Micturition in comatose patients

The ability to void spontaneously was ascertained in 135 comatose patients, 76 per cent of whom emptied the bladder automatically as soon as the indwelling catheter could be removed. With additional treatment (bethanechol and/or intermittent catheterization), spontaneous micturition was achieved in all of the remaining patients. Elderly men had statistically more difficulties in becoming independent of an indwelling catheter.     

A comparison of outcomes of transurethral versus suprapubic catheterization after Burch cystourethropexy

The objective of this study was to evaluate the outcomes of patients with transurethral vs suprapubic catheterization after Burch cystourethropexy. This is a retrospective cohort study of patients who had an anti-incontinence procedure primarily including Burch cystourethropexy with hysterectomy or Burch alone between July 1997 and June 2002 and comparing the outcomes of transurethral vs suprapubic catheters. The suprapubic and transurethral catheter placed were both 16-Fr Foley catheters. The variables analyzed were length of hospital stay, length of catheterization, postoperative fever, and urinary tract infection. The number of postoperative visits and complications within each group were also compared. Analysis was done utilizing Fishers exact test and Wilcoxons rank-sum analysis when indicated. We analyzed the charts of 217 patients. The outcomes of surgery (i.e., blood loss, postoperative morbidity, incidence of urinary tract infection, length of hospital stay) in each group did not statistically differ. There was a significant difference in length of cauterization: 7.1 days for the transurethral group and 9.61 days for the suprapubic group, a 1.79 day difference (p=0.001) and a difference in the number of visits for complaints of pain, 2.5 visits for the suprapubic group, 3.5 visits for the transurethral group (p=0.01). There were no differences in outcomes whether a transurethral or suprapubic catheter was used. There was a significant difference in duration of catheterization and extra visits to the clinic or hospital with a practitioner for the complaint of pain. Patients with a transurethral catheter had on the average one more visit than those with the suprapubic catheter.No financial support was received for any part of this projectEditorial Comment: The issue of transurethral vs suprapubic bladder drainage after open Burch urethropexy has been investigated in the past. Theofrastous et al. performed a randomized trial looking at this issue and concluded there was no difference in the mean duration of catheterization, hospital duration or rates of cystitis [1]. Retrospective studies on this issue are biased, and numerous confounding variables need to be accounted for including previous bladder surgery, urodynamic parameters, degree of tensioning of the colposuspension sutures, anesthetic protocols and use of intra- and post-op antibiotics.     

Incidence and Risk Factors for Postoperative Urinary Retention in Total Hip Arthroplasty Performed Under Spinal Anesthesia

Background

The objective of this study is to determine the risk factors for postoperative urinary retention (POUR) following total hip arthroplasty (THA) under spinal anesthesia.

Postoperative urinary outcomes in catheterized and non-catheterized patients undergoing laparoscopic-assisted vaginal hysterectomy—a randomized controlled trial

The objective of this study is to assess the impact of bladder catheterization on the incidence of postoperative urinary tract infection (UTI) and urinary retention (PUR) following laparoscopic-assisted vaginal hysterectomy (LAVH). One hundred fifty patients undergoing LAVH were randomly assigned to no catheter use, 1-day, and 2-day catheter groups. The relationship between preoperative, intraoperative, and postoperative factors and the rates of UTI and PUR were determined. The incidences of UTI and PUR were 9.3% and 18.7%, respectively. The highest rate of UTI occurred in the 2-day catheter group; the highest rate of PUR occurred in no-catheter-use group. Multivariable logistical regression showed the duration of catheterization was the single predictor of UTI; duration of catheterization and diabetes mellitus were predictors for PUR. While short-term indwelling catheterization resulted in decreased rate of PUR, UTI rate increased among patients undergoing LAVH. Nonetheless, most patients resumed normal urination shortly after surgery.     

Is an indwelling catheter necessary for bladder drainage after modified Burch colposuspension?

