INTRODUCTION
Surgical interventions may predispose to complications related to the surgery,
the anesthetic procedure, and pharmacological side effects1.
Postoperative urinary retention is frequent in many patients and can permanently
damage the bladder since it compromises its anatomy and predisposes it to
motility problems and atony2,3,4,5. In addition, this
situation favors the occurrence of recurrent urinary infections since incomplete
emptying of the bladder and the resulting volume of post-void residual urine
facilitates bacterial proliferation1.
Risk factors for its incidence include the type of anesthesia, type of surgery
(mainly anorectal), male gender, elderly, intravenous hydration therapy, use of
anticholinergic drugs, analgesics, and opioids, and loss of privacy4,6.
Previously, the diagnosis of this condition was suspected by clinical symptoms
(inability to urinate and pain) and physical examination (palpable and distended
bladder) and confirmed through bladder catheterization. More recently, the use
of portable ultrasound to measure the volume of the bladder allowed earlier
diagnosis, in addition to being a fast, effective, and non-invasive method5.
Complementary urodynamic tests are essential once the lesion is established to
assess bladder disorders and choose the most appropriate treatment
objectively7.
OBJECTIVE
This study aims to report the case of a patient with urinary retention in the
postoperative period of lipoabdominoplasty.
CASE REPORT
A female, 27-year-old patient without comorbidities or use of continuous
medication. Former smoker with a surgical history of cesarean delivery.
Preoperatively, she had a body mass index (BMI) of 27.8 kg/m2 and
tests within normal parameters, classified as ASA II (Figure 1).
Figure 1 - Preoperative. A: Front view; B: Oblique
view; C: Profile view.
Figure 1 - Preoperative. A: Front view; B: Oblique
view; C: Profile view.
She was admitted to the hospital asymptomatic. She underwent general anesthesia
associated with spinal anesthesia and antibiotic prophylaxis with 2g cefazolin.
In addition, indwelling bladder catheterization was performed. She underwent
lipoabdominoplasty lasting four hours, and there were no surgical or anesthetic
complications during this period.
The patient evolved well in the immediate postoperative period, with no
complaints. Hydration, antibiotic therapy, analgesics, opioids, antiemetics, and
prophylactic measures for venous thromboembolism (VTE) were prescribed.
On the first postoperative day, she urinated spontaneously after removing the
indwelling urinary catheter and reported only nausea and mild pain in the
liposuctioned region. She had a good surgical evolution, with no evidence of
complications. She was discharged with an indication of antibiotic therapy
(first-generation cephalosporin) for seven days, analgesics, opioids (500mg of
paracetamol associated with 30mg of codeine every eight hours if severe pain),
and antithrombotic prophylaxis with subcutaneous enoxaparin 40mg/day for seven
days.
On the second postoperative day, she complained of dysuria, urinary frequency,
and vesical tenesmus. She underwent a urinalysis1, showing only nitrite and mild hematuria (10,000 red blood
cells/ml). Phenazopyridine and 750mg/day levofloxacin antibiotic were prescribed
for seven days.
She returned to the office on the fourth postoperative day for medical
evaluation. She reported improvement in symptoms after two days of the new
therapy, with satisfactory bladder emptying and without dysuria. The dressing
was changed on that occasion, and the drain was removed.
On the 10th postoperative day, she went to the hospital complaining of
urinary retention. She reported still using 500mg of paracetamol associated with
30mg of codeine every eight hours. On physical examination, she had a palpable
and painful bladder in the suprapubic region. An ultrasound of the total abdomen
and abdominal wall was performed, showing bladder distention. She underwent a
relief urinary catheter, with immediate drainage of 2500ml of urine and
immediate pain relief.
In an interconsultation with Urology, she was instructed to keep a long-term
urinary catheter with occlusion of the probe every four hours, with a good
response. Magnetic resonance imaging of the lumbar spine excluded possible
traumatic complications related to spinal anesthesia, and computed tomography of
the abdomen excluded possible traumatic complications related to
lipoabdominoplasty.
She was discharged the following day with a urological follow-up and request for
an outpatient urodynamic study. The study revealed the absence of detrusor
contraction, reduced bladder sensitivity, and preserved bladder compliance and
capacity. The Urology team then recommended intermittent relief bladder
catheterization (every eight hours) and bladder training with physiotherapy.
She maintained outpatient follow-up with the Plastic Surgery (Figure 2) and Urology team, with a
progressive reduction in the use of relief bladder catheter and complete removal
in eight months of follow-up, after recovery of urination capacity.
Figure 2 - Postoperative 3 months. A: Front view;
B: Oblique view; C: Profile
view.
Figure 2 - Postoperative 3 months. A: Front view;
B: Oblique view; C: Profile
view.
The study protocol was approved by the Ethics and Research Committee (Opinion
number 5,922,090). Patient images in this publication have informed consent.
DISCUSSION
The objective of aesthetic plastic surgery is to improve the physical aspect of
the body of the individual who feels uncomfortable with a certain appearance
characteristic. However, like other surgical procedures, it is subject to
complications.
Pain seems to be the most frequent among the complaints reported in the
postoperative period, according to some authors8,9. The main strategies to
control this symptom involve using common analgesics, anticholinergics,
anti-inflammatories, and opioids. These medications can occasionally interfere
with urination pathways, since this complex mechanism involves many neural
connections.
Opioids are major contributors to the development of post-surgical urinary
retention. This is due to its side effects, which include relaxation of the
detrusor muscle, with a corresponding increase in maximum bladder capacity4. They can also increase the tone and
amplitude of urinary sphincter contractions and reduce ureteral
contractions10. As already well
established in the literature, urinary relief catheterization can be used to
prevent permanent complications to the urinary tract since a single episode of
bladder overdistension can result in significant morbidity4.
However, the early diagnosis of urinary retention in the postoperative period of
lipoabdominoplasty still has some obstacles. The plication of the rectus muscle
diastasis, associated with liposuction and using a compressive abdominal belt,
make it difficult to identify a possible bladder distention. In addition, in the
immediate postoperative period, swelling of the operative area, local pain, or
even the occurrence of seroma is expected, further impairing the clinical
diagnosis.
Portable ultrasound seems to be an effective method for identifying this
complication in the inhospital environment5. After discharge, objective guidelines and the rational use of
opioids seem to help with prevention, but these measures are still insufficient
in some cases.
The present report demonstrated the good evolution of a patient who developed
urinary retention in the postoperative period of lipoabdominoplasty. Given the
clinical picture, after an etiological investigation, the main diagnostic
hypothesis was that it was secondary to the use of opioids.
CONCLUSION
Urinary retention is a relatively frequent complication in postoperative
patients. Some individuals, at first, may be oligosymptomatic, and postoperative
symptoms may further mask this condition, which delays diagnosis and predisposes
to permanent consequences.
1. Serviço de Cirurgia Plástica Osvaldo Saldanha,
Santos, SP, Brazil
2. Universidade Santo Amaro, São Paulo, SP,
Brazil
Corresponding author: Taisa Szolomicki
Av. Ana Costa, 146, Cj 1201-04, Gonzaga, Santos, S P, Brazil Zip Code: 11060-000
E-mail: tszolomicki@hotmail.com