Long-term Urinary Tract Research Articles

Patients’ experiences of learning clean intermittent self‐catheterization: a qualitative study

This paper is a report of a study to explore the experiences of learning to carry out clean intermittent self-catheterization and user views of service provision. This treatment imposes a variety of challenges to users, both physical and emotional. Safety, infection rates and complications have been investigated, but the practicalities of learning and performing self-catheterization have not been addressed. What is currently known about the topic from a user perspective is based on audit, small projects or anecdotal reports provided by continence advisers. In-depth interviews were carried out in 2006 with eight men and seven women, aged 33-81 years (median 65), and carrying out self-catheterization for a variety of reasons. A grounded theory framework was used. Themes identified were psychological issues, physical problems and service interaction. The communication skills of nurses helped facilitate the learning experience. In conjunction with nurses' skills, a friendly relaxed approach alleviated embarrassment and anxiety, thus facilitating information exchange and retention of information. Adequate information and thorough instruction by healthcare professionals helps empower people to take control and master the treatment, with potential contribution to ongoing compliance and long-term urinary tract health. Development of a policy supporting evidence-based care and a consistent teaching programme is highly recommended for use where this treatment is regularly employed.

Long‐term results of tension‐free vaginal tape for female urinary incontinence: Follow up over 6 years

To describe the long-term outcome of using tension-free vaginal tape (TVT) with and without associated procedures. A questionnaire was mailed to a population of 61 women who had undergone TVT surgery more than 6 years ago. Of this population, 41 (80%) had suffered from stress urinary incontinence (SUI). The questionnaire included questions about urinary symptoms, satisfaction and quality of life. The questionnaire was answered by 51 of the 61 women. Mean follow up was 83 months. The women with SUI had a persistent cure rate of 80% with a satisfaction rate of 97%. The cure rate after 6 years was 37% in women with mixed incontinence. Concomitant hysterectomy (relative risks = 0.87) and body mass index (BMI) do not alter the long-term results of TVT procedure. Peroperative bladder injury is not associated with an increased risk of long-term lower urinary tract symptoms (LUTS) or with a decreased satisfaction rate (relative risks = 0.85). Concomitant hysterectomy, increased BMI and bladder injury do not alter good long-term results of TVT.

Long-term results of standard procedures in urology: the ileal neobladder

Over the past 20 years orthotopic urinary reconstruction with the techniques developed at Ulm and Bern has become a widely accepted form of urinary diversion. So far, both centers together have performed more than 1,300 orthotopic bladder substitutions with an overall rate of neobladder formation in 58% of all cystectomized patients. Today, the absolute contraindications for this procedure are urinary stress incontinence, damaged rhabdosphincter, severely impaired renal and liver function, severe intestinal diseases or an oncologic situation requiring urethrectomy. In patients treated for transitional cell carcinoma of the bladder, the rate of urethral recurrence in both centers was 1.5 and 5%, respectively, and the rate of upper urinary tract recurrence was 2-3%. Local tumor recurrence usually did not affect neobladder function. The rate of outlet obstruction by local recurrence was 2%, that of gross hematuria 1%, and of entero-reservoir fistulas 1-2%. Daytime continence at 12 months was 92%, while nighttime continence was lower around 80%. Transient or permanent urinary retention was seen in 11-12% of male patients. In both series, long-term upper urinary tract safety was good. The risk of stenoses of the uretero-intestinal anastomosis with consecutive loss of renal function decreased with the introduction of non-refluxing implantation techniques. The rate of long-term metabolic complications remains low when adequate substitution with sodium bicarbonate is guaranteed in patients with impaired renal function. Patient selection and meticulous postoperative follow-up contributed to achieve good long-term results after cystectomy and orthotopic ileal neobladder substitution of the two large series of patients from the Universities of Ulm and Bern.

