Urethral Catheter Drainage Research Articles

Imaging Findings Associated With Failure of Conservative Management After Blunt Extraperitoneal Bladder Injury

ObjectivesTo identify risk factors for failure of conservative management (CM) for uncomplicated extraperitoneal bladder injuries (EBI). MethodsThe trauma registry at a single Level 1 trauma center was queried for patients presenting with a blunt EBI between 2004 and 2022. Patients with CM and follow-up through at least one postoperative cystogram or catheter removal were included. A univariable analysis for associations with a composite outcome of either persistent leakage or delayed cystorrhaphy was completed. ResultsEighty-four patients with an EBI underwent CM. Seventy-eight (93%) patients had an associated pelvic fracture and 17 of 84 (20%) underwent embolization for pelvic hemorrhage. Thirty-four (41%) patients also had delayed phase imaging, 17 (20%) of whom had extravasation from their bladder on delays. Six (7%) patients failed initial CM. There was no association between the composite outcome and pelvic fracture (p=0.35) or embolization (p=0.41). American Association for the Surgery of Trauma (AAST) grade 5 injuries (p=0.01) and the presence of extravasation on delayed-phase Computed Tomography (p=0.03) were associated with the composite outcome. ConclusionsContrast extravasation on initial delayed-phase imaging despite urethral catheter drainage and AAST injury grade were associated with failed CM after EBI. This may reflect injuries that mechanistically yield incomplete antegrade drainage with CM.

Laparoscopic Hernia Repair: Tapp Versus Tep. A Single Centre Experience

Summary Surgery for inguinal hernia is currently the most common surgical procedure worldwide, and every year over 20 million patients undergo open or laparoscopic hernia repair. Two generally accepted endoscopic approaches are transabdominal preperitoneal procedure (TAPP) and total extraperitoneal procedure (TEP). For nine years (2010 – 2018), 48 patients with inguinal hernia had laparoscopic hernia repair (TAPP or TEP) at Villarobledo General Hospital. Forty-three patients (89.6%)) were male, and five (10.4%) were female. Of these, ten had right inguinal hernia (RIH), 18 - left inguinal hernia (LIH), 12 - bilateral inguinal hernia (BIH), 6 had recurrent unilateral inguinal hernia (RUIH), and 2 had recurrent bilateral inguinal hernia (RBIH). In 33 patients (68.7%), transabdominal preperitoneal laparoscopic hernia repair (TAPP) was performed. Total extraperitoneal laparoscopic hernia repair (TEP) was performed on 15 patients (12%). In 8 patients (16.6%), simultaneous surgical procedures were performed: umbilical hernioplasty in 4 (8.3%) patients and laparoscopic cholecystectomy in 4 (8.3%) patients. There were no conversions in any of the surgical procedures. The average operative time was 77 minutes. Twenty-six patients underwent one-day surgery, 18 were in the hospital for one day, and four patients were discharged on the second postoperative day following surgery. In 7 patients (14%), recurrences occurred: in the first postoperative year - 1 patient; in the second year after surgery - 3 patients; in the third after surgery - 2 patients; and in the sixth year - 1 patient. The recurrence rate was 2 in 33 patients after TAPP (6%) versus 5 in 15 patients after TEP (33%), Chi-squared=5.91 (p=0.015). In one patient, perforation of the bladder occurred after TEP and was managed conservatively using a urethral catheter and preperitoneal drainage. TAPP and TEP had a considerable discrepancy in recurrence rates. Such discrepancy in recurrences is probably due to the higher complexity of the TEP technique and the required supervising of experienced surgeons during the learning curve.

Retrograde endoscopic-assisted percutaneous treatment of transplanted kidney calyceal fistula

