The American Journal of Surgery (2014) 207, 288-292

Clinical Science

Incidence and risk factors for urinary retention following

laparoscopic inguinal hernia repair
Muthu V. Sivasankaran, M.D., Travis Pham, Pharm.D., Celia M. Divino, M.D., F.A.C.S.*
Division of General Surgery, Department of Surgery, Mount Sinai School of Medicine, 5 E 98th Street, 15th Floor, Box
1259, New York, NY 10029, USA

KEYWORDS:
Urinary retention;
Laparoscopic inguinal
hernia repair;
Postoperative urinary
retention;
Risk factors for urinary
retention;
Postoperative
complications after
laparoscopic inguinal
hernia repair;
Urinary retention in
laparoscopic inguinal
hernia procedures

Abstract
BACKGROUND: The incidence of postoperative urinary retention (PUR) has been reported to range
from 1% to 22% in patients who have undergone laparoscopic inguinal hernia procedures. The objectives of this study were to determine the incidence of PUR and examine different risk factors that may
be associated with the development of PUR in patients who have undergone laparoscopic inguinal hernia procedures.
METHODS: A retrospective chart review was performed on 350 patients. Demographics, comorbidities, and operative and postoperative information were collected in patients undergoing laparoscopic
inguinal hernia repair by 3 general surgeons from 2007 to 2011. Statistical analysis was done on patient
demographics, medical histories, anesthesia notes, and postoperative notes to identify risk factors for
the development of urinary retention after laparoscopic inguinal hernia repair.
RESULTS: Three hundred fifty consecutive patients who underwent laparoscopic inguinal hernia repairs were reviewed. Twenty-nine patients developed PUR, an incidence of 8.3%. Age R60 years and
history of benign prostatic hyperplasia showed significance on multivariate analysis, with odds ratios of
3.0 and 11.0 respectively (P , .05). Anesthesia time R2 hours (odds ratio, .75) was a contributing perioperative risk factor but only as an independent risk factor (P , .05).
CONCLUSIONS: History of benign prostatic hyperplasia, age R60 years, and anesthesia time R2
hours were significant independent risk factors for urinary retention after laparoscopic inguinal hernia
repair. On multivariate analysis, only history of group and age R60 years showed significance. This is
1 of the largest studies to show that the development of PUR in laparoscopic inguinal hernia repair patients is a multifactorial process. Further studies should be conducted to corroborate our findings.
2014 Elsevier Inc. All rights reserved.

Inguinal hernias are the most common type of hernias,

with approximately 700,000 treated on an annual basis in
the United States, making this 1 of the most frequently
performed operations in general surgery, accounting for

The authors declare no conflicts of interest.

Presented as a poster at the 2012 annual meeting of the American
College of Surgeons, Chicago, Illinois.
* Corresponding author. Tel.: 212-241-5499; fax: 212-241-5979.
E-mail address: celia.divino@mountsinai.org
Manuscript received January 15, 2013; revised May 30, 2013
0002-9610/$ - see front matter 2014 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.amjsurg.2013.06.005

about 10% of all general surgery procedures.1,2 The incidence of postoperative urinary retention (PUR) has been reported to range from 1% to 22% of patients who have
undergone laparoscopic inguinal hernia procedures.36 Laparoscopic inguinal hernia repairs are routinely performed as
outpatient procedures; however, the development of PUR
prevents same-day discharge in a considerable proportion
of this population. Patients experiencing PUR spend more
time in recovery, and some patients return to the emergency
department after being discharged for an inability to void,
all of which leads to increased medical costs. The

M.V. Sivasankaran et al.

Urinary retention following laparoscopic hernia repair

objectives of this study were to determine the incidence and

examine different risk factors that may be associated with
the development of PUR in patients who have undergone
laparoscopic inguinal hernia procedures.

Methods
After obtaining institutional review board approval, a
retrospective chart review was performed on 350 patients.
Demographics, comorbidities, and operative and postoperative information were collected from patients who underwent laparoscopic inguinal hernia repairs by 3 general
surgeons at Mount Sinai Medical Center from 2007 to
2011. Predictors and risk factors for the development of
PUR in patients undergoing laparoscopic inguinal hernia
procedures were determined using univariate and multivariate logistic regression analysis (SPSS version 18.0; SPSS,
Inc, Chicago, IL). Variables to be tested against the
dependent variable (urinary retention) were selected using
chi-square tests for categorical variables and t tests for continuous variables. Risk factors for the development of urinary retention in patients undergoing laparoscopic
inguinal hernia procedures were deemed significant at
P , .05.

