Holmium laser resection of the prostate (HoLRP) This technique copies that of TURP, whereby the precise cutting ability of the holmium laser is used to remove pieces of prostate down to the capsule to create a large and relatively bloodless channel. It can be used INVASIVE SURGICAL ALTERNATIVES TO TURP 99 on prostate glands of all sizes. Again, it has short catheterization times and hospital sta ys and is associated with minimal post-operative dysuria.18 1 Hammadeh MY, Madaan S, Hines J, Philp T (2000) Transurethral electrovaporization of the p rostate after 5 years; is it effective and durable? BJU Int 86:648 \200\22351. 2 Mc Allister WJ, Karim O, Plail RO, et al. (2003) Transurethral electrovaporization of the prostate: is it any better than conventional transurethral resection of the prostate? BJU Int 91:211 \200\2234. 3 National Institute for Health and Clinical Excellence (2010) The management of lower urin ary tract symptoms in men [online]. Available from: M www.nice.org.uk/CG97. 4 Sandhu JS, Ng C, Vanderbrink BA, et al. (2004) High-power potassium-titanyl-phosphate pho toselective laser vaporization of prostate for treatment of benign prostatic hyperplasia in men with large prostates. J Urol 64:1155 \200\2239. 5 Sandhu JS, Ng CK, Gonzalez RR, et al. (2005) Photoselective laser vaporization prostatect omy in men receiving anti-coagulants. J Endourol 19:1196 \200\2238. 6 National Institute for Health and Clinical Excellence (2010) The management of lower urin ary tract symptoms in men [online]. Available from: M www.nice.org.uk/CG97. 7 Sandhu JS, Ng CK, Gonzalez RR, et al. (2005) Photoselective laser vaporization prostatect omy in men receiving anti-coagulants. J Endourol 19:1196 \200\2238. 8 Sarica K, Alkan E, L leci H, et al. (2005) Photoselective vaporization of the enlarged p rostate with KTP laser: long-term results in 240 patients. J Endourol 19:1199 \200\223202. 9 Bachmann A, Sch rch L, Ruszat R, et al. (2005) Photoselective vaporization (PVP) versus transurethral resection of the prostate (TURP): a prospective bi-center study of perioperat ive morbidity and early functional outcome. Eur Urol 48:965 \200\22372. 10 Bouchier-Hayes DM, Anderson P, Van Appledorn S, et al. (2006) KTP laser versus transure- thral resection: early results of a randomized trial. J Endourol 20:580 \200\2235. 11 Sandhu JS, Ng C, Vanderbrink BA, et al. (2004) High-power potassium-titanyl-phosphate ph otoselective laser vaporization of prostate for treatment of benign prostatic hyperplasia i n men with large prostates. J Urol 64:1155 \200\2239. 12 Malek RS, Kuntzman RS, Barrett DM (2005) Photoselective potassium-titanyl-phosphate lase r vaporization of the benign obstructive prostate: observations on long-term outcomes. J Ur ol 174:1344 \200\2238. 13 Wilson LC, Gilling PJ, Williams A, et al. (2006) A randomized trial comparing holmium la ser enucleation versus transurethral resection in the treatment of prostates larger than 40 grams: results at 2 years. Eur Urol 50:569 \200\22373. 14 Elzayat EA, Habib EI, Elhilali MM (2005) Holmium laser enucleation of the prostate: a si ze-independent new \200\230gold standard \200\231. Urology 66:108 \200\22313. 15 Kuntz RM, Ahyai S, Lehrich K (2006) Transurethral holmium laser enucleation of the pros- tate compared with transvesical open prostatectomy: 3 years follow-up of a randomized tria l. Proc SPIE 6078:11. 16 Tan AHH, Gilling PJ, Kennett KM, et al. (2003) Long-term results of high-power holmium l aser vaporization (ablation) of the prostate. BJU Int 92:707 \200\2239. 17 Mottet N, Anidjar M, Bourdon O, et al. (1999) Randomized comparison of transurethral ele c- troresection and holmium:YAG laser vaporization for symptomatic benign prostatic hyperpl asia. J Endourol 13:127 \200\22330. 18 Gilling PJ, Cass CB, Cresswell MD, et al. (1996) The use of holmium laser in the treatme nt of benign prostatic hyperplasia. J Endourol 5:459-61. CHAPTER 4 Bladder outlet obstruction 100 TURP and open prostatectomy TURP Removal of the obstructing tissue of BPH or obstructing pr ostate can- cer from within the prostatic urethra, leaving the compressed outer zone intact (the \200\230surgical capsule \200\231). An electrically heated wire loop is used, throug h a resectoscope, to cut the tissue and diathermy bleeding vessels. The cut \200\230chips \200\231 of prostate are pushed back into the bladder by the \202 ow of irrigating \202 uid and at the end of resection, are evacuated using specially designed \200\230evacuator s \200\231 \200\224a plastic or glass chamber attached to a rubber bulb which allows \202 uid to be \202 ushed in and out of the