Evaluating the cost of iatrogenic urethral catheterisation injuries

Iatrogenic bladder neck rupture due to traumatic urethral catheterization: A case report

BACKGROUND

In this article, we present a case of iatrogenic bladder neck rupture due to catheter insertion in a 94-year-old comorbid male patient.

CASE SUMMARY

The patient, who had a urethral catheter inserted in the palliative service 3 d ago, was consulted because the catheter did not work. Because the fluid given to the bladder could not be recovered, computed tomography was performed, which revealed that the catheter had passed the bladder neck first into the retrovesical area then into the intraabdominal area. The appearance of the anterior urethra and verumontanum was normal at cystoscopy. However, extremely severe stenosis of the bladder neck, and perforated posterior wall of the urethral segment between the prostatic urethra and the bladder neck were observed. Internal urethrotomy was applied to the bladder neck with a urethrotome. An urethral catheter was sent over the guide wire into the bladder. The patient was followed in the palliative care service and the catheter was removed 7 d later. No extravasation was observed in the control urethrography.

CONCLUSION

Although catheter insertion is a simple and frequently performed procedure in hospitalized patients, it is necessary to avoid unnecessary extra-indication catheter insertion.

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.

RETention of urine After INguinal hernia Elective Repair (RETAINER study I and II)

Purpose:

Post-operative urinary retention (POUR) is a well-recognised complication of inguinal hernia repair (IHR). The magnitude of the problem is unclear, and contradictory evidence surrounds postulated risk factors. POUR risks patient distress, catheter-complications and a financial and logistical burden to services. Separately, in the field of IHR, there has been a lack of research into patients’ perceptions of surgical ‘success’. Our aim is to perform a two-phase, multi-centre prospective study to:

Methods:

RETAINER I: We propose a 24-week prospective study with voluntary international participation in 4 week blocks. All patients undergoing elective IH repair (minimally-invasive/open) will be eligible. Standardised data collection will include patient and perioperative factors. Primary outcome will be development of POUR, defined as the need for insertion of a urinary catheter as determined by the treating clinician. Secondary outcomes will be identification of factors predisposing to POUR and the impact of POUR.

RETAINER II: A patient reported outcome measure will be developed using representative patient focus groups for item generation, from which an initial questionnaire will be developed and piloted. Validity, reliability, sensitivity and reproducibility will be assessed using the QQ-10 and standard psychometric methodology.

Conclusions:

Using an international multicentre collaborative approach will produce the necessary volume of patients, whilst capturing inter-centre variability, to accurately reflect POUR rates and allow analysis of risk factors. This patient pool will provide an excellent opportunity to develop a PROM using appropriate qualitative methodology.

Highlights: RETAINER I & II Protocols

Catheter Balloon-trauma: Design, Development, and Ex-vivo Studies Using Intact Human Penis Specimens

OBJECTIVE

To present a novel urethral catheter design with a pilot balloon to reduce intraurethral retention balloon inflation pressures and to provide a visual alert during catheter placement.

METHODS

We manufactured our pilot balloon prototype from both molded and extruded silicone components. Various pilot balloon thicknesses were tested in order to determine the ideal compliance. We studied the filling pressures of the retention balloon of our prototype in a mechanical urethral model. The prototype catheter was then tested in ex-vivo human penis specimens obtained from gender affirming surgery and changes in the size of the retention balloon were measured under fluoroscopy.

RESULTS

The thickness of the pilot balloon was directly related to the inflation pressure of the retention balloon in the mechanical urethral model. The thickness chosen for the pilot balloon in our prototype was based on a retention balloon pressure of 70 kPa. In the ex-vivo human penis model, the presence of the pilot balloon resulted in a 40% reduction in the cross-sectional area of the retention balloon compared to a standard urinary catheter.

CONCLUSION

The prototype urinary catheter appears to decrease the filling pressure and size of an improperly positioned retention balloon inside a urethra. This can potentially reduce the risk of iatrogenic urethral catheter injuries. In addition, the prototype urinary catheter may act as a visual warning sign for the healthcare practitioner.

A prospective audit on the effect of training and educational workshops on the incidence of urethral catheterization injuries

INTRODUCTION

The incidence of iatrogenic urethral catheterization (UC) injuries is approximately 0.3%. Resultant complications are associated with patient morbidity and unnecessary healthcare costs. Our aim was to investigate whether educational training workshops decreased the incidence of UC-related injuries.

METHODS

A prospective audit was performed to calculate incidence, morbidity, and costs associated with iatrogenic UC injury from January to July 2015. Educational workshops were then conducted with healthcare staff and training modules for junior doctors. UC-related incidence, morbidity, and costs in the subsequent six-month period were recorded prospectively and compared with the previous data.

RESULTS

The incidence of iatrogenic UC injuries was reduced from 4.3/1000 catheters inserted to 3.8/1000 catheters after the intervention (p=0.59). Morbidity from UC increased in the second half in the form of increase in cumulative additional inpatient hospital stay (22 to 79 days; p=0.25), incidence of urosepsis (n=2 to n=4), and need for operative intervention (n=1 to n=2). The cost of managing UC injuries almost doubled in the period after the training intervention (€50 449 to €90 100).

CONCLUSIONS

Current forms of educational and training interventions for UC did not significantly change morbidity or cost of iatrogenic UC injuries despite a decrease in incidence. Improved and intensive training protocols are necessary for UC to prevent avoidable iatrogenic complications, as well as a safer urethral catheter design.