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Ambulatory Surgical Hemorrhoidectomy--A Solution to Postoperative Urinary Retention? Stuart D. Hoff, M.D., H. Randolph Bailey, M.D., Donald R. Butts, M.D., Ernest Max, M.D., Kenneth W. Smith, M.D., Luis F. Zamora, M.D., Gary B. Skakun, M.D. From the University of Texas Medical School at Houston, Houston, Texas PURPOSE: The most frequent complication of surgical hemorrhoidectomy is urinary retention. This study evaluates the incidence of urinary retention in a series of patients undergoing surgical hemorrhoidectomy in an ambulatory setting. METHODS: The records of all patients undergoing anorectal surgical operative procedures during the calendar year 1990 were reviewed, with particular emphasis on urinary retention and other postoperative complications. RESULTS: Of 201 patients undergoing full surgical hemorrhoidectomy by Colon and Rectal Clinic, 91 percent had operations performed on an ambulatory basis (discharge less than four hours following surgery). Of these 190 patients, only 1 (0.53 percent) required urinary catheterization during the postoperative period. CONCLUSIONS: The ambulatory setting, when combined with careful patient education and perioperative fluid restriction, allows surgical hemorrhoidectomy to be performed with a very low incidence of urinary retention to the benefit of both patient and surgeon. [Key words: Hemorrhoidectomy; Ambulatory surgery; Urinary retention] Hoff SD, Bailey HR, Butts DR, Max E, Smith KW, Zamora LF, Skakun GB. Ambulatory surgical hemorrhoidectomy--a solution to postoperative urinary retention? Dis Colon Rectum 1994;37:1242-1244. norectal surgical procedures have traditionally b e e n performed in an inpatient hospital setting. Pressures for cost containment during recent years have caused m a n y operations to be m o v e d to an ambulatory environment. Most surgeons have b e e n hesitant to add surgical hemorrhoidectomy to the list of outpatient procedures because of concerns regarding pain control and postoperative urinary retention. In 1983, a limited n u m b e r of anorectal surgical procedures were performed on ambulatory patients. Initially, hemorrhoidal excisions were limited to a single column in motivated patients w h o exhibited g o o d pain tolerance and had no urinary obstructive symptoms. As experience grew, it was a pleasant surprise to discover that both patient and surgeon

benefited w h e n the operations were performed on an outpatient basis, with almost complete absence of urinary retention. This report describes our clinic's experience with ambulatory surgical hemorrhoidectomy.

METHODS Data

Collection

Data were collected on all anorectal surgical procedures performed by Colon and Rectal Clinic (Houston, Texas) during the 1990 calendar year. Patients discharged from the Day Surgery Unit within four hours of surgery were considered outpatients. All patients undergoing excisional hemorrhoidectomy, either alone or in combination with another procedure, were evaluated,and the incidence of postoperative urinary retention requiring catheterization was determined.

A

Perioperative Care

Read at the meeting of The American Society of Colon and Rectal Surgeons, Chicago, Illinois, May 2 to 7, 1993. Address reprint requests to Dr. Bailey: 6550 Fannin, Suite 2307, Houston, Texas 77030.

Perioperative guidelines were established and used, attempting to decrease patient discomfort and anxiety. Preoperative teaching was emphasized, providing written instructions telling the patient what to expect with surgery and answering most questions that arose. Patients were asked to void immediately before surgery. An absolute minimum volume of balanced salt solution was infused intravenously during the procedure and was discontinued in the postanesthesia care unit. Our goal of infusing less than 250 ml of intravenous fluids was achieved in a high percentage of cases. A general anesthetic or intravenous sedation was combined with infiltration of the anal and perianal areas with local anesthesia (0.25 percent bupivacaine with epinephrine 1:200,000 and hyaluronidase 6

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AMBULATORYSURGICALHEMORRHOIDECTOMY

