全关节置换术中导尿管拔除前的膀胱训练：一项随机对照试验

Bladder training prior to urinary catheter removal in total joint arthroplasty.A randomized controlled tria

全关节置换术中导尿管拔除前的膀胱训练

一项随机对照试验

Abstract

Background

Urinary catheters are commonly used in patients undergoing total hip and knee arthroplasty. Bladder training before catheter removal is reported to shorten the time to return to normal bladder function and reduce the incidence of urinary retention.

Objective

To evaluate the results of bladder training in patients with total hip and knee arthroplasty.

Design

Randomized controlled trial.

Setting

Orthopaedic Department of a tertiary Military Hospital.

Participants

We enrolled consecutive patients undergoing total hip or knee arthroplasty during a period of 14 months.

Methods

We randomly allocated the participants into either a bladder training group, in which clamping was considered prior to catheter removal, or a free drainage removal group, using a computer-generated list and subsequently assessed their need for re-catheterization due to urinary retention. The primary outcome of this study was to evaluate if bladder training in patients with total hip and knee arthroplasty reduces the need for re-catheterization due to urinary retention. Multivariable logistic regression was used to model the association between postoperative urinary retention and independent variables (total hip or total knee arthroplasty, age, gender, and history of diabetes mellitus or prostatism). Secondary outcomes were the incidence of urinary tract infection, and subjective patients’ symptoms.

Results

We included 218 patients in the study; 114 in the bladder training group and 104 in the free drainage removal group. All patients were over 50 years old with a mean age of 69.3 (SD=8) years. We observed three cases of urinary retention in the bladder training and six in free drainage removal group, and the difference was not statistically significant (2.6% and 5.8% respectively, p=0.316). We also observed increased odds of re-catheterization in patients with prostatism under medication (odds ratio was 26.42, p<0.001). No infections or major subjective symptoms were noted.

Conclusion

This trial shows that bladder training by catheter clamping offers no advantage over free draining removal of short-term urinary catheters in patients with total hip and knee arthroplasty. Therefore, we conclude that the bladder training procedure is not indicated. However, healthcare providers should monitor patients’ urination after removal of the catheter.

Keywords: bladder training; Foley catheter removal; urinary retention; total joint arthroplasty

摘要

背景：

导尿管通常用于进行全髋关节和膝关节置换术的患者。据报道，导管拔除前的膀胱训练可缩短恢复正常膀胱功能的时间并减少尿潴留的发生率。

目的：

评估全髋关节和膝关节置换术患者的膀胱训练结果。

设计：随机对照试验。

研究地点：骨科高等军事医院。

研究对象：在14个月内接受全髋关节或膝关节置换术的患者。

方法

我们使用计算机生成的列表将患者随机分配到自由引流组和膀胱训练组中，膀胱训练组中患者在导管移除之前使用钳夹进行训练，随后评估他们由于尿潴留而再次导尿的需要。这项研究的主要结果是评估全髋关节和膝关节置换术患者的膀胱训练是否减少了因尿潴留导致再次导尿的需要。多变量logistic回归用于模拟术后尿潴留与自变量（全髋关节或全膝关节置换术，年龄，性别和糖尿病或前列腺病史）之间的关联。次要结果是尿路感染的发生率和患者的其他不良症状。

结果

我们纳入了研究中的218名患者;膀胱训练组114例，自由排水组104例。所有患者年龄均超过50岁，平均年龄为69.3（SD = 8）岁。我们在膀胱训练中观察到3例尿潴留，在自由引流清除组中观察到6例，差异无有统计学意义（分别为2.6％和5.8％，p = 0.316）。我们还观察到在服药期间前列腺炎患者再次插管的几率增加（优势比为26.42，p <0.001）。未发现任何感染或主观症状。

结论

该试验表明，通过导管夹持进行膀胱训练与完全髋关节和膝关节置换术患者的自由引流去除短期导尿管相比没有任何优势。因此，我们得出结论，该研究没有形成膀胱训练程序。然而，医疗保健提供者应在移除导管后监测患者的排尿情况。

关键词：膀胱训练;Foley导管切除;尿潴留;全关节置换术

Introduction

Patients undergoing total hip and knee arthroplasty may have difficulty or inability to urinate because of confinement in bed and postoperative pain. Male gender, intrathecal morphine and supplementary epidural anesthesia are additional risk factors, increasing the incidence of urinary retention up to 67% (Griesdale et al., 2011, Williams et al., 1995). Because of these difficulties, short-term urinary catheters are inserted before surgery and removed as soon as possible postoperatively.

