Prospective evaluation of combined suprapubic and urethral catheterization to urethral drainage alone for intraperitoneal bladder injuries

BACKGROUND: The role of suprapubic catheterization after repair of intraperitoneal bladder injury is controversial and has been found to be superfluous in retrospective studies. We sought to evaluate bladder drainage prospectively. METHODS: Patients were prospectively enrolled and were assigned to suprapubic catheter drain after bladder repair or urethral catheter alone determined by the unit admitting the patient. Factors that were evaluated were associated injuries, hospital stay, duration of catheterization, and catheter-related complications. RESULTS: There were 42 patients: there were 39 male patients, and the mean age was 29.6 years. The patients were matched for age and associated injuries. The morbidity (p = 0.004) and hospital stay (p = 0.028) were significantly higher in the suprapubic drainage group. CONCLUSION: Urethral catheterization is adequate to effect bladder drainage after intraperitoneal bladder injury. In addition, it is associated with a shorter hospital stay and lower morbidity.     

Assessing the effectiveness of different urinary catheters in emptying the bladder: an application of transvaginal ultrasound

The effectiveness of different types of urinary catheters in completely draining the bladder has not been tested. Transvaginal ultrasound, which is able to measure bladder volumes in women from 2 to 175 ml, provides a means of measuring any fluid volume remaining in the bladder following catheter drainage. Using transvaginal ultrasound, the post-catheterisation bladder volumes were measured in 26 female patients; 14 underwent urethral catheterisation using either a 14F short plastic female catheter or a Foley catheter of the same size (balloon not inflated); 12 had an indwelling 12F suprapublic catheter following bladder neck surgery. The mean post-catheterisation bladder volumes after using the short plastic female and Foley catheters were less than 1 ml and 77 ml respectively. A short plastic catheter should be used in women to collect the residual urine volume by urethral catheterisation. A Foley catheter is relatively ineffective in this task. A 12F suprapubic catheter was found to drain the bladder relatively well. The mean post-catheterisation bladder volume was 35 ml. Prior to removing a suprapubic catheter post-operatively, it is recommended that the residual urine volume (measured using the suprapubic catheter) be checked by measuring the post-catheterisation bladder volume (using either a short plastic catheter or transvaginal ultrasound).     

Use of a urethral splent in one-stage hypospadias repair

Over a 9-month period, 28 patients with distal penile or more proximal hypospadias underwent one-stage surgical repair. Bladder drainage was achieved in the traditional fashion with either an indwelling Foley catheter or suprapubic catheter or by using a modified urethral silicone stent ("splent"). Twenty-two patients had repair with a perimeatal skin flap, and the remaining six patients had major urethral reconstruction with a vascularized preputial island flap. Use of the urethral splent was associated with shorter postoperative hospitalization and minimal short-term complications. The authors' experience has shown that use of a urethral splent for urinary drainage is efficient and effective in postoperative management after hypospadias repair.     

Squamous cell carcinoma arising from suprapubic cystotomy site without bladder involvement

We report on an eighty-year-old Haitian man with a suprapubic mass of seven months duration after five years of urinary diversion for urethral stricture. Histologically the mass was a squamous cell carcinoma confined to the suprapubic tract without bladder involvement. We believe this is the first such case reported in the literature, and it stresses the need for close monitoring of patients with any type of long-term indwelling catheter.     

输尿管镜下尿道会师术治疗尿道断裂伤

目的探讨输尿管镜下留置导尿管治疗男性尿道断裂伤的方法与疗效。方法2007年5月～2012年4月采用输尿管镜下留置导尿管治疗男性尿道断裂伤18例。术中镜下寻找尿道球部或膜部近端断裂处,插入导丝于膀胱,沿导丝置入气囊导尿管恢复尿道连续性。结杲术后平均随访6个月,13例拔除导尿管后恢复正常排尿,5例合并尿道狭窄,其中3例结合尿道内切开、2例定期尿扩后排尿通畅。结论输尿管镜下留置导尿管治疗尿道断裂伤安全和有效。     

