Effect of incision location and type of fistula on postoperative urinary retention after radical surgery for anal fistula: a retrospective analysis

Effect of incision location and type of fistula on postoperative urinary retention after radical surgery for anal fistula: a retrospective analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Effect of incision location and type of fistula on postoperative urinary retention after radical surgery for anal fistula: a retrospective analysis Chen Li, Ningyuan Liu, Zichen Huang, Zijian Wei, Keyi Li, Wenxiao Hou, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4236957/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 14 Oct, 2024 Read the published version in BMC Gastroenterology → Version 1 posted 4 You are reading this latest preprint version Abstract Background Postoperative urinary retention (POUR) refers to the postoperative symptom of bladder fullness without the ability to urinate autonomously. The etiology of POUR in proctology surgery remains unclear, and the underlying causes are multifactorial. The aim of this study was to determine the risk factors for POUR after radical surgery for anal fistula. Methods We retrospectively reviewed the clinical records of 511 patients who underwent radical surgery for anal fistula under general anesthesia at the China-Japan Friendship Hospital from August 2022 to December 2023. Risk factors for POUR were determined using binary logistic regression analyses. Results 57 patients (11.2%) experienced urinary retention within 48 hours after surgery, while the majority of whom were male (84.4%). Multivariate logistic stepwise regression revealed that a history of urological disease (OR = 6.048; P < 0.001), incisions at position 1 (OR = 2.228; P = 0.046), the presence of high anal fistula (OR = 4.768; P < 0.001), a VAS score ≥ 7 (OR = 2.805; P = 0.010), and a GAD-7 score ≥ 5 (OR = 2.405; P = 0.024) were independent risk factors for POUR after radical surgery for anal fistula. Conclusion POUR is a common complication following radical surgery for anal fistula. Patients with urological disease or high anal fistula or incisions at position 1 are more likely to develop POUR. Surgeons should pay more attention to the surgical techniques of fistulas in the anterior rectum. Better postoperative pain and anxiety management strategies should be provided to reduce the incidence of POUR and avoid irreversible damage caused by persistent bladder overdistension. Postoperative urinary retention radical surgery for anal fistula risk factors loose combined cutting seton urological disease high anal fistula Introduction Postoperative urinary retention (POUR) refers to the symptom of bladder fullness without the ability to urinate autonomously after surgery and is characterized by the obstruction of bladder emptying and increased residual urine volume [ 1 ]. Anal fistula refers to an abnormal tunnel between the anorectum and the perianal skin. Approximately 80%-90% of anal fistulas are formed through the infection of glands within the anal crypt that form a perirectal abscess, which then breaks down or presses into the fistula. High anal fistulas traverse above a line marked by the deep portion of the external sphincter (i.e., the anorectal ring plane). Surgery is the main treatment approach for anal fistulas [ 2 ]. POUR is a frequent complication following proctology surgery. Sustained bladder dilatation may lead to permanent impairment of bladder function. However, the etiology of POUR in proctology surgery remains unclear. Previous studies have indicated that various factors, such as sex [ 3 , 4 ], age [ 5 , 6 ], history of previous illness [ 6 – 10 ], surgical method [ 11 ], anesthesia method [ 6 , 12 , 13 ], surgical duration [ 14 , 15 ], intraoperative fluid volume [ 16 , 17 ], and postoperative pain, could be risk factors for POUR. The mechanism of urinary retention includes mechanical obstruction of the bladder outlet and inhibition of contraction by the bladder detrusor muscle [ 18 , 19 ]. A variety of factors, such as perianal pain, anal packing discomfort, anxiety, and bladder overdistension, influence the mechanisms that lead to urinary retention. Moreover, intraoperative stimulation of the anal sphincter can also affect the associated nerves, leading to urinary retention. The multifactorial nature of urinary retention makes it a challenging issue to address following proctology surgeries [ 20 ]. The aim of this study was to determine the risk factors for POUR after radical surgery for anal fistula under general anesthesia. The results of this study can be used to identify strategies for its prevention and management to reduce the incidence of POUR and avoid irreversible damage caused by persistent bladder overdistension to improve patient satisfaction with surgery. Materials and methods Participants and surgical procedures for anal fistula Ethical approval for this study (2022-KY-121) was provided by the Ethical Committee of the China-Japan Friendship Hospital on 15 July 2022. In this study, 511 patients with anal fistula who underwent radical surgery for anal fistula under general anesthesia at China-Japan Friendship Hospital from August 2022 to December 2023 were selected as the study patients. We retrospectively analyzed their clinical records. Patients were excluded from the study if their clinical records were missing substantial data, if the patient suffered from serious systemic illnesses or psychiatric disorders, or if they had suspicious anorectal masses that prevented surgery from being completed. Patients with low anal fistulas were treated with direct incisions. The specific surgical operation involved the use of a probe from the external orifice and the internal orifice of the anal fistula near the anal sinus along the probe via a one-time incision. Patients with high anal fistulas were treated with a loose combined cutting seton (LCCS) [21]. The specific surgical operation involved the use of a probe from the external orifice, a probe in the direction of the fistula, a fully exposed fistula, and the use of a finger or hemostatic forceps to bluntly separate the fistula from the trauma along the direction of the fistula to the rectum. The potential cavity or fistula was explored to the sides of the tract until the probe reached the top of the fistula. Then, from the top of the fistula to the rectal lumen of the stoma, a silk thread seton was ligated on the highest spot of each fistula and tied firmly (a cutting seton), and a complex anal fistula was hung between the various incisions on the silk thread to keep the incision drainage open (a loose draining seton). All surgeries were performed after fentanyl hydrochloride was injected and propofol cream was applied for general anesthesia. At the end of the surgery, the anus was packed with hemostatic gauze, and compression was applied to slow the bleeding; bandages with sterile dressings were then applied under pressure. In the ward, the patients were given flurbiprofen (100 mg) or oral loxoprofen (60 mg) to relieve wound pain. If necessary, intramuscular tramadol hydrochloride (100 mg) or indomethacin suppositories were injected anally to assist in analgesia. Patients were dressed daily postoperatively and advised to use warm medicated sitz baths. If patients experienced significant bladder fullness and discomfort postoperatively but were unable to urinate or had incomplete urination, nursing staff first attempted to facilitate urination through supportive measures (advising the patient to apply warm compress and abdominal massage, take sitz baths, stand or walk). If these measures failed and the swollen bladder could be palpated by a physician, catheterization was performed. The decision to leave a catheter in place was based on the patient's condition. In this study, POUR was defined as the need for catheterization within 48 hours after surgery. Data collection The following details were documented from the patients’ clinical records: 1. Preoperative variables: sex, age, body mass index (BMI), duration of disease, prior history of diabetes, hypertension, urological diseases, neurological diseases, proctology surgery history, smoking history, and drinking history; 2. Intraoperative variables included the duration of surgery, intraoperative fluid volume, number of surgical incisions, number of quadrants involved, location of surgical incisions (twelve equal clockwise markings were used to divide the perineum into 12 parts, with the perineum in the center at position 12, the sacrococcygeal in the center at position 6, the left midpoint at position 3, the right midpoint at position 9, and the remaining position labeled accordingly), and whether the primary surgery was combined with other proctology surgeries. Patients with a high anal fistula whose number of cutting setons and loose draining setons were recorded; 3. Postoperative variables included: postoperative pain visual analogue scale (VAS) score, postoperative generalized anxiety disorder-7 (GAD-7) score, the presence of urinary tract infection, and length of hospital stay. Statistical analysis Odds ratios (ORs) and 95% confidence intervals (CIs) derived from binary logistic regression analysis were used to assess risk factors for POUR. The Shapiro‒Wilk test was used to assess the normality of the distribution of continuous data. Continuous normally distributed data are expressed as the mean and standard deviation (SD), and nonnormally distributed data are expressed as the median and interquartile range (IQR) and were evaluated by rank sum tests. Categorical data are described as the percentage (%) of cases and were evaluated by the chi-square test. Differences were considered significant when P < 0.05. All the statistical analyses were performed using SPSS (version 25.0, IBM, Inc., Chicago, Illinois, USA). Results Characteristics of participants with or without POUR In this study, of the 511 patients, 454 patients (88.8%) did not experience urinary retention following radical surgery for anal fistula under general anesthesia, while 57 patients (11.2%) experienced urinary retention within 48 hours after surgery. The average age of the patients was 39.79 ± 11.99 years, 85.5% were male, and 14.5% were female. A detailed comparison of the patients’ characteristics is provided in Table 1 . A previous history of urological disease is more prevalent among POUR patients According to the preoperative clinical records, there was no difference in the sex ratio between the POUR group and the non-POUR group (males: 91.2% vs. 84.4%, females: 8.8% vs. 15.2%, P = 0.194). The average age in the POUR group was greater than that in the non-POUR group (44.79 ± 13.7 vs. 39.17 ± 11.624, P = 0.002). There were no differences between the POUR and non-POUR groups in terms of BMI [25.51 (23.15, 26.70) kg/m 2 vs. 25.26 (23.17, 28.06) kg/m 2 , P = 0.558], a history of diabetes (7.0% vs. 5.1%, P = 0.759), hypertension (21.1% vs. 13.7%, P = 0.135), neuropsychiatric diseases (5.3% vs. 3.3%, P = 0.708), proctology surgery history (40.4% vs. 34.4%, P = 0.394), smoking history (36.8% vs. 26.5%, P = 0.102), drinking history (33.3% vs. 27.4%, P = 0.350), or duration of disease [5 (1,18) months vs. 6 (2,36) months, P = 0.070]. However, a greater proportion of patients in the POUR group had a history of urological disease (22.8% vs. 5.5%, P < 0.001). This showed that only age and history of urological disease were significantly different according to the preoperative data. Differences in surgical approaches exist between POUR and non-POUR patients According to the intraoperative clinical records, the duration of surgery [0.71 (0.52, 1.0050) h vs. 0.40 (0.26, 0.6925) h, P < 0.001], intraoperative fluid volume [500 (500, 1000) mL vs. 500 (300, 500) mL, P < 0.001], number of surgical incisions [3 (1, 4) vs. 1 (1, 3), P < 0.001], and number of quadrants [3 (1, 3) vs. 1 (1, 2), P < 0.001] involved were significantly greater in the POUR group. Interestingly, the proportion of patients with incisions at positions 1, 3 and 9 was significantly greater in the POUR group than in the non-POUR group (30.4% vs. 18.8%, P = 0.045; 60.7% vs. 30.8%, P < 0.001; 53.6% vs. 26.7%, P < 0.001). However, there was no significant difference when this technique was combined with other proctological surgeries (42.1% vs. 42.1%, P = 0.992). The proportion of patients with high anal fistula was greater in the POUR group than in the non-POUR group (77.2% vs. 44.3%, P < 0.001); among patients with high anal fistula, differences in the number of cutting setons [3 (0.25,3) vs. 0 (0,2), P < 0.001] and loose draining setons [2 (0,3.75) vs. 0 (0,2), P < 0.001] were also statistically significant between the POUR and non-POUR groups. In conclusion, the duration of surgery, the intraoperative fluid volume, and the complexity of the surgery were associated with POUR. More meaningfully, the location of the surgical incisions also had an important effect on the occurrence of POUR. POUR patients have greater VAS and GAD-7 scores According to the postoperative clinical records, the average VAS score [8 (6,9) vs. 6 (5,8), P < 0.001] and GAD-7 score [4 (1,7) vs. 1 (0,4), P = 0.001] was higher in the POUR group than in the non-POUR group, and the average length of hospital stay was also significantly longer for patients in the POUR group [8 (5.5,12.5) days vs. 5 (3,7) days, P < 0.001]. However, there was no significant difference in the incidence of urinary tract infections (8.0% vs. 3.4%, P = 0.251) between the two groups. Postoperative pain and anxiety were more likely to cause POUR, and POUR could prolong patients’ hospital stays. Univariate and multivariate logistic regression analyses findings The univariate analysis results were similar to those of previous studies. Table 2 shows the results of the univariate logistic regression analysis of risk factors for POUR following radical surgery for anal fistula. Age (OR = 1.036; P = 0.001), a history of neurological disease (OR = 5.070; P < 0.001), a longer duration of disease (OR = 1.008; P = 0.005), a duration of surgery ≥ 0.5 h (OR = 2.590; P < 0.001), an intraoperative fluid volume ≥ 500 mL (OR = 2.946; P < 0.001), a greater number of surgical incisions (OR = 1.482; P < 0.001), a greater number of involved quadrants (OR = 1.797; P < 0.001), incisions at position 1 (OR = 1.879; P = 0.047), incisions at position 3 (OR = 3.474; P < 0.001), incisions at position 9 (OR = 3.165; P < 0.001), the presence of high anal fistula (OR = 4.260; P < 0.001), a greater number of cutting setons (OR = 1.505; P < 0.001) and