前言：

由于床上空间的限制和术后疼痛的折磨，接受全髋关节和膝关节置换术的患者可能很难或无法排尿。男性在鞘内注射吗啡和补充硬膜外麻醉后也会排尿困难，这使尿潴留发生率增加至67％。由于这些困难，应在术前插入短期导尿管并在术后尽快切除。

Bladder training by intermittent clamping before catheter removal is reported to shorten the time to return to normal bladder function and reduce the incidence of urinary retention (Roe, 1990). However, there is no consensus on its use; a Cochrane review reported inconclusive evidence, and a more recent meta-analysis concluded that higher quality trials are needed to draw conclusions (Griffiths and Fernandez, 2007, Wang et al., 2016). Moreover, the effectiveness and safety of bladder training in total joint arthroplasty is not yet assessed.

据报道，在导管拔除前通过间歇钳夹进行膀胱训练可缩短恢复正常膀胱功能的时间并减少尿潴留的发生率。但是，研究人员对其使用的方式没有达成共识;最近的一项荟萃分析中，Cochrane系统评价报告了不确定的研究结果，需要更高质量的试验来提供证据支撑。此外，尚未评估膀胱训练在全关节置换术中的有效性和安全性。

The purpose of this randomized controlled trial was to evaluate the results of bladder training in patients with total hip and knee arthroplasty, evaluating the incidence of urinary retention after the removal of the catheter, and the occurrence of other adverse effects.

这项随机对照试验的目的是评估全髋关节和膝关节置换术患者的膀胱训练结果，评估拔除导尿管后尿潴留的发生率以及其他不良反应的发生率。

Material and methods

We conducted a prospective randomized controlled trial comparing bladder training by clamping before catheter removal, or free drainage removal. The study was approved by the institutional review board (IRB No 4337/424MGH).

材料与方法

我们进行了一项前瞻性随机对照试验，比较导管拔除前夹紧膀胱训练或自由排水的效果。该研究得到了机构审查委员会（IRB No 4337 / 424MGH）的批准。

Participants and randomization

We included consecutive adult patients undergoing total hip or knee arthroplasty from January 2015 to February 2016 in the Orthopaedic Department of a tertiary Military Hospital. Exclusion criteria were age under 50 years old, and known history of recurrent urinary tract infections, neurogenic bladder, previous urinary retention or voiding dysfunction, and diabetic cystopathy. 

研究对象和随机分组

我们连续招募了2015年1月至2016年2月在骨科高等军事医院进行全髋关节或膝关节置换术的成人患者。排除标准是年龄在50岁以下的，以及复发性尿路感染，神经源性膀胱，既往尿潴留或排尿功能障碍以及糖尿病性膀胱病的已知病史。研究对象的登记是由两名高级整形外科医生根据我们预先确定的纳入和排除标准进行的。所有患者都提供了知情同意书，并被告知他们可以随时退出研究。我们使用计算机生成的列表（www.randomizer.org）将患者随机分配到自由引流组和膀胱训练组中。

The enrollment of the participants was made by two senior orthopaedic surgeons with respect to our pre-determined inclusion and exclusion criteria (i.e, the last two authors). All patients provided informed consent and were informed that they could withdraw from the study at any time. We randomized the patients either in the bladder training group of the free drainage group using a computer-generated list (www.randomizer.org). We ensured allocation concealment using sealed pre-numbered envelopes containing the assignments, which were kept and distributed by the departments’ head nurse. Blinding of nurses and patients to the intervention was not possible.

