Urethral strictures in men with neurogenic lower urinary tract dysfunction using intermittent catheterization for bladder evacuation

A cost-effectiveness analysis of bladder management strategies in neurogenic lower urinary tract dysfunction after spinal cord injury: A publicly funded health care perspective

STUDY DESIGN

Economic evaluation study.

OBJECTIVES

To investigate the long-term cost-effectiveness of clean intermittent catheterization (CIC) compared with suprapubic catheters (SPC) and indwelling urethral catheters (UC) among individuals with neurogenic lower urinary tract dysfunction (NLUTD) related to spinal cord injury (SCI) from a public healthcare perspective.

SETTING

University affiliated hospital in Montreal, Canada.

METHODS

A Markov model with Monte Carlo simulation was developed with a cycle length of 1 year and lifetime horizon to estimate the incremental cost per quality-adjusted life years (QALYs). Participants were assigned to treatment with either CIC or SPC or UC. Transition probabilities, efficacy data, and utility values were derived from literature and expert opinion. Costs were obtained from provincial health system and hospital data in Canadian Dollars. The primary outcome was cost per QALY. Probabilistic and one-way deterministic sensitivity analyses were performed.

RESULTS

CIC had a lifetime mean total cost of $ 29,161 for 20.91 QALYs. The model predicted that a 40-year-old person with SCI would gain an additional 1.77 QALYs and 1.72 discounted life-years gained if CIC were utilized instead of SPC at an incremental cost savings of $330. CIC confer 1.96 QALYs and 3 discounted life-years gained compared to UC with an incremental cost savings of $2496. A limitation of our analysis is the lack of direct long-term comparisons between different catheter modalities.

CONCLUSIONS

CIC appears to be a dominant and more economically attractive bladder management strategy for NLUTD compared with SPC and/or UC from the public payer perspective over a lifetime horizon.

Translation and Validation of the Intermittent Catheterization Difficulty Questionnaire (ICDQ) into Greek

Purpose

Clean intermittent self-catheterization (CISC) is a safe and effective alternative to managing incomplete bladder emptying in patients afflicted with neurogenic bladder conditions. The Intermittent Catheterisation Difficulty Questionnaire (ICDQ) is a validated questionnaire concerning the assessment of catheter use and patient difficulties during CISC. The present study aimed to translate and validate the ICDQ into the Greek language. A subsequent outcome was to substantiate the requirement of both urologist consultation with patients undergoing CISC and the detailed evaluation of various therapeutic options with the consultation of other specialist physicians.

Material and Methods

The study was undertaken between March 2022 and July 2022 and involved patients in an outpatient department of a Rehabilitation Centre. Sixty-two neurologic patients suffering from spinal cord injury (SCI), multiple sclerosis (MS), cauda equina (CE), and myelitis represented a convenience sample. To calculate test-retest reliability, patients filled out two consecutive questionnaires; an initial one and a second after one week. The socio and demographic circumstances of all participants were evaluated.

Results

The mean ICDQ total score at the test and retest was 5.96±1.28 (mean total score ± standard deviation) and 5.91±1.29, respectively. Evaluation of the data concerning alterations between men and women did not reveal statistically significant differences. Cronbach’s alpha coefficient was 0.94, which proves the inter-correlation between the different topics. An ICC of 0.97 indicated very high intra-rater reliability.

Conclusion

ICDQ, a valid and reliable self-administered screening tool for CISC difficulties faced by patients using this procedure regularly, was successfully translated and validated into Greek. A more detailed evaluation and understanding of these difficulties would enhance the quality of CISC and allow for more suitable treatment and the selection of catheter types used. These improved treatment strategies are possible as repeated use and constant comparison of ICDQ scores determine treatment impact, facilitating treatment regimen modification, should it be required.

Diagnosis and treatment of urethral stricture in men with neurogenic lower urinary tract dysfunction: A systematic review

AIM

To summarize available data focused on diagnosis and management of urethral stricture in men with neurogenic lower urinary tract dysfunction by a systematic review of the literature.

MATERIALS AND METHODS

A systematic review of the literature was carried out through an extensive electronic database search performed in PubMed/MEDLINE and Scopus databases for full texts, and International Continence Society, American Urology Association, and European Association of Urology abstracts for citations related to urethral structure. This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis.

