A Prospective Multi-Institutional Evaluation of Iatrogenic Urethral Catheterization Injuries

Optimised Protocol for Managing Failed Catheterisation: Leveraging Bedside Retrograde Urethrography and Cystourethroscopy

Introduction Urethral catheterization is a routine procedure often required for many hospitalized patients. Various conditions, such as meatal stenosis, stricture urethra, false passage, benign prostatic hyperplasia, bladder neck contractures, and impacted urethral stones, can contribute to difficulty in catheterisation. In the setting of failed attempts at per urethral catheter placement, the subsequent intervention is suprapubic catheter (SPC) insertion. SPC placement has its associated complications and causes inconvenience to the patients. We framed an algorithm to minimise the need for SPC insertion in cases of difficult per urethral catheterisation in a non-trauma setting. This study aimed to evaluate the common causes of difficult per urethral catheterisation and establish the efficacy of our algorithm in managing difficult catheterisation with bedside retrograde urethrography (RGU) and cystoscopy while avoiding SPC placement. Materials and methods This prospective observational study was conducted from September 2022 to June 2024. Patients admitted with urinary retention or requiring routine catheterisation, with one failed attempt at catheterisation, were included in the study. Our algorithm for the management of difficult catheterisation in a non-trauma setting, to avoid SPC, integrates a bedside RGU and retrograde urethroscopy using either a 15.5 Fr cystoscope sheath or a 6 Fr ureteroscope to identify the urethral pathology, followed by dilatation and per urethral catheterisation. Results Among 55 patients (aged 34-82 years), 48 (87.27%) were male and seven (12.73%) were female. The most common indication for catheterisation was routine catheterisation for output monitoring (n = 30; 54.54%), followed by acute retention (n = 25; 45.45%). Bulbar urethral stricture (n = 28; 50.9%) was the most common cause of difficult catheterisation, followed by meatal/sub-meatal narrowing (n = 13; 23.63%), enlarged prostate or high bladder neck (n = 4; 7.27%), and impacted stones (n = 3; 5.45%). Successful catheterisation was achieved in 48 male patients following urethroscopy with a 6 Fr ureteroscope or 15.5 Fr cystoscope. In females, reducing the pelvic organ prolapse enabled catheterisation in two cases, while five required serial dilatation and catheterisation. Successful per-urethral catheterisation was achieved in all 55 (100%) patients, thus avoiding SPC. Conclusions Conventional blind catheterisation techniques have limited success in the setting of failed initial catheterisation. This approach, which employs bedside fluoroscopy and direct visualisation of the urethra using a cystoscope or ureteroscope, helped achieve higher success rates (n = 55; 100%) for difficult per-urethral catheterisation and avoided the need for SPC. Proper implementation of this protocol for dealing with difficult per-urethral catheterisation will reduce the unnecessary burden on the healthcare system by minimising the potential iatrogenic urethral injuries and reducing the need for SPC.

Urinary catheter placement and adverse urinary outcomes with a focus on elevated risk in men with indwelling Foley catheters

BACKGROUND

Prior studies indicated a link between urinary catheter use and urinary complications, highlighting the need for comprehensive, gender-specific investigations. This study explored the association through a national retrospective cohort, emphasizing gender disparities and long-term outcomes.

METHODS

Our study utilized data from the entire population covered by Taiwan's National Health Insurance Research Database from 2000 to 2017. We included 148,304 patients who had undergone Foley catheter placement and their propensity-scores matched controls in the study. We evaluated urinary complications, which encompassed urinary tract cancer, urolithiasis, urethral stricture, obstructive uropathy, reflux uropathy, fistula, diverticulum, caruncle, false passage, prolapsed urethral mucosa, urinary tract rupture, and urinary tract infection. These were assessed using the Fine and Gray sub-distribution proportional hazards model to compare between the Foley and non-Foley groups. Sensitivity analyses were conducted with different matching ratios.