bladder. Indications for TURP \200 Bothersome LUTS that fail to respond to changes in lifestyle or medical therapy. Recurrent acute urinary retention. Renal impairment due to BOO (high-pressure retention). Recurrent h aematuria due to BPE. Bladder stones due to prostatic obstruction. \200 chronic urinary \200 Open prostatectomy Indications \200 \200 \200 \200 \200 Large prostate (>100g). TURP not technically possible (e.g. limited hip abduction). Failed TURP (e.g. because of bleeding). Urethra too long for the resectoscope to gain access to th e prostate. Presence of bladder stones which are too large for endoscopic cystolitholapaxy, combined with marked enlargement of the prostate. Contraindications \200 \200 Small \201 brous prostate. Prior prostatectomy in which most of the gland has been resect ed or removed; this obliterates the tissue planes. Carcinoma of the prostate. Techniques Suprapubic (transvesical) The preferred operation if enlargement of the prostate involves mainly the middle lobe. The bladder is opened, the mucosa around the protruding a denoma is incised, and the plane between the adenoma and capsule is developed to enucleate the adenoma. A 22 Ch urethral and a suprapubic catheter are left, together with a retropubi c drain. Remove the urethral catheter in 3 days and clamp the suprapubic at 6 days, removin g it 24h later. The drain can be removed 24h after this (day 8). Simple retropubic Popularized by Terence Millin (Ireland, 1947). Compared with the suprapu- bic (transvesical) approach, it allows more precise anatomic exposure of the prostate, thu s giving better visualization of the prostatic cavity, which allows more accurate removal o f the adenoma, better control of bleeding TURP AND OPEN PROSTATECTOMY 101 points, and more accurate division of the urethra so reducing the risk of incontinence. As well as the contraindications noted, the retropubic approach should not be employed when the middle lobe is very large because it is dif \201 cult to get behind the middle lobe a nd so to incise the mucosa (safely) distal to the ureters. The prostate is exposed by a Pfannenstiel or lower midline incision. Haemostasis is achieve d before enucleating the prostate by ligating the dorsal vein complex with sutures placed d eeply through the prostate. The prostatic capsule and adenoma are incised transversely with the dia- thermy just distal to the bladder neck. The plane between the capsule and adenoma is found with scissors and developed with a \201 nger. Sutures are used for haemostasis. A wedge of bladder neck is resected. A catheter is inserted and left for 5 days and the tr ansverse capsular incision is closed. A large tube drain (30Ch Robinson \200\231s) is left for 1 \200\2232 days. Complications \200 \200 \200 Hemorrhage. Urinary infection. Rectal perforation (close and cover with a colostomy). CHAPTER 4 Bladder outlet obstruction 102 Acute urinary retention: de \201 nition, pathophysiology, and causes De \201 nition Painf ul inability to void, with relief of pain following drainage of the bladder by catheterizat ion. The combination of reduced or absent urine output with lower abdominal pain is not, in itse lf, enough to make a diagnosis of acute retention. Many acute surgical conditions cause abd ominal pain and \202 uid depletion, the latter leading to reduced urine output and this r educed urine output can give the erroneous impression that the patient is in retention when in fact they are not. Thus central to the diagnosis is the presence of a large vol- ume of urine which, when drained by catheterization, leads to resolution of the pain. What repres ents \200\230large \200\231 has not been strictly de \201 ned, but volumes of 500 \200 \223800mL are typical. Volumes <500mL should lead one to question the diagnosis. Volumes >8 00mL may be de \201 ned as acute-on-chronic retention. Pathophysiology Normal micturition requires: \200 \200 \200 \200 Afferent input to the brainstem and cerebral cortex. Coordinated relaxation of the external sphincter. Sustained detrusor contraction. The absence of an anatomic obstruction in the o utlet of the bladder. Four broad mechanisms can lead to urinary retention: \200 \200 \200 \200 Increased urethral Low bladder pressure (i.e. impaired bladder contractility). Interruption of sensory or motor innervation of bladder. Central failure of coordination of bladder con traction with external sphincter relaxation. resistance (i.e. BOO). Causes in men \200 \200 \200 Benign prostatic enlargement. Malignant enlargement of prostate. Urethral stricture; prosta tic abscess. Urinary retention in men is either spontaneous