RESULTS

A total of 316 articles were identified, 48 of which were selected for this review. Different strategies are currently being used for the management of urethral strictures, such as clean intermittent catheterization (CIC) which reduces stricture by up to 68%; direct vision internal urethrotomy which shows lower rates of renarrowing; urethroplasty which shows a success rate up to 70%; urinary diversion is the treatment of choice when reconstruction is not possible.

CONCLUSIONS

Further studies are needed in this population because of the heterogeneity of the outcomes and the lack of a standardized definition and classification of this population.

Optimising patients with long-term spinal cord injury for nephrectomy: A review of pre-, peri- and post-operative factors to safeguard outcomes

Objectives:

To review the potential challenges a urologist may encounter when embarking on simple/partial/radical nephrectomy in patients with long-term spinal cord injury and propose strategies to pre-empt and manage these.

Materials and methods:

Comprehensive literature review via PubMed, MEDLINE® and Google™ Scholar searching for relevant scientific articles published to date in English. Recommendations for strategies to safeguard surgical outcomes discussed with a panel of experienced upper-tract urologists.

Results:

Pre-operative considerations:  - urethral assessment via flexible cystoscopy due to higher incidence of urethral pathology in spinal cord injury;  - assessing for chronic constipation and distended bowel; and  - considering glomerular filtration rate assessment by radio-isotope techniques, such as 51chromium-EDTA Peri-operative considerations:  - adequate theatre staffing for safe patient transfer; and  - planned choice of incision, due to higher incidence of previous abdominal surgery, stoma bags and/or foreign body devices. Post-operative considerations:  - ensuring attending medical staff are trained to recognise autonomic dysreflexia;  - early re-mobilisation with physiotherapists experienced in treating spinal cord injury; and  - attentive antibiotic stewardship due to higher risk of hospital-acquired or urinary infections

Conclusions:

Patients with long-term spinal cord injury pose significant potential challenges in the pre-, peri- and post-operative stages of nephrectomy. Familiarisation and optimisation of such factors is recommended to safeguard outcomes.

Level of evidence:

Not applicable for this multicentre audit.

Vesicocutaneous fistula: continent vesicostomy, an easier route for comfortable clean intermittent catheterization

INTRODUCTION

Clean intermittent catheterization (CIC) through the urethra is the treatment of choice for patients with neurogenic bladder (NGB) or other etiologies that lead to incomplete bladder emptying. However, urethral catheterization can be problematic. Vesicocutaneous fistula (VCF) is a continent catheterizable channel with a low rate of complications. The aim of the study was to evaluate the safety and effectiveness of VCF as a route for CIC.

MATERIAL AND METHODS

The authors retrospectively reviewed patients who underwent creation of the VCF for bladder drainage from November 2001 to December 2017. Demographics, indication for VCF, pre-operative and postoperative laboratory/radiologic studies, incidence of febrile urinary tract infection (UTI), and adherence to CIC through VCF were examined.

RESULTS

Vesicocutaneous fistula was created in a total of 20 patients (nine males and 11 females; median age, 13.2 years [range: 3.8 months-22.8 years]). The median follow-up time was 30.5 months (range: 5.9 months-16.9 years). The underlying etiologies that resulted in NGB included spina bifida (n = 10), cerebral palsy (n = 2), caudal regression syndrome (n = 2), and others (n = 6). Before creation of the VCF, 13 patients (65%) had either grade ≥3 unilateral or bilateral hydronephrosis as per the Society for Fetal Urology grading system. Thirteen patients (65%) had experienced at least one febrile UTI the year before the creation of the VCF. At the last follow-up, renal function was improved or stabilized in 14 patients (70%). Fifteen patients (75%) had experienced no febrile UTI in the last 1 year. Upper urinary tract dilatation resolved or improved in 10 patients (77%). The VCF continence rate was 88%. In this study, bladder augmentation or the Mitrofanoff procedure was not performed. During maturation, nine patients (45%) had granuloma; five of those cases subsided within 2 years without any intervention. Five patients had VCF stricture, and only one required revision surgery (5%).

DISCUSSION

The VCF continence rate was comparable with that of the Mitrofanoff procedure. Adherence to CIC through VCF lowered the rate of UTI and preserved the upper urinary tract. Bladder emptying by CIC through VCF provided the same benefits as those of the Mitrofanoff procedure: extra privacy, social independence, and reduction of parental burden. Although a long maturation stage of 6 months was required, the rate of major complications was low. Most complications were conservatively manageable and seldom required revision surgery.