Results
Patient demographics of the study population (n 5 350)
are as follows. The average age was 48.7 years, 92% were
men (n 5 322), and 8% were women (n 5 28). Seventyeight percent of the procedures (n 5 273) were bilateral
laparoscopic inguinal hernia repairs, and 22% (n 5 77)
were unilateral repairs. In terms of race, 45% were Caucasian, 28% were Hispanic, 19% were African American,
and 8% were identified as of other races. The mode for
American Society of Anesthesiologists class in the patient
population was class II (n 5 221). None of the repairs were
converted to open procedures.
PUR was defined as the inability to void after laparoscopic
inguinal hernia surgery requiring catheterization after a void
trial of a period of 5 to 8 hours. In this study, 29 patients
developed PUR, making the incidence at our institution
8.3%. Table 1 demonstrates demographic and operative information in patients who developed urinary retention compared with those patients who did not. All patients who
developed PUR retention were men. In terms of race, 76%
were Caucasian (n 5 22), 10% were Hispanic (n 5 3), 7%
were African American (n 5 2), and 7% were identified as
of other races (n 5 2). Eighty percent (n 5 23) were bilateral
procedures and 20% (n 5 6) were unilateral. The average age
was 57.6 years (range, 25 to 85 years). The mode for American Society of Anesthesiologists class was class II (n 5 19).
Average anesthesia time was 147 minutes in the population of
patients who developed urinary retention. Five patients were
discharged home on the day of surgery and readmitted to the
hospital the next day for inability to void. Six patients had

289

Table 1 Demographic and perioperative data in patients

with and those without PUR
Variable
Demographics
Average age (y)
Gender
Male
Female
ASA class, mode
Medical history
BPH
Prostate cancer
Diabetes mellitus
Perioperative data
Site of hernia
Bilateral
Unilateral
Average anesthesia
time (min)
Average operative
time (min)
Intraoperative Foley
catheter use
Average LOS (d)
Intraoperative
complications

Patients with
PUR

Patients
without PUR

49.7

57.6

96.5% (310)
3% (11)
II (n 5 287)

100% (29)
0% (0)
II (n 5 19)

5.6% (18)
3.7% (12)
26% (85)

41% (12)
14% (4)
17% (5)

83% (266)
17% (55)
117

80% (23)
20% (6)
147

73

92

100% (321)

100% (29)

58
0

1.27
0

ASA 5 American Society of Anesthesiologists; BPH 5 benign

prostatic hyperplasia; LOS 5 length of stay; PUR 5 postoperative
urinary retention.

histories of voiding problems, 12 had a history of benign

prostatic hyperplasia (BPH), and 4 had histories of prostate
cancer. The average volume of urine voided after catheterization was 492 mL. All patients who developed PUR were initially managed with single-shot catheterization. Continued
drainage was defined as catheterization with a residual of
.250 mL of urine. All patients were either observed overnight or discharged on the day of surgery with a catheter.
Those admitted as inpatients stayed overnight, and void trial
was done on postoperative day 1. A total of 9 patients were
managed in this fashion. If they failed, in early morning
they were discharged with Foley catheters with follow-up
and void trial with the urologist between postoperative
days 3 and 5. Four patients failed void trial and were sent
home with Foley catheters and seen by a urology service
postoperatively.
Logistic regression analysis was performed to examine
predictive factors for the development of PUR, which
included demographic variables, medical histories, and
certain perioperative factors. Variables such as sex, site of
hernia (unilateral vs bilateral), body mass index, type of
hernia (primary vs recurrent), transabdominal preperitoneal versus total extraperitoneal, indirect versus direct, and
mesh type were not significant predictors of PUR. Among
patients who developed PUR, all had received general
anesthesia, and 8 patients were given additional local
anesthetic before incision (Table 2). Among patients who

