Long-term suprapubic catheterisation: clinical outcome and satisfaction survey

Intestinal Injury After Suprapubic Catheterisation: A Scoping Review

Suprapubic catheterisation (SPC) is a commonly performed urological procedure. Although it is generally safe, SPC-induced bowel injury is a rare but morbid complication. It is described in the literature, but management consensus is lacking. A scoping review was conducted assessing existing literature regarding the management of intestinal injury. The review highlighted that bowel perforation, particularly involving the small bowel and terminal ileum, is the commonest SPC-related bowel injury type. Depending on the severity of the injury and the patients' condition, various management strategies, ranging from exploratory laparotomy to less invasive techniques like laparoscopic intervention, are documented. Despite the introduction of preventive measures, such as ultrasound guidance, intestinal injury occurs. SPC-associated bowel injury is a serious but rare complication despite available preventative measures. Its management varies and depends on the part of the bowel injured and its severity. This review highlights reported management strategies specific to this injury and a literature summary to aid future quality improvement on the topic.

Safety of ultrasound-guided percutaneous suprapubic catheter insertion in spinal cord injury patients

STUDY DESIGN

Retrospective chart audit.

OBJECTIVES

To evaluate the safety of ultrasound-guided percutaneous suprapubic catheter (SPC) insertion in patients with spinal cord injury/disease (SCI/D) and to attempt to identify risk factors for complications.

SETTING

Specialized German centre for spinal cord injuries.

METHODS

This retrospective chart analysis evaluated demographic, neurologic, and neuro-urologic data and the incidence and type of complications within the first 30 days after suprapubic bladder catheter insertion in SCI/D patients in the period between January 1st, 2013, and December 31st, 2022.

RESULTS

The data of 721 SCI/D patients (244 women and 477 men, 386 tetraplegics and 355 paraplegics) were analysed. There were 44 complications (6.5%), of which 11 (1.5%) were major complications according to Clavien-Dindo ≥ 3. Among these were one small bowel injury and one peritoneal injury each, but no fatal complications. Regarding major complications (according to Clavien-Dindo ≥3), only patient age was identified as a risk factor (p = 0.0145). Gender, SCI/D level, neurological completeness, and severity of SCI/D or type of neurogenic lower urinary tract dysfunction (Odds ratio [95% CI] 1.6423 [0.4961;5.4361], 1.0421 [0.3152;3.4459], 0.3453 [0.0741;1.6101], 2.8379 [0.8567;9.4004] and 2.8095 [0.8097;9.7481] respectively) did not show any association with the frequency of major complications.

CONCLUSIONS

Mild complications, especially temporary hematuria or infectious complications, are not uncommon after SPC insertion in SCI/D patients. Major complications occur only rarely, and no risk factor other than age could be detected. On this basis, pre-intervention education on informed consent for SCI/D patients can be provided on an evidence-based approach.

Sleep and Overactive Bladder in Parkinson's Disease

Patients with Parkinson's disease (PD) have disturbances in their bladder and sleep physiology that lead to nocturia and overactive bladder (OAB). These symptoms can be extremely bothersome and impact not only their quality of life (QoL) but also the QoL of their caretakers. We aim to highlight the changes in bladder and sleep physiology in PD and explore OAB/nocturia treatment strategies in this population.

Herniation of the bladder through suprapubic catheter tract - An unusual complication

Long-term complications of suprapubic catheters are not well documented in the literature. The common complications includes infection, stone formation, urine leakage and malignant changes. We report an unusual complication of bladder prolapse in a patient with long-term suprapubic catheterization. Due to the rarity of this complication, its management has not been well studied.

Long-term Suprapubic Catheter-Related Care Requirements When Living at Home: Development of a Best Practice Guide

PURPOSE

The purpose of this study was to develop a best practice guideline specific to the health care needs of adults living at home with a long-term suprapubic catheter (SPC).

DESIGN

Guided by the theory of social constructionism, a mixed-methods, 2-phased study design enabled an integration of experiences and consensus from 2 groups of experts.

SUBJECTS AND SETTING

The first group of experts involved 10 people living with a long-term SPC at home. The second group comprised 23 nurses who provided care to people living with a long-term SPC at home.

METHODS

During phase 1, semistructured in-depth interviews were completed to explore people's day-to-day self-care practices and support needs when living at home with a long-term SPC. These data were evaluated via thematic analysis. The themes identified in phase 1 provided the phase 2 question framework in the development of a 3-round Delphi survey involving the expert nurse group. The first round elicited the respondents' opinions on specific aspects of SPC-related care. Using qualitative content analysis, practice statements were generated and used in subsequent survey rounds. The respondents rated their level of agreement to each statement. The guideline comprises the statements that achieved consensus.

RESULTS

The 6 elements of the best practice guideline contracted using this mixed-methods study were psychological support needs, cystostomy site care, SPC replacement, drainage equipment practices, complication avoidance and management, and planning ahead.

CONCLUSIONS

This best practice document provides a valuable resource to guide health professionals, promoting standardized best practices when caring for persons living at home with an SPC.

Suprapubic catheter encasement by bladder stone

Complications of suprapubic catheterization including acute urinary retention present often to the emergency department. Patients with chronic indwelling catheters are at increased risk of bladder calculi and recurrent infections, especially without appropriate follow up care. We describe a case of suprapubic catheter failure secondary to complete circumferential encrustation of the distal catheter tip by a bladder calculus. This case demonstrates the need for thorough evaluation of any case of catheter dysfunction and for careful consideration of bladder calculi in those patients at risk.

Experience sharing of conservative treatment after a 90-year-old male replacing the suprapubic bladder catheter enters the small intestine: A rare case report

Introduction

The treatment of intestinal perforation caused by the SBC enters the small intestine in elderly patients is a challenge for urologists. The report is to share our experience of conservative treatment after a 90-year-old male with the suprapubic bladder catheter enters the small intestine.