NERVE SPARING EXTRAVESICAL REPAIR OF BILATERAL VESICOURETERAL REFLUX: DESCRIPTION OF TECHNIQUE AND EVALUATION OF URINARY RETENTION

Prolonged urinary retention remains a controversial and feared complication following bilateral extravesical ureteral reimplantation. We report a modified approach to limit detrusor nerve damage during extravesical correction of bilateral ureteral reflux that significantly reduces this adverse outcome. A modified approach to the distal detrusor dissection and ureteral mobilization, along with limited periureteral dissection, was used to perform this technique. A retrospective review of 50 patients undergoing bilateral nerve sparing extravesical ureteral reimplantation (NSEVR) by a single surgeon between 1997 and 2002 was completed. Patient age, vesicoureteral reflux (VUR) grade, length of hospital stay, length of surgery and outcome were evaluated. The study included 36 girls and 14 boys, with an average age of 4 years 11 months (range 1 to 14 years). Average preoperative VUR grade was 2.61 (range 1 to 5). Average length of surgery when NSEVR was the only procedure performed was 105 minutes (range 54 to 185) and average length of hospital stay was 1.76 days (0 to 3). Transient urinary retention developed in 1 child on postoperative day 1, with a successful trial of voiding the next day. The rate of immediate urinary retention was 2%. There was no long-term urinary retention, voiding dysfunction or urinary tract infections. NSEVR for the correction of bilateral VUR is a simple modification that provides a reproducible and minimally invasive approach to treatment. We believe that limited distal ureteral dissection, preservation of the medial ureterovesical hiatus and judicious manipulation of the surrounding tissues result in elimination of long-term urinary retention.

Ileal orthotopic bladder substitute combined with an afferent tubular segment: long-term upper urinary tract changes and voiding pattern.

Assessment of the long-term morbidity of the upper urinary tract and of the voiding pattern in men with an ileal orthotopic bladder substitute with an afferent tubular segment. Men surviving more than 5 years after radical cystectomy and orthotopic bladder substitution were evaluated. The urinary tract was regularly assessed with ultrasound and IVU while functional reservoir capacity and continence status were prospectively assessed by voiding volume diaries and a standardized questionnaire. After 5 years 129, after 10 years 45 and after 15 years 8 patients were evaluable. Median age at surgery was 63 years (range 36-80) and median follow-up was 73 months (range 60-201). Of the 254 renal units assessed between April 1985 and September 1998, 199 (78%) had some degree of dilatation in the 20-minute IVU film but rarely at 60 minutes. In 246 (97%) the parenchyma size was normal. Ureteral obstruction presented in 9 (3.5%) units, 4 of which were complete (3 had obstruction preoperatively and 1 postoperatively). Mean creatinine levels remained unchanged from the preoperative values. Functional reservoir capacity averaged 462 ml after 1 year, remained stable and then decreased slightly after 5 years. The daytime continence rate was 94% and 91% after 5 and 10 years, while the nighttime rate was 72% and 60% respectively. Patient age at the time of surgery was an important determinant for reservoir capacity and continence status. These data suggest that an orthotopic bladder substitution combined with an afferent tubular segment offers a sufficient protection of the upper tract with a low complication rate and has good long-term voiding and continence results. Meticulous lifelong follow-up is an important factor for satisfactory functional long-term outcome.

589 Ileal orthotopic bladder substitute combined with an afferent tubular segment: Long-term upper urinary tract changes and voiding pattern

589 Ileal orthotopic bladder substitute combined with an afferent tubular segment: Long-term upper urinary tract changes and voiding pattern

Partial unilateral ureteral obstruction in rats.

