Management of false passages in patients practising clean intermittent self catheterisation

AIM OF STUDY: Clean intermittent self catheterisation (CISC) is commonly used by patients with impaired bladder emptying. But how to manage acute false passages in patients on CISC? METHODS: Six patients experienced difficulty when performing intermittent catheterisation. Urethrocystoscopy demonstrated a new false passage in all of them. Treatment consisted of urethral stenting with an 14-16F indwelling catheter during 3-6 weeks and antibiotic therapy for 5 days. RESULTS: The false passage disappeared on cystoscopy. During a mean follow up of 10 months (1-28 months), none of these patients developed another false passage. All are practising CISC without any further difficulty. CONCLUSIONS: Analysis of our data suggests that temporary urethral stenting and antibiotic therapy are an excellent management in patients on CISC who develop an acute false passage.     

Urethral false passage as a complication of intermittent catheterization

Intermittent catheterization is used commonly to treat bladder dysfunction. We treated 10 patients who were experiencing difficulty with intermittent catheterization, 9 of whom had a false urethral passage. Of these patients 6 had previously undergone a bladder neck or urethral operation. Endoscopy was helpful to diagnose the condition. Treatment consisted of stenting in 3 patients, transurethral incision and stenting in 3, and fulguration and stenting in 4. An indwelling catheter was left in place for 2 to 3 weeks, after which intermittent catheterization was resumed with a softer catheter. Two patients again experienced severe difficulty with catheterization and they underwent a continent urinary diversion. When intermittent catheterization becomes difficult or impossible, the presence of a urethral false passage should be suspected as a possible cause.     

Feasibility of a temporary urethral stent through the striated sphincter in patients in the early phase (6 months) of spinal cord injury

OBJECTIVE: To assess the feasibility of a temporary urethral stent through the striated sphincter in patients in the early phase (before 6 months) of spinal cord injury (SCI) in a department of neurological rehabilitation. METHODS: Fourteen consecutive men with SCI with urinary retention within 6 months after SCI were prospectively treated. Thirteen patients were tetraplegic (C2 to C7) and 1 was paraplegic. All patients were managed with indwelling catheters (10) or intermittent catheterization (4). The Nissenkorn polyurethane urethral stent was inserted across the external sphincter under local anesthesia for an anticipated 4-month duration. RESULTS: No perioperative complications were encountered. Hospital mean stay at the urological department was 1.9 days (range 1-4 days). All patients had good emptying of the bladder (residual urine less than 100 ml) and were free of all types of catheterization. Five stents had to be repositioned in the first 2 weeks, 1 was removed for obstruction at 2.5 months. There was no lithiasis, no upper urinary tract alteration, no symptomatic infection nor local discomfort during follow-up. At a mean of 3.7 months after implantation, 10/14 (71.5%) patients chose sphincterotomy by permanent urethral stent and 4 had stent removal for learning of self-intermittent catheterization (3) and indwelling catheter (1). CONCLUSIONS: The temporary sphincter stent is a new, feasible and reversible technique to manage neuropathic bladder dysfunction in the early phase after SCI. A randomized study on intermittent catheterization should be conducted. It should consider patients' and nursing caregivers' evaluations.     

A urethral stent for the treatment of detrusor-striated sphincter dyssynergia

OBJECTIVE: To assess the technique, efficacy and complications of the Ultraflex urethral stent (Boston Scientific Corp., Boston, MA) for the treatment of detrusor-striated sphincter dyssynergia (DSD). PATIENTS AND METHODS: Forty consecutive patients with DSD who had a Ultraflex stent placed in the membranous urethra were evaluated prospectively. DSD was caused by spinal cord injury in 30, multiple sclerosis in six and other neurological diseases in four. All patients were either tetraplegic or paraplegic and unable to use intermittent self-catheterization. Previous bladder management consisted of an indwelling catheter in 15 patients, chronic suprapubic catheters in two, intermittent catheterization in nine, and trigger reflex micturition in 14. The Ultraflex stent was placed under local anaesthesia. The stents were 50 mm long in 36 patients, 45 mm in two and 40 mm in two. The mean (SD) follow-up was 16.9 (13. 8) months. RESULTS: The mean (SD) residual urine decreased from 245. 9 (117) mL before stenting to 65.2 (19.3) mL at 12 months afterward (n = 19). One stent was removed at 13 months for chronic prostatic and urinary tract infection leading to autonomic dysreflexia. There was no stent stenosis and 17 of 18 stents had > 75% epithelial coverage at one year. None of the stents migrated. Seven patients underwent secondary bladder neck incision through the stent. The stent length was increased in four patients using a second overlapping distal stent, twice during the first procedure and twice within 6 months because the sphincter was inadequately covered. CONCLUSIONS: The Ultraflex stent achieved the expected results for a prosthetic sphincterotomy and appears to be an appropriate but less invasive treatment for DSD.     

