Safety and efficacy of fluoroscopy-guided urethral catheterization in case of failed blind or cystoscopy-assisted urethral catheterization.

This retrospective study evaluated the safety and efficacy of fluoroscopy-guided urethral catheterization in patients who failed blind or cystoscopy-assisted urethral catheterization. We utilized our institutional database between January 2011 and March 2023, and patients with failed blind or cystoscopy-assisted urethral catheterization and subsequent fluoroscopy-guided urethral catheterization were included. A 5-Fr catheter was inserted into the urethral orifice, and the retrograde urethrography (RGU) was acquired. Subsequently, the operator attempted to pass a hydrophilic guidewire to the urethra. If the guidewire and guiding catheter could be successfully passed into the bladder, but the urethral catheter failed pass due to urethral stricture, the operator determined either attempted again with a reduced catheter diameter or performed balloon dilation according to their preference. Finally, an appropriately sized urethral catheter was selected, and an endhole was created using an 18-gauge needle. The catheter was then inserted over the wire to position the tip in the bladder lumen and ballooned to secure it. We reviewed patients' medical histories, the presence of hematuria, and RGU to determine urethral abnormalities. Procedure-related data were assessed. Study enrolled a total of 179 fluoroscopy-guided urethral catheterizations from 149 patients (all males; mean age, 73.3 ± 13.3 years). A total of 225 urethral strictures were confirmed in 141 patients, while eight patients had no strictures. Urethral rupture was confirmed in 62 patients, and hematuria occurred in 34 patients after blind or cystoscopy-assisted urethral catheterization failed. Technical and clinical success rates were 100%, and procedure-related complications were observed in four patients (2.2%). The mean time from request to urethral catheter insertion was 129.7 ± 127.8 min. The mean total fluoroscopy time was 3.5 ± 2.5 min and the mean total DAP was 25.4 ± 25.1 Gy cm2. Balloon dilation was performed in 77 patients. Total procedure time was 9.2 ± 7.6 min, and the mean procedure time without balloon dilation was 7.1 ± 5.7 min. Fluoroscopy-guided urethral catheterization is a safe and efficient alternative in patients where blind or cystoscopy-assisted urethral catheterization has failed or when cystoscopy-urethral catheterization cannot be performed.

Ultrasound-guided suction curettage followed by cervico-isthmic placement of foley threeway catheter for cesarean scar pregnancy's treatment. Retrospective study.

OBJECTIVES: Cesarean scar pregnancy (CSP) is a rare dangerous condition with still no consensus on standard treatment. Suction curettage has been used as the first-line treatment for CSP with controversial outcomes. This study evaluates efficacy of ultrasound-guided suction curettage (UGSC) followed by cervical-isthmic placement of silicon semirigid three-way foley catheter. MATERIALS AND METHODS: This study included 24 women with CSP. Preoperative ultrasound study was conducted. UGSC followed by placement of catheter was performed in all patients. The success rate and incidence of major complication, surgical time and hospital stay were recorded. RESULTS: The success rate of UGSC followed by placement of foley catheter was 100 %, effectively reduced major complications and none of the patients had a blood loss higher than 900 ml. Median hospital stay was 2 days and median foley stay was 1 day. Surgery had limited last with a median of 17 min. CONCLUSION: UGSC followed by foley placement is a safe effective treatment for CSP with a clinical resolution of 100 %. The catheter is easy to place under ultrasound guidance and prevents bleeding, reducing major procedures to solve the bleeding. Suction curettage in CSP treatment should be performed under ultrasound guidance and followed by cervical-isthmic placement of foley balloon.

Patient Removal of Urinary Catheters After Urogynecologic Surgery: A Randomized Controlled Trial.

