Managing Neurogenic Bladder with a Suprapubic Catheter vs Urethral Foley – Which is Best?

To systematically compare the impact of catheter-based bladder drainage methods on the rate of urinary tract infections (UTIs) amongst patients with neurogenic bladder. A search of Cochrane Library, Embase, Medline, and Grey literature to February 2019 was performed using methods prepublished on PROSPERO. Reporting followed the Preferred Reporting Items for Systematic Review and Meta-analysis guidelines. Eligible studies were published in English and compared UTI incidence between neurogenic bladder patients utilizing bladder drainage methods of the indwelling urethral catheter (IUC), suprapubic catheter (SPC) or intermittent self-catheterization (ISC). The odds ratio of UTI was the sole outcome of interest. Eight nonrandomized observational cohort studies were identified, totaling 2321 patients who utilized either IUC, SPC, or ISC. Studies enrolled patients with neurogenic bladder due to spinal cord injury (seven studies) or from any cause (one study). UTI rates were compared between patients utilizing IUC vs SPC (four studies), IUC vs ISC (six studies), and SPC vs ISC (four studies). Compared with IUC, five of six studies suggested ISC use was associated with lower rates of UTI. Studies comparing IUC vs SPC and SPC vs ISC gave mixed results. Meta-analysis was not appropriate due to study methodology heterogeneity. Low-level evidence suggests amongst patients with neurogenic bladder requiring catheter-based drainage, the use of ISC is associated with lower rates of UTI than IUC. Comparisons of IUC vs SPC and SPC vs ISC gave mixed results. Future randomized trials are required to confirm these findings.

MP74-14 SUPRAPUBIC CATHETER DRAINAGE FOR THE LONG-TERM MANAGEMENT OF LOWER URINARY TRACT DYSFUNCTION: LONGITUDINAL OUTCOMES AND UTILIZATION PATTERNS FROM A TERTIARY CARE PRACTICE

BackgroundIt is unknown if suprapubic catheters (SCs) offer benefit over indwelling urethral catheters (IUCs) in incidence of asymptomatic bacteriuria and catheter-associated infection (CAUTI), or subsequent antibiotic exposure.MethodsWe conducted a retrospective cohort study of unique patients with SCs placed at VA Pittsburgh Healthcare System from February 2015 to March 2018, who had a prior IUC (≥30 days for each). Demographic, laboratory, microbiologic, and antibiotic use data were compared over the same number of days between IUC and SC periods. IDSA Guidelines were used to define CAUTI and asymptomatic bacteriuria.ResultsEighteen patients with SC were included. SCs were in place for a median of 213 days (range: 49–1,085). The indications for catheterization were urinary retention (n = 12), neurogenic bladder (n = 5), and decubitus healing (n = 1). The most common underlying conditions were benign prostatic hyperplasia (n = 9), multiple sclerosis (n = 2), and Parkinson’s disease (n = 2). The median number of urine cultures collected per 100 IUC and 100 SC days were 2.28 (range: 0–4.08) and 0.35 (range: 0–5.85), respectively (P = 0.02). Forty-four percent (8/18) and 39% (7/18) received at least one antibiotic course for asymptomatic bacteriuria during IUC and SC periods. A total of 170 days of antibiotic therapy were given for asymptomatic bacteriuria per 4,881 IUC days vs. 107 days for asymptomatic bacteriuria per 4,881 SC days (P = 0.0001). The median rate of CAUTI was 0.25 per 100 IUC days vs. 0.08 per 100 SC days (P = 0.15). The most common pathogens causing CAUTIs were Pseudomonas aeruginosa (n = 5), Candida albicans (n = 2), Klebsiella pneumoniae (n = 1) and Enterococcus faecalis (n = 1). A total of 163 days of antibiotic therapy were given for CAUTI per 4,881 IUC days vs. 38 days of antibiotic therapy for CAUTI per 4,881 SC days (P < 0.0001).ConclusionSCs were associated with significantly less overall antibiotic exposure than IUCs, both as treatment of CAUTIs and as inappropriate agents against asymptomatic bacteriuria. CAUTI rates were similar among patients with SCs and IUCs, although cultures were performed more often in those with IUCs. Reducing the treatment of asymptomatic bacteriuria remains a leading stewardship challenge.Disclosures All authors: No reported disclosures.

Virtually every person with a spinal cord injury (SCI) suffers from a neurogenic lower urinary tract dysfunction (NLUTD). In the long term, about 15% of persons with SCI depend on indwelling (suprapubic or transurethral) catheters for bladder management. About 50% of these patients suffer from catheter encrustation and blockage, which may become a vital threat for persons with SCI, as it can lead to septicemia or autonomic dysreflexia. Until today, no prophylaxis of catheter encrustations with an evidence-based proof of efficacy exists. The homeopathic remedy Hydrastis, made from the goldenseal root, is used for the treatment of thick, mucous urine sediment. In four patients with tetraplegia (three female, one male) who managed NLUTD by suprapubic catheters, recurrent encrustations and catheter blockage occurred despite irrigation and medical treatment. Surgical urinary diversion was envisioned. Applying Hydrastis C30 once weekly as a long-term medication, in three of the four patients, catheter obstructions ceased, with a follow-up for at least 1 year. One patient is awaiting ileal conduit surgery. According to the results of our case series, the application of Hydrastis seems to be beneficial in the prevention of encrustations of indwelling catheters in patients with SCI. As the treatment was effective and well tolerated, the problem is frequent, and effective solutions are scarce, a prospective trial seems justified.