290

The American Journal of Surgery, Vol 207, No 2, February 2014

Table 2 Variables examined for the development of PUR on

univariate analysis
Variable

Age R60 y
Male gender
Race
Caucasian
African American
Hispanic
Other
Hernia site
Unilateral
Bilateral
Hernia Type
Indirect
Direct
Both
Laparoscopic method
TEP
Mesh type
Polypropylene mesh
Coronary artery disease
Hypertension
Diabetes
BPH
Intraoperative fluid R500 mL
Anesthesia time R2 h
Postoperative narcotic use

.002
.087
.124
.164
.148
.162
.097
.075
.214
.187
.112
.314
.094
.218
.126
.157
.0019
.163
.041
.213

BPH 5 benign prostatic hyperplasia; PUR 5 postoperative urinary

retention; TEP 5 total extraperitoneal.

did not develop PUR, all 321 patients had received general
anesthesia, and of those, 126 were given additional local
anesthetic before incision. The use of local anesthetic
was not a statistically significant predictor of PUR. Among
patients who developed PUR, 6 patients presented with
both indirect and direct hernias; the remainder of the 23
patients presented with indirect hernias. None of the patients had bladder slide in the sac. Among patients who
did not develop PUR, 33 (10%) had direct hernias, 21
(6.5%) had both indirect and direct hernias, and the remainder (n 5 267) all had indirect hernias. No patients
were reported to have bladder slide in the sac in this cohort as well. A standard polypropylene mesh was used
in all patients. Mesh placement was standard for all patients; that is, the mesh covered indirect and direct spaces,
and it was tacked to the pubic tubercle medially and as far
laterally as possible for adequate coverage. Using a receiver operating characteristic curve and logistic regression analysis, it was shown that age R60 years was a
significant risk factor for the development of urinary retention in patients undergoing laparoscopic inguinal hernia
repairs (P , .05). Comorbidities such as coronary artery
disease, hypertension, diabetes, and dyslipidemia showed
no correlation to the development of PUR in these patients
(P . .05). A history of BPH was deemed to be a significant risk factor (P , .05).

Perioperative factors that were also examined included

surgery time, intraoperative fluid volumes, and postoperative narcotic use. None of these variables showed any
correlation with the development of PUR after laparoscopic
inguinal hernia repairs (P . .05). A perioperative factor
that showed significance was anesthesia time R2 hours
(P , .05). Sixteen of the 29 patients who developed urinary
retention had anesthesia times R2 hours.
Multivariate analysis was performed on the aforementioned significant independent variables for the development
of PUR (Table 3). Only age R60 years and history of BPH
showed significance, with odds ratios of 3 and 11, respectively, thus indicating that a patient exhibiting both factors
was 14 times more likely to develop urinary retention (P ,
.05) than a patient with neither. When investigated by multivariate analysis, anesthesia time R2 hours did not show statistical significance (P . .05) and thus can only be taken into
consideration when it is the only variable exhibited by the
subject.

Comments
PUR is seen after laparoscopic inguinal surgical procedures in upward of 22% of patients.6 Urinary retention can
be a significant source of patient anxiety and discomfort.
According to Darrah et al,7 patients undergoing inguinal
hernia repair are particularly susceptible to PUR. Predicting
who will likely develop PUR can aid health care teams in
the proper management of this complication in a timely
manner.
We report an incidence of 8.3% (n 5 29) in 350 subjects
who underwent laparoscopic inguinal hernia repairs at our
institution. Our observed incidence falls within the range of
previously reported incidences (1% to 22%) of urinary
retention after laparoscopic inguinal hernia surgeries.36
The variation in the range of incidences reported in previous studies may result from differences in anesthetic and
surgical techniques, different definitions and diagnosis of
PUR, and/or differences in the patient population studied.
There have been a few studies that looked at PUR retention
specifically in the setting of laparoscopic inguinal hernia
repairs. The results have been varying in nature, suggesting
that the development of PUR is multifactorial. One common
risk factor assessed for the development of PUR is advancing

Table 3 Multivariate analysis of predictive factors for the

development of urinary retention

Risk factor

Odds ratio
(95% confidence
interval)

Age R60 y
History of BPH
Anesthesia time R2 h

.017
.0031
..05

3.0 (1.85.2)
11.0 (3.613.4)
.96 (.792.2)

BPH 5 benign prostatic hyperplasia.

M.V. Sivasankaran et al.