Biodegradable braided poly(lactic-co-glycolic acid) urethral stent combined with dutasteride in the treatment of acute urinary retention due to benign prostatic enlargement: a pilot study

OBJECTIVE

To evaluate, in a pilot study, the efficacy and safety of combining a braided poly(lactic‐co‐glycolic acid) (PLGA, a copolymer of l ‐lactide and glycolide) urethral stent and dutasteride in the treatment of acute urinary retention (AUR) due to benign prostatic enlargement (BPE).

PATIENTS AND METHODS

Ten men with AUR due to BPE were treated as outpatients. A biodegradable braided PLGA urethral stent was inserted into the prostatic urethra, using a specially designed insertion device under visual control. Dutasteride treatment was started and the patients were followed up for 3 months after insertion of the stents.

RESULTS

In all patients the stents were placed successfully with the new insertion device. All men were able to void after inserting the stent. At 1 month five patients voided freely with a low residual urine volume (<150 mL), two voided but had a high residual urine volume and a suprapubic catheter was placed, and three needed a suprapubic or an indwelling catheter before 1 month, due to AUR or comorbidities. At 3 months five patients were voiding with no problems.

CONCLUSIONS

We have developed a new and effective insertion device for biodegradable braided prostatic stents. The new braided‐pattern stent overcomes the earlier problems of migration and sudden breakage into large particles associated with biodegradable spiral stents. However, the mechanical properties of the new stent need to be improved and tested in a longer follow‐up. We consider that this new biodegradable braided‐pattern urethral stent could provide a new option in the future treatment of AUR.     

Intraurethral stent prosthesis in spinal cord injured patients with sphincter dyssynergia

This study is an analysis of the Memotherm prosthesis in spinal cord injured patients with Detrusor-external sphincter dyssynergia (DESD). Twenty-four patients were evaluated urodynamically before and after placement of the intraurethral stent prosthesis. All the patients had been chronically managed with an indwelling urinary catheter, intermittent catheterization or condom catheters. Sixty-six per cent had history of recurrent urinary tract infection, 37% had symptoms of autonomic dysreflexia. Nine patients had previous external sphincterotomy. Follow-up ranged from 3 39 months (mean 15.4 months). After stent insertion all patients were able to achieve spontaneous reflex voiding with the use of condom catheter. Postoperative urodynamics parameters bladder leak point pressure and residual urine volume decreased significantly after stent insertion. Stent insertion was accomplished without any operative complications. In four patients stent migration (16%) required telescoping a new system over the migrated stent. In two patients the stent was removed because of problems of infection and calculus formation. In conclusion, this system (Memotherm) is an attractive, and potentially reversible treatment for DESD in SCI patients.     

Erosion of penile prostheses: a complication of urethral catheterization

We studied 9 patients with indwelling urethral catheters or who were using intermittent clean catheterization and who had received a penile prosthesis. A 56 per cent (5 of 9) incidence of urethral erosion was found in this population. Urethral erosion was a late complication, 80 per cent (4 of 5) of the time in our series, that usually presented several months after implantation of the prosthesis. We believe that the etiological factors that contributed to this disastrous complication were the friction and inflammation associated with catheterization. We currently construct a perineal urethrostomy in patients who desire a penile prosthesis and who perform intermittent catheterization. If intermittent catheterization is not feasible, insertion of a suprapubic tube is recommended. We additionally recommend insertion of an inflatable penile prosthesis, since this type is relatively soft most of the time and will not cause as much pressure at the end of the penis. Since instituting these procedures we have not encountered any erosion.     