loose draining setons (OR = 1.400; P < 0.001), a VAS score ≥ 7 (OR = 4.072; P < 0.001), and a GAD-7 score ≥ 5 (OR = 2.741; P = 0.001) were significant risk factors for POUR following radical surgery for anal fistula. Uncommon independent risk factors: postoperative anxiety and incisions at position 1 All significant risk factors identified in the univariate analysis were included in a multivariate logistic stepwise regression analysis, and the detailed results are presented in Table 3 . A history of urological disease (OR = 6.048; P < 0.001), incisions at position 1 (OR = 2.228; P = 0.046), the presence of high anal fistula (OR = 4.768; P < 0.001), a VAS score ≥ 7 (OR = 2.805; P = 0.010), and a GAD-7 score ≥ 5 (OR = 2.405; P = 0.024) were found to be independent risk factors for urinary retention following radical surgery for anal fistula. Table 1 Characteristics of the participants Variable non-POUR group (n = 454) POUR group (n = 57) \({\varvec{x}}^{2}\) P value Sex, n (%) Male 385 (84.8) 52 (91.2) 1.689 0.194 Female 69 (15.2) 5 (8.8) Age (years, IQR, mean±SD) 37 (31,45) 44.79±13.74 -3.118 0.002 BMI (kg/m 2 , IQR) 25.26 (23.17,28.06) 25.51 (23.15,26.70) -0.586 0.558 <24 kg/m 2 , n (%) 150 (33.0) 18 (31.6) 0.049 0.825 ≥24 kg/m 2 , n (%) 304 (67.0) 39 (68.4) Diabetes, n (%) Yes 23 (5.1) 4 (7.0) 0.094 0.759 No 431 (94.9) 53 (93.0) Hypertension, n (%) Yes 62 (13.7) 12 (21.1) 2.237 0.135 No 392 (86.3) 45 (78.9) Urological diseases, n (%) Yes 25 (5.5) 13 (22.8) 19.578 < 0.001 No 429 (94.5) 44 (77.2) Neurological diseases, n (%) Yes 15 (3.3) 3 (5.3) 0.141 0.708 No 439 (96.7) 54 (94.7) Proctology surgery history, n (%) Yes 140 (34.4) 21 (40.4) 0.726 0.394 No 267 (65.5) 31 (59.6) Smoking history, n (%) Yes 120 (26.5) 21 (36.8) 2.678 0.102 No 332 (73.5) 36 (62.3) Drinking history, n (%) Yes 124 (27.4) 19 (33.3) 0.872 0.350 No 328 (72.6) 38 (66.7) Duration of disease (months, IQR) 5 (1,18) 6 (2,36) -1.812 0.070 Duration of surgery (hours, IQR, mean±SD) 0.40 (0.26,0.6925) 0.81 ± 0.45 -5.411 < 0.001 <0.5 h, n (%) 272 (59.9) 13 (22.8) 28.266 < 0.001 ≥0.5 h, n (%) 182 (40.1) 44 (77.2) Intraoperative fluid volume (mL, IQR) 500 (300,500) 500 (500,1000) -5.021 < 0.001 <500 mL, n (%) 337 (87.8) 31 (57.4) 32.483 < 0.001 ≥500 mL, n (%) 47 (12.2) 23 (42.6) Number of surgical incisions (IQR) 1 (1,3) 3 (1,4) -4.799 < 0.001 Number of quadrants involved (IQR) 1 (1,2) 3 (1,3) -4.527 < 0.001 Incisions at position 1, n (%) Yes 74 (18.8) 17 (30.4) 4.031 0.045 No 319 (81.2) 39 (69.6) Incisions at position 2, n (%) Yes 27 (6.9) 5 (8.9) 0.080 0.778 No 366 (93.1) 51 (91.1) Incisions at position 3, n (%) Yes 121 (30.8) 34 (60.7) 19.419 < 0.001 No 272 (69.2) 22 (39.3) Incisions at position 4, n (%) Yes 8 (2.0) 3 (5.4) 1.086 0.297 No 385 (98.0) 53 (94.6) Incisions at position 5, n (%) Yes 75 (19.1) 9 (16.1) 0.292 0.589 No 318 (80.9) 47 (83.9) Incisions at position 6, n (%) Yes 213 (54.2) 37 (66.1) 2.800 0.094 No 180 (45.8) 19 (33.9) Incisions at position 7, n (%) Yes 57 (14.5) 11 (19.6) 1.007 0.316 No 336 (85.5) 45 (80.4) Incisions at position 8, n (%) Yes 4 (1.0) 0 (0.0) 0.000 1.000 No 389 (99.0) 56 (100.0) Incisions at position 9, n (%) Yes 105 (26.7) 30 (53.6) 16.810 < 0.001 No 288 (73.3) 26 (46.4) Incisions at position 10, n (%) Yes 8 (2.0) 1 (11.1) 0.000 1.000 No 385 (98.0) 55 (98.2) Incisions at position 11, n (%) Yes 54 (13.7) 13 (23.2) 3.465 0.063 No 339 (86.3) 43 (76.8) Incisions at position 12, n (%) Yes 31 (7.9) 6 (10.7) 0.211 0.646 No 362 (92.1) 50 (89.3) High anal fistula, n (%) Yes 201 (44.3) 44 (77.2) 21.990 < 0.001 No 253 (55.7) 13 (22.8) Cutting seton (IQR) 0 (0,2) 3 (0.25,3) -4.609 < 0.001 Loose draining seton (IQR) 0 (0,2) 2 (0,3.75) -4.633 < 0.001 Combined surgeries, n (%) Yes 190 (42.0) 24 (42.1) 0.000 0.992 No 262 (58.0) 33 (57.9) VAS score (IQR) 6 (5,8) 8 (6,9) -4.142 < 0.001 <7, n (%) 202 (58.2) 13 (25.5) 19.169 < 0.001 ≥7, n (%) 145 (41.8) 38 (74.5) GAD-7 score (IQR) 1 (0,4) 4 (1,7) -3.227 0.001 <5, n (%) 278 (79.7) 30 (58.8) 10.904 0.001 ≥5, n (%) 71 (20.3) 21 (41.2) Urinary tract infection, n (%) Yes 12 (3.4) 4 (8.0) 1.316 0.251 No 336 (96.6) 46 (92.0) Length of hospital stay (days, IQR) 5 (3,7) 8 (5.5,12.5) -5.384 < 0.001 Table 2 Univariate logistic regression analysis for risk factors for POUR following radical surgery for anal fistula Variable OR (95% CI) P value Sex, male 0.537 (0.207–1.391) 0.200 Age 1.036 (1.014–1.057) 0.001 BMI, ≥24 kg/m 2 1.069 (0.592–1.932) 0.825 Diabetes 1.414 (0.471–4.246) 0.537 Hypertension 1.686 (0.845–3.364) 0.138 Urological diseases 5.070 (2.423–10.611) < 0.001 Neurological diseases 1.626 (0.456–5.798) 0.454 Proctology surgery history 1.292 (0.716–2.332) 0.395 Smoking history 1.614 (0.906–2.875) 0.104 Drinking history 1.323 (0.734–2.382) 0.352 Duration of disease 1.008 (1.002–1.013) 0.005 Duration of surgery, ≥0.5 h 2.590 (1.786–3.756) < 0.001 Intraoperative fluid volume, ≥500 mL 2.946 (1.815–4.780) < 0.001 Number of surgical incisions 1.482 (1.253–1.752) < 0.001 Number of quadrants involved 1.797 (1.399–2.308) < 0.001 Combined surgeries 1.003 (0.574–1.752) 0.992 Incisions at position 1 1.879 (1.008–3.504) 0.047 Incisions at position 2 1.329 (0.490–3.606) 0.577 Incisions at position 3 3.474 (1.950–6.189) < 0.001 Incisions at position 4 2.724 (0.701–10.588) 0.148 Incisions at position 5 0.812 (0.381–1.730) 0.589 Incisions at position 6 1.646 (0.914–2.962) 0.097 Incisions at position 7 1.441 (0.704–2.950) 0.318 Incisions at position 8 0.000 (0.000-/) 0.999 Incisions at position 9 3.165 (1.789-5.600) < 0.001 Incisions at position 10 0.875 (0.107–7.131) 0.901 Incisions at position 11 1.898 (0.958–3.760) 0.066 Incisions at position 12 1.401 (0.557–3.526) 0.474 High anal fistula 4.260 (2.233–8.127) < 0.001 Cutting seton 1.505 (1.252–1.809) < 0.001 Loose draining seton 1.400 (1.197–1.636) < 0.001 VAS score, ≥7 4.072 (2.094–7.917) < 0.001 GAD-7 score, ≥5 2.741 (1.481–5.072) 0.001 Table 3 Multivariate logistic stepwise regression analysis of risk factors for POUR following radical surgery for anal fistula Variable OR (95% CI) P value Urological diseases 6.048 (2.329–15.706) < 0.001 Incisions at position 1 2.228 (1.015–4.893) 0.046 High anal fistula 4.768 (2.100-10.822) < 0.001 VAS score, ≥7 2.805 (1.282–6.138) 0.010 GAD-7 score, ≥5 2.405 (1.123–5.148) 0.024 Discussion Importance and purpose of this study POUR is defined as the inability to voluntarily void urine following surgical procedures, leading to the accumulation of urine in the bladder despite a sensation of fullness or the need to urinate. This condition can result from various factors, including anesthesia effects, pain, and the disruption of normal bladder nerve function during or after surgery. POUR can impose significant physical, emotional, and financial burdens on patients. First, overdistension of the bladder can cause a feeling of abdominal fullness, and together with postoperative pain, it might lead to autonomic dysregulation, triggering complications such as hypotension, hypertension, and arrhythmias. Furthermore, urinary tract infection is a direct complication of persistent urinary retention. In extreme cases, POUR can lead to acute kidney injury due to postrenal obstruction [ 22 ]. Second, animal studies by Tammela [ 23 ] have shown that stretching rat detrusor muscles to their maximum length and maintaining this length for 3 hours results in a significant reduction in muscle tension. Kitada's animal experiments [ 24 ] also indicated that continuous bladder overdistension for 4–24 hours can decrease the number of cholinergic receptors and alter the contraction function of the bladder wall. These findings suggest that persistent bladder overdistension can affect bladder emptying, ultimately leading to a vicious cycle. More importantly, the data reviewed in this study showed that the length of hospital stay in the POUR group was significantly longer than that in the non-POUR group. POUR has been observed to extend the length of stay for patients who undergo cholecystectomy [ 25 ] and outpatient surgeries [ 26 ]. Longer hospital stays can increase patient anxiety and stress and can also increase hospital costs and the number of workdays. Previous literature [ 27 , 28 ] also suggests that the clinical symptoms and the timing of bladder overdistension do not always coincide; some patients may be able to urinate in a timely manner postoperatively, yet their residual bladder volume still exceeds 600 mL, indicating continued bladder overdistension. Based on the principle of patient responsibility, this study aimed to identify the risk factors for POUR and guide the prevention, monitoring and management of POUR. Possible mechanisms and risk factors The bladder is a crucial organ and is used to store and empty urine. It is regulated by both sympathetic and parasympathetic nerve fibers. Activation of the parasympathetic nerves causes the detrusor muscle to contract and the muscles of the bladder neck to relax, allowing the bladder to empty smoothly; conversely, sympathetic nerve activation prevents urination through the opposite mechanism [ 6 ]. Previous studies have suggested that the underlying pathological mechanisms of urinary retention can be categorized into two main types: mechanical obstruction at the bladder outlet and inhibition of detrusor muscle contraction. According to Barone and Cummings [ 18 ], POUR after proctology surgery is due to obstruction at the bladder outlet. Early postoperative sympathetic nerve activation can lead to IUS contraction, causing functional blockage at the bladder outlet. Regarding the inhibition of detrusor muscle contraction, Pompeius [ 19 ] considered this inhibition to be the result of a reflex involving afferent fibers of the pudendal nerve and efferent fibers of the pelvic sympathetic nerve. Perianal pain, anal packing discomfort, anxiety, and bladder overdistension are among the factors that can excite the sympathetic nerves or stimulate the aforementioned nerve fibers, indicating that various stimuli around the perianal area can cause POUR. Moreover, the urethral and anal sphincters are part of the pelvic muscles and are innervated by common nerves. Knight's research [ 29 ] showed that stimulation of the pudendal nerve in Alcock's canal decreases detrusor contraction pressure, thereby increasing bladder capacity. In addition, anesthesia and analgesia may also cause bladder tone receptors to become less responsive to filling stimuli, leading to overfilling of the bladder [ 6 , 22 ]. Thus, POUR following radical surgery for anal fistula may involve multiple factors. Previous studies have indicated that various factors, such as sex [ 3 , 4 ], age [ 5 , 6 ], history of previous illness [ 6 – 10 ], surgical method [ 11 ], anesthesia method [ 6 , 12 , 13 ], surgical duration [ 14 , 15 ], intraoperative fluid volume [ 16 , 17 ], and postoperative pain, could be risk factors for POUR. In this study, all patients were underwent induction of general anesthesia, and a uniform surgical method was applied for the same type of anal fistula, with a direct incision for low anal fistulas and a LCCS for high anal fistulas. No effects of sex, age, surgery duration, or intraoperative fluid volume on the occurrence of POUR were observed. Multivariate logistic stepwise regression analysis revealed that patients with a history of urological diseases had a 6.048-fold greater incidence of POUR than did those without, patients with incisions at position 1 had a 2.228-fold greater incidence of POUR than did those without incisions at position 1, patients with high anal fistula had a 4.768-fold greater incidence of POUR than did those with low anal fistula, patients with VAS scores ≥ 7 had a 2.805-fold greater incidence of POUR than did those with scores < 7, and patients with GAD-7 scores ≥ 5 had a 2.405-fold greater incidence of POUR than did those with scores < 5. Using the results obtained in this study, clinicians can target the prevention and monitoring of POUR in patients with risk factors. With prophylactic medication, suitable pain management and psychological counseling during the postoperative period, the incidence of POUR could be reduced, and patient satisfaction with surgery could be improved. Definition and incidence of POUR According to previous reports, the incidence of urinary retention following proctology surgery varies widely, ranging from 1–52%, which may be related to differences in how POUR is defined, the study exclusion criteria, surgical methods, and anesthesia methods used across various studies [ 10 , 17 ]. The clinical records collected in this study showed that the incidence of urinary retention after radical surgery for anal fistula under general anesthesia was 11.2%, which falls within the reported range. There are various previous definitions of POUR [ 6 ], with some studies [ 30 ] defining POUR based on clinical signs and physical examination and others [ 27 ] defining POUR based on ultrasound assessment of the residual urine volume in the bladder. In this study, POUR was defined as patients who experienced significant bladder fullness and discomfort within 48 hours postoperatively, with a swollen bladder palpable by the physician necessitating catheterization. This definition is similar to that used in prior studies [ 4 ] and is practical due to its simplicity and expediency. Mechanistic analysis and management strategies The present study identified the presence of incisions at position 1 as a new independent risk factor. Although Kun [ 31 ] previously performed a similar investigation, the findings of the study were not significant. Patients with incisions at position 1 may be more prone to POUR due to the anatomy and physiology of the pelvis. Incisions on the anterior side of the anus are closer to the urethral anatomy, which means that damage to the muscles and connective tissues near the urethra can occur more easily. Additionally, surgical manipulation of the lower end of the rectum near position 1 might cause traction injury to the pelvic nerves. However, the axons of the nerves are not destroyed during surgery, allowing most patients to recover normal bladder function after a period [ 32 ]. Therefore, when patients have a fistula at position 1 or have an affliction on the anterior side of the anorectum that requires surgical treatment, surgeons are advised to pay more attention to the surgical technique, avoiding large tears in the anal sphincter that could damage the nerves and lead to further postoperative complications. Similar to previous literature [ 7 , 33 ], this study identified a history of urological diseases as an