Randomised controlled trial comparing the clinical and cost-effectiveness of various washout policies versus no washout policy in preventing catheter associated complications in adults living with long-term catheters: study protocol for the CATHETER II study

BACKGROUND

Various washout policies are widely used in adults living with long-term catheters (LTC). There is currently insufficient evidence on the benefits and potential harms of prophylactic LTC washout policies in the prevention of blockages and other LTC-related adverse events, such as urinary tract infections. CATHETER II tests the hypothesis that weekly prophylactic LTC washouts (normal saline or citric acid) in addition to standard LTC care reduce the incidence of catheter blockage requiring intervention compared to standard LTC care only in adults living with LTC.

METHODS

CATHETER II is a pragmatic three-arm open multi-centre superiority randomised controlled trial with an internal pilot, economic analysis, and embedded qualitative study. Eligible participants are adults aged ≥ 18 years, who have had a LTC in use for ≥ 28 days, have no plans to discontinue the use of the catheter, are able to undertake the catheter washouts, and complete trial documentation or have a carer able to help them. Participants are identified from general practitioner practices, secondary/tertiary care, community healthcare, care homes, and via public advertising strategies. Participants are randomised 1:1:1 to receive a weekly saline (0.9%) washout in addition to standard LTC care, a weekly citric acid (3.23%) washout in addition to standard LTC care or standard LTC care only. Participants and/or carers will receive training to administer the washouts. Patient-reported outcomes are collected at baseline and for 24 months post-randomisation. The primary clinical outcome is catheter blockage requiring intervention up to 24 months post-randomisation expressed per 1000 catheter days. Secondary outcomes include symptomatic catheter-associated urinary tract infection requiring antibiotics, catheter change, adverse events, NHS/ healthcare use, and impact on quality of life.

DISCUSSION

This study will guide treatment decision-making and clinical practice guidelines regarding the effectiveness of various prophylactic catheter washout policies in men and women living with LTC. This research has received ethical approval from Wales Research Ethics Committee 6 (19/WA/0015).

TRIAL REGISTRATION

ISRCTN ISRCTN17116445 . Registered prospectively on 06 November 2019.

Shifting the treatment paradigm in idiopathic overactive bladder

PURPOSE

Overactive Bladder (OAB) is a common condition that is known to have a significant impact on Health Related Quality of Life (HRQoL). Whilst all patients will initially benefit from lifestyle modifications and behavioural therapy in the first instance drug therapy remains integral in management pathways. The purpose of this review paper is to reappraise the evidence based approach to the management of OAB in addition to exploring a new treatment algorithm for the escalation of treatment in those patients with refractory symptoms.

DESIGN

Literature Review RESULTS: Antimuscarinic drugs are currently the most commonly used medication although the introduction of mirabegron, a β3 agonist, has provided an alternative and also allowed combination therapy in those patients who have failed to improve on primary therapy or who have troublesome side effects. For those patients with symptoms of refractory OAB more invasive therapies including OnabotulinumtoxinA, sacral neuromodulation and Percutaneous Tibial Nerve Stimulation (PTNS) may be indicated.

CONCLUSION

We propose a new, evidence based, treatment algorithm for the management of OAB in patients who remain refractory to first line therapy.

The one-year experience of tape and mesh removal at a urological tertiary referral centre

Objective:

There is increasing controversy surrounding the use of synthetic materials in transvaginal tape and vaginal mesh for stress incontinence and pelvic organ prolapse. The aim of this study was to review the case load and operative management of a tertiary referral urology centre dealing with surgical complications of these procedures within Scotland.

Participants/patients (or materials) and methods:

A retrospective review of patients undergoing removal of products and analysis of their symptom, operative findings and postoperative status was conducted.

Results:

Twenty-five patients were identified in a one-year period. Eighty per cent of initial procedures were performed by a gynaecologist. Patients presented with a variety of symptoms including pain, infections and haematuria. The most common device needing removal was a tension-free vaginal tape obturator (TVTO). Intraoperative findings were classified using an online calculator with the most common location for complications being within the urethra. Most patients underwent successful removal of all parts of the tape and a small number required combined abdominal and vaginal approach. Postoperatively there was significant symptom resolution for most women with recurrent urinary infections and pain. Over 50% of women were continent postoperatively.

Conclusion:

We have demonstrated the benefit of performing operative management of these patients in a tertiary referral centre in terms of outcomes regarding improvement of symptoms and continence rates.

