Further observations on self-catheterization

Perspectives on technology: Single-use catheters - evidence and environmental impact

OBJECTIVE

To explore the data comparing single- vs multi-use catheters for clean intermittent catheterisation (CIC), consider if the widespread use of single-use catheters is warranted given the cost and environmental impact, and put forth ideas for future consideration.

METHODS

A primary literature review was performed in PubMed over the past 50 years. Studies that performed comparative analysis of single- and multi-use catheters were included in our review. All studies that reported on primary data were narratively summarised.

RESULTS

A total of 11 studies were identified that reported on primary data comparing single- and multi-use catheters. There was no appreciable evidence suggesting reusable multi-use catheters were inferior to single-use catheters from an infection or usability standpoint. In addition, the environmental and monetary burden of single-use catheters is significant.

CONCLUSIONS

The intermittent catheter landscape in the USA has a complex past: defined by policy, shaped by industry, yet characterised by a paucity of data demonstrating superiority of single-use over multi-use catheters. We believe that the aversion to reusable catheters by many patients and healthcare professionals is unwarranted, especially given the cost and environmental impact. Moving forward, better comparative data and more sustainable practices are needed.

Prospective study of the epidemiology of urinary tract infections at short term and mid-term after initiation of intermittent self-catheterisation

INTRODUCTION

Self-catheterisation (CIsC) is the gold standard treatment for bladder emptying disorders. A frequent complaint of patients undergoing CIsC is urinary tract infection (UTI). However, the epidemiology of UTIs remains poorly documented, particularly in the urological population. The aim of our study was to establish the epidemiology of infectious complications of CIsC.

METHOD

A prospective, descriptive cohort study was carried out on a population educated in CIsC in a urology outpatient department of a university hospital.

RESULTS

From January 1, 2019 to November 15, 2020, 411 patients completed a CIsC education session. Sixty patients could be included and integrated for analysis. The mean age was 58.6±16.3years. Among the patients, 68% had a neurological pathology. The most common bacteria found was Escherichia coli. The incidence of total UTIs within the first 6weeks was 18%. After a mean follow-up of 15±6.5months, the median number of UTIs was 0 [0; 4]. The mean interval between two infectious episodes was 9±6.7months. Only one patient met the criteria for recurrent UTI. Febrile UTIs affected 7% of patients.

CONCLUSION

Self-catheterisation has a low infectious morbidity, occurring mainly in the first few weeks after its introduction.

LEVEL OF EVIDENCE: 2

Bladder augmentation in children: current problems and experimental strategies for reconstruction

Bladder augmentation is a demanding surgical procedure and exclusively offered for selected children and has only a small spectrum of indications. Paediatric bladder voiding dysfunction occurs either on a basis of neurological dysfunction caused by congenital neural tube defects or on a basis of rare congenital anatomic malformations. Neurogenic bladder dysfunction often responds well to a combination of specific drugs and/or intermittent self-catheterization. However, selected patients with spinal dysraphism and children with congenital malformations like bladder exstrophy and resulting small bladder capacity might require bladder augmentation. Ileocystoplasty is the preferred method of bladder augmentation to date. Because of the substantial long-and short-term morbidity of augmentation cystoplasty, recent studies have tried to incorporate new techniques and technologies, such as the use of biomaterials to overcome or reduce the adverse effects. In this regard, homografts and allografts have been implemented in bladder augmentation with varying results, but recent studies have shown promising data in terms of proliferation of urothelium and muscle cells by using biological silk grafts.

Urethrogluteal fistula developing secondary to the use of clean intermittent self-catheterization: first case report in the literature

Clean intermittent self-catheterization is the standard method for bladder evacuation in these patients today. The patient was diagnosed with urethrogluteal fistula and gluteal-perineal abscess by radiological evaluation. Gluteal drainage decreased after cystostomy. In our paper, a case of urethrogluteal fistula and pelvic urinoma that developed as a result of the use of clean intermittent self-catheterization (CISC), which is rarely found in the literature, is presented.