units/ml; total dose, approximately 50 ml). After excisional hemorrhoidectomy, the wounds were closed with an absorbable suture. Packing was rarely used in the anal canal. Operative procedures included in this report were performed by six attending and four resident surgeons. Patients were discharged upon recovery from the anesthetic. Voiding was not required or requested before discharge. Just before release from the hospital, the first dose of oral analgesic, usually propoxyphene napsylate and acetaminophen tablets (Darvocet N-100 | Eli Lilly and Co., Indianapolis, IN), was given. The same agent was continued at home, supplemented, if needed, by ibuprofen. An ice bag was applied to the operative site for four to eight hours following surgery to lessen swelling and slow absorption of the local anesthetic. Warm sitz baths were begun the evening of surgery and then continued at least three times a day. A phone call was placed to the patient the morning following surgery to answer questions and deal with any problems that might arise. RESULTS During 1990, 208 full (three column) surgical hemorrhoidectomies were performed, of which 18 patients (9 percent) were admitted to the hospital. Reasons for admission are listed in Table 1. None of the hospitalized patients required urinary catheterization solely because of the hemorrhoidectomy. Eight of the nine patients also undergoing a gynecologic operative procedure required catheterization for reasons unrelated to the hemorrhoidectomy. Of the 190 patients undergoing surgery as outpatients, 114 (60 percent) were men and 76 (40 percent) were women. Ages of the patients are depicted in Figure 1. Hemorrhoidectomy alone was performed in Table 1. Hospital Admissions Following Hemorrhoidectomy No.

Second operative procedures requiring admission Hysterectomy Rectocele repair Hysteroscopy Poor pain tolerance (anticipated) Postoperative bleeding (noted in PACU) Distance from home to hospital Total PACU = postanesthesia care unit.

10 7 2 1 4 3 1__ 18

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Figure 1. Age and sex of patients undergoing ambulatory surgical hemorrhoidectomy. 60 percent of patients, whereas 40 percent of patients underwent at least one additional anorectal procedure (Table 2). Of the 190 patients undergoing hemorrhoidectomy in an ambulatory setting, 1 (0.53 percent) required temporary placement of a urinary catheter. A 67-yearold man was catheterized 28 hours following surgery. There were no other complications related to the outpatient setting. DISCUSSION The reported incidence of urinary retention following hemorrhoidectomy, averaging around 15 percent, has ranged from less than one percent to as high as 52 percent of patients. 1-5 Urinary retention is feared by many patients because of the perceived discomfort of urinary catheterization. The exact etiology of urinary retention following anorectal surgery is unknown but may be caused by dysfunction of the detrusor muscle or the trigone of the bladder in response to pain or distention of the Table 2. Surgical Procedures Procedure

No. of Patients (%)

Hemorrhoidectomy only Hemorrhoidectomy and sphincterotomy Fistulotomy Sphincterotomy and fistulotomy Sphincterotomy and drainage of abscess Anoplasty Other anorectal procedures Total concomitant procedures Total Hemorrhoid Procedures

114 (60) 39 (21) 19 (10) 6 (3) 3 (1.5) 3 (1.5) 6 (3) 76 (40) 100

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HOFF E T A L

anal canal or perineum. 6' ; Reflex urethral spasm has also been implicated by some investigators. 8 Even in patients not exhibiting acute urinary retention, an increased residual volume and disturbances of the urinary flow rate may be more c o m m o n than is generally appreciated. 9 Restriction of fluids to avoid acute urinary retention following anorectal surgery was first championed by Hopping. 1~Many studies have since displayed its benefit. 11-13 Bailey and Ferguson 14 reported reduction of postoperative urinary retention from 15 percent to 4 percent of patients who had restriction of both intravenous and oral fluids. Perioperative fluid restriction can reduce the flow of urine into the bladder to 20 to 25 ml/hour. Desire to void typically occurs at bladder volumes of 250 to 300 ml, with normal bladder capacity being 400 to 500 ml. If the bladder is emptied before surgery and perioperative fluids are appropriately restricted, 18 to 24 hours should pass before bladder capacity is reached. By also instructing patients that pelvic discomfort might be interpreted as the need to void and reassuring them that they would be able to void, Bailey and Ferguson 14 showed a decreased incidence of urinary retention. Nursing personnel should not inquire excessively about the need to urinate following surgery, and the patient need not urinate before leaving the Day Surgery Unit. These measures reduce patient concern regarding bladder function, as anxiety about voiding may increase the probability of urinary retention. Most patients are more comfortable and relaxed in their home's familiar surroundings. Hospitalized patients feel a loss of control, leading to anxiety that may be lessened by the outpatient setting. Warm water tub baths, not easily available in many hospitals, are a great aid in postsurgical pain control and may even allow the patient to relax enough to urinate. In summary, there are several factors that may play a role in the low incidence (0.53 percent) of urinary retention following hemorrhoidectomy reported in this series. The proper management of fluids in the perioperative period seems to play a major role, as reported by other series. Beyond that, however, is the

Dis Colon Rectum, December 1994

need for patient comfort and relaxation, which is best achieved at home. We believe that the outpatient environment provides the final piece in the puzzle of solving the problem of postoperative urinary retention.

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