研究对象的登记是由两名高级整形外科医生根据我们预先确定的纳入和排除标准进行的。所有患者都提供了知情同意书，并被告知他们可以随时退出研究。我们使用计算机生成的列表（www.randomizer.org）将患者随机分配到自由引流组和膀胱训练组中。我们使用包含任务的密封预编号信封确保分配隐藏，这些信封由部门的护士长保存和分发。护士和病人对干预措施视而不见是不可能的。

Procedure

We inserted a Foley catheter to all patients prior to surgery, and we removed the catheter on postoperative day 2. In the bladder training group, we followed the protocol described by Williamson, by clamping the catheter for three hours and then unclamping for five minutes, to allow emptying of the bladder (Williamson, 1982). We started the procedure at 8 am and repeated this procedure three times, for a total of nine hours and ten minutes, before removal. In the free drainage group, the catheter was removed without clamping at 8 am.

流程

我们在手术前向所有患者插入了Foley导管，并在术后第2天取出导管。在膀胱训练组中，我们遵循了威廉姆森描述的方案，将导管夹紧3小时，然后松开5分钟，以排空膀胱。我们在早上8点开始手术，并在移除前重复此过程三次，总共9小时10分钟。在自由引流组中，导管并没有夹紧而被移除。

During the procedure of the bladder training, if a patient felt an urgent need to urinate, a drainage for five minutes was performed, to avoid discomfort. f the drained urine volume during bladder training did not exceed 300 ml, then we used an ultrasound examination of the bladder volume to exclude high residual urine volume and guide the treatment towards oliguria. If the drained urine volume exceeded 500ml, we performed rapid decompression of the bladder and increased the frequency of the catheterization.

在膀胱训练过程中，如果患者感到迫切需要排尿，则进行5分钟的引流，以避免不适。如果膀胱训练时排尿量不超过300ml，则对膀胱进行超声检查，排除高残余尿量，指导治疗少尿。如果排出的尿量超过500ml，我们进行了膀胱的快速减压并增加了导尿的频率。

Given the evidence from a clinical study demonstrating no significant difference in adverse effects between rapid and gradual decompression of the bladder in acute urinary retention, we considered rapid drainage of the bladder to be safe for the patients. It is also documented by manometric studies that the removal of the first 100 ml of urine in cases with acute urinary retention decreases the intravesical pressure approximately 50%, and after this initial substantial decrease in pressure, the intravesical pressure declines only slightly .

鉴于来自临床研究的证据表明急性尿潴留中膀胱的快速和逐渐减压之间的不良反应没有显着差异，我们认为膀胱的快速引流对患者是安全的。通过测压学研究还证明，在急性尿潴留的情况下去除前100毫升尿液会使膀胱内压力降低约50％，并且在压力初始显着降低后，膀胱内压力仅略微下降。

surgical procedures were performed under combined spinal and epidural anesthesia. The epidural catheter remained in place for postoperative analgesia until postoperative day 2 and was removed before the Foley catheter removal. Acetaminophen 1000mg was administered intravenously every six hours and tramadol was administered for additional analgesia if the patient complained about severe pain. Subcutaneous low molecular weight heparin and intravenous cefuroxime were administered according to the department’s protocol to all patients.

所有外科手术均在脊髓和硬膜外联合麻醉下进行。硬膜外导管保留在术后镇痛位置，直到术后第2天，并在Foley导管切除前移除。

每6小时静脉注射对乙酰氨基酚1000mg。

如果患者抱怨严重疼痛，则给予曲马多用于额外的镇痛。根据该部门的方案，对所有患者施用皮下低分子量肝素和静脉内头孢呋辛。

Outcomes

The primary outcome of the study was the need for re-catheterization due to urinary retention. We performed re-catheterization if the patient failed to urinate within 10 hours of catheter removal, if the patient experienced discomfort or if marked distention of the bladder was apparent. Secondary outcomes were the occurrence of symptomatic urinary tract infection, as well as subjective symptoms during and beyond the clamping process, including pain.