or precipitated by an event. Precipitated re tention is less likely to recur once the event, which caused it, has been removed. Spontane ous retention is more likely to recur after trial of catheter removal and therefore, to req uire de \201 nitive treatment (e.g. TURP). Precipitating events include anesthetic and oth er drugs (anti- cholinergics, sympathomimetic agents such as ephedrine in nasal decon- gest ants); non-prostatic abdominal or perineal surgery; immobility following surgical procedure s. Risk factors for retention in men Advancing age is a strong predictor of the risk of urinar y retention in men. Other factors that predict risk of urinary retention are the pres- ence of LUTS (higher symptom scores), previous episodes of spontaneous AUR: DEFINITION, PATHOPHYSIOLOGY, AND CAUSES 103 retention, low Qmax (though there is some debate), and larger prostate volume. Elevated PVR does not seem to predict risk of retention and nor does treatment with anticholinergic med ication.1 Causes of acute urinary retention in either sex \200 \200 \200 \200 Haematuria, leading to clot retention. Drugs (as above). Pain (adrenergic stimulation of th e bladder neck). Post-operative retention (see Risk factors for post-operative retention). Sacral cord (S2 \200\2234) injury. Sacral (S2 \200\2234) nerve or compression or damage, re sulting in detrusor are \202 exia \200\224cauda equina compression (due to prolapsed L2 \200\223L3 disc or L3 \200\223L4 intervertebral disc pressing on sacral nerve roots of the cauda equina, trauma to vertebrae, benign or metastatic tumors). Suprasacral spinal cord in jury (results in loss of coordination of external sphincter relaxation with detrusor contra ction \200\224so-called detrusor sphincter dyssynergia (DSD) \200\224so external sphincter contracts when bladder contracts). Radical pelvic surgery damaging pelvic parasympathetic p lexus (radical hysterectomy, abdominoperineal resection): unilateral injury to pelvic plexu s (preganglionic parasympathetic and post-ganglionic sympathetic neurons) denervates motor innervation of detrusor muscle. Pelvic fracture rupturing urethra (more likely in men than women). Neurotropic viruses involving sensory dorsal root ganglia of S2 \200\2234 (Herpes s implex or zoster). Multiple sclerosis (can affect any part of CNS; Fig. 4.2); retention cau sed by detrusor are \202 exia or DSD. Transverse myelitis. Diabetic cystopathy (causes sen sory and motor dysfunction). Damage to dorsal columns of spinal cord, causing loss of bladd er sensation (tabes dorsalis, pernicious anemia). \200 \200 \200 \200 Causes in women \200 Pelvic prolapse (cystocoele, rectocoele, uterine); urethral stricture; urethral diverticulu m. Post-surgery for \200\230stress \200\231 incontinence. Pelvic masses (e.g. ovarian mass es). Fowler \200\231s syndrome: increased electromyographic activity can be recorded in the external urethral sphincters of these women (which, on ultrasound, is of increased volume) and is hypothesized to cause impaired relaxation of external sphincter; occurs in premenop ausal women, often in association with polycystic ovaries. \200 \200 Risk factors for post-operative retention Instrumentation of lower urinary tract; surgery t o perineum or anorectum; gynecological surgery; bladder overdistension; reduced sensation o f blad- der fullness; pre-existing prostatic obstruction; epidural anesthesia. Post- partum retention is not uncommon, particularly with epidural anesthesia and instrumental delivery . CHAPTER 4 Bladder outlet obstruction 104 Fig. 4.2 MRI of cervical and sacral cord in a young patient presenting with urinary retenti on. The patient had undiagnosed multiple sclerosis. Signal changes are seen in the cervical , thoracic, and lumbosacral cord. 1 Kaplan SA, Wein AJ, Staskin DR, Roehrborn CG, Steers WD (2008). Urinary retention and pos t-void residual urine in men: separating truth from tradition. J Urol 180:47 \200\22354. This page intentionally left blank CHAPTER 4 Bladder outlet obstruction 106 Acute urinary retention: initial and de \201 nitive management Initial management Urethral catheterization to relieve pain (suprapubic catheterization if ure- thral route not possib le). Record the volume drained \200\224this con \201 rms the diagnosis, determines subsequ ent management, and provides prognostic information with regards to outcome from this treat ment. De \201 nitive management in men Discuss trial without catheter (TWOC) with the patient. P recipitated retention often does not recur; spontaneous retention often does. Fifty percent with spontaneous retention will experience a second episode