Introduction. Calyceal fistula is a rare complication of a renal transplantation. This complication can lead to postoperative graft failure. The treatment approaches range from a partial nephrectomy to a routine nephrostomy.Objective. To present the successful application of the retrograde endoscopic-assisted percutaneous treatment of transplanted kidney calyceal fistula.Clinical case. A patient after kidney allotransplantation is under our care. Control postoperative ultrasound examination revealed a pararenal fluid mass in the left iliac region. Its percutaneous drainage was performed. Biochemical analysis revealed high levels of creatinine and urea in the drainage discharge. Despite ureteral stent and urethral catheter drainage, about 500 to 600 ml of urine per day was excreted by the drainage. Percutaneous puncture nephrostomy could not be performed due to the absence of dilatation of the renal cavity system. In the lithotomic position, the damaged calyx was identified by performing flexible ureteropyeloscopy. Then we percutaneously targeted the injured calyx and the distal end of the ureteroscope inserted transurethrally, so that the needle tip appeared in the paranephral cavity opposite the injured calyx. Under the control of a flexible ureteroscope the needle was inserted into the kidney pelvis, a nephrostomy tube 12 Ch was placed along the string. The discharge through the drain stopped within a week and it was removed. Follow-up examination nine weeks after surgery revealed that the patient had no complaints and renal ultrasound showed no features, so the nephrostomy tube was removed.Conclusion. The described method is the minimally invasive, affordable, and efficient method for the treatment of transplanted kidney calyceal fistula.

Characteristics of Enterovesical Fistula Patients Visiting the Urology Department of Dr. Hasan Sadikin General Hospital Bandung, Indonesia, from 2015 to 2019

Enterovesical fistula (EVF) represents an abnormal channel between the intestine and the bladder. The EVF is a complication of inflammatory or neoplastic diseases and injuries. Diagnosis of EVF can be challenging and often delayed up to several months after the onset of the symptoms. This study aimed to determine the characteristics of patients with enterovesical fistula visiting Dr. Hasan Sadikin General Hospital Bandung, Indonesia. This retrospective descriptive study used the medical records of EVF patients treated in the urology department of Dr. Hasan Sadikin General Hospital from 2015 to 2019 as the secondary data to be analyzed. A total of 58 patients with EVF were enrolled in this study. By gender, that more than half of the patients were male patients (n=30, 51.7%) and 45% of patients were between 41 and 50 years old. The most common symptoms of EVF were pneumaturia and fecaluria which were seen in 30 (51.7%) and 20 (34.5%) patients, respectively. Twenty-nine (50%) patients experienced malnutrition and 18 (31.1%) patients had diabetes mellitus as a comorbid. The most common type of fistula was rectovesical fistula (n=45, 77.6%) and 26 (66.6%) patients suffered from rectosigmoid cancer and malignancy (68.95) had become the most predominant etiology. Escherichia coli was found in 42 (72.4%) urine cultures collected from the patients and cystoscopy with fistula biopsy was found in 43.1% of cases, followed by fistula repair (29.3%) and urethral catheter drainage (15.5%). Hence, malignancy and rectosigmoid cancer become the most common etiology of EVF while cystoscopy with fistula biopsy is the most frequently performed procedure.

Prolonged Indwelling Urethral Catheterization as Minimally Invasive Approach for Definitive Treatment of Posterior Urethral Valves in Unstable Premature Babies.

Premature newborns with posterior urethral valves (PUV) may present with medical conditions taking priority over definitive surgical care. We encountered three of such cases who underwent initial bladder decompression via transurethral catheterization and waited 2–3 weeks until they were fit enough for voiding cysto-urethrography to confirm PUV. An unexpected good urinary flow and negligible residual urine volume were documented during micturition, suggestive of valve disruption induced by insertion and prolonged duration of indwelling urethral catheter drainage. Cystoscopy documented non-obstructing remnant leaflets. Non-operative treatment may be considered as a viable alternative therapeutic option for PUV in tiny babies facing prolonged intensive care unit stay.

Clinical Case: Successful Use of Repeated Superselective Arterial Embolization in Metastatic Prostate Cancer Complicated by Bleeding

Persistent hematuria, the source of which is a neoplasm of the prostate gland, is a potentially life threatening condition that exacerbates major therapeutic problems. The most common causes of severe hematuria are prostate cancer. Most often, severe recurrent prostatic bleeding occurs with untreated lesions and especially with hormone-refractory form of cancer. In many patients, bleeding cannot be completely controlled by conservative measures, such as routine hemostatic drugs, topical cold, urethral catheter drainage with permanent irrigation with sterile solutions, silver nitrate instillation, or endoscopic diathermy. Currently, the «gold standard» for the treatment of localized prostate cancer is radical prostatectomy. However, radical surgery is not always possible, despite the high efficiency, due to various circumstances, namely: age and due to this factor comorbidities that increase the risk of anesthesia. In this group of patients, it is advisable to use pelvic angiography with embolization, which proved to be a safe and effective method of controlling prostate bleeding. However, the analysis of the results of this technique is based on clinical cases and small, with a limited number of patients, studies. Despite this, selective arterial embolization has become the method of choice when conservative treatments are ineffective.