结局

该研究的主要结局是患者由于尿潴留而需要再次导尿。如果患者在导管拔除后10小时内未能排尿，当患者出现不适或膀胱明显扩张，我们进行了再次导尿。次要结局是症状性尿路感染的发生，以及夹紧过程中和之后的主观症状，包括疼痛。

Statistical Analysis

The sample size calculation was based on a study which assessed the non-inferiority of bladder training in surgical patients (Fanfani et al., 2015). According to this study, for 80% power with a two-sided type I error of 0.05, a total of 110 patients would be necessary. For the primary outcome, we used Fisher’s exact test to compare the incidence of re-catheterization between the groups. Multivariable logistic regression was used to model the association between postoperative urinary retention and independent variables. Independent variables were chosen a priori based on their potential association with the outcome variable. These variables were the procedure (total hip or total knee arthroplasty), age, gender, and history of diabetes mellitus or prostatism.We used Chi-square or Fischer’s exact test for nominal data and Mann-Whitney test for skewed continuous data for the comparison of baseline characteristics between groups. SPSS software version 24 was used.

统计分析

样本量计算基于一项评估手术患者膀胱训练非劣效性的研究。根据这项研究，对于80％的功率，双侧I型误差为0.05，总共需要110名患者。对于主要结果，我们使用Fisher精确检验来比较各组之间的再次导尿的发生率。多变量逻辑回归用于模拟术后尿潴留与自变量之间的关联。基于它们与结果变量的潜在关联，先验地选择独立变量。这些变量是手术（全髋关节或全膝关节置换术），年龄，性别和糖尿病或前列腺病史。

We used Chi-square or Fischer’s exact test for nominal data and Mann-Whitney test for skewed continuous data for the comparison of baseline characteristics between groups. SPSS software version 24 was used.

我们对名义数据使用卡方检验或Fisher精确检验，对于偏差连续数据使用Mann-Whitney检验，以比较各组之间的基线特征。使用SPSS24软件进行分析。

Results

We included a total of 218 patients in theMANUSCRIPTstudy;114inthebladdertraininggroup and 104 in the free drainage removal group. All patients fulfilled the inclusion and

exclusion criteria, and there were no withdrawals from the study. All patients were over 50 years old with a mean age of 69.3 (SD 8) years. he baseline characteristics of the groups are presented in Table 1. No differences were found between the groups in preoperative demographic data. Of the 18 patients with prostatism, five were treated with tamsulosin 0.4 mg orally once a day, but they did not have symptoms at the preoperative assessment (two in bladder training group and three in free drainage group).

结果

我们在研究中共纳入218名患者;膀胱训练组114例，自由排水组104例。所有患者均符合纳入和排除标准，且未从研究中退出。所有患者均年龄超过50岁，平均年龄为69.3（标准差8）。表1列出了各组的基线特征。术前人口统计学数据组之间未发现差异。在18例前列腺炎患者中，5例每天口服坦索罗辛0.4 mg，但在术前评估时没有症状（膀胱训练组2例，自由引流组3例）。

Primary outcome

We observed three cases of re-catheterization in the bladder training group (2.6%) and six in the free drainage removal group (5.8%). The difference between the groups was not statistically significant (Fisher’s exact test, p=0.316).

主要结果

我们在膀胱训练组中观察到3例再次导尿情况（2.6％），在自由排水组中观察到6例（5.8％）。两组之间的差异无统计学意义（Fisher精确检验，p = 0.316）。

The independent variables which correlated with re-catheterization (p<0.2) and were inserted in the multivariate logistic regression model were age, joint (hip or knee), diabetes and prostatism (Table 2). Prostatism was associated with increased odds of re-catheterization (adjusted odds ratio: 26.42, p<0.001). It is noted that seven of the nine patients with urinary retention were male, with history of prostatism under medication.

All patients subjected to re-catheterization returned to normal bladder function prior to the time of discharge.