Catheterization is considered to be a mandatory procedure for adequate bladder drainage following an anti-incontinence operation until the recovery of normal voiding function occurs. We conducted this prospective study to challenge this practice. A total of 86 patients with genuine stress incontinence who underwent a modified Burch coplosuspension were randomized into two groups based on the day of operation. The study group consisted of 42 patients who had the transurethral Foley catheter removed postoperatively the next morning (Group A). The control group was composed of 43 patients who had the transurethral indwelling catheter left in place until the fifth postoperative day (Group B). The percentages of immediate voiding difficulties in Groups A and B were 7.1% and 0%, respectively (P >0.05). The postoperative urinary tract infection rates of Groups A and B were 16.6% and 23.3%, respectively (P >0.05). The success rates of our patients were not compromised after our modified operative procedures (78.6% with dry results and 19.0% with improved symptoms in Group A vs. 74.4% with dry results and 20.9% with improved symptoms in Group B, P >0.05). Our results imply that it is not necessary that an indwelling catheter, for bladder drainage, be left in place until the fifth postoperative day to prevent immediate voiding difficulties. Editorial Comment: The authors have performed a prospective randomized clinical trial of two different bladder management schemes involving a urethral catheter following a modified Burch colposuspension. Group A began their voiding trial on Day 1, Group B began their voiding trial on Day 5 after a 2-day clamped catheter bladder training program. Patients were not discharged until they had normal residuals (<100 ml). There were low, not statistically different, rates of immediate voiding difficulty in either group (7.1% vs. 0%) and therefore the only significant difference between the two groups was the length of hospitalization (5.3 days for Group A and 7.4 days for Group B). They conclude that it is not necessary for a urethral catheter to be left in for 5 days. Very few urogynecologists would disagree with this conclusion. The authors should be commended for performing a prospective randomized study of voiding trials. However, the relevance of this study to clinical practice is extremely limited since most urogynecologists do not perform urethral catheter clamping bladder training programs, nor wait 5 days to start a voiding trial     

Intermittent catheterization and bladder rehabilitation in spinal cord injury patients.

A review was made of 111 spinal cord injury patients who underwent bladder rehabilitation. The essential mode of treatment was intermittent catheterization. About 91 per cent of the patients were free of the catheter after 3 to 168 days of intermittent catheterization. Acute patients given an initial dosage of 30 to 40 mg. bethanechol chloride 3 times daily for 2 to 3 weeks recovered reflex activity in almost half the period (average of 32 days compared to 79 days). Modified sphincterotomy at the bladder neck was performed in 10 patients. This procedure improved the results to 98 per cent catheter-free reflex bladder status in the group of patients.     

The efficacy of tolterodine for prevention of catheter-related bladder discomfort: a prospective, randomized, placebo-controlled, double-blind study

Bladder discomfort secondary to an indwelling urinary catheter is distressing, particularly for patients awakening from anesthesia. We sought to discover the incidence and severity of bladder discomfort in patients who were catheterized intraoperatively and to evaluate the efficacy of tolterodine, a pure muscarinic receptor antagonist, in preventing this. Two-hundred-fifteen consecutive adult patients, ASA physical status I and II, either sex, undergoing urologic surgery requiring bladder catheterization were enrolled. Group C (control, n = 165) received placebo and group T (tolterodine, n = 50) received tolterodine 2 mg. Drugs were administered orally 1 h before surgery. After induction of anesthesia, patients were catheterized with a 16F Foley catheter and the balloon was inflated with 10 mL of normal saline. In the postanesthesia care unit, bladder discomfort was assessed on arrival (0), 1, 2 and 6 h. Severity of bladder discomfort was graded as mild, moderate, and severe. Bladder discomfort observed in group C was 55% (91 of 165). Tolterodine reduced both the incidence 36% (18 of 50) and severity of bladder discomfort (P < 0.05). IMPLICATIONS: Bladder discomfort secondary to an indwelling urinary catheter is distressing to patients. In the present study, we observed that tolterodine (2 mg), a competitive muscarinic receptor antagonist administered 1 h before surgery, reduced both the incidence and severity of bladder discomfort secondary to bladder catheterization.     