Traumatic Bladder Ruptures: A Ten-Year Review at a Level 1 Trauma Center.

Bladder rupture occurs in only 1.6% of blunt abdominopelvic trauma cases. Although rare, bladder rupture can result in significant morbidity if undiagnosed or inappropriately managed. AUA Urotrauma Guidelines suggest that urethral catheter drainage is a standard of care for both extraperitoneal and intraperitoneal bladder rupture regardless of the need for surgical repair. However, no specific guidance is given regarding the length of catheterization. The present study seeks to summarize contemporary management of bladder trauma at our tertiary care center, assess the impact of length of catheterization on bladder injuries and complications, and develop a protocol for management of bladder injuries from time of injury to catheter removal. A retrospective review was performed on 34,413 blunt trauma cases to identify traumatic bladder ruptures over the past 10 years (January 2008–January 2018) at our tertiary care facility. Patient data were collected including age, gender, BMI, mechanism of injury, and type of injury. The primary treatment modality (surgical repair vs. catheter drainage only), length of catheterization, and post-injury complications were also assessed. Review of our institutional trauma database identified 44 patients with bladder trauma. Mean age was 41 years, mean BMI was 24.8 kg/m2, 95% were Caucasian, and 55% were female. Motor vehicle collision (MVC) was the most common mechanism, representing 45% of total injuries. Other mechanisms included falls (20%) and all-terrain vehicle (ATV) accidents (13.6%). 31 patients had extraperitoneal injury, and 13 were intraperitoneal. Pelvic fractures were present in 93%, and 39% had additional solid organ injuries. Formal cystogram was performed in 59% on presentation, and mean time to cystogram was 4 hours. Gross hematuria was noted in 95% of cases. Operative management was performed for all intraperitoneal injuries and 35.5% of extraperitoneal cases. Bladder closure in operative cases was typically performed in 2 layers with absorbable suture in a running fashion. The intraperitoneal and extraperitoneal injuries managed operatively were compared, and length of catheterization (28 d vs. 22 d, p=0.46), time from injury to normal fluorocystogram (19.8 d vs. 20.7 d, p=0.80), and time from injury to repair (4.3 vs. 60.5 h, p=0.23) were not statistically different between cohorts. Patients whose catheter remained in place for greater than 14 days had prolonged time to initial cystogram (26.6 d vs. 11.5 d) compared with those whose foley catheter was removed within 14 days. The complication rate was 21% for catheters left more than 14 days while patients whose catheter remained less than 14 days experienced no complications. The present study provides a 10-year retrospective review characterizing the presentation, management, and follow-up of bladder trauma patients at our level 1 trauma center. Based on our findings, we have developed an institutional protocol which now includes recommendations regarding length of catheterization after traumatic bladder rupture. By providing specific guidelines for initial follow-up cystogram and foley removal, we hope to decrease patient morbidity from prolonged catheterization. Further study will seek to allow multidisciplinary trauma teams to standardize management, streamline care, and minimize complications for patients presenting with traumatic bladder injuries.

Suprapubic tube versus urethral catheter drainage after robot-assisted radical prostatectomy: a systematic review and meta-analysis

BackgroundProstate cancer is one of the most common cancers in the elderly population. The standard treatment is radical prostatectomy (RARP). However, urologists do not have consents on the postoperative urine drainage management (suprapubic tube (ST)/ urethral catheter (UC)). Thus, we try to compare ST drainage to UC drainage after robot-assisted radical prostatectomy regarding to comfort, recovery rate and continence using the method of meta-analysis.MethodsA systematic search was performed in Dec. 2017 on PubMed, Medline, Embase and Cochrane Library databases. The authors independently reviewed the records to identify studies comparing ST with UC of patients underwent RARP. Meta-analysis was performed using the extracted data from the selected studies.ResultsSeven studies, including 3 RCTs, with a total of 946 patients met the inclusion criteria and were included in our meta-analysis. Though there was no significant difference between the ST group and the UC group on postoperative pain (RR1.73, P 0.20), our study showed a significant improvement on bother or discomfort, defined as trouble in hygiene and sleep, caused by catheter when compared two groups at postoperative day (POD) 7 in ST group (RR2.05, P 0.006). There was no significant difference between the ST group and UC group on urinary continence (RR0.98, P 0.74) and emergency department visit (RR0.61, P 0.11). The rates of bladder neck contracture and other complications were very low in both groups.ConclusionCompared to UC, ST showed a weak advantage. So it might be a good choice to choose ST over RARP.