Presentation of case

Because of the device was obstructed, a 90-year-old male went to our hospital with his family and requested to replace the SBC. When the fistula tube was replaced, it entered the intestine through the intestinal injury site instead of entering the bladder. During the hospitalization, the patient was given supportive treatments and the SBC was dynamically monitored daily and it was intermittently withdrawn out during this period. After the drainage volume was less than 10 mL for three consecutive days and the intestinal fistula was healing gradually, the catheter was taken out.

Discussion

According to our experience, the common complications in the process include failure to pull out the SBC, abnormal position of the SBC, and poor drainage of the SBC. However, the drainage tube placing into the small intestine through the original hole of the suprapubic bladder fistula during the replacement process is quite rare. When elderly patients have traumatic small bowel perforation, the diagnosis and treatment of intestinal perforation in elderly patients was particularly important.

Conclusion

The conservative treatment of intestinal perforation is suitable for elderly patients who are unsuitable or unwilling to undergo a surgical operation. Of course, it should be in accordance with the patient's condition to make the right choice of treatment.

[CLINICAL ANALYSIS OF 95 CASES OF PERCUTANEOUS CYSTOSTOMY]

(Introduction) Percutaneous cystostomy is a standard urological procedure; however, very few reports have focused on the many cases of this procedure performed in Japan. We analyzed the background of the procedure and its approach as well as the incidence of its complications at our institution. (Material and methods) We examined 95 patients who underwent percutaneous cystostomy between April 2010 and March 2019. A comparative analysis was conducted for each type of procedure performed. Furthermore, cases that experienced accidental catheter extraction before the first catheter replacement were analyzed, and the three patient groups were compared based on the type of procedure performed and cases that needed another operation. (Result) The indications for cystostomy were urethral stricture (56.3%), neuropathic bladder (13.5%), and prostatic hyperplasia (11.5%). The complications included hemorrhage, peritoneal injury, urinary tract infection, and catheter damage caused by a puncture needle. The overall complication rate was 10.5%. Based on type of the procedure performed, the incidence of hemorrhage was found to be as high as 25% in patients who underwent the procedure using a cannula puncture needle. Accidental catheter extraction before the first catheter replacement occurred most frequently in patients treated with Seldinger technique (17.0%). The rate of complications including accidental catheter extraction ranged from 25.0% to 25.4% among the three groups. (Conclusion) We prefer the Seldinger technique for the first placement of the cystostomy catheter because of its low rate of hemorrhage, but a cannula puncture needle may also be used by using exploratory puncture if vascular damage and accidental catheter extraction are avoided.

A Foley folly: Unintended proximal urethral catheterization and balloon inflation causing urethral injury during suprapubic cystostomy exchange

Urinary catheter dysfunction is a common emergency department presentation for patients with neurogenic bladders. Many of these patients have cystostomies requiring routine suprapubic catheter exchange. On complication of outpatient catheter replacement, patients are often sent to the emergency department (ED). We describe the case of an 81-year-old male presenting with painless hematuria and blood from the urinary meatus after undergoing routine cystostomy exchange. During Foley replacement, the suprapubic catheter entered the proximal urethra and the balloon was inflated while in the prostatic urethra, leading to urethral injury and cystic clot formation. Emergency physicians should be aware of this rare complication of suprapubic catheter placement.

Inadvertent Bowel Injury Following Repeated Suprapubic Catheterisation in a Patient of Post-Pelvic Radiotherapy

Suprapubic catheterization (SPC) is one of the standard procedures in urological emergencies. The common complications of SPC include loss of track, hematuria, catheter blockage, and catheter-related infections. However, severe complications like bowel injuries, including intestinal obstructionand perforation, can also occur. We present the case of a 54-year-old lady who had received pelvic radiation 30 years ago for carcinoma cervix. She presented to a secondary-level care center with anuria. On failure of per urethral catheterization, she repeatedly underwent unguided SPC. However, unsatisfied with her recovery, she was brought to our tertiary care center by her relatives. She was found to have inadvertent placement of SPC in the small bowel, which was confirmed preoperatively by ultrasound and CT. Intraoperatively, the SPC catheter was seen inside the terminal ileum causing ileal wall necrosis and a localized feco-purulent collection. Urinary bladder rent was also noted at the site of the earlier SPC. Resection of distal ileum with double barrel ileostomy, followed by primary repair of the bladder wall, was done. Unfortunately, she succumbed to overwhelming sepsis and expired in the postoperative period. This case emphasizes a potential higher risk of life-threatening bowel injury due to SPC insertion in patients with previous pelvic irradiation. Such high-risk cases should be approached with the utmost care, preferably under ultrasound guidance. For safe practice, the British Association of Urological Surgeons' guidelines for SPC insertion should be followed.

A Systematic Review of the World of Validated Suprapubic Catheter Insertion Simulation Trainers: From 'Head-Blocks' to 'Lunch Boxes'

PURPOSE

Various suprapubic catheter insertion simulators have been described to aid in the training of this fundamental skill. The purpose of this review was to evaluate and critically appraise all validated simulators.

METHODS

The PubMed, Web of Science, Cochrane Library, Scopus, British Medical Journal and the Embase databases were searched (March 2018), by using key search terms "suprapubic trainer", "suprapubic model", "suprapubic simulation" and "suprapubic simulator".

RESULTS

A total of 196 articles were identified; 117 unrelated, 53 animal studies and 20 duplications. Only 6 articles met the inclusion criteria for this review. The median number of participants per study was 30.5. Material costs ranged from 1.71 to 60 dollars per model. Only 2 studies incorporated the use of ultrasound.

