the studies included in our literature search and use their clinical expertise to rate the appropriateness of different options for urinary catheter removal and trial of void after transurethral prostate surgery. This manuscript details and synthesizes findings from this approach in order to provide guidance for and promote standardization of urinary catheter use after this common BPH surgery within and across healthcare organizations.

We used the RAND/UCLA Appropriateness Method to develop these appropriateness criteria.

 We previously used this multidisciplinary, stepped approach to define appropriateness of urinary catheter use in hospitalized medical patients and perioperatively for general and orthopedic surgery patients.

 The methodology couples scientific evidence for a given practice—in this case, urinary catheterization after transurethral prostate surgery&mdash;with clinical judgment to produce clinically relevant guidance statements regarding a procedure’s appropriateness in light of a patient’s symptoms, test results, and medical/surgical history. This robust approach has been used to define appropriate care, and even develop quality indicators, across many clinical scenarios, including coronary revascularization, endoscopic sinus surgery, and active surveillance for prostate cancer.

 This approach has been shown to be useful to provide guidance when more definitive studies are lacking and has been predictive of future randomized controlled study results.

 Finally, managed care and accountable care organizations are increasingly adding metrics involving appropriateness of care (eg, appropriate diagnostic imaging services)

 for quality assessment, and even value-based purchasing programs for their beneficiaries’ providers, making this approach and its findings relevant and timely.

The first step of the RAND/UCLA Appropriateness Method is to conduct a literature review to identify the most relevant articles for a given practice. The literature is divided into categories based on relevance and level of evidence, and common clinical scenarios for appropriateness rating are identified. Similar to prior appropriateness research projects, we began our literature search with a systematic review of databases (Web of Science, CINAHL, Embase, Cochrane, and PubMed/MEDLINE). We searched available literature for studies assessing outcomes for patients undergoing transurethral resection (using monopolar or bipolar technique) or ablation (using plasma vaporization “button procedure” or photoselective vaporization for BPH, including enucleation of the prostate). We searched each database using Boolean logic (eg, AND, OR) for our various combinations of transurethral prostate surgery types. The MeSH system was also searched separately. The literature search and scenario development occurred between September 2014 and February 2015 and included 4428 articles before excluding duplicates across all databases (

). Our study team urologist (T.A.S.) reviewed 472 articles meeting subsequent criteria by abstract, title, keyword, and full text to select the final articles. Forty-four articles met inclusion criteria for our study.

We categorized these articles into 3 groups (A, B, and C) based on their relevance to urinary catheter strategies after transurethral prostate surgery and patient outcomes. Group A (n = 15) articles assessed a particular urinary catheter strategy and its impact on patient outcomes. We expected these articles to be of highest relevance for describing the evidence available to inform appropriateness ratings. Group B (n = 15) studies reported relevant patient outcomes without assessing a particular type of urinary catheter strategy. Group C (n = 14) included supplementary articles (eg, review articles). We provided copies of all articles and generated summary tables for articles in groups A and B (

]), highlighting outcomes of interest. We also provided the team with an overview of transurethral surgical procedures for treating BPH from UpToDate

 as a reference to give a general overview of BPH and its surgical treatments, particularly for the nonurologist members of the panel (eg, nurses, infectious disease physicians).

Next, we recruited experienced practicing clinicians, including urologists who had performed transurethral prostate surgery across a variety of practice types (academic, private, government) and US regions (West, Midwest, Northeast), and subject matter experts (eg, BPH, infectious disease, neurogenic bladder) to participate in this panel by sending an introductory email describing the panel and process. Panelists (N = 11) (

) included urologists (n = 8), nurses (n = 2) who care for urologic patients, and an infectious diseases physician with expertise in UTIs.

Participating panelists were sent materials to complete a round 1 independent rating of the clinical scenarios (March-April 2015). They were sent instructions, literature summary tables, relevant articles, and a scoring document (see 

 for example section of the round 1 scoring document) that included the clinical scenarios and asked when the first trial of void should occur after surgery. They were asked to examine appropriateness across 4 clinical scenarios (no preexisting catheter, preexisting catheter [including intermittent], difficult catheter placement, significant perforation) and 5 durations (postoperative day [POD] 0, 1, 2, 3-6, or ≥7). All scenarios were for adult male patients in acute care inpatient or ambulatory surgery settings undergoing routine surgery. Panelists were instructed to use their best clinical judgment in combination with evidence from the literature review and to assume no other relevant patient characteristics (eg, comorbidities, catheter trauma). They also rated the appropriateness of intermittent straight catheterization (ISC) and indwelling urinary catheter placement after a failed first trial of void, including time to a second trial of void.