OBJECTIVE: To compare postoperative urinary retention rates in the early postoperative period between home and office catheter removal. Secondary outcomes included pain, difficulty, satisfaction, likelihood to use again, and health care utilization. METHODS: We conducted a nonblinded, randomized controlled, noninferiority trial of women undergoing surgery for stress incontinence and prolapse from March 2021 to June 2022. Exclusion criteria were preoperative voiding dysfunction (need for self-catheterization or postvoid residual [PVR] greater than 150 mL), urethral bulking, and need for prolonged postoperative catheterization. Participants discharged with indwelling catheters because of an initial failed void trial were randomized 1:1 to home compared with office removal on postoperative day 3-4. For home removal, participants were instructed to remove the catheter at 7 am and to drink two glasses of water. If they had difficulty voiding 5 hours after catheter removal, they came to the office for a void trial. For office removal, participants returned for a backfill void trial with PVR assessment. Our primary outcome was rate of early postoperative urinary retention , defined as confirmed retention (PVR greater than half the voided volume) after catheter removal. Secondary outcomes were assessed at a 2-week call. Health care utilization (telephone calls and office visits) related to catheter issues was also assessed. At 80% power and α=0.05, we needed 100 participants (50/group) to detect a noninferiority margin of 11%. RESULTS: Among 117 participants, the home (n=59) and office (n=58) removal groups were similar in mean age (60 years vs 61 years), mean body mass index (29 vs 30), pelvic organ prolapse quantification system stage 3 or 4, and proportion who underwent hysterectomy or apical suspension. Sling procedures were more common in the office group (45.8% vs 77.6%). For our primary outcome, the rate of early postoperative retention was 11.9% in the home group and 22.4% in the office group ( P =.13). Our predetermined noninferiority margin was greater than the upper bound of our 95% CI; thus, we conclude noninferiority of home removal. For secondary outcomes, the home removal group was more likely to report "no pain" ( P =.02) and "very likely" to use this method again ( P =.004). There were no differences in difficulty or satisfaction between groups. Number of nursing calls was not different ( P =.66); however, number of office visits was higher in the office group (median 0 [interquartile range 0-1] vs 1 [1-1], P <.001). CONCLUSION: Postoperative urinary catheter removal by the patient at home was noninferior to office removal when early urinary retention rates were compared. Participants in the home removal group had fewer office visits and reported low pain, low difficulty, and high satisfaction. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov , NCT04783012.

Is Urethral Catheterization Necessary in Retzius-sparing Robot-assisted Radical Prostatectomy?

OBJECTIVE: To analyze whether urethral catheter (UC)-free anastomosis during Retzius-sparing radical prostatectomy (RP) results in worsening immediate perioperative and postoperative complications. METHODS: We retrospectively reviewed records of patients undergoing robotic-assisted RP with or without indwelling UC placement by a single surgeon between January 2020 and March 2022. Clinical and pathological characteristics were evaluated. An independent t-test was used to compare continuous variables, and Pearson's chi-square test or Fisher exact test was used to compare categorical variables. RESULTS: One hundred fifteen patients underwent robotic prostatectomy from January 2020 to June 2022. Sixty-two patients had both a UC for 12 hours postoperatively and a suprapubic catheter for 6days, while in 53 patients a UC was omitted. There was no significant difference noted between the groups regarding age, body mass index, American Society of Anesthesiology score, prostate-specific antigen, stage, node status, or positive margins. There were no significant differences in the rates of anastomotic leak, ileus, or urethral stricture. Patients had a significantly higher pad-free rate in the suprapubic catheter-only group (P = .04) at 3months. There was no difference in average number of pads used or the number using more than 1 pad/day. CONCLUSION: Omission of urethral catheterization during Retzius-sparing RP is safe and doesn't result in an increased risk in perioperative or postoperative complications, but rather appears to be associated with a significantly improved 3-month pad-free rate.

Assessment of patient satisfaction with home vs office indwelling catheter removal placed for urinary retention after female pelvic floor surgery: a randomized controlled trial.