This review comprises an overview of the current knowledge on experimental partial unilateral ureteral obstruction (PUUO) and a summary of our latest original experimental PUUO studies in rats. Neonatal PUUO is the type of obstruction that is most often encountered in pediatric clinical practice. However, the pathogenesis of PUUO is still incompletely understood. Most of our knowledge on PUUO has been derived from experimental studies in a variety of animal models. Although progress has been made, the natural history of congenital hydronephrosis is still incompletely described. The effects on kidney functions of long-term urinary tract obstruction, especially PUUO, have been less intensively studied. Recently, we created models with mild and severe PUUO in young rats by embedding the upper one fourth or the upper two thirds of the left ureter into the psoas muscle, respectively. Thereafter, the technique was used to create mild and severe PUUO in newborn rats and magnetic resonance imaging studies showed that both mild and severe obstruction caused a time-dependent decrease in renal blood flow. Compensatory increase in total kidney volume and renal vein blood flow in contralateral non-obstructed kidneys was not detectable when functional deterioration in the partially obstructed kidneys was present. Finally, we investigated the dynamic changes in renal relative signal intensity (RSI) of gadolinium-diethylenetriamine pentaacetic acid (Gd-DTPA) using magnetic resonance imaging in rats with partial, complete unilateral ureteral obstruction and sham-operated controls. The results showed that changes in Gd-DTPA RSI are compatible with the known physiological and anatomical changes in kidneys in response to ureteral obstruction and useful for distinguishing an obstructed from a non-obstructed collecting system and also for differentiating a partially obstructed from a completely obstructed collecting system.

Development of a long-term ascending urinary tract infection mouse model for antibiotic treatment studies.

A model of ascending unobstructed urinary tract infection (UTI) in mice was developed to study the significance of the antibiotic concentration in urine, serum, and kidney tissue for efficacy of treatment of UTI in general and pyelonephritis in particular. Outbred Ssc-CF1 female mice were used throughout the study, and Escherichia coli was used as the pathogen. The virulence of 11 uropathogenic E. coli isolates and 1 nonpathogenic laboratory E. coli strain was examined. Strain C175-94 achieved the highest counts in the kidneys, and this strain was subsequently used as the infecting organism. The model gave reproducible bladder infections, i.e., bacteria were recovered from 22 of 23 control mice after 3 days, and histological examination of kidney tissue showed that of 14 infected kidneys, 7 (50%) showed major histological changes, whereas 3 of 36 uninfected kidneys showed major histological changes (P = 0.018). Once the model was established, the efficacies of different doses of cefuroxime and gentamicin, corresponding to active concentrations in urine only or in urine, serum, and kidney tissue simultaneously, were examined. All cefuroxime doses resulted in significantly lower counts in urine than control treatments, but the dose which produced concentrations of cefuroxime only in urine and not in serum or kidney tissue had no effect on kidney infection. Even low doses of gentamicin (0.05 mg/mouse) resulted in concentrations in renal tissue for prolonged times due to accumulation. All gentamicin doses had a significant effect (compared to the effect of the control treatment) on bacterial counts in urine and kidneys. The antibiotic effect on bacterial counts in bladders was negligible for unknown reasons. Use of the mouse UTI model is feasible for study of the effect of an antibiotic in the urinary system, although the missing antibacterial effect in the bladder needs further evaluation.

LONG-TERM OUTCOME OF INCONTINENT ILEOVESICOSTOMY MANAGEMENT OF SEVERE LOWER URINARY TRACT DYSFUNCTION

Purpose We evaluated the extended 5-year followup outcome of incontinent ileovesicostomy. Materials and Methods We reviewed the charts of 25 men and 13 women with a mean age of 44.9 years who underwent incontinent ileovesicostomy, including the original 23 patients whom we reported on in 1993. Mean followup was 52 months. We compared the incidence of complications before and after ileovesicostomy as well as long-term urinary tract status. Results Before ileovesicostomy the incidence of serious complications associated with an indwelling catheter was significant, including poor bladder compliance in 50% of cases, urosepsis in 45%, hydronephrosis in 21%, renal struvite calculi in 18%, urethrocutaneous fistula in 18%, autonomic dysreflexia in 13% and bladder calculi in 2%. After conversion to ileovesicostomy our data show that 83 to 91% of this high risk population maintained a normal upper urinary tract and normal bladder storage compliance. Conclusions Compared with preoperative status the incidence of postoperative complications was relatively low and they were readily corrected. Ileovesicostomy is an excellent long-term management solution for severe lower urinary tract dysfunction in patients who are unable to perform intermittent self-catheterization.