CONCLUSIONS

Vesicocutaneous fistula is a continent catheterizable conduit, an alternative option for bladder management in patients with NGB who cannot undergo urethral CIC smoothly.

Classification systems for anterior urethral stricture disease in men: a systematic review

OBJECTIVE

To identify and explore the various classification systems that have been proposed for anterior urethral stricture disease (AUSD) and to identify the advantages and disadvantages of each.

METHODS

A comprehensive systematic review was conducted in MEDLINE, EMBASE, SCOPUS and COCHRANE databases with a search strategy created appropriately. Titles and abstracts of search results were screened by two authors and selected for full-text review. Studies exploring urethral stricture classification, clinical scoring or staging systems used in men over the age of 18 with benign anterior urethral stricture disease were included.

RESULTS

The search identified 3113 articles, of which 10 were selected for inclusion after scrutiny. Four classification systems were identified. These include ULTRA score, urethral stricture score, cystoscopy-based staging system and Gombe Urethrographic score. These were based on various modalities, including cystoscopy, retrograde urethrogram (RUG) and sonourethrogram (SUG). From the scoring systems identified, the urethral stricture scoring system has multiple external validation studies and is predictive of operative complexity, operative time, recurrence and postoperative complications.

CONCLUSIONS

Several classification systems have been proposed for AUSD. Each has its advantages and disadvantages. The urethral stricture score has been externally validated and shown to been predictive of surgical outcomes and recurrence. There are no scores that incorporate patient-related outcome measures (PROMs). Many classification systems have yet to provide sufficient external validation. Further external validation studies are needed before the general adoption of a particular system.

Adult Neurogenic Lower Urinary Tract Dysfunction and Intermittent Catheterisation in a Community Setting: Risk Factors Model for Urinary Tract Infections

A risk factor model for urinary tract infections in patients with adult neurogenic lower urinary tract dysfunction performing clean intermittent catheterisation was developed; it consists of four domains, namely, (1) general (systemic) conditions in the patient, (2) individual urinary tract conditions in the patient, (3) routine aspects related to the patient, and (4) factors related to intermittent catheters per se. The conceptual model primarily concerns patients with spinal cord injury, spina bifida, multiple sclerosis, or cauda equina where intermittent catheterisation is a normal part of the bladder management. On basis of several literature searches and author consensus in case of lacking evidence, the model intends to provide an overview of the risk factors involved in urinary tract infections, with specific emphasis to describe those that in daily practice can be handled and modified by the clinician and so come to the benefit of the individual catheter user in terms of fewer urinary tract infections.

Surveillance and management of urologic complications after spinal cord injury

PURPOSE

Neurogenic bladder due to spinal cord injury has significant consequences for patients' health and quality of life. Regular surveillance is required to assess the status of the upper and lower urinary lower urinary tracts and prevent their deterioration. In this review, we examine surveillance techniques in neurogenic bladder, describe common complications of this disease, and address strategies for their management.

METHODS

This work represents the efforts of SIU-ICUD joint consultation on Urologic Management of the Spinal Cord injury. For this specific topic, a workgroup was formed and comprehensive literature search of English language manuscripts regarding neurogenic bladder management was performed using key words of neurogenic bladder. Articles were compiled, and recommendations in the chapter are based on group discussion and follow the Oxford Centre for Evidence-based Medicine system for Levels of Evidence (LOEs) and Grades of Recommendation (GORs).

RESULTS

At a minimum, patients should undergo an annual history and physical examination, renal functional testing (e.g., serum creatinine), and upper tract imaging (e.g., renal ultrasonography). The existing evidence does not support the use of other modalities, such as cystoscopy or urodynamics, for routine surveillance. Urologic complications in neurogenic bladder patients are common and often more complex than in the general population.

CONCLUSIONS

There is a shortage of high-quality evidence to support any particular neurogenic bladder surveillance protocol. However, there is consensus regarding certain aspects of regular genitourinary system evaluation in these patients. Proper surveillance allows the clinician to avoid or address common urological complications, and to guide, alter, or maintain appropriate therapeutic regimens for individual patients.

Surgical Management of Anatomic Bladder Outlet Obstruction in Males with Neurogenic Bladder Dysfunction: A Systematic Review

CONTEXT

Surgical treatment of anatomic bladder outlet obstruction (BOO) may be indicated in males with neurogenic bladder dysfunction. A bothersome complication after surgery is urinary incontinence.