BACKGROUND: Postoperative urinary retention is burdensome for patients. We seek to improve patient satisfaction with the voiding trial process. OBJECTIVE: This study aimed to assess patient satisfaction with location of indwelling catheter removal placed for urinary retention after urogynecologic surgery. STUDY DESIGN: All adult women who were diagnosed with urinary retention requiring postoperative indwelling catheter insertion after undergoing surgery for urinary incontinence and/or pelvic organ prolapse were eligible for this randomized controlled study. They were randomly assigned to catheter removal at home or in the office. Those who were randomized to home removal were taught how to remove the catheter before discharge, and were discharged home with written instructions, a voiding hat, and 10-mL syringe. All patients had their catheter removed 2 to 4 days after discharge. Those patients who were allocated to home removal were contacted in the afternoon by the office nurse. Subjects who graded their force of urine stream 5, on a scale of 0 to 10, were considered to have safely passed their voiding trial. For patients randomized to the office removal group, the voiding trial consisted of retrograde filling the bladder to maximum they could tolerate up to 300 mL. Urinating >50% of instilled volume was considered successful. Those who were unsuccessful in either group had catheter reinsertion or self-catheterization training in the office. The primary study outcome was patient satisfaction, measured based on patients' response to a question, "How satisfied were you with the overall removal process of the catheter?" A visual analogue scale was created to assess patient satisfaction and 4 secondary outcomes. A sample size of 40 participants per group were needed to detect a 10 mm difference in satisfaction between groups on the visual analogue scale. This calculation provided 80% power and an alpha of 0.05. The final number accounted for 10% loss to follow up. We compared the baseline characteristics, including urodynamic parameters, relevant perioperative indices, and patient satisfaction between the groups. RESULTS: Of the 78 women enrolled in the study, 38 (48.7%) removed their catheter at home and 40 (51.3%) had an office visit for catheter removal. Median and interquartile range for age, vaginal parity, and body mass index were 60 (49-72) years, 2 (2-3), and 28 (24-32) kg/m2, respectively, in the overall sample. Groups did not differ significantly in age, vaginal parity, body mass index, previous surgical history, or type of concomitant procedures. Patient satisfaction was comparable between the groups, with a median score (interquartile range) of 95 (87-100) in the home catheter removal group and 95 (80-98) in the office catheter removal group (P=.52). Voiding trial pass rate was similar between women who underwent home (83.8%) vs office (72.5%) catheter removal (P=.23). No participants in either group had to emergently come into the office or hospital due to inadequate voiding afterwards. Within 30 days post operatively, a lower proportion of women in the home catheter removal group (8.3%) had urinary tract infection, compared to patients in the office catheter removal group (26.3%) (P=.04). CONCLUSION: In women with urinary retention after urogynecologic surgery, there is no difference in satisfaction concerning the location of indwelling catheter removal when comparing home and office.

Early Onset Clean Intermittent Catheterization May Decrease Prevalence and Severity of Urinary Concentration Defects in Myelomeningocele Patients with Neurogenic Bladder: A Retrospective Cohort Study.

PURPOSE: Myelomeningocele is the most severe form of spina bifida. Management of urologic consequences of spina bifida is life long, demanding and costly for both the patient and the public health system. There is a paucity of data in the literature regarding concentration defects and their consequences on this disease. This paper aims to describe retrospectively the effect of early onset clean intermittent catheterization (CIC) in on the severity of urinary concentration defects in myelomeningocele patients with neurogenic bladder in a retrospective observational study. MATERIALS AND METHODS: In this 10-year retrospective cohort study, children with myelomeningocele were selected with the Convenience sampling method. Demographic characteristics, polyuria index ratio (PIR) defined as 24 hour urine output of each patient divided by the maximum normal urine output of the same patient in a healthy state, and nocturnal polyuria index (NPI) were compared between early starters (< 2 years old) or late starters (≥ 2 years old) groups. RESULTS: Seven patients who underwent cystoplasty were excluded and 130 patients (63.8% male, 5.4 ± 3.2 years old, 14.3 ± 2.83 Kg, 28.5% early onset CIC) were investigated. PIR > 1 in inset (1.7 ± 0.2 vs. 2.2 ± 0.5, P = 0.021) and outset (1.5 ± 0.32 vs. 2.5 ± 0.7, P = 0.004) were lower in early starters group than in late starters group. NPI in inset (0.2 ± 0.007 vs. 0.32 ± 0.10, P = 0.018) and outset (0.25 ± 0.15 vs. 0.42 ± 0.095, P = 0.007) were also lower in the early starters group. No further adverse events were reported during the follow-up period. CONCLUSION: Early onset CIC is more effective than late-onset CIC in preserving the urinary ability of kidneys in myelomeningocele patients.

