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Catheter Management After Benign Transurethral Prostate Surgery: RAND/UCLA Appropriateness Criteria
Ted A. Skolarus, MD, MPH; Casey A. Dauw, MD; Karen E. Fowler, MPH; Jason D. Mann, MSA; Steven J. Bernstein, MD, MPH; and Jennifer Meddings, MD, MS
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Catheter Management After Benign Transurethral Prostate Surgery: RAND/UCLA Appropriateness Criteria

Ted A. Skolarus, MD, MPH; Casey A. Dauw, MD; Karen E. Fowler, MPH; Jason D. Mann, MSA; Steven J. Bernstein, MD, MPH; and Jennifer Meddings, MD, MS
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.
ABSTRACT

Objectives: 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.

Study Design: RAND/UCLA Appropriateness Methodology.

Methods: 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).

Results: 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.

Conclusions: 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.

Am J Manag Care. 2019;25(12):e366-e372
Takeaway Points

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.1 The procedure is performed using various approaches and routinely involves urinary catheter placement. Given an increasing focus on appropriateness of care for policy,2 payment,3 quality,4-6 and patient-centered care,7 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.8 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,9-11 relieving them of their 1-point restraint12 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).13,14 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.15 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,16 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.

METHODS

Appropriateness Methodology

We used the RAND/UCLA Appropriateness Method to develop these appropriateness criteria.16 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.17,18 The methodology couples scientific evidence for a given practice—in this case, urinary catheterization after transurethral prostate surgery—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.19-21 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.22 Finally, managed care and accountable care organizations are increasingly adding metrics involving appropriateness of care (eg, appropriate diagnostic imaging services)2,6,23 for quality assessment, and even value-based purchasing programs for their beneficiaries’ providers, making this approach and its findings relevant and timely.24

Literature Review

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 (Figure 1). 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 (eAppendix Table 1 [eAppendix available at ajmc.com]), highlighting outcomes of interest. We also provided the team with an overview of transurethral surgical procedures for treating BPH from UpToDate25 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).


 
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