Usefulness of nocturnal urethral indwelling catheter for treating bladder dysfunction with nocturnal polyuria: case report of 3 women

Clean intermittent catheterization is a well-known procedure of urinary drainage for patients who are unable to empty the bladder sufficiently. However, some patients with bladder dysfunction and nocturnal polyuria fail to obtain the benefits of intermittent catheterization and have annoying symptoms of nocturnal incontinence and low-compliance bladder, which threaten both their quality of life and renal function. We report the usefulness of nocturnal urethral indwelling catheterization using a specially designed catheter to treat patients (three women) with lower urinary tract dysfunction and nocturnal polyuria. Case 1: A 45-year-old woman with mental retardation suffered from difficulty of micturition and residual urine. A nocturnal urethral indwelling catheter freed her from difficulty with micturition and residual urine. Case 2: A 28-year-old woman with spina bifida and neuropathic bladder dysfunction suffered from urinary incontinence and recurrent pyelonephritis. The recurrent pyelonephritis was prevented and bladder compliance was improved with use of the nocturnal urethral indwelling catheter. Case 3: A 66-year-old woman with cervical myelopathy and multiple episodes of cerebral infarction suffered from nocturnal urinary incontinence. She underwent clean intermittent catheterization by her husband. Use of the nocturnal urethral indwelling catheter solved the problem of her nocturnal incontinence and relieved her husband of her nocturnal care. Nocturnal urethral indwelling catheterization is useful for treatment of nocturnal incontinence and recovery of bladder compliance in patients with lower urinary tract dysfunction and nocturnal polyuria.     

Comparison of nitinol urethral stent infections with indwelling catheter-associated urinary-tract infections

BACKGROUND AND PURPOSE: To determine the efficacy of intraurethral metal stents in preventing or eradicating urinary-tract infections (UTI) during the management of bladder outlet obstruction (BOO) by comparing the frequency and nature of the infections with indwelling-catheter-associated UTI. PATIENTS AND METHODS: The SAS relative-risk test was used to compare the risks of UTI in 76 patients with temporary urethral stents, 60 patients with BOO who had never been catheterized nor stented, and 34 patients with a permanent indwelling urethral catheter (PIUC). Infection was assessed 1 month after placement of the devices. Scanning electron microscopy (SEM) of the proximal and distal pieces of the stents removed from five patients with and five patients without UTI was carried out in a search for predisposing changes on the surfaces. RESULTS: After insertion of the catheter, UTI developed in 79.4% of the patients who originally had sterile urine. However, after insertion of the stent, UTI developed in only 40.9% of the patients with sterile urine. In 21 (44.6%) of the catheterized patients who had infected urine, UTI was eradicated after stent insertion. The SEM analysis of the stents showed that a thick organic layer had formed only on the infected devices but with no sign of erosion. CONCLUSION: Urinary infection is a significant problem in patients with PIUC but is significantly less frequent and less severe in patients with urethral stents. This advantage of stents over the conventional urethral catheter, in addition to their obvious convenience for the patient, make them good alternatives to reduce the risk of UTI.     

Initial clinical experience with full-length metal ureteral stents for obstructive ureteral stenosis

OBJECTIVES: Long-term ureteral stenting is used to ensure urinary drainage if a reconstructive approach or a release of an extrinsic obstruction is not possible. In this contribution, a long-term experience with a new full-length, metal indwelling stent is presented. METHODS: Fourteen patients with ureteral obstruction received full metal indwelling stents in 18 collecting systems (benign disease in 5 and malignant disease in 13). Stent placement was performed cystoscopically under fluoroscopic guidance. Follow-up was done every 3 months with ultrasonographic examination, creatinine levels, and a visual analog pain score. RESULTS: Eight stents were removed, whereas eight are still in situ. One patient without stent-related problems died because of progressive rectal cancer 9 months after bilateral stent insertion. Mean stent duration (8 stents still in situ) is 8.6 months, whereas mean stent duration for benign and malignant disease is 11.8 (median 13) and 7.3 (median 6) months, respectively (p<0.05). All removed stents were extracted endoscopically without any problems and had no incrustation except two. Neither migration nor mechanical damage was observed. CONCLUSION: This novel stent is easy to insert and remove. It is an option for patients in which a surgical reconstruction of the obstructed ureter is not possible. Stents have been developed further and are now available in various lengths. This might result in a reduction of problems associated with inadequate stent length and should increase patient comfort and stent durability.     