Imaging-Guided De Novo Retrograde Ureteral Access and Stent Placement without Cystoscopy in Women.

PURPOSE: To evaluate the feasibility of a new technique for imaging-guided de novo retrograde ureteral double J (DJ) stent placement without cystoscopy in women. MATERIALS AND METHODS: Eighty-four women referred for ureteral stent placement between April 2019 and January 2022 were included. In all the patients, the initial attempt for stent placement was performed in a retrograde fashion. Successful ureteral catheterization and DJ stent placement were considered as technical success. The fluoroscopy time required to catheterize the ureter and that for the entire procedure were recorded. Factors affecting the technical success rate and fluoroscopy time were examined. RESULTS: A total of 108 ureteral stent placement procedures in 84 women, with a mean age of 57.5 years (range, 19-85 years), were performed. The most common underlying pathologies were cervical (n = 33, 31%) and ovarian (n = 32, 30%) carcinomas. The most commonly involved segments of the ureter were the lower half (n = 44, 40%) and trigone (n = 39, 36%). The technical success rate was 81.5%, and it reached 93% in the case of lower-half ureteral obstruction. Distorted trigonal anatomy caused by external compression of the bladder wall by a mass was associated with a higher rate of technical failure (90.6% vs 47.8%; P < .001). The use of ultrasound guidance to guide the sheath to the ureteral orifice allowed for a significant decrease in the fluoroscopy time for ureteral catheterization (4.6 minutes ± 3.91 vs 2.26 minutes ± 2.32; P = .003) and that for the entire procedure (9.42 minutes ± 4.95 vs 5.93 minutes ± 4.06; P = .001). CONCLUSIONS: Imaging-guided de novo retrograde ureteral catheterization and stent placement can be successfully performed in a high percentage of patients within a reasonable fluoroscopy time without the need for cystoscopy in women.

Complex Foley Catheter Placement After Radical Prostatectomy.

OBJECTIVE: To describe a method for replacement of a dislodged critical urethral foley catheter following a robotic- assisted laparoscopic radical prostatectomy. BACKGROUND: Following robotic-assisted laparoscopic radical prostatectomy (RALP), a bladder drainage via catheter is necessary to allow for proper healing of the urethrovesical anastomosis. In most cases, this is done using a transurethral foley catheter.1,2 Early traumatic loss of the urethral catheter following RALP is consider a urologic emergency and can lead to vesicourethral anastomotic urine leak, ileus, infection or abscess, and future anastomotic stenosis.3 Replacing the urethral catheter in this situation can be difficult even in experienced hands and often requires imaging assistance. METHOD: A 53-year-old male with Grade Group 4 (Gleason 4 + 4) prostate cancer underwent an uncomplicated RALP. During his post-operative course, his urethral foley catheter fell out or was traumatically removed three times resulting in disruption of the posterior anastomosis. To replace the urethral catheter and prevent it from being dislodged again, a transabdominal approach under ultrasound and cystoscopic guidance was employed to replace the catheter into the bladder and secure it trans abdominally using a single G-tube safety Pexy T fastener. CONCLUSION: This case reports describes a technique used to replace and secure a urethral foley catheter in a patient who suffered from a posterior anastomotic disruption following repeated loss and traumatic removal of his urethral foley catheter during his RALP post-operative course. While replacement of a dislodged urethral foley catheter following a RALP can be challenging, the catheter can safely be placed and secured trans abdominally in these rare but serious situations where the conventional catheter secure devices and patient education alone are not sufficient to prevent removal.

Postpartum urinary retention: an expert review.