Catheter removal was considered appropriate if “the expected health benefit (eg, relief of pain, reduction in anxiety, improved functional capacity) exceeds the expected negative consequences (eg, mortality, morbidity, anxiety, pain, time lost from work) by a sufficiently wide margin that the procedure is worth doing, exclusive of cost.”

 For each scenario, we asked the panelist to rate the appropriateness of the duration of urethral catheterization by circling a number on a scale from 1 to 9. A rating of 1 indicated that the harms significantly outweigh the benefits (ie, inappropriate), whereas a rating of 9 indicated that the benefits significantly outweigh the harms (ie, appropriate). A central rating of 5 indicated that the benefits or harms were considered equal or that the participant was unable to make an informed rating of the clinical scenario.

After the initial round 1 ratings were complete, we conducted a 1-hour conference call (April 17, 2015) to clarify the clinical scenarios and reduce disagreement or uncertainty in panelist ratings. Gross hematuria requiring bladder irrigation was not included in the final scenarios because catheter removal would not be clinically appropriate per the panel. The panel was then brought together for a face-to-face meeting in which each scenario, preliminary scores, and rating differences were discussed to determine a final appropriateness score for each clinical scenario. This round 2 meeting was conducted on May 4, 2015. Panelists rerated each clinical scenario after the in-person discussion. The median round 2 scores were used to classify each scenario as appropriate (panel median score of 7-9), uncertain or neutral (panel median score of 4-6), or inappropriate (panel median score of 1-3). In addition, if 4 or more panelists rated a scenario as appropriate (median score of 7-9) and 4 or more rated it as inappropriate (median score of 1-3), the scenario was rated as uncertain or neutral due to disagreement.

As detailed in eAppendix Table 1, 15 studies

 published from 1991 to 2014 were identified for transurethral prostate and/or ablation procedures reporting at least 1 outcome of interest (catheter use, urinary retention, urinary tract infection, or other complications) for patients with respect to a specific postoperative urinary catheter removal protocol. Five studies were randomized controlled trials,

 5 were quasi-experimental studies with controls,

 and the remaining 5 were cohort studies without a comparison group.

 Variations in early catheter removal protocols included removal on same day of surgery; removal within 24 hours or on POD 1, including removal at midnight on day of surgery versus 6 am on POD 1

 Overall, the studies reported similar or improved outcomes for the early catheter removal strategy (compared with either concurrent or historical controls, as varied by study design), including the shortest catheterization periods investigated (all 4 studies investigating same-day removal

). Many studies also reported significantly reduced length of stay and either calculated or presumed reduced hospital costs for cases employing the early catheter removal protocols.

 details the panel responses across a group of common scenarios. Removing the urethral catheter on the day of surgery was deemed appropriate for patients both with and without preexisting catheter needs. However, a voiding trial on the day of surgery was rated inappropriate for patients with a difficult catheter placement after surgery or those with intraoperative findings of clinically significant prostatic capsule perforation (eg, obvious urine extravasation).

Based on our panel ratings, urinary catheter removal and first trial of void on POD 1 was appropriate for all scenarios except clinically significant perforations. In this case, waiting until POD 3 was deemed the earliest appropriate timing for removal. The panel was split with respect to catheter removal on PODs 1 and 2 for the perforation scenario, with some panelists rating removal appropriate and others rating it inappropriate. Furthermore, the perforation scenario was the only appropriate indication for waiting 7 or more days for initial trial of void. Conversely, waiting 3 or more days to remove the catheter for patients with or without preexisting catheter needs, or for those with difficult catheter placement in the operating room, was rated as inappropriate.

