Tamsulosin in the Prevention of Postoperative Urinary Retention After Laparoscopic Inguinal Hernia Repair

Abstract

Postoperative urinary retention (POUR) is a common complication after inguinal hernia repair (IHR). POUR is defined as the inability to urinate, which is treated with urinary straight or indwelling catheterization in the postoperative period. Laparoscopic totally extraperitoneal (LTEP) repair has the advantage of less incisional pain and need of narcotics, quicker recovery and resumption of daily activity, and more satisfaction when compared to open IHR, though it carries a risk of POUR up to 22%,¹ which could result in urinary catheterization, urethral injury, risk of urinary tract infection, prolonged hospital stay, and decreased patient satisfaction. POUR poses significant challenges in rural settings due to difficulty in transportation and limited access to after-hours surgical care.

The increased risks of POUR from LTEP IHR are attributed to general anesthesia and near the bladder dissection. Tamsulosin is an alpha 1 adrenergic blocking agent that relaxes smooth muscle in the bladder neck and prostate, resulting in improvement in urine flow rate and a reduction in symptoms of benign prostatic hypertrophy (BPH). The half-life of tamsulosin is 9 to 13 hours.² The effect of tamsulosin in the prevention of POUR after LTEP IHR has not yet been reported. We hypothesize that the perioperative use of tamsulosin is safe and effective in the prevention of POUR.

This was a retrospective analysis of prospectively collected data from patients who underwent LTEP IHR by a single surgeon in a rural hospital from November 2018 to April 2020. Inclusion criteria pertained to patients who were 18 years or older with unilateral or bilateral inguinal hernia. Exclusion criteria were the recent diagnosis of urethral trauma, the procedure of bladder or prostate, Foley catheter dependent status, or a history of chronic use of tamsulosin. A total of 3 doses of Flomax (.4 mg each tablet) was prescribed for patients to take orally for 3 consecutive days starting the day prior to LTEP IHR. A bladder scan would be performed if there was no voiding 3 hours after completion of the procedure. The data were analyzed using the IBM SPSS Statistics version 21 software for the independent samples T test. The descriptive statistics were expressed as mean ± SE.

A total of 30 male patients met the inclusion criteria. The average age (years) and body mass index (BMI) (kg/m²) were 60.1 ± 3.2 and 26.1 ± .7, respectively. The average American Society of Anesthesiologists score was 2.3 ± .6. The average duration of the anesthesia and procedure was 129 ± 6 minutes and 89 ± 6 minutes, respectively. Twenty-two patients had the unilateral, while 8 patients underwent the bilateral LTEP IHR. The average procedure time for the unilateral LTEP IHR was 84 minutes. It took an average of additional 22 minutes for the contralateral IHR (Table 1). There was no statistically significant difference in the time to void after completion of the procedure between the unilateral and bilateral repair groups (148 vs. 187 minutes). All patients in the study successfully voided prior to discharge from the ambulatory unit without a need of catheterization. There were no reported adverse events, including orthostatic reaction-related complications from the patients who took the perioperative tamsulosin. Although patients with bilateral IHR appeared older than those with unilateral IHR (66 ± 5, n = 8 vs. 58 ± 4, n = 22, P = .187), tamsulosin demonstrated the similar effect of voiding, regardless of the age difference.

Table 1.

Demographic and Clinical Characteristics of Patients Undergoing LTEP IHR.a

	Age (year)	BMI (kg/m²)	Procedure time	Anesthesia time	Postoperative void time
Unilateral (n = 22)	58 ± 4	26.3 ± 0.9	84 ± 7	123 ± 7	148 ± 24
Bilateral (n = 8)	66 ± 5	25.5 ± 1.2	106 ± 13	146 ± 13	187 ± 51

Abbreviations: LTEP, laparoscopic totally extraperitoneal; IHR, inguinal hernia repair; BMI, body mass index.

All time units are minutes.

POUR is a significant complication after laparoscopic IHR with an overall incidence rate up to 22%.¹ A study of 153 patients undergoing laparoscopic IHR reported that both the narcotic analgesia and the volume of intravenous postoperative fluid are risk factors that contribute to the high rate of POUR.¹ A recent retrospective study of 578 patients who underwent laparoscopic IHR identified other risk factors such as age of greater than 60 years, BPH, decreased BMI, and urinary tract infection within 30 days.³ To the best of our knowledge, this is the first study to date exploring the perioperative pharmacological prevention of POUR after LTEP IHR in a rural setting. The patients in this study exhibited similar preoperative risk factors related to developing POUR as reported,^3,4 which includes ages above 50, bilateral IHR, decreased BMI (<25.8 k/m²), etc. Tamsulosin has been shown to have some benefit in reducing POUR in men undergoing open IHR and other outpatient urologic procedures.^2,4 This positive impact was observed in patients when tamsulosin was given postoperatively following LTEP IHR. In this study, the perioperative use of tamsulosin was well tolerated by patients. This could be partially explained by the relatively short course (3-day doses). We observed early voiding in all patients (3 hours or less) which facilitated early discharge from the ambulatory unit. The preoperative tamsulosin is safe and effective in the prevention of POUR after LTEP IHR. A large prospective randomized study is required to further validate the prophylactic effect of tamsulosin.

Footnotes

Author’s Note

This study was presented at SESC meeting in New Orleans. It highlights the benefits of using Tamsulosin in the perioperative period of laparoscopic inguinal hernia repair.

Acknowledgments

We are grateful to Dr John Ferrara for his input and advice in regard to this study. We thank William Alley, RN, Amy Dilon, RN, Cindy Sluss, RN, and Joyce Jones, RN for data acquisition and protocol implementation. We thank Jessica C Wei for editing the manuscript.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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