independent risk factor for POUR following radical surgery for anal fistula. Chang [ 9 ] identified benign prostatic hyperplasia (BPH) as a risk factor for POUR after elective spine surgery. Patients with urological diseases may experience slower recovery of bladder function postoperatively. BPH is a urologic condition that is particularly common among middle-aged and older male patients. Of the cases reviewed in this study, 66% of patients with a history of urologic disease had BPH. A subset of patients were diagnosed with BPH when they underwent a urinary ultrasound after developing POUR. BPH can cause mechanical urethral obstruction to some extent, increasing the likelihood of postoperative urination difficulties. Currently, there are no specific reports on the prevalence of urological diseases (such as BPH, prostate calcification, and prostatitis) that may lead to urinary retention after anal fistula surgery. Future research should aim to identify which urological diseases are more likely to cause POUR following radical surgery for anal fistula. For clinicians, it is crucial to thoroughly inquire about the patient's history of urological diseases or abnormal urination before surgery. For patients with urological diseases, postoperative monitoring of bladder capacity is recommended, and if necessary, oral administration of alpha-adrenergic antagonists such as tamsulosin can be considered to prevent POUR [ 34 ]. If recurrent urinary retention occurs or if symptoms of difficulty urinating or discomfort persist after discharge, timely consultation with a urologist for further examination and systematic treatment is recommended. Multivariate logistic regression analysis indicated that patients with a high anal fistula were more likely to experience POUR. Previous studies on POUR following anal fistula surgery have rarely analyzed fistula classification as a factor. This may be due to the low incidence of high anal fistulas and the low success rate of surgery, making data collection and analysis challenging. Seton management for high anal fistulas is strongly recommended in China [ 35 ], with an efficacy rate of up to 90% [ 36 ]. Given the greater proportion of patients with high anal fistula in this study (48%), the analytical results are highly relevant. High anal fistulas involve a larger infection range around the anus and are more complex than low anal fistulas. This increased complexity is accompanied by increases in the number of surgical incisions, involved perianal quadrants, surgery duration, and intraoperative fluid volume, as is the risk of nerve and blood vessel damage. Due to the seton, more hemostatic gauze is packed inside the anus of patients postoperatively to prevent bleeding. Cotton balls were placed in all incisions to avoid incomplete wound healing. Seton stimulation can cause involuntary spasm of the anal sphincter, potentially leading to more intense pain. Moreover, compaction with the anal canal and pain stimulation can excite the sympathetic nerves, inhibiting detrusor muscle contraction while tightening the IUS, making it difficult to expel urine. Previous studies [ 37 , 38 ] have reported that constipation is a significant cause of urinary retention. In a study by Zhiqiang [ 38 ], which was based on clinical observations and bladder pressure measurements, the author speculated that prolonged fecal pressure on the rectum affects the rectosacral-bladder neural reflex arc, leading to POUR. Similarly, prolonged pressure and compaction within the anal canal might affect this reflex arc, triggering POUR. For patients with complex high anal fistulas, doctors may advise a residue-free diet or enteral nutrition fluids, along with intravenous rehydration, to prevent postoperative bleeding risk caused by hard stools, which may cause patients to produce a large amount of urine. Due to pain or hydration effects, patient mobility may be limited, preventing affected patients from standing or walking. However, many patients are uncomfortable with urinating in bed or are reluctant to urinate in a shared hospital room, which can eventually result in overdistension of the bladder and a decrease in the contractility of the bladder muscles, thereby leading to POUR. According to the above analysis, there are important considerations for clinicians. During the perioperative period, the intravenous fluid volume of high anal fistulas should be restricted to avoid excessive fluid administration, leading to increased blood volume and the rapid production of large amounts of urine, leading to overstretching of the bladder [ 16 , 17 , 39 ]. Additionally, early standing can help patients urinate more smoothly [ 40 , 41 ], but it should be noted that patients with severe complex high anal fistulas should not be forced to stand or move excessively to avoid increasing spasms of the anal sphincter, leading to intensified postoperative pain or bleeding. Most importantly, doctors should advise patients to undergo surgery as early as possible to avoid an increase in the extent of anal fistula infection, which can lead to further complications. The patients in this study reported that perianal pain worsened during urination, often leading to interrupted urination due to perianal pain and subsequently developing a fear of urination due to the anticipation of pain. Pain is one of the more extensively studied factors associated with POUR. Research by Toyonaga [ 17 ] has indicated that postoperative pain is an independent risk factor for POUR after surgery to treat benign proctology disease, and prophylactic analgesia can reduce the incidence of POUR. The region surrounding the anus is richly innervated, making patients particularly sensitive to pain following proctology surgery. As an infection-related disease, anal fistula surgeries are more prone to postoperative inflammatory responses and edema. Inflammation, edema, friction from dressing changes, and stimulation from packing materials in the anal canal can all lead to persistent severe perianal pain. Pain not only inhibits the initiation of the micturition reflex [ 41 ] but also, since the nerves affecting the anus originate from the pudendal nerve and the muscles in the anal area are closely related to those in the urethral area, anal pain can lead to spasms of the urethral sphincter, thereby causing difficulty urinating and eventually leading to urinary retention. Since pain is a risk factor for POUR, the choice of postoperative analgesic medication is very important. Some studies [ 6 , 42 ] suggest that the use of epidural analgesia, long-acting local anesthetics, and systemic analgesics of high doses of opioid medications may weaken the bladder reflex, increasing the likelihood of urinary retention. Such an analgesic approach should therefore be avoided. Instead, a multimodal approach combining short-acting local anesthetics and nonsteroidal anti-inflammatory drugs should be used to minimize the dosage while achieving optimal pain relief. In this study, many patients reported that severe pain induced more severe anxiety and difficulty sleeping. Persistent nervous tension might lead to autonomic dysfunction, resulting in POUR. A GAD-7 score ≥ 5 indicates that a patient is in a state of mild or higher anxiety. This study identified a GAD-7 score ≥ 5, which has rarely been studied, as an independent risk factor for POUR. Tammela [ 7 ] believes that anxiety is a cause of POUR. Moreover, a study by Jing on benign gynecological surgeries [ 43 ] suggested that patients with mild preoperative anxiety had a 4.226-fold greater incidence of POUR than patients without anxiety, and patients with moderate to severe preoperative anxiety had a 5.698-fold greater incidence of POUR. Anxiety can affect the normal function of pelvic floor muscles, causing them to be in a continuous state of contraction and leading to difficulty urinating. In animal studies, adrenocorticotropin-releasing factor (CRF) receptor expression was upregulated in Barrington's study of stress-exposed male rats. CRF contributes to the stress response by stimulating the release of ACTH, which has an inhibitory effect on the urination pathway, from the pituitary gland [ 44 , 45 ]. Hence, postoperative assessment of patients’ anxiety should be performed. When a patient's anxiety affects quality of life and recovery, psychological counseling or psychiatric treatment should be provided if necessary. Sex-related differences in POUR are controversial. Some studies [ 3 , 4 ] have suggested that males are more prone to urinary retention than females, while other studies [ 40 , 46 , 47 ] have reported no significant difference in the incidence of POUR between sexes; however, Toyonaga’s study [ 17 ] identified female sex as an independent risk factor for POUR. According to the data reviewed in this study, there was no significant difference in the sex ratio between the POUR group and the non-POUR group. Anatomically, the male pelvic plexus is closer to the lower end of the rectum and longer than the female pelvic plexus, which may increase the risk of traction injury during surgery [ 32 , 48 ]. Additionally, common conditions in middle-aged and older men, such as BPH, may increase their susceptibility to POUR. However, women may have less fear and resistance to catheterization than men, making them more likely to develop POUR. The combined effects of these sex differences might explain why no sex-based differences in POUR incidence were observed in the present study. Strengths and limitations This was a cross-sectional, retrospective, nonrandomized study. The collection of past medical history was based on patient-reported history, and the definition of POUR was not validated with objective examinations such as ultrasound, which may have led to an underestimation of the incidence of POUR. VAS and GAD-7 scores were recorded based on patient recall during telephone follow-ups, which may have introduced recall bias; moreover, the study did not account for women's greater acceptance of catheterization, which may have affected the study findings. An advantage of this study lies in the availability of data from many patients with high anal fistula. Additionally, patients with high anal fistula have a higher degree of surgical complexity. According to detailed surgical data, the study factors were comprehensive, including less frequently analyzed factors such as the location of surgical incisions, the number of cutting setons and loose draining setons, and postoperative anxiety, which is highly innovative. Conclusion POUR is a common complication following radical surgery for anal fistula and is associated with a variety of complex causes and influencing factors, making it a challenging clinical issue. Patients with urological disease or high anal fistula or are more likely to develop POUR. Given the unnecessary burdens and risks POUR poses to patients, we recommend that surgeons pay more attention to the surgical techniques of fistulas in the anterior rectum. Better postoperative pain and anxiety management strategies should be provided to reduce the incidence of POUR and avoid persistent bladder overdistension from POUR, which can cause irreversible damage to the patient, providing patients with a faster postoperative recovery and increased satisfaction with the procedure. Declarations Authors’ contributions Chen Li and Ningyuan Liu contributed equally to this work. Chen Li and Ningyuan Liu designed the research study. Chen Li, Zichen Huang, Zijian Wei, Keyi Li and Sangyu Ye contributed to the data collection. Chen Li analyzed the data and wrote the first draft of the manuscript. Chen Li, Ningyuan Liu and Wenxiao Hou commented on previous versions of the manuscript, while Lihua Zheng assisted in the study design and manuscript review. All authors have thoroughly reviewed and approved the final version of the manuscript. Funding This study funded by Clinical Research and was Transformation Jump Project of China-Japan Friendship Hospital: Perioperative Effect and Safety Evaluation of Integrated Traditional Chinese and Western Medicine Scheme on High Horseshoe Anal Fistula (2022-NHRHCRF-LX-02-0121) Availability of data and materials No datasets were generated or analyzed during the current study. Ethics approval and consent to participate Ethical approval for this study (2022-KY-121) was provided by the Ethical Committee of the China-Japan Friendship Hospital on 15 July 2022.This study was conducted in accordance with the ethical standards of China-Japan Friendship Hospital, the Declaration of Helsinki of the World Medical Association, International Ethical Guidelines for Health-related Research Involving Humans (2016) and China's Measures for Ethical Review of Biomedical Research Involving Human Beings (2016) and so on. Need for informed consent was waived by the Ethical Committee of the China-Japan Friendship Hospital. Consent for publication Not applicable. Competing interests The authors declare no competing interests. References Geller EJ. Prevention and management of postoperative urinary retention after urogynecologic surgery. Int J Womens Health. 2014;6:829–38. 10.2147/ijwh.S55383 . Vogel JD, Johnson EK, Morris AM, Paquette IM, Saclarides TJ, Feingold DL, et al. 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Factors influencing postoperative urinary retention in patients undergoing surgery for benign anorectal disease. Am J Surg. 1990;159(4):374–6. 10.1016/s0002-9610(05)81274-7 . Alkatout I, Wedel T, Pape J, Possover M, Dhanawat J, Review. Pelvic nerves - from anatomy and physiology to clinical applications. Transl Neurosci. 2021;12(1):362–78. 