Urinary-cutaneous Fistulae Following Conservative Management of Extraperitoneal Bladder Ruptures

To evaluate our experience with urinary-cutaneous fistulae (UCFs) in patients following conservative management of extraperitoneal bladder ruptures (EBRs) caused by blunt trauma. Patients with blunt-trauma related EBR who underwent primary management with urethral catheter drainage alone from 2000 to 2015 were identified in our institutional trauma registry. The demographics, the hospital courses, and the outcomes of patients who developed UCF were analyzed. A total of 96 patients with EBR were identified, of which 56 (58%) were managed with urethral catheter drainage. 10 patients (18%) developed major urologic complications including urosepsis (2), infected pelvic hardware (1), persistent extravasation without cutaneous fistulization (1), and UCF formation (6). Of the patients with UCF, the median time to diagnosis of EBR was 1.5 days (range 0-12), whereas the median time to diagnosis of UCF was 11 days (range 3-31). Two patients developed UCF to the perineum, whereas 4 developed UCF to the thigh. Four (66.7%) underwent nonurologic operations without cystorrhaphy before the development of UCF. One patient died without a resolution of her fistula. The remaining 5 patients all required operative repair, with a median time to repair from diagnosis of 21 days (range 2-106). The median time to resolution from diagnosis was 64 days (range 35-155). UCFs are an under-reported but morbid complication of the nonoperative management of EBR. Although rare, UCF in this setting should prompt surgical intervention given the potential for prolonged convalescence and a low probability of spontaneous resolution.

Combined urethral and suprapubic catheter drainage improves post operative management after open simple prostatectomy without bladder irrigation

Combined urethral and suprapubic catheter drainage improves post operative management after open simple prostatectomy without bladder irrigation

The risk of intra-urethral Foley catheter balloon inflation in spinal cord-injured patients: Lessons learned from a retrospective case series.

BackgroundInflating the balloon of Foley catheter in urethra is a complication of urethral catheterisation. We report five patients in whom this complication occurred because of unskilled catheterisation. Due to lack of awareness, the problem was not recognised promptly and patients came to harm.Case seriesA tetraplegic patient developed pain in lower abdomen and became unwell after transurethral catheterisation. CT pelvis revealed full bladder with balloon of Foley catheter in dilated urethra.Routine ultrasound examination in an asymptomatic tetraplegic patient with urethral catheter drainage, revealed Foley balloon in the urethra. He was advised to get catheterisations done by senior health professionals.A paraplegic patient developed bleeding and bypassing after transurethral catheterisation. X-ray revealed Foley balloon in urethra; urethral catheter was changed ensuring its correct placement in urinary bladder. Subsequently, balloon of Foley catheter was inflated in urethra several times by community nurses, which resulted in erosion of bulbous urethra and urinary fistula. Suprapubic cystostomy was performed.A tetraplegic patient developed sweating and increased spasms following urethral catheterisations. CT of abdomen revealed distended bladder with the balloon of Foley catheter located in urethra. Flexible cystoscopy and transurethral catheterisation over a guide-wire were performed. Patient noticed decrease in sweating and spasms.A paraplegic patient developed lower abdominal pain and nausea following catheterisation. CT abdomen revealed bilateral hydronephrosis and hydroureter and Foley balloon located in urethra. Urehral catheterisation was performed over a guide-wire after cystoscopy. Subsequently suprapubic cystostomy was done.ConclusionSpinal cord injury patients are at increased risk for intra-urethral Foley catheter balloon inflation because of lack of sensation in urethra, urethral sphincter spasm, and false passage due to previous urethral trauma. Education and training of doctors and nurses in proper technique of catheterisation in spinal cord injury patients is vital to prevent intra-urethral inflation of Foley catheter balloon. If a spinal cord injury patient develops bypassing or symptoms of autonomic dysreflexia following catheterisation, incorrect placement of urethral catheter should be suspected.