CONCLUSION

Despite validated suprapubic catheter insertion models being a specially needed learning resource, only few have been described-mostly for not resourceful environments. There exists a general lack of guidelines on model validation processes. There is a need to develop, appropriately validate and integrate models into training curriculum.

The effect of appropriate bladder management on urinary tract infection rate in patients with a new spinal cord injury: a prospective observational study

PURPOSE

This study aimed to determine the rate of urinary tract infection (UTI) in patients with a new spinal cord injury (SCI) and identify which bladder management technique is associated with the lowest rate of UTI.

METHODS

Adults admitted to the Victorian Spinal Cord Service with a new SCI from 2012 to 2014 were enrolled. Data collected included patient characteristics, SCI level, bladder management and diagnosis of UTI. Bacteriuria (≥ 102 colony-forming organisms/mL) with clinical signs of infection was used to define a UTI.

RESULTS

143 patients were enrolled. 36 (25%) were female; the median age was 42 years. An indwelling urethral catheter (IUC) was placed in all the patients initially. 55 (38%) patients developed a UTI with an IUC, representing a UTI rate of 8.7/1000 inpatient days. Long-term bladder management strategies were initiated after a median of 58 days. IUC removal and initiation of any other alternative bladder management halved the UTI rate to 4.4/1000 inpatient days, p < 0.001. Intermittent self-catheterisation (ISC) and suprapubic catheter placement had lower UTI rates compared to IUC, 6.84 and 3.81 UTI/1000 inpatient days, p = 0.36 and p = 0.007, respectively. An IUC was re-inserted in 29 patients and resulted in a higher UTI rate of 8.33/1000 inpatient days.

CONCLUSION

This study has identified a high UTI rate in new SCI patients with an IUC and reinforces the importance of early IUC removal and initiation of non-IUC bladder management in this cohort of patients.

Bladder emptying method is the primary determinant of urinary tract infections in patients with spinal cord injury: results from a prospective rehabilitation cohort study

OBJECTIVE

To understand the occurrence of and risk factors for urinary tract infections (UTIs) in patients with spinal cord injury (SCI) undergoing specialized SCI rehabilitation in Switzerland.

PATIENTS AND METHODS

This study used data collected from 369 patients, who participated in a nationwide rehabilitation cohort for SCI in Switzerland between 2013 and 2017. Information on UTIs as well as their potential determinants, including demographics, lesion characteristics, and time-updated data on functional independence and bladder management, was used. Multivariable regression methods were applied to perform a time-updated evaluation of determinants of UTI risk.

RESULTS

The crude incidence rate (IR) of UTIs was 0.55 UTIs per 100 person-days (95% confidence interval [CI] 0.49-0.62), the cumulative IR was 43%, and the median length of stay was 122 days. The bladder emptying method at discharge was largely determined by 28 days after admission. Among those using indwelling or assisted intermittent catheterization (IC), the likelihood of self-IC at discharge was positively related to the level of self-care independence, negatively related to age at injury, and lower in women than men. Catheter users consistently had higher adjusted IRs for UTI than spontaneous voiders. The IR ratios were: indwelling catheter: 5.97 (95% CI 2.63-13.57); assisted IC: 6.05 (95% CI 2.63-13.94); self-IC: 5.16 (95% CI 2.31-11.52); test for differences across catheter groups: P = 0.82. Lesion severity and previous UTI had additional but smaller effect sizes.

CONCLUSIONS

Bladder emptying method was identified as the main risk factor for UTI in patients with SCI. As spontaneous voiders had the lowest UTI rate, further research is warranted to reduce voiding dysfunction, for instance using neuromodulation procedures.

Unusual complication of bladder prolapse with subsequent diagnosis of urothelial carcinoma leading to a necrotizing soft tissue infection after radical cystectomy

There is lack of information in the literature on long-term complications of suprapubic catheters. The most common complications include urinary tract infection, bladder calculi, urine leakage and neoplastic changes. We report a case of an unusual complication of bladder prolapse, with subsequent diagnosis of urothelial carcinoma, leading to a necrotizing soft tissue infection after a radical cystectomy in a patient with long-term catheterization and its management. Due to the rarity of this complication, its management has not been well studied. In this particular case, the logical indication was radical cystectomy due to the presence of bladder necrosis.

Use of Urinary Collection Devices in Community and Nursing Homes in Istria County

INTRODUCTION

This study is aimed at assessing the use of various types of urinary catheters, appropriateness of catheter placement and factors associated with antibiotic use in a population of chronically catheterized patients in Istria County.

MATERIALS AND METHODS

This cross-sectional study, conducted between March and June 2017 in Istria County, Croatia, was initiated through a network of general family medicine offices. Data were collected from general practitioners (GPs) and from medical managers in nursing homes. Participants were asked to review medical records of their patients and to complete a 10-item questionnaire designed to retrieve information on patients with urinary catheter.

RESULTS

All GPs in the county were surveyed. We identified 309 patients with urinary catheter: 216 men (70%) and 93 women (30%). The overall prevalence of individuals with urinary catheters was 0.18%: 4.7% in nursing home population and 0.1% among non-institutionalized adult population. Most common indication for catheterization was chronic urinary retention (52%). One hundred eighty-six patients (60.4%) reported antibiotic usage in the previous 3 months for treating urinary infection.

CONCLUSIONS

In Istria County, the prevalence of indwelling urinary catheters is highest in males, especially among patients in nursing homes. There is a need for focused education among GPs regarding urinary catheter maintenance and antibiotic prescription for suspected urinary tract infections.

Safety and efficacy of ultrasound-guided percutaneous suprapubic cystostomy in resource-poor setting: A 7-year review

INTRODUCTION

Percutaneous cystostomy techniques are usually done using disposable sets in developed countries which are not affordable in poor-resource settings. However, the percutaneous technique can be done using reusable trocar or selected big size surgical blades. This is simple, safe, and cost effective in poor-resource setting. The procedure is best done under ultrasound guidance but can also be done blindly in select cases. We present our 7-year experience in ultrasound-guided percutaneous suprapubic cystostomy.