10.1515/tnsci-2020-0184 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 14 Oct, 2024 Read the published version in BMC Gastroenterology → Version 1 posted Editorial decision: Revision requested 12 Apr, 2024 Submission checks completed at journal 12 Apr, 2024 Editor assigned by journal 12 Apr, 2024 First submitted to journal 08 Apr, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4236957","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":290498447,"identity":"bdaa1aa6-3f93-4678-a4ca-b56c3033403e","order_by":0,"name":"Chen Li","email":"","orcid":"","institution":"Beijing University of Chinese Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Chen","middleName":"","lastName":"Li","suffix":""},{"id":290498448,"identity":"5d350976-5ae9-4c6f-b025-14972e134a13","order_by":1,"name":"Ningyuan Liu","email":"","orcid":"","institution":"Department of Proctology, China-Japan Friendship Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ningyuan","middleName":"","lastName":"Liu","suffix":""},{"id":290498450,"identity":"fc4a023a-5c62-4463-9b4a-7ee9ce4b1278","order_by":2,"name":"Zichen Huang","email":"","orcid":"","institution":"Beijing University of Chinese Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Zichen","middleName":"","lastName":"Huang","suffix":""},{"id":290498451,"identity":"2e3b73b9-84a4-4509-8d72-48364c1430a3","order_by":3,"name":"Zijian Wei","email":"","orcid":"","institution":"Beijing University of Chinese Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Zijian","middleName":"","lastName":"Wei","suffix":""},{"id":290498452,"identity":"c0c16b9d-68bf-434e-94f2-5374af2696dc","order_by":4,"name":"Keyi Li","email":"","orcid":"","institution":"Beijing University of Chinese Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Keyi","middleName":"","lastName":"Li","suffix":""},{"id":290498454,"identity":"9a86a763-ea3c-4912-af8d-6169550afe50","order_by":5,"name":"Wenxiao Hou","email":"","orcid":"","institution":"Department of Proctology, China-Japan Friendship Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Wenxiao","middleName":"","lastName":"Hou","suffix":""},{"id":290498455,"identity":"d81c725d-b7ba-4235-af0f-0215f55b2a03","order_by":6,"name":"Sangyu Ye","email":"","orcid":"","institution":"Beijing University of Chinese Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Sangyu","middleName":"","lastName":"Ye","suffix":""},{"id":290498456,"identity":"7b896d87-89b9-4dbd-ac58-c26bd7680bc7","order_by":7,"name":"Lihua Zheng","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAtElEQVRIiWNgGAWjYBACAyA+8KHChoefvYFYLWwMjAdnnEmTkew5QLwW5sO8LYdtDG44EKnFXL7H4ABvw3kehhsMjB8+5hChxbKNx+CA5I7bPIyzG5glZ24jxmHH2BIOGJ65zcMsc4CNmZdoLYlt53jYJBKI1sJ84MDBtgM8PERrsWxLPnCw4UwyjwTPwWbi/GLOfLD5858KO3v7480HP3wkRgsSYGwgTf0oGAWjYBSMAtwAAEADOUjKdYkQAAAAAElFTkSuQmCC","orcid":"","institution":"Department of Proctology, China-Japan Friendship Hospital","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Lihua","middleName":"","lastName":"Zheng","suffix":""}],"badges":[],"createdAt":"2024-04-08 13:52:33","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4236957/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4236957/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12876-024-03435-0","type":"published","date":"2024-10-14T15:56:59+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":67149064,"identity":"b0e5f734-e6ff-4adb-bdc2-f4540a719d3a","added_by":"auto","created_at":"2024-10-21 16:11:33","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1067484,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4236957/v1/0a20782a-9426-4c1c-8f67-4288de206d43.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effect of incision location and type of fistula on postoperative urinary retention after radical surgery for anal fistula: a retrospective analysis","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePostoperative urinary retention (POUR) refers to the symptom of bladder fullness without the ability to urinate autonomously after surgery and is characterized by the obstruction of bladder emptying and increased residual urine volume [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Anal fistula refers to an abnormal tunnel between the anorectum and the perianal skin. Approximately 80%-90% of anal fistulas are formed through the infection of glands within the anal crypt that form a perirectal abscess, which then breaks down or presses into the fistula. High anal fistulas traverse above a line marked by the deep portion of the external sphincter (i.e., the anorectal ring plane). Surgery is the main treatment approach for anal fistulas [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. POUR is a frequent complication following proctology surgery. Sustained bladder dilatation may lead to permanent impairment of bladder function. However, the etiology of POUR in proctology surgery remains unclear. Previous studies have indicated that various factors, such as sex [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], age [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], history of previous illness [\u003cspan additionalcitationids=\"CR7 CR8 CR9\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], surgical method [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], anesthesia method [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], surgical duration [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], intraoperative fluid volume [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], and postoperative pain, could be risk factors for POUR. The mechanism of urinary retention includes mechanical obstruction of the bladder outlet and inhibition of contraction by the bladder detrusor muscle [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. A variety of factors, such as perianal pain, anal packing discomfort, anxiety, and bladder overdistension, influence the mechanisms that lead to urinary retention. Moreover, intraoperative stimulation of the anal sphincter can also affect the associated nerves, leading to urinary retention. The multifactorial nature of urinary retention makes it a challenging issue to address following proctology surgeries [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The aim of this study was to determine the risk factors for POUR after radical surgery for anal fistula under general anesthesia. The results of this study can be used to identify strategies for its prevention and management to reduce the incidence of POUR and avoid irreversible damage caused by persistent bladder overdistension to improve patient satisfaction with surgery.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cp\u003e\u003cstrong\u003eParticipants and surgical procedures for anal fistula\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for this study (2022-KY-121) was provided by the Ethical Committee of the China-Japan Friendship Hospital on 15 July 2022.\u003c/p\u003e\n\u003cp\u003eIn this study, 511 patients with anal fistula who underwent radical surgery for anal fistula under general anesthesia at China-Japan Friendship Hospital from August 2022 to December 2023 were selected as the study patients. We retrospectively analyzed their clinical records. Patients were excluded from the study if their clinical records were missing substantial data, if the patient suffered from serious systemic illnesses or psychiatric disorders, or if they had suspicious anorectal masses that prevented surgery from being completed.\u003c/p\u003e\n\u003cp\u003ePatients with low anal fistulas were treated with direct incisions. The specific surgical operation involved the use of a probe from the external orifice and the internal orifice of the anal fistula near the anal sinus along the probe via a one-time incision. Patients with high anal fistulas were treated with a loose combined cutting seton (LCCS) [21]. The specific surgical operation involved the use of a probe from the external orifice, a probe in the direction of the fistula, a fully exposed fistula, and the use of a finger or hemostatic forceps to bluntly separate the fistula from the trauma along the direction of the fistula to the rectum. The potential cavity or fistula was explored to the sides of the tract until the probe reached the top of the fistula. Then, from the top of the fistula to the rectal lumen of the stoma, a silk thread seton was ligated on the highest spot of each fistula and tied firmly (a\u0026nbsp;cutting seton), and a complex anal fistula was hung between the various incisions on the silk thread to keep the incision drainage open (a loose draining seton).\u003c/p\u003e\n\u003cp\u003eAll surgeries were performed after fentanyl hydrochloride was injected and propofol cream was applied for general anesthesia. At the end of the surgery, the anus was packed with hemostatic gauze, and compression was applied to slow the bleeding; bandages with sterile dressings were then applied under pressure. In the ward, the patients were given flurbiprofen (100 mg) or oral loxoprofen (60 mg) to relieve wound pain. If necessary, intramuscular tramadol hydrochloride (100 mg) or indomethacin suppositories were injected anally to assist in analgesia. Patients were dressed daily postoperatively and advised to use warm medicated sitz baths.\u003c/p\u003e\n\u003cp\u003eIf patients experienced significant bladder fullness and discomfort postoperatively but were unable to urinate or had incomplete urination, nursing staff first attempted to facilitate urination through supportive measures (advising the patient to apply warm compress and abdominal massage, take sitz baths, stand or walk). If these measures failed and the swollen bladder could be palpated by a physician, catheterization was performed. The decision to leave a catheter in place was based on the patient\u0026apos;s condition. In this study, POUR was defined as the need for catheterization within 48 hours after surgery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe following details were documented from the patients\u0026rsquo; clinical records: 1. Preoperative variables: sex, age, body mass index (BMI), duration of disease, prior history of diabetes, hypertension, urological diseases, neurological diseases, proctology surgery history, smoking history, and drinking history; 2. Intraoperative variables included the duration of surgery, intraoperative fluid volume, number of surgical incisions, number of quadrants involved, location of surgical incisions (twelve equal clockwise markings were used to divide the perineum into 12 parts, with the perineum in the center at position 12, the sacrococcygeal in the center at position 6, the left midpoint at position 3, the right midpoint at position 9, and the remaining position labeled accordingly), and whether the primary surgery was combined with other proctology surgeries. Patients with a high anal fistula whose number of cutting setons and loose draining setons were recorded; 3. Postoperative variables included: postoperative pain visual analogue scale (VAS) score, postoperative generalized anxiety disorder-7 (GAD-7) score, the presence of urinary tract infection, and length of hospital stay.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOdds ratios (ORs) and 95% confidence intervals (CIs) derived from binary logistic regression analysis were used to assess risk factors for POUR.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eThe Shapiro‒Wilk test was used to assess the normality of the distribution of continuous data. Continuous normally distributed data are expressed as the mean and standard deviation (SD), and nonnormally distributed data are expressed as the median and interquartile range (IQR) and were evaluated by rank sum tests. Categorical data are described as the percentage (%) of cases and were evaluated by the chi-square test. Differences were considered significant when \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.05. All the statistical analyses were performed using SPSS (version 25.0, IBM, Inc., Chicago, Illinois, USA).\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eCharacteristics of participants with or without POUR\u003c/h2\u003e \u003cp\u003eIn this study, of the 511 patients, 454 patients (88.8%) did not experience urinary retention following radical surgery for anal fistula under general anesthesia, while 57 patients (11.2%) experienced urinary retention within 48 hours after surgery. The average age of the patients was 39.79\u0026thinsp;\u0026plusmn;\u0026thinsp;11.99 years, 85.5% were male, and 14.5% were female. A detailed comparison of the patients\u0026rsquo; characteristics is provided in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eA previous history of urological disease is more prevalent among POUR patients\u003c/h2\u003e \u003cp\u003eAccording to the preoperative clinical records, there was no difference in the sex ratio between the POUR group and the non-POUR group (males: 91.2% vs. 84.4%, females: 8.8% vs. 15.2%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.194). The average age in the POUR group was greater than that in the non-POUR group (44.79\u0026thinsp;\u0026plusmn;\u0026thinsp;13.7 vs. 39.17\u0026thinsp;\u0026plusmn;\u0026thinsp;11.624, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002). There were no differences between the POUR and non-POUR groups in terms of BMI [25.51 (23.15, 26.70) kg/m\u003csup\u003e2\u003c/sup\u003e vs. 25.26 (23.17, 28.06) kg/m\u003csup\u003e2\u003c/sup\u003e, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.558], a history of diabetes (7.0% vs. 5.1%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.759), hypertension (21.1% vs. 13.7%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.135), neuropsychiatric diseases (5.3% vs. 3.3%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.708), proctology surgery history (40.4% vs. 34.4%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.394), smoking history (36.8% vs. 26.5%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.102), drinking history (33.3% vs. 27.4%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.350), or duration of disease [5 (1,18) months vs. 6 (2,36) months, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.070]. However, a greater proportion of patients in the POUR group had a history of urological disease (22.8% vs. 5.5%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). This showed that only age and history of urological disease were significantly different according to the preoperative data.