Assessment of the introduction of an adolescent transition urology clinic using a validated questionnaire

BACKGROUND

Adolescents with complex urological conditions are at risk of bladder dysfunction, metabolic disturbances, neoplastic changes and deterioration in renal function. Hence they require appropriate transition to the adult service to ensure lifelong urological care is adequately provided.

OBJECTIVE

Barriers and difficulties to the transition process have been identified in the literature. To overcome these difficulties an Adolescent Transition Urology Clinic (ATUC) was established in 2009 where the patients are seen by a paediatric and an adult urologist, a urology nurse and if needed an adolescent gynaecologist. Our aim was to assess the ATUC and present the patient's perspective to this new service using a validated questionnaire.

MATERIALS AND METHODS

Data of all patients seen at the ATUC over the study period were prospectively recorded. Patients who completed the transition were contacted and asked to complete two online urological transition questionnaires: 1) The Care Transition Measure 15 (CTM-15) which is a validated questionnaire to assess the quality of care during transition from the patients' perspective. 2) The Transition Care Experience (TCE) which was created for the purpose of this study.

RESULTS

Thirty patients attended the ATUC over 4.5 years, with 26 (87%) completing the transition to the adult urological care. Of the 26 patients there were 14 (54%) males with a mean age of 18 years. The most common underlying urological condition was neurogenic bladder (85%). Nineteen (73%) patients completed the questionnaires. Only 1 (5%) patient thought that attending the ATUC was not beneficial, 17 (89%) would recommend the ATUC to other adolescents and 9 (47%) patients considered 18 as the appropriate transition age. Overall, 74% thought that written information would have been useful and 21% considered the adult hospital as an inappropriate environment for young adults. After attending the ATUC, 2 (11%) patients thought their preferences were not met and 3 (16%) patients were not confident that they can take care of their health.

DISCUSSION

Transition of patients with complex urological conditions should aim to facilitate transferring the care from the parent to the patient and preparing the adolescent to adult life by addressing their sexual and reproductive functions. Inadequate transition can have serious health consequences. On-going communication between the paediatric and the adult urologist facilitates the transition process even after the transfer of care has occurred. The CTM-15 has been considered as "the only available measure of quality of care during transition from the patients' perspective". Our study suggests that the large majority of adolescent attending the clinic are confident in looking after their complex urological condition. In addition one patient in 5 found the adult hospital environment an inappropriate place for adolescents and they would have preferred longer follow up in a children's hospital. The value of written information after clinic consultation seems to be a useful adjunct that might facilitate the complex transition process.

CONCLUSION

This is the first report evaluating the transition of adolescents with complex urological conditions using a validated transition questionnaire. The combined paediatric/adult urology clinic is beneficial in addressing the patients' needs and allowing smooth transition of these complex patients to the adult service.

Presentation of a benign fibroepithelial polyp with frank haematuria: an unusual diagnosis

INTRODUCTION

Fibroepithelial polyps are rare benign lesions which can mimic malignant disease symptomatically and radiologically. They should form part of the differential diagnosis in patients presenting with frank haematuria but they can present a diagnostic dilemma for clinicians.

CASE PRESENTATION

This is a case of a 30-year-old female who initially presented with a small palpable urethral lump, thought to be a urethral caruncle by her general practitioner, obstructive voiding and intermittent frank painless haematuria. A rigid cystoscopy identified a polypoid lesion protruding out of the left ureteric orifice. This was resected and pathology showed it to be a fibroepithelial polyp. A post-operative computerized tomography scan showed no hydronephrosis on either side and no lymphadenopathy was identified but the distal left ureter could not be visualised. Further resection with a flexible ureteroscopy confirmed the presence of a benign fibroepithelial polyp and the stalk remnant was ablated with a laser.

CONCLUSION

Fibroepithelial polyps mimic malignant disease symptomatically and radiologically and need to be considered in the differential diagnosis of frank haematuria.