Editorial Comment

The authors have put together a well-done retrospective review of men undergoing a bulbar urethroplasty over a 16-year time period. 1 Granieri M.A Webster G.D Peterson A.C. A critical evaluation of the utility of imaging after urethroplasty for bulbar urethral stricture disease. Urology. 2016; https://doi.org/10.1016/j.urology.2015.12.086 Abstract Full Text Full Text PDF Scopus (12) Google Scholar After analysis of their single-institution review, they concluded that increasing the urethral catheter drainage time by an additional week (3 weeks in total) decreased urinary extravasation rate in the excision and primary anastomosis (EPA) group (5% to < 1%). In a trade-off for the additional urethral catheter time, they are suggesting eliminating the use of pericatheter retrograde urethrogram prior to catheter removal in patients undergoing EPA.

Is peri-operative urethral catheter drainage enough? The case for stentless pediatric robotic pyeloplasty

The necessity for urinary diversion with trans-anastomotic ureteral stenting during pyeloplasty is currently under debate. Performing a stentless repair could eliminate stent-related morbidity, including: stent migration, urinary tract infection, flank pain, and bladder spasms. In addition, there would be no need for a second procedure and associated anesthesia required for stent removal. This study describes the outcomes of robotic-assisted laparoscopic pyeloplasty without use of a ureteral stent. An IRB-approved prospective database of all pediatric patients undergoing robotic pyeloplasty from July 2012 to July 2014 at a single institution was reviewed. The 'bypass pyeloplasty' or Anderson-Hynes dismembered pyeloplasty (DP) technique was performed. In both groups, neither a ureteral stent nor an abdominal drainage catheter was utilized. Complications were recorded, including: postoperative pain, bladder spasms, fever, and urinary tract infections. Follow-up renal ultrasound was reviewed for hydronephrosis. Twenty-seven children (17 male, 10 female) with a mean age of 25 months (range 6-157 months) underwent robotic ureteral stentless pyeloplasty during the study time period. The bypass pyeloplasty technique was performed on 19 children (70%). Mean length of stay was 20.2 hours (range 11-46). No fever, urinary tract infections, or hematuria requiring intervention were experienced. Additionally, there were no reports of bladder spasms or pain requiring pharmacotherapy. The mean follow-up was 8 months (range 4-21). Pre-operative Society of Fetal Urology grading was 3.5 and 3.4 for the dismembered and bypass cohort, respectively, with improvements to 1.1 for both groups at 3 months. Postoperative renal ultrasound hydronephrosis resolved in eight children (29.6%), improved in 14 (51.9%), and was stable in five (18.5%). The overall success rate was 100%. This study was limited by its small cohort and short follow-up, which may not thoroughly describe the efficacy of the stentless repair as it has been shown that stricture and re-obstruction can occur several years after surgery. Robotic stentless pyeloplasty is a feasible alternative to conventional methods, with excellent success rates and minimal complications. Importantly, this technique circumvents the need for a second procedure and the associated risks of anesthesia.

Complications and salvage options after laser lithotripsy for a vesical calculus in a tetraplegic patient: a case report

BackgroundLaser lithotripsy of vesical calculi in tetraplegic subjects with long-term urinary catheters is fraught with complications because of bladder wall oedema, infection, fragile urothelium, bladder spasms, and autonomic dysreflexia. Severe haematuria should be anticipated; failure to institute measures to minimise bleeding and prevent clot retention can be catastrophic. We present an illustrative case.Case presentationA tetraplegic patient underwent laser lithotripsy of vesical stone under general anaesthesia. During lithotripsy, severe bladder spasms and consequent rise in blood pressure occurred. Bleeding continued post-operatively resulting in clot retention. CT revealed clots within distended but intact bladder. Clots were sucked out and continuous bladder irrigation was commenced. Bleeding persisted; patient developed repeated clot retention. Cystoscopy was performed to remove clots. Patient developed abdominal distension. Bladder rupture was suspected; bed-side ultrasound scan revealed diffuse small bowel dilatation with mild peritoneal effusion; under-filled bladder containing small clot. Patient developed massive abdominal distension and ileus. Two days later, CT with oral positive contrast revealed intra-peritoneal haematoma at the dome of bladder with perforation at the site of haematoma. Free fluid was noted within the peritoneal cavity. This patient was managed by gastric drainage and intravenous fluids. Patient's condition improved gradually with urethral catheter drainage. Follow-up CT revealed resolution of bladder rupture, perivesical haematoma, and intra-peritoneal free fluid.ConclusionIf bleeding occurs, bladder irrigation should be commenced immediately after surgery to prevent clot retention. When bladder rupture is suspected, CT of abdomen should be done instead of ultrasound scan, which may not reveal bladder perforation. It is debatable whether laparotomy and repair of bladder rupture is preferable to nonoperative management in tetraplegics. Anti-muscarinic drugs should be prescribed prior to lithotripsy to control bladder spasms; aspirin and ibuprofen should be omitted. If significant bleeding occurs during lithotripsy, procedure should be stopped and rescheduled. Percutaneous cystolithotripsy using a wide channel could be quicker to clear stones, as larger fragments could be retrieved; lesser stimulant for triggering autonomic dysreflexia, as it avoids urethral manipulation. But in patients with small, contracted bladder, and protuberant abdomen, percutaneous access to urinary bladder may be difficult and can result in injury to bowels.