Urinary retention following laparoscopic hernia repair

age. Many studies have confirmed that elderly populations

are indeed at risk for developing PUR.811 This can be due to
the various neurogenic and myogenic changes that are seen in
the detrusor muscles of subjects with advancing age, leading
to diminished detrusor contractility and pressure and ultimately to the retention of urine.12 We examined patients
aged R60 years and found age R60 years to be a significant
predisposing factor (P ,.05) for the development of PUR after laparoscopic inguinal hernia repair. With an odds ratio of
3.0, subjects aged R60 years are 3 times more likely to develop PUR than those aged ,60 years. Diabetes mellitus
and female gender have also been suggested as predisposing
risk factors for the development of PUR in some studies.13
When diabetes mellitus was examined in our study population, only 5 patients who developed urinary retention had
this as a comorbidity, and it was not found to be a statistically
significant risk factor for PUR retention (P . .05); the same
deduction was reached for female gender as well in this study.
Another comorbidity examined in this study was BPH.
In a study by Koch et al,6 the authors conducted a 1:1 casecontrol analysis; in that study 9 subjects who developed urinary retention (of the total of 34) also had histories of BPH.
The authors noted that BPH was not a significant predisposing risk factor for the development of PUR in subjects who
have undergone laparoscopic inguinal hernia procedures.
Our findings suggest that BPH is a significant predisposing
factor in the development of PUR. Of the 29 patients who
developed urinary retention, 12 had histories of BPH. We
found both BPH and age R60 years to be statistically significant factors on multivariate analysis (P , .05), with
odds ratios of 11 and 3, respectively. This suggests that in
patients with histories of BPH who are R60 years of age,
the risk for developing urinary retention is increased 14
times compared with patients without histories of BPH
who are ,60 years of age.
The length of anesthesia time has also been examined as
a risk factor for the development of PUR. Some studies that
examined anesthesia time showed an association between
longer anesthesia times and the development of urinary
retention. For instance, in a study conducted by Hansen
et al,14 the investigators looked at 773 patients who underwent various types of abdominal, orthopedic, and gynecologic surgeries and developed PUR. They were able to
show through regression analysis that anesthesia time R2
hours (P , .05) was a significant predisposing risk factor
for the development of PUR. Our study has shown that anesthesia time R2 hours can be an independent risk factor
(P , .05), with an odds ratio of .75, but it would be wise
to note that when calculated through a multivariate analysis
(along with the other significant variables in this study, ie,
ageR 60 years and history of BPH), it was not shown to be
significant (P . .05). Hence, anesthesia time .2 hours can
be considered a predisposing risk factor only when it is
seen independently in a particular patient.
Previous studies have demonstrated the efficacy of using
portable ultrasound bladder scanners for the diagnosis of
urinary retention, because it facilitates rapid and accurate

291

measurements of bladder volume.15 Although this diagnostic

modality is superior to diagnosis solely dependent on plain
physical exam and patient symptoms, further investigation
is needed to determine the more widespread use of portable
ultrasound bladder scanners. Even with accurate measurements of bladder volume with ultrasound, it is still not clear
at what bladder volume patients should be catheterized. It is
known that a normal bladder can hold up to 400 to 600 mL of
urine. Some studies have suggested that the point at which a
patient should be catheterized is at a threshold of 600
mL.15,16 Parameters for the proper management of patients
with PUR who have undergone laparoscopic inguinal hernia
repair are not clearly defined. According to Darrah et al,7 urinary retention after ambulatory surgery is commonly managed with in-out urethral catheterization. However, the
choice of indwelling or clean intermittent urethral catheterization for PUR in patients remains controversial.7 Singer
et al17 devised an algorithm for the management of PUR after
various surgical procedures, in which the first step is to catheterize and remove the Foley catheter immediately once the
bladder has been drained. In another study, Haskell et al18
suggested leaving the catheter indwelling for a period of 24
hours to prevent urinary retention and the need for recatheterization in patients who have undergone inguinal hernia repairs. Further studies should be conducted to help clarify
this ambiguity regarding catheterization, specifically in patients undergoing laparoscopic inguinal hernia repairs.

Conclusions
This is one of the largest studies to show that the
development of PUR, specifically in laparoscopic inguinal
hernia repair patients, is a multifactorial process. The
effects of PUR are well known, including patient morbidity,
increasing length of hospital stay, and associated costs.
Further studies should be conducted to corroborate our
findings, which may aid in standardizing the management
of this condition in this patient population.

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2014 Elsevier