MP80-16 QUALITY OF LIFE IN NEUROGENIC BLADDER PATIENTS AFTER SUPRAPUBIC TUBE PLACEMENT

In a small subset of patients with neurogenic lower urinary tract dysfunction, insertion of suprapubic catheters (SPC) cannot be avoided. If SPC has to be utilized, catheter clamping and anticholinergic medication are often recommended, but evidence supporting this view is scarce. We determined the influence of anticholinergic medication and catheter clamping on urodynamic parameters and the status of the urinary tract in patients with chronic suprapubic catheterization. In a retrospective study, the results of urodynamic testing, sonographic evaluations, and urinalyses of 85 patients with chronic (>1 year) suprapubic catheterization due to neurogenic bladder dysfunction were analyzed. The 51 male and 34 female patients (mean age 55 years) were managed with an SPC for 65.3 ± 48.0 months. Forty patients had an SPC for more than 60 months. Comparing the results before SPC insertion with the last follow-up examination, no significant differences in detrusor compliance and maximum detrusor pressure were detected, whereas bladder capacity significantly decreased. In three patients, alterations of the upper urinary tract were found. The results were not significantly different between the patients using anticholinergic medication and/or catheter clamping and those who did not. According to our study, routine use of anticholinergic medication and clamping of catheter does not seem to be necessary to preserve detrusor compliance and renal function in patients with SPC and neurogenic bladder dysfunction.

72 URETHRAL VERSUS SUPRAPUBIC CATHETER FOR PATIENTS WITH SPINAL CORD INJURY-INDUCED NEUROGENIC BLADDER: A STUDY USING THE ELEVEN-YEAR NATIONWIDE DATABASE OF TAIWAN

Spinal cord injury (SCI) may lead to urinary system disturbances. Patients with SCI usually have neurogenic bladder, and treatment optionss for this condition include clean intermittent catheterization and a permanent indwelling urethral or suprapubic catheter. Complications of catheterization include urinary tract infection, calculi, urinary tract injury, bladder contraction, bladder spasm, renal dysfunction, bladder cancer, and so forth. To the best of our knowledge, ureteral rupture is an unusual complication of catheterization, and ureteral rupture has been rarely reported in SCI patients. Therefore, here we report a case of ureteral rupture caused by a suprapubic catheter used for the treatment of neurogenic bladder with vesicoureteral reflux in a male patient with SCI. Due to SCI with neurogenic bladder, ureteral size can be reduced and the suprapubic catheter tip can easily migrate to the distal ureteral orifice. Thus, careful attention is required when a catheter is inserted into the bladder in patients with SCI.

Twenty-four patients, with various combinations of non-healing decubitus ulcers, urethral fistulae, incontinence, and penile skin breakdown were candidates for proximal urinary diversion, having failed intermittent, external, and indwelling catheterization combined with pharmacologic therapy. Seventeen patients underwent bladder neck closure, including seven with multiple sclerosis and ten with spinal cord injury, and because they were unable or unwilling to do catheterization, had their urine diverted by suprapubic catheter. Seven patients, including four with spinal cord injury, underwent bladder neck closure and continent augmentation with formation of a catheterizable cutaneous stoma on the anterior abdominal wall, using right colon and right colon/ileum configurations. When ureteral reflux and obstruction are absent, the patient's bladder was used which spared the added risk of ureteral implantation and possible ureteral stricture while increasing total bladder capacity. In a select group of patients with intractable incontinence, perineal and penile skin breakdown, or urethral fistulae, bladder neck closure and urinary diversion by suprapubic catheter or continent augmentation has proven to be a reliable and effective alternative to an ileal conduit.

MP46-09 RISK OF URINARY TRACT INFECTION AFTER INTRADETRUSOR BOTULINUM TOXIN A INJECTION IN CATHETER-DEPENDENT PATIENTS WITH NEUROGENIC BLADDER WITH ASYMPTOMATIC BACTERIURIA

The objective of this study was, to prospectively and retro respectively evaluate urethral catheterization (UC) versus supra-pubic cystostomy (SPC) in prevention of urinary tract infection (UTI) in patients with spinal cord injury lesion. A total of 125 patients with neurogenic bladder and a mean age of 30 years had UC (n=80) and SPC (n=40) at the Jos University Teaching Hospital (JUTH) between January 1984 and June 2005. Episodes of UTI were significantly more; UC 65% versus 14% forS PC (P< O 0 5). Urinary tract infection occurred relatively late in the course of admission, in patient who had SPC. Patients in SPC group were significantly satisfied with this management option; 57% versus 8% for UC. Similarly, mortality at 1 year post admission was significantly less; 9% versus 36% for UC and death due to UTI related septicaemia was 33% versus 18% respectively. It was concluded that SPC was a better management option since it was associated with a low morbidity, better quality of life and a longer life expectancy than UC.