Bladder management after total joint arthroplasty

This study was undertaken to determine the impact of an indwelling Foley catheter on bladder dysfunction and incidence of urinary tract infections after total joint arthroplasty. A prospective randomized controlled trial was conducted assigning use of an indwelling Foley catheter (group 1) or intermittent catheterization (group 2) for 48 hours following operation. Postoperative cultures were obtained on days 2 and 5, and the number of intermittent catheterization events and void and catheterization volumes were recorded. Concurrent cost-effectiveness analysis was conducted. One hundred nineteen of 174 consecutive patients having elective primary total joint arthroplasty completed the study. Five of 62 patients (8%) in group 1 and 7 of 57 patients (12%) in group 2 developed urinary tract infections (NS, P = .45). Twenty patients (35%) in group 2 and 12 (19%) in group 1 required straight catheterization for inability to void 48 hours after surgery (P = .05). Seventeen patients (35%) in group 2 and eight patients (16%) in group 1 required straight catheterization after epidural analgesia was discontinued (P = .024). Bladder management by indwelling Foley catheter saved more than 150 minutes of direct nursing contact per patient and $3,000 in total hospital costs. Indwelling Foley catheters reduced the frequency of postoperative urinary retention, were less labor intensive than intermittent straight catheterization, and were not associated with an increased risk of urinary infection. In the setting of epidural anesthesia and postoperative analgesia for total joint arthroplasty, management by indwelling catheter is a cost-effective strategy to facilitate postoperative return of normal bladder function.     

Urethral catheterization in spinal surgery: a randomized prospective study

Summary In a prospective randomized study the effect of the use of an intraoperative indwelling urethral catheter (IUC) on urinary complications was investigated in patients undergoing spinal fusion. Two groups were formed; 16 patients received an intraoperative IUC and 16 patients had no intraoperative catheter (NC). All patients were, if necessary, intermittently catheterized in the postoperative period. Seven of the patients in the IUC group had positive cultures, defined as 100000 CFU/ml, compared with two patients in the NC group (n.s.). Another four patients in the NC group had cultures 10000 CFU/ml. Thirteen patients in the IUC group and 14 patients in the NC group had positive dip slides. The largest received urine volume in each patient at one intermittent catheterization did not differ significantly between the groups. However, in three patients in the NC group the volumes exceeded 1000 ml. Thus, irrespective of treatment dip slides showed bacteriuria in 84% of the patients. Perioperative indwelling catheters do not seem to cause many more infection complications than no bladder drainage during surgery, and the advantages of reduced risk of bladder distension injury and more accurate monitoring of fluid balance suggest their use.     

The role of bladder catheterization in total knee arthroplasty

The use of a urinary bladder catheter in the perioperative period for patients undergoing total knee arthroplasty is controversial. In the current study, two bladder management protocols were studied. One group of patients had an indwelling catheter inserted into the bladder before total knee arthroplasty. The other group of patients was observed and treated for urinary retention as necessary. From 1993 to 1998, 652 patients undergoing primary, unilateral total knee arthroplasty were randomized by surgeon into two groups: one group underwent preoperative insertion of an indwelling bladder catheter (306 patients), and one group (346 patients) had a catheter inserted postoperatively as necessary. Sixty-six percent (229 of 346) of these patients required catheterization (203 had indwelling catheters and 26 had intermittent straight catheters). A urinary tract infection developed in five patients (1.6%) in whom a catheter was inserted preoperatively. A urinary tract infection developed in six patients (1.7%) in whom a catheter was inserted if necessary. Five of these urinary tract infections developed in patients with delayed indwelling bladder catheters. A urinary tract infection did not develop in any patient in whom a straight catheter was inserted. There was no significant difference in the length of stay in the hospital between the two groups. The group in whom a catheter always was inserted generated $491 greater cost for total knee arthroplasty than patients in whom a catheter was inserted if necessary.     

Cost-effective treatment of female stress urinary incontinence: Modified pereyra bladder neck suspension

We herein report on the cost effectiveness of the modified Pereyra bladder neck suspension (MPBNS) compared with the Marshall-Marchetti-Krantz (MMK) retropubic suspension procedure. A total of 82 cases was reviewed retrospectively. The MPBNS was found to provide a 41 per cent cost savings with significantly shorter duration of intravenous fluid administration, shorter duration of postoperative indwelling catheter drainage, shorter operative time, and significantly shorter postoperative hospitalization. Early postoperative intermittent catheterization was a major factor in facilitating early discharge after MPBNS.     