MATERIALS AND METHODS

This is a 7-year retrospective review of patients, who had ultrasound-guided percutaneous suprapubic cystostomy at Urology Unit of our institution from January 2010 to December 2016. Disposable cystostomy sets were used for the initial experience, but this was replaced with more cost-effective reusable metallic trocar or selected big size surgical blade methods in the later experience. Data were extracted from procedure register and patients' case notes and entered into pro forma and analyzed using Statistical Package for Social Sciences 20.0 version (2011) for windows (IBM, SPSS Incorporation, Chicago, IL, USA) 20.0 version for Windows.

RESULTS

A total number of 135 patients had percutaneous cystostomy, which was ultrasound guided in 134 patients (99.3%). The mean age of the patients was 50.5 ± 23.3 years with a range of 2-90 years. The indications for the procedure include urine retention with failed urethral catheterization in 119 patients (88.1%), urethral injury in 14 patients (10.4%), and urethrocutaneous fistula in 2 patients (1.5%) with spinal cord injury. No major complication was recorded.

CONCLUSION

Ultrasound-guided suprapubic cystostomy using reusable trocar or selected surgical blade is simple, safe, effective, and associated with minimal complications in poor-resource setting.

First Irish and tenth case of small bowel obstruction secondary to suprapubic catheterisation in the world. Case report and case review of a rare complication of suprapubic catheterisation

•

We are reporting a very rare complication of suprapubic catheterisation that is small bowel obstruction.

•

Our case is first Irish and 10th global case of small bowel obstruction secondary to SPC.

•

We also searched the literature to find similar reported cases to extract useful information from these cases, use this information to draw conclusions and make recommendations to avoid injuries in future.

•

We found that significantly distended bladder, use of ultrasound and extra precaution in elderly patients can reduce the risk of damage to bowel.

Introduction

Percutaneous Suprapubic urinary bladder catheterisation (SPC) is a common procedure performed in cases of urinary retention where attempt to pass urethral catheter has failed. However, the procedure requires meticulous precision, vigilance and sound knowledge of anatomy, to avoid grave complications. We are reporting a very rare complication of Suprapubic catheterisation that is small bowel obstruction. Our case is first Irish and 10th global case of small bowel obstruction secondary to SPC.

Case presentation

Aim of this study was to report this rare complication of the SPC in our patient who was 88 years old retired farmer presenting to emergency department with small bowel obstruction. In our case after clinical examination diagnosis was made with CT scan. Laparoscopy done and found that SPC passed through mesentery before entering bladder and was released laparoscopically.

We also searched the literature to find similar reported cases to extract useful information from these cases and use this information to draw conclusions and make recommendations to avoid injuries in the future. Database search conducted in March 2017 on the bibliographic databases Ovid MEDLINE (1946 to November 2016) and EMBASE (1980 to November 2016) along with additional reference searching revealed only 9 reported cases of small bowel obstruction secondary to SPC.

Conclusions

From the extensive literature search we found that there are only nine cases reported so far globally, and our case is first Irish and tenth international case of bowel obstruction secondary to SPC. Significantly distended bladder, use of ultrasound and extra precaution in elderly patients can reduce the risk of damage to bowel.

Urethral calculi with a urethral fistula: a case report and review of the literature

BACKGROUND

To explore and summarize the reasons why urethral calculi cause a urethral fistula.

CASE PRESENTATION

We retrospectively studied 1 patient in Xiangya hospital and all relevant literature published in English between 1989 and 2015. The patients (including those reported in the literature) were characterized by age, origin, location of calculus, size of calculus, fistulous track, and etiological factors. Most of urethral calculi associated with a urethral fistula were native generated. Urethral calculi can be formed in various locations of the urethra, and the size of the calculus ranged from small (multiple) calculi to giant stones. The fistula external orifice located at the root of the penis was relatively common, and there were various etiological factors, such as urethral strictures, urethral trauma induced by long-term catheterization, lumbar fractures, and congenital anomaly factors. They were managed by the excision of the fistulous tract, retrieval of the urethral stones, and/or debridement and pus drainage operations.

CONCLUSION

Some elements, such as trauma, recurrent urinary tract infections, abscess formation induced by long-term catheterization, and urethral calculus, may be the risk factors for a urethral fistula.

Case Report: Vessel Injury During Suprapubic Catheter Placement and the Importance of Patient Positioning in Obese Patients

Obesity is a well-known risk factor for increased perioperative morbidity. As surgeons see higher volumes of obese patients, it is important to recognize how an elevated body mass index can impact even the most basic surgical steps, such as patient positioning. This case report describes an iatrogenic injury to the external iliac artery in a morbidly obese patient caused by an abdominal trocar during suprapubic catheter insertion secondary to malrotation of the bony pelvis. It highlights the importance of recognizing the impact of obesity on patient positioning.

Using central venous catheter for suprapubic catheterization in cardiac surgery

Suprapubic catheterization is an alternative method for urinary drainage that is used when transurethral catheterization fails. Traditionally, inserted large-bore suprapubic catheters may cause fatal complications. During the past decade, we used a small central venous catheter (CVC) suprapubicly in 16 male patients for the purpose of urinary drainage, when transurethral catheterization failed. The procedure is performed in no more than 10 minutes. Success rate was 100% and this approach did not lead to any complications. In conclusion, placing a CVC for suprapubic drainage is a safe method with a high success rate and we recommend it in patients with failed transurethral catheterization after a few attempts (2–3 attempts).