The next question was: “After failing the first trial of void after transurethral resection or ablation of prostate for BPH, how appropriate is this type of urinary catheterization to manage retention (ISC and/or indwelling urethral catheter)?” We instructed the panelists to make several assumptions, including no evidence of prostate cancer, acontractile bladder, urethral stricture, need for continuous bladder irrigation for hematuria, difficult catheter placement, or intraoperative clinically significant perforation. The panel uniformly rated both ISC and indwelling urethral catheter placement as appropriate.

, the panel was then asked “If a Foley was placed after a failure of first trial of void after transurethral resection or ablation (including enucleation) of prostate for benign prostatic hyperplasia, what is the appropriateness of the following durations of Foley catheter use before second trial of void?” to specifically inquire about appropriateness according to hospitalization status (inpatient, discharged home). The panel rated a second trial of void appropriate after 1 or 2 days in hospitalized patients. For patients discharged home, waiting up to 4 days was the longest appropriate duration per the expert panel, with waiting 5 to 7 days for a second trial of void rated as uncertain or raising disagreement among the panelists. However, waiting 8 or more days for a second trial of void for patients discharged home was deemed inappropriate.

We used the RAND/UCLA Appropriateness Method to determine appropriate urinary catheter management strategies following transurethral resection and ablation procedures for BPH, including enucleation. We found that waiting 3 or more days to remove a catheter for a first voiding trial after these procedures was inappropriate for the majority of patients. In other words, unless a clinically significant perforation occurs at the time of the procedure, it was deemed appropriate for most patients to have their catheter removed for a trial of void on POD 1. We also found that both ISC and indwelling catheter placement were acceptable approaches to manage patients after failing their first trial of void. If an indwelling catheter was placed after an initial failed trial of void, the panel indicated that hospitalized patients should be given another trial of void within 1 or 2 days. For patients discharged home, the appropriate duration was extended up to 4 days to allow for a second trial of void.

Given the lack of guidelines for urethral catheter duration and this robust expert panel approach to examining appropriate catheter use after one of the most common procedures in the United States, our findings may help improve the consistency and quality of care for patients undergoing transurethral surgery for BPH.

The implications of our findings depend on the extent to which current clinical practice varies with respect to catheter duration after transurethral prostate surgery. However, outside of limited research studies, the duration of catheter use after surgery is poorly understood for at least 2 reasons. First, research has focused on the tremendous variation in population-based rates of transurethral surgery itself, rather than catheter duration. Second, there is a paucity of BPH measures to motivate providers and healthcare systems to track quality of care. Nonetheless, length of stay is arguably a proxy for catheter duration and varies tremendously across hospitals. In fact, a recent study demonstrated greatest variation in length of stay after transurethral prostate resection compared with other common benign urologic surgery types including percutaneous nephrolithotomy and pyeloplasty.

 This is an important consideration for healthcare systems seeking to minimize length of stay after common procedures like transurethral prostate surgery. Standardizing postoperative catheter use is likely to decrease practice and length of stay variation, minimize catheter discomfort for patients, and potentially lower the risk of postoperative complications (eg, UTI).

The lack of quality indicators for transurethral prostate surgery is striking given the variation in practice across the United States. According to the Dartmouth Atlas, the adjusted rate of inpatient transurethral surgery per 1000 male Medicare beneficiaries varies 6-fold across hospital referral regions, from 0.3 to 1.8.

 In light of this heterogeneity across varied indications and preferences for the procedure, perhaps focusing initially on perioperative processes of care is warranted. Our appropriateness recommendations from practicing clinicians support urinary catheter duration after surgery as a potential initial quality measure to promote consistent, appropriate care for men surgically treated for BPH. In fact, the RAND/UCLA Appropriateness Method has been used to develop quality indicators across disease and treatment types, setting the precedent for such an approach.

 Finally, there is interest by the CDC, which collects measures of catheter-associated UTI and catheter use, in developing a measure of urinary catheter appropriateness that could be applied based on data from the electronic health record (eg, procedure type, comorbidity).

 In fact, an adjusted standardized utilization ratio for urinary catheter use has been proposed,

 and thus, our work would inform future modifications of this and similar metrics based on urinary catheter appropriateness to be used across healthcare organizations.