Postpartum urinary retention is a relatively common condition that can have a marked impact on women in the immediate days following childbirth. If left untreated, postpartum urinary retention can lead to repetitive overdistention injury that may damage the detrusor muscle and the parasympathetic nerve fibers within the bladder wall. In rare circumstances, postpartum urinary retention may even lead to bladder rupture, which is a potentially life-threatening yet entirely preventable complication. Early diagnosis and timely intervention are necessary to decrease long-term consequences. There are 3 types of postpartum urinary retention: overt, covert, and persistent. Overt retention is associated with an inability to void, whereas covert retention is associated with incomplete bladder emptying. Persistent urinary retention continues beyond the third postpartum day and can persist for several weeks in rare cases. Recognition of risk factors and prompt diagnosis are important for proper management and prevention of negative sequelae. However, lack of knowledge by providers and patients alike creates barriers to accessing and receiving evidence-based care, and may further delay diagnosis for patients, especially those who experience covert postpartum urinary retention. Nationally accepted definitions and management algorithms for postpartum urinary retention are lacking, and development of such guidelines is essential for both patient care and research design. We propose intrapartum recommendations and a standardized postpartum bladder management protocol that will improve patient outcomes and contribute to the growing body of evidence-based practice in this field.

Overnight removal of urinary indwelling catheter following vaginal prolapse surgery (OVERACT).

OBJECTIVE: Pelvic organ prolapse is a common condition in women. Adequate timing of urinary catheter removal after vaginal prolapse surgery is essential to reduce post-operative morbidity. We compared midnight removal of the indwelling urinary catheter to removal next morning. METHODS: We performed a retrospective cohort study among 266 women undergoing vaginal prolapse surgery, of whom 132 women had urinary catheter removal at midnight and 134 women morning after surgery. We compared the occurrence of urinary retention, time till first micturition, need for clean intermittent catherization and duration of hospital admission. Also, we assessed risk factors for the occurrence of retention. RESULTS: Retention occurred less after midnight removal of the urinary catheter, compared to removal next morning (6.1 % versus 23.9 %, p < 0.001). Furthermore, the time till catheter removal and discharge from hospital were shorter and the need for clean intermittent catheterization during hospital admission was lower after midnight compared to next morning removal of the urinary catheter. We identified anterior colporrhaphy as a risk factor for retention. CONCLUSION: Our results suggest that early removal of the indwelling urinary catheter after vaginal prolapse surgery seems save with respect to urinary retention and leads to earlier mobilization and shorter hospital admission.

A 66-Year-Old Woman with Achondroplasia and Quadriparesis with an Ovarian Cyst Erroneously Diagnosed as Urinary Retention by an Automated Bladder Scan.

BACKGROUND Automated bladder scanning has become a principal tool in the assessment and management of chronically debilitated patients residing in skilled nursing facilities, hospices, and acute inpatient settings. To a large extent, the bladder scan, generally performed by nursing staff, has replaced physical examination while addressing the differential diagnoses of anuria or voiding disturbances that require consideration of urinary catheterization. Health care providers can quickly master this easily performed technique, and currently, due to confidence in the bladder scan finding, physical examination with suprapubic palpation and percussion may be carelessly omitted. The case description presented here illustrates how not performing a physical examination can lead to misdiagnosis caused by misinterpretation of bladder scan findings. CASE REPORT A 66-year-old, quadriparetic, chronically ventilated female patient with achondroplasia underwent repeated hospital referrals and bladder catheterizations for presumed flaccid, neurogenic bladder with urinary retention. This postulated diagnosis was based on occasional reports of urinary catheter obstruction as well as on automated bladder scanning indicating a markedly distended bladder. However, the bladder could not be drained by insertion of urinary catheters. Eventually, a proper physical examination excluded the presence of suprapubic fullness compatible with distended bladder and contradicting bladder scan findings, prompting re-examining an overlooked evaluation of computed tomography that reported a huge ovarian cyst. The patient was found to have intact voiding capabilities and is now weaned from the catheter. CONCLUSIONS This case and the literature review underscore drawbacks in automated bladder scanning. This technique should be used as an adjunctive measure rather than a replacement for a physical examination in the evaluation of voiding disturbances, especially when there are discrepancies between bladder scan findings and the volume of urine drained by catheterization.

A scoping review on the impact of hydrophilic versus non-hydrophilic intermittent catheters on UTI, QoL, satisfaction, preference, and other outcomes in neurogenic and non-neurogenic patients suffering from urinary retention.

