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Acute Urinary Retention Following Percutaneous Interventions in Individuals with Congenital Heart Disease
Acute urinary retention is defined as the inability to void voluntarily and/or empty a full bladder. It usually requires placement of a urinary catheter.1 This is a potentially hazardous complication that may delay patient recovery. The incidence after surgical procedures has been documented at between 5– 70% depending on the type of surgery and anesthesia used.2 To our knowledge, it has however never been reported after cardiac catheterization, neither in the general population nor in those with congenital heart disease. Potential risk factors include advancing patient age, medications such as opioids, benzodiazepines and anticholinergic drugs, major surgery, prolonged anesthesia and intra-operative fluid administration exceeding 750 ml.3
Cardiac catheterization in adults with congenital heart disease (CHD) has become more common and also more challenging due to improved survival in those with moderate or complex defects. Technological advancements and improved equipment designs have enabled interventional cardiology to replace or complement surgery in a number of conditions and there is a growing body of experience in this field. In common with pediatric congenital heart disease practice, catheterization in adults with CHD is now predominantly performed to carry out therapeutic maneuvers. Not surprisingly, such catheterizations are often longer in duration, and many are performed under general anesthetic. This therefore exposes patients to risks associated with general anesthesia, such as post-procedural acute urinary retention.
Case Report. Patient #1. A 49-year-old woman with severe dyspnea underwent cardiac catheterization with a view to closing her patent foramen ovale and excluding other causes of breathlessness. Following induction with midazolam, fentanyl, propofol and vecuronium, her trachea was intubated and she underwent positive pressure ventilation for the procedure. Anesthesia was maintained with oxygen in nitrous oxide and isoflurane. Venous and arterial access were obtained via the right femoral vein (6 French sheath) and artery (20 gauge Leader catheter). Transesophageal echocardiography demonstrated a complex atrial shunt with multiple fenestrations distributed across a 2.5 cm radius in the inter-atrial septum. The operators cannulated a number of the defects and eventually deployed a single device (35 mm Amplatzer Cribriform device, AGA, Minneapolis, Minnesota) across the most central of the defects. The duration of the procedure was 2.5 hours. She also received ondansetron, cyclizine and cefuroxime as well as a further 5 mg vecuronium in divided doses. She received 1000 ml of intravenous fluid during the procedure and a further 60 ml of intravenous contrast agent. Her blood pressure was maintained between 75–100 mmHg systolic. On completion of the procedure, neuromuscular blockade was reversed with neostigmine and glycopyrrolate and her arterial puncture site was occluded with an Angioseal™ device (St Jude Medical, Minnetonka, Minnesota). After removal of her venous sheath, she was required to remain on bed rest for 6 hours. There was no clinical evidence of bleeding or hematoma formation at the injection site.
Overnight, she developed lower abdominal pain and was unable to pass urine. Subsequent urinary catheterization yielded 500 ml of retained urine. The catheter was removed the following morning with no further retention.
Patient #2. A 44-year-old man with a bicuspid aortic valve underwent cardiac catheterization for stent-angioplasty of severe aortic coarctation and associated systemic hypertension. On induction, he received fentanyl, propofol and vecuronium, his trachea was intubated and he received positive pressure ventilation. Anesthesia was maintained with oxygen in nitrous oxide and isoflurane. During the procedure, he received cefuroxime, ondansetron, paracetamol and a further dose of vecuronium. His blood pressure was maintained between 80–120 mmHg systolic and additional small doses of atropine, phenylephrine and ephedrine were required throughout the procedure. He received 1000 ml intravenous fluid and an additional 70 ml intravenous contrast agent during the procedure. Arterial access was obtained from the right femoral artery, after which a 12 Fr Mullins sheath was used for deployment of a 28 mm covered CP stent (NuMED Inc., Hopkinton, New York). This was assisted by rapid pacing at 180 pm. A stable stent position with good angiographic result was obtained. The total length of the procedure was 2.5 hours and neuromuscualar blockade was reversed at the end. His arterial access site was closed with use of a Perclose device (Abbott Vascular, Redwood City, California).
After the procedure, the patient developed symptoms of acute urinary retention. Despite numerous attempts by experienced medical staff over an 8-hour period, it was not possible to pass a urethral catheter due to hold-up in the distal penile urethra. The specialist urology team inserted a suprapubic catheter, draining 800 ml of residual urine. The patient was discharged with the suprapubic catheter in situ. One month later, the catheter was removed and the patient was able to void urine normally with no residual urine visible in the bladder.
