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Base de datos Cochrane de Revisiones Sistemáticas Revisión - Intervención

Estrategias para el retiro de sondas uretrales permanentes de corta duración en adultos

Declaraciones de intereses de los autores

Versión publicada: 29 junio 2021 Historial de versiones

https://doi.org/10.1002/14651858.CD004011.pub4
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Antecedentes

El sondaje urinario es un procedimiento frecuente, ya que aproximadamente a entre el 15% y el 25% de todas las personas ingresadas en el hospital se les realiza un sondaje uretral permanente de corta duración (14 días o menos) en algún momento de la atención. Sin embargo, el uso del sondaje urinario se asocia con un mayor riesgo de aparición de infección urinaria. La infección urinaria asociada con el sondaje (IUAS) es una de las infecciones nosocomiales más frecuentes. Se calcula que alrededor del 20% de las bacteriemias nosocomiales provienen del tracto urinario y se asocian con una mortalidad de alrededor del 10%.

Esta es una actualización de una revisión Cochrane publicada por primera vez en 2005 y actualizada por última vez en 2007.

Objetivos

Evaluar los efectos de las estrategias para el retiro de sondas permanentes de corta duración (hasta 14 días) en adultos.

Métodos de búsqueda

Se realizaron búsquedas en el Registro especializado del Grupo Cochrane de Incontinencia (Cochrane Incontinence) que contiene ensayos identificados en CENTRAL, MEDLINE, MEDLINE In‐Process, MEDLINE Epub Ahead of Print, CINAHL, ClinicalTrials.gov, la ICTRP de la OMS y búsquedas manuales en revistas y resúmenes de congresos (búsqueda del 17 de marzo de 2020) y en las listas de referencias de artículos relevantes.

Criterios de selección

Se incluyeron todos los ensayos controlados aleatorizados (ECA) y ensayos cuasialeatorizados que evaluaron la efectividad de las prácticas empleadas en el retiro de sondas uretrales permanentes a corto plazo en adultos por cualquier motivo y en cualquier contexto.

Obtención y análisis de los datos

Dos autores de la revisión realizaron el cribado de los resúmenes y del texto completo de todos los artículos pertinentes. Dos autores de la revisión, de forma independiente, realizaron la evaluación del riesgo de sesgo, la extracción de los datos y la evaluación con el método GRADE.

Resultados principales

Se incluyeron 99 ensayos con 12 241 participantes. Se consideró que la mayoría de los ensayos tuvo riesgo bajo o incierto de sesgo de selección y detección y riesgo alto de sesgo de realización. También se consideró que la mayoría de los ensayos tuvo un riesgo bajo de sesgo de desgaste y de notificación. Ninguno de los ensayos informó sobre la calidad de vida. La mayoría de los participantes de los ensayos se había sometido a algún tipo de procedimiento quirúrgico.

Trece ensayos con 1506 participantes compararon la extracción de sondas uretrales permanentes de corta duración en un momento del día (grupo de retiro a primera hora de la mañana, entre las 6:00 y las 7:00) versus otro (grupo de extracción a última hora de la noche, entre las 22:00 y la medianoche). La extracción de la sonda a última hora de la noche podría reducir ligeramente el riesgo de necesitar un nuevo sondaje en comparación con la extracción a primera hora de la mañana (razón de riesgos [RR] 0,71; intervalo de confianza [IC] del 95%: 0,53 a 0,96; diez ECA, 1920 participantes; evidencia de certeza baja). No se sabe si hay alguna diferencia entre el retiro a primera hora o a última hora del día en el riesgo de aparición de IUAS sintomática (RR 1,00; IC del 95%: 0,61 a 1,63; un ECA, 41 participantes; evidencia de certeza muy baja). No se sabe con certeza si el momento del día influye en el riesgo de disuria (RR 2,20; IC del 95%: 0,70 a 6, 86; un ECA, 170 participantes; evidencia de certeza baja).

Las duraciones cortas versus prolongadas del sondaje se compararon en 68 ensayos con 9247 participantes. Las duraciones más cortas podrían aumentar el riesgo de necesitar un nuevo sondaje comparadas con las más prolongadas (RR 1,81; IC del 95%: 1,35 a 2,41; 44 ensayos, 5870 participantes; evidencia de certeza baja), pero probablemente reducen el riesgo de IUAS sintomática (RR 0,52; IC del 95%: 0,45 a 0,61; 41 ECA, 5759 participantes; evidencia de certeza moderada) y podrían reducir el riesgo de disuria (RR 0,42; IC del 95%: 0,20 a 0,88; siete ECA, 1398 participantes; evidencia de certeza baja).

Siete ensayos con 714 participantes compararon las políticas de pinzamiento de la sonda versus drenaje libre. Podría haber poca o ninguna diferencia entre pinzar la sonda y dejar el drenaje libre con respecto al riesgo de necesitar un nuevo sondaje (RR 0,82; IC del 95%: 0,55 a 1,21; cinco ECA, 569 participantes; evidencia de certeza baja). No se sabe si hay alguna diferencia en el riesgo de aparición de IUAS sintomática (RR 0,99; IC del 95%: 0,60 a 1,63; dos ECA, 267 participantes; evidencia de certeza muy baja) o en la disuria (RR 0,84; IC del 95%: 0,46 a 1,54; un ensayo, 79 participantes; evidencia de certeza muy baja).

Tres ensayos con 402 participantes compararon el uso de alfabloqueantes profilácticos con ninguna intervención o placebo. No se sabe si hay los alfabloqueantes profilácticos antes de la extracción de la sonda tienen algún efecto en el riesgo de necesitar un nuevo sondaje (RR 1,18; IC del 95%: 0,58 a 2,42; dos ECA, 184 participantes; evidencia de certeza muy baja) o en el riesgo de aparición de IUAS sintomática (RR 0,20; IC del 95%: 0,01 a 4,06; un ensayo, 94 participantes; evidencia de certeza muy baja). Ninguno de los ensayos incluidos que investigaron los alfabloqueantes profilácticos informó del número de participantes con disuria.

Conclusiones de los autores

Existe cierta evidencia que indica que el retiro de las sondas uretrales permanentes a última hora de la noche en lugar de a primera hora de la mañana podría reducir el número de personas que requieren un nuevo sondaje. Parece que el retiro de la sonda después de una duración más corta en comparación con una más prolongada probablemente reduce el riesgo de IUAS sintomática y podría reducir el riesgo de disuria. Sin embargo, podría hacer que más personas necesiten un nuevo sondaje. El resto de la evidencia relacionada con el riesgo de IUAS sintomática y disuria es demasiado incierta para poder establecer conclusiones.

Debido a la certeza baja de la mayoría de la evidencia presentada en esta revisión, es probable que los resultados de nuevos estudios de investigación cambien los hallazgos y tengan repercusión adicional en la práctica clínica. Esta revisión sistemática ha destacado la necesidad de un conjunto estandarizado de desenlaces básicos, que deberán ser medidos e informados por todos los ensayos futuros que comparen estrategias para la extracción de sondas urinarias de corta duración. Los ensayos futuros también deberían estudiar los efectos de la extracción de la sonda uretral permanente a corto plazo en pacientes no quirúrgicos.

PICO

Population
Intervention
Comparison
Outcome

El uso y la enseñanza del modelo PICO están muy extendidos en el ámbito de la atención sanitaria basada en la evidencia para formular preguntas y estrategias de búsqueda y para caracterizar estudios o metanálisis clínicos. PICO son las siglas en inglés de cuatro posibles componentes de una pregunta de investigación: paciente, población o problema; intervención; comparación; desenlace (outcome).

Para saber más sobre el uso del modelo PICO, puede consultar el Manual Cochrane.

¿Cuáles son las mejores estrategias para retirar los tubos de drenaje (sondas urinarias) de la vejiga después de hasta 14 días?

Mensajes clave

• Retirar las sondas urinarias a última hora de la noche en lugar de a primera hora de la mañana podría reducir el número de personas que necesitan que se les vuelva a colocar la sonda.

• Retirar las sondas más pronto que tarde, probablemente reduzca el riesgo de infección causada por la sonda y el dolor al orinar. Sin embargo, podría hacer que más personas necesiten que se les vuelva a colocar la sonda.

• Se necesitan más estudios para investigar los efectos del retiro de la sonda urinaria en personas que no han sido operadas.

¿Qué son las sondas urinarias?

Las sondas urinarias son tubos flexibles y huecos que se utilizan para vaciar la vejiga y recogen la orina en una bolsa. Se suelen utilizar durante breves períodos de tiempo en las personas que no pueden orinar por sí mismas, por ejemplo, durante o después de una intervención quirúrgica, o cuando el personal sanitario necesita medir la cantidad de orina de la persona. Uno de los efectos perjudiciales de las sondas es el riesgo de aparición de infecciones de orina. Si las sondas se retiran rápidamente, se reduce el riesgo de infección, pero si se retiran demasiado pronto, podría ser necesario volver a colocarlas.

¿Qué se quería averiguar?

Se quiso investigar los efectos de distintas estrategias sobre los siguientes riesgos:

• necesitar una nueva colocación de la sonda;
• aparición de una infección de orina;
• experimentar dolor al orinar.

¿Qué se hizo?

Se buscaron estudios que analizaran el uso de sondas urinarias de corta duración en adultos. Se definió corta duración como 14 días o menos. Los estudios se podrían haber realizado en cualquier lugar y los participantes podrían tener cualquier afección o enfermedad.

Se compararon y resumieron los resultados de estos estudios y la confianza en la evidencia se evaluó sobre la base de factores como la metodología y el tamaño de los estudios.

¿Qué se encontró?

Se encontraron 99 estudios con 12 241 participantes. La mayoría de los participantes eran pacientes quirúrgicos y muchos de los estudios (50) evaluaron solo a mujeres.

Los estudios investigaron:

• retirar la sonda a primera hora de la mañana comparado con a última hora de la noche (13 estudios);
• mantener la sonda más o menos tiempo (68 estudios);
• pinzar la sonda o dejar que drene libremente (siete estudios); y
• dar a los hombres un tratamiento (alfabloqueantes) para relajar la próstata en comparación con ningún tratamiento antes de retirar la sonda (tres estudios). La próstata es una pequeña glándula situada entre el pene y la vejiga.

Retiro a primera hora de la mañana comparado con a última hora de la noche

Retirar la sonda a última hora de la noche podría reducir el riesgo de tener que volver a colocarla en comparación con retirarla a primera hora de la mañana. No se sabe si hay alguna diferencia entre el retiro a primera hora o a última hora del día en la aparición de infección de orina o dolor al orinar.

Uso más corto de la sonda comparado con más largo

Es probable que las personas a las que se les retiran las sondas después de un período de tiempo más corto tengan menos probabilidades de sufrir infecciones de orina y podrían ser menos propensas a experimentar dolor al orinar en comparación con las que mantienen las sondas durante más tiempo. Sin embargo, también se observó que las personas podrían tener más probabilidades de necesitar que se les vuelva a colocar la sonda si la tienen durante un período más corto en comparación con uno más largo.

Pinzamiento

Podría haber poca o ninguna diferencia entre pinzar la sonda y dejar que drene libremente con respecto al riesgo de necesitar volver a colocarla. No está claro si existe alguna diferencia en el riesgo de infección de orina o de dolor al orinar.

Tratamiento para relajar la próstata

No se sabe si la administración de alfabloqueantes antes de retirar la sonda tiene algún efecto sobre la necesidad de volver a colocarla o el riesgo de sufrir una infección de orina. No hubo evidencia acerca del riesgo de experimentar dolor al orinar.

¿Cuáles son las limitaciones de la evidencia?

Muchos de los ensayos incluidos tenían deficiencias en su diseño, no incluyeron a suficientes personas o no proporcionaron suficientemente información sobre sus resultados. Esto significa que la confianza en la evidencia es limitada.

¿Cuál es el grado de actualización de esta evidencia?

La evidencia está actualizada hasta el 17 de marzo de 2020.

Authors' conclusions

Implications for practice

The available evidence suggests that the removal of short‐term indwelling urethral catheters late at night, in comparison to early in the morning, may reduce the risk of requiring recatheterisation and the risk of dysuria. The same evidence was uncertain about the effect on the risk of symptomatic catheter‐associated urinary tract infections (CAUTI).

In addition, using a catheter for a shorter length of time may increase the risk of requiring recatheterisation compared with longer durations, but probably reduces the risk of symptomatic CAUTI. It may reduce the risk of dysuria.

Current evidence remains uncertain about the effect of clamping compared to free drainage or the use of prophylactic alpha blockers. We did not identify any trials comparing flexible duration versus fixed duration of catheter use and so we could not draw any conclusions.

Due to the low certainty of the majority of the evidence presented here, the results of further research are likely to change our findings and to have a further impact on clinical practice.

More research is needed to study the effects of short‐term indwelling urethral catheterisation removal on non‐surgical patients. 

Implications for research

This review highlights the need for adequately powered, well‐designed and well‐reported trials, which should measure the following important outcomes: the number of participants requiring recatheterisation; the number of participants developing symptomatic CAUTI; dysuria; and quality of life.

Future trials should ensure that the CONSORT statement is followed and that clinically relevant outcomes are measured. The development of a clearly defined core outcome set, such as those facilitated by the Core Outcome Measures in Effectiveness Trials initiative (COMET), for research relating to short‐term catheterisation would assist trialists in identifying and investigating clinically important questions. This would allow systematic reviewers more scope for the meaningful synthesis of the evidence and, in turn, lead to more robust clinical recommendations made by guideline panels and decision makers. 

In addition, patients consider clinically important outcomes important for decision‐making. By measuring these outcomes, improved recommendations can be made on the basis of higher quality evidence, which could improve the overall care of patients.

Future trials should aim to report the size of the catheter used as well as the use of antibiotic prophylaxis. This review highlighted how poorly both these outcomes were reported across the included trials and will allow future subgroup analysis to be more informed.

With regard to how data should be collected and measured, the complications associated with recatheterisation should be reported in more detail. When measuring outcomes such as symptomatic urinary tract infection and asymptomatic bacteriuria, future trials should adopt a standard definition, which has been outlined by a well‐recognised international guideline panel (Table 5; Table 6; Table 7). The reporting of the critical GRADE outcomes was particularly lacking across the RCTs. This resulted in a lack of evidence for dysuria and quality of life. Trials should use a standardised form that assesses the domain of dysuria in patients with short‐term catheters and report this in a systematic format. Quality of life should be measured by using a validated health questionnaire that is universally recognised (for example, SF‐36). All continuous data should also be measured and reported as means and standard deviations so the statistical significance of the results can be established.

Future trials should also aim to have adequate allocation concealment and blinding methods, as well as improve on their reporting of random sequence generation. More trials that investigate each of the comparisons discussed in this review are also needed as, more often than not, the cause for insufficient evidence was a lack of trials. The most common surgical procedures in this review were transurethral resection of prostate and vaginal hysterectomy. Future research should aim to include trial populations who have not undergone a surgical procedure or involve types of surgeries that are not already seen in this review. This will allow a better understanding of the effects of short‐term catheter removal in both surgical and non‐surgical patients. Future considerations should also involve mixed populations to help ascertain whether the strategies discussed benefit both sexes equally, or whether it favours one sex over another.

Summary of findings

Open in table viewer
Summary of findings 1. Removal of short‐term indwelling urethral catheters in adults at one time of day (6 am to 7 am) versus another time of day (10 pm to midnight)

Removal of short‐term indwelling urethral catheters in adults at one time of day (6 am to 7 am) versus another time of day (10 pm to midnight)

Patient or population: adults with short‐term indwelling urethral catheters that need to be removed
Setting: secondary care
Intervention: removal of indwelling urethral catheters at 10 pm to midnight
Comparison: removal of indwelling urethral catheters at 6 am to 7am

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

№ of participants
(trials)

Certainty of the evidence
(GRADE)

Comments

Risk with removal of IUC at 6 am to 7 am

Risk with removal of IUC at 10 pm to midnight

Number of participants requiring recatheterisation

Trial population

RR 0.70
(0.52 to 0.94)

1920
(10 RCTs)

⊕⊕⊝⊝
Lowa

94 per 1000

66 per 1000
(50 to 90)

Symptomatic catheter‐associated urinary tract infection (CAUTI)

Trial population

RR 1.00
(0.61 to 1.63)

41
(1 RCT)

⊕⊝⊝⊝
Very lowb,c

611 per 1000

611 per 1000
(373 to 996)

Dysuria

Trial population

RR 2.20

(0.70 to 6.86)

170
(1 RCT)

⊕⊕⊝⊝
Lowc

48 per 1000

105 per 1000
(33 to 327)

Condition‐specific QoL or generic QoL measure

‐

‐

‐

‐

‐

Not reported

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: confidence interval; IUC: indwelling urethral catheter; QoL: quality of life; RCT: randomised controlled trial; RR: risk ratio

GRADE Working Group grades of evidence
High certainty: we are very confident that the true effect lies close to that of the estimate of the effect.
Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.
Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.

aDowngraded two levels for risk of bias (random sequence generation, allocation concealment and blinding of outcome assessors are all unclear).
bDowngraded one level for risk of bias (random sequence generation and blinding of outcome assessors are unclear).
cDowngraded two levels for imprecision: few participants and 95% confidence interval is consistent with possible benefit and possible harm.

Open in table viewer
Summary of findings 2. Removal of short‐term indwelling urethral catheters in adults after shorter versus longer durations

Removal of short‐term indwelling urethral catheters in adults after shorter versus longer durations

Patient or population: adults with short‐term indwelling urethral catheters that need to be removed
Setting: secondary care
Intervention: shorter durations of IUC
Comparison: longer durations of IUC

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

№ of participants
(trials)

Certainty of the evidence
(GRADE)

Comments

Risk with longer durations of catheterisation

Risk with shorter durations of catheterisation

Number of participants requiring recatheterisation

Trial population

RR 1.81
(1.35 to 2.41)

5870
(44 RCTs)

⊕⊕⊝⊝
Lowa,b

 

75 per 1000

136 per 1000
(102 to 182)

Symptomatic catheter associated urinary tract infection (CAUTI)

 

Trial population

RR 0.52
(0.45 to 0.61)

5759
(41 RCTs)

⊕⊕⊕⊝
Moderatea

 

126 per 1000

66 per 1000
(57 to 77)

Dysuria

Trial population

RR 0.42
(0.20 to 0.88)

1398
(7 RCTs)

⊕⊕⊝⊝
Lowa,b

 

118 per 1000

50 per 1000
(24 to 104)

Condition‐specific QoL or generic QoL measure

‐

‐

‐

‐

‐

Not reported

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: confidence interval; IUC: indwelling urethral catheter; QoL: quality of life; RCT: randomised controlled trial; RR: risk ratio

GRADE Working Group grades of evidence
High certainty: we are very confident that the true effect lies close to that of the estimate of the effect.
Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.
Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.

aDowngraded one level for risk of bias (unclear risk of selection bias and detection bias).
bDowngraded one level for inconsistency (heterogeneity in direction and size of effect).

Open in table viewer
Summary of findings 3. Removal of short‐term indwelling urethral catheters in adults: clamping compared to free drainage

Removal of short‐term indwelling urethral catheters in adults: clamping compared to free drainage

Patient or population: adults with short‐term indwelling urethral catheters that need to be removed
Settings: secondary care

Intervention: clamping of indwelling urethral catheter
Comparison: free drainage of indwelling urethral catheter

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

№ of participants
(trials)

Certainty of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Risk with free drainage

Risk with clamping regimes

Number of participants requiring recatheterisation

Trial population

RR 0.82
(0.55 to 1.21)

569
(5 RCTs)

⊕⊕⊝⊝
Lowa,b

160 per 1000

131 per 1000
(88 to 193)

Symptomatic catheter associated urinary tract infection (CAUTI)

Trial population

RR 0.99
(0.60 to 1.63)

267
(2 RCTs)

⊕⊝⊝⊝
Very lowc,d

195 per 1000

193 per 1000

(117 to 318)

Dysuria

Trial population

RR 0.84
(0.46 to 1.54)

79
(1 RCT)

⊕⊝⊝⊝
Very lowd,e

385 per 1000

323 per 1000

(177 to 592)

Condition‐specific QoL or generic QoL measure

‐

‐

‐

‐

‐

Not reported

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: confidence interval; IUC: indwelling urethral catheter; QoL: quality of life; RCT: randomised controlled trial; RR: risk ratio

GRADE Working Group grades of evidence
High certainty: we are very confident that the true effect lies close to that of the estimate of the effect.
Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.
Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.

aDowngraded one level for risk of bias (unclear random sequence generation, allocation concealment and blinding of outcome assessors).
bDowngraded one level for imprecision (95% CI is consistent with possible benefit and possible harm).
cDowngraded one level for risk of bias (unclear random sequence generation and high risk due to lack of blinding of outcome assessors.
dDowngraded two levels for imprecision (few participants and 95% CI is consistent with possible benefit and possible harm).
eDowngraded one level for risk of bias (high risk for randomisation and allocation concealment).

Open in table viewer
Summary of findings 4. Removal of short‐term indwelling urethral catheters in adults: prophylactic use of alpha blocker versus no drug or intervention

Removal of short‐term indwelling urethral catheters in adults: prophylactic use of alpha blocker versus no drug or intervention

Patient or population: adults with short‐term indwelling urethral catheters that need to be removed
Settings: secondary care

Intervention: prophylactic use of alpha blocker
Comparison: no drug or intervention

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

№ of participants
(trials)

Certainty of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Risk with no alpha blocker

Risk with prophylactic alpha blocker

Number of participants requiring recatheterisation

Trial population

RR 1.18
(0.58 to 2.42)

184
(2 RCTs)

⊕⊝⊝⊝
Very lowa,b

120 per 1000

141 per 1000
(69 to 289)

Symptomatic catheter associated urinary tract infection

Trial population

RR 0.20

(0.01 to 4.06)

94
(1 RCT)

⊕⊝⊝⊝
Very lowa,b

43 per 1000

9 per 1000

(0 to 173)

Dysuria

‐

‐

‐

‐

‐

Not reported

Condition‐specific QoL or generic QoL measure

‐

‐

‐

‐

‐

Not reported

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: confidence interval; IUC: indwelling urethral catheter; QoL: quality of life; RCT: randomised controlled trial; RR: risk ratio

GRADE Working Group grades of evidence
High certainty: we are very confident that the true effect lies close to that of the estimate of the effect.
Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.
Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.

aDowngraded one level for risk of bias (unclear random sequence generation, allocation concealment and blinding of outcome assessors).
bDowngraded two levels for imprecision: few participants and wide 95% confidence interval that is consistent with possible benefit and possible harm.

Background

This is an update of a Cochrane Review first published in 2005 and last published in 2007. See Appendix 1 for a glossary of medical terms.

Description of the condition

Catheterisation is an important and common clinical procedure. Approximately 15% to 25% of all people who are hospitalised will be catheterised at some point during their management (CDC 2016). However, it should be noted that not every patient who has a urethral catheter inserted requires one. Trials have shown that it is common for catheters to be placed in patients without an appropriate indication (Loeb 2008; Meddings 2014). Catheterisation could be for the short term (up to 14 days) or long term (14 days or longer). The indications for short‐term catheterisation include monitoring of urine output during the perioperative stage or in acutely unwell patients, as part of a urological procedure, or the treatment of patients with acute urinary retention. Short‐term catheterisation could also be used for investigative purposes, such as imaging of the urinary tract and urodynamic trials (Dunn 2000a). Long‐term catheterisation is usually a last resort option in people with recurrent urinary retention, reduced bladder contractility or urinary incontinence.

Retention of urine has been reported as a common problem following the removal of indwelling urethral catheters, particularly following surgery and anaesthesia, where post‐operative urinary retention has a reported incidence between 5% and 70% (Baldini 2009). The risk factors associated with an increase the risk of developing post‐operative urinary retention have been thoroughly researched and include age (over 50 years), sex (male), type of surgery, duration of surgery, type of anaesthesia (general or regional, e.g. epidural), analgesia (use of opiates) and the amount of intravenous fluids used. Post‐operative urinary retention may lead to urinary tract infections, abnormal autonomic responses (e.g. cardiac arrhythmias) as well as over‐distension of the bladder resulting in permanent detrusor muscle damage (Baldini 2009; Madersbacher 2012; Rosseland 2002; Zaouter 2009). For hospital inpatients, the duration of catheterisation in the peri‐operative period remains controversial and is one that is ultimately down to the preference of the surgeon or anaesthetist responsible for the patient. Removal too early, however, may result in the patient developing urinary retention again and thus risking requiring recatheterisation alongside the complications associated with it (Baldini 2009).

The procedure of indwelling urethral catheterisation is associated with complications such as catheter‐associated urinary tract infection (CAUTI), bacteruria, stricture formation, structural damage to the urinary tract, bleeding, cystitis or prostatitis, and patient discomfort (Igawa 2008; Fisher 2017). CAUTI is the most common cause of hospital‐acquired infections with some 70% to 80% of these associated with the use of indwelling urethral catheters (Lo 2014; Nicolle 2014). CAUTI arise from the formation of a biofilm on both the extraluminal and intraluminal portal surfaces of the catheter. This biofilm mainly consists of extraluminal organisms, which adhere to the surfaces of the catheter as soon as it has been inserted. It has the ability to defend microbes from the host's defences as well as antimicrobials (Haque 2018; Nicolle 2014). It is estimated that around 20% of hospital‐acquired bacteraemias arise from the urinary tract and are associated with a mortality of around 10%. The incidence of bacteraemia following a single catheterisation episode has been shown to be as high as 8%, with the duration of catheterisation being the most important risk factor (EAU 2020). Development of symptomatic CAUTI can have serious consequences in some patients and has been shown to increase the length of hospital stay, worsen patient renal function, increase patient mortality and lead to increased costs for healthcare providers. However, with aseptic technique during placement of the catheter, the risk of CAUTI can be reduced (Baldini 2009; EAU 2020; Fisher 2017; Gould 2009; Lo 2014; NICE 2012).

Indwelling urethral catheters are prone to various other complications that prevent effective drainage of urine. The most common non‐infective cause is due to urethral stricture formation. Urethral strictures can develop after repeated urethral catheterisation with long‐term urinary catheter use, as well as after urethral trauma. The most common infective cause is the development of encrustation within the catheter. This is when crystalline compounds (such as calcium phosphate and struvite) precipitate in the alkaline conditions of urine to form solid deposits in the catheter lumen. This process is accelerated in the presence of micro‐organisms such as Proteus mirabilis which resides in the body's own bowel flora. These micro‐organisms produce the enzyme urease, allowing the production of ammonia, which causes further alkalinisation of the urine and catalyses the encrustation process. Catheter encrustation and blockage is thought to be experienced by roughly 50% of patients with long‐term catheters (Stickler 2010). Once a urethral catheter is failing to drain properly, flushing them with saline can often help in trying to relieve the obstruction. However, if this fails it is likely that the urethral catheter will need to be removed and the patient's need for a urinary catheter reassessed (Cravens 2000).

There are two routes of infection through which symptomatic urinary tract infections (UTIs) occur: endogenous and exogenous. Endogenous infections are due to bacteria naturally present in the human body. Typical routes of infection of the urinary tract are rectal, vaginal and meatal (bodily passages). Exogenous sources of infection include contamination by healthcare workers or non‐sterile equipment.

Pathogens typically gain access to the urinary tract either by migrating alongside the exterior surface of the lumen, or by movement alongside the inner lumen of the catheter via contaminated urine collection bags. Thus, maintenance of a sterile, closed urinary drainage system is key to prevent symptomatic CAUTIs. Clinical features of symptomatic UTIs include dysuria, urinary frequency or urgency, haematuria, suprapubic pain or tenderness, loin or flank pain, rigors, fever, altered mental status (e.g. confusion, particularly in the elderly), and nausea and vomiting (CDC 2016; Gould 2009; Grabe 2015; Hollingsworth 2013).

The Centers for Disease Control and Prevention (CDC) has defined symptomatic CAUTI as a UTI in the presence of an indwelling catheter which is in place for two or more calendar days on the date of the UTI, where day one was the date upon which the catheter was placed; or, the catheter was in place on the date of the UTI or the day before and then removed. The patient’s urine culture (from a mid‐stream or catheter bag sample) must also contain no more than two species of organisms, where one of which has a bacterial colony count of ≥ 105 colony forming unit (cfu)/mL. The CDC criteria for symptomatic UTI must also be met, which states that the patient must also have at least one of the following signs or symptoms: fever (> 38 °C); suprapubic tenderness; urinary urgency; increased urinary frequency or dysuria (pain during voiding) (CDC 2016; Gould 2009).

The Infectious Disease Society of America (IDSA) definition differs slightly according to their published guidelines. The IDSA considers symptomatic CAUTI as any UTI associated with a catheter in the presence of clinical features consistent with UTI, with no other identified sources of infection and a bacterial count of ≥ 103 cfu/mL of ≥ 1 bacterial species in a single midstream urine (MSU) or catheter specimen. The IDSA definition of symptomatic CAUTI covers patients with indwelling, intermittent and suprapubic catheters, unlike the CDC definition, which excludes intermittent catheterisation (Hooton 2010).

Patients who do not meet this criterion may still meet the various criteria for asymptomatic bacteraemic urinary tract infections (ABUTI), which is defined by the CDC as people who are asymptomatic but have a urine culture of at least 105 cfu/mL of a bacterial species in their urine sample. Between 75% to 90% of people who have ABUTIs have been shown not to produce a systemic inflammatory response or other indications, which would indicate infection (Gould 2009). The decision on how to monitor and treat these individuals is still undecided and varies amongst health providers. The CDC guidelines on symptomatic CAUTI state that the treatment of ABUTI has not been shown to provide any clinical benefit.

Description of the intervention

For the purpose of this review, we only considered short‐term indwelling urethral catheterisation. We defined short term as an intended duration of urethral catheterisation of 14 days or less. While there is extensive literature on the type, maintenance and techniques for insertion of urinary catheters, limited attention has been given to the policies and procedures for their removal. Although the insertion, removal and management of the catheter are usually undertaken by nurses, decisions about the removal of the catheter often remain with the medical practitioner. While the importance of short‐term urethral catheter management is recognised, there is no consensus among clinicians about the optimal time and method for removal of indwelling urethral catheters. Policies are likely to be based on personal preference and established practices rather than on research evidence (Irani 1995). While clinicians have established policies, there has been no objective and systematic examination of the effect of the time of day the catheter is removed, the length of time the catheter is left in place or if clamping the catheter prior to removal influences patient outcomes.

Indwelling urethral catheters are catheters that are inserted into the bladder, via the urethra, to allow continuous drainage of urine into a closed urine collection system. In some clinical contexts, valves may also be used as an alternative to continuous drainage. The urethral route is most commonly used by health professionals. Other routes of urinary catheterisation include intermittent urethral and suprapubic urinary catheterisation. However, these routes of urinary catheterisation are outwith the scope of this systematic review. Urethral catheterisation usually requires the use of a lubricant gel, which often contains a local anaesthetic, and can be used both in short‐term and long‐term catheterisation. The length of duration of urethral catheterisation is commonly associated with the development of complications, the most common being UTI (Nicolle 2014). Around 60% to 80% of hospitalised patients with indwelling catheters will require antibiotics at some stage of their care, although this is usually for reasons other than UTI (Durojaiye 2015; Foxman 2003). A recent prevalence survey published in The New England Journal of Medicine found that urinary catheters are the most common indwelling device in hospitals, used in 23.6% of patients in 183 hospitals in the USA and roughly 17.5% of patients in 66 European hospitals (Magil 2014).

As a result, the bacteria present in urine are continuously exposed to antimicrobials, thus aiding the development of antimicrobial‐resistant organisms. This rise in antimicrobial‐resistant organisms has proven to be a huge burden for healthcare providers from both an economic and medical standpoint, with many providers struggling to control devastating outbreaks. There is limited evidence for the use of antibiotic prophylaxis in short‐term indwelling urethral catheters (Lusardi 2013).

How the intervention might work

Some investigators have hypothesised the potential advantage of morning or midnight removal of catheters. One argument for the removal of urethral catheters early in the morning is that reduced staff at night might fail to respond to complications, such as urinary retention, that can develop following the removal of the catheter (Blandy 1989; Crowe 1993; Ganta 2005; Kelleher 2002; Webster 2006). Other suggested benefits of removing the catheter early in the morning include allowing the patient to rest through the night and then to adjust back to their normal voiding pattern during the day (Gross 2007).

Researchers have also reported that patients whose catheters were removed in the night had larger volumes at first void compared to other people whose catheters were removed in the morning (Chillington 1992; Noble 1990; Webster 2006). It has been suggested that the timing of catheter removal may affect a patient's length of stay in hospital with consequent resource implications. In one trial it was found that removal of catheters at midnight resulted in patients being discharged a mean of 14 hours earlier than patients whose catheters were removed in the morning (Chillington 1992), thus resulting in economic benefits related to a shorter length of hospitalisation and efficient discharge planning (Kelleher 2002).

There has been some debate about whether flexible policies are better than relatively fixed policies for catheter removal (Wyman 1987). However, practice is known to vary. For example, local clinical audits for catheter removal have indicated that 49% of catheters are removed either at the discretion of the nurse or at the time of the medical rounds and only 34% were removed at midnight (Watt 1998). Of those indwelling urethral catheters that were scheduled for removal in the morning, only 70% were removed on time (Noble 1990; Watt 1998).

Practice also varies with respect to the length of time the catheter is left in situ and the procedure for its removal. The factors that influence this decision include: the condition/reason for which the patient is catheterised; clinician/surgeon preference; patient tolerance; and hospital policy (EAUN 2012). Various international guideline panels agree that indwelling urethral catheters should be removed as soon as they are no longer necessary (CDC 2016; EAU 2020; Grabe 2015; Hooton 2010; NICE 2012). The removal of indwelling urethral catheters after shorter durations may prove to be beneficial, as it has the potential to reduce hospital stays and the number of patients developing symptomatic CAUTIs, thus saving healthcare costs and improving patient outcomes (Baldini 2009; Lo 2014).

Bladder dysfunction and post‐operative voiding impairment has been documented following catheterisation and can lead to infections of the urinary tract. The intermittent clamping of the indwelling urethral catheter draining tube prior to withdrawal has been suggested on the basis that this simulates normal filling and emptying of the bladder (EAUN 2012). While clamping catheters might minimise post‐operative neurogenic urinary dysfunction, it could also result in bladder infection or distension if the clamps are not released as scheduled (Roe 1990; Wang 2016).

Another strategy practised prior to removal of urethral catheters is the use of alpha adrenergic blocker drugs. It is thought that post‐operative urinary retention is potentially linked to the stress‐induced, high sympathetic activity occurring around the peri‐operative period. Counteracting its activity with the inhibition of alpha receptors located in the bladder and urethra may potentially reduce the risk of acute urinary retention (Ghuman 2018; Madani 2014; Patel 2018). It has also been reported that alpha blockers are effective in the treatment of voiding dysfunction by enhancing detrusor contractibility and lowering urethral resistance in patients with underactive bladder (Yamanishi 2004). Thus, prophylactic usage of alpha blockers in people with indwelling urethral catheters could reduce the episodes of developing voiding dysfunction after catheter removal.

Why it is important to do this review

This systematic review summarises the evidence from randomised controlled trials (RCTs) related to alternative approaches to the removal of short‐term indwelling urethral catheters. The findings of this review will help determine the safest method of short‐term catheter removal as well as potentially help reduce the risks associated with catheterisation for patients. Since the last version of this review was published (Griffiths 2007), the evidence base has grown substantially and it is important to incorporate findings from new trials into the review in a manner that will enable clinicians to develop evidence‐based policies for practice.