Cleaning and re-using intermittent self catheters: a questionnaire to gauge patient’s perceptions and prejudices

Introduction:

An estimated 60,000 people in the UK are currently performing some form of intermittent catheterisation, using 57.5 million catheters yearly. Current policy in the UK is to utilise single use, disposable catheters: however, this is not worldwide policy as repeated catheter use is common in many nations. The aim of this study was to determine UK patients’ views on re-using catheters and their willingness to re-use catheters.

Method:

Patients attending the clean intermittent self catheterisation [CISC]/urethral dilatation (UD) clinic over an eight-month period were asked to prospectively complete a standard, anonymous questionnaire.

Results:

A total of 100 questionnaires were returned, of which two-thirds were from men. Mean age was 61 years, (median 63 years). Indications for CISC/UD were urethral or meatal stenosis (7%), urethral stricture (25%) and residual volume in (67%). The majority of patients (71%) are unwilling to reuse catheters. Women were statistically very significantly more likely to refuse to re-use their catheters, ( p<0.01, Fisher’s exact test). Patients aged 70 years and older were significantly more likely to agree to re-use their catheters compared to those under 70 years, ( p=0.02, Fisher’s exact test). Patients performing intermittent self catheterisation [ISC] up to a maximum of twice per day were statistically more likely to agree to catheter re-use, ( p=0.03, Fisher’s exact test). Risk of infection was the main reason cited (by 87%) to not re-use a catheter. Lack of lubrication and less convenience were other quoted reasons. Finances and less waste were stated reasons to re-use catheters.

Conclusions:

Certain patient cohorts, men, patients over 70 years old and those performing CISC/UD less than three times daily are significantly more likely to agree to catheter re-usage.

Bladder calculi formed over a hair nidus in spinal injury cases

Clean intermittent catheterization has been demonstrated to be a safe and effective method of bladder drainage in patients with neurogenic bladder dysfunction. However, breakdowns in technique may allow the introduction of foreign matter into the bladder and thereby result in bladder calculi. The three cases reported herein demonstrate this potential problem in persons with spinal cord injury (SCI) with hair nidus as the source of bladder calculi causing neurogenic bladder. In each situation, the problem was identified, calculi were removed cystoscopically and the patient and/or the ancillary aid were reinstructed. We recommend annual renal function tests, ultrasound and cytoscopic screening in high suspicion cases to allow early detection of bladder calculi in persons with SCI and prevent further urinary tract infections. This report also emphasizes the need for patient education and a careful follow-up preventing bladder calculi and thus, minimizing the morbidity in persons with SCI.

Variation in definitions of urinary tract infections in spina bifida patients: a systematic review

OBJECTIVE

Urinary tract infections (UTIs) are a common source of morbidity among children with spina bifida (SB) and are a frequently reported outcome in studies of this patient population. However, the criteria for a diagnosis of UTI are often not stated. We evaluated the literature on SB patients for the criteria that authors use to define parameters in reporting UTI outcomes.

METHODS

Embase and Medline were queried with the medical subject heading terms “spinal dysraphism,” “myelomeningocele,” “infection,”and “urinary tract infection.” A second search with the exploded term“spina bifida” and “urinary tract infection” was performed. Original research studies reporting a UTI outcome in SB patients were included and evaluated by 2 independent reviewers for the presence of a UTI definition and diagnostic criteria.

RESULTS

We identified 872 publications, of which 124 met inclusion criteria. Forty-five of 124 (36.3%) studies reporting UTI as an outcome provided a definition of UTI. Of 124 studies, 28 (22.6%) were published in pediatric journals and 69 (55.6%) in urology journals. A definition of UTI was provided in 11 (39.3%) and 26 (37.7%) studies, respectively. “Fever,culture, and symptoms” defined a UTI in 17 of 45 studies. Journal category and presence of UTI definitions did not correlate (P = .71).

CONCLUSIONS

Explicit definitions for UTI are heterogeneous and infrequently applied in studies of SB patients, limiting study reliability and estimates of true UTI rates in this population. Future studies will benefit from the development and application of a standard definition for UTI in this population.