Pelvic fracture urethral injuries: the unresolved controversy

PURPOSE: The unresolved controversies about pelvic fracture urethral injuries and whether any conclusions can be reached to develop a treatment plan for this lesion are determined. MATERIALS AND METHODS: All data on pelvic fracture urethral injuries in the English literature for the last 50 years were critically analyzed. Studies were eligible only if data were complete and conclusive. RESULTS: The risk of urethral injury is influenced by the number of broken pubic rami as well as involvement of the sacroiliac joint. Depending on the magnitude of trauma, the membranous urethra is first stretched and then partially or completely ruptured at the bulbomembranous junction. Injuries to the prostatic urethra and bladder neck occur only in children. Injury to the female urethra usually is a partial tear of the anterior wall and rarely complete disruption of the proximal or distal urethra. Diagnosis depends on urethrography in men and on a high index of suspicion and urethroscopy in women. Of the 3 conventional treatment methods primary suturing of the disrupted urethral ends has the greatest complication rates of incontinence and impotence (21 and 56%, respectively). Primary realignment has double the incidence of impotence and half that of stricture compared to suprapubic cystostomy and delayed repair (36 versus 19 and 53 versus 97%, respectively, p <0.0001). CONCLUSIONS: In men surgical and endoscopic procedures do not compete but rather complement each other for treatment of different injuries under different circumstances, including indwelling catheter for urethral stretch injury, endoscopic stenting or suprapubic cystostomy for partial rupture, endoscopic realignment or suprapubic cystostomy for complete rupture with a minimal distraction defect and surgical realignment if the distraction defect is wide. Associated injury to the bladder, bladder neck or rectum dictates immediate exploration for repair but does not necessarily indicate exploration of the urethral injury site. In women treatment modalities are dictated by the level of urethral injury, including immediate retropubic realignment or suturing for proximal and transvaginal urethral advancement for distal injury.     

Isolated condyloma acuminatum of the bladder in a patient with multiple sclerosis: etiological and pathological considerations

We report a solitary condyloma acuminatum of the bladder without cutaneous, anogenital or urethral involvement in a patient with multiple sclerosis who had an indwelling suprapubic catheter. The lesion was treated by endoscopic resection.     

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.     

Erosion of a penile prosthesis due to an indwelling urethral catheter as a late complication

A case of erosion of a penile prosthesis caused by indwelling of a catheter in the urethra is reported. A 73-year-old man had maintained sexual intercourse with penile prostheses (Jonas prosthesis, 19 cm) for 11 years without any complications until he developed cerebral infarction. One month after starting an indwelling urethral catheter in a neurosurgery clinic, the left-side penile prosthesis eroded from the area of the fossa navicularis, and was immediately removed. This type of complication is not unusual in patients with a neurogenic bladder. However, it is not well recognized in patients who suddenly develop a neurogenic bladder following a long-term uneventful period after the implantation of penile prostheses. Therefore, urologists should inform patients who receive this type of treatment that erosion of the prosthesis may develop when they need an indwelling urethral catheter as a late complication.     

Cyberwand双导管超声吸附碎石治疗特殊人群膀胱结石

目的 探讨应用Cyberwand双导管超声吸附碎石系统治疗特殊人群膀胱结石的价值.方法 2008年7月～ 2011年10月我院收治因各种原因需长期留置膀胱造瘘管致膀胱结石形成患者89例,其中神经源性膀胱49例,前列腺增生不能耐受手术行膀胱造瘘者14例,肿瘤局部浸润行尿流改道者1 1例,反复尿道狭窄手术失败保留造瘘者15例.均通过膀胱造瘘口肾镜应用Cyberwand双导管超声吸附碎石. 结果 所有手术均顺利完成,手术时间平均40(30～70)min.无膀胱穿孔、大出血、结石残留、输尿管开口损伤等.所有患者均获随访,平均6(1 ～24)个月.13例患者术后7个月再发膀胱结石,再次行上述处理,结石清除干净. 结论 对于各种原因需长期留置膀胱造瘘管的患者所形成的膀胱结石,通过造瘘口Cyberwand双导管超声吸附碎石,效果良好,创伤轻微,具有很好的推广价值.     

Bladder rupture due to accidental oxygen insufflation via an indwelling urethral catheter--a report of two cases

Two cases of bladder rupture caused by accidental insufflation of oxygen through an indwelling urethral catheter are described. Both patients were ill with multiple diseases. Conservative treatment, including an open indwelling urethral catheter, and surveillance of abdominal status seem appropriate when managing this complication.     