To evaluate quality of life in patients with neurogenic bladder (NGB) conditions who have elected to undergo suprapubic catheterization (SPC), as well as assess adverse events (AEs) related to the procedure. This is a retrospective review from a database of NGB patients from 1/1/2003 to 6/30/2013. Patients who underwent SPC placement were invited to complete a validated, single item Patient Global Impression of Improvement (PGI-I) questionnaire. Success or positive response was defined as 1 or 2 on a scale of 1-7. All patients were included in the assessment of AEs. Of the 128 patients who underwent SPC, 89 patients (54 female, 35 male) met inclusion criteria. Response rate to the PGI-I questionnaire was 65.2% (58/89). Mean age at the time of SPC placement was 54.4 years (± 14.4). The mean time from SPC placement to PGI-I questionnaire was 48.3 months (Range 4.4-128.4). Overall, success was seen in 49/58 patients (84.5%). Only 5.2% (3/58) patients reported a negative PGI-I (score 5/7). There was an 18.8% rate of short term complications, with the majority of these being classified as Clavien I. There was one Clavien IIIb complication (0.8%), which consisted of a small bowel perforation. SPC is an effective bladder management in carefully selected NGB patients who have failed other options. Over 80% considered the SPC to have improved their urological quality of life with a mean time to questionnaire of 4 years. Severe AEs are rare, though can be particularly serious in this group of neurologically impaired patients. Neurourol. Urodynam. 35:831-835, 2016. © 2015 Wiley Periodicals, Inc.

Management of the neurogenic bladder has the primary objectives of maintaining continence, ensuring low bladder pressure (to avoid renal damage) and avoiding or minimising infection. Options include intermittent urethral catheterisation, indwelling urethral or suprapubic catheterisation, timed voiding, use of external catheter (for men), drug treatment, augmentation cystoplasty and urinary diversion. The primary objective was to determine the effects of different methods of managing long-term voiding problems (persisting after three months) with catheters in patients with neurogenic bladder.Specific hypotheses to be addressed included:1. that intermittent catheterisation is better than indwelling catheterisation;2. that indwelling urethral catheterisation is better than suprapubic catheterisation;3. that external (sheath) catheters are better than indwelling or intermittent urethral catheters;4. that external (sheath) catheters are better than suprapubic catheters;5. that intermittent catheterisation is better than timed voiding. We searched the Cochrane Incontinence Group Specialised Register (searched 3 July 2013), which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and MEDLINE in process, and handsearched journals and conference proceedings. We sought additional trials from other sources such as the reference lists of relevant articles and by contacting consultants in Spinal Cord Injury Centres throughout the United Kingdom. All randomised and quasi-randomised controlled trials comparing methods of using catheters to manage urinary voiding in people with neurogenic bladder. Abstracts were independently inspected by the reviewers and full papers were obtained where necessary. Approximately 400 studies were scrutinised. No trials were found that met the inclusion criteria, and five studies were excluded from the review. Despite a comprehensive search no evidence from randomised or quasi-randomised controlled trials was found. It was not possible to draw any conclusions regarding the use of different types of catheter in managing the neurogenic bladder.

Suprapubic Cystostomy for Neurogenic Bladder Using Lowsley Retractor Method: A Procedure Revisited

To study the outcome of different bladder management strategies in patients with neoplastic spinal cord compression. 22 patients with neoplastic spinal cord compression underwent urodynamic examination. According to the urodynamic data and the underlying disease different bladder management strategies were recommended. In patients with curatively treated disease a full bladder rehabilitation program was arranged. In patients with metastatic malignant disease, voluntary voiding was continued if possible or a suprapubic catheter was placed. Eight patients were treated with curative intention. Of those, 2 patients were able to void during urodynamics continued normal voluntary voiding. Six patients were taught intermittent catheterisation, with three additionally received oral anticholinergic treatment because of UMN lesion. At follow-up, all patients had successfully finished bladder rehabilitation program and at follow up, all patients were continuing their previously recommended bladder rehabilitation program. Fourteen patients had malignant disease and were treated palliatively. In 2 patients with UMN lesion, voluntary control of micturition was maintained and both continued voluntary voiding. In 12 patients a suprapubic catheter was inserted. At follow-up, 9 out of 14 had died (mean 8 month after primary visit), the remaining 5 continued treatment with suprapubic catheters. Underlying disease and life expectancy should be considered for the selection of bladder management in patients with neoplastic spinal cord compression. In patients with curatively treated disease, a full bladder rehabilitation program is recommended while in patients with malignant disease and palliative care, a suprapubic catheter might be the treatment of choice.