Suprapubic versus transurethral bladder drainage following reconstructive pelvic surgery: a comparison of patient satisfaction and quality of life

INTRODUCTION AND HYPOTHESIS

To assess the differences in patient-reported, catheter-specific satisfaction and quality of life with either suprapubic or transurethral postoperative bladder drainage following reconstructive pelvic surgery.

METHODS

This was a prospective study of all eligible women who were scheduled to undergo reconstructive surgery requiring bladder drainage during the study period November 2013 to March 2015. Women who did not undergo the planned procedure(s) or did not require bladder drainage were excluded. The primary outcome was patient-reported quality of life using catheter-specific instruments including the Catheter-related Quality of Life (CIQOL) instrument, and a modified version of the Intermittent Self-Catheterization Questionnaire (ISC-Q), designed to evaluate aspects of catheter-related quality of life and satisfaction specific to the needs of the individual.

RESULTS

A total of 178 women were analyzed, 108 in the transurethral catheter group and 70 in the suprapubic group. Women with suprapubic bladder drainage had higher quality of life and satisfaction scores than women with transurethral bladder drainage as measured by the ISC-Q (68.31 ± 16.87 vs. 54.04 ± 16.95, mean difference 14.27, 95 % CI 9.15 - 19.39). There was no difference in quality of life by the CIQOL. After regression analysis, women with suprapubic bladder drainage were more satisfied with their catheter-specific needs despite longer duration of catheter use, more concurrent continence surgery, and higher trait anxiety.

CONCLUSIONS

Differences in catheter-specific quality of life and patient satisfaction scores favoring suprapubic bladder drainage support its continued use in appropriately selected women for treatment of temporary postoperative urinary retention after reconstructive pelvic surgery.

Comparing transurethral and suprapubic catheterization for long-term bladder drainage: a qualitative study of the patients' perspective

PURPOSE

To explore why men and women decide to have a suprapubic catheter, how the decision is made, and to compare people's experiences of suprapubic and transurethral catheterization for long-term bladder drainage.

DESIGN

Narrative interviews followed by thematic analysis.

SUBJECTS AND SETTING

Thirty-six long-term catheter users living in England, Wales, or Scotland were interviewed. The sample included men and women from various socioeconomic backgrounds, with a wide range of conditions. They were aged 22 to 96 years (M = 57 years).

METHODS

Interviews lasted between 1 and 3 hours; they were audiotaped and fully transcribed for analysis. A qualitative interpretive approach was taken, combining thematic analysis with constant comparison.

RESULTS

Some respondents were satisfied with or preferred a urethral catheter; others preferred a suprapubic catheter because they perceived that suprapubic catheters led to fewer infections, were more hygienic, more comfortable, improved self-image, allowed a sense of control, and were better suited for sexual relations. Participants also mentioned the decision-making process, including how the decision was made to have a suprapubic catheter and where to insert the catheter at a particular point in the abdomen. Even with a suprapubic catheter, some worried about sex or were put off sexual intimacy because of the catheter.

CONCLUSION

Our findings suggest that patients should be better informed before a suprapubic catheter is inserted and that issues such as sex should be raised in consultations when appropriate.

Conservative bladder management in advanced multiple sclerosis

Anticholinergics and intermittent catheterization are the cornerstones of bladder management in early multiple sclerosis (MS). In advanced MS however, bladder management is based more on tradition than on evidence. Nurses seem to deal with catheter problems and chronic incontinence. Despite the abundant use of indwelling catheters, there is a lack for guidelines on catheter-induced problems. The psychosexual and social impact of bladder problems in advanced MS is often neglected. The international multidisciplinary special interest group on sexual, urological and bowel dysfunction in MS (SUBDIMS) as a special interest group of the Rehabilitation in Multiple Sclerosis (RIMS) was confronted with a high variability in practice and a lack of guidelines. A literature review was prepared during three multidisciplinary expert meetings. This review will be the basis of further initiatives to improve the urological treatment of patients with advanced MS.

SUPRAPUR(®): Safe and convenient percutaneous suprapubic catheterisation in high-risk patients

Introduction

Ultrasound-guided percutaneous placement of a suprapubic cystostomy is a common and generally safe procedure in everyday surgery. In case of adverse patient characteristics such as small bladder capacity or high body mass index, however, the procedure carries an increased risk of severe complications, including bowel perforation. The Suprapur^® cystostomy set is supposed to enable a safer procedure. The aim of our work was to evaluate the safety and ease of use of the Suprapur^® cystostomy set.

Material and methods

We prospectively evaluated the Suprapur^® set in high-risk patients, having either a small bladder capacity below 250 ml or a BMI above 30 kg/m². Complications and surgical outcome were monitored. In addition, patients’ contentment and pain during the procedure was assessed with a visual analogue scale (VAS). Possible drawbacks and ease of use were evaluated by customized questionnaires for the operating physician.

Results

In total, 26 cystostomies were performed by 15 different physicians, 40% (n = 6) of whom were inexperienced first or second year residents. No complications occurred. Mild gross haematuria occurred in 11.5% (n = 4) of cases. Average VAS for pain during and two hours after the procedure was 2.1 (±1.2) and 0.3 (±0.5) respectively. In 91%, (n = 20) of the procedures, the physicians claimed to have felt safe using SUPRAPUR^® and more comfortable (82%, n = 18) than with a conventional cystostomy set.

Conclusions

SUPRAPUR^® allows a safe and simple placement of a suprapubic cystostomy even in high-risk patients or in inexperienced hands. It might help to reduce the complications of a common and frequent surgical procedure.