Perioperative bladder management after primary total hip arthroplasty

A retrospective review of 95 consecutive primary total hip arthroplasty patients was performed to assess the clinical outcome of two postoperative bladder management protocols. The first 49 patients (group 1) were treated with a pro re nata straight catheterization protocol. The next 46 patients (group 2) were treated with an indwelling catheterization protocol. There were no differences between the groups with respect to sex or age. The patients in group 2 had significantly lower incidences of urinary retention (P < .0005) and bladder distention (P < .0005) than those in group 1. Preoperative systemic diseases and urologic symptoms did not correlate with the occurrence of postoperative urinary retention or bladder distention. There were no infections in group 1. In group 2, one patient (2%) had bacteriuria and one patient (2%) had a urinary tract infection (P > .1). This trend of increased contamination in the catheterization group may be related to a mean catheterization duration of 72 hours.     

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.     

Total joint arthroplasty and incidence of postoperative bacteriuria with an indwelling catheter or intermittent catheterization with one-dose antibiotic prophylaxis: a prospective randomized trial

This study examined the difference in postoperative bacteriuria in total joint arthroplasty after use of either an indwelling catheter or intermittent catheterization. Previous studies showed a preference for an indwelling catheter over intermittent catheterization to resolve postoperative urinary retention in total joint arthroplasty, but these studies generally used 48 hours of antibiotic prophylaxis. Increasing awareness of costs and bacterial resistance to antibiotics have prompted many centers to reduce prophylaxis to only 1 preoperative dose A prospective, randomized, controlled trial was conducted in primary total hip and primary total knee arthroplasty patients. One dose of cefazolin, 1 g, was administered intravenously immediately preoperatively. Five of 13 (38%) men in the indwelling catheter group and 0 of 14 (0%) men in the intermittent catheterization group developed postoperative bacteriuria (P =.016), and 6 of 33 (18%) women in the indwelling catheter group and 3 of 39 (8%) women in the intermittent catheterization group developed postoperative bacteriuria (not significant). A total of 11 (24%) patients in the indwelling catheter group (n = 46) and 3 (6%) patients in the intermittent catheterization group (n = 53) developed postoperative bacteriuria (P =.018). In this setting with 1-dose antibiotic prophylaxis, intermittent catheterization resulted in a lower incidence of postoperative bacteriuria compared with an indwelling catheter. For men, this difference is significant.     

The Effect of Urinary Tract Reconstruction On Neurologically Impaired Women Previously Treated With An Indwelling Uretheral Catheter

Purpose

We investigated the changes in sexuality and quality of life that evolve after lower urinary tract reconstruction in neurologically impaired women previously treated with an indwelling urethral catheter.

Materials and Methods

A total of 18 neurologically impaired women treated with an indwelling urethral catheter underwent bladder reconstruction. Pubovaginal sling urethral compression was required to restore perineal dryness in 13 patients and was the only operation required in conjunction with intermittent catheterization in 3. Eight patients underwent ileocystostomy, that is creation of a "bladder chimney," and 4 underwent augmentation cystoplasty with creation of a continent catheterizable stoma. In 3 patients ileocystoplasty alone with intermittent urethral catheterization was performed. All patients were followed 6 to 40 months (mean 18) after reconstructive surgery using a 9-part questionnaire to score numerically the effect of surgical reconstruction on sexuality and quality of life issues.

Results

On a scale of 0 (worst) to 5 (best) mean scores for self-esteem improved from 1 preoperatively to 4 postoperatively, self-image from 1 to 4, sexual desire from 2 to 4 and ability to cope with disability from 1 to 4, respectively. In 4 of the 15 women who were sexually active preoperatively the frequency of sexual intercourse doubled from a mean of 3 to 6 times per month, respectively, and all 4 women reported improved sexual satisfaction. All 13 patients with pelvic pain and 5 with symptoms of autonomic dysreflexia noticed significant improvement if not complete resolution of the symptoms.

Conclusions

Neurogenic lower urinary tract dysfunction treated with an indwelling urethral catheter is detrimental to sexuality and quality of life in neurologically impaired women. Urinary tract reconstruction restores not only quality of life but also sexuality by improving self-image, self-esteem and the ability to cope. Indwelling catheterization as a method of long-term urinary treatment should be avoided in women.     