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eDifferences in surgical approaches exist between POUR and non-POUR patients\u003c/h2\u003e \u003cp\u003eAccording to the intraoperative clinical records, the duration of surgery [0.71 (0.52, 1.0050) h vs. 0.40 (0.26, 0.6925) h, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001], intraoperative fluid volume [500 (500, 1000) mL vs. 500 (300, 500) mL, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001], number of surgical incisions [3 (1, 4) vs. 1 (1, 3), \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001], and number of quadrants [3 (1, 3) vs. 1 (1, 2), \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001] involved were significantly greater in the POUR group. Interestingly, the proportion of patients with incisions at positions 1, 3 and 9 was significantly greater in the POUR group than in the non-POUR group (30.4% vs. 18.8%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.045; 60.7% vs. 30.8%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001; 53.6% vs. 26.7%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). However, there was no significant difference when this technique was combined with other proctological surgeries (42.1% vs. 42.1%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.992). The proportion of patients with high anal fistula was greater in the POUR group than in the non-POUR group (77.2% vs. 44.3%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001); among patients with high anal fistula, differences in the number of cutting setons [3 (0.25,3) vs. 0 (0,2), \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001] and loose draining setons [2 (0,3.75) vs. 0 (0,2), \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001] were also statistically significant between the POUR and non-POUR groups. In conclusion, the duration of surgery, the intraoperative fluid volume, and the complexity of the surgery were associated with POUR. More meaningfully, the location of the surgical incisions also had an important effect on the occurrence of POUR.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003ePOUR patients have greater VAS and GAD-7 scores\u003c/h2\u003e \u003cp\u003eAccording to the postoperative clinical records, the average VAS score [8 (6,9) vs. 6 (5,8), \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001] and GAD-7 score [4 (1,7) vs. 1 (0,4), \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001] was higher in the POUR group than in the non-POUR group, and the average length of hospital stay was also significantly longer for patients in the POUR group [8 (5.5,12.5) days vs. 5 (3,7) days, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001]. However, there was no significant difference in the incidence of urinary tract infections (8.0% vs. 3.4%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.251) between the two groups. Postoperative pain and anxiety were more likely to cause POUR, and POUR could prolong patients\u0026rsquo; hospital stays.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eUnivariate and multivariate logistic regression analyses findings\u003c/h2\u003e \u003cp\u003e \u003cb\u003eThe univariate analysis results were similar to those of previous studies.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the results of the univariate logistic regression analysis of risk factors for POUR following radical surgery for anal fistula. Age (OR\u0026thinsp;=\u0026thinsp;1.036; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001), a history of neurological disease (OR\u0026thinsp;=\u0026thinsp;5.070; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), a longer duration of disease (OR\u0026thinsp;=\u0026thinsp;1.008; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.005), a duration of surgery\u0026thinsp;\u0026ge;\u0026thinsp;0.5 h (OR\u0026thinsp;=\u0026thinsp;2.590; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), an intraoperative fluid volume\u0026thinsp;\u0026ge;\u0026thinsp;500 mL (OR\u0026thinsp;=\u0026thinsp;2.946; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), a greater number of surgical incisions (OR\u0026thinsp;=\u0026thinsp;1.482; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), a greater number of involved quadrants (OR\u0026thinsp;=\u0026thinsp;1.797; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), incisions at position 1 (OR\u0026thinsp;=\u0026thinsp;1.879; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.047), incisions at position 3 (OR\u0026thinsp;=\u0026thinsp;3.474; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), incisions at position 9 (OR\u0026thinsp;=\u0026thinsp;3.165; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), the presence of high anal fistula (OR\u0026thinsp;=\u0026thinsp;4.260; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), a greater number of cutting setons (OR\u0026thinsp;=\u0026thinsp;1.505; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and loose draining setons (OR\u0026thinsp;=\u0026thinsp;1.400; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), a VAS score\u0026thinsp;\u0026ge;\u0026thinsp;7 (OR\u0026thinsp;=\u0026thinsp;4.072; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and a GAD-7 score\u0026thinsp;\u0026ge;\u0026thinsp;5 (OR\u0026thinsp;=\u0026thinsp;2.741; P\u0026thinsp;=\u0026thinsp;0.001) were significant risk factors for POUR following radical surgery for anal fistula.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eUncommon independent risk factors: postoperative anxiety and incisions at position 1\u003c/h2\u003e \u003cp\u003eAll significant risk factors identified in the univariate analysis were included in a multivariate logistic stepwise regression analysis, and the detailed results are presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. A history of urological disease (OR\u0026thinsp;=\u0026thinsp;6.048; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), incisions at position 1 (OR\u0026thinsp;=\u0026thinsp;2.228; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.046), the presence of high anal fistula (OR\u0026thinsp;=\u0026thinsp;4.768; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), a VAS score\u0026thinsp;\u0026ge;\u0026thinsp;7 (OR\u0026thinsp;=\u0026thinsp;2.805; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.010), and a GAD-7 score\u0026thinsp;\u0026ge;\u0026thinsp;5 (OR\u0026thinsp;=\u0026thinsp;2.405; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.024) were found to be independent risk factors for urinary retention following radical surgery for anal fistula.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of the participants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003enon-POUR group (n\u0026thinsp;=\u0026thinsp;454)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePOUR group (n\u0026thinsp;=\u0026thinsp;57)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\({\\varvec{x}}^{2}\\)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e385 (84.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52 (91.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e1.689\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.194\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69 (15.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (8.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years, IQR, mean\u0026plusmn;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37 (31,45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44.79\u0026plusmn;13.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-3.118\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e, IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25.26 (23.17,28.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.51 (23.15,26.70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.586\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.558\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;24 kg/m\u003csup\u003e2\u003c/sup\u003e, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e150 (33.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (31.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.049\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.825\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;24 kg/m\u003csup\u003e2\u003c/sup\u003e, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e304 (67.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39 (68.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (5.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (7.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.094\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.759\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e431 (94.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53 (93.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62 (13.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (21.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e2.237\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.135\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e392 (86.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45 (78.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrological diseases, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (5.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (22.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e19.578\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt; 0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e429 (94.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44 (77.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeurological diseases, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (3.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (5.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.141\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.708\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e439 (96.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e54 (94.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProctology surgery history, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e140 (34.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (40.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.726\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.394\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e267 (65.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31 (59.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSmoking history, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e120 (26.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (36.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e2.678\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.102\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e332 (73.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e36 (62.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDrinking history, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e124 (27.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.872\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.350\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e328 (72.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38 (66.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuration of disease (months, IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (1,18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (2,36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-1.812\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.070\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuration of surgery (hours, IQR, mean\u0026plusmn;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.40 (0.26,0.6925)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.81\u0026thinsp;\u0026plusmn;\u0026thinsp;0.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-5.411\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt; 0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;0.5 h, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e272 (59.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (22.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e28.266\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt; 0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;0.5 h, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e182 (40.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44 (77.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntraoperative fluid volume (mL, IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e500 (300,500)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e500 (500,1000)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-5.021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt; 0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;500 mL, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e337 (87.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31 (57.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e32.483\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt; 0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;500 mL, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47 (12.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (42.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of surgical incisions (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1,3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (1,4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-4.799\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt; 0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of quadrants involved (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1,2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (1,3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-4.527\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt; 0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncisions at position 1, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e74 (18.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (30.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e4.031\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e0.045\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e319 (81.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39 (69.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncisions at position 2, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27 (6.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (8.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.080\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.778\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e366 (93.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51 (91.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncisions at position 3, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e121 (30.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34 (60.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e19.419\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt; 0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e272 (69.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 (39.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncisions at position 4, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (2.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (5.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e1.086\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.297\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e385 (98.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53 (94.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncisions at position 5, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e75 (19.