Indwelling urethral catheters (IUCs) are inserted in approximately 15–25% of all hospitalised patients mainly to assist clinicians to accurately monitor urine output during acute illness or following surgery, to treat urinary retention and for investigative purposes. However, this procedure is associated with significant morbidity. Although research has focused on the type and maintenance of urinary catheters and techniques for insertion, limited attention has been given to the procedures for their removal, in particular whether the time of day the IUC is removed influences patient outcomes. There is no consensus among clinicians about the optimal time for removal of IUCs, rather practices tend to be based on personal preference and tradition rather than on evidence from research.
The objective of this review was to determine whether the timing of the removal of IUCs influences patient outcomes. The primary outcomes of interest included duration to and volume of first void; length of hospitalisation; number of patients developing urinary retention and number requiring recatheterisation. Secondary outcome measures included patient satisfaction and the percentage of IUCs removed according to the scheduled time for removal.
A literature search was performed using the following databases Medline (1966–2000), CINAHL (1982–2002), Nursing Collection (1995–2002), EMBASE (1980-current) and the Cochrane Controlled Trials Register (Issue 2, 2002 of Cochrane Library). In addition, the reference lists of relevant trials and conference proceedings were also scrutinised. No language restrictions were applied. Company representatives, experts and investigators were contacted to elicit further information.
All published and unpublished randomised and quasi-randomised controlled trials that compared the effects of the timing of removal of short-term IUC on patient outcomes were considered for inclusion in the review. Trials were included if they reported objective measures of time to and volume of the first void, length of hospital stay (number of hours from removal of the IUC to discharge), the number of patients who developed urinary retention following the removal of the IUC and the incidence of recatheterisation. Trials that included subjective measures of patient satisfaction were also considered for inclusion in the review.
Data collection and analysis
Eligibility of the trials for inclusion in the review, details of eligible trials and the methodological quality of the trials was assessed independently by two reviewers. All information was verified by a third reviewer. Odds ratios for dichotomous data and weighted mean differences for continuous data were calculated with 95% confidence intervals. Where synthesis was inappropriate a narrative overview was undertaken. Trials were grouped according to the types of operation.
Eight randomised controlled trials comparing the effectiveness of early morning versus late night removal of IUCs were eligible for this review. Four trials (three following urological surgery and procedures and one involving patients following gynaecological surgery) demonstrated a statistically significant increase in the volume of the first void in patients whose IUCs were removed late at night compared to those removed in the morning. In the two trials on patients following transurethral resection of the prostate (TURP) there was no statistically significant difference in the volume of the first void.
One trial that involved patients having gynaecological surgery reported that the time to first void was shorter when the IUC was removed at midnight (median 3 h 20 min) compared to early morning (median 5 h) (P = 0.012). Three trials undertaken on patients following urological surgery and procedures reported the time to first void was longer in patients whose IUCs were removed at midnight compared to those removed in the morning with all three trials demonstrating a statistically significant difference. The time to first void was shorter following TURP when IUCs were removed in the morning, although these results were not statistically significant. Patients who had their IUC removed at midnight were discharged from hospital significantly earlier (P < 0.00001) than those who had their IUC removed in the morning, which would result in potential cost savings for the hospitals.
Based on the limited available evidence, this review suggests a benefit in terms of patient outcomes and reduction in the length of hospitalisation following midnight removal of the IUCs. Further trials should be undertaken in wider settings and on specific groups of patients to enhance generalisability. The trials should also examine the efficacy of midnight or early morning IUC removal compared to removal at any time of the day.