Long-term usefulness and safety of the contemporary balloon catheter

OBJECTIVE: To evaluate usefulness and safety of an indwelling contemporary balloon catheter, we compared complication rates among five methods of urinary tract management. PATIENTS AND METHODS: History of febrile episode, bladder stones, pyuria and the miscellaneous urinary tract problems of 114 patients were retrospectively reviewed. The rates of complications were compared among five types of urinary tract management as clean intermittent catheterization dry (not incontinent) (CIC-dry: n = 33), clean intermittent catheterization with incontinence (CIC-wet: n = 16), clean intermittent catheterization with a contemporary balloon catheter indwelling at night (Contemporary catheter: n = 20), a suprapubic cystostomy catheter indwelling (Cystostomy: n = 22) and permanent urethral balloon catheter indwelling (Urethral catheter: n = 24). The contemporary balloon catheter used consisted of a reusable balloon catheter and a reservoir to inflate the balloon. The patients in the Contemporary catheter group self-inserted the catheter every night before sleeping, and then removed it in the next morning. After use, the catheter was washed with tap water, and stored in a special purpose case filled with disinfectant. RESULTS: The mean follow up period was 41 months. The incidence of febrile episode in CIC-wet was 3.36 times/100 months, Urethral catheter was 2.96, Cystostomy was 1.26, Contemporary catheter was 0.57, and CIC-dry was 0.42. The incidence of febrile episode in CIC-wet and Urethral catheter were significantly higher than in CIC-dry (p<0.05). The incidence of bladder stone in Urethral catheter was 1.11 times/100 months, Cystostomy was 1.05, Contemporary catheter was 0.96, CIC-wet was 0.61, and CIC-dry was 0.21. The Urethral catheter group had significantly higher incidence of bladder stone than CIC-dry (p<0.05). CONCLUSIONS: The indwelling contemporary balloon catheter is recommended for long-term use in CIC-wet group.     

Temporarily implanted urethral coil stent for the treatment of recurrent urethral strictures: a preliminary report

A new urethral stent developed for use in recurrent urethral strictures is presented. This metallic coil is self-expanding when released from its introducing catheter. The stent was used in 18 patients with recurrent strictures necessitating frequent dilation or urethrotomy. The stent is introduced under fluoroscopic guidance after internal urethrotomy or simple dilation. Strictures of 5 to 60 mm. were treated successfully with this device. All strictures were distal to the external sphincter. No serious complications attributed to the device were recorded. When necessary, the stent could be repositioned either under fluoroscopic control or endoscopically. This device can hold the stenotic area of the urethra open for long intervals allowing for complete healing. Even after 6 months the stent is not covered with urethral epithelium and does not become incorporated into the urethral wall. It can be removed easily without an operation by simple manipulation. The large internal caliber permits passage of endoscopes up to 17F in patients who require cystoscopy. The device can be removed before transurethral resections and then a new stent can be inserted at the end of the procedure. Mean followup of our patients with the stent indwelling was 8 months (range 4 to 11 months). Followup after removal of the stent (6 patients) was 3 to 8 months (mean 5 months). The patients voided well during followup and were fully continent. No incrustations were noted in the removed stents even after 6 months and no stent became obstructed due to tissue proliferation or incrustation. In 1 patient the stricture recurred after 3 months and a new stent was inserted. Urine sterilization was obtained in 7 patients with infected urine after relatively short courses of antibiotics. This stent seems to be a promising tool for the nonoperative treatment of recurrent urethral strictures.     