BACKGROUND: For patients suffering from urinary retention due to neurogenic [e.g., spinal cord injury (SCI), spina bifida (SB), multiple sclerosis (MS)] or non-neurogenic [e.g., cancer, benign prostate hypertrophy (BPH)] causes, intermittent catheterization is the primary choice for bladder emptying. This scoping review compared hydrophilic-coated intermittent catheters (HCICs) with non-hydrophilic (uncoated) catheters in neurogenic and non-neurogenic patients with respect to satisfaction, preference, adverse events, urinary tract infection (UTI), quality of life (QoL), cost effectiveness, pain, and discomfort. METHODS: A systematic literature search was conducted using PubMed, Cochrane Library, Google Scholar, Embase, and available clinical practice guidelines and was limited to systematic reviews/meta-analysis and clinical studies (randomized trials, cohort and case-control studies) published in English between 2000 and 2020. A narrative synthesis was performed, comparing HCIC with non-hydrophilic catheters in each pathology. The articles where critically appraised and weighted according to their level of evidence based on the Oxford Centre for Evidence-Based Medicine Levels of Evidence grading. RESULTS: Thirty seven original articles and 40 reviews were included. The comparison of HCICs versus non-hydrophilic catheters was well-documented in patients with mixed pathology, SCI, and to some extent SB. The available evidence predominantly indicates better outcomes with HCICs as reported by study authors, particularly, greater UTI reduction and improved satisfaction, cost-effectiveness, and QoL. However, SB studies in children did not report reduction in UTIs. Children complained about slippery catheters, indicating possible touching of the surface during insertion, which may compromise cleanliness of the procedure and affect outcomes such as UTI. Limited studies were available exclusively on BPH and none on MS; however, most studies performed on mixed pathologies, including BPH and MS, indicated strong preference for HCICs compared to non-hydrophilic catheters. CONCLUSIONS: The findings generally support HCICs over non-hydrophilic catheters; however, most studies were fairly small, often used a mix of pathologies, and the conclusions were often based on studies with high drop-out rates that were therefore underpowered. Larger studies are needed to support the general finding that HCICs are the preferred choice in most populations. Additional training in children or redesigned catheters may be necessary for this age-group to fully benefit from the advantages of HCICs.

A Prospective Multi-Institutional Evaluation of Iatrogenic Urethral Catheterization Injuries.

OBJECTIVES: To perform a multi-institutional investigation of incidence and outcomes of urethral trauma sustained during attempted catheterization. PATIENTS & METHODS: A prospective, multi-center study was conducted over a designated 3-4 month period, incorporating seven academic hospitals across the UK and Ireland. Cases of urethral trauma arising from attempted catheterization were recorded. Variables included sites of injury, management strategies and short-term clinical outcomes. The catheterization injury rate was calculated based on the estimated total number of catheterizations occurring in each center per month. Anonymised data were collated, evaluated and described. RESULTS: Sixty-six urethral catheterization injuries were identified (7 centers; mean 3.43 months). The mean injury rate was 6.2 ± 3.8 per 1000 catheterizations (3.18-14.42/1000). All injured patients were male, mean age 76.1 ± 13.1 years. Urethral catheterization injuries occurred in multiple hospital/community settings, most commonly Emergency Departments (36%) and medical/surgical wards (30%). Urological intervention was required in 94.7% (54/57), with suprapubic catheterization required in 12.3% (n = 7). More than half of patients (55.56%) were discharged with an urethral catheter, fully or partially attributable to the urethral catheter injury. At least one further healthcare encounter on account of the injury was required for 90% of patients post-discharge. CONCLUSIONS: This is the largest study of its kind and confirms that iatrogenic urethral trauma is a recurring medical error seen universally across institutions, healthcare systems and countries. In addition, urethral catheter injury results in significant patient morbidity with a substantial financial burden to healthcare services. Future innovation to improve the safety of urinary catheterization is warranted.

Can we really make catheter-associated urinary tract infections a never event? A level 1 trauma center's experience with prophylactic antibiotic bladder irrigation.