与再插管（p <0.2）相关并且插入多变量逻辑回归模型的独立变量是年龄，关节（髋或膝），糖尿病和前列腺（表2）。前列腺增生与再次导尿的可能性增加有关（调整后的比值比：26.42，p <0.001）。我们注意到9例尿潴留患者中有7例为男性，有药物治疗前列腺病史。

所有再次置管的患者出院前膀胱功能恢复正常。

Secondary outcomes

Most of the patients in the bladder training group stated the sensation of bladder filling during the clamping process, but the sensation was painless and none felt an urgent need to urinate. In all cases the drained urine volume exceeded 300 ml, and there was no need of urine culture tests because no patient complained of suspicious symptoms.

次要结果

膀胱训练组中的大多数患者在钳夹过程中表达了膀胱充盈的感觉，但感觉是无痛的，并且没有人感到迫切需要排尿。在所有情况下，排出的尿量超过300毫升，并且不需要进行尿培养测试，因为没有患者报告不良症状。

Discussion

We compared bladder training by intermittent clamping with free drainage removal of the Foley catheter in patients undergoing total hip or knee arthroplasty. Our study shows that bladder training has no effect on the need for re-catheterization in patients undergoing total hip or knee arthroplasty (p=0.316). We observed normal bladder function in patients who were subjected to free drainage removal. We also observed increased odds of re-catheterization in patients with prostatism under medication (odds ratio: 26.42, p<0.001). No infections or major subjective symptoms were noted.

讨论

我们通过间歇性钳夹比较膀胱训练，并在接受全髋关节或膝关节置换术的患者中自由引流去除Foley导管。我们的研究表明，膀胱训练对全髋关节或膝关节置换术患者重新插管的需求没有影响（p = 0.316）。我们观察到经受自由排水的患者具有正常膀胱功能。我们还观察到药物治疗前列腺病患者再次插管的几率增加（优势比：26.42，p <0.001）。未发现任何感染或主观症状。

Our results are consistent with other studies conducted in surgical patients, which showed no difference between these two types of catheter removal procedures in relation to re-catheterization. One study was performed in orthopaedic patients with hip fracture surgery (Nyman et al., 2010). Other studies concerned urogynecology-related surgery, colorectal surgery, and surgical patients in general (Bergman et al., 1987, Fanfani et al., 2015, Oberst et al., 1981, Ratnaval et al., 1996, Sun et al., 2004, Williamson, 1982).

我们的结果与在外科患者中进行的其他研究一致，两种类型的导管拔除方法在再次置管方面没有区别。一项研究是在接受髋关节骨折手术的骨科患者中进行的。其他研究涉及妇科泌尿外科、结直肠外科和一般外科病人。

We noticed a low frequency of postoperative urinary retention requiring re-catheterization in our patients (4.1%). Other studies in total hip and knee arthroplasty patients reported a higher incidence of urinary retention (David et al., 2015, Fernandez et al., 2014, Macdowell et al., 2004, O'Riordan et al., 2000, Tischler et al., 2016, Waterhouse et al., 1987, Williams et al., 1995). This could be explained by the occurrence of additional risk factors in these studies, including male gender, intrathecal morphine, and previous history of outflow symptoms.

我们注意到术后尿潴留的频率较低，需要在我们的患者中重新插管（4.1％）。全髋关节和膝关节置换术患者的其他研究报告尿潴留发生率较高。这可以通过这些研究中出现的其他风险因素来解释，包括男性，鞘内吗啡和既往流出症状史。

There is a divergence in the literature in the use of the bladder training intervention. Williamson proposed the “Q3h” clamping protocol, which includes clamping of the catheter for three hours and unclamping for five minutes, repeated three times, for a total of nine hours and ten minutes (Williamson, 1982). Another proposed protocol, the “Q4h”, includes clamping the catheter and when the patient needs to urinate, the catheter is removed clamped. Then, every fourth hour until normal bladder function resumed, the patients have their bladder scanned with an ultrasound device and if the bladder volume exceeds 450 ml, the patient is re-catheterized.