Objectives

To assess the effects of strategies for removing short‐term (14 days or less) indwelling catheters in adults.

Methods

Criteria for considering studies for this review

Types of studies

We included RCTs and quasi‐RCTs that evaluated the effects of strategies for removing short‐term indwelling urethral catheters.

For the purposes of this review, we defined 'indwelling catheterisation' in accordance with the European Association of Urology (EAU), which states that it is the passage of a urinary catheter into the bladder via the urethra and held in place by an inflatable balloon (EAU 2020; Grabe 2015; Tenke 2008). We defined as 'short‐term' cases where the intended duration of catheterisation was 14 days or less (Dunn 2000a; Kidd 2015; Lam 2014).

Types of participants

We included trials of adults requiring short‐term indwelling urethral catheterisation in any setting (hospital, community, nursing home) for any reason. These included individuals who were acutely unwell, required surgery, had urinary retention or women during childbirth.

Types of interventions

We included all interventions involving short‐term indwelling urethral catheterisation and made the following comparisons.

  • Removal of indwelling urethral catheters at one specified time of day (6 am to 7 am) versus another specified time of day (10 pm to midnight)

  • Shorter durations of indwelling urethral catheterisation versus longer durations of indwelling urethral catheterisation e.g. immediate/early removal versus removal of the indwelling urethral catheter one day post‐surgery

  • Flexible durations of indwelling urethral catheterisation versus fixed duration of indwelling urethral catheterisation

  • Clamping of indwelling urethral catheterisation versus free drainage of indwelling urethral catheterisation prior to removal

  • Prophylactic use of alpha blocker prior to indwelling urethral catheter removal versus no intervention or placebo

We defined early removal of catheters as the removal of an indwelling urethral catheter up to eight hours post‐operatively.

We have not considered the following interventions as they are either covered in separate Cochrane Reviews or do not meet the objectives of this review:

  • Suprapubic or intermittent urethral catheterisation (Kidd 2015)

  • Long‐term catheterisation (Cooper 2016)

  • Differing catheter insertion techniques (e.g. use of aseptic liquid/cream based agents or topical antibiotic creams)

  • Meatal care management techniques

  • Types of catheter materials for short‐term catheters (e.g. latex, silicone) (Lam 2014)

  • Types of catheter coatings for short‐term catheters (e.g. antibiotic coating, silver) (Lam 2014)

  • Types of drainage container

  • Treatment of drainage bag with antiseptic/antibiotic

  • The use of antibiotic prophylaxis as a primary or secondary outcome (Foon 2012; Lusardi 2013)

  • The use of reminders or protocols for catheter removal, for example, stop‐orders

It should be noted that the use of alpha blockers prior to urethral catheter removal in acute urinary retention (AUR) is covered by another Cochrane Review (Fisher 2014). Our review only looks at the use of prophylactic alpha blockers in short‐term indwelling urethral catheters in instances other than AUR. We excluded trials that looked at the use of antibiotic prophylaxis as a primary or secondary outcome on the basis that this is covered by another Cochrane Review and is not related to the intervention of interest of this review (Lusardi 2013). We did not exclude trials that used antibiotic prophylaxis for both intervention and control groups as part of their hospital policy.

Types of outcome measures

We analysed the following outcomes in this review. It should be noted that we did not use them as a basis for including or excluding trials.

Primary outcomes

  • Number of participants who required recatheterisation following removal of indwelling urethral catheter

Secondary outcomes

  • Complications/adverse effects

    • Incidence of UTI

      • symptomatic CAUTI

      • asymptomatic bacteriuria

    • Incidence of urinary retention

    • Other complications of catheterisation (or recatheterisation), for example, haemorrhage, stricture formation, fever

  • Patient‐reported

    • Patient pain or discomfort

    • Patient satisfaction

    • Urinary incontinence

    • Number of patients reporting dysuria

  • Clinician‐reported

    • Volume of first void (mL)

    • Time to first void (hours)

    • Post‐void residual volume (mL)

    • Length of hospitalisation (days)

    • Time between removal of catheter to discharge (days)

  • Health status/quality of life

    • Condition‐specific or generic quality‐of‐life measures (e.g. Short Form 36 (Ware 1992))

    • Psychological outcome measures (e.g. Hospital Anxiety and Depression Scale (Zigmond 1983))

Main outcomes for summary of findings tables

  • Number of participants requiring recatheterisation

  • Symptomatic CAUTI

  • Dysuria

  • Condition‐specific or generic quality‐of‐life measures (e.g. Short Form 36)

Search methods for identification of studies

We did not impose any language or other restrictions on any of the searches described below.

Electronic searches

We identified relevant trials from the Cochrane Incontinence Specialised Register. For more details of the search methods used to build the Specialised Register, please see the Group's webpages where details of the Register's development (from inception) and the most recent searches performed to populate the Register can be found. The Register contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In‐Process, MEDLINE Epub Ahead of Print, CINAHL, ClinicalTrials.gov, WHO ICTRP, Be Part of Research and handsearching of journals and conference proceedings. Many of the trials in the Cochrane Incontinence Specialised Register are also contained in CENTRAL.

The date of the last search was: 17 March 2020.

The terms used to search the Cochrane Incontinence Specialised Register are given in Appendix 2.

For an earlier version of this review update we searched CINAHL (on EBSCO), covering December 1981 to 11 May 2016 (searched on 12 May 2016). For the most recent update of the search (17 March 2020) only the Cochrane Incontinence Specialised Register was searched, as this now incorporates the CINAHL search. The search strategy used in CINAHL is given in Appendix 3.

The search strategies used to search for the previous version of this review (Griffiths 2007) are given in Appendix 4.

Searching other resources

We also searched the reference lists of all relevant articles.

Data collection and analysis

For this update, we used the following methods to assess the new reports that were identified as a result of the updated search. For methods used in the previous version of this review, see Griffiths 2007.

Selection of studies

Two review authors (AE and IO) independently screened the titles and abstracts of each trial using Covidence before obtaining the full text for all potentially eligible trials. If the title and abstract were inconclusive, we obtained the full text for further assessment. We attempted to obtain any missing trial data by contacting the trial authors for further information. Duplicate trials that had been reported in more than one publication were included only once. We reached decisions about trial eligibility by a discussion between the author team and resolved any disagreements by consulting an independent third party.

Data extraction and management

Four review authors (AE, FS, EK, IO) extracted data independently using a standardised form and AE compared their results. If the data in trials had not been fully reported, we attempted to contact the trial authors for further classification. We entered the extracted data into Review Manager 5 software (Review Manager 2020). 

We have only reported those outcomes that were pre‐specified in the Types of outcome measures. However, there were occasions where the outcomes reported were worded differently despite belonging to the same underlying theme ‐ for example, asymptomatic bacteriuria was also reported as positive urine culture. As these are the same underlying concepts, omitting this information was not appropriate. We therefore chose to collate all data from trials that reported positive urine culture with asymptomatic bacteriuria if they met the CDC definition for asymptomatic bacteriuria.

Assessment of risk of bias in included studies

Four review authors (AE, FS, EK, IO) assessed the included trials for risk of bias using Cochrane's 'Risk of bias' tool (Higgins 2011). We assessed the following domains: random sequence generation (selection bias); allocation concealment (selection bias); blinding of participants and personnel (performance bias); blinding of outcome assessment (detection bias); blinding of microbiological outcome (detection bias); incomplete outcome data (attrition bias); selective reporting of outcomes (reporting bias); and other potential sources of bias.

Two of the review authors (AE and one of either IO, FS or EK) independently assessed each of the trials and rated each as 'low risk', 'unclear risk' or 'high risk'. We resolved any difference in opinion by discussion or by consulting an independent third party.

Measures of treatment effect

We processed all trial data as outlined in the Cochrane Handbook for Systematic Reviews of Interventions (Li 2021). Where appropriate, we undertook meta‐analysis. We combined outcome data by using a fixed‐effect model to calculate pooled estimates and their 95% confidence intervals (CI). We considered the random‐effects model only when there were concerns about heterogeneity affecting the analysis. For categorical outcomes, we related the numbers reporting an outcome to the numbers at risk in each group to calculate a risk ratio (RR) with 95% CI. For continuous variables, we used means and standard deviations to derive the mean difference (MD) with 95% CI.

Unit of analysis issues

In parallel‐group trials, the primary analysis was per participant randomised. Where there were trials that involved a variation of this type of randomisation, for example, cross‐over trials or cluster‐randomised trials, we performed analysis as outlined by the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2021).

Dealing with missing data

We analysed the data on an intention‐to‐treat (ITT) basis where possible, meaning that all participants were analysed according to the group they were randomised in irrespective of whether they received their assigned intervention.

Where participants were excluded after allocation or withdrew from the trial, we reported any details provided in full. If there were data missing, we attempted to contact the original trial authors to obtain the missing trial data. If there was evidence of differential dropout between the groups, the review authors imputed data for the missing results once we had contacted the trial authors. Where trials reported mean values without standard deviations (SDs) but with P values or 95% CI, we used a conversion Excel document designed by a statistician to obtain the SDs. In cases of missing SDs with no P values or 95% CIs, we estimated the SD from another trial in the same meta‐analysis.

Assessment of heterogeneity

We only combined trials if there was evidence that they were clinically similar. We assessed heterogeneity by visual inspection of forest plots, the Chi² test for heterogeneity and the I² statistic (Higgins 2003). If significant heterogeneity existed, we used a random‐effects model. We considered statistical heterogeneity significant if either the P value for the Chi² test was low (P < 0.10) or if the I² statistic suggested heterogeneity. We used the following thresholds for interpreting the I² statistic (Deeks 2021):

  • 0% to 40%: heterogeneity might not be that important

  • 30% to 60%: moderate heterogeneity

  • 50% to 90%: substantial heterogeneity

  • 75% to 100%: considerable heterogeneity

Assessment of reporting biases

In view of the difficulties associated with the detection and correction of publication bias, as well as various other reporting biases, we employed a comprehensive search strategy involving multiple databases and sources. We assessed the likelihood of any potential publication bias by using funnel plots.

Data synthesis

We combined trials for analysis if the interventions were considered to be clinically similar and used a fixed‐effect approach to carry out meta‐analysis. We considered using a random‐effects model if there was substantial statistical heterogeneity (as judged by the Chi² test or I² statistic).

For illustrative purposes, we displayed data in subgroups in the meta‐analysis to help identify the different types of surgery and catheter durations participants were undergoing.

Subgroup analysis and investigation of heterogeneity

We performed the following subgroup analyses for the primary outcome for each comparison.

  • The type of surgery (urological versus non‐urological) that participants underwent is likely to have an impact with regard to infection, dysuria, haemorrhage and stricture formation etc. If a participant was to be admitted for surgery involving the urological tract (e.g. transurethral resection of the prostate (TURP)), it is likely that the passage of a urethral catheter in these participants would have a potentially worsening impact than those participants with urethral catheters who did not have any urological surgery. This is because the urological tract is likely to have sustained some damage as a result of the trauma involved during the surgery.

  • The sex of an individual can impact the intervention being studied. Women are more prone to urinary tract infections due to their shorter urethra when compared to the anatomy of men. However, the passage of urethral catheters in women is likely to be less challenging than men. Many men in this review were hospitalised for TURP, implying that passing a urethral catheter is likely to be more technically difficult in men.

  • Antibiotic prophylaxis: the use of antibiotic prophylaxis for participants with short‐term indwelling urethral catheters is likely to impact outcomes looking at infections (e.g. the number of participants developing symptomatic CAUTI and asymptomatic bacteriuria). Attitudes towards antibiotic prophylaxis in short‐term urethral catheterisation vary, as their use is also associated with an increased risk of developing a hospital‐acquired infection by Clostridium difficile.

Where data were available, we performed post hoc subgroup analysis to assess the impact of prophylactic antibiotics on the number of participants developing symptomatic CAUTI. The use of prophylactic antibiotics is a confounding factor in the number of participants developing CAUTI. We also conducted post hoc subgroup analysis for the outcome of length of hospitalisation to explore the effect of type of surgery as a possible explanation for very high heterogeneity in the meta‐analysis.

For outcomes other than the primary outcome and CAUTI, we used the subgroup function for illustrative purposes only to show the different types of surgery that participants underwent and the different catheter durations. It should be noted that, in these cases, we did not report any results of subgroup analysis in relation to the statistical test for subgroup differences. 

Sensitivity analysis

Where data were available, we conducted sensitivity analyses for our primary outcome by excluding trials we judged as high risk of bias for the domains relating to random sequence generation and allocation concealment.

Summary of findings and assessment of the certainty of the evidence

We prepared summary of findings tables for our main comparisons and presented the results for the outcomes prespecified in the Types of outcome measures.

We assessed the certainty of the body of evidence using the GRADE approach. When choosing which outcomes to select, we looked at previous Cochrane Reviews involving urethral catheterisation, the review teams for which had conducted group discussions with people who had undergone short‐term indwelling urethral catheterisation to assist with the selection of appropriate outcomes for inclusion in the summary of findings tables (Kidd 2015; Lam 2014; Omar 2013). We classified the primary and secondary outcomes as critical, important or not important from the patients' perspective for decision‐making.

Results

Description of studies

Results of the search

We screened 1583 records, which were identified by the literature search for this review, and retrieved the full texts of 223 reports of trials to assess their eligibility for inclusion. We included 124 reports of 99 trials in this review, and excluded 89 reports of 85 trials from the review. There are nine reports of eight ongoing trials, details of which can be located in the Characteristics of ongoing studies. One trial is still awaiting classification after we obtained further information regarding the trial during the final stages of this review (NCT02602132). Please see the Characteristics of studies awaiting classification for more details. The flow of literature through the assessment process is shown in the PRISMA diagram (Page 2020; Figure 1).

Figure 1
PRISMA flow diagram

PRISMA flow diagram

Newly included trials

In this update, we re‐assessed the 26 trials included in the previous version of this review and re‐extracted their data (Griffiths 2007). We also evaluated their risk of bias. After performing a new search, we identified a further 73 eligible trials. 

Included studies

The trials are detailed in the Characteristics of included studies. We were unable to include 12 trials (13 reports) in the meta‐analysis because they reported data in insufficient detail (Azarkish 2005; Bristoll 1989; Dunn 1999; Dunn 2000b; Iversen Hansen 1984; Nguyen 2012; Ruminjo 2015; Talreja 2016; Wilson 2000; Yee 2015), or they were single trials reporting an outcome for a particular comparison (Liu 2015; Williamson 1982), or reported zero events for a particular outcome and so the result was not estimable (Liu 2015). We contacted the trial authors by email to request further data.

Design

Ninety‐four trials included in the review were RCTs and five trials were quasi‐RCTs (Li 2014; Liu 2015; Noble 1990; Valero Puerta 1998; Zhou 2012).

Sample sizes

The number of participants randomised in the included trials ranged from eight (Williamson 1982), to 501 (Barone 2015). In total, the 99 trials randomised 12,241 participants.

Reason for hospitalisation/catheterisation

The reasons for catheterisation varied between the trials (see Table 1).

Open in table viewer
Table 1. Types of participants

Trial ID

Reason for hospitalisation

Type of surgery/reason for being admitted

Gender

Ahmed 2014

Elective gynaecological surgery

Total abdominal hysterectomy with or without bilateral salpingo‐oophorectomy

Female

Alessandri 2006

Elective gynaecological surgery

Vaginal hysterectomy

Female

Allen 2016

Patients undergoing cardiothoracic surgery

General thoracic surgical procedure, in whom an epidural catheter was placed for analgesia

Mixed

Alonzo‐Sosa 1997

Elective gynaecological surgery

Anterior colporrhapy, anterior and posterior colporrhaphy with or without vaginal hysterectomy

Female

Aref 2020

Elective CS

Participants admitted for elective CS

Female

Aslam 2019

Elective gynaecological surgery

Participants undergoing minimally invasive pelvic organ prolapse surgery

Female

Azarkish 2003

Elective CS

Participants admitted for elective CS

Female

Azarkish 2005

Emergency CS

Participants admitted for emergency CS

Female

Barone 2015

Elective gynaecological surgery

Participants admitted for vaginal fistula repair

Female

Basbug 2020

Elective CS

Participants admitted for elective CS

Female

Benoist 1999

Elective GI surgery

Extensive rectal resection (total or subtotal proctectomy)

Mixed

Bristoll 1989

Not reported

Not reported

Unknown

Carpiniello 1988

Elective orthopaedic surgery

Total joint replacement (hip or knee)

Female

Carter‐Brooks 2018

Elective gynaecological surgery

Participants undergoing pelvic organ prolapse surgery

Female

Chai 2011

Elective gynaecological surgery

Total abdominal hysterectomy with or bilateral salpingo‐oophorectomy for various benign gynaecological diseases

Female

Chen 2013

Admitted to ICU

Patients requiring mechanical ventilation for respiratory failure

Mixed

Chia 2009

Elective cardiothoracic surgery

Thoracotomy

Mixed

Chillington 1992

Elective urological surgery

TURP

Male

Cornia 2003

Admitted to medicine and cardiology services

Patients admitted to the medicine and cardiology services

Mixed

Coyle 2015

Elective GI surgery

Elective transabdominal colectomy, proctectomy or coloproctectomy

Mixed

Crowe 1993

Admitted to urology ward

Patients admitted to the urology ward with IUCs or who were catheterised during their inpatient stay

Mixed

Dunn 1999

Elective obstetric and gynaecological surgery

Patients undergoing elective obstetric or gynaecological surgery

Female

Dunn 2000b

Elective gynaecological surgery or CS

Patients undergoing hysterectomy or CS who do not require bladder suspension or strict fluid management

Female

Dunn 2003

Elective gynaecological surgery

Women undergoing hysterectomy for various benign diseases (e.g. fibroid tumours, abnormal uterine bleeding, chronic pain, and persistent cervical dysplasia or micro invasive cancer

Female

Durrani 2014

Elective urological surgery

Patients with bladder outflow obstruction due to benign prostatic enlargement undergoing TURP

Male

El‐Mazny 2014

Primary or elective CS

Patients admitted to the prenatal wards for primary or repeat elective CS

Female

Ganta 2005

Elective urological surgery

TURP

Male

Glavind 2007

Elective gynaecological surgery

Patients undergoing any type of vaginal prolapse surgery

Female

Gong 2017

Elective gynaecological surgery

Patients undergoing radical hysterectomy for cervical cancer FIGO stage IB‐IIB

Female

Gross 2007

Admitted to stroke ward

Patients with a stroke admitted to the ward

Mixed

Gungor 2014

Elective gynaecological surgery

Patients with pelvic organ prolapse and/or urinary incontinence undergoing anterior colporrhaphy

Female

Guzman 1994

Elective gynaecological surgery

Patients undergoing vaginal surgery

Female

Hakvoort 2004

Elective gynaecological surgery

Patients undergoing anterior colporrhaphy for vaginal prolapse surgery

Female

Hall 1998

Elective general surgery

Patients admitted to the general surgery wards

Mixed

Han 1997

Elective urological surgery

Patients with benign prostatic enlargement undergoing TURP

Male

Hewitt 2001

Elective urological surgery

Patients requiring radical perineal prostatectomy

Male

Huang 2011

Elective gynaecological surgery

Patients with cystocele of at least stage II, who were symptomatic and desired operative treatment with anterior vaginal repair with or without other concomitant pelvic surgeries

Female

Ind 1993

Elective hysterectomy, posterior exenteration, colposuspension, anterior colporrhaphy, total/radical vulvectomy, radical oophorectomy, ovarian cystectomy, adhesiolysis myomectomy

Patients which were admitted for any of the following operations: hysterectomy, posterior exenteration, colposuspension, anterior colporrhaphy, total/radical vulvectomy, radical oophorectomy, ovarian cystectomy, adhesiolysis myomectomy

Female

Irani 1995

Elective transurethral prostatic surgery

Patients admitted for transurethral prostatic surgery due to benign hyperplasia

Male

Iversen Hansen 1984

Urethral strictures

Patients with urethral strictures

Not reported

Jang 2012

Surgery for rectal cancer

Patients undergoing elective rectal surgery for cancer

Mixed

Jeong 2014

Robot‐assisted laparoscopic radical prostatectomy

Patients with localised or advanced prostate cancer

Men

Joshi 2014

Elective hysterectomy with salpingo‐oophorectomy

Patients undergoing uneventful hysterectomy with salpingo‐oophorectomy

Female

Jun 2011

Elective TURP

Patients admitted for TURP

Male

Kamilya 2010

Vaginal prolapse surgery

Patients undergoing vaginal prolapse surgery

Female

Kelleher 2002

Urological surgery

Patients admitted to urology or renal unit

Not reported

Kim 2012

Radical prostatectomy

Patients undergoing extraperitoneal laparoscopic radical prostatectomy

Men

Koh 1994

Elective TURP

Patients admitted for TURP

Men

Kokabi 2009

Anterior colporrhaphy for pelvic organ prolapse

Patients undergoing anterior colporrhaphy due to pelvic organ prolapse and stress incontinence

Female

Lang 2020

Elective gynaecological surgery

Patients admitted for elective benign gynaecological surgery

Female

Lau 2004

Elective general surgery

Patients admitted for elective general surgery

Mixed

Li 2014

Elective TURP

Patients admitted for TURP

Men

Liang 2009

Laparoscopic vaginal hysterectomy

Patients admitted for laparoscopic vaginal hysterectomy

Female

Lista 2020

Elective urological surgery

Patients admitted for robot‐assisted radical prostatectomy for localised prostate cancer

Male

Liu 2015

Neurosurgery

Patients undergoing neurosurgery

Mixed

Lyth 1997

TURP or bladder neck incision

Patients undergoing TURP or bladder neck incision

Unclear

Mao 1994

Elective gynaecological surgery

Patients undergoing surgery for total hysterectomy or salpingo‐oophorectomy

Female

Matsushima 2015

Surgery for prostate cancer removal (unclear what operation was done)

Patients with prostate cancer

Male

McDonald 1999

TURP

Patients undergoing TURP

Male

Naguimbing‐Cuaresma 2007

Elective CS

Participants admitted for elective CS

Female

Nathan 2001

Elective gynaecological surgery

Patients undergoing surgery for benign gynaecological conditions

Female

Nguyen 2012

Elective urological surgery for urethral strictures

Patients undergoing surgery for urethral strictures

Unclear

Nielson 1985

Elective urological surgery for urethral strictures

Patients undergoing surgery for urethral strictures

Unclear

Noble 1990

Elective urological surgery and procedures

Patients admitted to the urological unit

Mixed

Nyman 2010

Orthopaedic surgery

Patients admitted with hip fractures in need of surgery

Mixed

Oberst 1981

Elective general surgery

Patients undergoing surgery for bowel cancer; low anterior bowel resection or abdominoperineal resection

Mixed

Onile 2008

Elective CS

Patients admitted for elective CS

Female

Ouladsahebmadarek 2012

Elective gynaecological surgery

Patienst admitted for elective abdominal hysterectomy or laparotomy for being pathology (fibroma, AUB, chronic pelvic pain, ovarian cysts etc.)

Female

Pervaiz 2019

Elective urological surgery

Patients undergoing TURP

Male

Popiel 2017

Elective gynaecological surgery

Patients undergoing robotic sacrocolpopexy for vaginal prolapse

Female

Rajan 2017

Elective gynaecological surgery

Patients undergoing surgery for Ward Mayo operation; Manchester repair; vaginal hysterectomy and amputation of cervix

Female

Ruminjo 2015

Elective gynaecological surgery

Patients undergoing fistula repair surgery

Female

Sahin 2011

Elective urological surgery

Patients admitted for TURP due to benign prostate hypertrophy

Male

Sandberg 2019

Elective gynaecological surgery

Patients undergoing laparoscopic hysterectomy

Female

Schiotz 1995

Elective gynaecological surgery

Patients admitted for vaginal plastic surgery (anterior colporrhaphy, anterior plus posterior colporrhaphy or a full Manchester repair)

Female

Schiotz 1996

Elective urogynaecological surgery

Patients admitted for elective retro‐pubic surgery for stress incontinence

Female

Sekhavat 2008

Elective gynaecological surgery

Patients undergoing anterior colporrhaphy

Female

Shahnaz 2016

Elective gynaecological surgery

Patients undergoing surgery for pelvic organ prolapse

Female

Shrestha 2013

Elective gynaecological surgery

Patients admitted for vaginal hysterectomy, anterior colporrhaphy or Manchester operations

Female

Souto 2004

Elective urological surgery

Patients admitted for retropubic radical prostatectomy

Male

Sun 2004

Elective urogynaecological surgery

Patients admitted for Burch's colposuspension

Female

Tahmin 2011

Elective gynaecological surgery

Patients with genital prolapses admitted for vaginal hysterectomy and or pelvic floor repair

Female

Talreja 2016

Elective urological surgery

Patients with benign prostatic enlargement undergoing TURP

Male

Taube 1989

AUR

Patients admitted to the hospital with AUR

Male

Toscano 2001

Elective urological surgery

Patients with benign prostatic enlargement undergoing TURP

Male

Valero Puerta 1998

Elective urological surgery

Patients with benign prostatic enlargement undergoing TURP

Male

Vallabh‐Patel 2020

Elective gynaecological surgery

Patients undergoing robotic sacrocolpopexy for pelvic organ prolapse

Female

Webster 2006

General surgery and medical patients

Patients who required IUC on general surgery and medical wards

Mixed

Weemhoff 2011

Elective gynaecological surgery

Patients admitted for anterior colporrhaphy

Female

Williamson 1982

Elective surgery (unspecific)

Patients undergoing surgery (not specified by trial)

Female

Wilson 2000

Elective urological surgery

Patients with benign prostatic enlargement undergoing TURP

Male

Wu 2015

Elective gallbladder or biliary tree surgery

Pateints undergoing gallbladder or biliary tree surgery

Mixed

Wyman 1987

Elective urological surgery

Patients with benign prostatic enlargement undergoing TURP

Male

Yaghmaei 2017

Elective CS

Patients who underwent CS

Female

Yee 2015

Elective CS

Patients who underwent CS under spinal anaesthesia

Female

Zaouter 2009

Elective major abdominal and thoracic surgery

Patients admitted for elective major abdominal and thoracic surgery

Mixed

Zhou 2012

Elective CS

Patients who underwent CS

Female

Zmora 2010

Elective colon and rectal surgery with pelvic dissection

Patients admitted for elective colon and rectal surgery

Mixed

Zomorrodi 2018

Elective renal transplant surgery

Patients with end‐stage renal failure undergoing renal transplant surgery

Mixed

AUB: abnormal uterine bleeding; AUR: acute urinary retention; CS: cesarean section; GI: gastrointestinal; FIGO: International Federation of Gynecology and Obstetrics; ICU: intensive care unit; IUC: indwelling urethral catheter; TURP: transurethral resection of the prostate

Sex

Fifty trials included women only (Ahmed 2014; Alessandri 2006; Alonzo‐Sosa 1997; Aref 2020; Aslam 2019; Azarkish 2003; Azarkish 2005; Barone 2015; Basbug 2020; Carpiniello 1988; Carter‐Brooks 2018; Chai 2011; Dunn 1999; Dunn 2000b; Dunn 2003; El‐Mazny 2014; Glavind 2007; Gong 2017; Gungor 2014; Guzman 1994; Hakvoort 2004; Huang 2011; Ind 1993; Joshi 2014; Kamilya 2010; Kokabi 2009; Lang 2020; Liang 2009; Mao 1994; Naguimbing‐Cuaresma 2007; Nathan 2001; Onile 2008; Ouladsahebmadarek 2012; Popiel 2017; Rajan 2017; Ruminjo 2015; Sandberg 2019; Schiotz 1995; Schiotz 1996; Sekhavat 2008; Shahnaz 2016; Shrestha 2013; Sun 2004; Tahmin 2011; Vallabh‐Patel 2020; Weemhoff 2011; Williamson 1982; Yaghmaei 2017; Yee 2015; Zhou 2012).

Twenty‐two trials included men only (Chillington 1992; Durrani 2014; Ganta 2005; Han 1997; Hewitt 2001; Irani 1995; Jeong 2014; Kim 2012; Koh 1994; Li 2014; Lista 2020; Matsushima 2015; McDonald 1999; Pervaiz 2019; Sahin 2011; Souto 2004; Talreja 2016; Taube 1989; Toscano 2001; Valero Puerta 1998; Wilson 2000; Wyman 1987).

Twenty‐one trials included participants of both sexes (Allen 2016; Benoist 1999; Chen 2013; Chia 2009; Cornia 2003; Coyle 2015; Crowe 1993; Gross 2007; Hall 1998; Jang 2012; Jun 2011; Lau 2004; Liu 2015; Noble 1990; Nyman 2010; Oberst 1981; Webster 2006; Wu 2015; Zaouter 2009; Zmora 2010; Zomorrodi 2018).

Six trials did not report participants' sex (Bristoll 1989; Iversen Hansen 1984; Kelleher 2002; Lyth 1997; Nguyen 2012; Nielson 1985).

Age

A wide range of ages was reported in the included trials (see Table 2). Twenty‐three trials did not report the age of participants (Aslam 2019; Azarkish 2005; Bristoll 1989; Chillington 1992; Cornia 2003; Crowe 1993; Dunn 1999; Dunn 2000b; Dunn 2003; Hall 1998; Hewitt 2001; Kelleher 2002; Kim 2012; Kokabi 2009; Lyth 1997; Mao 1994; Naguimbing‐Cuaresma 2007; Nguyen 2012; Noble 1990; Popiel 2017; Ruminjo 2015; Wilson 2000; Yee 2015). In trials that did report age of participants, reported it for each trial arm, overall or both.

Open in table viewer
Table 2. Interventions and age of participants

TrialID

InterventionA

Intervention B

Age (A), years

Mean (SD)

Age (B), years

Mean (SD)

Age (overall), years

Ahmed 2014

IUC removal immediately post‐op

IUC removal 24 h post‐op

59.1(8.3) 

61.3 (10.5)

Not reported

Alessandri 2006

IUC removal immediately post‐op

IUC removal 12 h post‐op

51 (4.3)

47 (5)

Not reported

Allen 2016

IUC removed within 48 h post‐op

IUC removed within 6 h after epidural removal

61.1 (range 31–85)

61.7 (range 21–87)

61.5 (range 21‐87)

Alonzo‐Sosa 1997

IUC removal 1 day post‐op

IUC removal 3 days post‐op

53.5 (range 37‐63)

47.1 (range 37‐67)

Not reported

Aref 2020

IUC removal 6 h post‐op

IUC removal 24 h post‐op

25.3 (2)

25.6 (3)

Not reported

Aslam 2019

IUC removal immediately post‐op

IUC removal 1‐day post‐op

Not reported

Not reported

Not reported

Azarkish 2003

IUC removal 2‐3 h after surgery

IUC removal the morning after surgery

24.96 (4.88)

27.06 (5.56)

Not reported

Azarkish 2005

IUC removal 2‐3 h after surgery

IUC removal 24 h after surgery

Not reported

Not reported

Not reported

Barone 2015

IUC removal 7 days after surgery

IUC removal 14 days after surgery

31.9 (11.5)

30.6

(11.7)

Not reported

Basbug 2020

IUC removal 2 h after surgery

IUC removal 12 h after surgery

30.13 (5.83)

29.96 (4.71)

Not reported

Benoist 1999

IUC removal 1 day post‐op

IUC removal 5 days post‐op

55 (18)

56 (17)

Not reported

Bristoll 1989

threshold clamping

complete drainage

Not reported

Not reported

Not reported

Carpiniello 1988

IUC removal immediately post‐op

IUC removal 1‐day post‐op

73 (6.6)

70 (8.6)

Not reported

Carter‐Brooks 2018

IUC removal 4 h after surgery

IUC removal 6 am on post‐op day 1

64.9 (11.5)

65.2 (10.3)

Not reported

Chai 2011

IUC removal immediately post‐op

IUC removal 1 day post‐op

46.4 (3.9)

46.4 (4.0)

Not reported

Chen 2013

IUC removal ≤ 7 days

IUC removal > 7 days

77 (12.7)

78 (10.5)

Not reported

Chia 2009

IUC removal 1 day post‐op

IUC removal 3 days post‐op

54.7 (11.2)

55.7 (10.3)

Not reported

Chillington 1992

IUC removal at midnight

IUC removal at 6 am the next morning

Not reported

Not reported

Not reported

Cornia 2003

A computer study order was used to remind staff to remove the IUC after 3 days

A computer study order was not used to remind staff to remove the IUC after 3 days

Not reported

Not reported

Not reported

Coyle 2015

IUC removal 2 days post‐op

IUC removal within 12 h of withdrawal of epidural anaesthesia

63.5 (SD not reported)

62 (SD not reported)

Not reported

Crowe 1993

IUC removal at 6 am

IUC removal at midnight

Not reported

Not reported

Not reported

Dunn 1999

IUC removal immediately post‐op

Delayed IUC removal post‐op

Not reported

Not reported

Not reported

Dunn 2000b

IUC removal immediately post‐op

IUC removal 1 day post‐op

Not reported

Not reported

Not reported

Dunn 2003

IUC removal immediately post‐op

IUC removal 1 day post‐op

Not reported

Not reported

Not reported

Durrani 2014

IUC removal 1 day post‐op

IUC removal 4 or 5 days post‐op

Not reported

Not reported

71.32 (5.94)

El‐Mazny 2014

IUC removal immediately post‐op

IUC removal 12 h post‐op

24.5 (4.2)

23.8 (3.9)

Not Reported

Ganta 2005

IUC removal at midnight

IUC removal at 6 am

69.9 (SD not reported)

68.2 (SD not reported)

68.9 (SD not reported)

Glavind 2007

IUC removal 3 h post‐op

IUC removal the next morning

Not reported

Not reported

61 (range 31‐88)

Gong 2017

IUC for 48 h with intermittent clamping

IUC for 48 h without intermittent clamping

46.14 (8.33)

45.70 (9.63)

Not Reported

Gross 2007

IUC removal at 10 pm the day the order for removal was written

IUC removal at 7 am the day after the order for removal was written

Not reported

Not reported

70.3 (11.7)

Gungor 2014

IUC removal 2 days post‐op

IUC removal 3 or 4 days post‐op

55.7 (8.8)

3 days: 58.5 (10.1)

4 days: 55.8 (9.0)

Not reported

Guzman 1994

IUC removal 1 day post‐op

IUC removal 3 days post‐op (with and without bladder‐clamping)

56 (range 40‐75)

No clamping: 58 (range 8‐79)

Clamping: 57 (range 36‐75)

Not reported

Hakvoort 2004

IUC removal on the morning after surgery

IUC removal 5 days post‐op

67 (range 36 ‐ 86)

66 (range 33‐87)

Not reported

Hall 1998

IUC removal between 7 am and 9 am

IUC removal between 9 pm and 11 pm

Not reported

Not reported

Not reported

Han 1997

IUC removal 2 days post‐op

IUC removal ≥ 3 days post‐op

64.6 (range 50‐86)

68.2 (range 50‐90)

Not reported

Hewitt 2001

IUC removal 4‐6 days post‐op

IUC removal at 14 days post‐op

Not reported

Not reported

Not reported

Huang 2011

IUC removal 2 days post‐op

IUC removal 3 or 4 days post‐op

61.21, (10.17)

3 days: 63.93 (10.43)

4 days: 63.7 (12.5)