Urinary tract infection in the neurogenic bladder

There is a high incidence of urinary tract infection (UTI) in patients with neurogenic lower urinary tract function. This results in significant morbidity and health care utilization. Multiple well-established risk factors unique to a neurogenic bladder (NB) exist while others require ongoing investigation. It is important for care providers to have a good understanding of the different structural, physiological, immunological and catheter-related risk factors so that they may be modified when possible. Diagnosis remains complicated. Appropriate specimen collection is of paramount importance and a UTI cannot be diagnosed based on urinalysis or clinical presentation alone. A culture result with a bacterial concentration of ≥10(3) CFU/mL in combination with symptoms represents an acceptable definition for UTI diagnosis in NB patients. Cystoscopy, ultrasound and urodynamics should be utilized for the evaluation of recurrent infections in NB patients. An acute, symptomatic UTI should be treated with antibiotics for 5-14 days depending on the severity of the presentation. Antibiotic selection should be based on local and patient-based resistance patterns and the spectrum should be as narrow as possible if there are no concerns regarding urosepsis. Asymptomatic bacteriuria (AB) should not be treated because of rising resistance patterns and lack of clinical efficacy. The most important preventative measures include closed catheter drainage in patients with an indwelling catheter and the use of clean intermittent catheterization (CIC) over other methods of bladder management if possible. The use of hydrophilic or impregnated catheters is not recommended. Intravesical Botox, bacterial interference and sacral neuromodulation show significant promise for the prevention of UTIs in higher risk NB patients and future, multi-center, randomized controlled trials are required.

Fecal Fistula Communicating with a Femur Shaft Fracture Secondary to a Malpositioned Suprapubic Catheter: A Case Report

Patient: Male, 18

Final Diagnosis: Fecal fistula communicating with fracture shaft femur secondary to malpositioned SPC

Symptoms: —

Medication: —

Clinical Procedure: Advertisement and rail fixator application

Specialty: Orthopedics and Trauamtology

A practical approach to difficult urinary catheterizations

Routine placement of transurethral catheters can be challenging in some situations, such as urethral strictures, severe phimosis and false passages. Intravaginal retraction of the urethral meatus can complicate Foley placement in postmenopausal females. In men, blind urethral procedures with mechanical or metal sounds without visual guidance or guidewire assistance are now discouraged due to the increased risk of urethral trauma and false passages. Newer techniques of urethral catheterization including guidewires, directed hydrophilic mechanical dilators, urethral balloon dilation, and direct vision endoscopic catheter systems are discussed, along with the new standardized protocol for difficult transurethral catheter insertions. Suprapubic catheter placement techniques, including percutaneous trocars and the use of the curved Lowsley tractor for initial suprapubic catheter insertion, are reviewed. Prevention and management of common catheter-related problems such as encrustation, leakage, Foley malposition, balloon cuffing and frequent blockages are discussed.

Changing a urethral or suprapubic catheter: the patient's perspective

Understanding the patient's perspective in any area of health care is now recognised as being crucial to good practice, but little is known about patients' views on living with an indwelling urinary catheter. In this study, 36 people living with either a urethral or suprapubic catheter across the UK were interviewed. After thematic analysis, the authors interpreted what they learned. Many issues were raised, including the need to know who was responsible for changing the catheter, the importance of continuity of care, 24-hour access to services, and good hygiene. Patients valued nurses with training and experience, with plenty of time, who took care and who listened to what mattered to the patient. The patient's perspective is important at all levels, not only when designing and planning an integrated continence service, but also in delivering services in the community.

Options for independent bladder management in patients with spinal cord injury and hand function prohibiting intermittent catheterization

AIMS

Choosing the appropriate bladder management strategy for the spinal cord injury patient with neurogenic bladder and hand function prohibitive of self catheterization (urethral or stomal) catheterization is complex and based on limited literature. We have catalogued the available data in this review.

METHODS

A literature review was conducted on external sphincterotomy, suprapubic tube, ileal conduit, and ileovesicostomy between 1994 and 2012. Articles on neurogenic bladder focused primarily on spinal cord injury were included. Important aspects of each technique, patient selection, urologic events, and quality of life are described.

CONCLUSION

The available literature consists primarily of level 3 data. Patient reported outcomes were rarely measured. External sphincterotomy is a good option for males who are candidates for an external catheter and who wish to avoid a complicated reconstruction-most will need re-operations for failure. Suprapubic tube is an option in both genders. Complaints usually involve urine leakage and urinary tract infection, which typically resolve with conservative measures. There is some evidence to support patient satisfaction. Ileal conduit is an option for all patients with quadriplegia, offering continuous drainage and absence of foreign material. Many providers and patients will choose more conservative options first. The ileovesicostomy is best applied to small bladders with severe overactivity. The "reversibility" of this procedure makes it attractive to those not interested in an ileal conduit and who have had complications from prolonged suprapubic tube placement. The authors conclude with recommendations for future research, most importantly more standard reporting of objective data.

Long-term bladder drainage: Suprapubic catheter versus other methods: a scoping review

AIMS

The purpose of this scoping review was to examine research activity comparing suprapubic catheterization to any other method of chronic bladder emptying such as intermittent and indwelling catheterization in adults in relation to complications, patient satisfaction, and health-related quality of life (QoL).

METHODS

A search of electronic databases (MEDLINE, CINAHL, SCOPUS, and OVID) was performed 1950-May 2012 using the search terms, singly or combined: suprapubic, catheter, long term, effectiveness, urinary, health promotion, incontinence, retention, QoL, and evidence based. All research designs were included. Papers were excluded if catheter duration was <30 days or were single case reports.

RESULTS

Twenty-six articles were identified for potential inclusion from an initial 394 and 14 retained after final review. Studies varied in subjects, outcome measures, and publication dates. The majority were retrospective reviews; four were descriptive/qualitative studies. Based on the clinical findings, suprapubic catheters are associated with a low incidence of urethral injury and stricture, but have similar rates of upper tract damage, vesicoureteral reflux, renal or bladder calculi, and symptomatic urinary tract infections compared to urethral catheters. Users report being generally satisfied with suprapubic catheters. No studies addressed stoma or skin care, urethral leakage, or adherence to the suprapubic catheter after insertion.