A Comparison of Patient Comfort and Satisfaction After Robotic Prostatectomy with Suprapubic Tube Versus Urethral Catheter Drainage

Abstract Introduction and Objective: Robot-assisted laparoscopic prostatectomy (RALP) with suprapubic tube (SPT), compared to urethral catheter (UC) drainage, has been proposed to improve patient's...

Early Removal of Urethral Catheter with Suprapubic Tube Drainage Versus Urethral Catheter Drainage Alone after Robot-Assisted Laparoscopic Radical Prostatectomy

Retrospective single institution data suggest that postoperative pain after robot-assisted laparoscopic radical prostatectomy is decreased by early removal of the urethral catheter with suprapubic tube drainage. In a randomized patient population we determined whether suprapubic tube drainage with early urethral catheter removal would improve postoperative pain compared with urethral catheter drainage alone. Men with a body mass index of less than 40 kg/m(2) who had newly diagnosed prostate cancer and elected robot-assisted laparoscopic radical prostatectomy were included in analysis. Block randomization by surgeon was used and randomization assignment was done after completing the urethrovesical anastomosis. In patients assigned to suprapubic tube drainage the urethral catheter was removed on postoperative day 1 and all catheters were removed on postoperative day 7. Visual analog pain scale and satisfaction questionnaires were administered on postoperative days 0, 1 and 7. A total of 29 patients were randomized to the urethral catheter vs 29 to the suprapubic tube plus early urethral catheter removal at the time of interim futility analysis. Mean visual analog pain scale scores did not differ between the groups at any time point and a similar percent of patients cited the catheter as the greatest bother with nonsignificant differences in treatment related satisfaction. Complications during postoperative week 1 did not vary between the groups. Based on interim results the trial was terminated due to lack of effect. Patients randomized to suprapubic tube vs urethral catheter drainage for the week after prostatectomy had similar pain, catheter related bother and treatment related satisfaction in the perioperative period. We no longer routinely offer suprapubic tube drainage with early urethral catheter removal at our institution.

Magnetic resonance imaging to detect vesico-symphyseal fistula following robotic prostatectomy

Pubic complications following radical prostatectomy are rare. Osteitis pubis typically presents with symptoms related to irritation of the pubic rami including pain with ambulation and adduction of the leg. A 60-year-old male with prostatic adenocarcinoma underwent uneventful robotic assisted laparoscopic prostatectomy. The patient noted the onset of severe pubic pain exacerbated by ambulation approximately one month post-surgery. An abdominal/pelvic CT scan was negative for acute pathology. Due to continued discomfort, a multiplanar MRI of the pelvis was performed with and without intravenous contrast material (20 ml Omniscan). The MRI demonstrated irregularity of the bladder base and proximal urethra with a fistulous tract extending anteriorly in direct communication with the pubic symphysis joint space. Vague periarticular marrow edema-like signal and enhancement at the pubic symphysis was thought to represent osteitis pubis. The patient's symptoms resolved after one month of urethral catheter drainage, intravenous antibiotics, and anti-inflammatory therapy.

Failure of Urological Implants in Spinal Cord Injury Patients due to Infection, Malfunction, and Implants Becoming Obsolete due to Medical Progress and Age-Related Changes in Human Body Making Implant Futile: Report of Three Cases