The Kennedy Krieger Independence Scales-Spina Bifida Version: a measure of executive components of self-management

PURPOSE/OBJECTIVE

Successful implementation of functional self-care skills depends upon adequate executive functioning; however, many scales assessing adaptive skills do not address the inherent executive burden of these tasks. This omission is especially relevant for individuals with spina bifida, for whom medical self-care tasks impose a significant burden requiring initiation and prospective memory. The Kennedy Krieger Independence Scales-Spina Bifida Version (KKIS-SB) is a caregiver-reported measure designed to address this gap; it assesses skills for managing both typical and spina bifida-related daily self-care demands, with a focus on the timely and independent initiation of adaptive skills.

RESEARCH METHOD/DESIGN

Parents of 100 youth and young adults with spina bifida completed the KKIS-SB. Exploratory factor analysis and Pearson's correlations were used to assess the factor structure, reliability, and construct validity of the KKIS-SB.

RESULTS

The scale demonstrates excellent internal consistency (Cronbach's alpha = .891). Exploratory factor analysis yielded four factors, explaining 65.1% of the total variance. Two primary subscales were created, initiation of routines and prospective memory, which provide meaningful clinical information regarding management of a variety of typical (e.g., get up on time, complete daily hygiene routines on time) and spina bifida-specific self-care tasks (e.g., begin self-catheterization on time, perform self-examination for pressure sores).

CONCLUSIONS/IMPLICATIONS

Based upon internal consistency estimates and correlations with measures of similar constructs, initial data suggest good preliminary reliability and validity of the KKIS-SB.

Clean intermittent catheterization and urinary tract infection: review and guide for future research

What's known on the subject? and What does the study add? Clean intermittent catheterization (CIC) is considered the method of choice for bladder emptying when neurological or non-neurological causes make normal voiding impossible or incomplete. The outcome is overall good, also in the long-term. There is neither one best technique nor one best material, as both depend greatly on patients' individual anatomic, social and economic possibilities. The most frequent complication is urinary tract infection (UTI). Studies differ in the definition criteria for UTI, methods for evaluation, CIC techniques, frequency of urine analysis, prophylaxis and patients studied. The study provides a literature review and shows that most studies do not have a high level of evidence. There are various risk factors for UTI and phenotyping them helps to assess prognosis by considering what can happen if treatment is not initiated. The study concludes, that the role of biofilms in CIC deserves more attention and that diagnosis should be made on urine sample obtained with catheterization, because symptoms are often less reliable. It also concludes that treatment in those who catheterize for a long time is only necessary for symptomatic infections. The study identifies the following areas for further research: prevention of UTI in patients performing CIC; the use of special catheter types; and the role of frequency of catheterization, prophylactic antibiotics and preservation of natural defence mechanisms in the lower urinary tract.

OBJECTIVE

• To review the factors related to urinary tract infection (UTI), the most prevalent complication in patients who perform clean intermittent catheterization (CIC).

METHODS

• We conducted a literature search then a group discussion to gather relevant information on aspects of UTI to guide future research and to help provide clearer recommendations for the prevention of UTI in patients performing CIC.

RESULTS

• UTI is a major complication of CIC, the incidence of which varies widely in the literature owing to differences in methodology and definitions. • Phenotyping the risk factors for UTI helps to assess prognosis by considering what can happen if treatment is not initiated. The role of biofilms in CIC deserves more attention. • Diagnosis is made using the urine sample obtained by catheterization. Because of neurological or other deficiencies in patients performing CIC, symptoms are less reliable. Thorough evaluation for the source of signs and symptoms should be made before attributing them to UTI. • There have been many different proposals for the prevention of UTI in patients performing CIC, but most need more research. The role of the type of catheter is unclear but further exploration of special catheter types might be worthwhile. • Treatment in those who perform CIC for a long time is best reserved for symptomatic infections.

CONCLUSIONS

• Several mechanisms are relevant in UTI related to CIC. • As UTI is prevalent, more research into its prevention is needed.