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (16.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.292\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.589\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e318 (80.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47 (83.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncisions at position 6, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e213 (54.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37 (66.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e2.800\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.094\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e180 (45.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (33.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncisions at position 7, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57 (14.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (19.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e1.007\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.316\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e336 (85.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45 (80.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncisions at position 8, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (1.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e389 (99.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56 (100.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncisions at position 9, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e105 (26.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (53.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e16.810\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt; 0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e288 (73.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26 (46.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncisions at position 10, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (2.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (11.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e385 (98.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55 (98.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncisions at position 11, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54 (13.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (23.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e3.465\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.063\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e339 (86.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43 (76.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncisions at position 12, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31 (7.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (10.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.211\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.646\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e362 (92.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50 (89.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh anal fistula, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e201 (44.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44 (77.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e21.990\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt; 0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e253 (55.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (22.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCutting seton (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0,2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (0.25,3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-4.609\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt; 0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLoose draining seton (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0,2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (0,3.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-4.633\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt; 0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCombined surgeries, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e190 (42.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (42.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.992\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e262 (58.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33 (57.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVAS score (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (5,8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (6,9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-4.142\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt; 0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;7, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e202 (58.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (25.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e19.169\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt; 0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;7, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e145 (41.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38 (74.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGAD-7 score (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0,4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (1,7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-3.227\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;5, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e278 (79.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (58.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e10.904\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;5, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e71 (20.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (41.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrinary tract infection, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (3.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (8.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e1.316\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.251\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e336 (96.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46 (92.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLength of hospital stay (days, IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (3,7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (5.5,12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-5.384\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt; 0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eUnivariate logistic regression analysis for risk factors for POUR following radical surgery for anal fistula\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex, male\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.537 (0.207\u0026ndash;1.391)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.200\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.036 (1.014\u0026ndash;1.057)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI, \u0026ge;24 kg/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.069 (0.592\u0026ndash;1.932)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.825\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.414 (0.471\u0026ndash;4.246)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.537\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.686 (0.845\u0026ndash;3.364)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.138\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrological diseases\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5.070 (2.423\u0026ndash;10.611)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt; 0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeurological diseases\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.626 (0.456\u0026ndash;5.798)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.454\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProctology surgery history\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.292 (0.716\u0026ndash;2.332)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.395\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSmoking history\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.614 (0.906\u0026ndash;2.875)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.104\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDrinking history\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.323 (0.734\u0026ndash;2.382)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.352\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuration of disease\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.008 (1.002\u0026ndash;1.013)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.005\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuration of surgery, \u0026ge;0.5 h\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.590 (1.786\u0026ndash;3.756)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt; 0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntraoperative fluid volume, \u0026ge;500 mL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.946 (1.815\u0026ndash;4.780)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt; 0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of surgical incisions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.482 (1.253\u0026ndash;1.752)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt; 0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of quadrants involved\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.797 (1.399\u0026ndash;2.308)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt; 0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCombined surgeries\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.003 (0.574\u0026ndash;1.752)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.992\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncisions at position 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.879 (1.008\u0026ndash;3.504)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.047\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncisions at position 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.329 (0.490\u0026ndash;3.606)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.577\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncisions at position 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.474 (1.950\u0026ndash;6.189)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt; 0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncisions at position 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.724 (0.701\u0026ndash;10.588)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.148\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncisions at position 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.812 (0.381\u0026ndash;1.730)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.589\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncisions at position 6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.646 (0.914\u0026ndash;2.962)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.097\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncisions at position 7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.441 (0.704\u0026ndash;2.950)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.318\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncisions at position 8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.000 (0.000-/)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncisions at position 9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3.165 (1.789-5.600)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt; 0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncisions at position 10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.875 (0.107\u0026ndash;7.131)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.901\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncisions at position 11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.898 (0.958\u0026ndash;3.760)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.066\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncisions at position 12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.401 (0.557\u0026ndash;3.526)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.474\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh anal fistula\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4.260 (2.233\u0026ndash;8.127)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt; 0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCutting seton\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.505 (1.252\u0026ndash;1.809)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt; 0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLoose draining seton\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.400 (1.197\u0026ndash;1.636)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt; 0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVAS score, \u0026ge;7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4.072 (2.094\u0026ndash;7.917)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt; 0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGAD-7 score, \u0026ge;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.741 (1.481\u0026ndash;5.072)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMultivariate logistic stepwise regression analysis of risk factors for POUR following radical surgery for anal fistula\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrological diseases\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6.048 (2.329\u0026ndash;15.706)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt; 0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncisions at position 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.228 (1.015\u0026ndash;4.893)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.046\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh anal fistula\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4.768 (2.100-10.822)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt; 0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVAS score, \u0026ge;7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.805 (1.282\u0026ndash;6.138)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.010\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGAD-7 score, \u0026ge;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.405 (1.123\u0026ndash;5.148)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.024\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eImportance