Any new clinical data, whether positive or negative, generated about a medical device should be published because health professionals should know which devices do not work, as well as those which do. We report three spinal cord injury patients in whom urological implants failed to work. In the first, paraplegic, patient, a sacral anterior root stimulator failed to produce erection, and a drug delivery system for intracavernosal administration of vasoactive drugs was therefore implanted; however, this implant never functioned (and, furthermore, such penile drug delivery systems to produce erection had effectively become obsolete following the advent of phosphodiesterase type 5 inhibitors). Subsequently, the sacral anterior root stimulator developed a malfunction and the patient therefore learned to perform self-catheterisation. In the second patient, also paraplegic, an artificial urinary sphincter was implanted but the patient developed a postoperative sacral pressure sore. Eight months later, a suprapubic cystostomy was performed as urethral catheterisation was very difficult. The pressure sore had not healed completely even after five years. In the third case, a sacral anterior root stimulator was implanted in a tetraplegic patient in whom, after five years, a penile sheath could not be fitted because of penile retraction. This patient was therefore established on urethral catheter drainage. Later, infection with Staphylococcus aureus around the receiver block necessitated its removal. In conclusion, spinal cord injury patients are at risk of developing pressure sores, wound infections, malfunction of implants, and the inability to use implants because of age-related changes, as well as running the risk of their implants becoming obsolete due to advances in medicine. Some surgical procedures such as dorsal rhizotomy are irreversible. Alternative treatments such as intermittent catheterisations may be less damaging than bladder stimulator in the long term.

Pyonephrosis and urosepsis in a 41-year old patient with spina bifida: Case report of a preventable death

BackgroundUrological complications are the major cause of ill health in patients with spina bifida. Urinary sepsis accounted for the majority of admissions in patients with spina bifida. As the patient grows older, changes occur in the adult bladder, leading to increases in storage pressure and consequent risk of deterioration of renal function, which may occur insidiously.Case presentationA 34-year-old male spinal bifida patient had been managing neuropathic bladder by penile sheath. Intravenous urography revealed normal kidneys. This patient was advised intermittent catheterisations. But self-catheterisation was not possible because of long, overhanging prepuce and marked spinal curvature. This patient developed repeated urine infections. Five years later, ultrasound examination of urinary tract revealed hydronephrotic right kidney with echogenic debris within the collecting system. There was no evidence of dilatation of the ureter near the vesicoureteric junction. The left kidney appeared normal. There was no evidence of calculus disease seen in either kidney. Indwelling urethral catheter drainage was established.Two years later, MAG-3 renogram revealed normal uptake and excretion by left kidney. The right kidney showed little functioning tissue. Following a routine change of urethral catheter this patient became unwell. Ultrasound examination revealed hydronephrotic right kidney containing thick hyper-echoic internal septations and debris in the right renal pelvis suspicious of pyonephrosis. Under both ultrasound and fluoroscopic guidance, an 8 French pig tail catheter was inserted into the right renal collecting system. 150 ml of turbid urine was aspirated immediately. This patient developed large left pleural effusion, collapse/consolidation of the left lower lobe, a large fluid collection in the abdomen extending into the pelvis and expired twenty days later because of sepsis and respiratory failure.ConclusionAlthough penile sheath drainage may be convenient for a spina bifida patient and the carers, hydronephrosis can occur insidiously. With recurrent urine infections, hydronephrotic kidney can become pyonephrosis, which is life-threatening. Therefore, every effort should be made to carry out intermittent catheterisations along with antimuscarinic drug therapy.

Hydronephrosis and renal failure following inadequate management of neuropathic bladder in a patient with spinal cord injury: Case report of a preventable complication

BackgroundCondom catheters are indicated in spinal cord injury patients in whom intravesical pressures during storage and voiding are safe. Unmonitored use of penile sheath drainage can lead to serious complications.Case reportA 32-year old, male person, sustained complete paraplegia at T-11 level in 1985. He had been using condom catheter. Eleven years after sustaining spinal injury, intravenous urography showed no radio-opaque calculus, normal appearances of kidneys, ureters and bladder. Blood urea and Creatinine were within reference range. A year later, urodynamics revealed detrusor pressure of 100 cm water when detrusor contraction was initiated by suprapubic tapping. This patient was advised intermittent catheterisation and take anti-cholinergic drug orally; but, he wished to continue penile sheath drainage. Nine years later, this patient developed bilateral hydronephrosis and renal failure. Indwelling urethral catheter drainage was established. Five months later, ultrasound examination of urinary tract revealed normal kidneys with no evidence of hydronephrosis.ConclusionSpinal cord injury patients with high intravesical pressure should not have penile sheath drainage as these patients are at risk for developing hydronephrosis and renal failure. Intermittent catheterisation along with antimuscarinic drug should be the preferred option for managing neuropathic bladder.