62.9 (10.93)

Ind 1993

IUC removal at 6 am

IUC removal at midnight

49.59 (14.2)

49.84 (16.6)

Not reported

Irani 1995

IUC removal within 48 h

IUC removal at surgeon's discretion

70.7 (range 42‐88)

70 (range 58‐85)

Not reported

Iversen Hansen 1984

IUC removal 1 day post‐op

IUC removal 14 days post‐op

Not reported

Not reported

70 (range 24‐85)

Jang 2012

No alpha blockers given

Prophylactic alpha blockers given

54 (range 48‐62)

59 (range 54‐66)

Not reported

Jeong 2014

Prophylactic alpha blockers given

No alpha blockers given

63.6 (6.6)

63.4 (8)

Not reported

Joshi 2014

IUC removal immediately post‐op

IUC removal 1 day post‐op

46.8 (6.9)

45.09 (6.44)

Not reported

Jun 2011

Prophylactic alpha blockers given

No alpha blockers given

68.71 (7.6)

71.4 (7.85)

Not reported

Kamilya 2010

IUC removal 1 day post‐op

IUC removal 4 days post‐op

46.9 (12.02)

47.9 (12.78)

Not reported

Kelleher 2002

IUC removal at 6 am

IUC removal at midnight

Not reported

Not reported

Not reported

Kim 2012

IUC removal on post‐op day 3/4

IUC removal on post‐op day 7/8

Not reported

Not reported

Not reported

Koh 1994

IUC removal 1 day post‐op

IUC removal 2 days post‐op

68.8, 7.3 (mean, SD)

73, 7.6 (mean, SD)

Not reported

Kokabi 2009

IUC removal 1 day post‐op

IUC removal 2 days post‐op OR 4 days post‐op (3‐arm trial)

Not reported

Not reported

Not reported

Lang 2020

IUC removal 4 h post‐op

IUC removal day 1 post‐op

Not reported

Not reported

44.4 (8.8)

Lau 2004

"In out" catheterisation

IUC overnight

Not reported

Not reported

63.3 (4.9)

Li 2014

IUC removal on day 1‐2 post‐op

IUC removal on day 5‐7 post‐op

Not reported

Not reported

Range 56 ‐ 92

Liang 2009

IUC removal immediately

IUC removal 1 day post‐op OR 2 days post‐op

(3‐arm trial)

43.7 (3.9)

B) 45.7 ( 3.5)

C) 45.7 ( 5.8)

Not reported

Lista 2020

IUC removal on day 3 post‐op

IUC removal on day 5 post‐op

63 (range 48 ‐ 75)

64 (range 45 – 75)

Not reported

Liu 2015

Clamping of IUC

No clamping of IUC i.e. free drainage

51 (13.2)

52 (16.4 SD)

Not reported

Lyth 1997

IUC removal at 6 am

IUC removal at midnight

Not reported

Not reported

Not reported

Mao 1994

IUC duration 7 am to 8 pm (same day)

IUC duration 7 am to 6 am (next day)

Not reported

Not reported

Not reported

Matsushima 2015

IUC removal 2 days post‐op

IUC removal 4 days post‐op

Not reported

Not reported

65.9 (5.5)

McDonald 1999

IUC removal at midnight

IUC removal at 6 am

66.7 (range 51‐81)

68.7 (range 57‐89)

67.8 (range 51‐89)

Naguimbing‐Cuaresma 2007

IUC removal 4 h post‐op

IUC removal day 1 post‐op

Not reported

Not reported

Not reported

Nathan 2001

IUC removal at 6 am

IUC removal at midnight

46.5 (5.6)

45.7 (5.4)

Not reported

Nguyen 2012

IUC removal 2 days post‐op

IUC removal 10 days post‐op

Not reported

Not reported

Not reported

Nielson 1985

IUC removal 3 days post‐op

IUC removal 28 days post‐op

64 (range 21‐81)

64 (range 16‐78)

Not reported

Noble 1990

IUC removal at 6 am

IUC removal at midnight

Not reported

Not reported

Not reported

Nyman 2010

Clamping of IUC

No clamping of IUC

79 (11)

80 (11.2)

Not reported

Oberst 1981

Clamping of IUC

No clamping of IUC

64.5 (10.26)

59 (11.92)

Not reported

Onile 2008

IUC removal 1 day post‐op

IUC removed immediately post‐op

31.67 (6.042)

32.72 (5.96)

Not reported

Ouladsahebmadarek 2012

IUC removed immediately post‐op

IUC removal 1 day post‐op

37.48 (8.85)

39.48 (9.54)

Not reported

Pervaiz 2019

IUC removal on day 1 post‐op

IUC removal on day 4 post‐op

67.00 (9.11)

65.56 (9.25)

Not reported

Popiel 2017

IUC removal within 6 h of operation completion

IUC removal on day 1 post‐op

Not reported

Not reported

Not reported

Rajan 2017

IUC removal within 3 h of operation completion

IUC removal on day 1 post‐op

50 (18)

48 (2.4)

Not reported

Ruminjo 2015

IUC removal on day 7 post‐op

IUC removal on day 14 post‐op

Not reported

Not reported

Not reported

Sahin 2011

IUC removal 1 day post‐op

IUC removal 2 days post‐op AND 3 days post‐op

(3‐arm trial)

 62.5 (SD not reported)

B: 61.5, C: 62 (SD not reported)

62 (range 48‐77)

Sandberg 2019

IUC removal immediately post‐op

IUC removal 18‐24 h post‐op

49.3 (10.5)

51.5 (11.9)

Not reported

Schiotz 1995

IUC removal 1 day post‐op

IUC removal 3 days post‐op

Not reported

Not reported

65.9 (range 29.9‐95.2)

Schiotz 1996

IUC removal 1 day post‐op

IUC removal 1 day post‐op

Not reported

Not reported

50.3 (range 26.9‐72.6)

Sekhavat 2008

IUC removed immediately post‐op

IUC removal 1 day post‐op

38.9 (2.9)

39 (3.8)

Not reported

Shahnaz 2016

IUC removal 24 h post‐op

IUC removal 72 h post‐op

39.4 (3.2)

38.8 (2.8)

Not reported

Shrestha 2013

IUC removal 1 day post‐op

IUC removal 3 days post‐op

Not reported

Not reported

53.35 (10.94)

Souto 2004

IUC removal 7 days post‐op

IUC removal 14 days post‐op

64 (7.3)

61 (7.3)

62 (range 50‐73)

Sun 2004

IUC removal on the next morning post‐op

IUC removal 5 days post‐op

46.7 (6.7)

48.3 (8.3)

Not reported

Tahmin 2011

IUC removal 2 days post‐op

IUC removal 5 days post‐op

51.75 (10.8)

53.95 (12.8)

Not reported

Talreja 2016

Clamping of IUC

No clamping of IUC i.e. free drainage

63.05 (4.69)

64.21 (5.36)

Not reported

Taube 1989

IUC removal immediately after emptying of bladder

IUC removal 1 day post‐op AND 2 days post‐op

(3‐arm trial)

Not reported

Not reported

Not reported

Toscano 2001

IUC removal 1 day post‐op

IUC removal 2 days post‐op

Not reported

Not reported

Not reported

Valero Puerta 1998

IUC removal on day 2 post‐op

IUC removal according to usual care

70 (range 53‐83)

69 (range 50‐87)

Not reported

Vallabh‐Patel 2020

IUC removal 6 h post‐op

IUC removal 1 day post‐op

59.52 (8.5)

59.57 (11.2)

Not reported

Webster 2006

IUC removal at 6 am

IUC removal at 10 pm

55.02 (19.97)

55.05 (18.99)

Not reported

Weemhoff 2011

IUC removal 2 days post‐op

IUC removal 5 days post‐op

59.9 (10.2)

60.7 (11.1)

Not reported

Williamson 1982

Clamping of IUC

No clamping of IUC i.e. free drainage

Not reported

Not reported

Range 22‐40

Wilson 2000

Bladder infusion with normal saline by gravity until bladder was full

IUC removal at 6 am

Not reported

Not reported

Not reported

Wu 2015

Catheter clamped when patient woke up post‐op. On Day 1 morning post‐op, when the patient felt urge to pass urine, the urinary catheter balloon was deflated and the catheter allowed to be self‐dislodged during urination

On the morning of Day1 post‐op, after the patient passed urine (through the catheter), saline was used to wash the bladder and the catheter clamped. 10 min after clamping, the balloon was deflated and the catheter allowed to be self‐dislodged during urination

45.6 (7.2)

46.1 (7)

Not reported

Wyman 1987

IUC removal between 6 am and 7 am

IUC removal between 10 pm and 11 pm

Not reported

Not reported

70.8 (range 50‐89)

Yaghmaei 2017

IUC removal 6 h post‐op

IUC removal 12‐24 h post‐op

28.19 (5.80)

28.01 (5.83)

Not reported

Yee 2015

IUC removal 8 h post‐op

IUC removal 1 day post‐op

Not reported

Not reported

Not reported

Zaouter 2009

IUC removal on the same morning as the surgery

IUC removal when the epidural anaesthesia was removed

57 (15)

63 (11)

Not reported

Zhou 2012

IUC removal 6‐8 h post‐op

IUC removal 24 h post‐op

25.11(4.88)

26.33 (5.08)

Not reported

Zmora 2010

IUC removal 1 day post‐op

IUC removal 3 days post‐op AND 5 days post‐op

(3‐arm trial)

57.4 (range 18‐85)

B: 54.6 (range 25‐81)

C: 54.2 (range 22‐78)

Not reported

Zomorrodi 2018

IUC removal 3 days post‐op

IUC removal 7 days post‐op

43.52 (13.6)

43.20 (14.39)

Not reported

IUC: indwelling urethral catheter

In eight trials participants were less than 35 years old (Aref 2020; Azarkish 2003; Barone 2015; Basbug 2020; El‐Mazny 2014; Onile 2008; Yaghmaei 2017; Zhou 2012). In 49 trials, participants were 35 to 65 years old (Ahmed 2014; Alessandri 2006; Allen 2016; Alonzo‐Sosa 1997; Benoist 1999; Carter‐Brooks 2018; Chai 2011; Chia 2009; Coyle 2015; Dunn 2003; Glavind 2007; Gong 2017; Gungor 2014; Guzman 1994; Huang 2011; Ind 1993; Jang 2012; Jeong 2014; Joshi 2014; Kamilya 2010; Lang 2020; Lau 2004; Liang 2009; Lista 2020; Liu 2015; Nathan 2001; Nielson 1985; Oberst 1981; Ouladsahebmadarek 2012; Rajan 2017; Sahin 2011; Sandberg 2019; Schiotz 1996; Sekhavat 2008; Shahnaz 2016; Shrestha 2013; Souto 2004; Sun 2004; Tahmin 2011; Talreja 2016; Valero Puerta 1998; Vallabh‐Patel 2020; Webster 2006; Weemhoff 2011; Williamson 1982; Wu 2015; Zaouter 2009; Zmora 2010; Zomorrodi 2018). Nineteen trials had participants between 65 to 75 years old (Carpiniello 1988; Chen 2013; Durrani 2014; Ganta 2005; Gross 2007; Hakvoort 2004; Han 1997; Irani 1995; Iversen Hansen 1984; Jun 2011; Koh 1994; Li 2014; Matsushima 2015; McDonald 1999; Pervaiz 2019; Schiotz 1995; Taube 1989; Toscano 2001; Wyman 1987). The participants of one trial were more than 75 years old (Nyman 2010).

Participants who received antibiotics during hospitalisation

There was considerable variation between trials in participants receiving antibiotic prophylactic therapy (see Table 3). We think this is most likely due to the reasons for hospitalisation.

Open in table viewer
Table 3. Use of antibiotic prophylaxis

TrialID

Comparison

Antibiotic prophylaxis used

Details

Ahmed 2014;

2

Yes

Prophylaxis was given to all patients on the morning of surgery in the form of 1 g of ceftriaxone IM

Alessandri 2006

2

Yes

Prophylaxis was given as a single dose before operation

Allen 2016

2

No

N/A

Alonzo‐Sosa 1997

2

No

N/A

Aref 2020

2

Yes

Single dose of prophylactic antibiotic in the form of ceftriaxone 1 g IM

Aslam 2019

2

Not reported

Not reported

Azarkish 2003

2

Not reported

Not reported

Azarkish 2005

2

Not reported

Perineum wash by povidone iodine 10% before catheter insertion

Barone 2015

2

No

N/A

Basbug 2020

2

Yes

All participants received 1 g IV cefazolin as prophylaxis

Benoist 1999

2

Yes

All participants received IV antibiotics as a single dose at the induction of anaesthesia

Bristoll 1989

3

Not reported

N/A

Carpiniello 1988

2

Yes

Prophylactic cefazolin sodium or clindamycin was given on post‐op day 3

Carter‐Brooks 2018

2

Not reported

N/A

Chai 2011

2

No

N/A

Chen 2013

2

No

Routine prophylaxis was not given. Antibiotics were only used in symptomatic participants.

Chia 2009

2

Yes

Single dose of prophylactic antibiotic was given IV in all participants

Chillington 1992

1

Not reported

Not reported

Cornia 2003

2

Not reported

Not reported

Coyle 2015

2

Not reported

Not reported

Crowe 1993

1

Not reported

Not reported

Dunn 1999

N/A

Not reported

Not reported

Dunn 2000b

N/A

Not reported

Not reported

Dunn 2003

2

Yes

Single dose of antibiotic prophylaxis before operation

Durrani 2014

2

Yes

Cephalosporin 1 g was administered IV at the time of induction of anaesthesia

El‐Mazny 2014

2

Yes

Cefazolin 2 g IV single dose 30 min before surgery

Ganta 2005

1

Not reported

Not reported

Glavind 2007

2

Yes

Participants who had vaginal hysterectomy or high uterosacral suspension received 1 pre‐op injection of cefuroxime. No antibiotic prophylaxis was used in the remaining participants.

Gong 2017

3

Not reported

Not reported

Gross 2007

1

Not reported

Not reported

Gungor 2014

2

Not reported

Not reported

Guzman 1994

2 and 3

Yes

All participants received Quemicetina as prophylaxis

Hakvoort 2004

2

Not reported

Not reported

Hall 1998

1

Not reported

Not reported

Han 1997

2

Not reported

Not reported

Hewitt 2001

2

Not reported

Not reported

Huang 2011

2

Yes

Ciprofloxacin used during all days of hospitalisation in all 3 groups

Ind 1993

1

Not reported

Not reported

Irani 1995

2

Yes

Antibiotics (quinolones) were given from the day of operation until the participant was discharged home

Iversen Hansen 1984

2

Yes

Antibiotics were not administered routinely but participants with urinary infections pre‐ or post‐op were treated with antibiotics according to urine culture results.

Jang 2012

4

Yes

All participants were given an IV dose of antibiotic during anaesthesia induction before operation

Jeong 2014

4

Not reported

Not reported

Joshi 2014

2

Yes

All participants received 1 dose of antibiotic prophylaxis at the time of surgery and continued post‐op as per department protocol

Jun 2011

4

Not reported

Not reported

Kamilya 2010

2

Yes

All participants received 2 doses of antibiotic injection ceftriaxone 1 g, one just before the operation and another 12 h after the first dose

Kelleher 2002

1

Not reported

Not reported

Kim 2012

2

Not reported

Not reported

Koh 1994

2

Yes

Antibiotics were given at induction to participants with IUCs or proven urinary tract infections

Kokabi 2009

2

Not reported

Not reported

Lang 2020

2

Yes

All participants received pre‐op antibiotics with either American College of Obstetricians and Gynecologists approved dosing of cefazolin (78%) or a combination of gentamicin and clindamycin (22%) with no difference between fast‐track or conventional Foley management groups

Lau 2004

2

Yes

Single dose of parenteral antibiotic was given upon induction of general anaesthesia in most cholecystectomies, hernia repairs, gastrointestinal and anorectal operations

Li 2014

2

Not reported

Not reported

Liang 2009

2

Yes

IV antibiotics consisting of cefazolin 500 mg after induction of general anaesthesia

Lista 2020

2

Not reported

Not reported

Liu 2015

3

Not reported

Not reported

Lyth 1997

1

Not reported

Not reported

Mao 1994

2

Not reported

Not reported

Matsushima 2015

2

Not reported

Not reported

McDonald 1999

1

Not reported

Not reported

Naguimbing‐Cuaresma 2007

2

Not reported

Not reported

Nathan 2001

1

Not reported

Not reported

Nguyen 2012

2

Not reported

Not reported

Nielson 1985

2

Not reported

Not reported

Noble 1990

1

Not reported

Not reported

Nyman 2010

3

Not reported

Not reported

Oberst 1981

3

Not reported

Not reported

Onile 2008

2

Not reported

Not reported

Ouladsahebmadarek 2012

2

Yes

Cephazoline 1 g IV half an hour before surgery started and continued every 6 h for another 2 doses

Pervaiz 2019

2

Not reported

Not reported

Popiel 2017

2

Not reported

Not reported

Rajan 2017

2

Not reported

Not reported

Ruminjo 2015

2

Not reported

Not reported

Sahin 2011

2

Not reported

Not reported

Sandberg 2019

2

Not reported

Not reported

Schiotz 1995

2

Not reported

Not reported

Schiotz 1996

2

Not reported

Not reported

Sekhavat 2008

2

Not reported

Not reported

Shahnaz 2016

2

No

"antibiotic was not regularly given except for patients who had abnormal urinary symptoms and unusual urinary analysis in urinary sample 48 h after the surgery"

Shrestha 2013

2

Yes

Antibiotics given for 7 days

Souto 2004

2

Not reported

Not reported

Sun 2004

2

Yes

All participants were given prophylactic antibiotics for 2 days (1 g cefazolin IV 3 times daily)

Tahmin 2011

2

Not reported

Not reported

Talreja 2016

3

Yes

Participants were given 1 dose of third‐generation cephalosporin in pre‐op period

Taube 1989

2

Not reported

Not reported

Toscano 2001

2

Yes

Antiobiotic prophylaxis with first generation cephalosporin was given at the induction of anaesthesia for up to 7 days after the operation

Valero Puerta 1998

2

Yes

1 g of ceftriaxone every 24 h for 2 days

Vallabh‐Patel 2020

2

Yes

All participants received appropriate perioperative antibiotics per American College of Obstetricians and Gynecologists guidelines

Webster 2006

1

Not reported

Not reported

Weemhoff 2011

2

Yes

All participants received antibiotic prophylaxis at the beginning of the operation.

Williamson 1982

3

Not reported

Not reported

Wilson 2000

1

Not reported

Not reported

Wu 2015

3

Not reported

Not reported

Wyman 1987

1

Not reported

Not reported

Yaghmaei 2017

2

Yes

Cefazolin 1 g

Yee 2015

2

Not reported

Not reported

Zaouter 2009

2

Yes

2 g cefazolin with or without 500 mg of metronidazole was given IV

Zhou 2012

2

Not reported

Not reported

Zmora 2010

2

Yes

Prophylactic antibiotics were given 24 h in the perioperative period according to department protocol

Zomorrodi 2018

2

Not reported

Not reported

IM: intramuscular(ly); IUC: indwelling urethral catheter; IV: intravenous(ly); N/A: not applicable

Sixty trials did not report whether antibiotic prophylaxis was given to participants or not (Allen 2016; Aslam 2019; Azarkish 2003; Azarkish 2005; Bristoll 1989; Carter‐Brooks 2018; Chillington 1992; Cornia 2003; Coyle 2015; Crowe 1993; Dunn 1999; Dunn 2000b; Ganta 2005; Gong 2017; Gross 2007; Gungor 2014; Hakvoort 2004; Hall 1998; Han 1997; Hewitt 2001; Ind 1993; Jeong 2014; Jun 2011; Kelleher 2002; Kim 2012; Kokabi 2009; Li 2014; Lista 2020; Liu 2015; Lyth 1997; Mao 1994; Matsushima 2015; McDonald 1999; Naguimbing‐Cuaresma 2007; Nathan 2001; Nguyen 2012; Nielson 1985; Noble 1990; Nyman 2010; Oberst 1981; Onile 2008; Pervaiz 2019; Popiel 2017; Rajan 2017; Ruminjo 2015; Sahin 2011; Sandberg 2019; Schiotz 1995; Schiotz 1996; Souto 2004; Tahmin 2011; Taube 1989; Webster 2006; Williamson 1982; Wilson 2000; Wu 2015; Wyman 1987; Yee 2015; Zhou 2012; Zomorrodi 2018).

Participants received antibiotic therapy in 33 trials (Ahmed 2014; Alessandri 2006; Aref 2020; Basbug 2020; Benoist 1999; Carpiniello 1988; Chia 2009; Dunn 2003; Durrani 2014; El‐Mazny 2014; Glavind 2007; Guzman 1994; Huang 2011; Irani 1995; Jang 2012; Joshi 2014; Kamilya 2010; Koh 1994; Lang 2020; Lau 2004; Liang 2009; Ouladsahebmadarek 2012; Sekhavat 2008; Shrestha 2013; Sun 2004; Talreja 2016; Toscano 2001; Valero Puerta 1998; Vallabh‐Patel 2020; Weemhoff 2011; Yaghmaei 2017; Zaouter 2009; Zmora 2010).

Participants did not receive routine prophylactic antibiotic therapy in five trials (Alonzo‐Sosa 1997; Barone 2015; Chai 2011; Chen 2013; Shahnaz 2016). Some participants received antibiotic therapy when others did not (Iversen Hansen 1984).

Interventions

We split the trials into five different interventions with the following comparisons for the removal of indwelling urethral catheters:

  1. Thirteen trials (1506 participants) compared the removal of indwelling urethral catheters at one specified time of day (6 am to 7 am) versus another specified time of day (10 pm to midnight) (Chillington 1992; Crowe 1993; Ganta 2005; Gross 2007; Hall 1998; Ind 1993; Kelleher 2002; Lyth 1997; McDonald 1999; Nathan 2001; Noble 1990; Webster 2006; Wyman 1987);

  2. Sixty‐eight trials (9247 participants) compared shorter durations of indwelling urethral catheterisation versus longer durations of indwelling urethral catheterisation (Ahmed 2014; Alessandri 2006; Allen 2016; Alonzo‐Sosa 1997; Aref 2020; Aslam 2019; Azarkish 2003; Barone 2015; Basbug 2020; Benoist 1999; Carpiniello 1988; Carter‐Brooks 2018; Chai 2011; Chen 2013; Chia 2009; Cornia 2003; Coyle 2015; Dunn 2003; Durrani 2014; El‐Mazny 2014; Glavind 2007; Gungor 2014; Guzman 1994; Hakvoort 2004; Han 1997; Hewitt 2001; Huang 2011; Irani 1995; Joshi 2014; Kamilya 2010; Kim 2012; Koh 1994; Kokabi 2009; Lang 2020; Lau 2004; Li 2014; Liang 2009; Lista 2020; Mao 1994; Matsushima 2015; Naguimbing‐Cuaresma 2007; Nguyen 2012; Nielson 1985; Onile 2008; Ouladsahebmadarek 2012; Pervaiz 2019; Popiel 2017; Rajan 2017; Sahin 2011; Sandberg 2019; Schiotz 1995; Schiotz 1996; Sekhavat 2008; Shahnaz 2016; Shrestha 2013; Souto 2004; Sun 2004; Tahmin 2011; Taube 1989; Toscano 2001; Valero Puerta 1998; Vallabh‐Patel 2020; Weemhoff 2011; Yaghmaei 2017; Zaouter 2009; Zhou 2012; Zmora 2010; Zomorrodi 2018);

  3. No trials compared flexible durations of indwelling urethral catheterisation versus fixed duration of indwelling urethral catheterisation;

  4. Seven trials (714 participants) compared clamping of indwelling urethral catheterisation versus free drainage of indwelling urethral catheterisation prior to removal (Gong 2017; Guzman 1994; Liu 2015; Nyman 2010; Oberst 1981; Williamson 1982; Wu 2015);

  5. Three trials (402 participants) compared prophylactic use of alpha blocker prior to indwelling urethral catheter removal versus no intervention or placebo (Jang 2012; Jeong 2014; Jun 2011).

Guzman 1994 reported data for both clamping regimes as well as shorter versus longer durations of catheters and is therefore included in both comparisons.

Outcome measures

Thirty‐five of the 99 included trials did not report our primary outcome of number of participants who required recatheterisation (Azarkish 2003; Azarkish 2005; Barone 2015; Benoist 1999; Bristoll 1989; Coyle 2015; Crowe 1993; El‐Mazny 2014; Gross 2007; Gungor 2014; Han 1997; Iversen Hansen 1984; Jeong 2014; Lang 2020; Li 2014; Liang 2009; Mao 1994; McDonald 1999; Nguyen 2012; Nielson 1985; Noble 1990; Popiel 2017; Ruminjo 2015; Souto 2004; Sun 2004; Taube 1989; Toscano 2001; Valero Puerta 1998; Williamson 1982; Wilson 2000; Wu 2015; Yaghmaei 2017; Yee 2015; Zhou 2012; Zomorrodi 2018).

Forty‐four trials reported symptomatic CAUTI (Ahmed 2014; Alessandri 2006; Allen 2016; Alonzo‐Sosa 1997; Aref 2020; Aslam 2019; Azarkish 2003; Barone 2015; Benoist 1999; Carter‐Brooks 2018; Chai 2011; Chen 2013; Chia 2009; Cornia 2003; Coyle 2015; Dunn 2003; Durrani 2014; Gong 2017; Gross 2007; Guzman 1994; Huang 2011; Jang 2012; Kamilya 2010; Koh 1994; Kokabi 2009; Lang 2020; Lau 2004; Li 2014; Liang 2009; Lista 2020; Ouladsahebmadarek 2012; Pervaiz 2019; Popiel 2017; Rajan 2017; Sandberg 2019; Schiotz 1995; Schiotz 1996; Sekhavat 2008; Sun 2004; Vallabh‐Patel 2020; Weemhoff 2011; Zaouter 2009; Zmora 2010; Zomorrodi 2018).

Nineteen trials reported asymptomatic bacteriuria (Ahmed 2014; Aref 2020; Basbug 2020; Carpiniello 1988; Chai 2011; Chen 2013; El‐Mazny 2014; Glavind 2007; Hakvoort 2004; Irani 1995; Joshi 2014; Kamilya 2010; Nathan 2001; Onile 2008; Sandberg 2019; Shahnaz 2016; Shrestha 2013; Tahmin 2011; Zmora 2010).

Twenty‐four trials reported incidence of urinary retention (Barone 2015; Benoist 1999; Coyle 2015; El‐Mazny 2014; Guzman 1994; Han 1997; Irani 1995 ; Jeong 2014; Jun 2011; Kim 2012; Lista 2020; Mao 1994; Nielson 1985; Popiel 2017; Rajan 2017; Schiotz 1995; Sekhavat 2008; Shahnaz 2016; Taube 1989; Toscano 2001; Valero Puerta 1998; Webster 2006; Wu 2015: Zhou 2012).

Four trials reported data on complications of catheterisation (Dunn 2003; Nielson 1985; Webster 2006; Yaghmaei 2017).

Twelve trials reported data on patient pain or discomfort (Carter‐Brooks 2018; Chai 2011; Chia 2009; Dunn 2003; Joshi 2014; Naguimbing‐Cuaresma 2007; Nielson 1985; Ouladsahebmadarek 2012; Sandberg 2019; Sekhavat 2008; Webster 2006; Zaouter 2009).

Four trials reported data on patient satisfaction (Chillington 1992; Lyth 1997; Noble 1990; Yaghmaei 2017).

Eight trials reported data on urinary incontinence (Ahmed 2014; Barone 2015; Gungor 2014; Han 1997; Kim 2012; Onile 2008; Souto 2004; Webster 2006).

Nine trials reported dysuria (Ahmed 2014; Aref 2020; Basbug 2020; El‐Mazny 2014; Liu 2015; Onile 2008; Ouladsahebmadarek 2012; Webster 2006; Yaghmaei 2017).

Seventeen trials reported volume of first void (Chillington 1992; Crowe 1993; Ganta 2005; Gross 2007; Gungor 2014; Hall 1998; Huang 2011; Ind 1993; Kelleher 2002; Liu 2015; Lyth 1997; Mao 1994; McDonald 1999; Nathan 2001; Noble 1990; Webster 2006; Yaghmaei 2017).

Sixteen trials reported time to first void (Carter‐Brooks 2018; Chillington 1992; Crowe 1993; Ganta 2005; Gross 2007; Hall 1998; Ind 1993; Kelleher 2002; McDonald 1999; Naguimbing‐Cuaresma 2007; Nathan 2001; Noble 1990; Oberst 1981; Webster 2006; Williamson 1982; Yaghmaei 2017).

Six trials reported post‐void residual volume (Gross 2007; Gungor 2014; Huang 2011; Jang 2012; Jeong 2014; Nguyen 2012).

Forty trials reported length of hospitalisation (Ahmed 2014; Alessandri 2006; Allen 2016; Alonzo‐Sosa 1997; Aref 2020; Aslam 2019; Basbug 2020; Carter‐Brooks 2018; Chillington 1992; Durrani 2014; El‐Mazny 2014; Guzman 1994; Hakvoort 2004; Han 1997; Ind 1993; Irani 1995; Jang 2012; Jun 2011; Kamilya 2010; Kim 2012; Koh 1994; Lau 2004; Li 2014; Lista 2020; Naguimbing‐Cuaresma 2007; Nathan 2001; Nyman 2010; Onile 2008; Ouladsahebmadarek 2012; Sandberg 2019; Schiotz 1996; Sekhavat 2008; Shahnaz 2016; Shrestha 2013; Sun 2004; Tahmin 2011; Valero Puerta 1998; Weemhoff 2011; Yaghmaei 2017; Zaouter 2009).

Two trials reported time between removal of catheter and discharge (Lyth 1997; Webster 2006).

We did not identify any trials that reported condition‐specific or generic quality of life measures or psychological outcome measures.

The included trials used a number of different ways to define microbiological outcomes. Sixteen trials reported symptomatic UTI defined in one of the following ways:

Six trials reported UTI as significant bacteriuria (≥ 105 cfu/mL) with or without symptoms of UTI (Benoist 1999; Carter‐Brooks 2018; Cornia 2003; Gong 2017; Kamilya 2010; Sekhavat 2008), whilst there were 13 trials that reported UTI as a urine culture of ≥ 105 cfu/mL regardless of clinical features of UTI (Alessandri 2006; Basbug 2020; Carpiniello 1988; El‐Mazny 2014; Glavind 2007; Guzman 1994; Hakvoort 2004; Pervaiz 2019; Shahnaz 2016; Sun 2004; Tahmin 2011; Weemhoff 2011; Zhou 2012). By following the EAU criteria, these outcomes were classified as asymptomatic bacteriuria.

Four trials defined asymptomatic bacteriuria:

Sixty‐five trials did not report any clear definitions for symptomatic UTI or asymptomatic bacteriuria (Allen 2016; Aslam 2019; Azarkish 2003; Azarkish 2005; Barone 2015; Bristoll 1989; Chia 2009; Chillington 1992; Coyle 2015; Crowe 1993; Dunn 1999; Dunn 2000b; Dunn 2003; Durrani 2014; Ganta 2005; Gungor 2014; Hall 1998; Han 1997; Hewitt 2001; Huang 2011; Ind 1993; Irani 1995; Iversen Hansen 1984; Jang 2012; Jeong 2014; Jun 2011; Kelleher 2002; Kim 2012; Koh 1994; Kokabi 2009; Lang 2020; Lau 2004; Li 2014; Lista 2020; Liu 2015; Lyth 1997; Mao 1994; Matsushima 2015; McDonald 1999; Naguimbing‐Cuaresma 2007; Nathan 2001; Nguyen 2012; Nielson 1985; Noble 1990; Nyman 2010; Oberst 1981; Ouladsahebmadarek 2012; Popiel 2017; Rajan 2017; Ruminjo 2015; Sahin 2011; Sandberg 2019; Souto 2004; Talreja 2016; Taube 1989; Toscano 2001; Valero Puerta 1998; Webster 2006; Williamson 1982; Wilson 2000; Wu 2015; Wyman 1987; Yaghmaei 2017; Yee 2015; Zomorrodi 2018).

While there was some consistency in the choice of outcome measures amongst trials, the differences in the measures or the way the data were reported limited the possibilities for combining results from individual trials.

Excluded studies

We excluded 89 reports of 85 trials from the review for a variety of reasons, including inappropriate trial design (i.e. not RCTs or quasi‐RCTs), or because the intervention was not relevant, as the trial focused on suprapubic or intermittent catheterisation or centred on long‐term catheterisation (i.e. intended catheterisation of more than 14 days).

Further details regarding the excluded trials can be found in the Characteristics of excluded studies.

Ongoing studies

We identified eight ongoing trials, details of which can be found in the Characteristics of ongoing studies.

Risk of bias in included studies

We give the details of the risk of bias of each trial included in the review in the Characteristics of included studies. The 'Risk of bias' graph and summary figures also provide further information regarding the included trials (see Figure 2 and Figure 3).

Figure 2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included trials

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included trials

Figure 3
Risk of bias summary: review authors' judgements about each risk of bias item for each included trial

Risk of bias summary: review authors' judgements about each risk of bias item for each included trial

Allocation

Random sequence generation

We judged random sequence generation to be adequate and deemed to be low risk of bias in 39 trials (Ahmed 2014; Alessandri 2006; Allen 2016; Aref 2020; Barone 2015; Basbug 2020; Benoist 1999; Carter‐Brooks 2018; Chai 2011; Chen 2013; Chia 2009; Coyle 2015; Dunn 2003; Durrani 2014; El‐Mazny 2014; Gong 2017; Gungor 2014; Huang 2011; Irani 1995; Jang 2012; Joshi 2014; Kamilya 2010; Lang 2020; Matsushima 2015; Naguimbing‐Cuaresma 2007; Nyman 2010; Ouladsahebmadarek 2012; Pervaiz 2019; Rajan 2017; Sandberg 2019; Sekhavat 2008; Shahnaz 2016; Tahmin 2011; Vallabh‐Patel 2020; Webster 2006; Weemhoff 2011; Wu 2015; Zaouter 2009; Zmora 2010).

There were eight trials that we judged to have inadequate methods of random sequence generation and deemed to be at high risk of bias (Cornia 2003; Ind 1993; Lau 2004; Li 2014; Liu 2015; Noble 1990; Valero Puerta 1998; Zhou 2012). Two of these trials used quasi‐randomisation (Liu 2015; Noble 1990).

The remaining 52 trials provided insufficient information regarding the method of random sequence generation so we judged them to be at unclear risk of bias (Alonzo‐Sosa 1997; Aslam 2019; Azarkish 2003; Azarkish 2005; Bristoll 1989; Carpiniello 1988; Chillington 1992; Crowe 1993; Dunn 1999; Dunn 2000b; Ganta 2005; Glavind 2007; Gross 2007; Guzman 1994; Hakvoort 2004; Hall 1998; Han 1997; Hewitt 2001; Iversen Hansen 1984; Jeong 2014; Jun 2011; Kelleher 2002; Kim 2012; Koh 1994; Kokabi 2009; Liang 2009; Lista 2020; Lyth 1997; Mao 1994; McDonald 1999; Nathan 2001; Nguyen 2012; Nielson 1985; Oberst 1981; Onile 2008; Popiel 2017; Ruminjo 2015; Sahin 2011; Schiotz 1995; Schiotz 1996; Shrestha 2013; Souto 2004; Sun 2004; Talreja 2016; Taube 1989; Toscano 2001; Williamson 1982; Wilson 2000; Wyman 1987; Yaghmaei 2017; Yee 2015; Zomorrodi 2018).