BACKGROUND: Hospital-acquired catheter-associated urinary tract infections (CAUTIs) are considered "never events" and are reportable to Centers for Medicare and Medicaid Services as a quality indicator. Despite protocols to determine appropriate removal of urinary catheters as soon as possible, severely injured trauma patients often require prolonged catheterization during ongoing resuscitation or develop retention requiring catheter replacement, exposing them to risk for CAUTI. We evaluated whether prophylactic antibiotic bladder irrigation reduces the incidence of CAUTI in critically ill trauma patients. METHODS: As a quality initiative, gentamicin bladder catheter irrigation (GBCI) was performed on a level 1 trauma center's patients at risk for CAUTI in 2021, defined by indwelling Foley catheterization for a minimum of 3 days. We then conducted a retrospective study using a comparison cohort of 2020 admissions as the control group. Catheter-associated urinary tract infection rates per 1,000 catheterized days were compared between these two groups. Patients with traumatic bladder injuries were excluded. RESULTS: Our cohort included 342 patients with a median hospitalization of 11 (7-17) days, Injury Severity Score of 17 (10-26), and 6 (4-11) days of catheterization. Eighty-six patients, catheterized for 939 at-risk days, received twice-daily GBCI compared with 256, catheterized for 2,114 at-risk days, who did not. Zero patients in the GBCI group versus nine patients in the control group developed CAUTI. The incidence of CAUTI in the GBCI group was significantly less than in the control group (0/1,000 vs. 4.3/1,000 catheterized days, p = 0.018). CONCLUSION: Prophylactic antibiotic bladder irrigation was associated with a zero incidence of CAUTI among trauma patients at risk for CAUTI. This practice holds promise as effective infection prophylaxis for such patients. The optimal duration and frequency of irrigation remain to be determined. LEVEL OF EVIDENCE: Therapeutic/care management, Level III.

Implementation of a standardized voiding protocol after minimally invasive surgery: A quality improvement initiative.

OBJECTIVES: To assess the effects of the implementation of a standardized voiding protocol in patients undergoing minimally invasive hysterectomy at a single cancer center in terms of the urinary tract infection (UTI) rate, time to first void, and overnight stays secondary to urinary retention. METHODS: We enrolled 102 consecutive patients undergoing minimally invasive hysterectomy at a single cancer center during a 12-month period. A pre-intervention cohort of 100 consecutive patients was identified for comparison. A multidisciplinary team developed and implemented a standardized voiding protocol using quality improvement methodology. We compared the demographics, time to first void, rate of urinary retention, and UTI rates between the pre- and post-intervention cohorts. RESULTS: Our intervention led to a significant reduction in the time to first void (289 min vs. 566 min; P < 0.001), rate of urinary retention (2% vs. 10%; P = 0.015), and postoperative UTI (4% vs. 8%; P = 0.249). There was a similar rate of patients going home with a Foley catheter (9% vs. 11%; P = 0.850). CONCLUSIONS: Implementation of a standardized voiding protocol was associated with a reduction in rate of UTI, time to first void, and overnight stays secondary to urinary retention.

Bladder management in individuals with spinal cord injury or disease during and after primary rehabilitation: a retrospective cohort study.

PURPOSE: The purpose of this study was to investigate the course of bladder evacuation and the predictors of intermittent self-catheterization (ISC) in individuals with neurogenic lower urinary tract dysfunction (NLUTD) during and after primary rehabilitation. METHODS: The patient database of a single spinal cord injury rehabilitation center was screened for patients with NLUTD admitted for primary rehabilitation. Patient characteristics and bladder evacuation details were collected during and after rehabilitation. Binary logistic regression analysis was used to evaluate predictors of ISC: sex, age > 65 years, injury severity, and bladder capacity ≥ 400 ml. RESULTS: Data of 255 men (74.3%) and 88 women (25.7%) with a mean age of 54 ± 19 years were analyzed. Early in rehabilitation, 21.6% of the evaluated individuals used ISC. In 17.8%, the bladder was evacuated by transurethral catheterization (TUC). The proportion of TUC decreased during rehabilitation and dropped below 2% at the last follow-up. In contrast, the proportion of ISC and suprapubic catheterization (SPC) increased to 28% and 12.8%, respectively, during rehabilitation. These proportions increased further thereafter and reached 37.7% and 18.6% for ISC and SPC, respectively. Age and injury severity were significant (p ≤ 0.041) negative predictors, whereas male sex and above-average bladder capacity were positive predictors of ISC. CONCLUSIONS: There is a shift toward bladder evacuation by ISC and SPC during and after primary rehabilitation. Bladder evacuation by ISC, regarded as the gold standard, is less common in individuals > 65 years or with high-level tetraplegia. The optimal bladder evacuation method needs to be established individually, considering all medical and psychosocial factors rather than simply following a guideline.