Urinary diversion after cystectomy: An Indian perspective

Radical cystectomy remains the standard treatment for muscle-invasive carcinoma bladder. Various methods have been described for the urinary diversion. In the last 150 years urinary diversion has evolved from cutaneous ureterostomy to the orthotopic neobladder. Especially during the last 20 years, much advancement has been made. We hereby have reviewed the current approaches being used at different centers in India. We have also analyzed the evolution of diversion from conduit to the orthotopic substitution at our center.

Strategies to promote intermittent self-catheterisation in adults with neurogenic bladders: A comprehensive systematic review

EXECUTIVE SUMMARY

Background Clean intermittent self-catheterisation is the gold standard in the management of neurogenic/neuropathic bladder disorders, providing independence, alleviating symptoms and complications of the urinary tract.Objectives The objective of this systematic review was to establish the best available evidence on strategies to promote intermittent urethral self-catheterisation in adults with neurogenic/neuropathic bladders.Methods The search strategy identified published and unpublished studies reported from 1970 to 2009. Individual search strategies were developed for the 12 databases accessed and search alerts established. The review considered qualitative and quantitative studies, mixed methods and case studies. Interventions, programs and strategies preparing adults to self-catheterise included education, suitability for selfcatheterisation and interventions promoting compliance and continuity. Outcomes of interest were the quality of life and depression, long-term compliance, advantages/disadvantages of urethral self-catheterisation and limitations to selfcatheterisation.Standardised critical appraisal instruments developed by the Joanna Briggs Institute were used by two independent reviewers to assess the quality of eligible studies for inclusion in the review. Standardised Joanna Briggs Institute tools were also used to extract data. Criteria developed by Yin were employed to assess case studies. Qualitative findings were synthesised. As statistical pooling of the quantitative results was not possible, these results were presented in narrative form.Results From the 18 studies reviewed, three interventions (education and preparation, suitability to self-catheterise, and interventions promoting compliance/continuity), and three outcomes (effect of self-catheterisation on quality of life and depression, and longterm compliance) were addressed with multiple studies in each intervention and outcome. The results are discussed under four headings: (i) education essentials for selfcatheterisation (ii) factors promoting compliance and continuity with self-catheterisation, (iii) factors influencing quality of life and (IV) diagnostic sub-groups of people with a neurogenic bladder.

CONCLUSION

The narrative and synthesised data from the 18 included studies identified findings to provide a basis for strategies to promote clean intermittent self-catheterisation in adults. These include an extended education program with a pre-education component, ongoing support and skills training. All aspects of education should reflect sound research findings related to quality of life issues.Implications for Practice The implications for clinical practice are the development of a comprehensive standardised education program that includes background information, skills training and follow-up support.Implications for Research The review highlights the need for further experimental research to confirm factors that will promote self-catheterisation in adults with neurogenic/neuropathic bladders, with particular reference specific sub-groups.

Intermittent catheterization with hydrophilic catheters as a treatment of chronic neurogenic urinary retention

AIMS

Neurogenic bladder can be effectively managed with intermittent catheterization (IC) to improve or restore continence, but there is no consensus on which type of catheter is preferred. Hydrophilic catheters were developed to reduce urethral friction, thereby minimizing trauma and sticking, and making them more acceptable to the patient, and easier and safer to use. The objective of this article was to review the literature on the benefits of hydrophilic catheters in patients with neurogenic bladder.

METHODS

A large body of experimental and observational evidence, including randomized controlled trials, was identified using PubMed.

RESULTS

Compared with plastic catheters that have been manually lubricated with gel, hydrophilic catheters reduce urinary tract infection and microhematuria. Hydrophilic catheters are also associated with high levels of patient satisfaction because they are comfortable to use.

CONCLUSIONS

There is a wealth of evidence, including randomized controlled trials, to support the benefits of hydrophilic catheters in terms of safety and quality of life, especially in men with spinal cord injury. More data are required for spina bifida, multiple sclerosis, and in women. Further research is warranted, especially large-scale and long-term robust comparisons of different types of catheter, and in well-defined and stratified populations.