OBJECTIVE

To identify the optimal practice in the surgical treatment of anatomic BOO in males with neurogenic bladder dysfunction, due to multiple sclerosis, Parkinson disease, spinal cord injury (SCI), spina bifida, or cerebrovascular accident (CVA).

EVIDENCE ACQUISITION

A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Medline, Embase, Cochrane controlled trial databases, Web of Science, and Google Scholar were searched for publications until January 2017.

EVIDENCE SYNTHESIS

A total of 930 abstracts were screened. Eight studies were included. The types of anatomic BOO discussed were benign prostate obstruction, urethral stricture, and bladder neck sclerosis. The identified surgical treatments were transurethral resection of the prostate (TURP) in patients with Parkinson, CVA or SCI, endoscopic treatment of urethral stricture by laser ablation or urethrotomy (mainly in SCI patients), and bladder neck resection (BNR) in SCI patients. The outcome of TURP may be highly variable, and includes persistent or de novo urinary incontinence, regained normal micturition control, and urinary continence. Good results were seen in BNR and endoscopic urethrotomy studies. Laser ablation and cold knife urethrotomy resulted in restarting intermittent catheterization or adequate voiding. Overall, a high risk of bias was found.

CONCLUSIONS

This systematic review provides an overview of the current literature on the outcome of several surgical approaches of different types of anatomic BOO in males with neurogenic bladder dysfunction. Identifying the optimal practice was impossible due to limited availability of high-quality studies.

PATIENT SUMMARY

The outcome of several surgical approaches in males with neurogenic bladder dysfunction with benign prostate obstruction, urethral stricture, or bladder neck sclerosis is overviewed. The optimal practice could not be identified.

Rehabilitation Nurses' Knowledge, Attitudes, and Behaviors for Preventing Urinary Tract Infections From Intermittent Catheterization

PURPOSE

The aim of this study was to develop and examine the reliability of a survey to assess knowledge, attitudes, and behaviors (KAB) of rehabilitation nurses for preventing urinary tract infections in persons requiring intermittent catheterization.

DESIGN

Cross-sectional survey with principal component analysis.

METHODS

Survey development and administration based on national guidelines.

FINDINGS

Principal component analysis produced three reliable components of KAB explaining 54.5% of response variance. Results indicate that nurses report adequate knowledge and training. Although the facility had an evidence-based online catheterization procedure, staff reported that the procedure was not helpful nor useable. Twenty-eight percent incorrectly identified the root cause of urinary tract infection, and 45% reported that other nurses always washed their hands. Barriers to using standard intermittent catheterization technique were staff, time, and patient variables.

CONCLUSION

The modified survey is a reliable measure of KAB.

CLINICAL RELEVANCE

The survey assists with identifying knowledge gaps, customizing education, and changing practice.

Results of a prospective randomized control trial comparing hydrophilic to uncoated catheters in children with neurogenic bladder

INTRODUCTION

Children with neurogenic bladder (NGB) often require a lifetime of clean intermittent catheterization (CIC), typically using uncoated catheters (UCs). Hydrophilic catheters (HCs) have lower friction than UCs with reported less damage to the urethra. The purpose of this study is to compare outcomes between these catheters.

METHODS

An investigator-initiated, prospective, randomized clinical trial was conducted to compare HCs versus UCs. Children aged 2-17 years with NGB on CIC were enrolled for 1 year. Block randomization was used. Dexterity scores were obtained in those who perform self-catheterization. Outcomes were UTI, difficulty passing the catheter, urethral injury, and patient satisfaction.

RESULTS

Demographic data is presented in the Table. Seventy-eight patients were enrolled. Age and gender were similar between the groups. Fifteen patients in each group performed CIC via an abdominal wall stoma. Eight and 15 patients withdrew from the UC and HC groups, respectively. The HC group overall had more problems with the catheter, mainly difficulty with handling. There were no differences for passing the catheter, pain, hematuria, or urethral injuries. There were two urinary tract infections (UTIs) in two HC patients and 17 UTIs in seven UC patients (p = 0.003). Patients with UTIs in the HC group went from 16% in the previous year to 5% during the study. Three children in the HC group had three or more UTIs in the year before enrollment and none during the study. The patients that completed the study with HC were overall satisfied and many requested to continue with the HC.

CONCLUSIONS

HCs may decrease the risk of UTI in children with NGB. Urethral complications were low in both groups. Most HC patients were pleased but some found the slippery coating difficult to handle.