在使用膀胱训练干预的文献中存在分歧。威廉姆森提出了“Q3h”夹紧方案，其中包括将导管夹紧3小时并松开5分钟，重复3次，总共9小时10分钟。另一个提出的方案“Q4h”，这个方案需要夹紧导管，当患者需要排尿时，导管被夹紧。然后，每隔4小时松开一次，直到恢复正常膀胱功能，患者用超声装置扫描膀胱，如果膀胱体积超过450ml，则将导管重新插入患者体内。

The progressive clamping protocol includes clamping the catheter for increasingly longer periods beginning with a one-hour interval until the maximum four-hour interval after two days; the clamping periods are alternated with drainage periods of 5 to 15 minutes (Bergman et al., 1987, Oberst et al., 1981, Sun et al., 2004). None of these protocols seems to have superior results (Wang et al., 2016). We utilized the “Q3h”, which has been used in other studies, because it is faster than the other two, thus allowing the patients to be mobilized sooner and easier (Fanfani et al., 2015). Also, it does not require the use of an ultrasound device, thus being more flexible for daily practice.

渐进式夹紧方案包括将导管夹持越来越长的时间，从一小时的间隔开始，直到两天后的最大四小时间隔;夹紧周期与排水交替5至15分钟的时间段。这些协议似乎都没有出色的结果。我们使用了其他研究中使用的“Q3h”，因为它比其他两项研究更快，因此可以更快更容易地动员患者。此外，它不需要使用超声设备，因此对于日常练习更灵活。

It is well known that prostatism and diabetes mellitus predispose patients to voiding dysfunctions. Especially diabetes predisposes to a wide range of lower urinary tract dysfunction, from the classic diabetic cystopathy (the triad of decreased bladder sensation, increased bladder capacity, and poor bladder emptying) to urgency incontinence. In the current study, we did not include patients with lower urinary tract complications. The 27 patients with diabetes presented with adequate blood glucose control (preoperative blood glucose between 100 and 180 mg/dL) and no history of urinary tract complications. It is our current practice to delay elective surgery until the blood glucose control improves (preoperative fasting blood glucose less than 200 mg/dL) and we temporarily introduce insulin treatment for better control of blood glucose. With proper management of the blood glucose, studies have found that the perioperative prognosis of patients with diabetes and no diabetic complications is similar to the prognosis in patients without diabetes .

众所周知，前列腺炎和糖尿病使患者容易患排尿功能障碍。尤其是糖尿病易患多种下尿路功能障碍，从典型的糖尿病性膀胱病（膀胱感觉降低，膀胱容量增加和膀胱排空不良三联征）到急迫性尿失禁。在目前的研究中，我们没有招募下尿路并发症的患者。27名糖尿病患者表现出足够的血糖控制（术前血糖在100和180 mg / dL之间）并且没有尿路并发症史。我们目前的做法是延迟择期手术，直到血糖控制改善（术前空腹血糖低于200 mg / dL），我们暂时引入胰岛素治疗以更好地控制血糖。，研究发现，通过适当管理血糖，糖尿病患者和无糖尿病并发症患者的围手术期预后与非糖尿病患者的预后相似。

As life expectancy increases, an even larger number of patients will require total joint arthroplasty. Therefore, it is critical to optimize all aspects of treating such patients, one aspect being the strategy of removing the Foley catheter. Our study implies that bladder training by clamping is not necessary for returning to normal bladder function after catheter removal. The procedure of clamping, although not an expensive procedure, increases the workload of the nursing staff. Furthermore, it prolongs the duration of catheterization and the risk of related complications, such as infection or urinary tract injury (Colli et al., 2014).