of retention within the next w eek or so and 70% within the next year. A maximum \202 ow rate (Qmax) <5mL/s and low void ing detrusor pres- sure predict subsequent retention. Thus while most will require de \201 nitive treatment (e.g. TURP), a substantial minority will get away without needing surgery . In men, mortality in the \201 rst year after acute urinary retention is 2 \200\2233 times higher than the general male population. Not surprisingly it increases with age (Table 4.5 ). A substantial proportion of this increased mortality seems to be linked to comorbidity i n these men.1 Thus when deciding whether to \200\230subject \200\231 a man to TURP for ret ention, remember that acute retention represents a harbinger of severe systemic disease. A care- ful assessment for comorbidity (cardiovascular disease, diabetes, chronic pulmonary d isease) should be made and referral for appropriate specialist advice on management of this comorbidity should be considered. Table 4.5 One-year mortality rates in men with acute retention Age (y) Spontaneous acute retention (%) Precipitated acute retention (%) 45 \200\22354 4 10 85 or over 33 45 All ages 15 25 Options to avoid TURP \200 Prostate shrinking drugs followed by a TWOC several months later (5 -reductase inhibitors in those with benign-feeling prostates, luteinizing hormone-releasing hormone (LHRH) agonis ts in those with malignant feeling prostates on DRE, con \201 rmed by TURS-guided prostate biopsy). Prostatic stents. Long-term urethral or suprapubic catheter. Clean intermittent s elf-catheterization (CISC) \200\224not a realistic option for most men, but some will be ab le and happy to do this. \200 \200 AUR: INITIAL AND DEFINITIVE MANAGEMENT 107 De \201 nitive management in women CISC, either until normal voiding function recovers or permanently if it does not. Fowler \200\231s syndrome \200\224sacral neuromodulation (e.g. Medtronic Interstim). Risks and outcomes of TURP for retention Relative risks of TURP for retention vs TURP for L UTS: post-operative complications, 26:1; blood transfusion, 2.5:1; in-hospital death, 3:1.1 ,2 Failure to void after initial catheter removal: high retention volume, greater age, and low maximum detrusor pressure are predictive for failure to void after TURP. Ten percent in th ose with acute retention of urine and 40% in those with acute-on-chronic retention fail to void after initial post-TURP TWOC. Overall, 1% of men will fail to void after subsequent TW OCs and will require long-term catheterization.3 1 Armitage JN, Sibanda N, Cathcart P, et al. (2008) Mortality in men admitted to hospital w ith acute urinary retention: database analysis. BMJ 335:1199 \200\223202. 2 Pickard R, Emberton M, Neal D (1998) The management of men with acute urinary retention. Br J Urol 81:712 \200\22320. 3 Reynard JM (1999) Failure to void after transuretural resection of the prostate and mode of presentation. Urology 53:336 \200\2239. CHAPTER 4 Bladder outlet obstruction 108 Indications for and technique of urethral catheterization Indications \200 \200 Relief of urinary retention. Prevention of urinary retention \200\224a period of post-opera tive catheterization is commonly employed after many operations where limited mobility make s normal voiding dif \201 cult. Monitoring of urine output (e.g. post-operatively); preven tion of damage to the bladder during Cesarean section. Bladder drainage following surgery t o the bladder, prostate, or urethra (e.g. TURP, TURBT, open bladder stone removal, radical prostatectomy). Bladder drainage following injuries to the bladder. Technique Explain the need for and method of catheterization to the patient. Use the smalle st catheter \200\224in practical terms, usually a 12Ch, with a 10mL bal- loon. For longer c atheterization periods (weeks), use a silastic catheter to limit tissue \200\230reaction \200\231, thereby reducing risk of a catheter-induced urethral stricture. If clot retention , use a 3-way catheter (20Ch or greater) to allow evacuation of clots and bladder irrigatio n to prevent subsequent catheter blockage. Technique is aseptic. One gloved hand is sterile, the other is \200\230dirty \200\231. Dir ty hand holds penis or separates labia to allow cleansing of urethral meatus; this hand sho uld not touch catheter. Use sterile water or sterile cleaning solution to \200\230prep \200\231 skin around meatus. Apply lubricant jelly to urethra. Traditionally, this contains local anaes- thetic (e.g. 2% lignocaine), which takes between 3 and 5min to work. However, a randomized, placebo-contro lled trial showed that 2% ligno- caine was no more effective