Patient #3. A 27-year-old man with transposition of the great arteries underwent a diagnostic catheterization to assess his aortic coarctation. He underwent a Mustard procedure at 2 years of age followed by an arterial switch at 11 years. He also had aortic valve replacement and a pacemaker inserted. His current problems included severe tricuspid regurgitation, severe left ventricular dysfunction and moderate right ventricular dysfunction and suspected coarctation. His American Society of Anesthesiologists (ASA) physical status classification was recorded as class 4. This signifies severe systemic disease that is a constant threat to life. At induction, he received fentanyl, midazolam, vecuronium and ketamine. His trachea was intubated and he received positive pressure ventilation, requiring 2 phenylephrine boluses at the beginning of the procedure to maintain blood pressure. Anesthesia was maintained with oxygen in nitrous oxide and isoflurane. He received further doses of vecuronium during the course of the procedure. His blood pressure was maintained between 80–90 mmHg systolic.
A diagnostic right and left cardiac catheterization was performed. Multiple arteriovenous malformations were noted in the right lung. As the coarctation gradient despite adrenaline provocation was only 7 mmHg, no intervention to the arch was performed. He received 1000 ml intravenous fluids during the procedure, with an additional 70 ml intravenous contrast agent. After extubation and transfer to the recovery room, he required small incremental doses of naloxone to reverse opioid-induced drowsiness and respiratory depression.
His femoral arterial puncture was closed with an AngioSeal device and the venous sheath was removed at 6 hours due to a high activated clotting time after heparin administration. The patient was transferred to the cardiac high care unit for further monitoring of his conscious level.
Ten hours after the procedure, the patient developed symptoms of acute urinary retention. An ultrasound scan of the bladder showed more than 800 ml of urine in the bladder and per-urethral bladder catheterization drained 600 ml of urine. The urinary catheter remained in situ to 2 days and was removed without any residual post-voiding urine.
Patient #4. A 68-year-old man with an atrial septal defect (ASD), paroxysmal atrial fibrillation, and previous failed ablation, underwent cardiac catheterization under general anesthesia with a view to ASD closure. He had moderate left ventricular systolic dysfunction and his ASA grade was assessed as 3 (severe systemic disease, but not incapacitating). Following induction with propofol and vecuronium, his trachea was intubated and he received positive pressure ventilation. Anesthesia was maintained with oxygen in nitrous oxide and sevoflurane. During the procedure, he received boluses of glycopyrrolate and phenylephrine, cefuroxime, paracetamol and 800 ml intravenous fluid and only 10 ml of additional intravenous contrast agent. His blood pressure was maintained between 90–110 mmHg systolic.
Vascular access was obtained via the right femoral artery and vein and the left femoral vein. Diagnostic coronary angiography was normal. Diagnostic right heart study was then performed with test occlusion of the ASD. Left atrial pressure rose only to 14 mmHg and cardiac output was well maintained. The ASD was closed with a 26 mm Amplatzer septal occluder. The arterial puncture was sealed with an AngioSeal device. The procedure lasted 90 minutes and the patient was awakened after reversal of neuromuscular blockade with neostigmine and glycopyrrolate. Removal of the venous sheath was delayed for a further 2 hours following the procedure due to an elevated activated clotting time. He remained on bed rest for 6 hours.
During the evening of the procedure, the patient developed symptoms of acute urinary retention. While straining to pass urine, a hematoma developed at the puncture site in the right femoral region. A per-urethral catheter was placed and 700 ml of urine were drained. A Femstop (Radi Medical Systems, Uppsala, Sweden) was applied to the hematoma. When assessed the next day, the hematoma was soft with no evidence of false aneurysm formation and the patient was able to pass urine after removal of the catheter.
Discussion. The prevalence of congenital heart disease in the adult is increasing rapidly due to significantly improved surgical survival of more complex defects. These patients may present during long-term follow-up with worsening symptoms that are related to their underlying congenital cardiac disease or to the sequelae of their surgery. Many of these late hemodynamic problems are now treated with percutaneous techniques. Cardiac catheterization in this group is often prolonged, and often requires general anesthesia. Although urinary retention is well recognized following general anesthesia for surgery, it has not yet been documented in the cardiac catheterization literature. In this report, we have described 4 cases of urinary retention over a 1-year period resulting in an incidence of 3% in our unit.
The bladder is innervated by parasympathetic, sympathetic and somatic nerve fibres. Parasympathetic stimulation causes detrusor muscle contraction and bladder neck relaxation allowing bladder emptying. Sympathetic stimulation, on the other hand, causes relaxation of the detrusor and closes the internal urethral sphincter. Both systems act at a spinal level. Voluntary control of bladder emptying is via somatic innervations under the influence of higher centers.