and purpose of this study\u003c/h2\u003e \u003cp\u003ePOUR is defined as the inability to voluntarily void urine following surgical procedures, leading to the accumulation of urine in the bladder despite a sensation of fullness or the need to urinate. This condition can result from various factors, including anesthesia effects, pain, and the disruption of normal bladder nerve function during or after surgery. POUR can impose significant physical, emotional, and financial burdens on patients. First, overdistension of the bladder can cause a feeling of abdominal fullness, and together with postoperative pain, it might lead to autonomic dysregulation, triggering complications such as hypotension, hypertension, and arrhythmias. Furthermore, urinary tract infection is a direct complication of persistent urinary retention. In extreme cases, POUR can lead to acute kidney injury due to postrenal obstruction [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Second, animal studies by Tammela [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] have shown that stretching rat detrusor muscles to their maximum length and maintaining this length for 3 hours results in a significant reduction in muscle tension. Kitada's animal experiments [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] also indicated that continuous bladder overdistension for 4\u0026ndash;24 hours can decrease the number of cholinergic receptors and alter the contraction function of the bladder wall. These findings suggest that persistent bladder overdistension can affect bladder emptying, ultimately leading to a vicious cycle. More importantly, the data reviewed in this study showed that the length of hospital stay in the POUR group was significantly longer than that in the non-POUR group. POUR has been observed to extend the length of stay for patients who undergo cholecystectomy [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] and outpatient surgeries [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Longer hospital stays can increase patient anxiety and stress and can also increase hospital costs and the number of workdays. Previous literature [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] also suggests that the clinical symptoms and the timing of bladder overdistension do not always coincide; some patients may be able to urinate in a timely manner postoperatively, yet their residual bladder volume still exceeds 600 mL, indicating continued bladder overdistension. Based on the principle of patient responsibility, this study aimed to identify the risk factors for POUR and guide the prevention, monitoring and management of POUR.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003ePossible mechanisms and risk factors\u003c/h2\u003e \u003cp\u003eThe bladder is a crucial organ and is used to store and empty urine. It is regulated by both sympathetic and parasympathetic nerve fibers. Activation of the parasympathetic nerves causes the detrusor muscle to contract and the muscles of the bladder neck to relax, allowing the bladder to empty smoothly; conversely, sympathetic nerve activation prevents urination through the opposite mechanism [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Previous studies have suggested that the underlying pathological mechanisms of urinary retention can be categorized into two main types: mechanical obstruction at the bladder outlet and inhibition of detrusor muscle contraction. According to Barone and Cummings [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], POUR after proctology surgery is due to obstruction at the bladder outlet. Early postoperative sympathetic nerve activation can lead to IUS contraction, causing functional blockage at the bladder outlet. Regarding the inhibition of detrusor muscle contraction, Pompeius [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] considered this inhibition to be the result of a reflex involving afferent fibers of the pudendal nerve and efferent fibers of the pelvic sympathetic nerve. Perianal pain, anal packing discomfort, anxiety, and bladder overdistension are among the factors that can excite the sympathetic nerves or stimulate the aforementioned nerve fibers, indicating that various stimuli around the perianal area can cause POUR. Moreover, the urethral and anal sphincters are part of the pelvic muscles and are innervated by common nerves. Knight's research [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] showed that stimulation of the pudendal nerve in Alcock's canal decreases detrusor contraction pressure, thereby increasing bladder capacity. In addition, anesthesia and analgesia may also cause bladder tone receptors to become less responsive to filling stimuli, leading to overfilling of the bladder [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Thus, POUR following radical surgery for anal fistula may involve multiple factors.\u003c/p\u003e \u003cp\u003ePrevious studies have indicated that various factors, such as sex [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], age [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], history of previous illness [\u003cspan additionalcitationids=\"CR7 CR8 CR9\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], surgical method [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], anesthesia method [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], surgical duration [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], intraoperative fluid volume [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], and postoperative pain, could be risk factors for POUR. In this study, all patients were underwent induction of general anesthesia, and a uniform surgical method was applied for the same type of anal fistula, with a direct incision for low anal fistulas and a LCCS for high anal fistulas. No effects of sex, age, surgery duration, or intraoperative fluid volume on the occurrence of POUR were observed. Multivariate logistic stepwise regression analysis revealed that patients with a history of urological diseases had a 6.048-fold greater incidence of POUR than did those without, patients with incisions at position 1 had a 2.228-fold greater incidence of POUR than did those without incisions at position 1, patients with high anal fistula had a 4.768-fold greater incidence of POUR than did those with low anal fistula, patients with VAS scores\u0026thinsp;\u0026ge;\u0026thinsp;7 had a 2.805-fold greater incidence of POUR than did those with scores\u0026thinsp;\u0026lt;\u0026thinsp;7, and patients with GAD-7 scores\u0026thinsp;\u0026ge;\u0026thinsp;5 had a 2.405-fold greater incidence of POUR than did those with scores\u0026thinsp;\u0026lt;\u0026thinsp;5. Using the results obtained in this study, clinicians can target the prevention and monitoring of POUR in patients with risk factors. With prophylactic medication, suitable pain management and psychological counseling during the postoperative period, the incidence of POUR could be reduced, and patient satisfaction with surgery could be improved.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eDefinition and incidence of POUR\u003c/h2\u003e \u003cp\u003eAccording to previous reports, the incidence of urinary retention following proctology surgery varies widely, ranging from 1\u0026ndash;52%, which may be related to differences in how POUR is defined, the study exclusion criteria, surgical methods, and anesthesia methods used across various studies [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The clinical records collected in this study showed that the incidence of urinary retention after radical surgery for anal fistula under general anesthesia was 11.2%, which falls within the reported range. There are various previous definitions of POUR [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], with some studies [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] defining POUR based on clinical signs and physical examination and others [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] defining POUR based on ultrasound assessment of the residual urine volume in the bladder. In this study, POUR was defined as patients who experienced significant bladder fullness and discomfort within 48 hours postoperatively, with a swollen bladder palpable by the physician necessitating catheterization. This definition is similar to that used in prior studies [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] and is practical due to its simplicity and expediency.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eMechanistic analysis and management strategies\u003c/h2\u003e \u003cp\u003eThe present study identified the presence of incisions at position 1 as a new independent risk factor. Although Kun [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] previously performed a similar investigation, the findings of the study were not significant. Patients with incisions at position 1 may be more prone to POUR due to the anatomy and physiology of the pelvis. Incisions on the anterior side of the anus are closer to the urethral anatomy, which means that damage to the muscles and connective tissues near the urethra can occur more easily. Additionally, surgical manipulation of the lower end of the rectum near position 1 might cause traction injury to the pelvic nerves. However, the axons of the nerves are not destroyed during surgery, allowing most patients to recover normal bladder function after a period [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Therefore, when patients have a fistula at position 1 or have an affliction on the anterior side of the anorectum that requires surgical treatment, surgeons are advised to pay more attention to the surgical technique, avoiding large tears in the anal sphincter that could damage the nerves and lead to further postoperative complications.\u003c/p\u003e \u003cp\u003eSimilar to previous literature [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e], this study identified a history of urological diseases as an independent risk factor for POUR following radical surgery for anal fistula. Chang [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] identified benign prostatic hyperplasia (BPH) as a risk factor for POUR after elective spine surgery. Patients with urological diseases may experience slower recovery of bladder function postoperatively. BPH is a urologic condition that is particularly common among middle-aged and older male patients. Of the cases reviewed in this study, 66% of patients with a history of urologic disease had BPH. A subset of patients were diagnosed with BPH when they underwent a urinary ultrasound after developing POUR. BPH can cause mechanical urethral obstruction to some extent, increasing the likelihood of postoperative urination difficulties.\u003c/p\u003e \u003cp\u003eCurrently, there are no specific reports on the prevalence of urological diseases (such as BPH, prostate calcification, and prostatitis) that may lead to urinary retention after anal fistula surgery. Future research should aim to identify which urological diseases are more likely to cause POUR following radical surgery for anal fistula. For clinicians, it is crucial to thoroughly inquire about the patient's history of urological diseases or abnormal urination before surgery. For patients with urological diseases, postoperative monitoring of bladder capacity is recommended, and if necessary, oral administration of alpha-adrenergic antagonists such as tamsulosin can be considered to prevent POUR [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. If recurrent urinary retention occurs or if symptoms of difficulty urinating or discomfort persist after discharge, timely consultation with a urologist for further examination and systematic treatment is recommended.\u003c/p\u003e \u003cp\u003eMultivariate logistic regression analysis indicated that patients with a high anal fistula were more likely to experience POUR. Previous studies on POUR following anal fistula surgery have rarely analyzed fistula classification as a factor. This may be due to the low incidence of high anal fistulas and the low success rate of surgery, making data collection and analysis challenging. Seton management for high anal fistulas is strongly recommended in China [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e], with an efficacy rate of up to 90% [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Given the greater proportion of patients with high anal fistula in this study (48%), the analytical results are highly relevant. High anal fistulas involve a larger infection range around the anus and are more complex than low anal fistulas. This increased complexity is accompanied by increases in the number of surgical incisions, involved perianal quadrants, surgery duration, and intraoperative fluid volume, as is the risk of nerve and blood vessel damage. Due to the seton, more hemostatic gauze is packed inside the anus of patients postoperatively to prevent bleeding. Cotton balls were placed in all incisions to avoid incomplete wound healing. Seton stimulation can cause involuntary spasm of the anal sphincter, potentially leading to more intense pain. Moreover, compaction with the anal canal and pain stimulation can excite the sympathetic nerves, inhibiting detrusor muscle contraction while tightening the IUS, making it difficult to expel urine. Previous studies [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e] have reported that constipation is a significant cause of urinary retention. In a study by Zhiqiang [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e], which was based on clinical observations and bladder pressure measurements, the author speculated that prolonged fecal pressure on the rectum affects the rectosacral-bladder neural reflex arc, leading to POUR. Similarly, prolonged pressure and compaction within the anal canal might affect this reflex arc, triggering POUR. For patients with complex high anal fistulas, doctors may advise a residue-free diet or enteral nutrition fluids, along with intravenous rehydration, to prevent postoperative bleeding risk caused by hard stools, which may cause patients to produce a large amount of urine. Due to pain or hydration effects, patient mobility may be limited, preventing affected patients from standing or walking. However, many patients are uncomfortable with urinating in bed or are reluctant to urinate in a shared hospital room, which can eventually result in overdistension of the bladder and a decrease in the contractility of the bladder muscles, thereby leading to POUR.