Psychological Predictors of Symptoms of Urinary Tract Infection and Bacteriuria in Patients Treated with Clean Intermittent Catheterization: A Prospective 7-Year Study

Objective: One of the major clinical problems in relation to clean intermittent catheterization (CIC) are symptoms of urinary tract infection (UTI) and bacteriuria. The aim of the present work was to study to what extent measures of psychological well-being, distress and neurotic personality traits in patients performing CIC could predict symptoms of UTI or bacteriuria 7 years later. Patients and Methods: Included in the study were 170 patients with a mean age of 57 years, who had used CIC for 105 months. CIC was practised due to neurogenic bladder dysfunction in two thirds of the patients, and non-neurogenic dysfunction in the remaining patients. All patients had been clinically examined 7 years prior to inclusion. Information about subjective symptoms of UTI and examination of bacteriuria in urine samples had been assessed. All subjects had also undergone repeated psychometric evaluations of psychosocial function, well-being and distress (General Health Questionnaire; GHQ-28; Spielberger State-Trait Anxiety Inventory; STAI X-1) and neuroticism (Eysenck Personality Questionnaire; EPQ-N). The results from selected assessments done 7 years earlier were used to predict reported UTI and findings of bacteriuria in urine samples in 1995. Results: Clinical UTI symptoms were reported by 35% of the patients. These patients had significantly higher GHQ-28 scores in 1988, 1989 and 1995 compared to the remaining 65%. Patients without clinical UTI during 1988/89, but with symptoms suggesting UTI in 1995, had significantly higher GHQ-28, STAI-X1 and EPQ-N scores in 1988 compared to those who did not report symptoms 7 years later. Patients with UTI during 1988/89 who were free of symptoms of UTI in 1995 had scores similar to those who were free of symptoms of UTI both in 1988/89 and in 1995. GHQ-28, STAI X-1 and EPQ-N scores in 1988/89 did not predict current bacteriuria, found in 62% of the urine samples in 1995. Conclusion: Social function, well-being and distress are significant predictors of long-term urinary tract complaints, but not of bacteriuria. This finding indicates that the aetiology of UTI complaints and of actual bacteriuria is different. Complaints of UTI may often express distress and not symptomatic infection. Physicians’ non-recognition of distress may lead to unnecessary and aggressive interventions for assumed infection such as the prescription of antibiotics. Identification and treatment of psychological distress and impaired social function should become routine in the clinical follow-up of CIC patients. Such a routine could reduce urinary tract complaints, lower the unnecessary use of antibiotics and increase the tolerability of CIC. Prospective intervention studies are needed to verify this hypothesis.

Colonization of Urinary Catheters by Escherichia Coli and Providencia Stuartii in a Laboratory Model System

A laboratory model system was developed to investigate the progressive colonization of urinary catheters by Escherichia coli and Providencia stuartii, prominent organisms in the polymicrobial bacteriuria of the long-term catheterized urinary tract. We hypothesized that colonization of the catheter and artificial urine by E. coli is influenced by the presence of P. stuartii. E. coli or P. stuartii in pure culture both rapidly colonized the artificial urine and catheters, and both persisted throughout all experiments. In systems containing both organisms, P. stuartii occurred in significantly higher numbers in the artificial urine and on the catheters than E. coli (p <0.05). To obtain similar numbers of E. coli and P. stuartii in the artificial urine, citrate was eliminated; however, P. stuartii still dominated on the catheter surfaces. The presence of P. stuartii appeared to facilitate growth of E. coli in the artificial urine, yet reduce numbers of E. coli on the catheter. In a separate experiment using different strains of E. coli and P. stuartii, the latter was dominant in the artificial urine and on the catheter surfaces. However, this strain of P. stuartii (which was urease positive) did not facilitate growth of E. coli. The interaction between these strains may have been considerably affected by urea hydrolysis, which resulted in an increase in pH (6.5 to >8.5) and considerable precipitate formation in the model system. The paradox of P. stuartii enhancing colonization by E. coli in the artificial urine, yet inhibiting its colonization on the catheter surface, illustrates the complexity of polymicrobial interactions in colonization of the catheterized urinary tract.