Allocation concealment

We judged 22 trials to have used adequate allocation concealment methods and so were at low risk of bias (Alessandri 2006; Allen 2016; Barone 2015; Carter‐Brooks 2018; Chai 2011; Coyle 2015; Dunn 2003; Durrani 2014; Glavind 2007; Gross 2007; Huang 2011; Joshi 2014; Kamilya 2010; Lang 2020; Liang 2009; Nyman 2010; Schiotz 1995; Schiotz 1996; Webster 2006; Weemhoff 2011; Wu 2015; Zmora 2010).

We judged 10 trials to have inadequate allocation concealment methods and therefore were at high risk of bias (Cornia 2003; El‐Mazny 2014; Ind 1993; Kokabi 2009; Lau 2004; Liu 2015; Noble 1990; Sandberg 2019; Zaouter 2009; Zhou 2012).

The remaining 66 trials had insufficient information to judge allocation concealment so we judged them to be at unclear risk of bias (Ahmed 2014; Alonzo‐Sosa 1997; Aref 2020; Aslam 2019; Azarkish 2003; Azarkish 2005; Basbug 2020; Benoist 1999; Bristoll 1989; Carpiniello 1988; Chen 2013; Chia 2009; Chillington 1992; Crowe 1993; Dunn 1999; Dunn 2000b; Ganta 2005; Gong 2017; Gungor 2014; Guzman 1994; Hakvoort 2004; Hall 1998; Han 1997; Hewitt 2001; Irani 1995; Iversen Hansen 1984; Jang 2012; Jeong 2014; Jun 2011; Kelleher 2002; Kim 2012; Koh 1994; Li 2014; Lista 2020; Lyth 1997; Mao 1994; Matsushima 2015; McDonald 1999; Naguimbing‐Cuaresma 2007; Nathan 2001; Nguyen 2012; Nielson 1985; Oberst 1981; Onile 2008; Ouladsahebmadarek 2012; Pervaiz 2019; Popiel 2017; Rajan 2017; Ruminjo 2015; Sahin 2011; Sekhavat 2008; Shahnaz 2016; Shrestha 2013; Souto 2004; Sun 2004; Talreja 2016; Tahmin 2011; Taube 1989; Toscano 2001; Valero Puerta 1998; Vallabh‐Patel 2020; Williamson 1982; Wilson 2000; Wyman 1987; Yaghmaei 2017; Yee 2015; Zomorrodi 2018).

Blinding

Blinding of participants and personnel

We judged one trial to have used adequate blinding methods of participants and personnel, which we therefore assessed as being at low risk of bias (Chen 2013). We judged the remaining 98 trials to have used inadequate methods of blinding of participants and personnel and we therefore assessed them as being at high risk of bias.

Blinding of outcome assessment

Eight trials reported no blinding of outcome assessment, so we deemed them to be at high risk of bias (Alessandri 2006; Barone 2015; Bristoll 1989; Chen 2013; Gong 2017; Ind 1993; Joshi 2014; Liu 2015).

Five trials did report blinding of the principal investigator or the health professional who conducted the outcome assessment on participants (Chai 2011; Durrani 2014; Hall 1998; Naguimbing‐Cuaresma 2007; Nyman 2010). As a result, we deemed them to be at low risk of bias.

The remaining 86 trials did not report blinding of the outcome assessors. Thus, we decided to assign them to unclear risk of bias (Ahmed 2014; Allen 2016; Alonzo‐Sosa 1997; Aref 2020; Aslam 2019; Azarkish 2003; Azarkish 2005; Basbug 2020; Benoist 1999; Carpiniello 1988; Carter‐Brooks 2018; Chia 2009; Chillington 1992; Cornia 2003; Coyle 2015; Crowe 1993; Dunn 1999; Dunn 2000b; Dunn 2003; El‐Mazny 2014; Ganta 2005; Glavind 2007; Gross 2007; Gungor 2014; Guzman 1994; Hakvoort 2004; Han 1997; Hewitt 2001; Huang 2011; Irani 1995; Iversen Hansen 1984; Jang 2012; Jeong 2014; Jun 2011; Kamilya 2010; Kelleher 2002; Kim 2012; Koh 1994; Kokabi 2009; Lang 2020; Lau 2004; Li 2014; Liang 2009; Lista 2020; Lyth 1997; Mao 1994; Matsushima 2015; McDonald 1999; Nathan 2001; Nguyen 2012; Nielson 1985; Noble 1990; Oberst 1981; Onile 2008; Ouladsahebmadarek 2012; Pervaiz 2019; Popiel 2017; Rajan 2017; Ruminjo 2015; Sahin 2011; Sandberg 2019; Schiotz 1995; Schiotz 1996; Sekhavat 2008; Shahnaz 2016; Shrestha 2013; Souto 2004; Sun 2004; Tahmin 2011; Talreja 2016; Taube 1989; Toscano 2001; Valero Puerta 1998; Vallabh‐Patel 2020; Webster 2006; Weemhoff 2011; Williamson 1982; Wilson 2000; Wu 2015; Wyman 1987; Yaghmaei 2017; Yee 2015; Zaouter 2009; Zhou 2012; Zmora 2010; Zomorrodi 2018).

Blinding of assessment of microbiological outcomes

We assumed that microbiological outcomes were assessed by a microbiologist who would not be aware of the catheter duration or the fact that participants were involved in a trial. We rated all 99 included trials as being low risk of bias for microbiological outcomes.

Incomplete outcome data

We deemed 68 trials to be at low risk of attrition bias (Alessandri 2006; Alonzo‐Sosa 1997; Aref 2020; Aslam 2019; Azarkish 2003; Barone 2015; Basbug 2020; Carpiniello 1988; Carter‐Brooks 2018; Chai 2011; Chia 2009; Cornia 2003; Crowe 1993; Dunn 2003; Durrani 2014; El‐Mazny 2014; Ganta 2005; Gong 2017; Guzman 1994; Hakvoort 2004; Ind 1993; Jang 2012; Joshi 2014; Jun 2011; Kamilya 2010; Kelleher 2002; Koh 1994; Lau 2004; Li 2014; Liang 2009; Liu 2015; Mao 1994; Naguimbing‐Cuaresma 2007; Nathan 2001; Nguyen 2012; Nielson 1985; Noble 1990; Nyman 2010; Oberst 1981; Onile 2008; Ouladsahebmadarek 2012; Pervaiz 2019; Rajan 2017; Sandberg 2019; Sahin 2011; Schiotz 1995; Schiotz 1996; Sekhavat 2008; Shahnaz 2016; Shrestha 2013; Souto 2004; Sun 2004; Tahmin 2011; Talreja 2016; Taube 1989; Toscano 2001; Valero Puerta 1998; Vallabh‐Patel 2020; Webster 2006; Weemhoff 2011; Williamson 1982; Wilson 2000; Wu 2015; Wyman 1987; Zaouter 2009; Zhou 2012; Zmora 2010; Zomorrodi 2018). These trials either had no dropouts or no differential dropouts.

Nine trials had incomplete outcome data as well as having a differential loss to follow‐up (Ahmed 2014; Azarkish 2005; Gross 2007; Huang 2011; Irani 1995; Lang 2020; Lyth 1997; Yaghmaei 2017; Yee 2015). As a result of this, we deemed them to be at high risk of attrition bias.

The remaining 22 trials had insufficient information to make a decision and therefore we judged them to be at unclear risk of attrition bias (Allen 2016; Benoist 1999; Bristoll 1989; Chen 2013; Chillington 1992; Coyle 2015; Dunn 1999; Dunn 2000b; Glavind 2007; Gungor 2014; Hall 1998; Han 1997; Hewitt 2001; Iversen Hansen 1984; Jeong 2014; Kim 2012; Kokabi 2009; Lista 2020; Matsushima 2015; McDonald 1999; Popiel 2017; Ruminjo 2015).

Selective reporting

We assessed selective reporting based on the outcomes mentioned in the Methods section (Types of outcome measures), and the results that were reported, as well as whether the trials reported all the expected outcomes in accordance with their objectives. We did not conduct a search for the protocols for each trial due to time constraints.

We deemed 72 trials to be low risk of bias (Ahmed 2014; Alessandri 2006; Allen 2016; Alonzo‐Sosa 1997; Aref 2020; Aslam 2019; Barone 2015; Basbug 2020; Benoist 1999; Carter‐Brooks 2018; Chai 2011; Chen 2013; Coyle 2015; Dunn 2003; Durrani 2014; El‐Mazny 2014; Ganta 2005; Glavind 2007; Gong 2017; Gungor 2014; Guzman 1994; Hakvoort 2004; Hall 1998; Ind 1993; Irani 1995; Jang 2012; Jeong 2014; Kamilya 2010; Kelleher 2002; Kim 2012; Koh 1994; Lang 2020; Lau 2004; Li 2014; Liang 2009; Lista 2020; Liu 2015; Lyth 1997; Mao 1994; Matsushima 2015; McDonald 1999; Nathan 2001; Nielson 1985; Noble 1990; Nyman 2010; Oberst 1981; Onile 2008; Ouladsahebmadarek 2012; Pervaiz 2019; Rajan 2017; Sandberg 2019; Schiotz 1995; Schiotz 1996; Sekhavat 2008; Shahnaz 2016; Shrestha 2013; Souto 2004; Sun 2004; Tahmin 2011; Talreja 2016; Toscano 2001; Valero Puerta 1998; Vallabh‐Patel 2020; Webster 2006; Weemhoff 2011; Wilson 2000; Wu 2015; Yaghmaei 2017; Zaouter 2009; Zhou 2012; Zmora 2010; Zomorrodi 2018).

We deemed 14 trials to be at high risk of bias for selective reporting (Azarkish 2003; Azarkish 2005; Bristoll 1989; Carpiniello 1988; Cornia 2003; Dunn 2000b; Gross 2007; Hewitt 2001; Huang 2011; Iversen Hansen 1984; Naguimbing‐Cuaresma 2007; Popiel 2017; Sahin 2011; Yee 2015).

We assigned the remaining 13 trials to unclear risk of bias for selective reporting (Chia 2009; Chillington 1992; Crowe 1993; Dunn 1999; Han 1997; Joshi 2014; Jun 2011; Kokabi 2009; Nguyen 2012; Ruminjo 2015; Taube 1989; Williamson 1982; Wyman 1987).

Other potential sources of bias

We judged one trial to be at high risk of bias (Williamson 1982). This trial included just eight participants and, as a result, we deemed this trial to be underpowered. The remaining 98 trials included in this review appeared to be free from other sources of bias and we therefore judged them to be at low risk of bias.

Effects of interventions

See: Summary of findings 1 Removal of short‐term indwelling urethral catheters in adults at one time of day (6 am to 7 am) versus another time of day (10 pm to midnight); Summary of findings 2 Removal of short‐term indwelling urethral catheters in adults after shorter versus longer durations; Summary of findings 3 Removal of short‐term indwelling urethral catheters in adults: clamping compared to free drainage; Summary of findings 4 Removal of short‐term indwelling urethral catheters in adults: prophylactic use of alpha blocker versus no drug or intervention

Comparison 1: removal of indwelling urethral catheter at one specified time of day (6 am to 7 am) versus another specified time of day (10 pm to midnight)

Thirteen trials compared catheter removal at different times of the day (Chillington 1992; Crowe 1993; Ganta 2005; Gross 2007; Hall 1998; Ind 1993; Kelleher 2002; Lyth 1997; McDonald 1999; Nathan 2001; Noble 1990; Webster 2006; Wyman 1987). We were not always able to perform meta‐analysis due to either a lack of included trials reporting the same outcome or the presence of considerable clinical heterogeneity between included trials.

Primary outcomes
Number of participants who required recatheterisation following removal of indwelling urethral catheter

Ten trials reported the number of participants who required recatheterisation following removal of indwelling urethral catheters (Chillington 1992; Crowe 1993; Ganta 2005; Hall 1998; Ind 1993; Kelleher 2002; Lyth 1997; Nathan 2001; Webster 2006; Wyman 1987). Removal of indwelling urethral catheters at midnight may slightly reduce the risk of requiring recatheterisation compared with early morning removal (RR 0.70, 95% CI 0.52 to 0.94; I² = 0%; 10 trials, 1920 participants; low‐certainty evidence; Analysis 1.1; summary of findings Table 1). 

The asymmetry in the funnel plot could be indicative of bias due to missing results (Figure 4). However, with only ten trials contributing to the analysis, we cannot rule out the play of chance as the source of asymmetry.

Figure 4
Funnel plot of comparison 1. Removal of indwelling urethral catheter at one time of day (6 am to 7 am) versus another time of day (10 pm to midnight). Outcome 1.1. number needing to be recatheterised

Funnel plot of comparison 1. Removal of indwelling urethral catheter at one time of day (6 am to 7 am) versus another time of day (10 pm to midnight). Outcome 1.1. number needing to be recatheterised

In the sensitivity analysis, we removed the one trial that we judged to be high risk of bias in the randomisation and allocation concealment domains (Ind 1993). This changed the effect estimate and 95% confidence interval slightly (RR 0.75, 95% CI 0.54 to 1.03; I2 = 0%), which indicates that the overall effect estimate with all trials included may need to be interpreted with caution.

Subgroup analysis based on type of surgery did not suggest evidence that the effect of removing indwelling catheters at midnight versus early in the morning is different in groups of people undergoing different types of surgery (test for subgroup differences: P = 0.07, overlapping confidence intervals; Analysis 1.1).

Subgroup analysis based on sex also did not suggest that the effect of removing indwelling catheters at midnight versus early in the morning on risk of requiring recatheterisation is different between men and women (test for subgroup differences: P = 0.25, overlapping confidence intervals; Analysis 1.2).

No trials reported the use of antibiotic prophylaxis for this outcome.

Secondary outcomes
Complications/adverse events

Incidence of urinary tract infection

  • Symptomatic catheter‐associated urinary tract infections (CAUTI): one trial reported the number of participants with symptomatic CAUTIs (Gross 2007). We are uncertain if removing the indwelling urethral catheter at midnight compared with early morning removal has any effect on the risk of symptomatic CAUTI (RR 1.00, 95% CI 0.61 to 1.63; very low‐certainty evidence; Analysis 1.3; summary of findings Table 1).

  • Asymptomatic bacteriuria: one trial (107 participants) reported the number of participants undergoing gynaecological surgery who had asymptomatic bacteriuria as a result of indwelling urethral catheterisation (Nathan 2001). There was insufficient evidence to suggest whether removal of the indwelling urethral catheter at midnight or in the morning affected the number of participants developing this (RR 0.74, 95% CI 0.37 to 1.49; Analysis 1.4).

Incidence of urinary retention

One trial, Webster 2006, reported on the development of urinary retention following discharge and indicated that eight participants in each group (10%) developed this complication (RR 0.98; 95% CI 0.38 to 2.48; 170 participants; Analysis 1.5).

There was insufficient evidence to suggest any difference between the two groups in terms of difficulty passing urine post‐discharge (9/86 versus 8/84; RR 1.10; 95% CI 0.45 to 2.71; 170 participants; Analysis 1.6; Webster 2006).

Other complications of catheterisation (or recatheterisation)

Not reported.

Patient‐reported

Patient pain or discomfort

  • Loin pain: in Webster 2006, four out of 86 participants whose indwelling urethral catheters were removed in the morning experienced loin pain following discharge compared with one out of 84 participants whose catheter was removed in the morning (RR 3.91, 95% CI 0.45 to 34.24; Analysis 1.7).

  • Fever: Webster 2006 reported the number of participants who developed urinary‐related fever post‐discharge (7/86 versus 4/84; RR 1.71, 95% CI 0.52 to 5.62; Analysis 1.8). It should be noted that, although the post‐discharge fever was indicated as urinary‐related in the trial, Webster 2006 did not specify whether this was likely to be a direct result of urethral catheterisation or the procedure that the participant underwent.

Patient satisfaction

One trial reported participant satisfaction and indicated that late night removal of the indwelling urethral catheter was associated with more sleep disturbances (P = 0.004; Ganta 2005). Another trial reported that participants whose indwelling urethral catheters were removed late at night had "disturbed sleep, were tired and confused in the morning and had a delayed establishment of voiding pattern" (Lyth 1997). Five other trials in this review contrasted with Lyth 1997 and reported that late night removal of indwelling urethral catheters did not interrupt the participants' sleep (Chillington 1992; Crowe 1993; Ind 1993; Kelleher 2002; Noble 1990). Some participants went back to sleep immediately after the indwelling urethral catheter was removed, whilst others slept through the removal process. This could be due to the anaesthesia or other medications given to the participants.

When recatheterisation was required, one trial reported that two of the three participants who had their indwelling urethral catheters removed in the morning were recatheterised at "unsocial hours" (8.30 pm and 3 am; Chillington 1992). This was reported to not only be distressing for the participant but also resulted in recatheterisation being performed by a doctor who was on call and not familiar with the case.

Urinary incontinence

In Webster 2006, seven out of 86 participants whose indwelling urethral catheters were removed at night developed urinary incontinence after discharge compared with 11 out of 84 in the morning group (RR 0.62, 95% CI 0.25 to 1.53; Analysis 1.9). Webster 2006 included participants on both medical and surgical wards. The participants on surgical wards were hospitalised for either bladder‐related surgery, non‐bladder related surgery, gynaecological surgery, general surgery or orthopaedic surgery. The trial also included participants on medical wards. Thus, we found it difficult to ascertain whether the urinary incontinence was due to the urethral catheter or due to another medical or surgical intervention for which the participants were hospitalised.

Number of patients reporting dysuria

One trial reported that fewer participants whose indwelling urethral catheters were removed in the morning developed pain following discharge (9/86 versus 4/84; Webster 2006). We are uncertain if indwelling urethral catheter removal at 10 pm increases the risk of dysuria compared with removal at 6 am because the quality of evidence is low and the 95% CI is consistent with possible benefit and possible harm (RR 2.20, 95% CI 0.70 to 6.86; 1 trial, 170 participants; low‐certainty evidence; Analysis 1.10; summary of findings Table 1).

Clinician‐reported

Volume of first void (mL)

Twelve trials reported data on the volume of the first void following the removal of the indwelling urethral catheter (Chillington 1992; Crowe 1993; Ganta 2005; Gross 2007; Hall 1998; Ind 1993; Kelleher 2002; Lyth 1997; McDonald 1999; Nathan 2001; Noble 1990; Webster 2006). Ind 1993 reported the median volume of first void (Analysis 1.12), and therefore was not included in the meta‐analysis (Analysis 1.11); the difference between medians was 175 mL more in the group who had their catheter removed late at night (P > 0.0001). The remaining nine trials were included in the meta‐analysis (Chillington 1992; Crowe 1993; Gross 2007; Hall 1998; Kelleher 2002; McDonald 1999; Nathan 2001; Noble 1990; Webster 2006), along with two trials that reported means but no SDs (Ganta 2005; Lyth 1997).

Participants who had their catheter removed late at night passed larger volumes at first void when compared to those participants who had their catheters removed in the morning (MD 21.98 mL, 95% CI 3.04 to 40.92; I² = 80%; 11 trials, 1198 participants; Analysis 1.11). It should be noted that although this result indicates statistical significance, the increase in volume of first void is not likely to be of any clinical importance.

Time to first void (hours)

Eleven trials reported data on the time to first void (Chillington 1992; Crowe 1993; Ganta 2005; Gross 2007; Hall 1998; Ind 1993; Kelleher 2002; McDonald 1999; Nathan 2001; Noble 1990; Webster 2006). Ind 1993 reported the median time to first void (see Analysis 1.14); the difference between medians was 1 hour 40 minutes less in the group who had their catheter removed late at night (P = 0.012). The remaining eight trials were included in the meta‐analysis (Chillington 1992; Crowe 1993; Gross 2007; Kelleher 2002; McDonald 1999; Nathan 2001; Noble 1990; Webster 2006), along with two trials that reported means but no SDs (Ganta 2005; Hall 1998). 

Those participants who had their catheters removed late at night were found to have a longer time to first void when compared to morning removal (MD 0.71, 95% CI 0.41 to 1.01; I² = 0%; 10 trials, 1140 participants; Analysis 1.13).

Post‐void residual volume (mL)

One trial (48 participants) reported post‐void residual volume in participants hospitalised to general medical and surgical wards (Gross 2007). There was insufficient evidence to suggest that the removal of an indwelling catheter late at night or in the early morning had any effect on post‐void residual volume (MD −25.50, 95% CI −214.40 to 163.40; Analysis 1.15).

Length of hospitalisation (days)

Three trials provided data on the length of hospitalisation of participants (Chillington 1992; Ind 1993; Nathan 2001). Only one trial reported means and SDs, which favoured late night catheter removal as it reduced participant hospital stay (MD −0.60, 95% CI −1.13 to −0.07; 107 participants; Nathan 2001; Analysis 1.16). The remaining trials reported their data in a format unsuitable for meta‐analysis (Analysis 1.17). One trial reported the mean but no SDs (Chillington 1992), while the other reported median values only (Ind 1993).

Time between removal of catheter to discharge (days)

Two trials reported the time between removal of catheter to discharge (Lyth 1997; Webster 2006). There was insufficient evidence to suggest that late night or early morning removal of catheters affected the time between catheter removal to discharge (MD 0.08, 95% CI −5.96 to 6.12; I² = 0%; 2 trials 272 participants; Analysis 1.18).

Health status/quality of life

Condition‐specific or generic quality‐of‐life measures

Not reported

Psychological outcome measures

Not reported

Comparison 2: shorter versus longer duration of indwelling urethral catheterisation

Sixty‐eight trials included in this review investigated the effects of shorter versus longer durations of indwelling urethral catheterisation (Ahmed 2014; Alessandri 2006; Allen 2016; Alonzo‐Sosa 1997; Aref 2020; Aslam 2019; Azarkish 2003; Barone 2015; Basbug 2020; Benoist 1999; Carpiniello 1988; Carter‐Brooks 2018; Chai 2011; Chen 2013; Chia 2009; Cornia 2003; Coyle 2015; Dunn 2003; Durrani 2014; El‐Mazny 2014; Glavind 2007; Gungor 2014; Guzman 1994; Hakvoort 2004; Han 1997; Hewitt 2001; Huang 2011; Irani 1995; Joshi 2014; Kamilya 2010; Kim 2012; Koh 1994; Kokabi 2009; Lang 2020; Lau 2004; Li 2014; Liang 2009; Lista 2020; Mao 1994; Matsushima 2015; Naguimbing‐Cuaresma 2007; Nguyen 2012; Nielson 1985; Onile 2008; Ouladsahebmadarek 2012; Pervaiz 2019; Popiel 2017; Rajan 2017; Sahin 2011; Sandberg 2019; Schiotz 1995; Schiotz 1996; Sekhavat 2008; Shahnaz 2016; Shrestha 2013; Souto 2004; Sun 2004; Tahmin 2011; Taube 1989; Toscano 2001; Valero Puerta 1998; Vallabh‐Patel 2020; Weemhoff 2011; Yaghmaei 2017; Zaouter 2009; Zhou 2012; Zmora 2010; Zomorrodi 2018).

We have not yet incorporated data from three trials into the results for outcomes because the trials did not clearly report numbers per group (Dunn 1999; Dunn 2000b; Ruminjo 2015). We have contacted the authors and we are awaiting clarification before we can use the data. We have not incorporated data from Yee 2015 into the results for outcomes as the conference abstract only reported P values. We have contacted the author to provide further information and we are currently awaiting a reply. Iversen Hansen 1984 and Azarkish 2005 reported data in insufficient detail for us to use them for the meta‐analysis. We have contacted the author to provide further information and we await their reply.

Outcomes for this comparison reported by trials that were not mentioned in the Types of outcome measures are reported in Appendix 5.

We have used subgrouping for illustrative purposes only according to the following: early removal of urinary catheter versus later; one‐day policy versus later; and two to seven‐day policy versus later removal.

Primary outcomes
Number of participants who required recatheterisation following removal of indwelling urethral catheter

Forty‐four trials reported incidence of recatheterisation in participants undergoing either a shorter duration of indwelling urethral catheterisation or longer duration (Ahmed 2014; Alessandri 2006; Allen 2016; Alonzo‐Sosa 1997; Aref 2020; Aslam 2019; Basbug 2020; Carpiniello 1988; Carter‐Brooks 2018; Chai 2011; Chen 2013; Chia 2009; Dunn 2003; Durrani 2014; Glavind 2007; Guzman 1994; Hakvoort 2004; Hewitt 2001; Huang 2011; Irani 1995; Joshi 2014; Kamilya 2010; Kim 2012; Koh 1994; Kokabi 2009; Lau 2004; Lista 2020; Matsushima 2015; Naguimbing‐Cuaresma 2007; Onile 2008; Pervaiz 2019; Rajan 2017; Sahin 2011; Sandberg 2019; Schiotz 1995; Schiotz 1996; Sekhavat 2008; Shahnaz 2016; Shrestha 2013; Tahmin 2011; Vallabh‐Patel 2020; Weemhoff 2011; Zaouter 2009; Zmora 2010), with one trial comparing three different intervention groups (Irani 1995).

Shorter durations of catheterisation may increase the risk of requiring recatheterisation (RR 1.81, 95% CI 1.35 to 2.41; I² = 56%; 44 trials, 5870 participants; low‐certainty evidence; Analysis 2.1; summary of findings Table 2).

There was evidence of clinical heterogeneity between the trials and so we decided to compare the fixed‐effect (RR 1.75, 95% CI 1.51 to 2.04; I² = 56%) and random‐effects (RR 1.81, 95% CI 1.35 to 2.41; I² = 56%) models. We decided to use the random‐effects model due to the presence of heterogeneity. The presence of heterogeneity was factored in when we assessed the certainty of evidence.

The symmetry in the funnel plot did not suggest any bias due to missing results or small study effects (Figure 5).

Figure 5
Funnel plot of comparison 2. Shorter versus longer duration of catheter. Outcome: 2.1 number needing to be recatheterised

Funnel plot of comparison 2. Shorter versus longer duration of catheter. Outcome: 2.1 number needing to be recatheterised

The sensitivity analysis, in which we removed the one trial that we judged to be high risk of bias in the randomisation and allocation concealment domains (Lau 2004), did not substantially change the effect estimate (RR 1.84, 95% CI 1.37 to 2.46).

The test for subgroup differences based on type of surgery indicated heterogeneity between subgroups (P = 0.03, I² = 72.4%). The 95% confidence intervals of the summary effect estimate in the urological surgery subgroup do not substantially overlap with those of the gynaecological or obstetric surgery subgroups, which suggests that the effect of shorter versus longer duration of catheterisation may be different in people undergoing urological surgery in terms of the risk of requiring recatheterisation (Analysis 2.2). For people undergoing urological surgery, it is not certain whether there is a difference between shorter and longer indwelling urethral catheter durations in terms of the risk of requiring recatheterisation (RR 0.91, 95% CI 0.50 to 1.67; 9 trials, 1104 participants).

Subgroup analysis based on sex also suggested that the effect of shorter versus longer duration of catheterisation may be different in men and women (test for subgroup differences: P = 0.009, I² = 85%, 95% CIs do not substantially overlap; Analysis 2.3). For men, it is not certain if there is a difference between shorter and longer indwelling urethral catheter durations in terms of the risk of requiring recatheterisation (RR 0.91, 95% CI 0.50 to 1.67; 9 trials, 1104 participants).

Subgroup analysis based on the use of antibiotic prophylaxis did not reveal heterogeneity between the subgroups (test for subgroup differences: P = 0.92, I² = 0%, overlapping 95% CIs; Analysis 2.4).

Not all trials could participate in the subgroup analysis by surgery type, either because participants did not undergo surgery or because the type of surgery was too unique to meet the subgroup definitions (Allen 2016; Carpiniello 1988; Chen 2013; Lau 2004; Zmora 2010). The following trials did not mention whether they used antibiotic prophylaxis or not (Aslam 2019; Carter‐Brooks 2018; Hakvoort 2004; Hewitt 2001; Kim 2012; Kokabi 2009; Lista 2020; Matsushima 2015; Naguimbing‐Cuaresma 2007; Onile 2008; Pervaiz 2019; Rajan 2017; Sahin 2011; Sandberg 2019; Schiotz 1995; Schiotz 1996; Tahmin 2011).

Secondary outcomes
Complications/adverse events

Incidence of urinary tract infection

Open in table viewer
Table 4. Measurement of symptomatic urinary tract infection

TrialID

Outcome as defined by trial authors

Trial definition

Relevant definition outlined by International Guideline Panel

Ahmed 2014

Symptomatic UTI

Significant bacteriuria with at least one of the following symptoms:

dysuria, frequency of micturition, urgency, suprapubic pain ir burning sensation at micturition

CDC

Alessandri 2006

UTI

Significant bacteria which is determined by: urine culture and defined as at least 105 cfu/mL

EAU: symptomatic bacteriuria

Allen 2016

UTI

Not reported

N/A

Alonzo‐Sosa 1997

UTI

Defined as a positive urine sample associated with: dysuria, polyuria, incomplete emptying, pain, fever or sepsis.

A positive urine sample was defined as the presence of > 105 cfu/mL if MSU and 104 cfu/mL in a catheter sample.

CDC

Aref 2020

Symptomatic UTI

“The diagnosis of symptomatic urinary tract infection was based on the following criteria: significant bacteriuria with at least one of the following symptoms; dysuria, frequency of micturition, urgency, supra pubic pain, or burning sensation at micturition.”

CDC

Aslam 2019

UTI

Not reported

N/A

Azarkish 2003

UTI

Not reported

N/A

Azarkish 2005

Not reported

Not reported

N/A

Barone 2015

UTI

Not reported

N/A

Basbug 2020

Significant bacteruria

Significant microscopic bacteriuria was defined as ≥ 100,000 bacteria/ mL MSU

EAU: asymptomatic bacteriuria

Benoist 1999

UTI

Culture yield of > 105 cfu/mL with or without symptoms

With symptoms: CDC

Without symptoms: EAU definition for "Asymptomatic bacteriuria"

Bristoll 1989

Not reported

Not reported

N/A

Carpiniello 1988

UTI

Culture yield of 105 cfu/mL

EAU: asymptomatic bacteriuria

Carter‐Brooks 2018

UTI

Defined as a positive culture or symptoms and antibiotic treatment

N/A

Chai 2011

Symptomatic UTI

Positive urine culture: > 105 cfu/mL of an identified single uropathogen/mL of urine

Symptomatic UTI: fever (> 38 °C) and dysuria with a positive urine culture

CDC

Chen 2013

CAUTI

CDC criteria used to define symptomatic UTI and asymptomatic bacteriuria

CDC

Chia 2009

CAUTI

Not reported

N/A

Chillington 1992

Not reported

N/A

N/A

Cornia 2003

CAUTI

Growth from a urine specimen aseptically aspirated from the catheter of ≥ 100 cfu of a predominant pathogen OR ≥ 10 leukocytes per high‐power field on urinalysis in a patient with a clinical diagnosis of UTI

N/A

Coyle 2015

Bacteriuria

Symptomatic or asymptomatic bacteriuria used. No definition given

N/A

Crowe 1993

Not reported

N/A

N/A

Dunn 1999

Not reported

N/A

N/A

Dunn 2000b

UTI

Not reported

N/A

Dunn 2003

UTI

Determined by either microscopic abnormality or any patient symptoms

N/A

Durrani 2014

UTI

Not reported

N/A

El‐Mazny 2014

Significant bacteriuria

Significant bacteriuria: > 105 cfu/mL of urine in a MSU sample collected 24 h post‐op

EAU: asymptomatic bacteriuria

Ganta 2005

Not reported

N/A

N/A

Glavind 2007

Positive urine culture

Defined as the presence of ≥ 105 cfu/mL

EAU: asymptomatic bacteriuria

Gong 2017

Symptomatic UTI

Defined as bacteriuria with fever, frequent or painful urination or burning on urination

CDC

Gross 2007

UTI

Used CDC criteria

CDC

Gungor 2014

Not reported

N/A

N/A

Guzman 1994

UTI

Urine culture of > 105 cfu/mL reported as outcome. Definition is not provided

EAU: asymptomatic bacteriuria

Hakvoort 2004

UTI

Signs of UTI: having > 10 WBC/high‐powered field and significant microscopic bacteriuria (1/high‐powered field) in the urine sediment

UTI: presence of > 105 cfu/mL in urine culture

EAU: asymptomatic bacteriuria

Hall 1998

Not reported

N/A

N/A

Han 1997

Not reported

N/A

N/A

Hewitt 2001

Not reported

N/A

N/A

Huang 2011

UTI

Not reported

N/A

Ind 1993

Not reported

N/A

N/A

Irani 1995

UTI

Not reported

N/A

Iversen Hansen 1984

Not reported

N/A

N/A

Jang 2012

Not reported

N/A

N/A

Jeong 2014

Not reported

N/A

N/A

Joshi 2014

Symptomatic UTI

Symptomatic UTI: based on the presence of significant bacteriuria accompanied by at least 1 of the following symptoms: fever, dysuria, increased frequency of micturition, urinary urgency, suprapubic pain and dysuria

CDC

Jun 2011

Not reported

N/A

N/A

Kamilya 2010

Symptomatic UTI

Symptomatic UTI: positive urine culture of > 105 cfu/mL plus 1 of the following symptoms: dysuria, fever (> 38 °C) or rigors

CDC

Kelleher 2002

Not reported

N/A

N/A

Kim 2012

Not reported

N/A

N/A

Koh 1994

UTI

Not reported

N/A

Kokabi 2009

UTI

Not reported

N/A

Lang 2020

UTI

Not reported

N/A

Lau 2004

Positive urine culture

Not reported

N/A

Li 2014

Infection

Not reported

N/A

Liang 2009

UTI

UTI: positive urine culture of > 105 cfu/mL. However, treatment was only given for positive urine cultures if participant had adverse urinary symptoms or post‐op pyrexia (> 38 °C)

CDC

Lista 2020

UTI

Not reported

N/A

Liu 2015

Not reported

N/A

N/A

Lyth 1997

Not reported

N/A

N/A

Mao 1994

Not reported

N/A

N/A

Matsushima 2015

Not reported

N/A

N/A

McDonald 1999

Not reported

N/A

N/A

Naguimbing‐Cuaresma 2007

Not reported

N/A

N/A

Nathan 2001

Positive catheter specimen urine (CSU)

Not reported

N/A

Nguyen 2012

Not reported

N/A

N/A

Nielson 1985

Not reported

N/A

N/A

Noble 1990

Not reported

N/A

N/A

Nyman 2010

Not reported

N/A

N/A

Oberst 1981

Not reported

N/A

N/A

Onile 2008

Significant bacteriuria

Significant bacteriuria: positive urine culture of > 105 cfu/mL in a sample of MSU collected 72 h post‐op with signs of a fever ( a temperature of > 38 °C on 2 occasions within 10 days of the procedure, excluding the first 24 h)

CDC

Ouladsahebmadarek 2012

Symptomatic UTI

Not reported

N/A

Pervaiz 2019

UTI

Urine sample was obtained to assess UTI (bacterial colony count > 105 cfu/mL on urine culture after removal of catheter assessed on day 7)

EAU: catheter‐associated asymptomatic bacteriuria

Popiel 2017

UTI

Not reported

N/A

Rajan 2017

UTI

Urinary infections defined as when microscopic examination of the urine revealed pus cells or when urine culture showed growth of pathogenic organisms

N/A

Ruminjo 2015

Not reported

N/A

N/A

Sahin 2011

Not reported

N/A

N/A

Sandberg 2019

UTI

Standard urine test for nitrite and leucocytes in combination with clinical symptoms

Not clear whether test is dipstick only or whether it involves microscopy/culture

Schiotz 1995

UTI

Positive cultures: culture of > 105 cfu/mL in a sample of MSU or CSU culture of > 104 cfu/mL

UTI: positive urine culture in the absence of symptoms. Patients were defined as having UTI if there was any doubt

EAU: asymptomatic bacteriuria

Schiotz 1996

UTI

Positive cultures: culture of > 105 cfu/mL in a sample of MSU or CSU culture of > 104 cfu/mL

UTI: positive urine culture in the absence of symptoms. Participants were defined as having UTI if there was any doubt

EAU: asymptomatic bacteriuria

Sekhavat 2008

Positive urine culture

Positive urine culture: prevalence of symptomatic UTI was confirmed through a positive urine culture OR through signs of UTI such as: frequency, urgency, dysuria, suprapubic pain or fever

Does not fully meet the criteria for CDC. Must be positive cultures AND clinical features

Shahnaz 2016

Positive urine culture

The presence of positive urinary culture or > 100,000 colony counts in each mL of urine or > 10 pieces of leukocyte in each microscopy field was considered as a urinary infection.