\u003c/p\u003e \u003cp\u003eAccording to the above analysis, there are important considerations for clinicians. During the perioperative period, the intravenous fluid volume of high anal fistulas should be restricted to avoid excessive fluid administration, leading to increased blood volume and the rapid production of large amounts of urine, leading to overstretching of the bladder [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Additionally, early standing can help patients urinate more smoothly [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e], but it should be noted that patients with severe complex high anal fistulas should not be forced to stand or move excessively to avoid increasing spasms of the anal sphincter, leading to intensified postoperative pain or bleeding. Most importantly, doctors should advise patients to undergo surgery as early as possible to avoid an increase in the extent of anal fistula infection, which can lead to further complications.\u003c/p\u003e \u003cp\u003eThe patients in this study reported that perianal pain worsened during urination, often leading to interrupted urination due to perianal pain and subsequently developing a fear of urination due to the anticipation of pain. Pain is one of the more extensively studied factors associated with POUR. Research by Toyonaga [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] has indicated that postoperative pain is an independent risk factor for POUR after surgery to treat benign proctology disease, and prophylactic analgesia can reduce the incidence of POUR. The region surrounding the anus is richly innervated, making patients particularly sensitive to pain following proctology surgery. As an infection-related disease, anal fistula surgeries are more prone to postoperative inflammatory responses and edema. Inflammation, edema, friction from dressing changes, and stimulation from packing materials in the anal canal can all lead to persistent severe perianal pain. Pain not only inhibits the initiation of the micturition reflex [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e] but also, since the nerves affecting the anus originate from the pudendal nerve and the muscles in the anal area are closely related to those in the urethral area, anal pain can lead to spasms of the urethral sphincter, thereby causing difficulty urinating and eventually leading to urinary retention.\u003c/p\u003e \u003cp\u003eSince pain is a risk factor for POUR, the choice of postoperative analgesic medication is very important. Some studies [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e] suggest that the use of epidural analgesia, long-acting local anesthetics, and systemic analgesics of high doses of opioid medications may weaken the bladder reflex, increasing the likelihood of urinary retention. Such an analgesic approach should therefore be avoided. Instead, a multimodal approach combining short-acting local anesthetics and nonsteroidal anti-inflammatory drugs should be used to minimize the dosage while achieving optimal pain relief.\u003c/p\u003e \u003cp\u003eIn this study, many patients reported that severe pain induced more severe anxiety and difficulty sleeping. Persistent nervous tension might lead to autonomic dysfunction, resulting in POUR. A GAD-7 score\u0026thinsp;\u0026ge;\u0026thinsp;5 indicates that a patient is in a state of mild or higher anxiety. This study identified a GAD-7 score\u0026thinsp;\u0026ge;\u0026thinsp;5, which has rarely been studied, as an independent risk factor for POUR. Tammela [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] believes that anxiety is a cause of POUR. Moreover, a study by Jing on benign gynecological surgeries [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e] suggested that patients with mild preoperative anxiety had a 4.226-fold greater incidence of POUR than patients without anxiety, and patients with moderate to severe preoperative anxiety had a 5.698-fold greater incidence of POUR. Anxiety can affect the normal function of pelvic floor muscles, causing them to be in a continuous state of contraction and leading to difficulty urinating. In animal studies, adrenocorticotropin-releasing factor (CRF) receptor expression was upregulated in Barrington's study of stress-exposed male rats. CRF contributes to the stress response by stimulating the release of ACTH, which has an inhibitory effect on the urination pathway, from the pituitary gland [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. Hence, postoperative assessment of patients\u0026rsquo; anxiety should be performed. When a patient's anxiety affects quality of life and recovery, psychological counseling or psychiatric treatment should be provided if necessary.\u003c/p\u003e \u003cp\u003eSex-related differences in POUR are controversial. Some studies [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] have suggested that males are more prone to urinary retention than females, while other studies [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e] have reported no significant difference in the incidence of POUR between sexes; however, Toyonaga\u0026rsquo;s study [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] identified female sex as an independent risk factor for POUR. According to the data reviewed in this study, there was no significant difference in the sex ratio between the POUR group and the non-POUR group. Anatomically, the male pelvic plexus is closer to the lower end of the rectum and longer than the female pelvic plexus, which may increase the risk of traction injury during surgery [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. Additionally, common conditions in middle-aged and older men, such as BPH, may increase their susceptibility to POUR. However, women may have less fear and resistance to catheterization than men, making them more likely to develop POUR. The combined effects of these sex differences might explain why no sex-based differences in POUR incidence were observed in the present study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eThis was a cross-sectional, retrospective, nonrandomized study. The collection of past medical history was based on patient-reported history, and the definition of POUR was not validated with objective examinations such as ultrasound, which may have led to an underestimation of the incidence of POUR. VAS and GAD-7 scores were recorded based on patient recall during telephone follow-ups, which may have introduced recall bias; moreover, the study did not account for women's greater acceptance of catheterization, which may have affected the study findings. An advantage of this study lies in the availability of data from many patients with high anal fistula. Additionally, patients with high anal fistula have a higher degree of surgical complexity. According to detailed surgical data, the study factors were comprehensive, including less frequently analyzed factors such as the location of surgical incisions, the number of cutting setons and loose draining setons, and postoperative anxiety, which is highly innovative.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003ePOUR is a common complication following radical surgery for anal fistula and is associated with a variety of complex causes and influencing factors, making it a challenging clinical issue. Patients with urological disease or high anal fistula or are more likely to develop POUR. Given the unnecessary burdens and risks POUR poses to patients, we recommend that surgeons pay more attention to the surgical techniques of fistulas in the anterior rectum. Better postoperative pain and anxiety management strategies should be provided to reduce the incidence of POUR and avoid persistent bladder overdistension from POUR, which can cause irreversible damage to the patient, providing patients with a faster postoperative recovery and increased satisfaction with the procedure.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eChen Li and Ningyuan Liu contributed equally to this work. Chen Li and Ningyuan Liu designed the research study. Chen Li, Zichen Huang, Zijian Wei, Keyi Li and Sangyu Ye contributed to the data collection. Chen Li analyzed the data and wrote the first draft of the manuscript. Chen Li, Ningyuan Liu and Wenxiao Hou commented on previous versions of the manuscript, while Lihua Zheng assisted in the study design and manuscript review. All authors have thoroughly reviewed and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study funded by Clinical Research and was Transformation Jump Project of China-Japan Friendship Hospital: Perioperative Effect and Safety Evaluation of Integrated Traditional Chinese and Western Medicine Scheme on High Horseshoe Anal Fistula (2022-NHRHCRF-LX-02-0121)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo datasets were generated or analyzed during the current study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eand consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for this study (2022-KY-121) was provided by the Ethical Committee of the China-Japan Friendship Hospital on 15 July 2022.This study was conducted in accordance with the ethical standards of China-Japan Friendship Hospital, the Declaration of Helsinki of the World Medical Association, International Ethical Guidelines for Health-related Research Involving Humans (2016) and China\u0026apos;s Measures for Ethical Review of Biomedical Research Involving Human Beings (2016) and so on. Need for informed consent was waived by the Ethical Committee of the China-Japan Friendship Hospital.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGeller EJ. Prevention and management of postoperative urinary retention after urogynecologic surgery. 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Transl Neurosci. 2021;12(1):362\u0026ndash;78. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1515/tnsci-2020-0184\u003c/span\u003e\u003cspan address=\"10.1515/tnsci-2020-0184\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-gastroenterology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmge","sideBox":"Learn more about [BMC Gastroenterology](http://bmcgastroenterol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmge/default.aspx","title":"BMC Gastroenterology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Postoperative urinary retention, radical surgery for anal fistula, risk factors, loose combined cutting seton, urological disease, high anal fistula","lastPublishedDoi":"10.21203/rs.3.rs-4236957/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4236957/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003ePostoperative urinary retention (POUR) refers to the postoperative symptom of bladder fullness without the ability to urinate autonomously. The etiology of POUR in proctology surgery remains unclear, and the underlying causes are multifactorial. The aim of this study was to determine the risk factors for POUR after radical surgery for anal fistula.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe retrospectively reviewed the clinical records of 511 patients who underwent radical surgery for anal fistula under general anesthesia at the China-Japan Friendship Hospital from August 2022 to December 2023. Risk factors for POUR were determined using binary logistic regression analyses.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003e57 patients (11.2%) experienced urinary retention within 48 hours after surgery, while the majority of whom were male (84.4%). Multivariate logistic stepwise regression revealed that a history of urological disease (OR\u0026thinsp;=\u0026thinsp;6.048; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), incisions at position 1 (OR\u0026thinsp;=\u0026thinsp;2.228; P\u0026thinsp;=\u0026thinsp;0.046), the presence of high anal fistula (OR\u0026thinsp;=\u0026thinsp;4.768; P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), a VAS score\u0026thinsp;\u0026ge;\u0026thinsp;7 (OR\u0026thinsp;=\u0026thinsp;2.805; P\u0026thinsp;=\u0026thinsp;0.010), and a GAD-7 score\u0026thinsp;\u0026ge;\u0026thinsp;5 (OR\u0026thinsp;=\u0026thinsp;2.405; P\u0026thinsp;=\u0026thinsp;0.024) were independent risk factors for POUR after radical surgery for anal fistula.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003ePOUR is a common complication following radical surgery for anal fistula. Patients with urological disease or high anal fistula or incisions at position 1 are more likely to develop POUR. Surgeons should pay more attention to the surgical techniques of fistulas in the anterior rectum. Better postoperative pain and anxiety management strategies should be provided to reduce the incidence of POUR and avoid irreversible damage caused by persistent bladder overdistension.\u003c/p\u003e","manuscriptTitle":"Effect of incision location and type of fistula on postoperative urinary retention after radical surgery for anal fistula: a retrospective analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-16 09:02:52","doi":"10.21203/rs.3.rs-4236957/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-04-12T11:24:51+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-04-12T05:00:13+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-04-12T05:00:13+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Gastroenterology","date":"2024-04-08T13:51:12+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-gastroenterology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmge","sideBox":"Learn more about [BMC Gastroenterology](http://bmcgastroenterol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmge/default.aspx","title":"BMC Gastroenterology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4d589b1a-027e-46ad-97ef-17463c604d68","owner":[],"postedDate":"April 16th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-10-21T16:04:00+00:00","versionOfRecord":{"articleIdentity":"rs-4236957","link":"https://doi.org/10.1186/s12876-024-03435-0","journal":{"identity":"bmc-gastroenterology","isVorOnly":false,"title":"BMC Gastroenterology"},"publishedOn":"2024-10-14 15:56:59","publishedOnDateReadable":"October 14th, 2024"},"versionCreatedAt":"2024-04-16 09:02:52","video":"","vorDoi":"10.1186/s12876-024-03435-0","vorDoiUrl":"https://doi.org/10.1186/s12876-024-03435-0","workflowStages":[]},"version":"v1","identity":"rs-4236957","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4236957","identity":"rs-4236957","version":["v1"]},"buildId":"FbvkV6FR0MCFSLy54lSbu","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}