There are limitations to our approach. First, our panel included 11 members. However, all 8 of the participating urologists performed at least 1 type of transurethral prostate surgery, and the spectrum of procedures (resection, ablation, enucleation) was covered within their clinical expertise. Moreover, the panelists represented a variety of institutions and practice settings across the United States, increasing the generalizability of the findings. Additionally, including a mix of specialists and nonspecialists on our panel provided differing perspectives.

 Second, there were few randomized trials included in our literature review to support appropriateness ratings. However, we did use a systematic approach to identify relevant literature across a range of study types, although several of the studies were published in the 1990s. The panelists were instructed to use their best clinical judgment in addition to the literature review to inform their ratings. Third, our final ratings applied to 4 common clinical scenarios for men undergoing transurethral prostate surgery that emerged through our rating process. Although these likely address the majority of cases in real-world practice, other patient, disease, and procedure characteristics outside of our appropriateness ratings could create challenges for implementation. We did include prostate size in our initial rating tool, but it was removed from our final rating tool based on the limited perceived relevance to catheter duration among the panelists. Furthermore, we did not specifically inquire regarding anticoagulation, although this is typically temporarily discontinued for the majority of patients undergoing this surgery. Last, we did not include all BPH surgery types in our literature review or appropriateness ratings. Although patients having prostate enucleation, by virtue of the degree of tissue removal, may slightly differ from the general population having transurethral resection surgery (eg, larger gland size), the panel felt that catheter management strategies afterward should be largely similar to other transurethral surgery approaches. Overall, our findings are relevant to the majority of transurethral prostate resection, ablation, and enucleation surgery types.

We defined clinically relevant guidance statements for the appropriateness of catheter duration after transurethral prostate surgery. Findings from our robust methodological approach, including urethral catheter removal and trial of void on POD 1 being rated as appropriate for all scenarios except clinically significant perforations, may help promote the consistency and quality of care for patients undergoing transurethral surgery for BPH within and across healthcare delivery systems.

The authors thank Helen McGuirk for her assistance with coordination of the panels, and they also thank all of the panelists who participated in this project.

 VA Center for Clinical Management Research, VA Ann Arbor Healthcare System (TAS, KEF, SJB, JM), Ann Arbor, MI; Department of Urology, University of Michigan (TAS, CAD), Ann Arbor, MI; Division of General Medicine, Department of Internal Medicine, University of Michigan (JDM, SJB, JM), Ann Arbor, MI; School of Public Health, University of Michigan (SJB), Ann Arbor, MI; Division of General Pediatrics, Department of Pediatrics and Communicable Diseases, University of Michigan (JM), Ann Arbor, MI.

 This panel was funded by a contract from the Agency for Healthcare Research and Quality (AHRQ) (HHSA2902010000025I/HHSA29032001T). The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the AHRQ or the Department of Veterans Affairs.

 This work was accepted as a moderated poster for the 2017 Annual Meeting of the American Urological Association in Boston, Massachusetts.

 Dr Meddings is an investigator for an AHRQ subcontract for development and implementation of an intervention to prevent catheter-associated urinary tract infection in the intensive care unit setting. Her research involves development of products to improve patient safety by reducing hospital-acquired complications. Her team has a provisional patent involving one of these products (US20180339133A1). She has no associations with any companies or manufacturers, has no ownership in a commercial entity, and receives no royalties. The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

 Concept and design (TAS, KEF, JM); acquisition of data (TAS, KEF, JM); analysis and interpretation of data (TAS, CAD, KEF, SJB, JM); drafting of the manuscript (TAS, CAD, SJB); critical revision of the manuscript for important intellectual content (TAS, CAD, KEF, JDM, SJB, JM); provision of patients or study materials (TAS, JM); obtaining funding (JM); administrative, technical, or logistic support (TAS, KEF, JDM); and supervision (TAS, JM).

 Ted A. Skolarus, MD, MPH, University of Michigan, Taubman Center, Room 3875, 1500 E Medical Center Dr, SPC 5330, Ann Arbor, Michigan 48109. Email: tskolar@med.umich.edu.

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Articles

This manuscript synthesizes findings from a multidisciplinary panel following the RAND/UCLA Appropriateness Method to guide standardization of urinary catheter use after transurethral prostate surgery.

Karen E. Fowler, MPH

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Catheter Management After Benign Transurethral Prostate Surgery: RAND/UCLA Appropriateness Criteria