Long-term Urinary Tract Catheterization

As the nursing home population expands, the number of patients exposed to the risks of chronic indwelling urinary catheters will increase. The physician must therefore be familiar with the characteristic findings in such patients and be able to recognize complications as they arise. Mechanical or local problems, such as asymptomatic bacteriuria, catheter blockage, nondeflatable balloon, and chronic cystitis, are very common. Further studies are needed to define optimum measures to control these problems. The clinician must be aware that pyuria and bacteriuria are universal and not helpful in diagnosis of infection in this population. Use of chronic antibiotics is not recommended and there is no evidence to support elaborate daily care regimens, such as antibiotic ointments or irrigations. Careful consideration of the indications for catheter use on a long-term basis may reduce the population at risk. Physician awareness of the possibility of life-threatening complications, such as squamous cell carcinoma, bacteremia, and bladder perforation, can help avoid serious consequences of the use of urinary drainage devices.

Bladder Irrigation or Irritation?

Exfoliation rates of urothelial cells following bladder irrigation were studied in patients with long-term indwelling catheters and chronic urinary tract infections (UTI). The irrigations were associated with an increased shedding of urothelial cells. Ultrastructural studies of these cells demonstrated increased disruption when compared with those obtained from normal subjects without catheters or chronic infection. The findings suggest that bladder irrigation further damages the already disrupted urothelium, which may in turn increase the predisposition of the bladder to the recurrent infections, commonly associated with patients who have indwelling urinary catheters. Bladder irrigation methods and the indications for their use require reassessment.

Survey of multiply resistant Providencia stuartii in a chronic care unit

Providencia stuartii was cultured over a 4-year period from the urinary tract, throat, perineum, axilla and stools of patients in a long-term chronic care unit, the most common site of colonization being the urinary tract. A total of 17 patients had Prov. stuartii bacteraemia and manipulation of the urinary tract preceded bacteraemia in 10 cases. Eighty-two per cent of the patients had long-term urinary tract colonization from 1 month to 4 years. Although most isolates were resistant to all aminoglycosides except amikacin, the organisms were all susceptible to thienamycin, ceftazidime, cefotaxime, ceftizoxime and moxalactam.

Adherence to uroepithelial cells of Providencia stuartii isolated from the catheterized urinary tract.

The long-term catheterized urinary tract appears to offer a niche for Providencia stuartii, otherwise an unusual clinical isolate. P. stuartii, the most frequent and persistent isolate from the urine of 51 long-term catheterized patients, was recovered from 761 of 1230 (62%) weekly urine specimens. To test the hypothesis that prevalence of this species may be due to adherence properties of the organism, 20 selected strains from 14 patients at two nursing homes, representing six distinct serotypes and harbouring combinations of nine different plasmid species, were tested for adherence to uroepithelial cells (UEC). Optimal conditions were determined for differentiating strains on the basis of in vitro adherence to UEC. These strains, grown in nutrient broth, were incubated with UEC isolated from the urine of a healthy adult female (10(8) bacteria per 10(5) cells). Washed UEC, retained on 8 micron pore diameter filters, were transferred to slides, fixed and stained; bacteria were counted on each of 40 cells. Fourteen of the 20 strains were defined as adherent to UEC by comparison of mean adherent bacteria and percentage of uroepithelial cells with more than 10 bacteria. Adherence was compared to that of a P-fimbriated strain of Escherichia coli. It was not inhibited by 50 mM-mannose. We conclude that the majority of P. stuartii isolates are adherent to UEC in vitro and suggest that this may play a role in the persistence of this organism in the catheterized urinary tract.