CONCLUSION

Most studies focused on clinical urologic issues rather than patient understanding of suprapubic catheter management, satisfaction, stoma and skin care, or health related QoL. Further studies are needed to elucidate efficacy from an individual user and clinician perspective.

A peculiar complication of suprapubic catheterization: recurrent ureteral obstruction and hydronephrosis

CONTEXT

Suprapubic cystostomy (SPC) catheterization is a common and important technique for the management of vesicular drainage, especially in patients with neurogenic bladder. Some serious complications include bowel perforation and obstruction.

FINDINGS

A 55-year-old man with C6 American Spinal Injury Association B tetraplegia and a urethral stricture requiring a chronic SPC was admitted for recurrent urosepsis. Computed tomography (CT) of the abdomen revealed severe right hydronephrosis and hydroureter due to obstruction of the right distal ureter by the SPC tip. The SPC (30 French/10-mm silicone catheter with a 10-ml balloon) was removed and replaced with a similar suprapubic catheter (30 French/10-mm silicone catheter with an 8-ml balloon). Symptoms recurred 2 months later and he was readmitted for urosepsis. CT of the abdomen again revealed severe right hydronephrosis and hydroureter due to obstruction of the right distal ureter by the SPC tip. The SPC was removed, and the patient was given a 14 French/4.67-mm urethral silicone catheter with a 5-ml balloon. Follow-up CT of the abdomen 2 months later showed complete resolution of the hydronephrosis and hydroureter. Of note, urodynamic studies 2 years earlier revealed an extremely small bladder with a capacity less than 20 ml.

CONCLUSION

This case illustrates that obstruction of the ureter by the tip of an SPC can be a cause of recurrent hydronephrosis and urosepsis.

An adverse event of suprapubic catheter SPC insertion. A call for updating the existing guidelines

The suprapubic catheter (SPC) is a useful and widely used tool in urological practice. However, complications can arise from its insertion or ongoing care. We add to the literature a case of an adverse event of its insertion where it has gone through a vascular graft and recommending updating the SPC insertion guidelines.

Safe percutaneous suprapubic catheterisation

INTRODUCTION

We describe our technique of percutaneous suprapubic catheter insertion with special reference to steps that help to avoid common complications of haematuria and catheter misplacement.

METHODS

The procedure is performed using a stainless steel reusable trocar under local infiltrative anaesthesia, usually at the bedside. After clinical confirmation of a full bladder, the trocar is advanced into the bladder through a skin incision. Once the bladder is entered, the obturator is removed and the assistant inserts a Foley catheter followed by rapid balloon inflation. Slight traction is applied to the catheter for about five minutes. Patients with previous lower abdominal surgery, an inadequately distended bladder or acute pelvic trauma do not undergo suprapubic catheterisation using this method.

RESULTS

The procedure was performed in 72 men (mean age: 42.4 years, range: 18-78 years) with urinary retention with a palpable bladder. The average duration of the procedure was less than five minutes. No complications were noted in any of the patients.

CONCLUSIONS

Trocar suprapubic catheter insertion is a safe and effective bedside procedure for emergency bladder drainage and can be performed by resident surgeons. The common complications associated with the procedure can be avoided with a few careful steps.

Types of indwelling urinary catheters for long-term bladder drainage in adults

BACKGROUND

Prolonged urinary catheterization is common amongst people in long-term care settings and this carries a high risk of developing a catheter-related urinary tract infection and associated complications. A variety of different kinds of urethral catheters are available. Some have been developed specifically to lower the risk of catheter-associated infection, for example antiseptic or antibiotic impregnated catheters. Ease of use, comfort and handling for the caregivers and patients, and cost-effectiveness are also important factors influencing choice.

OBJECTIVES

The primary objective was to determine which type of indwelling urinary catheter is best to use for long-term bladder drainage in adults.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Register (last searched 31 March 2011), which includes searches of CENTRAL, MEDLINE and handsearching of journals and conference proceedings, and the reference lists of relevant articles.

SELECTION CRITERIA

All randomised trials comparing types of indwelling urinary catheters for long-term catheterization in adults. Long-term catheterization was defined as more than 30 days.

DATA COLLECTION AND ANALYSIS

Data extraction has been undertaken by two review authors working independently and simultaneously. Any disagreement has been resolved by a third review author. The included trial data were handled according to the methods of the Cochrane Handbook for Systematic Reviews of Interventions.

MAIN RESULTS

Three trials were included, involving 102 adults in various settings. Two trials had a parallel group design and one was a randomised cross-over trial.Only two of the six targeted comparisons were assessed by these trials: antiseptic impregnated catheters versus standard catheters (one trial) and one type of standard catheter versus another standard catheter (two trials).The single small cross-over trial was inadequate to assess the value of silver alloy (antiseptic) impregnated catheters. In the two trials comparing different types of standard catheters, estimates of differences were all imprecise because the trials also had small sample sizes; confidence intervals (CI) were too wide to rule out clinically important differences. One trial did suggest, however, that the use of a hydrogel coated latex catheter rather than a silicone catheter may be better tolerated (risk ratio (RR) for need for early removal 0.41, 95% CI 0.22 to 0.77).

AUTHORS' CONCLUSIONS

The updated search could not reveal any additional evidence. Very few trials have compared different types of catheter for long-term bladder drainage. All trials were small and showed methodological weaknesses. Therefore, the evidence was not sufficient as a reliable basis for practical conclusions. Further, better quality trials are needed to address the current lack of evidence in this clinically important area.