Sacral nerve stimulation for urinary dysfunction: the first year of the Scottish national service

Sacral nerve stimulation (SNS) has become an established treatment option for patients with intractable detrusor overactivity and non-obstructive urinary retention. The Scottish Sacral Nerve Stimulation service was established in April 2010 to provide a service for the population of Scotland. We report our experience from the first year of this new national service. All patients referred for SNS from the inception of the service in April 2010 until the end of March 2011 were studied. During the one-year period, there were 50 referrals. Thirty-three percutaneous nerve evaluations, eight tined lead tests and 16 permanent implantation procedures were performed during this period. Morbidity was low and both incontinence and quality-of-life questionnaires demonstrated statistically significant improvements (International Consultation on Incontinence Questionnaire [ICIQ-SF], P = 0.005; Incontinence Impact Questionnaire [IIQ 7], P = 0.0007; Urogenital Distress Inventory [UDI 6], P = 0.0002). Referral pattern was skewed towards the west of Scotland with some health boards producing no referrals during the year. Results from the first year of the service have shown that it is a safe and efficient procedure with significant improvement in incontinence, voluntary voiding and quality-of-life parameters. The limitation of funding for permanent implants inevitably impacts on the role of the technique as a management option in these patients.

The use of the artificial urinary sphincter in the West of Scotland: a single centre 10-year experience

BACKGROUND

The artificial urinary sphincter (AUS) has been used successfully to treat sphincter weakness incontinence in males over the past 30 years. Postoperative complications are well-recognised, but patient satisfaction remains high.

METHODS

We performed a retrospective single centre study of all patients who had an artificial urinary sphincter inserted over a 10-year period. We assessed patient satisfaction and continence post operatively as well as complication rate and need for revision or replacement surgery.

RESULTS

Thirty-eight male patients (mean age 57 years) and 1 female patient had an AMS 800 (American Medical systems) AUS inserted between 1995 and 2005. Five (13%) patients have required replacement surgery to date. Male patients were divided into two groups according to the aetiology of their incontinence: neuropathic (n = 11) and non-neuropathic (n = 27). Social continence was achieved in all patients. Three (11%) non-neuropathic patients developed complications. Revision surgery was undertaken in 4 (15%) of non-neuropathic patients and in 1 (9%) neuropathic patient. The mean lifespan of the AUS in patients who required further surgery is 6.6 years.

CONCLUSION

For patients with severe sphincter weakness incontinence the AMS 800 AUS is a safe and reliable solution. Our results are comparable with previous published studies of larger patient numbers from dedicated reconstructive units.

Urological follow-up of adult spina bifida patients

AIMS

The vast majority of the current urological literature understandably has concentrated on the management of children with spina bifida, because in the past the majority did not survive into adulthood. With improvements in the understanding and multidisciplinary care of spina bifida patients it has become a disease of adults. Our aim was to evaluate the current literature to attempt to formulate evidence based guidelines for the management of this difficult group of patients.

METHODS

We reviewed the literature on adult urological management of spina bifida, all relevant articles which concentrated on adults and long-term management were studied in full.

RESULTS

Renal function may begin/continue to deteriorate into adulthood, becoming the leading cause of adult death. This is thought to occur because of changes in the adult bladder, with increases in storage pressure. Medical and surgical management should aim to preserve renal function as well as the maintenance of continence in the face of the growing and changing urinary tract. Follow-up should be regular and in the context of a specialist multidisciplinary clinic. Despite being unvalidated in the follow-up of adult spina bifida patient's annual serum creatinine, ultrasound and urodynamics are currently the best tools available.

CONCLUSIONS

There is no reason why the majority of spina bifida sufferers cannot use their own kidneys for the rest of their lives. This however relies on urological treatment being instigated soon after birth and continuing into adulthood.

Chronic testicular pain: an overview

Chronic testicular pain (orchialgia, orchidynia or chronic scrotal pain) is common and well recognized but its pathophysiology is poorly understood. Currently treatment is largely empirical. This article aims to present an overview of its prevalence, possible aetiology and the available treatment options. The contribution of psychological factors is unclear, although some of these patients undoubtedly are depressed. Post vasectomy chronic testicular pain may be due to functional obstruction of the vas, or to spermatic granuloma. The surgical technique used may be relevant and the application of intraoperative local anaesthetic may have a role in reducing the risk. The importance of the sympathetic nervous system and the role of a possible alteration of the adrenergic receptors of the vas deferens in patients with chronic testicular pain are discussed. For patients failing to respond to conservative treatment, microsurgical denervation of the spermatic cord, epididymectomy and vasovasostomy have all shown a degree of relief. Unfortunately a small number of patients fail to respond to both conservative and more invasive treatment methods and for them the only available therapeutic option is inguinal orchiectomy.