EAU: asymptomatic bacteriuria

Shrestha 2013

Asymptomatic bacteriuria

Asymptomatic bacteriuria: pus cells of > 5 per high‐power field in routine examination of urine and bacterial culture positive

EAU: asymptomatic bacteriuria

Souto 2004

Not reported

N/A

N/A

Sun 2004

UTI

UTI: positive urine culture of > 105 cfu/mL or WBC > 5/high‐power field in urine analysis

EAU: asymptomatic bacteriuria

Tahmin 2011

UTI

UTI: positive urine culture of > 105 cfu/mL

EAU: asymptomatic bacteriuria

Talreja 2016

Not reported

N/A

N/A

Taube 1989

Not reported

N/A

N/A

Toscano 2001

Not reported

N/A

N/A

Valero Puerta 1998

Not reported

N/A

N/A

Vallabh‐Patel 2020

UTI

For the purpose of this trial, participants were considered positive for a UTI if they had (1) positive urine cultures per CDC guidelines or (2) treated empirically over the phone for symptoms of UTI, even in the absence of a urine culture

CDC

Webster 2006

Not reported

N/A

N/A

Weemhoff 2011

UTI

UTI: > 25 WBC/high‐power field, nitrate production, > 20 bacteria/high‐power field, positive urine culture of > 105 cfu/mL

EAU: asymptomatic bacteriuria

Williamson 1982

Not reported

N/A

N/A

Wilson 2000

Not reported

N/A

N/A

Wu 2015

Not reported

N/A

N/A

Wyman 1987

Not reported

N/A

N/A

Yaghmaei 2017

Not reported

N/A

N/A

Yee 2015

Not reported

N/A

N/A

Zaouter 2009

UTI

UTI: pyrexia of > 38 °C, clinical features of UTI (dysuria, frequency, urgency, suprapubic pain, urinary incontinence) and a positive urine culture (107 bacterial colonies of micro‐organism‐forming units/L within 2 weeks after the removal of bladder catheter)

CDC

EAU: complicated UTI

Zhou 2012

Not reported

Defined as post‐catheter removal MSU clean catch culture of ≥ 104 cfu/mL for Gram positive organisms or ≥ 105 cfu/mL for Gram negative organisms

EUA: asymptomatic bacteriuria

Zmora 2010

UTI

Asymptomatic bacteriuria

UTI: positive urine culture and symptoms suggestive of UTI

CDC

Zomorrodi 2018

UTI

Not reported

N/A

CAUTI: catheter‐associated urinary tract infection; CDC: Centers for Disease Control and Prevention; cfu: colony forming unit; CSU: catheter specimen urine; EAU: European Association of Urology; MSU: midstream urine; N/A: not applicable; UTI: urinary tract infection; WBC: white blood count

Figure 6
Funnel plot of comparison 2. Shorter versus longer duration of catheter. Outcome: 2.2. symptomatic catheter‐associated urinary tract infection (number of participants)

Funnel plot of comparison 2. Shorter versus longer duration of catheter. Outcome: 2.2. symptomatic catheter‐associated urinary tract infection (number of participants)

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Table 5. Definitions for urinary tract infection

Guideline Committee

Population

Clinical features

Microbiological findings

Centres for Disease Control and Prevention (CDC)

(CDC 2016; Gould 2009)

CAUTI ‐ UTI in patients who have IUCs that have been in place for > 2 days (day 1 being when the catheter was placed)

At least one of the following:

  • Urgency

  • Dysuria

  • Frequency

  • Suprapubic tenderness

  • Fever (> 38 °C)

  • Costovertebral angle pain or tenderness

AND a urine culture of at least ≥ 105 cfu/mL with no more than 2 species of organisms

Infectious Diseases Society of America (IDSA)

(Hooton 2010)

UTI in patients with urethral (indwelling or intermittent) or suprapubic catheters that are inserted at the time or removed in the previous 48 h

Patient must have clinical features compatible with UTI (not specified)

AND a MSUor CSU with a urine culture of ≥ 103 cfu/mL of ≥ 1 species of bacterial organism (single‐catheter specimen or MSU)

European Association of Urology (EAU)

(EAU 2020; Grabe 2015)

Asymptomatic bacteriuria

No clinical features

  • A single, catheterised sample bacterial growth may be as low as 102 cfu/mL to be considered representing true bacteriuria in both men and women

  • > 105 cfu/mL on 2 consecutive MSU in women or 1 MSU in men

Uncomplicated UTI

(see Table 6 for definition)

  • Urgency

  • Dysuria

  • Frequency

  • Suprapubic tenderness

  • No urinary symptoms in 4 weeks before this episode

  • Positive urine culture of ≥ 105 cfu/mL and pyuria of > 10 WBC/mm3

Complicated UTI
(see Table 6 for definition)

  • Urgency

  • Dysuria

  • Frequency

  • Suprapubic pain

  • Fever

  • Chills

  • Flank pain

No urinary symptoms 4 weeks before

  • > 105 cfu/mL for women

  • > 104 cfu/mL for men or in women with straight catheters

  • > 10 WBC/mm3

CAUTI: catheter‐associated urinary tract infection; CDC: Centers for Disease Control and Prevention; cfu: colony forming unit; CSU: catheter specimen urine; EAU: European Association of Urology; MSU: midstream urine; UTI: urinary tract infection; WBC: white blood count

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Table 6. European Association of Urology classification of urinary tract infection

Uncomplicated UTIs

Acute, sporadic or recurrent lower (uncomplicated cystitis) and/or upper (uncomplicated pyelonephritis) UTI, limited to non‐pregnant, premenopausal women with no known relevant anatomical and functional abnormalities within the urinary tract or co‐morbidities

Complicated UTIs

All UTIs that are not defined as uncomplicated. Meaning in a narrower sense UTIs in a patient with an increased chance of a complicated course: i.e. all men, pregnant women, patients with relevant anatomical or functional abnormalities of the urinary tract, IUCs, renal diseases, and/or with other concomitant immunocompromising diseases for example, diabetes

Recurrent UTIs

Recurrences of uncomplicated and/or complicated UTIs, with a frequency of at least 3 UTIs/year or 2 UTIs in the last 6 months

Catheter associated UTIs (CAUTI)

Catheter‐associated urinary tract infection (CAUTI) refers to UTIs occurring in a person whose urinary tract is currently catheterised or has had a catheter in place within the past 48 h

Urosepsis

Urosepsis is defined as life‐threatening organ dysfunction caused by a disregulated host response to infection originating from the urinary tract and/or male genital organs

CAUTI: catheter‐associated urinary tract infection; IUC: indwelling urethral catheter; UTI: urinary tract infection

Table obtained from EAU Guidelines on Urological Infections (EAU 2020).

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Table 7. Heterogeneity of reported outcomes

Reported outcomes in this review

Similar outcomes reported by trials

Asymptomatic bacteriuria

  • Positive urine culture

Incidence of urinary retention

  • Post‐discharge urinary retention

  • Short‐term retention

  • Acute urinary retention

  • Delayed voiding after catheter removal

  • Chronic urinary retention

Loin pain

  • Post‐discharge loin pain

Fever

  • Post‐discharge fever

Dysuria

  • Post‐discharge pain on passing urine

Difficulty in passing urine

  • Post‐discharge difficulty in passing urine

  • Post‐operative voiding dysfunction

Incontinence

  • Post‐discharge incontinence

Incidence of urinary retention

Fifteen trials reported data on short‐term urinary retention (Barone 2015; Benoist 1999; Coyle 2015; El‐Mazny 2014; Han 1997; Kim 2012; Mao 1994; Nielson 1985; Popiel 2017; Rajan 2017; Sekhavat 2008; Taube 1989; Toscano 2001; Valero Puerta 1998; Zhou 2012). One trial had three different intervention groups (Taube 1989), while another trial had participants who had different types of surgery (Benoist 1999). We decided not to pool the results as doing so would involve double counting of Taube 1989 (see Analysis 2.8). We decided to use the random‐effects model due to the presence of heterogeneity.

It is uncertain if early catheter removal versus later catheter removal has any effect on incidence of urinary retention (RR 1.07, 95% CI 0.57 to 2.00; I² = 70%; 7 trials; 1108 participants; Analysis 2.8.1). Participants who received catheter removal policies involving removal the day after surgery were more likely to develop short‐term urinary retention then those whose catheters were removed after longer durations (RR 1.36, 95% CI 1.03 to 1.81; I² = 6%; 7 trials; 680 participants; Analysis 2.8.2). It is uncertain if there is any difference in incidence of urinary retention between catheter removal at two days or seven days (RR 1.37, 95% CI 0.88 to 2.12; I² = 0%; 6 trials, 881 participants).

Two trials addressed delayed voiding after catheter removal (Schiotz 1996; Sun 2004), with both comparing the removal of indwelling urethral catheters on post‐operative day 1 to a longer duration. Schiotz 1996 compared urethral catheter removal on day 1 and day 3, whereas Sun 2004 compared catheter removal on day 1 and day 5 post‐operatively. There was no evidence to suggest that shorter or longer durations of catheterisation caused delayed voiding after catheter removal (RR 1.02, 95% CI 0.53 to 1.97; I² = 53%; 2 trials, 176 participants; Analysis 2.9). Both trials involved procedures for the treatment of stress urinary incontinence. Sun 2004 used a bladder retraining programme on the third post‐operative day, which involved clamping the catheter for 1 hour and 45 minutes. We think that this could likely be the cause of heterogeneity between the two trials.

Two trials reported chronic urinary retention (Benoist 1999; Irani 1995). Irani 1995 reported two sets of results, as participants received either TURP or transurethral incision of prostate (TUIP). From the evidence available, we are unable to ascertain whether earlier or later removal of the indwelling urinary catheter has an effect on the development of chronic urinary retention (RR 0.84, 95% CI 0.29 to 2.44; I² = 0%; 2 trials; 339 participants; Analysis 2.10).

Other complications of catheterisation (or recatheterisation)

It is uncertain whether shorter or longer durations of catheterisation has any effect on the risk of fever (RR 1.17, 95% CI 0.40 to 3.40; I2 = 0%; 2 trials; 470 participants; Analysis 2.11). Dunn 2003 compared immediate removal of IUC and removal on day 1 post‐op in patients undergoing hysterectomy and the other, Yaghmaei 2017, compared IUC removal 6 hours post‐op and 12‐24 hours post‐op in participants undergoing caesarean section. Another trial, which compared immediate removal of IUC and removal on day one post‐op in patients undergoing abdominal hysterectomy or laparotomy (Ouladsahebmadarek 2012), reported more fever in the later removal group but the data were not presented in useable form (OR 3.97, 95% CI 1.62 to 9.75).

One trial reported data on epididymitis (Nielson 1985). Of the 20 participants whose catheters were removed 28 days after urethrotomy, two developed epididymitis compared with none of 20 in the three‐day removal group (RR 0.20, 95% CI 0.01 to 3.92; Analysis 2.12). There were insufficient data to suggest there was any evidence that early or later removal of urethral catheters affected the incidence of epididymitis.

Patient‐reported

Patient pain or discomfort

Eleven trials reported data on pain or discomfort (Carter‐Brooks 2018; Chai 2011; Chia 2009; Dunn 2003; Joshi 2014; Naguimbing‐Cuaresma 2007; Nielson 1985; Ouladsahebmadarek 2012; Sandberg 2019; Sekhavat 2008; Zaouter 2009). Five trials used a visual analogue scale (VAS) to assess pain (Carter‐Brooks 2018; Chai 2011; Chia 2009; Ouladsahebmadarek 2012; Zaouter 2009), whilst the other five trials measured pain as a dichotomous variable (Chia 2009; Joshi 2014; Naguimbing‐Cuaresma 2007; Nielson 1985; Sekhavat 2008). Dunn 2003 reported data on pain as a percentage but did not report the number of participants in each group. The authors were contacted for more information.

It is uncertain if early removal has any effect on pain or discomfort measured as a dichotomous outcome (presence/absence of pain or discomfort) (RR  0.52 95% CI 0.21  1.27; I2 = 82%; 5 trials; 510 participants; Analysis 2.13). Pain scores measured on a 0‐10 visual analogue scale (higher score = greater pain) may be reduced with early removal compared with later removal (MD ‐0.34, 95% CI ‐0.47 to ‐0.20; I2 = 28%; 5 trials; 695 participants; Analysis 2.14). However, the difference may not be clinically meaningful.

Patient satisfaction

One trial reported data on patient satisfaction using a questionnaire and compared IUC removal 6 hours post‐op compared to 12‐24 hours post‐op in females undergoing caesarean section (Yaghmaei 2017). This trial was originally written in Persian and, after being translated, it is unclear when their participants were asked to complete this questionnaire. More women were satisfied or very satisfied in the early removal group than in the later removal group (RR 3.27, 95% CI 2.30 to 4.64; 220 women; Analysis 2.15).

Urinary incontinence

Seven trials addressed this outcome (Ahmed 2014; Barone 2015; Gungor 2014; Han 1997; Kim 2012; Onile 2008; Souto 2004). Fewer participants developed urinary incontinence when their catheter was removed earlier (RR 0.55, 95% CI 0.35 to 0.86; I2 = 45%; 7 trials, 1195 participants; Analysis 2.16).

Number of patients reporting dysuria

Seven trials reported data on dysuria (Ahmed 2014; Aref 2020; Basbug 2020; El‐Mazny 2014; Onile 2008; Ouladsahebmadarek 2012; Yaghmaei 2017). Low‐certainty evidence suggests participants may be less likely to report dysuria when their catheters were removed early post‐operatively compared to later (RR 0.42, 95% CI 0.20 to 0.88; I² = 61%; 7 trials, 1398 participants; Analysis 2.17; summary of findings Table 2).

Clinician‐reported

Volume of first void (mL)

Three trials reported the volume of the first void (Gungor 2014; Huang 2011; Mao 1994). There was insufficient evidence to suggest that participants who had their catheters removed after a shorter duration of catheterisation tended to have larger volumes of first void (MD 27.02, 95% CI 1.00 to 53.04; I² = 31%; 3 trials, 364 participants; Analysis 2.18). Although this result was not statistically significant, the mean volume is not likely to be of any clinical significance.

Time to first void (hours)

Two trials reported time to first void (Carter‐Brooks 2018; Yaghmaei 2017). We decided to use the random‐effects model due to the presence of heterogeneity. Those participants who had their catheters removed earlier were found to have a shorter time to first void when compared to later removal (MD ‐5.52, 95% CI ‐6.08 to ‐4.95; I2 = 98%; 2 trials, 277 participants; Analysis 2.19). The heterogeneity may be explained by variations in the type of surgery and level of anaesthesia which are likely to have a substantial impact on an individual’s ability to control their bladder.

Post‐void residual volume (mL)

Three trials reported data on post‐void residual volume (Gungor 2014; Huang 2011; Nguyen 2012). There were insufficient data to suggest post‐void residual volume was affected by shorter or longer durations of catheterisation in participants undergoing indwelling urethral catheterisation for two to seven days compared to longer durations (MD 6.37, 95% CI −9.14 to 21.88; I2 = 0%; 2 trials, 137 participants; Analysis 2.20). No trials included participants having catheters removed early or after a one‐day removal policy. Nguyen 2012 reported median and range without SDs and, as a result, could not be incorporated into the meta‐analysis (Analysis 2.21).

Length of hospitalisation (days)

Twenty‐six trials reported data on length of hospitalisation (Ahmed 2014; Alessandri 2006; Aref 2020; Aslam 2019; Basbug 2020; Carter‐Brooks 2018; Durrani 2014; El‐Mazny 2014; Hakvoort 2004; Han 1997; Irani 1995; Kamilya 2010; Kim 2012; Koh 1994; Lau 2004; Li 2014; Naguimbing‐Cuaresma 2007; Onile 2008; Ouladsahebmadarek 2012; Schiotz 1996; Sekhavat 2008; Shahnaz 2016; Shrestha 2013; Sun 2004; Yaghmaei 2017). Six trials did not report SDs (Han 1997; Irani 1995; Koh 1994; Shrestha 2013; Tahmin 2011; Valero Puerta 1998), while six trials reported the median and range values (Allen 2016; Alonzo‐Sosa 1997; Lista 2020; Sandberg 2019; Weemhoff 2011; Zaouter 2009; Analysis 2.22; Analysis 2.24). We calculated SDs for two trials by using their reported P values and inserting them into a conversion Excel document designed by a statistician (Hakvoort 2004; Schiotz 1996).

Early removal may reduce hospital stay compared with later removal (MD ‐1.13 days, 95% CI ‐1.42 to ‐0.83; I2 = 98%; 3917 participants; Analysis 2.22). The substantial statistical heterogeneity in this analysis is most likely due to the variation between studies in type of surgery, which in turn has an impact on length of hospital stay. The test for subgroup differences suggests that the type of surgery that the participants underwent could be an effect modifier (P = 0.0006, I² = 82.6%; Analysis 2.23).

Time between removal of catheter to discharge (days)

Not reported

Health status/quality of life

Condition‐specific or generic quality‐of‐life measures

Not reported

Psychological outcome measures

Not reported

Comparison 3: flexible versus fixed duration of indwelling urethral catheterisation

We did not find any trials that addressed this comparison.

Comparison 4: clamping versus free drainage before catheter removal

Seven trials involving 714 participants investigated the practices of clamping and release polices versus free drainage of indwelling urethral catheters (Gong 2017; Guzman 1994; Liu 2015; Nyman 2010; Oberst 1981; Williamson 1982; Wilson 2000). All seven trials used different clamping regimes. We used subgrouping to present the analysis according to the following: clamping versus removal (of catheter) at 24 hours; clamping versus removal (of catheter) at 48 hours; and clamping versus removal (of catheter) at 72 hours.

We were unable to include three trials in the meta‐analysis (Bristoll 1989; Talreja 2016; Wilson 2000). We do not know the duration of catheterisation in Talreja 2016. We have contacted the author and we are currently awaiting a reply. Two trials reported data that were not relevant to the outcomes measured by this review (Bristoll 1989; Wilson 2000).

Outcomes for this comparison not pre‐stated in the Types of outcome measures are reported in Appendix 6.

Primary outcomes
Number of participants who required recatheterisation following removal of indwelling urethral catheter

Five trials addressed this outcome (Gong 2017; Guzman 1994; Liu 2015; Nyman 2010; Oberst 1981). There may be little to no difference between using a clamping regimen and free drainage in terms of the risk of requiring recatheterisation (RR 0.82, 95% CI 0.55 to 1.21; I² = 0%; 5 trials, 569 participants; low‐certainty evidence; Analysis 3.1; summary of findings Table 3).

The test for subgroup differences did not suggest a difference in effect between trials with women only and trials with a mixed population of men and women, or between urological surgery and non‐urological surgery (P = 0.64, overlapping confidence intervals; Analysis 3.2). We could not perform subgroup analysis based on antibiotic prophylaxis as only one trial reported it (Guzman 1994).

The sensitivity analysis, in which we removed the one trial that we judged to be high risk of bias in the randomisation and allocation concealment domains (Liu 2015), did not change the effect estimate (RR 0.82, 95% CI 0.55 to 1.21; I² = 0%; 5 trials, 490 participants).

Secondary outcomes
Complications/adverse events

Incidence of urinary tract infection

  • Symptomatic catheter associated urinary tract infections (CAUTI): two trials reported data on symptomatic CAUTI (Gong 2017; Guzman 1994). We are uncertain if there is any difference between clamping regimes and free drainage effects in terms of the risk of symptomatic CAUTI (RR 0.99, 95% CI 0.60 to 1.63; I² = 1%; 2 trials, 267 participants; very low‐certainty evidence; Analysis 3.3; summary of findings Table 3).

  • Asymptomatic bacteriuria: not reported

Incidence of urinary retention

Two trials reported data on urinary retention (Guzman 1994; Wu 2015). There was insufficient evidence to suggest that the use of clamping regimes versus free drainage affects the incidence of urinary retention in participants (RR 1.18, 95% CI 0.69 to 2.02; I² = 0%; 2 trials, 169 participants; Analysis 3.4).

Other complications of catheterisation (or recatheterisation)

Not reported

Patient‐reported

Patient pain or discomfort

Not reported

Patient satisfaction

Not reported

Urinary incontinence

Not reported

Number of patients reporting dysuria

One trial reported data on dysuria (Liu 2015). It is uncertain if there is any difference between clamping regimes and free drainage in terms of the risk of dysuria for (RR 0.84, 95% CI 0.46 to 1.54; 1 trial, 79 participants; very low‐certainty evidence; Analysis 3.5; summary of findings Table 3).

Clinician‐reported

Volume of first void (mL)

One trial reported data on the volume of first void (Liu 2015). For participants who had their catheters removed at 72 hours, participants with free drainage catheters tended to have larger volumes of first void when compared to those with clamped catheters (MD 39.60, 95% CI 2.23 to 76.97; 1 trial, 79 participants; Analysis 3.6). Although this result was statistically significant in this trial, the increase in mean volume is unlikely to be of any clinical significance.

Time to first void (minutes)

Two trials addressed this outcome (Oberst 1981; Williamson 1982). One trial did not report SDs (Williamson 1982). As a result, we could not perform meta‐analysis. One trial found that, on average, there was a shorter duration of time to first void in participants receiving the clamping regime when compared to those with free drainage (MD −118, 95% CI −190.54 to −45.46; Analysis 3.7).

Post‐void residual volume (mL)

Not reported

Length of hospitalisation (days)

Two trials reported data on the length of hospitalisation (Guzman 1994; Nyman 2010). One trial presented their data with medians and no SDs (Guzman 1994; Analysis 3.8). This left one trial (Nyman 2010), so we could not perform meta‐analysis. There was insufficient evidence to suggest that the use of clamping regimes over free drainage affected the length of hospital stay of participants (Analysis 3.9).

Time between removal of catheter to discharge (days)

Not reported

Health status/quality of life

Condition‐specific or generic quality‐of‐life measures

Not reported

Psychological outcome measures

Not reported

Comparison 5: Removal using prophylactic alpha blocker drugs versus other methods

Three trials investigated the effects of the use of prophylactic alpha blockers in participants undergoing indwelling urethral catheterisation (Jang 2012; Jeong 2014; Jun 2011). All trials differed in the dosage of alpha blocker and the time when alpha blockers were given to participants. Tamsulosin was the alpha blocker of choice across the three trials, with two trials opting to use 0.2 mg (Jang 2012; Jun 2011), and one trial using 0.4 mg (Jeong 2014).

Primary outcomes
Number of participants who required recatheterisation following removal of indwelling urethral catheter

Two trials reported this outcome (Jang 2012; Jun 2011). We are uncertain if prophylactic alpha blockers have any effect on the risk of requiring recatheterisation (RR 1.18, 95% CI 0.58 to 2.42; I² = 0%; 2 trials, 184 participants; very low‐certainty evidence; Analysis 4.1; summary of findings Table 4). We did not perform subgroup analysis due to only two trials reporting this outcome.

Secondary outcomes
Complications/adverse events

Incidence of urinary tract infection

  • Symptomatic catheter associated urinary tract infections (CAUTI): one trial addressed the incidence of symptomatic CAUTI (Jang 2012). We are uncertain if prophylactic alpha blockers have any effect on the risk of symptomatic CAUTI (0/47 versus 2/47; RR 0.20, 95% CI 0.01 to 4.06; 1 trial, 94 participants; very low‐certainty evidence; Analysis 4.2; summary of findings Table 4).

  • Asymptomatic bacteriuria: not reported

Incidence of urinary retention

Two trials reported data on acute urinary retention (Jeong 2014; Jun 2011). Fewer participants developed acute urinary retention in the prophylactic alpha blocker group than in the control group (RR 0.38, 95% CI 0.20 to 0.73; I² = 0% ; 2 trials, 308 participants; Analysis 4.3).

Other complications of catheterisation (or recatheterisation)

Not reported

Patient‐reported

Patient pain or discomfort

Not reported

Patient satisfaction

Not reported

Incidence of urinary incontinence

Not reported

Number of patients reporting dysuria

Not reported

Clinician‐reported

Volume of first void (mL)

Not reported

Time to first void (hours)

Not reported

Post‐void residual volume (mL)

Two trials addressed this outcome (Jang 2012; Jeong 2014). There was insufficient evidence to suggest that the use of prophylactic alpha blockers affected post‐void residual volumes in participants receiving indwelling urethral catheterisation (MD −2.00, 95% CI −11.42 to 7.42; I² = 55%; 2 trials, 301 participants; Analysis 4.4). It should be noted that one trial measured post‐void residual volume on post‐operative day seven (Jang 2012), whereas the other trial measured post‐void residual volume two weeks post‐operatively (Jeong 2014).

Length of hospitalisation (days)

Two trials addressed this outcome (Jang 2012; Jun 2011). One trial reported data in a format that we could not use for statistical analysis (Jang 2012; Analysis 4.6). Participants who received prophylactic alpha blockers tended to have shorter stays in hospital when compared to those participants who did not (MD −1.22, 95% CI −1.54 to −0.90; Analysis 4.5).

Time between removal of catheter to discharge (days)

Not reported

Health status/quality of life

Condition‐specific or generic quality‐of‐life measures

Not reported

Psychological outcome measures

Not reported

Discussion

Summary of main results

This review includes 99 eligible trials that addressed 14 outcome measures (see Appendix 5 and Appendix 6 for a list of additional outcomes reported by trials).

Removal of indwelling urethral catheters at one specified time of day (6 am to 7 am) versus another specified time of day (10 pm to midnight)

Based on summary data from 13 trials, removal of indwelling urethral catheters late at night may slightly reduce the risk of requiring recatheterisation compared with early morning removal (low‐certainty evidence; summary of findings Table 1). It is uncertain if there is any difference between late night or early morning removal of indwelling urethral catheters in terms of the number of people developing symptomatic CAUTI (very low‐certainty evidence; summary of findings Table 1) or dysuria (low certainty‐evidence; summary of findings Table 1). None of the trials that compared late night to early morning removal of indwelling urethral catheters reported data relating to quality of life.

Shorter versus longer durations of indwelling urethral catheterisation

Based on summary data from 68 trials, shorter durations of catheterisation may increase the risk of requiring recatheterisation compared with longer durations (low‐certainty evidence; summary of findings Table 2). However, shorter durations of catheterisation probably reduce the risk of symptomatic CAUTI (moderate‐certainty evidence; summary of findings Table 2) and may reduce the risk of dysuria (low‐certainty evidence; summary of findings Table 2).

Subgroup analysis suggested that the effect of shorter versus longer indwelling urethral catheterisation duration may be more uncertain in men undergoing urological surgery compared with women or with people undergoing other types of surgery.

None of the trials comparing shorter to longer indwelling urethral catheterisation duration reported data relating to quality of life.

Clamping regimes compared to free drainage

Summary data from seven trials revealed there may be little to no difference between clamping regimes and free drainage in terms of the number of participants who required recatheterisation (low‐certainty evidence; summary of findings Table 3). Two trials reported data on the number of participants with symptomatic CAUTI. We are very uncertain whether the use of clamping regimes compared with free drainage has any effect on the risk of symptomatic CAUTI or dysuria (both very low‐certainty evidence; summary of findings Table 3). Condition‐specific or generic quality of life measures were not reported for this comparison.

Use of prophylactic alpha blocker therapy versus no drug or intervention before catheter removal

Based on summary data from three trials, we are uncertain if the use of prophylactic alpha blockers has any effect on the risk of requiring recatheterisation, risk of symptomatic CAUTI (both very low‐certainty evidence) or risk of dysuria (summary of findings Table 4). Trials did not report dysuria and condition‐specific or generic quality of life measures for this comparison.

Overall completeness and applicability of evidence

The comprehensive search strategy, along with the increased efforts made to obtain unpublished data, means that we can be confident that the evidence presented in this review is as complete as possible. We did not conduct a search for the protocols for each trial due to time constraints. We found that the population in each of the included trials tended to vary considerably due to participants being catheterised for a variety of different indications. The majority of participants included in this systematic review had some form of surgical procedure. Additionally, the type of surgery that participants underwent varied significantly across the trials, with the most common being gynaecological surgery. It is likely that this heterogeneity between the trial populations had an impact during the analysis of the trials.

Despite the large number of trials identified, uncertainties still remain regarding the effects different indwelling urethral catheter removal strategies. Two of our most important participant‐centred outcomes (recatheterisation and CAUTI) were generally well reported but dysuria was less commonly reported and no trials at all reported any quality‐of‐life data.

Ten trials included in this review did not provide data that could contribute to meta‐analysis. We contacted their authors for further information and we await their reply. It should be noted that we identified very few trials that involved non‐surgical populations.

Diagnostic criteria for symptomatic UTI and recatheterisation

For this review, we chose to use the definition of symptomatic UTI outlined by the CDC. The reasoning for using this definition was that various international guideline committees such as the AUA and EAU also use this definition (Gould 2009; Trautner 2010). The IDSA has also outlined definitions for symptomatic UTI in their guidelines. However, these recommendations are tailored for other types of catheterisation, such as suprapubic or intermittent catheterisation and, as a result, we did not use it (Hooton 2010). The current definitions for symptomatic UTI and asymptomatic bacteriuria outlined by various guideline committees can be found in Table 5 and Table 6.

The definition for symptomatic UTI used in each trial was down to the trial authors' preference, as no international agreement exists as to which definition should be used in trials assessing symptomatic UTI. However, this is an important outcome and future trials should use standardised definitions of CAUTI (see Table 5). Only seven trials in this review stated that symptomatic CAUTI was defined using the CDC guidelines (Ahmed 2014; Aref 2020; Chai 2011; Chen 2013; Gong 2017; Joshi 2014; Kamilya 2010). Six trials reported UTI that met the definition for symptomatic UTI by the CDC (Alonzo‐Sosa 1997; Gross 2007; Liang 2009; Vallabh‐Patel 2020; Zaouter 2009; Zmora 2010). Similar issues have been encountered by the EAU guideline committee, who have found assessing the urinary catheter literature problematic due to this lack of definition by trials (EAU 2020).

As the primary outcome of this review was the number of participants requiring recatheterisation, it was noted that very few trials provided a definition for recatheterisation or information regarding the circumstances that led participants to be recatheterised. Given that the insertion of catheters is associated with its own complications and risks (urethral trauma, urethral stricture formation, increased patient pain or discomfort, and bladder perforation (Hollingsworth 2013; Igawa 2008; Fisher 2017)), it may be useful for future trials to report whether any of these complications occurred in participants who were recatheterised. Future trials should aim to improve the reporting of complications of catheterisation (or recatheterisation) as this will help improve future recommendations for recatheterisation as an intervention.

Other strategies to prevent CAUTI

Emerging literature has shown that other strategies can be devised in an attempt to reduce both the placement and the duration of urethral catheters.

Meddings 2014 has explored the use of various other strategies to help reduce unnecessary indwelling urethral catheter use. One of these methods includes stop‐orders, which prompt healthcare workers to remove an indwelling urethral catheter after a certain time has elapsed or a specific condition has occurred. Stop‐order protocols tended to be similar in that they would all generally include a list of appropriate circumstances for which patients should be catheterised, as well as state a default time period before the catheter had to be removed. Meddings 2014 argued that the use of protocols designed to reduce inappropriate catheter placement or prompting their removal can result in reduced catheter usage and rates of CAUTI. By reminding clinicians and nurses of the catheter's existence, stop‐orders and other strategies could potentially help reduce the number of patients developing problems associated with prolonged or unnecessary urinary catheterisation. Although the use of stop‐orders does not meet the inclusion criteria for this review, it should be noted that other methods are available to help not only reduce the duration of catheterisation but also potentially reduce the need for them in the first place.

Quality of the evidence

Despite a large number of trials in this review, we found the certainty of evidence for most outcomes to be low or very low. This was primarily due to many of the included trials suffering from methodological flaws as well as insufficient reporting. This subsequently affected the risk of bias domains of trials, resulting in them being assigned to unclear risk of bias and consequently downgrading the certainty of evidence. We judged the risk of selection bias through randomisation and allocation concealment to be unclear due to inadequate reporting. We generally deemed the risk of performance and detection bias to be high for most trials as it became clear that it was not possible in many instances for the outcome assessor or healthcare professionals to be adequately blinded due to the nature of the intervention. As a result, we downgraded the certainty of evidence due to serious concerns about risk of bias. 

In addition to downgrading for risk of bias, we also downgraded the certainty of evidence for some outcomes for imprecision due to the low numbers of participants in the included trials. Higher numbers of participants give the trials more power and consequently, the effect estimate is more precise and more likely to be closer to the true effect of the intervention.

Potential biases in the review process

We searched all relevant databases during our search process without imposing any language restrictions. This allowed our search to identify as many relevant trials as possible. The search also included ongoing trials, which are registered in trial registries. However, even with this rigorous search strategy, it is possible that we did not identify all eligible trials. Although challenging for older trials, we contacted trial authors when more data were required, with no replies received to our emails. We did not conduct a search for the protocols for each trial due to time constraints.

To reduce the risk of bias in the review process, two or more review authors independently undertook study selection, data extraction, risk of bias assessment and GRADE assessments. Another potential source of bias may have occurred during the process of determining the certainty of evidence when we chose the critical GRADE outcomes. We attempted to reduce the risk of bias in the selection of outcomes for inclusion in the GRADE evidence profile. We took into account patients' views obtained through focus groups, as well as advice from clinical experts.

Agreements and disagreements with other studies or reviews

We found the following reviews or guidelines, or both, to be related to this systematic review. We noted that the GRADE certainty of evidence framework was not performed by any other review. Some overlap was found to exist between this update and another Cochrane Review (Phipps 2006). Their review evaluated the use of urinary catheters after urogenital surgery and looked at various outcomes to establish the optimal use of urinary catheters post‐surgery.

Comparison 1: removal of indwelling urethral catheter at one time of day (6 am to 7 am) versus another time of day (10 pm to midnight)

Number of participants requiring recatheterisation

  • One systematic review conducted by Fernandez 2003a found that the removal of indwelling urethral catheters late at night had no effect on recatheterisation rates in participants undergoing TURP or urological surgery. These findings are similar to the findings in this review.