Catheterization: possible complications and their prevention and treatment

Intermittent catheterization (IC) is a more preferable method for bladder drainage than indwelling urethral or suprapubic catheterization. Several complications with IC have been described, however, including urinary tract infection, genital infection, urethral bleeding, urethritis, urethral stricture, and bladder stones. To prevent these complications, patients should be well instructed on the technique and the risks of IC. Indwelling catheterization should be used only exceptionally, under close control and the catheter should be changed with adequate frequency.

Detrusor myectomy: long-term results with a minimum follow-up of 2 years

OBJECTIVES

To assess the long-term results of detrusor myectomy, which has obvious theoretical advantages over enterocystoplasty for refractory detrusor overactivity (DO), and for which the early results have been encouraging.

PATIENTS AND METHODS

The medical records were reviewed of 30 consecutive patients (median age 33 years, range 10-62) who had a detrusor myectomy between November 1992 and April 2002 in our unit. Twenty-four patients (80%) had idiopathic DO (six males and 18 females) and six (20%) had neurogenic DO (four males and two females). The median (range) follow-up was 79 (28-142) months. All patients were confirmed to have DO on urodynamics before surgery and 26 (87%) had urodynamics afterward.

RESULTS

Nineteen (79%) of those with idiopathic DO and two with neurogenic DO showed a continued overall improvement. The cystometric capacity improved in 80% of patients after surgery, whilst the detrusor pressure at maximum flow and the bladder contractility index decreased in 60% and 78% of the patients, respectively. Ten patients (45%) had to start clean intermittent self-catheterization after surgery.

CONCLUSIONS

Detrusor myectomy is successful in approximately 80% of patients with idiopathic DO, although detrusor contractility is affected in most and almost half of the patients required clean intermittent self-catheterization afterward. This procedure should be offered as an alternative to enterocystoplasty as it is less morbid and does not preclude subsequent surgery if required. However, further evaluation of this technique is required in neuropathic patients.

The ‘no-touch’ method of intermittent urinary catheter insertion: can it reduce the risk of bacteria entering the bladder?

OBJECTIVE

This in vitro model was designed to determine whether using a no-touch method for catheter preparation and insertion would affect the degree of contamination transmitted to intermittent urinary catheters.

SETTING

Northview Laboratories, Northbrook, IL 60062, USA.

METHODS

This was a parallel experimental study conducted in vitro at an independent testing laboratory under Good Manufacturing Practices. Six different models of intermittent urinary catheter were tested in triplicate, in accordance with the manufacturer's Instructions For Use (IFU). Gloved hands were contaminated with a known amount of Staphylococcus aureus or Escherichia coli, preparation for insertion was mimicked according to the manufacturer's IFU. The number of bacteria transferred to the catheter was then quantified using a validated technique. The null hypothesis tested was that the bacterial contamination resulting from handling would be the same for all of the catheters. The primary outcome measure was the amount of bacteria, expressed as colony forming units (CFU), recovered from the catheters. The catheter wrappers were sampled to confirm that active transfer of microorganisms had taken place and nonhandled samples served as the negative controls.

RESULTS

For both test organisms, the number of bacteria recovered from the catheters was significantly lower (P < 0.05) for the catheters featuring the no-touch design (approximately 5 CFU/plate versus 2.1 x 10(2) to 4.4 x 10(2) for the traditional hydrophilic catheters). The bacterial recovery from those catheters with the no-touch design often fell below the nominal detection limit.

CONCLUSION

The results of this study allow the null hypothesis to be rejected; it can be concluded that the no-touch method provides a significant benefit in reducing the potential for external contamination of an intermittent urinary catheter. This result supports the recent recommendations for aseptic intermittent catheterization promoted within the guidelines issued by the European Association of Urologists (EAU).

An assessment of the use of a continent catheterizable stoma in female tetraplegics

OBJECTIVES

To evaluate the success of a continent catheterizable stoma in females with cervical spinal cord injury which resulted in neurogenic bladder dysfunction, the management of which may require clean intermittent catheterization despite altered hand function.