The indwelling ureteric stent: a 'friendly' procedure with unfriendly high morbidity

OBJECTIVE: To review the morbidity and complications of ureteric stent insertion and to evaluate specifically the effect of an indwelling ureteric stent on the changes in hydronephrosis after stenting. PATIENTS AND METHODS: In a prospective study, 110 renal units with a stent in place were evaluated in 90 patients. Of the 110 stents, 52 were left in place for 3 months, 23 for 6, 11 for 9, 19 for 12 and five (forgotten stents) for 13-30 months. The patients were followed using plain abdominal X-ray at 1 and 30 days after stenting. They were further followed using ultrasonography and plain films every 3 months until the scheduled date for stent removal or the appearance of complications. RESULTS: Thirty-four patients had fever and bacteriuria after stent insertion. Of the 110 stents, 11 (10%) fragmented and nine (8%) migrated. Seventeen patients complained of flank pain on voiding. In 21 renal units (19%) there was no change in the severity of hydronephrosis, whereas in six (5.5%) hydronephrosis developed or worsened after stenting. CONCLUSION: Although ureteric stenting is undoubtedly an important procedure to relieve ureteric obstruction, the indications for stent insertion should be considered carefully in every patient. The close follow-up of stented patients is valuable for the early detection of morbidity or complications and in such cases the stent should be removed or exchanged as soon as possible.     

Outcome after treatment of detrusor-sphincter dyssynergia by temporary stent

OBJECTIVES: To evaluate follow-up treatments used after treatment of detrusor-sphincter dyssynergia (DSD) by a temporary urethral sphincter stent. MATERIALS AND METHODS: Between February 1994 and June 2003, 147 men with a mean age of 41.3+/-14.4 years were treated by temporary urethral stent inserted across the external sphincter for DSD. The underlying neurologic disease was quadriplegia in 85 cases, multiple sclerosis in 24 cases and paraplegia in 21 cases. A Nissenkorn (Bard) stent was used in 130 cases and a Diabolo (Porgès) stent was used in 17 cases. All patients were either unable to or they refused to perform intermittent self-catheterization. DSD was demonstrated by urodynamic studies in every case. RESULTS: The mean duration of temporary stenting was 10.15+/-16.07 months. After temporary stenting, 92 patients were treated by permanent stent (Ultraflex, Boston Scientifics), 7 started intermittent self-catheterization, 12 had repeated changes of the temporary stent, 4 had an indwelling catheter, 3 underwent cystectomy with non-continent diversion, 2 were treated by endoscopic sphincterotomy, 1 was treated by bladder neck incision, 1 was treated by neuromodulation and 1 was treated by cystostomy. Fifteen patients were lost to follow-up. Two patients died during follow-up (not related to DSD). CONCLUSION: After treatment of DSD by a temporary urethral sphincter stent, 70.7% of patients subsequently require a permanent urethral sphincter stent. This period allows selection of patients unlikely to benefit from permanent urethral sphincter stent.     

Perineal abscess formation as a complication of intermittent self-catheterization

STUDY DESIGN: Case report. OBJECTIVES: To present a rare but severe complication of intermittent catheterization. SETTING: Paraplegic centre in Switzerland. METHOD AND RESULTS: A 52-year-old man presenting with fever and septicaemia was diagnosed with a perineal abscess due to a bulbar urethral lesion caused by acute false passage during intermittent catheterization. CONCLUSION: Especially in patients with a history of urethral strictures performing intermittent catheterization, the possibility of perineal abscess formation should be taken into account when treating such a patient with fever of unknown origin.     

Late complications of ureteral stents

OBJECTIVE: To review morbidity and late complications of ureteral stent insertion and to specifically evaluate hydronephrosis as a radiologic finding of obstruction in the presence of an indwelling ureteral stent. METHODS: In this prospective study, we evaluated 110 stented kidneys in a group of 90 patients. Of 110 stents, 52 were left in place for 3 months, 23 for 6 months, 11 for 9 months, and 24 for up to 12 months. With the stent in place, patients were followed by plain abdominal X-ray 1 and 30 days after stenting. Further follow-up was performed through ultrasound and plain film every 3 months until scheduled date for stent removal or the appearance of complications. RESULTS: In 11 of 110 cases (10%) there was stent fragmentation and in 9 (8.2%) stent migration. In 10 cases (9.1%), there was no change in the severity of the hydronephrosis, but because of flank pain or urinary tract infection with fever, the stents had to be removed. In 6 cases (5.4%) hydronephrosis developed or worsened after stenting. Of the 110 ureteral stents, 32.7% had to be removed because of late complications. CONCLUSIONS: Although ureteral stenting is undoubtedly an important procedure for the release of ureteral obstruction, the indications for stent insertion should be carefully considered in each patient. Late complications of ureteral stents are frequent and appear in one third of the patients. Close follow-up of stented patients is valuable in early detection of morbidity or complications, and in such cases the stent should be removed or exchanged as soon as possible.     

