MONTREAL—Patients who received sugammadex to reverse a neuromuscular block for inguinal hernia repair had significantly lower rates of postoperative urinary retention (POUR) than those given an acetylcholinesterase inhibitor, according to results of a study presented at the 2023 annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.
In a series of 3,345 inguinal hernia repairs, 1.5% of patients who received sugammadex developed POUR compared with 4.4% in the anticholinesterase group (P<0.001).
Sugammadex (Bridion, Merck) was associated with a lower odds of POUR in all elective, clean inguinal repairs, regardless of operative approach or laterality, in a propensity score-matched analysis.
“Definitely, we think there is potential for changing how we practice in terms of anesthesia reversal for those receiving inguinal hernia repairs at our center,” said Lucy Ching Chau, MD, a PGY-4 general surgery resident at Henry Ford Hospital, in Detroit, during her presentation.
She said there is a strong case for using sugammadex in routine clean cases, especially for patients considered at high risk for POUR, including older patients or those who have had prior pelvic surgery or urinary retention.
The study did not show a reduction in urinary retention after urgent or clean-contaminated cases when sugammadex was used. Dr. Chau said this may reflect the challenge of POUR in cases when sepsis and infection are present.
A common complication following inguinal hernia repair, POUR has a reported incidence of between 5.9% and 38%.
Anesthesiologists at Henry Ford Hospital started using sugammadex more often because patients awaken faster from anesthesia. Sugammadex reverses amino steroid muscle relaxants by forming a stable complex with free molecules and takes effect more quickly than acetylcholinesterase inhibitors.
Dr. Chau and her colleagues decided to do the study after noticing that patients who had received sugammadex appeared to have fewer issues with POUR.
They examined outcomes in adult patients who underwent inguinal hernia repairs at a single center between January 2019 and January 2022. All patients received either rocuronium- and vecuronium-induced neuromuscular blockade, for which sugammadex has received an FDA approval.
About one-third of patients (1,101) received sugammadex and the rest of the cohort received anticholinesterase. Patients in the latter group were more likely to have a peripheral nerve block, 33.8% versus 24.3% (P<0.001), and less likely to have a glucocorticoid administered, 67.2% versus 80% (P<0.001).
The investigators examined whether there were differences in POUR based on surgical approach, laterality and whether a case was clean or elective.
“I think this was a really important analysis and the Achilles’ heel, in my mind, of minimally invasive inguinal hernia repair is post-op urinary retention, and at least in my experience is a little higher than what you’ve quoted,” said Michael Brunt, MD, the Pruett Family Professor of Surgery at the Washington University School of Medicine in St. Louis, after the presentation at the meeting.
This is the second study to show that neuromuscular blockade reversal with sugammadex is associated with lower rates of POUR after inguinal hernia repair. In a series of 181 patients treated at a single institution between 2013 and 2020, POUR was reported in 3% of patients in the sugammadex group compared with 15% who were given neostigmine-glycopyrrolate (Surg Laparosc Endosc Percutan Tech 2021;31[5]:613-617).
Dr. Chau’s team is planning a follow-up study to examine the cost-effectiveness of sugammadex in inguinal hernia repair.
Their analysis to date suggests that 34.5 patients need to be treated with sugammadex to prevent one case of POUR. Sugammadex is the more expensive option at roughly $100 per dose in contrast to $6 for an anticholinesterase inhibitor, she said. But there may be a cost benefit by reducing complications, she noted.
“Even though that sugammadex costs more on paper compared to an anticholinesterase, the cost of readmitting someone for urinary retention, the cost of the morbidity and sometimes mortality associated with this far outweighs that,” she said.