PATIENTS AND METHODS

Six female tetraplegic patients with a lesion at C7 or above (age range 12-22 years) had a continent catheterizable abdominal stoma formed as part of their bladder management. As an objective measure of effectiveness, the time to complete catheterization was assessed before and after surgery. A quality-of-life survey at a mean (range) of 44 (6-90) months was also evaluated.

RESULTS

All six patients can catheterize while in their wheelchair. The mean (range) time required for catheterization decreased from 27 (10-40) to 7.8 (1-15) min after surgery. All six reported a significant improvement in continence, body image, independence, convenience, time saving and satisfaction.

CONCLUSION

Constructing a continent catheterizable stoma is a valuable option in selected tetraplegic patients.

Continent lower urinary tract reconstruction in the cervical spinal cord injured population

PURPOSE

Patients with cervical spinal cord injury and upper extremity dysfunction are treated primarily with indwelling or condom catheters. We present our experience with a select group of patients with limited upper extremity function to determine long-term success and patient satisfaction after lower urinary tract reconstruction.

MATERIALS AND METHODS

Between May 1988 and November 1996, 28 patients with cervical spinal cord injury underwent lower urinary tract reconstruction. Postoperative information was obtained on 21 patients. Charts were reviewed and patients were contacted by an independent reviewer to ascertain patient satisfaction and quality of life. Patient age was 17 to 51 years (average 34.6). Reconstructive procedures requiring catheterization included augmentation ileocystoplasty in 4 patients plus Mitrofanoff appendicovesicostomy in 7, a Kock ileal reservoir in 8 and an Indiana pouch in 2.

RESULTS

Catheterization was regularly performed by 20 of the 21 patients (95%). A total of 12 patients (60%) performed self-intermittent catheterization and 8 (40%) relied on an attendant or family member. Of the patients 80% reported improved quality of life since reconstruction, citing such reasons as lack of a need for urinary drainage bags, increased freedom and an improved sense of body image. Using a visual analog scale to grade satisfaction from 1 to 10 (1-extremely unsatisfied to 10-extremely satisfied) 14 patients (67%) reported a score of 8 or more.

CONCLUSIONS

With appropriate preoperative selection of the cervical spinal cord injured patient intermittent catheterization is successfully maintained in the long term, allowing greater flexibility in choice, and a resultant high level of patient satisfaction and improved quality of life.

Complications of intermittent catheterization: their prevention and treatment

STUDY DESIGN

Literature review to evaluate the complications seen in patients on intermittent catheterization (IC) and intermittent self-catheterization (ISC).

OBJECTIVES

To find the prevalence of most complications seen in patients on IC. To study the prevention and the treatment of these complications.

SETTING

An international literature review.

METHODS

Most relevant articles on the subject are reviewed.

CONCLUSION

Urinary tract infection is the most frequent complication in patients performing IC. Catheterization frequency and the avoidance of bladder overfilling are amongst the most important prevention measures. Asymptomatic bacteriuria does not need to be treated with antibiotics. Long-term antibacterial prevention does seem to bear a risk of development of bacterial resistance. Previous treatment with indwelling catheters is a risk factor for chronic infection and urinary sepsis. Prostatitis is more frequently present than often thought. Epididymitis and urethritis are rare. Trauma from catheterization occurs regularly, but lasting effects are more limited. However, the prevalence of urethral strictures and false passages increases with longer use of IC. The use of hydrophilic catheters might be able to lower the urethral complication rate but additional proof through comparative studies is needed. The most important prevention measures are good education of all involved in IC, good patient compliance, the use of a proper material and the application of a good catheterization technique.

Sigmoid reconfigured vaginal construction in children

PURPOSE

We present a modified technique of sigmoid neovaginal construction in children that protects the sigmoid pedicle from traction, allows easy adjustment of caliber and reorients the mucosal fold in a longitudinal direction.