Impact of Percutaneous Suprapubic Tube Drainage on Patient Discomfort after Radical Prostatectomy

Background

Patients undergoing radical prostatectomy (RP) traditionally require urethral catheterization for adequate bladder drainage in the postoperative period. However, many patients have significant discomfort from the urethral catheter.

Objective

To describe a technique of percutaneous suprapubic tube (PST) bladder drainage after robotic-assisted laparoscopic radical prostatectomy (RALP) and to evaluate patient discomfort, complications, continence, and stricture rate after this procedure.

Design, setting, and participants

Two hundred two patients undergoing RALP were drained with a 14F PST instead of a urethral catheter. The PST was placed robotically at the conclusion of the urethrovesical anastomosis and secured to the skin over a plastic button. Beginning on postoperative day 5, patients clamped the PST, urinated per urethra, and measured the postvoid residual (PVR) drained by PST. The PST was removed when residuals were <30 cm³ per void. The control group consisted of 50 consecutive patients undergoing RALP with urethral catheter drainage.

Measurements

The primary end point was catheter-associated discomfort as measured with the Faces Pain Score-Revised (FPS-R). Secondary end points included use of anticholinergics, complications related to the PST, urinary continence, and urethral stricture.

Results and limitations

When compared with urethral catheter patients, PST patients had significantly decreased catheter-related discomfort on postoperative days 2 and 6 (p < 0.001). Anticholinergic medication was required by one PST and four urethral catheter patients (p < 0.001). Ten patients required urethral catheterization for PST dislodgement (n = 5) or urinary retention (n = 5). No patient has developed a urethral stricture at a mean follow-up of 7 mo.

Conclusions

PST provides adequate urinary drainage following RALP with less patient discomfort and no increased risk of urethral stricture.     

Electromotive administration of intravesical bethanechol and the clinical impact on acontractile detrusor management: introduction of a new test

PURPOSE: It is often difficult to determine the functional status of the detrusor muscle in patients with detrusor areflexia. We performed a clinical study to establish a test defining residual detrusor capacity in such patients. MATERIALS AND METHODS: In phase 1, 5 controls with detrusor areflexia were tested with an intravesical instillation of 20 mg. bethanechol in 150 cc of sodium chloride 0.3% with and without 20 mA. of pulsed current applied via an electrode catheter through the saline. Cystometry simultaneously recorded intravesical pressure changes. In phase 2, 45 patients with detrusor areflexia were tested with electromotive administration of intravesical bethanechol. In phase 3, 25 mg. bethanechol given orally once daily were prescribed for 15 patients and voiding control was assessed after 6 weeks of therapy. RESULTS: Neither bethanechol without current nor current through saline only led to increased intravesical pressure. However, we noted a mean pressure increase of 34 cm. water during the electromotive administration of bethanechol in 24 of 26 patients with areflexia and neurological disease compared to only 3 cm. water in 3 of 11 with a history of chronic bladder dilatation. Oral bethanechol restored spontaneous voiding in 9 of 11 patients who had had a positive response to the electromotive administration of bethanechol, whereas all 4 without a pressure increase during the electromotive administration of bethanechol did not void spontaneously. CONCLUSIONS: Electromotive administration of intravesical bethanechol identifies patients with an atonic bladder and adequate residual detrusor muscle function who are candidates for restorative measures, such as oral bethanechol and intravesical electrostimulation. Those who do not respond to the electromotive administration of bethanechol do not benefit from oral bethanechol and are candidates for catheterization.     

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.     

New Use of Foley Catheter for Precise Vesicourethral Anastomosis during Radical Retropubic Prostatectomy

Purpose

We describe a new method of using a Foley catheter to assist vesicourethral anastomosis during radical retropubic prostatectomy.

Materials and Methods

A total of 81 patients underwent radical retropubic prostatectomy with this technique. Followup ranged from 4 to 48 months. Peri-catheter urethrograms were performed at 3 weeks. Patients were evaluated specifically for bladder neck contracture, urinary continence and prolonged catheterization.

Results

Bladder neck contracture occurred in 4.9 percent of the patients and 87.6 percent were completely continent of urine. Only 1 patient required extended postoperative catheterization.

Conclusions

Use of a Foley catheter for vesicourethral anastomosis is consistent and simple, and provided good surgical results in our experience.