P047: TRADITIONAL NEOSTIGMINE IS STILL A VIABLE ALTERNATIVE TO CATHETERIZATION IN POST?OPERATIVE URINARY RETENTION
Juliet Galtes, MD1; Mitch Daniel1; Victoria Martin, MD1; Tanjina Jalil, MA2; John Hodgson, MD1; Enrico M Camporesi, MD1
1University of South Florida Morsani College of Medicine; 2TeamHealth Anesthesia, Tampa General Hospital
Background: Postoperative urinary retention (POUR) is a common complication of surgery and anesthesia, with an incidence of 4–5% in elective procedures 1. Risk factors include advanced age, perioperative medications, and urologic comorbidities such as benign prostatic hyperplasia (BPH). POUR is traditionally managed with bladder catheterization, which carries risks of infection, urethral trauma, and prolonged hospitalization. Pharmacologic alternatives such as alpha-adrenergic antagonists or cholinergic agonists have been trialed, but with variable efficacy. Neostigmine, an acetylcholinesterase inhibitor, enhances parasympathetic activity to promote detrusor contraction and may represent a noninvasive treatment option, although recently its use in POUR is rarely reported 2.
Case Presentation: A 73-year-old male with a history of benign prostatic hyperplasia (BPH), bladder cancer status-post transurethral resection of bladder tumor (TURBT), and interstitial pulmonary fibrosis, presented for magnetic resonance image (MRI)-guided transperineal prostate biopsy. The procedure was performed under general anesthesia and tolerated without complication. Postoperatively, the patient developed acute urinary retention that persisted for over 5 hours despite ambulation, caffeine, and tamsulosin administration. Wishing to avoid catheterization, the patient elected to trial neostigmine after a risk–benefit-alternatives discussion. A 0.5 mg intravenous injection of neostigmine was administered without anticholinergic. Within 20 minutes, the patient achieved complete voiding (volume of 565 mL) without adverse hemodynamic effects and was discharged home promptly.
Discussion: Neostigmine retains a particular relevance for postoperative urinary retention despite the growing use of sugammadex for rocuronium reversal. While sugammadex shortens neuromuscular recovery to roughly?2?minutes—compared with the 10–17?minutes typically required for neostigmine—and lowers the incidence of residual paralysis and minor respiratory complications, several characteristics continue to favor neostigmine in the context of POUR 3. Its low cost and universal availability contrast with the uncertain cost-effectiveness of sugammadex for routine application, making neostigmine especially attractive in resource-limited settings. Moreover, when administered at modest doses without concomitant anticholinergic agents, neostigmine exhibits a stable hemodynamic profile that has been confirmed across diverse surgical populations. In patients with severe renal impairment, neostigmine’s reversal time is prolonged (approximately?15?minutes versus?3.5?minutes for sugammadex), yet it still provides satisfactory neuromuscular recovery when sugammadex is contraindicated or unavailable4.
Conclusion: This case adds to the limited body of evidence supporting neostigmine as a non-invasive alternative for POUR. While catheterization remains the preferred method of management, neostigmine may offer a safe, inexpensive, and effective option for patients who decline or are at high risk for catheter-related complications. Further studies are warranted to better define its safety, efficacy, and role in perioperative urinary retention protocols.
References:
1. Scott AJ, et al. Risk factors for postoperative urinary retention after ambulatory surgery. World J Surg. 2018;42:3874–3879.
2. Brouwer TA, et al. Postoperative urinary retention: risk factors and timing. Perioper Med (Lond). 2021;10:2.
3. Abad-Gurumeta A, et al. Sugammadex vs neostigmine for reversal: systematic review. Anaesthesia. 2015;70:1441–1452.
4. Oh MW, et al. Sugammadex vs neostigmine in renal impairment: RCT. Anesth Analg. 2024;138:1043–1051.