MATERIALS AND METHODS

From 1997 to 2000, 10 genetically male (46 XY) children 1 to 13 years old underwent construction of a neovagina with sigmoid, incorporating the Yang-Monti concept of intestinal reconfiguration. The diagnosis was androgen insensitivity in 7 patients, congenital adrenal hyperplasia in 2 due to 17 alpha-hydroxylase deficiency and 3 beta-hydroxysteroid dehydrogenase deficiency, respectively, and bladder exstrophy in 1 who required sex reassignment.

RESULTS

Eight children had an adequate caliber neovagina after an initial period of systematic dilation. In 1 case a relevant stricture required reoperation using the same technique and the outcome was good. In another child a stricture developed in the middle of the reconfigured sigmoid segment and a regular dilation schedule is still being followed after 23 months of followup.

CONCLUSIONS

The new sigmoid reconfiguration technique enables the use of smaller dimension intestinal segments and construction of a long vaginal conduit of adequate caliber. Its optimal adequacy for penetration must be assessed in the future after these patients begin sexual activity.

Clean intermittent self-catheterisation and children

The best chance for good renal health and continence for children with a neuropathic bladder is clean intermittent self-catheterisation. In order to maximize potential for good renal health and continence the child and family need to be well supported by the multidisciplinary team, making good use of the knowledge of the children's urology specialist nurse who is able to provide relevant information, advice and education. With support many children with a neuropathic bladder are able to achieve continence while maintaining good renal health.

Application of the Mitrofanoff principle for intermittent self-catheterization in quadriplegic patients

OBJECTIVES

Patients with cervical spinal cord lesions have impaired hand function, which often prohibits clean intermittent self-catheterization (CIC), especially in female patients. Enabling these patients to perform CIC gives them control of their bladder management and can improve their quality of life considerably. We have used an appendicovesicostomy to provide easy access for CIC in such patients.

METHODS

Five patients (4 women, 1 man) with a mean age of 31 years (range 20 to 52) and a mean duration of the cervical cord lesion of 22 months (range 7 to 37) underwent appendicovesicostomy. Three patients were young victims of motor vehicle accidents, 1 patient had a progressive rheumatoid arthritic disorder, and 1 patient had a complex functional paraplegia syndrome and underwent bladder augmentation at the same time.

RESULTS

The surgical procedure with the creation of a catheterizable stoma in the right lower abdominal quadrant was successful in all cases but was complicated by mechanical ileus in the patient with simultaneous bladder augmentation. All patients learned to perform independent CIC with continuing anticholinergic medication. Stomal stenosis did not occur in any of the 5 patients, and urinary tract infections occurred once in 2 patients and repeatedly in 1 patient. Three of 5 patients have been enabled by independent bladder management to achieve occupational rehabilitation.

CONCLUSIONS

Appendicovesicostomy is a suitable procedure in patients with cervical spinal cord lesions who are otherwise unable to perform independent CIC. The creation of a catheterizable abdominal stoma enables these patients to gain independent control of their bladder management. However, caution in patient selection is advisable as probably the best results are achieved in highly motivated, younger patients with traumatic cervical cord lesions.

Hydrophilic versus non-coated catheters for intermittent catheterization

Since Lapides reintroduced clean intermittent catheterization (CIC) in 1972, this procedure has been used routinely in individualized programmes for bladder evacuation in various bladder disorders. It has been suggested that in clinical practice hydrophilic catheters are preferable to non-coated catheters. In reviewing the literature on CIC, many of the reports were found to rely on data from non-randomized retrospective studies. In some recent prospective studies, involving a limited number of patients, hydrophilic and non-coated catheters have been evaluated and compared, especially with regard to bacteriuria and urethral irritation. The available data indicate that using hydrophilic catheters for CIC may induce lower rates of bacteriuria and long-term urethral complications such as urethral strictures. However, to reach a reliable conclusion about the supposed advantage of the hydrophilic catheters, there is a need for a prospective, randomized long-term multicentre study. It is important in such a study to define patient characteristics including age, gender, diagnosis of bladder dysfunction, reason for CIC, physical and mental handicap, manual dexterity and previous treatments. Effect parameters should include number of catheterizations, urinary tract infection, early and long-term urethral complications, patient satisfaction, preferences and dropout rates. It is obligatory to include factors such as cost-benefit and cost-effectiveness.