  • An earlier Cochrane Review looked at short‐term indwelling urethral catheterisation policies and found that removing the indwelling urethral catheter late at night resulted in fewer participants requiring recatheterisation (Phipps 2006).

  • The CDC acknowledged that further research is required into the removal of indwelling urethral catheters at different times of the day in their guidelines on symptomatic CAUTI (Gould 2009).

Comparison 2: shorter versus longer duration of indwelling urethral catheterisation

Number of participants requiring recatheterisation

  • Zhang 2015 found similar results in their meta‐analysis when comparing early versus delayed catheter removal in women following uncomplicated hysterectomy. Removal of the catheter early resulted in a significant increase in recatheterisation in participants (RR 3.32, 95% CI 1.48 to 7.46).

  • Phipps 2006 also looked at shorter post‐operative catheter durations compared to longer durations. However, their review only involved 12 trials, whereas this systematic review involved 98. Phipps and colleagues reported that there was insufficient evidence to conclude whether shorter durations of catheterisation affected recatheterisation rates in participants. Phipps 2006 did not perform an analysis of the quality of this evidence.

  • The CDC guidelines acknowledge that there is an increased risk of recatheterisation in shorter durations of catheterisation compared to longer durations (Gould 2009).

Number of participants with symptomatic CAUTI

  • Zhang 2015 found that early removal of the indwelling urethral catheters resulted in a significant reduction in symptomatic UTI (RR 0.23, 95% CI 0.10 to 0.52). Although this result is similar to this review, we found a larger effect due to more trials being included in our meta‐analysis. A reduction in asymptomatic bacteriuria was also found by Zhang 2015 in the early removal group, which we also saw in our review (RR 0.60, 95% CI 0.40 to 0.88).

  • Phipps 2006 also reported a reduction in UTI when catheters were removed after a shorter duration versus longer duration (RR 0.50, 95% CI 0.29 to 0.87), which agrees with the findings of this review.

  • Our findings relating to shorter compared with longer indwelling urethral catheterisation duration and the risk of CAUTI are consistent with existing literature on catheter duration and the risk of developing symptomatic CAUTI (CDC 2016; EAU 2020; Gould 2009; Grabe 2015; Hooton 2010; NICE 2012; Tenke 2008; Tiguert 2004).

Comparison 3: clamping regimes compared to free drainage

Number of participants requiring recatheterisation

  • The CDC guidelines report that there is no benefit from clamping short‐term indwelling urethral catheters before removal (CDC 2016; Gould 2009). This was classified as a weak recommendation based on evidence reported by two Cochrane Reviews, one of which is the previous version of this review (Fernandez 2003b), the other being Phipps 2006.

  • A systematic review conducted by Fernandez 2005 found that there was no statistically significant difference in the number of patients requiring recatheterisation between both the clamped and unclamped groups. The results of this trial are similar to the findings in this review.

  • A systematic review and meta‐analysis conducted by Wang 2016 found that there were no significant differences between clamping and unclamping groups in reference to risk of recatheterisation, urinary retention, rate of UTI or subjective symptoms related to voiding.

Number of participants with symptomatic CAUTI

  • The CDC guidelines have outlined that clamping policies should not be used in short‐term catheterisation as it has been shown that clamping policies do not provide any benefit with regards to bacteriuria (CDC 2016; Gould 2009).

  • The EAU has made a slightly different recommendation, however. Upon their evaluation of the evidence, they concluded that the literature was of poor methodological quality and, as a result, no clinical recommendations could be made as to whether or not there is any benefit from the use of clamping policies. It concludes by stating that further research is required to fully determine the value of clamping regimes in short‐term catheterisation (EAUN 2012; Grabe 2015).

  • Fernandez 2005 found no statistically significant difference between the clamped and free drainage groups with regards to the number of patients developing UTIs at 72 hours (RR 0.55, 95% CI 0.15 to 2.01).

Comparison 4: use of prophylactic alpha blocker therapy versus no drug or intervention before catheter removal

Number of participants requiring recatheterisation

  • Another Cochrane Review has evaluated the use of alpha blockers in short‐term indwelling urethral catheters in men with AUR (Fisher 2014). However, their prophylactic use has not been studied in a Cochrane Review.

  • A RCT conducted by Patel 2018 looked at the use of alpha blockers in participants undergoing colorectal surgery below the peritoneal reflection. Their trial compared indwelling urethral catheter removal on day 1 post‐operatively in combination with an alpha blocker versus standard removal of the catheter at 3 days post‐operatively with no alpha blocker. There was no significant difference in the number of participants requiring recatheterisation between both groups. There was significant reduction in symptomatic CAUTI and length of stay in the early catheter removal group. Their trial was excluded from this systematic review as the trial compared both shorter versus longer durations of catheterisation (comparison 2) and the use of alpha blockers in their participants (comparison 5).

  • A systematic review and meta‐analysis performed by Ghuman 2018 assessed the use of prophylactic alpha blockers on the prevention of post‐operative urinary retention. Their systematic review did not define duration of catheterisation (short or long‐term indwelling urethral catheterisation) and also included intermittent catheterisation. The administration of prophylactic alpha blockers varied across their trials from one week before surgery to four to six hours post‐operation. Two of the trials in their review were also included in our meta‐analysis. The use of prophylactic alpha‐1 adrenergic blockers resulted in a significant reduction in the risk of post‐operative urinary retention (RR 0.48, 95% CI 0.33 to 0.70; P = 0.001; I² = 65.49%); however, their results showed substantial heterogeneity. Further subgroup analysis revealed a strong risk reduction in men (RR 0.33, 95% CI 0.23 to 0.47; P < 0.001, I² = 10.58%) and participants receiving spinal anaesthesia (RR 0.26, 95% CI 0.14 to 0.46; P < 0.0001, I2 = 0%).

Number of participants with symptomatic CAUTI

  • Ghuman 2018 found no evidence to suggest the use of alpha blockers had any effect on the number of participants with symptomatic CAUTI (RR 0.64, 95% CI 0.30 to 1.37; P = 0.25).

PRISMA flow diagram

Figuras y tablas -
Figure 1

PRISMA flow diagram

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Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included trials

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Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included trials

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Risk of bias summary: review authors' judgements about each risk of bias item for each included trial

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Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included trial

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Funnel plot of comparison 1. Removal of indwelling urethral catheter at one time of day (6 am to 7 am) versus another time of day (10 pm to midnight). Outcome 1.1. number needing to be recatheterised

Figuras y tablas -
Figure 4

Funnel plot of comparison 1. Removal of indwelling urethral catheter at one time of day (6 am to 7 am) versus another time of day (10 pm to midnight). Outcome 1.1. number needing to be recatheterised

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Funnel plot of comparison 2. Shorter versus longer duration of catheter. Outcome: 2.1 number needing to be recatheterised

Figuras y tablas -
Figure 5

Funnel plot of comparison 2. Shorter versus longer duration of catheter. Outcome: 2.1 number needing to be recatheterised

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Funnel plot of comparison 2. Shorter versus longer duration of catheter. Outcome: 2.2. symptomatic catheter‐associated urinary tract infection (number of participants)

Figuras y tablas -
Figure 6

Funnel plot of comparison 2. Shorter versus longer duration of catheter. Outcome: 2.2. symptomatic catheter‐associated urinary tract infection (number of participants)

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Comparison 1: Removal of indwelling urethral catheter at one specified time of day (10 pm to midnight) versus another specified time of day (6 am to 7 am), Outcome 1: Number needing to be recatheterised

Figuras y tablas -
Analysis 1.1

Comparison 1: Removal of indwelling urethral catheter at one specified time of day (10 pm to midnight) versus another specified time of day (6 am to 7 am), Outcome 1: Number needing to be recatheterised

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Comparison 1: Removal of indwelling urethral catheter at one specified time of day (10 pm to midnight) versus another specified time of day (6 am to 7 am), Outcome 2: Number needing to be recatheterised: subgroup analysis based on sex

Figuras y tablas -
Analysis 1.2

Comparison 1: Removal of indwelling urethral catheter at one specified time of day (10 pm to midnight) versus another specified time of day (6 am to 7 am), Outcome 2: Number needing to be recatheterised: subgroup analysis based on sex

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Comparison 1: Removal of indwelling urethral catheter at one specified time of day (10 pm to midnight) versus another specified time of day (6 am to 7 am), Outcome 3: Symptomatic catheter‐associated urinary tract infection (number of participants)

Figuras y tablas -
Analysis 1.3

Comparison 1: Removal of indwelling urethral catheter at one specified time of day (10 pm to midnight) versus another specified time of day (6 am to 7 am), Outcome 3: Symptomatic catheter‐associated urinary tract infection (number of participants)

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Comparison 1: Removal of indwelling urethral catheter at one specified time of day (10 pm to midnight) versus another specified time of day (6 am to 7 am), Outcome 4: Asymptomatic bacteriuria (number of participants)

Figuras y tablas -
Analysis 1.4

Comparison 1: Removal of indwelling urethral catheter at one specified time of day (10 pm to midnight) versus another specified time of day (6 am to 7 am), Outcome 4: Asymptomatic bacteriuria (number of participants)

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Comparison 1: Removal of indwelling urethral catheter at one specified time of day (10 pm to midnight) versus another specified time of day (6 am to 7 am), Outcome 5: Incidence of urinary retention

Figuras y tablas -
Analysis 1.5

Comparison 1: Removal of indwelling urethral catheter at one specified time of day (10 pm to midnight) versus another specified time of day (6 am to 7 am), Outcome 5: Incidence of urinary retention

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Comparison 1: Removal of indwelling urethral catheter at one specified time of day (10 pm to midnight) versus another specified time of day (6 am to 7 am), Outcome 6: Difficulty in passing urine

Figuras y tablas -
Analysis 1.6

Comparison 1: Removal of indwelling urethral catheter at one specified time of day (10 pm to midnight) versus another specified time of day (6 am to 7 am), Outcome 6: Difficulty in passing urine

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Comparison 1: Removal of indwelling urethral catheter at one specified time of day (10 pm to midnight) versus another specified time of day (6 am to 7 am), Outcome 7: Loin pain

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Analysis 1.7

Comparison 1: Removal of indwelling urethral catheter at one specified time of day (10 pm to midnight) versus another specified time of day (6 am to 7 am), Outcome 7: Loin pain

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Comparison 1: Removal of indwelling urethral catheter at one specified time of day (10 pm to midnight) versus another specified time of day (6 am to 7 am), Outcome 8: Fever

Figuras y tablas -
Analysis 1.8

Comparison 1: Removal of indwelling urethral catheter at one specified time of day (10 pm to midnight) versus another specified time of day (6 am to 7 am), Outcome 8: Fever

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Comparison 1: Removal of indwelling urethral catheter at one specified time of day (10 pm to midnight) versus another specified time of day (6 am to 7 am), Outcome 9: Incontinence

Figuras y tablas -
Analysis 1.9

Comparison 1: Removal of indwelling urethral catheter at one specified time of day (10 pm to midnight) versus another specified time of day (6 am to 7 am), Outcome 9: Incontinence

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Comparison 1: Removal of indwelling urethral catheter at one specified time of day (10 pm to midnight) versus another specified time of day (6 am to 7 am), Outcome 10: Dysuria (number of participants)

Figuras y tablas -
Analysis 1.10

Comparison 1: Removal of indwelling urethral catheter at one specified time of day (10 pm to midnight) versus another specified time of day (6 am to 7 am), Outcome 10: Dysuria (number of participants)

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Comparison 1: Removal of indwelling urethral catheter at one specified time of day (10 pm to midnight) versus another specified time of day (6 am to 7 am), Outcome 11: Volume of the first void (mL)

Figuras y tablas -
Analysis 1.11

Comparison 1: Removal of indwelling urethral catheter at one specified time of day (10 pm to midnight) versus another specified time of day (6 am to 7 am), Outcome 11: Volume of the first void (mL)

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Volume of first void (median and range)

Study

Midnight removal

Morning removal

Significance

Following gynaecological surgery

Ind 1993

275 ml (10 to 600 ml)

49 participants

100 ml (5 to 450 ml)

46 participants

P < 0.0001 (95% CI 124.9 to 225.5)

Figuras y tablas -
Analysis 1.12

Comparison 1: Removal of indwelling urethral catheter at one specified time of day (10 pm to midnight) versus another specified time of day (6 am to 7 am), Outcome 12: Volume of first void (median and range)

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Comparison 1: Removal of indwelling urethral catheter at one specified time of day (10 pm to midnight) versus another specified time of day (6 am to 7 am), Outcome 13: Time to first void (hours)

Figuras y tablas -
Analysis 1.13

Comparison 1: Removal of indwelling urethral catheter at one specified time of day (10 pm to midnight) versus another specified time of day (6 am to 7 am), Outcome 13: Time to first void (hours)

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Time to first void (median)

Study

Midnight removal

Morning removal

Significance

Following gynaecological surgery

Ind 1993

Median time
3 hours 20 minutes

49 participants

Median time
5 hours

46 participants

P = 0.012 (95% CI 0.33 to 2.58)

Figuras y tablas -
Analysis 1.14

Comparison 1: Removal of indwelling urethral catheter at one specified time of day (10 pm to midnight) versus another specified time of day (6 am to 7 am), Outcome 14: Time to first void (median)

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Comparison 1: Removal of indwelling urethral catheter at one specified time of day (10 pm to midnight) versus another specified time of day (6 am to 7 am), Outcome 15: Post‐void residual volume

Figuras y tablas -
Analysis 1.15

Comparison 1: Removal of indwelling urethral catheter at one specified time of day (10 pm to midnight) versus another specified time of day (6 am to 7 am), Outcome 15: Post‐void residual volume

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Comparison 1: Removal of indwelling urethral catheter at one specified time of day (10 pm to midnight) versus another specified time of day (6 am to 7 am), Outcome 16: Length of hospitalisation in days

Figuras y tablas -
Analysis 1.16

Comparison 1: Removal of indwelling urethral catheter at one specified time of day (10 pm to midnight) versus another specified time of day (6 am to 7 am), Outcome 16: Length of hospitalisation in days

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Length of hospitalisation in days

Study

Midnight removal

Morning removal

significance

Urological surgery and procedures (mean, total)

Chillington 1992

4.7 (35)

5.4 (48)

Gynaecological surgery involving the bladder /urethra (median, range)

Ind 1993

9 days (4 to 17 days)

12 days (5 to 20 days)

p=0.043

Gynaecological surgery not involving the bladder/urethra (median, range)

Ind 1993

6 days (1 to 14 days)

7 days (2 to 18 days)

Figuras y tablas -
Analysis 1.17

Comparison 1: Removal of indwelling urethral catheter at one specified time of day (10 pm to midnight) versus another specified time of day (6 am to 7 am), Outcome 17: Length of hospitalisation in days

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Comparison 1: Removal of indwelling urethral catheter at one specified time of day (10 pm to midnight) versus another specified time of day (6 am to 7 am), Outcome 18: Time between removal of catheter to discharge

Figuras y tablas -
Analysis 1.18

Comparison 1: Removal of indwelling urethral catheter at one specified time of day (10 pm to midnight) versus another specified time of day (6 am to 7 am), Outcome 18: Time between removal of catheter to discharge

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Comparison 2: Shorter versus longer duration of catheter, Outcome 1: Number needing to be recatheterised

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Analysis 2.1

Comparison 2: Shorter versus longer duration of catheter, Outcome 1: Number needing to be recatheterised

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Comparison 2: Shorter versus longer duration of catheter, Outcome 2: Number needing to be recatheterised: subgroup analysis based on type of surgery

Figuras y tablas -
Analysis 2.2

Comparison 2: Shorter versus longer duration of catheter, Outcome 2: Number needing to be recatheterised: subgroup analysis based on type of surgery

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Comparison 2: Shorter versus longer duration of catheter, Outcome 3: Number needing to be recatheterised: subgroup analysis based on sex

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Analysis 2.3

Comparison 2: Shorter versus longer duration of catheter, Outcome 3: Number needing to be recatheterised: subgroup analysis based on sex

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Comparison 2: Shorter versus longer duration of catheter, Outcome 4: Number needing to be recatheterised: subgroup analysis based on antibiotic prophylaxis

Figuras y tablas -
Analysis 2.4

Comparison 2: Shorter versus longer duration of catheter, Outcome 4: Number needing to be recatheterised: subgroup analysis based on antibiotic prophylaxis

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Comparison 2: Shorter versus longer duration of catheter, Outcome 5: Symptomatic catheter‐associated urinary tract infection (number of participants)

Figuras y tablas -
Analysis 2.5

Comparison 2: Shorter versus longer duration of catheter, Outcome 5: Symptomatic catheter‐associated urinary tract infection (number of participants)

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Comparison 2: Shorter versus longer duration of catheter, Outcome 6: Symptomatic catheter‐associated urinary tract infection: post‐hoc subgroup analysis by antibiotic prophylaxis

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Analysis 2.6

Comparison 2: Shorter versus longer duration of catheter, Outcome 6: Symptomatic catheter‐associated urinary tract infection: post‐hoc subgroup analysis by antibiotic prophylaxis

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Comparison 2: Shorter versus longer duration of catheter, Outcome 7: Asymptomatic bacteruria (number of participants)

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Analysis 2.7

Comparison 2: Shorter versus longer duration of catheter, Outcome 7: Asymptomatic bacteruria (number of participants)

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Comparison 2: Shorter versus longer duration of catheter, Outcome 8: Incidence of urinary retention

Figuras y tablas -
Analysis 2.8

Comparison 2: Shorter versus longer duration of catheter, Outcome 8: Incidence of urinary retention

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Comparison 2: Shorter versus longer duration of catheter, Outcome 9: Delayed voiding after catheter removal

Figuras y tablas -
Analysis 2.9

Comparison 2: Shorter versus longer duration of catheter, Outcome 9: Delayed voiding after catheter removal

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Comparison 2: Shorter versus longer duration of catheter, Outcome 10: Chronic urinary retention

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Analysis 2.10

Comparison 2: Shorter versus longer duration of catheter, Outcome 10: Chronic urinary retention

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Comparison 2: Shorter versus longer duration of catheter, Outcome 11: Other complications of catheterisation: fever

Figuras y tablas -
Analysis 2.11

Comparison 2: Shorter versus longer duration of catheter, Outcome 11: Other complications of catheterisation: fever

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Comparison 2: Shorter versus longer duration of catheter, Outcome 12: Other complications of catheterisation: epididymitis

Figuras y tablas -
Analysis 2.12

Comparison 2: Shorter versus longer duration of catheter, Outcome 12: Other complications of catheterisation: epididymitis

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Comparison 2: Shorter versus longer duration of catheter, Outcome 13: Pain or discomfort (dichotomous)

Figuras y tablas -
Analysis 2.13

Comparison 2: Shorter versus longer duration of catheter, Outcome 13: Pain or discomfort (dichotomous)

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Comparison 2: Shorter versus longer duration of catheter, Outcome 14: Pain or discomfort: 0‐10 VAS (higher score = greater pain)

Figuras y tablas -
Analysis 2.14

Comparison 2: Shorter versus longer duration of catheter, Outcome 14: Pain or discomfort: 0‐10 VAS (higher score = greater pain)

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Comparison 2: Shorter versus longer duration of catheter, Outcome 15: Patient satisfaction

Figuras y tablas -
Analysis 2.15

Comparison 2: Shorter versus longer duration of catheter, Outcome 15: Patient satisfaction

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Comparison 2: Shorter versus longer duration of catheter, Outcome 16: Urinary incontinence 

Figuras y tablas -
Analysis 2.16

Comparison 2: Shorter versus longer duration of catheter, Outcome 16: Urinary incontinence 

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Comparison 2: Shorter versus longer duration of catheter, Outcome 17: Dysuria

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Analysis 2.17

Comparison 2: Shorter versus longer duration of catheter, Outcome 17: Dysuria

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Comparison 2: Shorter versus longer duration of catheter, Outcome 18: Volume of first void (mL)

Figuras y tablas -
Analysis 2.18

Comparison 2: Shorter versus longer duration of catheter, Outcome 18: Volume of first void (mL)

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Comparison 2: Shorter versus longer duration of catheter, Outcome 19: Time to first void (hours)

Figuras y tablas -
Analysis 2.19

Comparison 2: Shorter versus longer duration of catheter, Outcome 19: Time to first void (hours)

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Comparison 2: Shorter versus longer duration of catheter, Outcome 20: Post‐void residual volume (mL)

Figuras y tablas -
Analysis 2.20

Comparison 2: Shorter versus longer duration of catheter, Outcome 20: Post‐void residual volume (mL)

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Post‐void residual volume (median and range) (mL)

Study

Outcome

IUC for 2 days

IUC for 10 days

Nguyen 2012

Median (range) post‐void residual volume (mls)

Pre‐op: 100 (20 ‐ 400)

3 months post‐op: 35 (30 ‐ 200)

Pre‐op: 50 (0 ‐ 180)

3 months post‐op: 20 (0 ‐ 180)

6 months post‐op: 20 (0 ‐ 65)

12 months post‐op: 30 (0 ‐ 100)

Figuras y tablas -
Analysis 2.21

Comparison 2: Shorter versus longer duration of catheter, Outcome 21: Post‐void residual volume (median and range) (mL)

Ir a la figura de la revisión

Comparison 2: Shorter versus longer duration of catheter, Outcome 22: Length of hospitalisation in days

Figuras y tablas -
Analysis 2.22

Comparison 2: Shorter versus longer duration of catheter, Outcome 22: Length of hospitalisation in days

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Comparison 2: Shorter versus longer duration of catheter, Outcome 23: Length of hospitalisation in days: subgrouping based on type of surgery

Figuras y tablas -
Analysis 2.23

Comparison 2: Shorter versus longer duration of catheter, Outcome 23: Length of hospitalisation in days: subgrouping based on type of surgery

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Length of hospitalisation in days (median and range)

Study

Early Removal; median and range

Later Removal; median and range

Allen 2016

5 (4‐42)

5 (3‐24)

Alonzo‐Sosa 1997

2 (range not reported)

3 (range not reported)

Lista 2020

4 (3‐7)

6 (4‐8)

Sandberg 2019

1.5 (0‐4)

1 (1‐4)

Weemhoff 2011

3 (2‐42)

5 (1‐59)

Zaouter 2009

7 (5‐11)

9 (6‐14)

Figuras y tablas -
Analysis 2.24

Comparison 2: Shorter versus longer duration of catheter, Outcome 24: Length of hospitalisation in days (median and range)

Ir a la figura de la revisión

Comparison 2: Shorter versus longer duration of catheter, Outcome 25: Frequency of micturition

Figuras y tablas -
Analysis 2.25

Comparison 2: Shorter versus longer duration of catheter, Outcome 25: Frequency of micturition

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Comparison 2: Shorter versus longer duration of catheter, Outcome 26: Time to first ambulation (hours)

Figuras y tablas -
Analysis 2.26

Comparison 2: Shorter versus longer duration of catheter, Outcome 26: Time to first ambulation (hours)

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Comparison 3: Clamping versus free drainage, Outcome 1: Number needing to be recatheterised

Figuras y tablas -
Analysis 3.1

Comparison 3: Clamping versus free drainage, Outcome 1: Number needing to be recatheterised

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Comparison 3: Clamping versus free drainage, Outcome 2: Number needing to be recatheterised: subgroup analysis based on type of surgery and sex

Figuras y tablas -
Analysis 3.2

Comparison 3: Clamping versus free drainage, Outcome 2: Number needing to be recatheterised: subgroup analysis based on type of surgery and sex

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Comparison 3: Clamping versus free drainage, Outcome 3: Symptomatic catheter‐associated urinary tract infection (number of participants)

Figuras y tablas -
Analysis 3.3

Comparison 3: Clamping versus free drainage, Outcome 3: Symptomatic catheter‐associated urinary tract infection (number of participants)

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Comparison 3: Clamping versus free drainage, Outcome 4: Incidence of urinary retention (number of participants)

Figuras y tablas -
Analysis 3.4

Comparison 3: Clamping versus free drainage, Outcome 4: Incidence of urinary retention (number of participants)

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Comparison 3: Clamping versus free drainage, Outcome 5: Dysuria (number of participants)

Figuras y tablas -
Analysis 3.5

Comparison 3: Clamping versus free drainage, Outcome 5: Dysuria (number of participants)

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Comparison 3: Clamping versus free drainage, Outcome 6: Volume of first void (mL)

Figuras y tablas -
Analysis 3.6

Comparison 3: Clamping versus free drainage, Outcome 6: Volume of first void (mL)

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Comparison 3: Clamping versus free drainage, Outcome 7: Time to first void (minutes)

Figuras y tablas -
Analysis 3.7

Comparison 3: Clamping versus free drainage, Outcome 7: Time to first void (minutes)

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Length of hospitalisation (median days)

Study

Catheter Removal at 72 hours without bladder re‐training (median)

Catheter Removal at 72 hours with bladder re‐training i.e. clamping (median)

Guzman 1994

6.9

6.9

Figuras y tablas -
Analysis 3.8

Comparison 3: Clamping versus free drainage, Outcome 8: Length of hospitalisation (median days)

Ir a la figura de la revisión

Comparison 3: Clamping versus free drainage, Outcome 9: Length of hospitalisation (days)

Figuras y tablas -
Analysis 3.9

Comparison 3: Clamping versus free drainage, Outcome 9: Length of hospitalisation (days)

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Time required to return to normal bladder function (hours)

Study

Clamping

Free Drainage

Nyman 2010

6 (4‐8); median (quartiles)

4 (3‐7.25); median (quartiles)

Figuras y tablas -
Analysis 3.10

Comparison 3: Clamping versus free drainage, Outcome 10: Time required to return to normal bladder function (hours)

Ir a la figura de la revisión

Comparison 4: Prophylactic use of alpha blocker versus no drug or intervention, Outcome 1: Number of participants needing to be recatheterised

Figuras y tablas -
Analysis 4.1

Comparison 4: Prophylactic use of alpha blocker versus no drug or intervention, Outcome 1: Number of participants needing to be recatheterised

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Comparison 4: Prophylactic use of alpha blocker versus no drug or intervention, Outcome 2: Symptomatic catheter‐associated urinary tract infection (number of participants)

Figuras y tablas -
Analysis 4.2

Comparison 4: Prophylactic use of alpha blocker versus no drug or intervention, Outcome 2: Symptomatic catheter‐associated urinary tract infection (number of participants)

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Comparison 4: Prophylactic use of alpha blocker versus no drug or intervention, Outcome 3: Incidence of urinary retention (number of participants)

Figuras y tablas -
Analysis 4.3

Comparison 4: Prophylactic use of alpha blocker versus no drug or intervention, Outcome 3: Incidence of urinary retention (number of participants)

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Comparison 4: Prophylactic use of alpha blocker versus no drug or intervention, Outcome 4: Post‐void residual volume

Figuras y tablas -
Analysis 4.4

Comparison 4: Prophylactic use of alpha blocker versus no drug or intervention, Outcome 4: Post‐void residual volume

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Comparison 4: Prophylactic use of alpha blocker versus no drug or intervention, Outcome 5: Length of hospitalisation in days

Figuras y tablas -
Analysis 4.5

Comparison 4: Prophylactic use of alpha blocker versus no drug or intervention, Outcome 5: Length of hospitalisation in days

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Length of hospitalisation in days (median, range, N)

Study

Alpha Blocker

No Intervention

Jang 2012

9, (7.0‐12.0), 47

9, (8.0‐11.0), 47

Figuras y tablas -
Analysis 4.6

Comparison 4: Prophylactic use of alpha blocker versus no drug or intervention, Outcome 6: Length of hospitalisation in days (median, range, N)

Ir a la figura de la revisión
Summary of findings 1. Removal of short‐term indwelling urethral catheters in adults at one time of day (6 am to 7 am) versus another time of day (10 pm to midnight)

Removal of short‐term indwelling urethral catheters in adults at one time of day (6 am to 7 am) versus another time of day (10 pm to midnight)

Patient or population: adults with short‐term indwelling urethral catheters that need to be removed
Setting: secondary care
Intervention: removal of indwelling urethral catheters at 10 pm to midnight
Comparison: removal of indwelling urethral catheters at 6 am to 7am

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

№ of participants
(trials)

Certainty of the evidence
(GRADE)

Comments

Risk with removal of IUC at 6 am to 7 am

Risk with removal of IUC at 10 pm to midnight

Number of participants requiring recatheterisation

Trial population

RR 0.70
(0.52 to 0.94)

1920
(10 RCTs)

⊕⊕⊝⊝
Lowa

94 per 1000

66 per 1000
(50 to 90)

Symptomatic catheter‐associated urinary tract infection (CAUTI)

Trial population

RR 1.00
(0.61 to 1.63)

41
(1 RCT)

⊕⊝⊝⊝
Very lowb,c

611 per 1000

611 per 1000
(373 to 996)

Dysuria

Trial population

RR 2.20

(0.70 to 6.86)

170
(1 RCT)

⊕⊕⊝⊝
Lowc

48 per 1000

105 per 1000
(33 to 327)

Condition‐specific QoL or generic QoL measure

‐

‐

‐

‐

‐

Not reported

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: confidence interval; IUC: indwelling urethral catheter; QoL: quality of life; RCT: randomised controlled trial; RR: risk ratio

GRADE Working Group grades of evidence
High certainty: we are very confident that the true effect lies close to that of the estimate of the effect.
Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.
Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.

aDowngraded two levels for risk of bias (random sequence generation, allocation concealment and blinding of outcome assessors are all unclear).
bDowngraded one level for risk of bias (random sequence generation and blinding of outcome assessors are unclear).
cDowngraded two levels for imprecision: few participants and 95% confidence interval is consistent with possible benefit and possible harm.

Figuras y tablas -
Summary of findings 1. Removal of short‐term indwelling urethral catheters in adults at one time of day (6 am to 7 am) versus another time of day (10 pm to midnight)
Ir a la tabla de la revisión
Summary of findings 2. Removal of short‐term indwelling urethral catheters in adults after shorter versus longer durations

Removal of short‐term indwelling urethral catheters in adults after shorter versus longer durations

Patient or population: adults with short‐term indwelling urethral catheters that need to be removed
Setting: secondary care
Intervention: shorter durations of IUC
Comparison: longer durations of IUC

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

№ of participants
(trials)

Certainty of the evidence
(GRADE)

Comments

Risk with longer durations of catheterisation

Risk with shorter durations of catheterisation

Number of participants requiring recatheterisation

Trial population

RR 1.81
(1.35 to 2.41)

5870
(44 RCTs)

⊕⊕⊝⊝
Lowa,b

 

75 per 1000

136 per 1000
(102 to 182)

Symptomatic catheter associated urinary tract infection (CAUTI)

 

Trial population

RR 0.52
(0.45 to 0.61)

5759
(41 RCTs)

⊕⊕⊕⊝
Moderatea

 

126 per 1000

66 per 1000
(57 to 77)

Dysuria

Trial population

RR 0.42
(0.20 to 0.88)

1398
(7 RCTs)

⊕⊕⊝⊝
Lowa,b

 

118 per 1000

50 per 1000
(24 to 104)

Condition‐specific QoL or generic QoL measure

‐

‐

‐

‐

‐

Not reported

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: confidence interval; IUC: indwelling urethral catheter; QoL: quality of life; RCT: randomised controlled trial; RR: risk ratio

GRADE Working Group grades of evidence
High certainty: we are very confident that the true effect lies close to that of the estimate of the effect.
Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.
Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.

aDowngraded one level for risk of bias (unclear risk of selection bias and detection bias).
bDowngraded one level for inconsistency (heterogeneity in direction and size of effect).

Figuras y tablas -
Summary of findings 2. Removal of short‐term indwelling urethral catheters in adults after shorter versus longer durations
Ir a la tabla de la revisión
Summary of findings 3. Removal of short‐term indwelling urethral catheters in adults: clamping compared to free drainage

Removal of short‐term indwelling urethral catheters in adults: clamping compared to free drainage

Patient or population: adults with short‐term indwelling urethral catheters that need to be removed
Settings: secondary care

Intervention: clamping of indwelling urethral catheter
Comparison: free drainage of indwelling urethral catheter

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

№ of participants
(trials)

Certainty of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Risk with free drainage

Risk with clamping regimes

Number of participants requiring recatheterisation

Trial population

RR 0.82
(0.55 to 1.21)

569
(5 RCTs)

⊕⊕⊝⊝
Lowa,b

160 per 1000

131 per 1000
(88 to 193)

Symptomatic catheter associated urinary tract infection (CAUTI)

Trial population

RR 0.99
(0.60 to 1.63)

267
(2 RCTs)

⊕⊝⊝⊝
Very lowc,d

195 per 1000

193 per 1000

(117 to 318)

Dysuria

Trial population

RR 0.84
(0.46 to 1.54)

79
(1 RCT)

⊕⊝⊝⊝
Very lowd,e

385 per 1000

323 per 1000

(177 to 592)

Condition‐specific QoL or generic QoL measure

‐

‐

‐

‐

‐

Not reported

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: confidence interval; IUC: indwelling urethral catheter; QoL: quality of life; RCT: randomised controlled trial; RR: risk ratio

GRADE Working Group grades of evidence
High certainty: we are very confident that the true effect lies close to that of the estimate of the effect.
Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.
Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.

aDowngraded one level for risk of bias (unclear random sequence generation, allocation concealment and blinding of outcome assessors).
bDowngraded one level for imprecision (95% CI is consistent with possible benefit and possible harm).
cDowngraded one level for risk of bias (unclear random sequence generation and high risk due to lack of blinding of outcome assessors.
dDowngraded two levels for imprecision (few participants and 95% CI is consistent with possible benefit and possible harm).
eDowngraded one level for risk of bias (high risk for randomisation and allocation concealment).

Figuras y tablas -
Summary of findings 3. Removal of short‐term indwelling urethral catheters in adults: clamping compared to free drainage
Ir a la tabla de la revisión
Summary of findings 4. Removal of short‐term indwelling urethral catheters in adults: prophylactic use of alpha blocker versus no drug or intervention

Removal of short‐term indwelling urethral catheters in adults: prophylactic use of alpha blocker versus no drug or intervention

Patient or population: adults with short‐term indwelling urethral catheters that need to be removed
Settings: secondary care

Intervention: prophylactic use of alpha blocker
Comparison: no drug or intervention

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

№ of participants
(trials)

Certainty of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Risk with no alpha blocker

Risk with prophylactic alpha blocker

Number of participants requiring recatheterisation

Trial population

RR 1.18
(0.58 to 2.42)

184
(2 RCTs)

⊕⊝⊝⊝
Very lowa,b

120 per 1000

141 per 1000
(69 to 289)

Symptomatic catheter associated urinary tract infection

Trial population

RR 0.20

(0.01 to 4.06)

94
(1 RCT)

⊕⊝⊝⊝
Very lowa,b

43 per 1000

9 per 1000

(0 to 173)

Dysuria

‐

‐

‐

‐

‐

Not reported

Condition‐specific QoL or generic QoL measure

‐

‐

‐

‐

‐

Not reported

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: confidence interval; IUC: indwelling urethral catheter; QoL: quality of life; RCT: randomised controlled trial; RR: risk ratio

GRADE Working Group grades of evidence
High certainty: we are very confident that the true effect lies close to that of the estimate of the effect.
Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.
Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.

aDowngraded one level for risk of bias (unclear random sequence generation, allocation concealment and blinding of outcome assessors).
bDowngraded two levels for imprecision: few participants and wide 95% confidence interval that is consistent with possible benefit and possible harm.