Guide wire-assisted urethral dilatation for urethral strictures in pediatric urology

Purpose: The aim of this study was to report the results of 32 cases of dilatation of urethral stricture using a guide wire and sheath dilator technique supplemented by clean intermittent catheterization if further stabilization of the urethral stricture was felt warranted.Methods: The procedure involves insertion of a straight flexi-tip lubricated guide wire through the urethral stricture under cystoscopic guidance followed by insertion of a series of sheath dilators. Dilatation was followed by insertion of a Foley catheter, which was left in situ for 1 to 3 days. Patients underwent repeat cystoscopy to evaluate the urethra for recurrent stricture and those with a recalcitrant stricture were commenced on clean intermittent catheterization (CIC) to stabilize the narrowing.Results: Thirty-two patients were included. They have been followed up for up to 2 years after their last cystoscopy (mean, 16 months). Thirteen of 32 patients had more than 4 dilatations under anesthesia. Twelve patients had undergone CIC postoperatively. Complications included a urinary tract infection in 3 boys and bladder spasms in one. No false passage or sepsis occurred with this approach.Conclusions: Guide wire-assisted urethral dilatation helps avoid risks associated with blind dilatation techniques and appears to be a safe and simple alternative for management of urethral strictures in pediatric urology.     

Sacral nerve stimulation to treat nonobstructive urinary retention in women

Nonobstructive urinary retention is an uncommon finding in women that may represent a difficult management problem for urologists and patients. Pharmacotherapy and urethral dilatation are rarely successful, and clean intermittent catheterization may be cumbersome. Those patients who cannot self-catheterize may be subjected to an indwelling catheter. Sacral nerve stimulation is a minimally invasive treatment for nonobstructive urinary retention, with 10 years of data documenting its long-term safety and efficacy. This minimally invasive treatment can restore satisfactory voiding in most patients and should be a routine part of treatment for this rare but important condition.     

Endourethral prostheses for urethral stricture

A number of urethral stents made of different materials, with different time of indwelling and different designs, primarily based on the vascular stent concept, have been applied in the clinical practice so far. According to the published studies, urethral stents have justified their clinical application, however with certain limitations. Within an attempt to overcome the limitations, a covered, temporary urethral stent was initially designed by Daniel Yachie and Zeljko Markovic in Allium corporation from Israel. With its triangular shape, the stent is a replica of the obstructive urethral lumen. The follow-up of resuIts was done according to a priori established protocol including the following: UCG, uroflowmetry and interview with patients. Due to stent migration, the stent over stent technique was applied in two case, while reposition by balloon-catheter outward traction was performed in two cases of caudal migration. No irritative discomforts were reported in the first 6 months after stent dwelling. Uroflowmetric controls verified at least four times better results than before the insertion. Given it is the question of covered stent, there is no possibility of proliferative secondary lumen obstruction. On account of soft structure and conic shape of posterior part of stent, no lesions of the external urethral sphincter were manifested. The stent is simply withdrawn after 12 months by outward traction using the forceps at the time when the stent construction turns into soft and straight wire. After 12-16 months in all cases we removel stent and in all patients we find complete recanalisation without any disuric problem. In 5 cases we find new "contact" stricture on anterior part of stent and treated succeed with balloon recanalisation.     

Stenturia: An unusual manifestation of spontaneous ureteral stent fragmentation.

Two patients presented with passage of worm-like stent fragments in the urine. The first had undergone attempted percutaneous removal of left renal calculus and ureteral stenting 4 months prior to presentation. The second had left-sided stent placement for obstructive anuria on account of bilateral renal calculi 3 months earlier. The stents had fragmented into multiple pieces over a mean indwelling time of only 3.5 months. Apart from calculus disease, both patients had documented urinary tract infection. Stent fragmentation is a relatively rare (0.3%) but major complication. However, spontaneous excretion of these fragments has not been hitherto reported. These cases of rapid stent disintegration highlight the need for closer monitoring of the indwelling stents, especially in patients with calculus disease and associated persistent infection. In such patients the stent should probably be changed within 3 months.