for pain relief than anestheti c-free lubri- cant,1 suggesting that it is lubricant action that prevents urethral pain. If using local anesthetic lubricant, warn patient that it may \200\230STING \200\231. Local anesthetic lubricant is contraindicated in patients with allergies to local anesthetics and in those with urethral trauma where there is a (theoreti- cal) risk of complications arisi ng from systemic absorption of lignocaine. When instilling jelly, do so gently \200\224a su dden, forceful depression of the plunger of the syringe can rupture the urethra! In male, \200\230milk \200\231 gel towards posterior urethra while squeezing meatus to prevent it fr om coming back out of meatus. Insert the catheter using sterile hand until \202 ow of urine con \201 rms it is in the bladder. Failure of urine \202 ow may indicate that the catheter balloon is in the urethr a. Intraurethral in \202 ation of balloon can rupture urethra. If no urine \202 ows, att empt aspiration of urine using a 50mL blad- der syringe (lubricant gel can occlude eye-hole s of catheter). Absence of urine \202 ow indicates either catheter is not in the bladder or, if the indication for catheterization is retention, that the diagnosis is wrong TECHNIQUE OF URETHRAL CATHETERIZATION 109 (there will usually be a few mL of urine in the bladder even in cases where the absence of micturition is due to oliguria or anuria so complete absence of urine \202 ow usually ind icates the catheter is not in the bladder). If the catheter will not pass into the bladder and you are sure that the patient is in retention, proceed with suprapubic catheterization. 1 Birch BR (1994) Flexible cystoscopy in men: is topical anesthesia with lignocaine gel wor thwhile? Br J Urol 73:155. CHAPTER 4 Bladder outlet obstruction 110 Technique of suprapubic catheterization Indications \200 \200 Failed urethral catheterization in urinary retention. Preferred site for long-term catheter s, e.g. intractable urinary incontinence where other methods have failed; neurological dise ase (long-term bladder management in spinal cord injury or multiple sclerosis). Long-term u rethral catheters commonly lead to acquired hypospadias in males (ventral splitting of glan s penis) and patulous urethra in females (leading to frequent balloon expulsion and bypassi ng of urine around the catheter); hence, suprapubic site is preferred for long-term cathete rs. Used in the initial management of urethral trauma where urethral catheterization has fa iled. Contraindications Insertion of suprapubic catheterization is best avoided in: \200 Patients with clot retention, the cause of which may be an underlying bladder cancer (the c ancer could be \200\230spread \200\231 along the catheter track to involve the skin). Pati ents with known carcinoma of the bladder. Patients with lower midline incisions (bowel may be \200\230stuck \200\231 to the deep aspect of the scar, leading to the potential for bow el perforation). Pelvic fractures, where the catheter may inadvertently enter the large pel vic haematoma which always accompanies severe pelvic fracture. This can lead to infection o f the haematoma and the resulting sepsis can be fatal. Failure to pass a urethral catheter in a patient with a pelvic fracture usually indicates a urethral rupture (con \201 rmed by urethrography) and is an indication for formal open, suprapubic cystotomy. Patients on ant icoagulation and antiplatelet treatment. Abdominal wall sepsis. Patients with subcutaneous vascular graft in the suprapubic region, e.g. femoro-femoral cross-over graft. \200 \200 \200 Assessment prior to insertion \200 \200 Ask if previous abdominal surgery in the suprapubic or pelvic region. Enquire if there is n eurological disease (bladder capacity often small and urethral incompetence in women is com mon which makes bladder distension dif \201 cult; spinal cord injury (SCI) autonomic dysre \202 exia is common in bladder distension so a spinal or general anesthetic may be requir ed). Abdominal examination: inspect for lower abdominal scars; palpate and percuss the lowe r abdomen to con \201 rm the bladder is distended. Consider stopping anticoagulation (or m odifying with heparin \200\230bridging \200\231 therapy) and antiplatelet treatment if saf e to do so. TECHNIQUE OF SUPRAPUBIC CATHETERIZATION 111 Consent for suprapubic catheter (SPC) insertion British Association of Urological Surgeons (BAUS) suprapubic catheter practice guidelines. Risks include: \200 \200 \200 \200 \200 Hemorrhage, including haematuria and intra-abdominal bleeding. Infection, including UTI and infection of track site or wound. Pain. Injury