Suprapubic catheterisation: a study of 1000 elective procedures.

OBJECTIVES: To investigate the risks and long-term outcomes of suprapubic catheter (SPC) insertion in a population predominantly with spinal cord injury. MATERIALS AND METHODS: We used the theatre database at the National Spinal Injuries Centre in Stoke Mandeville Hospital to identify 1000 consecutive SPC insertions from 1998 to 2015. We retrospectively analysed all records for these patients. RESULTS: Follow-up ranged from 4 weeks to 16.45 years (median 3.3 years). Either cystoscopy-guided suprapubic puncture (Lawrence Add-a-Cath trochar) or a direct incision onto a urethral sound (Lowsley retractor) followed by cystoscopy was used for 98% of insertions. Complications graded as Clavien-Dindo IIIb or higher occurred in 0.6% of patients. Return to theatre was necessary in 0.4%, including three laparotomies due to bleeding or misplacement of the catheter, but no bowel injuries occurred. One death occurred within 30 days due to pulmonary embolism. There were no significant differences in outcomes between insertion methods. Tolerance of long-term suprapubic catheterisation was high, despite 59% of cases experiencing mostly minor complications. Tract losses during routine community change and variability in antibiotic prescribing highlighted areas for educational development which could improve patient outcomes. CONCLUSIONS: This study supports the view that the risk of major complications from SPC insertion is lower than previously reported. Minor complications related to the catheter are common in the long term but are generally well tolerated.

Mode of Anesthesia and Bladder Management Following Orthopaedic Surgery in Children With Cerebral Palsy: A System Level Analysis.

BACKGROUND: Postoperative urinary retention (POUR) is a surgical complication more prevalent in children with neurodisability and associated with an increase length of hospitalization. Risk factors include pre-existing bladder dysfunction, type and duration of surgery, anesthesia medications, postoperative opioid pain management, and patient demographics. The purpose of this investigation was (1) to determine the frequency of POUR following hip/lower limb orthopaedic procedures in which epidural analgesia was used for pain management; (2) to explore factors influencing postoperative bladder management. METHODS: A retrospective analysis of clinical data was performed in an orthopaedic specialty care health care system. A health outcomes network was queried for patients with a diagnoses of cerebral palsy (ICD-9/10 codes) who had one of 57 unique CPT procedure codes corresponding to hip osteotomies or tenotomies from 2011 to 2019. All surgical observations included in analysis required a discrete data element and the confirmation of a secondary proxy. The database was also queried for postoperative medications received and patient demographics of interest. RESULTS: A total of 704 surgical procedures met inclusion criteria resulting in a patient population with a mean age of 11 years, 58% male, 53% Caucasian, and 55% classified as quadriplegia [51% Gross Motor Function Classification System (GMFCS) levels IV/V]. Three hundred and thirty-five procedures (48%) involved epidural anesthesia. Sixty-five patients required intermittent catheterization (9.2%) postoperatively following foley catheter removal, of which 23 (3.3%) required recatheterization. The rate of recatheterization was similar regardless of anesthesia mode; 1.8% for general and 1.4% for epidural and was associated with a greater number of pain medications. Epidural anesthesia resulted in significantly longer periods of catheterization. For the total group the time to urinary catheter removal differed significantly among cerebral palsy subtypes, GMFCS Level, race, and ethnicity. Factors identified as significant predictors of the length of catheterization were epidural analgesia, number of pain medications, and osteotomy. CONCLUSIONS: The number of postoperative pain medications utilized was more predictive of POUR than the mode of analgesia delivery; however, epidural analgesia and the type of surgical procedure did significantly impact the length of catheterization. LEVEL OF EVIDENCE: Level III.