随着预期寿命的增加，更多的患者将需要全关节置换术。因此，全面优化治疗这些患者是至关重要的，其中一方面是优化去除Foley导管的策略。我们的研究意味着在移除导管后，通过夹紧进行膀胱训练不需要恢复正常的膀胱功能。夹紧程序虽然并不昂贵，但增加了护理人员的工作量。此外，它延长了导管插入的持续时间和相关并发症的风险，例如感染或尿路损伤。

The strong point of our study is that the MANUSCRIPTanaesthetic,surgical,andnursingpractices described are commonly performed in orthopaedic centres with large numbers of patients. Combined with the large sample size and the randomization process, our results can be generalized to the general population. Then again, our study has certain limitations. Firstly, blinding patients and nurses was not possible, introducing a possibility of observer bias.

我们研究的重点是，麻醉、手术和护理实践所描述的通常是在骨科中心进行的大量病人。结合大样本量和随机化过程，我们的结果可以推广到一般人群。然后，我们的研究有一定的局限性。首先，护士和病人对干预措施视而不见是不可能的，这有引入观察者偏见的可能性。

Secondly, the procedures were not performed by a single researcher, because nurses varied according to their shifts. hirdly, although severe bladder dysfunction disorders can be safely diagnosed using ultrasound or urodynamic studies, we just relied on patients’ medical history to determine our exclusion criterion on severe bladder dysfunction, including diabetic cystopathy. The rationale behind this decision was that we aimed to have conclusions comparable and applicable by other orthopaedic centres and surgeons in the mainstream of the clinical practice. 

其次，试验流程不是由一名研究人员进行的，因为护士根据他们的班次而变化。第三，虽然可以使用超声或尿动力学研究安全地诊断严重的膀胱功能障碍，但我们只依靠患者的病史来确定我们对严重膀胱功能障碍的排除标准，包括糖尿病性膀胱病。这一决定背后的理由是，我们的目标是得出其他骨科中心和外科医生在主流临床诊断方式中具有可比性和适用性的结论。

Finally, it is true that with current techniques the patients begin weight bearing as tolerated immediately. However, we currently use short-term Foley catheters, because patients undergoing total hip or knee arthroplasty experience significant perioperative pain, despite the use of a pre-emptive multimodal pain management approach (Gaffney et al., 2017). This pain may result in inability to properly urinate. All that, combined with the use of spinal with or without supplementary epidural anesthesia, increases the risk of urinary retention, especially in male patients (Griesdale et al., 2011). Such difficulties in urinating may result in decreasing the patient’s satisfaction with the procedure. 

最后，通过现有技术，患者立即开始承受耐受性。然而，我们目前使用短期Foley导管，因为尽管采用了先发制人的多模式疼痛管理方法，但接受全髋关节或膝关节置换术的患者仍会出现明显的围手术期疼痛。这种疼痛可能导致无法正常排尿。所有这些，再加上使用或不使用辅助硬膜外麻醉，都会增加尿潴留的风险，特别是在男性患者中。排尿时的这些困难可能导致患者对手术的满意度降低。

 We also believe that our results may reflect on the need of bladder training in other types of surgery under combined spinal and epidural anesthesia or even in complex cases, monitoring the patient’s urine flow may help in intraoperative and postoperative fluid management.

我们还认为，我们的结果可能反映了在脊柱和硬膜外联合麻醉下甚至在复杂病例中进行其他类型手术的膀胱训练的需要，监测患者的尿流量可能有助于术中和术后的液体管理。

Conclusion

Our results show that bladder training by catheter clamping has no advantage over free draining removal of short-term urinary catheters in patients with total hip and knee arthroplasty. We observed normal bladder function in patients who were subjected to free drainage removal. We also observed increased odds of re-catheterization in patients with prostatism under medication. We conclude that the bladder training procedure is not indicated. However, healthcare providers should monitor patients’ urination after removal of the catheter.

结论

我们的研究结果表明，对于全髋关节和膝关节置换术患者，通过导管夹持进行膀胱训练对于自由引流去除短期导尿管没有优势。我们观察到经受自由排水的患者具有正常膀胱功能。我们还观察到药物治疗前列腺病患者再次插管的几率增加。我们得出结论，该试验没有形成膀胱训练程序。然而，医疗保健提供者应在移除导管后监测患者的排尿情况。