Table 1 summarizes the drugs patients commonly receive during catheterization under conscious sedation and general anesthesia which can cause urinary retention.
Although the induction techniques and inhalational agents used were not identical in each case, each patient received drugs with a recognized predisposition to urinary retention. Benzodiazepines and opioid analgesics may cause post-operative urinary retention in isolation or in a cumulative fashion.3 The mechanism is presumed to be due to inhibition of detrusor muscle contraction and reduction in pain sensation normally created by a full bladder.5 Anticholinergic agents and alpha-1 adrenergic receptor agonists such as glycopyrrolate and phenylephrine, respectively, have also been linked with 
post-operative urinary retention mediating their effect either through blocking parasympathetic bladder innervation or by stimulating sympathetic nervous system activity.6 Table 2 summarizes the other events which can predispose to urinary retention. Age greater than 50 years and a previous history of urinary symptoms have been identified as risk factors for urinary retention. However, none of the patients reported here had significant pre-procedural risk factors and, specifically, none had urinary symptoms prior to cardiac catheterization. Only 1 patient was older than 50 years.
The amount of fluid given intra-operatively has also been shown to increase the risk of developing urinary retention. Over-distension of the bladder by the administration of intra-operative fluids can inhibit detrusor function and hence lead to retention.7 It has been reported in a multivariable analysis that fluid administration in excess of greater than 750 ml is an independent predictive risk factor for the development of post-operative urinary retention.3
Longer procedure length is also a well-recognized risk factor for post-operative urinary retention.2 Duration of surgery greater than 60 minutes and duration of anesthesia more than 80 minutes are felt to significantly increase this risk.3 The procedure lengths in these cases were all longer than these time limitations. Each patient was also required to remain on bed rest for an extended period of time after the procedure to maintain hemostasis at the point of vascular access. Various authors have clearly documented an association between prolonged bed rest and developing urinary retention.7
Conclusion. Many factors may contribute to the development of post-surgical and thus also post-cardiac catheterization urinary retention. The incidence in our unit over a 1-year period was 3%. Risk factors may include performance of complex and lengthy 
procedures in patients with congenital disease, general anesthesia, generous intraprocedural fluid administration, and prolonged bedrest post-operatively. Our impression is that probably the single most important factor contributing to catheter-related urinary retention may be bladder over-distension during prolonged procedures in combination with other risk factors as listed above. Table 3 summarizes a list of our recommendations.
Specialist teams should be equipped to minimize time under general anesthetic. Our current practice now dictates the deployment of 2 experienced interventionists to maximize time utilization and reduce total procedure duration. When procedures are likely to be prolonged to more than 60 minutes, due consideration should be given to the prophylactic insertion of a urinary catheter. The use of vascular closure devices is likely to reduce prolonged supine bedrest. However, the absence of closure devices suitable for closing venous access sites is a limiting factor. The reduction of intra-operative fluid administration, to the minimum required, should be considered. The use of benzodiazepines and opioids should be kept to a minimum or where possible avoided altogether. Local anesthetic infiltration and the use of simple analgesic drugs, such as paracetamol and non-steroidal anti-inflammatory drugs, may reduce the incidence of urinary retention. To our knowledge, there is no information on the use of new anesthetic techniques such as total intravenous anesthesia with the short-acting agents proprofol and remifentanil in this context.
References
- Youngson R. Collins Dictionary of Medicine. Harper Collins Publishers, Glasgow, 1999.
- Baldini G, Bagry H, Aprikian A, Carli F. Post-operative urinary retention anesthetic and peri-operative considerations. Anesthesiology 2009;110:1139–1157.
- Keita H, Diouf E, Tubach F, et al. Predictive factors of early post-operative urinary retention in the post-anesthesia care unit. Anesth Analg 2005;101:592–596.
- British National Formulary 58. BMJ Group and RPS Publishing, September 2009.
- Stallard S, Prescott S. Post-operative urinary retention in general surgical patients. Br J Surg 1988;75:1141–1143.
- Verhamme K, Sturkenboom M, Sticker B, Bosch R. Drug-induced urinary retention incidence, management, and prevention. Drug Safety 2008;31:373–388.
- Tammela T, Kontturi M, Lukkarinen. Post-operative urinary retention incidence and predisposing factors. Scand J Urol Nephrol 1986;20:197–201.