Figuras y tablas -
Summary of findings 4. Removal of short‐term indwelling urethral catheters in adults: prophylactic use of alpha blocker versus no drug or intervention
Ir a la tabla de la revisión
Table 1. Types of participants

Trial ID

Reason for hospitalisation

Type of surgery/reason for being admitted

Gender

Ahmed 2014

Elective gynaecological surgery

Total abdominal hysterectomy with or without bilateral salpingo‐oophorectomy

Female

Alessandri 2006

Elective gynaecological surgery

Vaginal hysterectomy

Female

Allen 2016

Patients undergoing cardiothoracic surgery

General thoracic surgical procedure, in whom an epidural catheter was placed for analgesia

Mixed

Alonzo‐Sosa 1997

Elective gynaecological surgery

Anterior colporrhapy, anterior and posterior colporrhaphy with or without vaginal hysterectomy

Female

Aref 2020

Elective CS

Participants admitted for elective CS

Female

Aslam 2019

Elective gynaecological surgery

Participants undergoing minimally invasive pelvic organ prolapse surgery

Female

Azarkish 2003

Elective CS

Participants admitted for elective CS

Female

Azarkish 2005

Emergency CS

Participants admitted for emergency CS

Female

Barone 2015

Elective gynaecological surgery

Participants admitted for vaginal fistula repair

Female

Basbug 2020

Elective CS

Participants admitted for elective CS

Female

Benoist 1999

Elective GI surgery

Extensive rectal resection (total or subtotal proctectomy)

Mixed

Bristoll 1989

Not reported

Not reported

Unknown

Carpiniello 1988

Elective orthopaedic surgery

Total joint replacement (hip or knee)

Female

Carter‐Brooks 2018

Elective gynaecological surgery

Participants undergoing pelvic organ prolapse surgery

Female

Chai 2011

Elective gynaecological surgery

Total abdominal hysterectomy with or bilateral salpingo‐oophorectomy for various benign gynaecological diseases

Female

Chen 2013

Admitted to ICU

Patients requiring mechanical ventilation for respiratory failure

Mixed

Chia 2009

Elective cardiothoracic surgery

Thoracotomy

Mixed

Chillington 1992

Elective urological surgery

TURP

Male

Cornia 2003

Admitted to medicine and cardiology services

Patients admitted to the medicine and cardiology services

Mixed

Coyle 2015

Elective GI surgery

Elective transabdominal colectomy, proctectomy or coloproctectomy

Mixed

Crowe 1993

Admitted to urology ward

Patients admitted to the urology ward with IUCs or who were catheterised during their inpatient stay

Mixed

Dunn 1999

Elective obstetric and gynaecological surgery

Patients undergoing elective obstetric or gynaecological surgery

Female

Dunn 2000b

Elective gynaecological surgery or CS

Patients undergoing hysterectomy or CS who do not require bladder suspension or strict fluid management

Female

Dunn 2003

Elective gynaecological surgery

Women undergoing hysterectomy for various benign diseases (e.g. fibroid tumours, abnormal uterine bleeding, chronic pain, and persistent cervical dysplasia or micro invasive cancer

Female

Durrani 2014

Elective urological surgery

Patients with bladder outflow obstruction due to benign prostatic enlargement undergoing TURP

Male

El‐Mazny 2014

Primary or elective CS

Patients admitted to the prenatal wards for primary or repeat elective CS

Female

Ganta 2005

Elective urological surgery

TURP

Male

Glavind 2007

Elective gynaecological surgery

Patients undergoing any type of vaginal prolapse surgery

Female

Gong 2017

Elective gynaecological surgery

Patients undergoing radical hysterectomy for cervical cancer FIGO stage IB‐IIB

Female

Gross 2007

Admitted to stroke ward

Patients with a stroke admitted to the ward

Mixed

Gungor 2014

Elective gynaecological surgery

Patients with pelvic organ prolapse and/or urinary incontinence undergoing anterior colporrhaphy

Female

Guzman 1994

Elective gynaecological surgery

Patients undergoing vaginal surgery

Female

Hakvoort 2004

Elective gynaecological surgery

Patients undergoing anterior colporrhaphy for vaginal prolapse surgery

Female

Hall 1998

Elective general surgery

Patients admitted to the general surgery wards

Mixed

Han 1997

Elective urological surgery

Patients with benign prostatic enlargement undergoing TURP

Male

Hewitt 2001

Elective urological surgery

Patients requiring radical perineal prostatectomy

Male

Huang 2011

Elective gynaecological surgery

Patients with cystocele of at least stage II, who were symptomatic and desired operative treatment with anterior vaginal repair with or without other concomitant pelvic surgeries

Female

Ind 1993

Elective hysterectomy, posterior exenteration, colposuspension, anterior colporrhaphy, total/radical vulvectomy, radical oophorectomy, ovarian cystectomy, adhesiolysis myomectomy

Patients which were admitted for any of the following operations: hysterectomy, posterior exenteration, colposuspension, anterior colporrhaphy, total/radical vulvectomy, radical oophorectomy, ovarian cystectomy, adhesiolysis myomectomy

Female

Irani 1995

Elective transurethral prostatic surgery

Patients admitted for transurethral prostatic surgery due to benign hyperplasia

Male

Iversen Hansen 1984

Urethral strictures

Patients with urethral strictures

Not reported

Jang 2012

Surgery for rectal cancer

Patients undergoing elective rectal surgery for cancer

Mixed

Jeong 2014

Robot‐assisted laparoscopic radical prostatectomy

Patients with localised or advanced prostate cancer

Men

Joshi 2014

Elective hysterectomy with salpingo‐oophorectomy

Patients undergoing uneventful hysterectomy with salpingo‐oophorectomy

Female

Jun 2011

Elective TURP

Patients admitted for TURP

Male

Kamilya 2010

Vaginal prolapse surgery

Patients undergoing vaginal prolapse surgery

Female

Kelleher 2002

Urological surgery

Patients admitted to urology or renal unit

Not reported

Kim 2012

Radical prostatectomy

Patients undergoing extraperitoneal laparoscopic radical prostatectomy

Men

Koh 1994

Elective TURP

Patients admitted for TURP

Men

Kokabi 2009

Anterior colporrhaphy for pelvic organ prolapse

Patients undergoing anterior colporrhaphy due to pelvic organ prolapse and stress incontinence

Female

Lang 2020

Elective gynaecological surgery

Patients admitted for elective benign gynaecological surgery

Female

Lau 2004

Elective general surgery

Patients admitted for elective general surgery

Mixed

Li 2014

Elective TURP

Patients admitted for TURP

Men

Liang 2009

Laparoscopic vaginal hysterectomy

Patients admitted for laparoscopic vaginal hysterectomy

Female

Lista 2020

Elective urological surgery

Patients admitted for robot‐assisted radical prostatectomy for localised prostate cancer

Male

Liu 2015

Neurosurgery

Patients undergoing neurosurgery

Mixed

Lyth 1997

TURP or bladder neck incision

Patients undergoing TURP or bladder neck incision

Unclear

Mao 1994

Elective gynaecological surgery

Patients undergoing surgery for total hysterectomy or salpingo‐oophorectomy

Female

Matsushima 2015

Surgery for prostate cancer removal (unclear what operation was done)

Patients with prostate cancer

Male

McDonald 1999

TURP

Patients undergoing TURP

Male

Naguimbing‐Cuaresma 2007

Elective CS

Participants admitted for elective CS

Female

Nathan 2001

Elective gynaecological surgery

Patients undergoing surgery for benign gynaecological conditions

Female

Nguyen 2012

Elective urological surgery for urethral strictures

Patients undergoing surgery for urethral strictures

Unclear

Nielson 1985

Elective urological surgery for urethral strictures

Patients undergoing surgery for urethral strictures

Unclear

Noble 1990

Elective urological surgery and procedures

Patients admitted to the urological unit

Mixed

Nyman 2010

Orthopaedic surgery

Patients admitted with hip fractures in need of surgery

Mixed

Oberst 1981

Elective general surgery

Patients undergoing surgery for bowel cancer; low anterior bowel resection or abdominoperineal resection

Mixed

Onile 2008

Elective CS

Patients admitted for elective CS

Female

Ouladsahebmadarek 2012

Elective gynaecological surgery

Patienst admitted for elective abdominal hysterectomy or laparotomy for being pathology (fibroma, AUB, chronic pelvic pain, ovarian cysts etc.)

Female

Pervaiz 2019

Elective urological surgery

Patients undergoing TURP

Male

Popiel 2017

Elective gynaecological surgery

Patients undergoing robotic sacrocolpopexy for vaginal prolapse

Female

Rajan 2017

Elective gynaecological surgery

Patients undergoing surgery for Ward Mayo operation; Manchester repair; vaginal hysterectomy and amputation of cervix

Female

Ruminjo 2015

Elective gynaecological surgery

Patients undergoing fistula repair surgery

Female

Sahin 2011

Elective urological surgery

Patients admitted for TURP due to benign prostate hypertrophy

Male

Sandberg 2019

Elective gynaecological surgery

Patients undergoing laparoscopic hysterectomy

Female

Schiotz 1995

Elective gynaecological surgery

Patients admitted for vaginal plastic surgery (anterior colporrhaphy, anterior plus posterior colporrhaphy or a full Manchester repair)

Female

Schiotz 1996

Elective urogynaecological surgery

Patients admitted for elective retro‐pubic surgery for stress incontinence

Female

Sekhavat 2008

Elective gynaecological surgery

Patients undergoing anterior colporrhaphy

Female

Shahnaz 2016

Elective gynaecological surgery

Patients undergoing surgery for pelvic organ prolapse

Female

Shrestha 2013

Elective gynaecological surgery

Patients admitted for vaginal hysterectomy, anterior colporrhaphy or Manchester operations

Female

Souto 2004

Elective urological surgery

Patients admitted for retropubic radical prostatectomy

Male

Sun 2004

Elective urogynaecological surgery

Patients admitted for Burch's colposuspension

Female

Tahmin 2011

Elective gynaecological surgery

Patients with genital prolapses admitted for vaginal hysterectomy and or pelvic floor repair

Female

Talreja 2016

Elective urological surgery

Patients with benign prostatic enlargement undergoing TURP

Male

Taube 1989

AUR

Patients admitted to the hospital with AUR

Male

Toscano 2001

Elective urological surgery

Patients with benign prostatic enlargement undergoing TURP

Male

Valero Puerta 1998

Elective urological surgery

Patients with benign prostatic enlargement undergoing TURP

Male

Vallabh‐Patel 2020

Elective gynaecological surgery

Patients undergoing robotic sacrocolpopexy for pelvic organ prolapse

Female

Webster 2006

General surgery and medical patients

Patients who required IUC on general surgery and medical wards

Mixed

Weemhoff 2011

Elective gynaecological surgery

Patients admitted for anterior colporrhaphy

Female

Williamson 1982

Elective surgery (unspecific)

Patients undergoing surgery (not specified by trial)

Female

Wilson 2000

Elective urological surgery

Patients with benign prostatic enlargement undergoing TURP

Male

Wu 2015

Elective gallbladder or biliary tree surgery

Pateints undergoing gallbladder or biliary tree surgery

Mixed

Wyman 1987

Elective urological surgery

Patients with benign prostatic enlargement undergoing TURP

Male

Yaghmaei 2017

Elective CS

Patients who underwent CS

Female

Yee 2015

Elective CS

Patients who underwent CS under spinal anaesthesia

Female

Zaouter 2009

Elective major abdominal and thoracic surgery

Patients admitted for elective major abdominal and thoracic surgery

Mixed

Zhou 2012

Elective CS

Patients who underwent CS

Female

Zmora 2010

Elective colon and rectal surgery with pelvic dissection

Patients admitted for elective colon and rectal surgery

Mixed

Zomorrodi 2018

Elective renal transplant surgery

Patients with end‐stage renal failure undergoing renal transplant surgery

Mixed

AUB: abnormal uterine bleeding; AUR: acute urinary retention; CS: cesarean section; GI: gastrointestinal; FIGO: International Federation of Gynecology and Obstetrics; ICU: intensive care unit; IUC: indwelling urethral catheter; TURP: transurethral resection of the prostate

Figuras y tablas -
Table 1. Types of participants
Ir a la tabla de la revisión
Table 2. Interventions and age of participants

TrialID

InterventionA

Intervention B

Age (A), years

Mean (SD)

Age (B), years

Mean (SD)

Age (overall), years

Ahmed 2014

IUC removal immediately post‐op

IUC removal 24 h post‐op

59.1(8.3) 

61.3 (10.5)

Not reported

Alessandri 2006

IUC removal immediately post‐op

IUC removal 12 h post‐op

51 (4.3)

47 (5)

Not reported

Allen 2016

IUC removed within 48 h post‐op

IUC removed within 6 h after epidural removal

61.1 (range 31–85)

61.7 (range 21–87)

61.5 (range 21‐87)

Alonzo‐Sosa 1997

IUC removal 1 day post‐op

IUC removal 3 days post‐op

53.5 (range 37‐63)

47.1 (range 37‐67)

Not reported

Aref 2020

IUC removal 6 h post‐op

IUC removal 24 h post‐op

25.3 (2)

25.6 (3)

Not reported

Aslam 2019

IUC removal immediately post‐op

IUC removal 1‐day post‐op

Not reported

Not reported

Not reported

Azarkish 2003

IUC removal 2‐3 h after surgery

IUC removal the morning after surgery

24.96 (4.88)

27.06 (5.56)

Not reported

Azarkish 2005

IUC removal 2‐3 h after surgery

IUC removal 24 h after surgery

Not reported

Not reported

Not reported

Barone 2015

IUC removal 7 days after surgery

IUC removal 14 days after surgery

31.9 (11.5)

30.6

(11.7)

Not reported

Basbug 2020

IUC removal 2 h after surgery

IUC removal 12 h after surgery

30.13 (5.83)

29.96 (4.71)

Not reported

Benoist 1999

IUC removal 1 day post‐op

IUC removal 5 days post‐op

55 (18)

56 (17)

Not reported

Bristoll 1989

threshold clamping

complete drainage

Not reported

Not reported

Not reported

Carpiniello 1988

IUC removal immediately post‐op

IUC removal 1‐day post‐op

73 (6.6)

70 (8.6)

Not reported

Carter‐Brooks 2018

IUC removal 4 h after surgery

IUC removal 6 am on post‐op day 1

64.9 (11.5)

65.2 (10.3)

Not reported

Chai 2011

IUC removal immediately post‐op

IUC removal 1 day post‐op

46.4 (3.9)

46.4 (4.0)

Not reported

Chen 2013

IUC removal ≤ 7 days

IUC removal > 7 days

77 (12.7)

78 (10.5)

Not reported

Chia 2009

IUC removal 1 day post‐op

IUC removal 3 days post‐op

54.7 (11.2)

55.7 (10.3)

Not reported

Chillington 1992

IUC removal at midnight

IUC removal at 6 am the next morning

Not reported

Not reported

Not reported

Cornia 2003

A computer study order was used to remind staff to remove the IUC after 3 days

A computer study order was not used to remind staff to remove the IUC after 3 days

Not reported

Not reported

Not reported

Coyle 2015

IUC removal 2 days post‐op

IUC removal within 12 h of withdrawal of epidural anaesthesia

63.5 (SD not reported)

62 (SD not reported)

Not reported

Crowe 1993

IUC removal at 6 am

IUC removal at midnight

Not reported

Not reported

Not reported

Dunn 1999

IUC removal immediately post‐op

Delayed IUC removal post‐op

Not reported

Not reported

Not reported

Dunn 2000b

IUC removal immediately post‐op

IUC removal 1 day post‐op

Not reported

Not reported

Not reported

Dunn 2003

IUC removal immediately post‐op

IUC removal 1 day post‐op

Not reported

Not reported

Not reported

Durrani 2014

IUC removal 1 day post‐op

IUC removal 4 or 5 days post‐op

Not reported

Not reported

71.32 (5.94)

El‐Mazny 2014

IUC removal immediately post‐op

IUC removal 12 h post‐op

24.5 (4.2)

23.8 (3.9)

Not Reported

Ganta 2005

IUC removal at midnight

IUC removal at 6 am

69.9 (SD not reported)

68.2 (SD not reported)

68.9 (SD not reported)

Glavind 2007

IUC removal 3 h post‐op

IUC removal the next morning

Not reported

Not reported

61 (range 31‐88)

Gong 2017

IUC for 48 h with intermittent clamping

IUC for 48 h without intermittent clamping

46.14 (8.33)

45.70 (9.63)

Not Reported

Gross 2007

IUC removal at 10 pm the day the order for removal was written

IUC removal at 7 am the day after the order for removal was written

Not reported

Not reported

70.3 (11.7)

Gungor 2014

IUC removal 2 days post‐op

IUC removal 3 or 4 days post‐op

55.7 (8.8)

3 days: 58.5 (10.1)

4 days: 55.8 (9.0)

Not reported

Guzman 1994

IUC removal 1 day post‐op

IUC removal 3 days post‐op (with and without bladder‐clamping)

56 (range 40‐75)

No clamping: 58 (range 8‐79)

Clamping: 57 (range 36‐75)

Not reported

Hakvoort 2004

IUC removal on the morning after surgery

IUC removal 5 days post‐op

67 (range 36 ‐ 86)

66 (range 33‐87)

Not reported

Hall 1998

IUC removal between 7 am and 9 am

IUC removal between 9 pm and 11 pm

Not reported

Not reported

Not reported

Han 1997

IUC removal 2 days post‐op

IUC removal ≥ 3 days post‐op

64.6 (range 50‐86)

68.2 (range 50‐90)

Not reported

Hewitt 2001

IUC removal 4‐6 days post‐op

IUC removal at 14 days post‐op

Not reported

Not reported

Not reported

Huang 2011

IUC removal 2 days post‐op

IUC removal 3 or 4 days post‐op

61.21, (10.17)

3 days: 63.93 (10.43)

4 days: 63.7 (12.5)

62.9 (10.93)

Ind 1993

IUC removal at 6 am

IUC removal at midnight

49.59 (14.2)

49.84 (16.6)

Not reported

Irani 1995

IUC removal within 48 h

IUC removal at surgeon's discretion

70.7 (range 42‐88)

70 (range 58‐85)

Not reported

Iversen Hansen 1984

IUC removal 1 day post‐op

IUC removal 14 days post‐op

Not reported

Not reported

70 (range 24‐85)

Jang 2012

No alpha blockers given

Prophylactic alpha blockers given

54 (range 48‐62)

59 (range 54‐66)

Not reported

Jeong 2014

Prophylactic alpha blockers given

No alpha blockers given

63.6 (6.6)

63.4 (8)

Not reported

Joshi 2014

IUC removal immediately post‐op

IUC removal 1 day post‐op

46.8 (6.9)

45.09 (6.44)

Not reported

Jun 2011

Prophylactic alpha blockers given

No alpha blockers given

68.71 (7.6)

71.4 (7.85)

Not reported

Kamilya 2010

IUC removal 1 day post‐op

IUC removal 4 days post‐op

46.9 (12.02)

47.9 (12.78)

Not reported

Kelleher 2002

IUC removal at 6 am

IUC removal at midnight

Not reported

Not reported

Not reported

Kim 2012

IUC removal on post‐op day 3/4

IUC removal on post‐op day 7/8

Not reported

Not reported

Not reported

Koh 1994

IUC removal 1 day post‐op

IUC removal 2 days post‐op

68.8, 7.3 (mean, SD)

73, 7.6 (mean, SD)

Not reported

Kokabi 2009

IUC removal 1 day post‐op

IUC removal 2 days post‐op OR 4 days post‐op (3‐arm trial)

Not reported

Not reported

Not reported

Lang 2020

IUC removal 4 h post‐op

IUC removal day 1 post‐op

Not reported

Not reported

44.4 (8.8)

Lau 2004

"In out" catheterisation

IUC overnight

Not reported

Not reported

63.3 (4.9)

Li 2014

IUC removal on day 1‐2 post‐op

IUC removal on day 5‐7 post‐op

Not reported

Not reported

Range 56 ‐ 92

Liang 2009

IUC removal immediately

IUC removal 1 day post‐op OR 2 days post‐op

(3‐arm trial)

43.7 (3.9)

B) 45.7 ( 3.5)

C) 45.7 ( 5.8)

Not reported

Lista 2020

IUC removal on day 3 post‐op

IUC removal on day 5 post‐op

63 (range 48 ‐ 75)

64 (range 45 – 75)

Not reported

Liu 2015

Clamping of IUC

No clamping of IUC i.e. free drainage

51 (13.2)

52 (16.4 SD)

Not reported

Lyth 1997

IUC removal at 6 am

IUC removal at midnight

Not reported

Not reported

Not reported

Mao 1994

IUC duration 7 am to 8 pm (same day)

IUC duration 7 am to 6 am (next day)

Not reported

Not reported

Not reported

Matsushima 2015

IUC removal 2 days post‐op

IUC removal 4 days post‐op

Not reported

Not reported

65.9 (5.5)

McDonald 1999

IUC removal at midnight

IUC removal at 6 am

66.7 (range 51‐81)

68.7 (range 57‐89)

67.8 (range 51‐89)

Naguimbing‐Cuaresma 2007

IUC removal 4 h post‐op

IUC removal day 1 post‐op

Not reported

Not reported

Not reported

Nathan 2001

IUC removal at 6 am

IUC removal at midnight

46.5 (5.6)

45.7 (5.4)

Not reported

Nguyen 2012

IUC removal 2 days post‐op

IUC removal 10 days post‐op

Not reported

Not reported

Not reported

Nielson 1985

IUC removal 3 days post‐op

IUC removal 28 days post‐op

64 (range 21‐81)

64 (range 16‐78)

Not reported

Noble 1990

IUC removal at 6 am

IUC removal at midnight

Not reported

Not reported

Not reported

Nyman 2010

Clamping of IUC

No clamping of IUC

79 (11)

80 (11.2)

Not reported

Oberst 1981

Clamping of IUC

No clamping of IUC

64.5 (10.26)

59 (11.92)

Not reported

Onile 2008

IUC removal 1 day post‐op

IUC removed immediately post‐op

31.67 (6.042)

32.72 (5.96)

Not reported

Ouladsahebmadarek 2012

IUC removed immediately post‐op

IUC removal 1 day post‐op

37.48 (8.85)

39.48 (9.54)

Not reported

Pervaiz 2019

IUC removal on day 1 post‐op

IUC removal on day 4 post‐op

67.00 (9.11)

65.56 (9.25)

Not reported

Popiel 2017

IUC removal within 6 h of operation completion

IUC removal on day 1 post‐op

Not reported

Not reported

Not reported

Rajan 2017

IUC removal within 3 h of operation completion

IUC removal on day 1 post‐op

50 (18)

48 (2.4)

Not reported

Ruminjo 2015

IUC removal on day 7 post‐op

IUC removal on day 14 post‐op

Not reported

Not reported

Not reported

Sahin 2011

IUC removal 1 day post‐op

IUC removal 2 days post‐op AND 3 days post‐op

(3‐arm trial)

 62.5 (SD not reported)

B: 61.5, C: 62 (SD not reported)

62 (range 48‐77)

Sandberg 2019

IUC removal immediately post‐op

IUC removal 18‐24 h post‐op

49.3 (10.5)

51.5 (11.9)

Not reported

Schiotz 1995

IUC removal 1 day post‐op

IUC removal 3 days post‐op

Not reported

Not reported

65.9 (range 29.9‐95.2)

Schiotz 1996

IUC removal 1 day post‐op

IUC removal 1 day post‐op

Not reported

Not reported

50.3 (range 26.9‐72.6)

Sekhavat 2008

IUC removed immediately post‐op

IUC removal 1 day post‐op

38.9 (2.9)

39 (3.8)

Not reported

Shahnaz 2016

IUC removal 24 h post‐op

IUC removal 72 h post‐op

39.4 (3.2)

38.8 (2.8)

Not reported

Shrestha 2013

IUC removal 1 day post‐op

IUC removal 3 days post‐op

Not reported

Not reported

53.35 (10.94)

Souto 2004

IUC removal 7 days post‐op

IUC removal 14 days post‐op

64 (7.3)

61 (7.3)

62 (range 50‐73)

Sun 2004

IUC removal on the next morning post‐op

IUC removal 5 days post‐op

46.7 (6.7)

48.3 (8.3)

Not reported

Tahmin 2011

IUC removal 2 days post‐op

IUC removal 5 days post‐op

51.75 (10.8)

53.95 (12.8)

Not reported

Talreja 2016

Clamping of IUC

No clamping of IUC i.e. free drainage

63.05 (4.69)

64.21 (5.36)

Not reported

Taube 1989

IUC removal immediately after emptying of bladder

IUC removal 1 day post‐op AND 2 days post‐op

(3‐arm trial)

Not reported

Not reported

Not reported

Toscano 2001

IUC removal 1 day post‐op

IUC removal 2 days post‐op

Not reported

Not reported

Not reported

Valero Puerta 1998

IUC removal on day 2 post‐op

IUC removal according to usual care

70 (range 53‐83)

69 (range 50‐87)

Not reported

Vallabh‐Patel 2020

IUC removal 6 h post‐op

IUC removal 1 day post‐op

59.52 (8.5)

59.57 (11.2)

Not reported

Webster 2006

IUC removal at 6 am

IUC removal at 10 pm

55.02 (19.97)

55.05 (18.99)

Not reported

Weemhoff 2011

IUC removal 2 days post‐op

IUC removal 5 days post‐op

59.9 (10.2)

60.7 (11.1)

Not reported

Williamson 1982

Clamping of IUC

No clamping of IUC i.e. free drainage

Not reported

Not reported

Range 22‐40

Wilson 2000

Bladder infusion with normal saline by gravity until bladder was full

IUC removal at 6 am

Not reported

Not reported

Not reported

Wu 2015

Catheter clamped when patient woke up post‐op. On Day 1 morning post‐op, when the patient felt urge to pass urine, the urinary catheter balloon was deflated and the catheter allowed to be self‐dislodged during urination

On the morning of Day1 post‐op, after the patient passed urine (through the catheter), saline was used to wash the bladder and the catheter clamped. 10 min after clamping, the balloon was deflated and the catheter allowed to be self‐dislodged during urination

45.6 (7.2)

46.1 (7)

Not reported

Wyman 1987

IUC removal between 6 am and 7 am

IUC removal between 10 pm and 11 pm

Not reported

Not reported

70.8 (range 50‐89)

Yaghmaei 2017

IUC removal 6 h post‐op

IUC removal 12‐24 h post‐op

28.19 (5.80)

28.01 (5.83)

Not reported

Yee 2015

IUC removal 8 h post‐op

IUC removal 1 day post‐op

Not reported

Not reported

Not reported

Zaouter 2009

IUC removal on the same morning as the surgery

IUC removal when the epidural anaesthesia was removed

57 (15)

63 (11)

Not reported

Zhou 2012

IUC removal 6‐8 h post‐op

IUC removal 24 h post‐op

25.11(4.88)

26.33 (5.08)

Not reported

Zmora 2010

IUC removal 1 day post‐op

IUC removal 3 days post‐op AND 5 days post‐op

(3‐arm trial)

57.4 (range 18‐85)

B: 54.6 (range 25‐81)

C: 54.2 (range 22‐78)

Not reported

Zomorrodi 2018

IUC removal 3 days post‐op

IUC removal 7 days post‐op

43.52 (13.6)

43.20 (14.39)

Not reported

IUC: indwelling urethral catheter

Figuras y tablas -
Table 2. Interventions and age of participants
Ir a la tabla de la revisión
Table 3. Use of antibiotic prophylaxis

TrialID

Comparison

Antibiotic prophylaxis used

Details

Ahmed 2014;

2

Yes

Prophylaxis was given to all patients on the morning of surgery in the form of 1 g of ceftriaxone IM

Alessandri 2006

2

Yes

Prophylaxis was given as a single dose before operation

Allen 2016

2

No

N/A

Alonzo‐Sosa 1997

2

No

N/A

Aref 2020

2

Yes

Single dose of prophylactic antibiotic in the form of ceftriaxone 1 g IM

Aslam 2019

2

Not reported

Not reported

Azarkish 2003

2

Not reported

Not reported

Azarkish 2005

2

Not reported

Perineum wash by povidone iodine 10% before catheter insertion

Barone 2015

2

No

N/A

Basbug 2020

2

Yes

All participants received 1 g IV cefazolin as prophylaxis

Benoist 1999

2

Yes

All participants received IV antibiotics as a single dose at the induction of anaesthesia

Bristoll 1989

3

Not reported

N/A

Carpiniello 1988

2

Yes

Prophylactic cefazolin sodium or clindamycin was given on post‐op day 3

Carter‐Brooks 2018

2

Not reported

N/A

Chai 2011

2

No

N/A

Chen 2013

2

No

Routine prophylaxis was not given. Antibiotics were only used in symptomatic participants.

Chia 2009

2

Yes

Single dose of prophylactic antibiotic was given IV in all participants

Chillington 1992

1

Not reported

Not reported

Cornia 2003

2

Not reported

Not reported

Coyle 2015

2

Not reported

Not reported

Crowe 1993

1

Not reported

Not reported

Dunn 1999

N/A

Not reported

Not reported

Dunn 2000b

N/A

Not reported

Not reported

Dunn 2003

2

Yes

Single dose of antibiotic prophylaxis before operation

Durrani 2014

2

Yes

Cephalosporin 1 g was administered IV at the time of induction of anaesthesia

El‐Mazny 2014

2

Yes

Cefazolin 2 g IV single dose 30 min before surgery

Ganta 2005

1

Not reported

Not reported

Glavind 2007

2

Yes

Participants who had vaginal hysterectomy or high uterosacral suspension received 1 pre‐op injection of cefuroxime. No antibiotic prophylaxis was used in the remaining participants.

Gong 2017

3

Not reported

Not reported

Gross 2007

1

Not reported

Not reported

Gungor 2014

2

Not reported

Not reported

Guzman 1994

2 and 3

Yes

All participants received Quemicetina as prophylaxis

Hakvoort 2004

2

Not reported

Not reported

Hall 1998

1

Not reported

Not reported

Han 1997

2

Not reported

Not reported

Hewitt 2001

2

Not reported

Not reported

Huang 2011

2

Yes

Ciprofloxacin used during all days of hospitalisation in all 3 groups

Ind 1993

1

Not reported

Not reported

Irani 1995

2

Yes

Antibiotics (quinolones) were given from the day of operation until the participant was discharged home

Iversen Hansen 1984

2

Yes

Antibiotics were not administered routinely but participants with urinary infections pre‐ or post‐op were treated with antibiotics according to urine culture results.

Jang 2012

4

Yes

All participants were given an IV dose of antibiotic during anaesthesia induction before operation

Jeong 2014

4

Not reported

Not reported

Joshi 2014

2

Yes

All participants received 1 dose of antibiotic prophylaxis at the time of surgery and continued post‐op as per department protocol

Jun 2011

4

Not reported

Not reported

Kamilya 2010

2

Yes

All participants received 2 doses of antibiotic injection ceftriaxone 1 g, one just before the operation and another 12 h after the first dose

Kelleher 2002

1

Not reported

Not reported

Kim 2012

2

Not reported

Not reported

Koh 1994

2

Yes

Antibiotics were given at induction to participants with IUCs or proven urinary tract infections

Kokabi 2009

2

Not reported

Not reported

Lang 2020

2

Yes

All participants received pre‐op antibiotics with either American College of Obstetricians and Gynecologists approved dosing of cefazolin (78%) or a combination of gentamicin and clindamycin (22%) with no difference between fast‐track or conventional Foley management groups

Lau 2004

2

Yes

Single dose of parenteral antibiotic was given upon induction of general anaesthesia in most cholecystectomies, hernia repairs, gastrointestinal and anorectal operations

Li 2014

2

Not reported

Not reported

Liang 2009

2

Yes

IV antibiotics consisting of cefazolin 500 mg after induction of general anaesthesia

Lista 2020

2

Not reported

Not reported

Liu 2015

3

Not reported

Not reported

Lyth 1997

1

Not reported

Not reported

Mao 1994

2

Not reported

Not reported

Matsushima 2015

2

Not reported

Not reported

McDonald 1999

1

Not reported

Not reported

Naguimbing‐Cuaresma 2007

2

Not reported

Not reported

Nathan 2001

1

Not reported

Not reported

Nguyen 2012

2

Not reported

Not reported

Nielson 1985

2

Not reported

Not reported

Noble 1990

1

Not reported

Not reported

Nyman 2010

3

Not reported

Not reported

Oberst 1981

3

Not reported

Not reported

Onile 2008

2

Not reported

Not reported

Ouladsahebmadarek 2012

2

Yes

Cephazoline 1 g IV half an hour before surgery started and continued every 6 h for another 2 doses

Pervaiz 2019

2

Not reported

Not reported

Popiel 2017

2

Not reported

Not reported

Rajan 2017

2

Not reported

Not reported

Ruminjo 2015

2

Not reported

Not reported

Sahin 2011

2

Not reported

Not reported

Sandberg 2019

2

Not reported

Not reported

Schiotz 1995

2

Not reported

Not reported

Schiotz 1996

2

Not reported

Not reported

Sekhavat 2008

2

Not reported

Not reported

Shahnaz 2016

2

No

"antibiotic was not regularly given except for patients who had abnormal urinary symptoms and unusual urinary analysis in urinary sample 48 h after the surgery"

Shrestha 2013

2

Yes

Antibiotics given for 7 days

Souto 2004

2

Not reported

Not reported

Sun 2004

2

Yes

All participants were given prophylactic antibiotics for 2 days (1 g cefazolin IV 3 times daily)

Tahmin 2011

2

Not reported

Not reported

Talreja 2016

3

Yes

Participants were given 1 dose of third‐generation cephalosporin in pre‐op period

Taube 1989

2

Not reported

Not reported

Toscano 2001

2

Yes

Antiobiotic prophylaxis with first generation cephalosporin was given at the induction of anaesthesia for up to 7 days after the operation

Valero Puerta 1998

2

Yes

1 g of ceftriaxone every 24 h for 2 days

Vallabh‐Patel 2020

2

Yes

All participants received appropriate perioperative antibiotics per American College of Obstetricians and Gynecologists guidelines

Webster 2006

1

Not reported

Not reported

Weemhoff 2011

2

Yes

All participants received antibiotic prophylaxis at the beginning of the operation.

Williamson 1982

3

Not reported

Not reported

Wilson 2000

1

Not reported

Not reported

Wu 2015

3

Not reported

Not reported

Wyman 1987

1

Not reported

Not reported

Yaghmaei 2017

2

Yes

Cefazolin 1 g

Yee 2015

2

Not reported

Not reported

Zaouter 2009

2

Yes

2 g cefazolin with or without 500 mg of metronidazole was given IV

Zhou 2012

2

Not reported

Not reported

Zmora 2010

2

Yes

Prophylactic antibiotics were given 24 h in the perioperative period according to department protocol

Zomorrodi 2018

2

Not reported

Not reported

IM: intramuscular(ly); IUC: indwelling urethral catheter; IV: intravenous(ly); N/A: not applicable

Figuras y tablas -
Table 3. Use of antibiotic prophylaxis
Ir a la tabla de la revisión
Table 4. Measurement of symptomatic urinary tract infection

TrialID

Outcome as defined by trial authors

Trial definition

Relevant definition outlined by International Guideline Panel

Ahmed 2014

Symptomatic UTI

Significant bacteriuria with at least one of the following symptoms:

dysuria, frequency of micturition, urgency, suprapubic pain ir burning sensation at micturition

CDC

Alessandri 2006

UTI

Significant bacteria which is determined by: urine culture and defined as at least 105 cfu/mL

EAU: symptomatic bacteriuria

Allen 2016

UTI

Not reported

N/A

Alonzo‐Sosa 1997

UTI

Defined as a positive urine sample associated with: dysuria, polyuria, incomplete emptying, pain, fever or sepsis.