Innovations in indwelling urethral catheterisation

The indwelling urethral catheter remains an integral part of contemporary medical care, despite its significant design shortcomings. Urethral catheterisation is responsible for well-recognised complications including catheter-associated urinary tract infection (CAUTI), catheter-associated urethral injury (CAUI), catheter blockage, and bladder mucosal irritation. In this narrative review, we provide an update on current innovations in urethral catheter design, aimed at safeguarding against these complications. There is an obvious need to improve catheter technology and urologists should support the translation of innovations into clinical practice.     

Transvaginal closure of the bladder neck and placement of a suprapubic catheter for destroyed urethra after long-term indwelling catheterization

We report on 6 women with continuous urinary incontinence as a late complication of an indwelling urethral catheter for neurogenic bladder. Pressure necrosis by the balloon resulted in progressive destruction of the entire urethra, with subsequent incontinence despite the catheter. Surgical attempts at bladder neck closure to correct the incontinence generally have been unsuccessful. Instead of supravesical urinary diversion, we performed transvaginal closure of the bladder neck and percutaneous placement of a permanent suprapubic tube cystostomy. All 6 patients remained dry after closure and none has shown upper urinary tract deterioration at followup for as long as 5 years.     

BLADDER NECK CLOSURE FOR NEUROGENIC INCONTINENCE

Some female patients with neurogenic bladders are treated by means of an indwelling urethral catheter, which, in the long term, commonly leads to marked urethral dilatation, such that, despite the use of larger catheters with bigger balloons, bypassing incontinence occurs with distressing frequency. This problem has been overcome by operation to close the bladder neck and drain the bladder with a suprapubic catheter. Two techniques are described. Provided that there is correct catheter placement with unobstructed drainage, continence is total. Patients with sufficient dexterity have been taught to change their own catheters, and catheter problems have been nil. A technique for males is also described.     

Longitudinal cleavage of the penis in chronic spinal cord injury: two case reports

Context: Penile cleavage is a rare complication of spinal cord injury (SCI) in patients with a chronic indwelling catheter. We report two cases of chronic SCI who developed penile urethral cleavage after prolonged use of an indwelling catheter for bladder management.

Findings: A 25-year-old wheelchair mobile male with T7 American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade A paraplegia developed a 4?×?1.5?cm ventral urethral cleavage after using an indwelling catheter for four months with inadequate care. He had an associated urinary tract infection and undiagnosed diabetes mellitus. A suprapubic catheter was inserted and surgical repair recommended after resolution of UTI and adequate control of his diabetes mellitus. After initial treatment he was lost to follow-up.

The second patient was a 15-year-old male with AIS grade B tetraplegia who presented with a 2.5?cm cleavage on the ventral aspect of penis for the preceding three months. He had been using an indwelling catheter for bladder management for the previous 18 months. He had modified Ashworth scale grade III spasticity in lower limbs resistant to conservative management. There was no history of trauma, infection or diabetes mellitus. The patient was advised penile urethral repair surgery but was lost to follow-up.

Conclusion: Penile cleavage is a rare complication of neurogenic bladder in SCI patients. Patients and care givers should be trained in proper bladder management techniques during the hospital stay, counseled regarding the need for regular follow up, and be taught identification and prevention of common complications.     

Primary endoscopic realignment following posterior urethral disruption

We describe 5 cases in which complete posterior urethral disruption associated with pelvic fracture was managed by primary endoscopic realignment 7 to 19 days after injury. Realignment was accomplished using a flexible endoscope through the suprapubic tract and a rigid or flexible cystoscope in the distal urethra. A guide wire was passed from the suprapubic tract through the disrupted membranous urethra and out the distal urethra. A Councill catheter was left indwelling for 5 to 10 weeks. After removal a program of intermittent self-catheterization was continued for 3 months. Excellent results were obtained in 4 patients who are continent, including 2 who are potent. This technique allows considerable reduction of patient morbidity without compromising formal urethroplasty should it later be required.     

前尿道损伤早期处理的治疗体会

目的 探讨前尿道损伤早期处理方式的选择.方法 回顾性总结2001年9月至2011年6月我科47例尿道损伤患者的临床资料,分析术后并发症及排尿情况.结果 47例患者随访41例,随访时间1～84个月,术后2～6周拔除尿管;采用膀胱穿刺造瘘术3例,留置导尿8例,输尿管镜尿道置管术18例,腔镜下尿道会师术4例,尿道修补术或断端吻合术14例(术后会阴伤口感染2例,尿漏2例),术后31例排尿良好,尿道狭窄10例,失访6例.结论 前尿道不全断裂首选输尿管镜尿道置管术,不成功时行腔镜下尿道会师术,而对于前尿道断裂仍宜行尿道断端吻合术.     