RESULTS

In the study, the non-Foley group presented a marginally higher mean age (75.24 ± 10.47 years) than the Foley group (74.09 ± 10.47 years). The mean duration of Foley catheterization was 6.1 ± 4.19 years. Men with Foley catheterization exhibited the highest adjusted sub-distribution hazard ratios for urinary tract cancer (6.57, 95% CI: 5.85-7.37), followed by women with Foley catheterization (4.48, 95% CI: 3.98-5.05), and men without catheterization (1.58, 95% CI: 1.39-1.8) in comparison with women without the procedure. Furthermore, men with Foley catheterization were found to be at the greatest risk for complications such as urolithiasis, urethral stricture, obstructive and reflux uropathy, fistula, diverticulum, caruncle, false passage, prolapsed urethral mucosa, and urinary tract rupture. Conversely, women with urinary catheterization were most susceptible to urinary tract infections.

CONCLUSIONS

The evidence confirms that urinary catheterization significantly increases urinary complications, particularly among men. Our study underscores the crucial need for healthcare providers to carefully evaluate the necessity of catheterization, aim to shorten its duration whenever feasible, and strictly adhere to established protocols to minimize complications.

Iatrogenic bladder neck rupture due to traumatic urethral catheterization: A case report

BACKGROUND

In this article, we present a case of iatrogenic bladder neck rupture due to catheter insertion in a 94-year-old comorbid male patient.

CASE SUMMARY

The patient, who had a urethral catheter inserted in the palliative service 3 d ago, was consulted because the catheter did not work. Because the fluid given to the bladder could not be recovered, computed tomography was performed, which revealed that the catheter had passed the bladder neck first into the retrovesical area then into the intraabdominal area. The appearance of the anterior urethra and verumontanum was normal at cystoscopy. However, extremely severe stenosis of the bladder neck, and perforated posterior wall of the urethral segment between the prostatic urethra and the bladder neck were observed. Internal urethrotomy was applied to the bladder neck with a urethrotome. An urethral catheter was sent over the guide wire into the bladder. The patient was followed in the palliative care service and the catheter was removed 7 d later. No extravasation was observed in the control urethrography.

CONCLUSION

Although catheter insertion is a simple and frequently performed procedure in hospitalized patients, it is necessary to avoid unnecessary extra-indication catheter insertion.

Mechanical and morphological characterisation of porcine urethras for the assessment of paediatric urinary catheter safety

Paediatric urinary catheters are often necessary in critical care settings or to address congenital anomalies affecting the urogenital system. Iatrogenic injuries can occur during the placement of such catheters, highlighting the need for a safety device that can function in paediatric settings. Despite successful efforts to develop devices that improve the safety of adult urinary catheters, no such devices are available for use with paediatric catheters. This study investigates the potential for utilising a pressure-controlled safety mechanism to limit the trauma experienced by paediatric patients during inadvertent inflation of a urinary catheter anchoring balloon in the urethra. Firstly, we establish a paediatric model of the human urethra using porcine tissue by characterising the mechanical and morphological properties of porcine tissue at increasing postnatal timepoints (8, 12, 16 and 30 weeks). We identified that porcine urethras harvested from pigs at postnatal week 8 and 12 exhibit morphological properties (diameter and thickness) that are statistically distinct from adult porcine urethras (postnatal week 30). We therefore utilise urethra tissue from postnatal week 8 and 12 pigs as a model to evaluate a pressure-controlled approach to paediatric urinary catheter balloon inflation intended to limit tissue trauma during inadvertent inflation in the urethra. Our results show that limiting catheter system pressure to 150 kPa avoided trauma in all tissue samples. Conversely, all of the tissue samples that underwent traditional uncontrolled urinary catheter inflation experienced complete rupture. The findings of this study pave the way for the development of a safety device for use with paediatric catheters, thereby alleviating the burden of catastrophic trauma and life changing injuries in children due to a preventable iatrogenic urogenital event.