InstantCath from Hollister: pre-lubricated self-catheterization

Over the centuries a variety of substances have been used to make a hollow tube to pass through the urethra to empty a poorly functioning bladder. The ancient Greeks used dried water reeds from the riverbank. The Romans and the Egyptians experimented with gold and silver. Following the industrial revolution stainless steel was used and catheters are still manufactured today using stainless steel. PVC and plastic catheters became popular in the 1970s and various hydrophilic coatings have been added to provide self-lubrication of the catheter when it comes into contact with water. The most recent development in the clean, intermittent self-catheterization (CISC) range is the Hollister InstantCath which is a self-lubricating catheter that does not require any water. It has shown itself to be well received by patients and is a welcome addition to the choice available to healthcare professionals and their patients when instigating CISC as therapy.

Evaluation and treatment of children with neurogenic bladders

The evaluation and treatment of children with neurogenic bladders can be difficult because of the complexity of the neurologic deficit and the subjectivity of the history and physical exam. The primary emphasis of the physicians caring for these children should be to preserve renal function and facilitate continence when possible. As knowledge of both normal and abnormal lower urinary-tract dynamics increases, so does the ability to care for children with abnormal bladder dynamics caused by various neurologic conditions. With recent advancements in medical and surgical treatment of the neurogenic bladder, most children can maintain adequate renal function and attain urinary continence. This article reviews the pertinent innervation, anatomy, and physiology of the lower urinary tract, and discusses current evaluation and treatment of children with neurogenic bladders.

Neurological disorders of micturition and their treatment

An overview of the current concepts of the neurological control of the bladder is given, based on laboratory experiments and PET scanning studies in human subjects. This is followed by a description of the various causes of the neurogenic bladder, discussed in a hierarchical order starting with cortical lesions and descending through the basal ganglia and brainstem, spinal cord, conus and cauda equina to disorders of peripheral innervation. Then follows a description of the condition of isolated urinary retention in young women. The article concludes with a review of the methods available for treating neurogenic bladder disorders. These are largely medical but brief mention of appropriate surgical procedures is made.

Indications for and principles of intermittent self-catheterization

Intermittent self-catheterization (ISC) or carer/nurse assisted intermittent catheterization has developed over the past few years as a means of treating patients with bladder emptying problems. Initially the process was designed for patients with the dexterity to carry out the procedure; today, however, more nurses are trained in the technique and are therefore able to support people with coordination problems in carrying out the procedure. Education programmes on catheterization are becoming increasingly popular and many district nurses have become skilled in its practice. This article describes some of the conditions that may be associated with bladder dysfunction and which warrant ISC. The support required from nurses in the planning, implementing, intervention and evaluation of a package of care are discussed. Simple advice such as avoiding constipation, monitoring urine to identify infection and general measures to improve hygiene all play a role in maintaining good health.

The Mitrofanoff principle in continent urinary reconstruction

Continent urinary diversion has increasingly become important for treating children and adults with urinary tract pathology that cannot be managed by direct reconstructive techniques. The Mitrofanoff principle, a term that has become synonymous with the flap valve mechanism for promoting the unidirectorial flow of a fluid medium, is a recapitulation of nature's design for the competent ureterovesical junction. Construction of a catheterizable channel using this principle can be performed with a variety of tissues and serves well as a continence mechanism for either the native bladder or intestinal reservoirs. In addition to its utility in managing urinary incontinence, implantation of a catheterizable channel into the cecum can be used to manage fecal incontinence in patients with neurogenic bowel dysfunction.

Historical perspective of the use of bowel in urology

The use of bowel has been used in urinary tract reconstruction for more than a century. In the past 20 years, however, indications and methods for bowel utilization have multiplied enormously. This article outlines some of these exciting developments.