to abdominal organs. General risks of long- term catheterization. Technique Local anesthetic or spinal or general anesthetic if: \200 \200 At risk of autonomic dysre \202 exia (or at patient \200\231s request). The bladder cannot be distended suf \201 ciently to allow safe SPC insertion. Give antibiotic prophylaxis if there is likely to be urine bacterial colonization. Prior to insertion of trocar, be sure to con \201 rm the diagnosis by: Abdominal examinati on (palpate and percuss lower abdomen to con \201 rm bladder is distended). Ultrasound: BA US suprapubic catheter practice guidelines state that ultrasound can be used to determine i f there is interposing bowel in the planned suprapubic track \200\230if carried out by a c ompetent, trained practitioner \200\231. They do not de \201 ne \200\230competent \200 \231 or \200\230trained \200\231. They admit that \200\230the reliability of ultrasonogra phy in excluding the presence of a loop of intestine in the suprapubic region has not been formally evaluated \200\231. Aspiration of urine using a 21G (green) needle, usually 2cm ab ove the pubic symphysis. Use a wide-bore trocar if you anticipate that the catheter will be in place for more than 2 4h (small-bore catheters will block within a few days). Aim to place the catheter about 2cm above the pubis symphysis. Placement too close to the symphysis will result in dif \201 c ult trocar insertion (the tro- car will hit the symphysis). Instill a few mL of local anest hetic into the skin of intended puncture site and down to the rectus sheath. Con \201 rm t he location of bladder by drawing back on the needle to aspirate urine from the bladder. Th is helps guide the angle of trocar insertion. Make a 1cm incision with a sharp blade throug h the skin. Hold the trocar handle in your right hand and steady the needle end with your l eft hand (this hand helps prevent insertion too deeply). Push the trocar in the same direct ion in which you previously aspirated urine. As soon as urine issues from the trocar, withd raw the latter, holding the attached sheath in place. Push the catheter in as far as it wil l go. In \202 ate the balloon. Peel away the side of the sheath and remove it. Complications of urethral and suprapubic catheters At the time of insertion \200 Bowel perforation that accounts for the reported mortality of SPC insertion of 1 \200\2232% .1,2 Try to avoid the temptation to describe SPC insertion as a \200\230minor \200\231 pro cedure. BAUS suprapubic catheter practice CHAPTER 4 Bladder outlet obstruction 112 guidelines state the patient and their carers should be given written guidance, including i nstructions for \200\230prompt referral to the team who inserted the catheter if the patie nt is unexpectedly unwell and/ or has marked abdominal pain. The instructions should includ e contact numbers and clear instructions to make contact in the event of bleeding that is e ither heavy or persistent, symptoms to suggest infection, or the presence of lower abdomina l pain that is failing to improve or spreading away from the immediate catheter site \200 \231. Persistent haematuria (may require bladder washouts and even very occasionally, retur n to theaters for cystoscopic diathermy of the bleeding point if it can be found). Pass a u rethral catheter to assist bladder washouts and irrigation. Pull the SPC balloon back again st the anterior bladder wall to tamponade the bleeding. Track site or wound infection. Anti biotics and if an abscess, incision and drainage. The author has never seen a case of cellu litis, \200\230track infection \200\231, or abscess in over 500 SPC insertions in patients at high risk of these potential complications, i.e. SCI patients with urine bacterial colo nization. He advises patients of the very common occurrence of granulation tissue around th e SPC track and that this does not represent track infection and should not be treated with antibiotics. The track often takes many months to \200\230mature \200\231, i.e. for skin to grow down the track. BAUS suprapubic catheter practice guidelines state \200\230Systemi c antibiotics should not be used to treat uncomplicated pericatheter discharge or asymptoma tic bacteriuria \200\231. Long-term problems and complications: \200 The de \201 nition of what represents a \200\230UTI \200\231 is a source Recurrent UTIs. of much confusion and the cause of much inappropriate prescribing of antibi otics, which inevitably leads to the development of resistant bacteria in the urine. Inevit ably, any foreign body in the bladder will become colonized with bacteria very rapidly. We do not regard