[The relevance of catheterization in neurourology]

Together with comprehension and therapy of neurogenic failure of the storage function of the urinary bladder, intermittent catheterization as a pressure-free voiding method without residual urine, represents a major principle of therapy in lower urinary tract dysfunction. Aseptic intermittent catheterization is recommended in Germany and Europe and seems to be acceptable even in long-term application with low complication rates. It is a precondition that patients are seen for clinical and urodynamic reevaluation at risk-adapted time intervals. The major focus is on early recognition and avoidance of threatening complications. The most important preventive measures are the motivation and compliance of the well-educated patient and the use of careful catheterization techniques with individually optimized catheters.Although aseptic intermittent catheterization has been used effectively for many years there is still a lack of randomized controlled studies for some important questions of details and an optimal catheter has still to be defined. Furthermore, valid conclusions based on well-conducted studies on the self-estimated quality of life of patients with intermittent catheterization, especially those with catheterization by attendant, are urgently needed. Intermittent catheterization is never a ready-made solution but always an individually tailored treatment for patients with lower urinary tract dysfunction.

Suprapubic cystostomy for neurogenic bladder using Lowsley retractor method: a procedure revisited

OBJECTIVE

To report our experience with the Lowsley retractor method for suprapubic cystostomy (SPC) in patients with neurogenic bladder (NGB).

METHODS

A retrospective study was performed of 44 patients with NGB who underwent SPC with the Lowsley retractor method. The subjects were selected from 90 patients undergoing SPC by 1 surgeon from 1995 to 2010. The age, sex, indication, anesthesia type, catheter type, blood loss, fluids administered, and duration and complications were recorded.

RESULTS

A total of 49 primary catheter placements were performed in 44 patients. A total of 23 men and 21 women were included. The etiology of NGB was spinal cord injury and multiple sclerosis in 38 subjects (86%). The mean age was 44 years (range 18-86). The cases were performed under general anesthesia, except for 8 (16%) that were successfully performed with local and monitored anesthesia. The operation time documented in 19 cases (39%) was 20.2 ± 5.5 minutes (range 11-31). The Foley catheter size ranged from 16F to 22F. The blood loss was minimal, and there were no intraoperative complications or incorrect catheter placements. One patient returned with significant hematuria 1 day after the procedure. No other minor or major complications were noted.

CONCLUSION

Patients with NGB have been shown to have a greater risk of complication during percutaneous suprapubic catheter placement. SPC using the Lowsley retractor was described by Zeidman et al in 1988. Their report did not detail the patient characteristics or operative experience. To our knowledge, no other institutional experience with the technique has been reported. The present report describes the Lowsley retractor method as a quick and safe ambulatory procedure for patients with NGB.

Quality of life and urological morbidity in tetraplegics with artificial ventilation managed with suprapubic or intermittent catheterisation

STUDY DESIGN

Mono-centric, retrospective study.

OBJECTIVE

Analysis of correlation between bladder management and age in respirator-dependant high-tetraplegic patients. Additionally suprapubic catheter (SPC) and intermittent catheterisation (IC) were reviewed concerning urological complications and quality of life (QoL).

SETTING

Level 1 trauma centre.

METHODS

A QoL questionnaire 'International Consultation on Incontinence' (ICIQ-SF) was sent to 56 tetraplegic respirator device-dependant (RDD)-spinal cord injury (SCI) patients. Their scores concerning urological morbidity were reviewed. For analysis reasons they were divided in three groups: SPC, IC and others.

RESULTS

SPC 38, IC 12 and others 6 patients. Significant difference in age (SPC vs IC=49.9 vs 31.8 years) was observed but no disparity in gender. Within a follow-up period 2-26 years (median 8 years) significant urological complications in patients with IC (P<0.05) were ascertained. These were in general minor complications. Especially renal deterioration or bladder cancer was not diagnosed in any of the group. The questionnaire return rate was high (83.9%) with complete answers (SPC=32, IC=11). Self assessment of QoL with ICIQ-SF revealed no significant difference for both groups on low level, but SPC patients tend to score better.

CONCLUSION

In our study, tetraplegic RDD-SCI patients with SPC suffered less urological complications and tend to score a better QoL. Therefore we recommend SPC as a serious alternative for these selected patients and concurrently underline the necessity of close urological surveillance at least annually.

Medical and psychosocial complications associated with method of bladder management after traumatic spinal cord injury

OBJECTIVES

To determine the relationships between bladder management method and medical complications (renal calculi or decubitus ulcers), number of hospital days, and psychosocial factors. We hypothesized that indwelling catheterization would be associated with more complications, more hospitalizations, and worse psychosocial outcomes compared with other bladder management methods.

DESIGN

Inception cohort study.

SETTING

Model spinal cord injury (SCI) centers funded by the National Institute on Disability and Rehabilitation Research from 1973 to 2005.

PARTICIPANTS

Persons with new traumatic SCI (N=24,762) enrolled in the National SCI Database entire data set forms I and II. Patients were stratified according to the bladder management method recorded at each time of data collection into 1 of 4 groups as follows: indwelling catheterization, spontaneous voiding, condom catheterization, and intermittent catheterization. Those who reported no management method or errors in reporting were excluded (n=1564).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Medical complications, including pressure ulcer number and grade of worst ulcer, kidney stones, and hospitalizations, as well as psychosocial factors (satisfaction with life, perceived health status, societal participation), were stratified by bladder management method. Results were adjusted for level and completeness of neurologic injury and other confounding and modifying factors.

RESULTS

Compared with other forms of bladder management, use of an indwelling catheter was associated with more pressure ulcers and longer and more hospitalizations for all causes and urology-specific causes. Indwelling catheter use was associated with the lowest levels of participation, but similar satisfaction with life and perceived health status.

CONCLUSIONS

Indwelling catheterization was associated with more medical complications and lower levels of participation than other bladder management methods, but more research is required to ascertain the causality of these complications.