Pelvic fracture urethral injuries in girls

PURPOSE: Injuries to the female urethra associated with pelvic fracture are uncommon. They may vary from urethral contusion to partial or circumferential rupture. When disruption has occurred at the level of the proximal urethra, it is usually complete and often associated with vaginal laceration. We retrospectively reviewed the records of a series of girls with pelvic fracture urethral stricture and present surgical treatment to restore urethral continuity and the outcome. MATERIALS AND METHODS: Between 1984 and 1997, 8 girls 4 to 16 years old (median age 9.6) with urethral injuries associated with pelvic fracture were treated at our institutions. Immediate therapy involved suprapubic cystostomy in 4 cases, urethral catheter alignment and simultaneous suprapubic cystostomy in 3, and primary suturing of the urethra, bladder neck and vagina in 1. Delayed 1-stage anastomotic repair was performed in 1 patient with urethral avulsion at the level of the bladder neck and in 5 with a proximal urethral distraction defect, while a neourethra was constructed from the anterior vaginal wall in a 2-stage procedure in 1 with mid urethral avulsion. Concomitant vaginal rupture in 7 cases was treated at delayed urethral reconstruction in 5 and by primary repair in 2. The surgical approach was retropubic in 3 cases, vaginal-retropubic in 1 and vaginal-transpubic in 4. Associated injuries included rectal injury in 3 girls and bladder neck laceration in 4. Overall postoperative followup was 6 months to 6.3 years (median 3 years). RESULTS: Urethral obliteration developed in all patients treated with suprapubic cystostomy and simultaneous urethral realignment. The stricture-free rate for 1-stage anastomotic repair and substitution urethroplasty was 100%. In 1 girl complete urinary incontinence developed, while another has mild stress incontinence. Retrospectively the 2 incontinent girls had had an associated bladder neck injury at the initial trauma. Two recurrent vaginal strictures were treated successfully with additional transpositions of lateral labial flaps. CONCLUSIONS: This study emphasizes that combined vaginal-partial transpubic access is a reliable approach for resolving complex obliterative urethral strictures and associated urethrovaginal fistulas or severe bladder neck damage after traumatic pelvic fracture injury in female pediatric patients. Although our experience with the initial management of these injuries is limited, we advocate early cystostomy drainage and deferred surgical reconstruction when life threatening clinical conditions are present or extensive traumatized tissue in the affected area precludes immediate ideal surgical repair.     

Catheterization: Possible complications and their prevention and treatment

Abstract:   Intermittent catheterization (IC) is a more preferable method for bladder drainage than indwelling urethral or suprapubic catheterization. Several complications with IC have been described, however, including urinary tract infection, genital infection, urethral bleeding, urethritis, urethral stricture, and bladder stones. To prevent these complications, patients should be well instructed on the technique and the risks of IC. Indwelling catheterization should be used only exceptionally, under close control and the catheter should be changed with adequate frequency.     

Prevention of urethral strictures following coronary artery bypass graft surgery.

A total of 62 patients undergoing coronary artery bypass graft surgery were randomized into three groups using one of three methods for bladder drainage: 12F Foley catheter introduced after anesthesia prior to surgery (21 patients); 12F Foley catheter introduced after termination of cardiopulmonary bypass period (17 patients); or a suprapubic catheter, introduced after termination of the bypass period (24 patients). Later we also studied 39 consecutive patients undergoing coronary artery bypass graft surgery with a 12F Foley catheter introduced after anesthesia to assess the risk of urethral stricture in a larger group of patients. The patients' records were reviewed and a postal questionnaire was sent to all patients six months after surgery. The response rate was 84 percent, with 36 percent having complaints about micturition; of these 79 percent were evaluated by cystourethrography, and 2 cases of urethral stricture were found. The incidence of major postoperative complications was low, with no differences in rate among the various groups. Our results indicate that the use of small caliber Foley catheters is associated with a low incidence of urethral strictures following coronary artery bypass graft surgery; and when indicated, this type of surgery can be performed with other methods of bladder drainage without increased morbidity.