As-needed use reduces painful, bloody urination
Getting rid of routine bladder catheterization improved outcomes for people undergoing atrial fibrillation (Afib) ablation, a single-center randomized trial showed.
Use on an as-needed basis, rather than routinely, reduced risk of cystitis, urethral injury, hematuria, dysuria, or urinary retention (56% vs 14%, P<0.001) -- driven by less hematuria and dysuria, according to Parin Patel, MD, of St. Vincent Hospital in Indianapolis, and colleagues reporting in JACC: Clinical Electrophysiology.
Independent predictors of that primary composite outcome were routine catheterization (adjusted OR 10.5, 95% CI 4.5-24) and male gender (adjusted OR 5.4, 95% CI 2.1-13).
"Placement of an indwelling urinary catheter is standard of care for longer surgical procedures, especially in cases of general anesthesia. However, in this study, we show that routine use of bladder catheters is unnecessary for Afib ablations and is associated with a higher risk of adverse outcomes," the authors concluded.
"Though some centers are starting to avoid routine catheterization, our study is the largest randomized controlled trial that provides data about the safety and efficacy of this strategy," they said. "By systematically changing the way we perform Afib ablation procedures, we can positively affect the long-term outcomes of our patients. This can result in significant cost savings to the health care system."
Bladder catheterization equipment alone costs $110 per kit at their institution, they said.
This was a single-center trial of 160 consecutive patients presenting for Afib ablation under general anesthesia at Patel's institution. All received pulmonary vein isolation, with nearly half receiving an additional arrhythmia ablation as well.
The average procedure lasted roughly 3 hours, which may be short enough for patients to go without needing an indwelling bladder catheter to relieve urine.
"Several technologic advances could explain our dramatically shorter procedure duration with almost 100 minutes saved compared to early reports of Afib ablation," according to the investigators, citing high-density mapping, irrigation-minimizing algorithms, higher power and shorter duration lesion sets, and improved laboratory workflow.
People were randomized to get a standard indwelling bladder catheter or only intermittent straight catheterization when bladder ultrasound performed every 4 hours post-procedure showed a residual volume over 400 mL.
The two study arms shared similar patient demographics. Mean age was 63 years, and one in three participants were women.
On subgroup analysis, men had a strong association with worse outcomes if they were randomized to bladder catheterization (OR 14.6, 95% CI 5.6-38.1). This was not a significant trend for women, however.
"Although subgroup analysis indicated no harm in female subjects, catheterization remained significantly associated with the primary outcome in the multivariable model even after adjusting for gender. The primary reason for the use of bladder catheterization is the concern about urinary retention and bladder/kidney injury, and our data shows no increased risk of urinary retention with omission of the bladder catheter even in prolonged complex cases," according to Patel's team.
Patients who did not get routine bladder catheters often wound up not needing one.
Three out of 80 received straight catheterization at the end of the procedure per operator preference and without bladder scans; an additional person was given an indwelling catheter in the middle of the procedure for better hemodynamic monitoring and a concern for baseline heart failure from filling pressures.
The single-center experience limits the generalizability of the results, however, according to Patel and colleagues. They noted exclusion of Afib patients with prostate or bladder cancer or recurrent cystitis, among others.
Patel disclosed no conflicts.
JACC: Clinical Electrophysiology
Source Reference: Ahmed AS, et al "Avoiding bladder catheters during atrial fibrillation ablation" JACC Clin Electrophysiol 2019
Read the original article on Medpage Today: Trial: Bladder Catheters Not Necessary in Afib Ablation Anymore