A positive urine sample was defined as the presence of > 105 cfu/mL if MSU and 104 cfu/mL in a catheter sample.

CDC

Aref 2020

Symptomatic UTI

“The diagnosis of symptomatic urinary tract infection was based on the following criteria: significant bacteriuria with at least one of the following symptoms; dysuria, frequency of micturition, urgency, supra pubic pain, or burning sensation at micturition.”

CDC

Aslam 2019

UTI

Not reported

N/A

Azarkish 2003

UTI

Not reported

N/A

Azarkish 2005

Not reported

Not reported

N/A

Barone 2015

UTI

Not reported

N/A

Basbug 2020

Significant bacteruria

Significant microscopic bacteriuria was defined as ≥ 100,000 bacteria/ mL MSU

EAU: asymptomatic bacteriuria

Benoist 1999

UTI

Culture yield of > 105 cfu/mL with or without symptoms

With symptoms: CDC

Without symptoms: EAU definition for "Asymptomatic bacteriuria"

Bristoll 1989

Not reported

Not reported

N/A

Carpiniello 1988

UTI

Culture yield of 105 cfu/mL

EAU: asymptomatic bacteriuria

Carter‐Brooks 2018

UTI

Defined as a positive culture or symptoms and antibiotic treatment

N/A

Chai 2011

Symptomatic UTI

Positive urine culture: > 105 cfu/mL of an identified single uropathogen/mL of urine

Symptomatic UTI: fever (> 38 °C) and dysuria with a positive urine culture

CDC

Chen 2013

CAUTI

CDC criteria used to define symptomatic UTI and asymptomatic bacteriuria

CDC

Chia 2009

CAUTI

Not reported

N/A

Chillington 1992

Not reported

N/A

N/A

Cornia 2003

CAUTI

Growth from a urine specimen aseptically aspirated from the catheter of ≥ 100 cfu of a predominant pathogen OR ≥ 10 leukocytes per high‐power field on urinalysis in a patient with a clinical diagnosis of UTI

N/A

Coyle 2015

Bacteriuria

Symptomatic or asymptomatic bacteriuria used. No definition given

N/A

Crowe 1993

Not reported

N/A

N/A

Dunn 1999

Not reported

N/A

N/A

Dunn 2000b

UTI

Not reported

N/A

Dunn 2003

UTI

Determined by either microscopic abnormality or any patient symptoms

N/A

Durrani 2014

UTI

Not reported

N/A

El‐Mazny 2014

Significant bacteriuria

Significant bacteriuria: > 105 cfu/mL of urine in a MSU sample collected 24 h post‐op

EAU: asymptomatic bacteriuria

Ganta 2005

Not reported

N/A

N/A

Glavind 2007

Positive urine culture

Defined as the presence of ≥ 105 cfu/mL

EAU: asymptomatic bacteriuria

Gong 2017

Symptomatic UTI

Defined as bacteriuria with fever, frequent or painful urination or burning on urination

CDC

Gross 2007

UTI

Used CDC criteria

CDC

Gungor 2014

Not reported

N/A

N/A

Guzman 1994

UTI

Urine culture of > 105 cfu/mL reported as outcome. Definition is not provided

EAU: asymptomatic bacteriuria

Hakvoort 2004

UTI

Signs of UTI: having > 10 WBC/high‐powered field and significant microscopic bacteriuria (1/high‐powered field) in the urine sediment

UTI: presence of > 105 cfu/mL in urine culture

EAU: asymptomatic bacteriuria

Hall 1998

Not reported

N/A

N/A

Han 1997

Not reported

N/A

N/A

Hewitt 2001

Not reported

N/A

N/A

Huang 2011

UTI

Not reported

N/A

Ind 1993

Not reported

N/A

N/A

Irani 1995

UTI

Not reported

N/A

Iversen Hansen 1984

Not reported

N/A

N/A

Jang 2012

Not reported

N/A

N/A

Jeong 2014

Not reported

N/A

N/A

Joshi 2014

Symptomatic UTI

Symptomatic UTI: based on the presence of significant bacteriuria accompanied by at least 1 of the following symptoms: fever, dysuria, increased frequency of micturition, urinary urgency, suprapubic pain and dysuria

CDC

Jun 2011

Not reported

N/A

N/A

Kamilya 2010

Symptomatic UTI

Symptomatic UTI: positive urine culture of > 105 cfu/mL plus 1 of the following symptoms: dysuria, fever (> 38 °C) or rigors

CDC

Kelleher 2002

Not reported

N/A

N/A

Kim 2012

Not reported

N/A

N/A

Koh 1994

UTI

Not reported

N/A

Kokabi 2009

UTI

Not reported

N/A

Lang 2020

UTI

Not reported

N/A

Lau 2004

Positive urine culture

Not reported

N/A

Li 2014

Infection

Not reported

N/A

Liang 2009

UTI

UTI: positive urine culture of > 105 cfu/mL. However, treatment was only given for positive urine cultures if participant had adverse urinary symptoms or post‐op pyrexia (> 38 °C)

CDC

Lista 2020

UTI

Not reported

N/A

Liu 2015

Not reported

N/A

N/A

Lyth 1997

Not reported

N/A

N/A

Mao 1994

Not reported

N/A

N/A

Matsushima 2015

Not reported

N/A

N/A

McDonald 1999

Not reported

N/A

N/A

Naguimbing‐Cuaresma 2007

Not reported

N/A

N/A

Nathan 2001

Positive catheter specimen urine (CSU)

Not reported

N/A

Nguyen 2012

Not reported

N/A

N/A

Nielson 1985

Not reported

N/A

N/A

Noble 1990

Not reported

N/A

N/A

Nyman 2010

Not reported

N/A

N/A

Oberst 1981

Not reported

N/A

N/A

Onile 2008

Significant bacteriuria

Significant bacteriuria: positive urine culture of > 105 cfu/mL in a sample of MSU collected 72 h post‐op with signs of a fever ( a temperature of > 38 °C on 2 occasions within 10 days of the procedure, excluding the first 24 h)

CDC

Ouladsahebmadarek 2012

Symptomatic UTI

Not reported

N/A

Pervaiz 2019

UTI

Urine sample was obtained to assess UTI (bacterial colony count > 105 cfu/mL on urine culture after removal of catheter assessed on day 7)

EAU: catheter‐associated asymptomatic bacteriuria

Popiel 2017

UTI

Not reported

N/A

Rajan 2017

UTI

Urinary infections defined as when microscopic examination of the urine revealed pus cells or when urine culture showed growth of pathogenic organisms

N/A

Ruminjo 2015

Not reported

N/A

N/A

Sahin 2011

Not reported

N/A

N/A

Sandberg 2019

UTI

Standard urine test for nitrite and leucocytes in combination with clinical symptoms

Not clear whether test is dipstick only or whether it involves microscopy/culture

Schiotz 1995

UTI

Positive cultures: culture of > 105 cfu/mL in a sample of MSU or CSU culture of > 104 cfu/mL

UTI: positive urine culture in the absence of symptoms. Patients were defined as having UTI if there was any doubt

EAU: asymptomatic bacteriuria

Schiotz 1996

UTI

Positive cultures: culture of > 105 cfu/mL in a sample of MSU or CSU culture of > 104 cfu/mL

UTI: positive urine culture in the absence of symptoms. Participants were defined as having UTI if there was any doubt

EAU: asymptomatic bacteriuria

Sekhavat 2008

Positive urine culture

Positive urine culture: prevalence of symptomatic UTI was confirmed through a positive urine culture OR through signs of UTI such as: frequency, urgency, dysuria, suprapubic pain or fever

Does not fully meet the criteria for CDC. Must be positive cultures AND clinical features

Shahnaz 2016

Positive urine culture

The presence of positive urinary culture or > 100,000 colony counts in each mL of urine or > 10 pieces of leukocyte in each microscopy field was considered as a urinary infection.

EAU: asymptomatic bacteriuria

Shrestha 2013

Asymptomatic bacteriuria

Asymptomatic bacteriuria: pus cells of > 5 per high‐power field in routine examination of urine and bacterial culture positive

EAU: asymptomatic bacteriuria

Souto 2004

Not reported

N/A

N/A

Sun 2004

UTI

UTI: positive urine culture of > 105 cfu/mL or WBC > 5/high‐power field in urine analysis

EAU: asymptomatic bacteriuria

Tahmin 2011

UTI

UTI: positive urine culture of > 105 cfu/mL

EAU: asymptomatic bacteriuria

Talreja 2016

Not reported

N/A

N/A

Taube 1989

Not reported

N/A

N/A

Toscano 2001

Not reported

N/A

N/A

Valero Puerta 1998

Not reported

N/A

N/A

Vallabh‐Patel 2020

UTI

For the purpose of this trial, participants were considered positive for a UTI if they had (1) positive urine cultures per CDC guidelines or (2) treated empirically over the phone for symptoms of UTI, even in the absence of a urine culture

CDC

Webster 2006

Not reported

N/A

N/A

Weemhoff 2011

UTI

UTI: > 25 WBC/high‐power field, nitrate production, > 20 bacteria/high‐power field, positive urine culture of > 105 cfu/mL

EAU: asymptomatic bacteriuria

Williamson 1982

Not reported

N/A

N/A

Wilson 2000

Not reported

N/A

N/A

Wu 2015

Not reported

N/A

N/A

Wyman 1987

Not reported

N/A

N/A

Yaghmaei 2017

Not reported

N/A

N/A

Yee 2015

Not reported

N/A

N/A

Zaouter 2009

UTI

UTI: pyrexia of > 38 °C, clinical features of UTI (dysuria, frequency, urgency, suprapubic pain, urinary incontinence) and a positive urine culture (107 bacterial colonies of micro‐organism‐forming units/L within 2 weeks after the removal of bladder catheter)

CDC

EAU: complicated UTI

Zhou 2012

Not reported

Defined as post‐catheter removal MSU clean catch culture of ≥ 104 cfu/mL for Gram positive organisms or ≥ 105 cfu/mL for Gram negative organisms

EUA: asymptomatic bacteriuria

Zmora 2010

UTI

Asymptomatic bacteriuria

UTI: positive urine culture and symptoms suggestive of UTI

CDC

Zomorrodi 2018

UTI

Not reported

N/A

CAUTI: catheter‐associated urinary tract infection; CDC: Centers for Disease Control and Prevention; cfu: colony forming unit; CSU: catheter specimen urine; EAU: European Association of Urology; MSU: midstream urine; N/A: not applicable; UTI: urinary tract infection; WBC: white blood count

Figuras y tablas -
Table 4. Measurement of symptomatic urinary tract infection
Ir a la tabla de la revisión
Table 5. Definitions for urinary tract infection

Guideline Committee

Population

Clinical features

Microbiological findings

Centres for Disease Control and Prevention (CDC)

(CDC 2016; Gould 2009)

CAUTI ‐ UTI in patients who have IUCs that have been in place for > 2 days (day 1 being when the catheter was placed)

At least one of the following:

  • Urgency

  • Dysuria

  • Frequency

  • Suprapubic tenderness

  • Fever (> 38 °C)

  • Costovertebral angle pain or tenderness

AND a urine culture of at least ≥ 105 cfu/mL with no more than 2 species of organisms

Infectious Diseases Society of America (IDSA)

(Hooton 2010)

UTI in patients with urethral (indwelling or intermittent) or suprapubic catheters that are inserted at the time or removed in the previous 48 h

Patient must have clinical features compatible with UTI (not specified)

AND a MSUor CSU with a urine culture of ≥ 103 cfu/mL of ≥ 1 species of bacterial organism (single‐catheter specimen or MSU)

European Association of Urology (EAU)

(EAU 2020; Grabe 2015)

Asymptomatic bacteriuria

No clinical features

  • A single, catheterised sample bacterial growth may be as low as 102 cfu/mL to be considered representing true bacteriuria in both men and women

  • > 105 cfu/mL on 2 consecutive MSU in women or 1 MSU in men

Uncomplicated UTI

(see Table 6 for definition)

  • Urgency

  • Dysuria

  • Frequency

  • Suprapubic tenderness

  • No urinary symptoms in 4 weeks before this episode

  • Positive urine culture of ≥ 105 cfu/mL and pyuria of > 10 WBC/mm3

Complicated UTI
(see Table 6 for definition)

  • Urgency

  • Dysuria

  • Frequency

  • Suprapubic pain

  • Fever

  • Chills

  • Flank pain

No urinary symptoms 4 weeks before

  • > 105 cfu/mL for women

  • > 104 cfu/mL for men or in women with straight catheters

  • > 10 WBC/mm3

CAUTI: catheter‐associated urinary tract infection; CDC: Centers for Disease Control and Prevention; cfu: colony forming unit; CSU: catheter specimen urine; EAU: European Association of Urology; MSU: midstream urine; UTI: urinary tract infection; WBC: white blood count

Figuras y tablas -
Table 5. Definitions for urinary tract infection
Ir a la tabla de la revisión
Table 6. European Association of Urology classification of urinary tract infection

Uncomplicated UTIs

Acute, sporadic or recurrent lower (uncomplicated cystitis) and/or upper (uncomplicated pyelonephritis) UTI, limited to non‐pregnant, premenopausal women with no known relevant anatomical and functional abnormalities within the urinary tract or co‐morbidities

Complicated UTIs

All UTIs that are not defined as uncomplicated. Meaning in a narrower sense UTIs in a patient with an increased chance of a complicated course: i.e. all men, pregnant women, patients with relevant anatomical or functional abnormalities of the urinary tract, IUCs, renal diseases, and/or with other concomitant immunocompromising diseases for example, diabetes

Recurrent UTIs

Recurrences of uncomplicated and/or complicated UTIs, with a frequency of at least 3 UTIs/year or 2 UTIs in the last 6 months

Catheter associated UTIs (CAUTI)

Catheter‐associated urinary tract infection (CAUTI) refers to UTIs occurring in a person whose urinary tract is currently catheterised or has had a catheter in place within the past 48 h

Urosepsis

Urosepsis is defined as life‐threatening organ dysfunction caused by a disregulated host response to infection originating from the urinary tract and/or male genital organs

CAUTI: catheter‐associated urinary tract infection; IUC: indwelling urethral catheter; UTI: urinary tract infection

Table obtained from EAU Guidelines on Urological Infections (EAU 2020).

Figuras y tablas -
Table 6. European Association of Urology classification of urinary tract infection
Ir a la tabla de la revisión
Table 7. Heterogeneity of reported outcomes

Reported outcomes in this review

Similar outcomes reported by trials

Asymptomatic bacteriuria

  • Positive urine culture

Incidence of urinary retention

  • Post‐discharge urinary retention

  • Short‐term retention

  • Acute urinary retention

  • Delayed voiding after catheter removal

  • Chronic urinary retention

Loin pain

  • Post‐discharge loin pain

Fever

  • Post‐discharge fever

Dysuria

  • Post‐discharge pain on passing urine

Difficulty in passing urine

  • Post‐discharge difficulty in passing urine

  • Post‐operative voiding dysfunction

Incontinence

  • Post‐discharge incontinence
Figuras y tablas -
Table 7. Heterogeneity of reported outcomes
Ir a la tabla de la revisión
Comparison 1. Removal of indwelling urethral catheter at one specified time of day (10 pm to midnight) versus another specified time of day (6 am to 7 am)

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1.1 Number needing to be recatheterised Show forest plot

10

1920

Risk Ratio (M‐H, Fixed, 95% CI)

0.70 [0.52, 0.94]

1.1.1 Urological surgery and procedures

6

1400

Risk Ratio (M‐H, Fixed, 95% CI)

0.87 [0.60, 1.27]

1.1.2 Gynaecological surgery

2

202

Risk Ratio (M‐H, Fixed, 95% CI)

0.33 [0.15, 0.69]

1.1.3 General medical and surgical patients

2

318

Risk Ratio (M‐H, Fixed, 95% CI)

0.73 [0.36, 1.46]

1.2 Number needing to be recatheterised: subgroup analysis based on sex Show forest plot

6

1200

Risk Ratio (M‐H, Fixed, 95% CI)

0.44 [0.25, 0.76]

1.2.1 Men only

4

998

Risk Ratio (M‐H, Fixed, 95% CI)

0.63 [0.28, 1.44]

1.2.2 Women only

2

202

Risk Ratio (M‐H, Fixed, 95% CI)

0.33 [0.15, 0.69]

1.3 Symptomatic catheter‐associated urinary tract infection (number of participants) Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

1.3.1 General medical and surgical patients

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

1.4 Asymptomatic bacteriuria (number of participants) Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

1.4.1 Gynaecological surgery

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

1.5 Incidence of urinary retention Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

1.5.1 General medical and surgical patients

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

1.6 Difficulty in passing urine Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

1.6.1 General medical and surgical patients

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

1.7 Loin pain Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

1.7.1 General medical and surgical patients

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

1.8 Fever Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

1.8.1 General medical and surgical patients

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

1.9 Incontinence Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

1.9.1 General medical and surgical patients

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

1.10 Dysuria (number of participants) Show forest plot

1

170

Risk Ratio (M‐H, Fixed, 95% CI)

2.20 [0.70, 6.86]

1.10.1 General medical and surgical patients

1

170

Risk Ratio (M‐H, Fixed, 95% CI)

2.20 [0.70, 6.86]

1.11 Volume of the first void (mL) Show forest plot

11

1198

Mean Difference (IV, Fixed, 95% CI)

21.98 [3.04, 40.92]

1.11.1 Urological surgery and procedures

8

923

Mean Difference (IV, Fixed, 95% CI)

11.63 [‐10.65, 33.91]

1.11.2 Gynaecological surgery

1

107

Mean Difference (IV, Fixed, 95% CI)

34.00 [‐11.30, 79.30]

1.11.3 General medical and surgical patients

2

168

Mean Difference (IV, Fixed, 95% CI)

74.54 [15.35, 133.73]

1.12 Volume of first void (median and range) Show forest plot

1

Other data

No numeric data

1.12.1 Following gynaecological surgery

1

Other data

No numeric data

1.13 Time to first void (hours) Show forest plot

10

1140

Mean Difference (IV, Fixed, 95% CI)

0.71 [0.41, 1.01]

1.13.1 Urological surgery and procedures

6

703

Mean Difference (IV, Fixed, 95% CI)

0.72 [0.39, 1.06]

1.13.2 Gynaecological surgery

1

107

Mean Difference (IV, Fixed, 95% CI)

0.10 [‐1.46, 1.66]

1.13.3 General medical and surgical patients

3

330

Mean Difference (IV, Fixed, 95% CI)

0.79 [0.02, 1.57]

1.14 Time to first void (median) Show forest plot

1

Other data

No numeric data

1.14.1 Following gynaecological surgery

1

Other data

No numeric data

1.15 Post‐void residual volume Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

1.15.1 General medical and surgical patients

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

1.16 Length of hospitalisation in days Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

1.16.1 Gynaecological surgery

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

1.17 Length of hospitalisation in days Show forest plot

2

Other data

No numeric data

1.17.1 Urological surgery and procedures (mean, total)

1

Other data

No numeric data

1.17.2 Gynaecological surgery involving the bladder /urethra (median, range)

1

Other data

No numeric data

1.17.3 Gynaecological surgery not involving the bladder/urethra (median, range)

1

Other data

No numeric data

1.18 Time between removal of catheter to discharge Show forest plot

2

272

Mean Difference (IV, Fixed, 95% CI)

0.08 [‐5.96, 6.12]

1.18.1 Urological surgery and procedures

1

72

Mean Difference (IV, Fixed, 95% CI)

0.00 [‐6.06, 6.06]

1.18.2 General medical and surgical patients

1

200

Mean Difference (IV, Fixed, 95% CI)

15.50 [‐67.34, 98.34]
Figuras y tablas -
Comparison 1. Removal of indwelling urethral catheter at one specified time of day (10 pm to midnight) versus another specified time of day (6 am to 7 am)
Ir a la tabla de la revisión
Comparison 2. Shorter versus longer duration of catheter

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

2.1 Number needing to be recatheterised Show forest plot

44

5870

Risk Ratio (M‐H, Random, 95% CI)

1.81 [1.35, 2.41]

2.1.1 Early removal versus later

19

2528

Risk Ratio (M‐H, Random, 95% CI)

2.59 [1.47, 4.57]

2.1.2 1‐day policy versus later

16

1874

Risk Ratio (M‐H, Random, 95% CI)

1.45 [0.93, 2.25]

2.1.3 2‐day to 7‐day policy versus later

10

1468

Risk Ratio (M‐H, Random, 95% CI)

1.67 [0.93, 2.99]

2.2 Number needing to be recatheterised: subgroup analysis based on type of surgery Show forest plot

37

4736

Risk Ratio (M‐H, Random, 95% CI)

1.85 [1.36, 2.51]

2.2.1 Urological surgery

9

1104

Risk Ratio (M‐H, Random, 95% CI)

0.91 [0.50, 1.67]

2.2.2 Gynaecological surgery

24

2935

Risk Ratio (M‐H, Random, 95% CI)

2.25 [1.58, 3.22]

2.2.3 Obstetric surgery

4

697

Risk Ratio (M‐H, Random, 95% CI)

3.36 [0.93, 12.15]

2.3 Number needing to be recatheterised: subgroup analysis based on sex Show forest plot

37

4736

Risk Ratio (M‐H, Random, 95% CI)

1.85 [1.36, 2.51]

2.3.1 Men only

9

1104

Risk Ratio (M‐H, Random, 95% CI)

0.91 [0.50, 1.67]

2.3.2 Women only

28

3632

Risk Ratio (M‐H, Random, 95% CI)

2.29 [1.64, 3.18]

2.4 Number needing to be recatheterised: subgroup analysis based on antibiotic prophylaxis Show forest plot

27

3839

Risk Ratio (M‐H, Random, 95% CI)

1.72 [1.11, 2.65]

2.4.1 Antibiotic prophylaxis given

22

3040

Risk Ratio (M‐H, Random, 95% CI)

1.73 [1.04, 2.89]

2.4.2 No antibiotic prophylaxis

5

799

Risk Ratio (M‐H, Random, 95% CI)

1.65 [0.70, 3.86]

2.5 Symptomatic catheter‐associated urinary tract infection (number of participants) Show forest plot

41

5759

Risk Ratio (M‐H, Fixed, 95% CI)

0.52 [0.45, 0.61]

2.5.1 Early versus later

17

2220

Risk Ratio (M‐H, Fixed, 95% CI)

0.55 [0.43, 0.71]

2.5.2 1 day versus later

15

1879

Risk Ratio (M‐H, Fixed, 95% CI)

0.48 [0.37, 0.62]

2.5.3 2 to 7 days versus later

9

1660

Risk Ratio (M‐H, Fixed, 95% CI)

0.55 [0.39, 0.78]

2.6 Symptomatic catheter‐associated urinary tract infection: post‐hoc subgroup analysis by antibiotic prophylaxis Show forest plot

24

3516

Risk Ratio (M‐H, Fixed, 95% CI)

0.47 [0.38, 0.59]

2.6.1 Antibiotic prophylaxis

20

2871

Risk Ratio (M‐H, Fixed, 95% CI)

0.49 [0.39, 0.62]

2.6.2 No antibiotic prophylaxis given

4

645

Risk Ratio (M‐H, Fixed, 95% CI)

0.28 [0.11, 0.72]

2.7 Asymptomatic bacteruria (number of participants) Show forest plot

18

2611

Risk Ratio (M‐H, Fixed, 95% CI)

0.47 [0.38, 0.58]

2.7.1 Early versus later

10

1461

Risk Ratio (M‐H, Fixed, 95% CI)

0.59 [0.45, 0.77]

2.7.2 1 day versus later

6

683

Risk Ratio (M‐H, Fixed, 95% CI)

0.37 [0.26, 0.54]

2.7.3 2 to 7 days versus later

3

467

Risk Ratio (M‐H, Fixed, 95% CI)

0.32 [0.18, 0.59]

2.8 Incidence of urinary retention Show forest plot

19

Risk Ratio (M‐H, Random, 95% CI)

Subtotals only

2.8.1 Early versus later

7

1108

Risk Ratio (M‐H, Random, 95% CI)

1.07 [0.57, 2.00]

2.8.2 1 day versus later

7

680

Risk Ratio (M‐H, Random, 95% CI)

1.36 [1.03, 1.81]

2.8.3 2 to 7 days versus later

6

881

Risk Ratio (M‐H, Random, 95% CI)

1.37 [0.88, 2.12]

2.9 Delayed voiding after catheter removal Show forest plot

2

176

Risk Ratio (M‐H, Fixed, 95% CI)

1.02 [0.53, 1.97]

2.9.1 1 day versus later

2

176

Risk Ratio (M‐H, Fixed, 95% CI)

1.02 [0.53, 1.97]

2.10 Chronic urinary retention Show forest plot

2

339

Risk Ratio (M‐H, Fixed, 95% CI)

0.84 [0.29, 2.44]

2.10.1 1‐day policy versus later

2

230

Risk Ratio (M‐H, Fixed, 95% CI)

0.81 [0.26, 2.59]

2.10.2 2 to 7 days versus later

1

109

Risk Ratio (M‐H, Fixed, 95% CI)

1.02 [0.07, 15.87]

2.11 Other complications of catheterisation: fever Show forest plot

2

470

Risk Ratio (M‐H, Fixed, 95% CI)

1.17 [0.40, 3.40]

2.11.1 Early versus later

2

470

Risk Ratio (M‐H, Fixed, 95% CI)

1.17 [0.40, 3.40]

2.12 Other complications of catheterisation: epididymitis Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

2.12.1 2 to 7 days versus later

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

2.13 Pain or discomfort (dichotomous) Show forest plot

5

510

Risk Ratio (M‐H, Random, 95% CI)

0.52 [0.21, 1.27]

2.13.1 Immediate post‐op removal versus removal 24 hours post‐op

3

230

Risk Ratio (M‐H, Random, 95% CI)

0.31 [0.04, 2.64]

2.13.2 Removal 4 hours post‐op versus removal 24 hours post‐op

1

240

Risk Ratio (M‐H, Random, 95% CI)

1.00 [0.78, 1.29]

2.13.3 Removal 3 days post‐op versus removal 28 days post‐op

1

40

Risk Ratio (M‐H, Random, 95% CI)

0.20 [0.01, 3.92]

2.14 Pain or discomfort: 0‐10 VAS (higher score = greater pain) Show forest plot

5

695

Mean Difference (IV, Fixed, 95% CI)

‐0.34 [‐0.47, ‐0.20]

2.14.1 Removal 4 hours post‐op versus removal at 6am 1 day post‐op

1

57

Mean Difference (IV, Fixed, 95% CI)

‐0.60 [‐1.65, 0.45]

2.14.2 Immediate post‐op removal versus removal 24 hours post‐op

3

433

Mean Difference (IV, Fixed, 95% CI)

‐0.37 [‐0.52, ‐0.23]

2.14.3 Immediate removal post‐op versus removal 3‐5 days post‐op

1

205

Mean Difference (IV, Fixed, 95% CI)

0.10 [‐0.37, 0.56]

2.15 Patient satisfaction Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

2.16 Urinary incontinence  Show forest plot

7

1195

Risk Ratio (M‐H, Fixed, 95% CI)

0.55 [0.35, 0.86]

2.16.1 Early versus later

2

396

Risk Ratio (M‐H, Fixed, 95% CI)

0.13 [0.03, 0.55]

2.16.2 2 to 7 days versus later

5

799

Risk Ratio (M‐H, Fixed, 95% CI)

0.82 [0.52, 1.32]

2.17 Dysuria Show forest plot

7

1398

Risk Ratio (M‐H, Random, 95% CI)

0.42 [0.20, 0.88]

2.17.1 Early versus later

7

1398

Risk Ratio (M‐H, Random, 95% CI)

0.42 [0.20, 0.88]

2.18 Volume of first void (mL) Show forest plot

3

364

Mean Difference (IV, Fixed, 95% CI)

27.02 [1.00, 53.04]

2.18.1 Early removal versus later

1

227

Mean Difference (IV, Fixed, 95% CI)

12.00 [‐21.97, 45.97]

2.18.2 2‐day to 7‐day policy versus later

2

137

Mean Difference (IV, Fixed, 95% CI)

48.36 [7.88, 88.84]

2.19 Time to first void (hours) Show forest plot

2

277

Mean Difference (IV, Random, 95% CI)

‐8.59 [‐16.16, ‐1.01]

2.19.1 Early removal versus later

2

277

Mean Difference (IV, Random, 95% CI)

‐8.59 [‐16.16, ‐1.01]

2.20 Post‐void residual volume (mL) Show forest plot

2

137

Mean Difference (IV, Fixed, 95% CI)

6.37 [‐9.14, 21.88]

2.20.1 2‐day to 7‐day policy versus later

2

137

Mean Difference (IV, Fixed, 95% CI)

6.37 [‐9.14, 21.88]

2.21 Post‐void residual volume (median and range) (mL) Show forest plot

1

Other data

No numeric data

2.22 Length of hospitalisation in days Show forest plot

27

Mean Difference (IV, Random, 95% CI)

Subtotals only

2.22.1 Early removal versus later

13

2012

Mean Difference (IV, Random, 95% CI)

‐0.54 [‐0.82, ‐0.27]

2.22.2 1‐day policy versus later

10

1249

Mean Difference (IV, Random, 95% CI)

‐1.66 [‐2.25, ‐1.07]

2.22.3 2‐day to 7‐day policy versus later

5

474

Mean Difference (IV, Random, 95% CI)

‐5.00 [‐5.89, ‐4.11]

2.23 Length of hospitalisation in days: subgrouping based on type of surgery Show forest plot

27

3735

Mean Difference (IV, Random, 95% CI)

‐1.13 [‐1.42, ‐0.83]

2.23.1 Urological procedures

7

1005

Mean Difference (IV, Random, 95% CI)

‐3.40 [‐4.75, ‐2.05]

2.23.2 Gynaecological procedures

13

1453

Mean Difference (IV, Random, 95% CI)

‐0.92 [‐1.33, ‐0.51]

2.23.3 Obstetric procedures

6

1217

Mean Difference (IV, Random, 95% CI)

‐0.50 [‐0.87, ‐0.13]

2.23.4 General surgical procedures

1

60

Mean Difference (IV, Random, 95% CI)

‐1.10 [‐2.77, 0.57]

2.24 Length of hospitalisation in days (median and range) Show forest plot

6

Other data

No numeric data

2.25 Frequency of micturition Show forest plot

2

Risk Ratio (M‐H, Fixed, 95% CI)

Subtotals only

2.25.1 Early versus later

2

521

Risk Ratio (M‐H, Fixed, 95% CI)

0.18 [0.06, 0.53]

2.26 Time to first ambulation (hours) Show forest plot

9

1688

Mean Difference (IV, Fixed, 95% CI)

‐5.06 [‐5.24, ‐4.88]

2.26.1 Early versus later

9

1688

Mean Difference (IV, Fixed, 95% CI)

‐5.06 [‐5.24, ‐4.88]
Figuras y tablas -
Comparison 2. Shorter versus longer duration of catheter
Ir a la tabla de la revisión
Comparison 3. Clamping versus free drainage

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

3.1 Number needing to be recatheterised Show forest plot

5

569

Risk Ratio (M‐H, Fixed, 95% CI)

0.82 [0.55, 1.21]

3.1.1 Clamping versus removal at 48 hours

2

311

Risk Ratio (M‐H, Fixed, 95% CI)

0.94 [0.51, 1.71]

3.1.2 Clamping versus removal at 72 hours or longer

3

258

Risk Ratio (M‐H, Fixed, 95% CI)

0.73 [0.44, 1.21]

3.2 Number needing to be recatheterised: subgroup analysis based on type of surgery and sex Show forest plot

5

569

Risk Ratio (M‐H, Fixed, 95% CI)

0.82 [0.55, 1.21]

3.2.1 Gynaecological surgery (women)

2

267

Risk Ratio (M‐H, Fixed, 95% CI)

0.92 [0.48, 1.77]

3.2.2 Non‐gynaecological surgery (men and women)

3

302

Risk Ratio (M‐H, Fixed, 95% CI)

0.76 [0.47, 1.23]

3.3 Symptomatic catheter‐associated urinary tract infection (number of participants) Show forest plot

2

267

Risk Ratio (M‐H, Fixed, 95% CI)

0.99 [0.60, 1.63]

3.3.1 Clamping versus removal at 48 hours

1

198

Risk Ratio (M‐H, Fixed, 95% CI)

1.13 [0.65, 1.95]

3.3.2 Clamping versus removal at 72 hours or longer

1

69

Risk Ratio (M‐H, Fixed, 95% CI)

0.55 [0.15, 2.01]

3.4 Incidence of urinary retention (number of participants) Show forest plot

2

169

Risk Ratio (M‐H, Fixed, 95% CI)

1.18 [0.69, 2.02]

3.4.1 Clamping versus removal at 24 hours

1

100

Risk Ratio (M‐H, Fixed, 95% CI)

0.86 [0.31, 2.37]

3.4.2 Clamping versus removal at 72 hours or longer

1

69

Risk Ratio (M‐H, Fixed, 95% CI)

1.39 [0.74, 2.61]

3.5 Dysuria (number of participants) Show forest plot

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

3.5.1 Clamping versus removal at 72 hours or longer

1

Risk Ratio (M‐H, Fixed, 95% CI)

Totals not selected

3.6 Volume of first void (mL) Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

3.6.1 Clamping versus removal at 72 hours or longer

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

3.7 Time to first void (minutes) Show forest plot

2

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

3.7.1 Clamping versus removal at 24 hours

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

3.7.2 Clamping versus removal at 72 hours or longer

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

3.8 Length of hospitalisation (median days) Show forest plot

1

Other data

No numeric data

3.9 Length of hospitalisation (days) Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

3.9.1 Clamping versus removal at 48 hours

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

3.10 Time required to return to normal bladder function (hours) Show forest plot

1

Other data

No numeric data
Figuras y tablas -
Comparison 3. Clamping versus free drainage
Ir a la tabla de la revisión
Comparison 4. Prophylactic use of alpha blocker versus no drug or intervention

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

4.1 Number of participants needing to be recatheterised Show forest plot

2

184

Risk Ratio (M‐H, Fixed, 95% CI)

1.18 [0.58, 2.42]

4.2 Symptomatic catheter‐associated urinary tract infection (number of participants) Show forest plot

1

94

Risk Ratio (M‐H, Fixed, 95% CI)

0.20 [0.01, 4.06]

4.3 Incidence of urinary retention (number of participants) Show forest plot

2

308

Risk Ratio (M‐H, Fixed, 95% CI)

0.38 [0.20, 0.73]

4.4 Post‐void residual volume Show forest plot

2

301

Mean Difference (IV, Fixed, 95% CI)

‐2.00 [‐11.42, 7.42]

4.5 Length of hospitalisation in days Show forest plot

1

Mean Difference (IV, Fixed, 95% CI)

Totals not selected

4.6 Length of hospitalisation in days (median, range, N) Show forest plot

1

Other data

No numeric data
Figuras y tablas -
Comparison 4. Prophylactic use of alpha blocker versus no drug or intervention
Ir a la tabla de la revisión