Complications of combined radical hysterectomy and pelvic radiation

Long-term gastrointestinal (GI) and urinary tract (UT) complications were evaluated in 48 women treated by radical hysterectomy (RH) and pelvic node dissection (PND) and in 25 women who received 5000–5400 rad of external pelvic radiation (RT) after RH-PND. No major complications developed in the surgery-only group, but the 5-year minor GI complication rate was 4% and the 5-year minor UT complication rate was 10%. In 9 patients receiving RT at 200 rad/day, one major GI complication (13%) and one major UT complication (14%) developed. In 16 patients receiving RT at 180 rad/day only minor GI complications (7%) and minor UT complications (13%) developed. The conclusion is that after RH-PND, adjunctive RT delivered at 180 rad/day through four ports results in acceptable, minimal complications.

Complications of combined surgery and radiation therapy for carcinoma of the endometrium

Long-term gastrointestinal (GI) and urinary tract (UT) complications were evaluated in 133 women with carcinoma of the endometrium who were treated by both radiotherapy and hysterectomy. Major complications developed in 8% of patients who received external pelvic radiation but in none with intracavitary radiation. GI complications were more frequent and more severe in patients receiving external pelvic radiation than in those who received only intracavitary radiotherapy, irrespective of the sequence of treatment. UT complications were more frequent with prehysterectomy external radiotherapy (N = 39) than with posthysterectomy external radiotherapy (N = 21).

Characterization of Escherichia Coli Strains From Long-term Urinary Tract Infections by Combined Typing Techniques

AbstractWe present examples of patients with long-term urinary tract infections, in whom persistence and reinfection were readily distinguished when their Escherichia coli isolates were typed by biotyping and resistotyping. Even with strains which showed in vivo variation in their typing markers, questions about strain identity were generally answered by these 2 techniques used in combination; supportive data were available from additional techniques.

Radical hysterectomy preceded by pelvic irradiation

A total of 124 patients, who had prior pelvic irradiation, had radical hysterectomy performed at the University of Minnesota Hospitals from 1939 to 1977. The patients fall into two groups: those who had pelvic radiation and radical hysterectomy as primary therapy and those who had radical hysterectomy for postradiation persistent or recurrent cancer of the cervix. A major objective of this report is to describe the incidence, management, and long-term follow-up of patients with complications. Pelvic irradiation followed by radical hysterectomy as primary therapy for cancer of the cervix cannot be justified because of the high risk of urinary tract complications, some of which eventually result in demise of the patient. Radical hysterectomy for postradiation persistent or recurrent cancer is an acceptable procedure for early disease. It would appear from this experience that many patients with small cervical or vaginal postradiation neoplasms can be successfully managed with more conservative procedures such as simple hysterectomy and partial vaginectomy. The value of pelvic lymphadenectomy was not demonstrated. Exenterative procedures are becoming more frequently indicated for eradication of malignancies, with a reduction of long-term urinary tract complications.

Indwelling urinary catheterisation.

SUMMARY One hundred and six patients continuously catheterised after gynocological surgery were followed up after 9 to 15 months. The long-term urinary tract infection rate was low. Prophylactic penicillin and streptomycin were superior to the other chemotherapeutic agents used in preventing infection. Self-infection with vaginal ftora seems an important factor and the presence of urinary pathogens in the vagina seems to carry a higher risk of post-operative urinary infection. There is a gap in correlation at follow-up between clinical and bacteriological fmdings; since the latter are more critical, it is suggested that urine be examined at each follow-up visit of every patient who has had an indwelling catheter.