the mere presence of bacteria or pus cells (of whatever number) as indicative of a UTI (the presence of bacteria in the absence of constitutional symptoms of feeling un well, fever, and cloudy smelly urine is not regarded as \200\230active \200\231 infection, but rather is better termed \200\230colonization \200\231). Avoid the temptation to presc ribe antibiotics for mere colonization. Symptomatic UTIs (fever, feeling generally unwell, smelly cloudy urine) can be a very dif \201 cult problem to manage. Not infrequently, pati ents (particularly those with SCI managed with long- term catheter drainage) report such sy mptoms in the absence of any bacterial growth in the urine. Others report feeling perfectly well, for months on end, in the face of urine that is full of bacteria! Remember, although short courses of antibiotics (7 \200\22310 days) may resolve what we think may be the symp toms of UTI, no amount of antibiotics will, over the long term, be able to sterilize the ur ine of a patient with a foreign body such as a catheter in it. Low-dose antibiotics (a four th of the normal daily treatment dose) may keep the symptoms at bay or reduce the frequency of \200\230infective \200\231 episodes (but long- term use of nitrofurantoin or trimethop rim \200\224two popular low-dose antibiotics \200\224is associated, albeit rarely, with sev ere side effects such TECHNIQUE OF SUPRAPUBIC CATHETERIZATION 113 as blood dyscrasias or pulmonary \201 brosis). In some patients, the only solution is to change bladder management. There is a greater risk of pyelonephritis in the chronically cat heterized patient. Catheter blockages with bacterial bio \201 lms. Proteus mirabilis, Morg anella and Providencia species secrete a polysaccharide matrix. Within this, urease-produci ng bacteria generate ammonia from nitrogen in urine, raising urine pH and precipitating mag nesium and calcium phosphate crystals. The matrix \200\223crystal complex blocks the cathet er. Catheter blockage causes bypassing which soils the patient \200\231s clothes. Bladder d istension can cause autonomic dysre \202 exia in patients with thoracic or cervical spinal cord injuries, leading to extreme rises in blood pressure that, believe it or not, can cau se stroke and death! Regular bladder washouts and increased catheter size sometimes help. T here is a suggestion, based on in vitro experiments on catheters in the laboratory, that in termittent catheter drainage (by the use of a valve inserted between the catheter and the d rainage bag) can reduce the likelihood of catheter blockages. Whether this holds true in pa tients remains to be documented. Bladder stone formation open cystolithotomy) occurs in 1 i n 4 patients followed over a 5y period.3 \200\230Track \200\231 problems at the time of ca theter changes: removing the catheter (some catheter balloons have a \200\230memory \200 \231, retaining an awkward shape such that they resist removal); dif \201 culty reinsertin g the catheter (may require repositioning of the SPC site). In female patients managed by a long-term urethral catheter, the pressure of the catheter can cause urethral and bladder n eck erosion, leading to a so-called patulous urethra. In the male, a long-term urethral cat heter can lead to pressure atrophy of the meatus of the penis, leading to an acquired hypos padias ( \200\230kippering \200\231 of the glans penis and even the shaft of the penis). Wh ile a mild acquired hypospadias has no great functional effect, cosmetically it does. Cathe ter bypassing Management is empirical. Try as small a balloon size as possible. If the leak age is due to bladder spasms, then a smaller balloon may possibly reduce their intensity an d frequency. Anticholinergics may help as may intravesical botox injections. Other options include condom sheath drainage (in men) or bladder neck closure. This is not the minor oper ation ( \200\230just a few stitches \200\231) that patients are sometimes led to believe an d often \200\22430% of cases \200\224the closure breaks down so the leak persists. Bladder neck closure is irreversible and access to the bladder via the suprapubic track is not alwa ys easy, particularly if access to the ureteric ori \201 ces is required for upper tract e ndoscopy. Bladder cancer regarding the incidence of bladder cancer in SCI patients, some st udies suggesting an increased risk and others suggesting the risk is the same as in the non -spinal injured population.4 The author feels that the risk of SCC is greater than in the a mbulant, non-catheterized population, but that the risk is still low. The pathogenesis is l ikely to involve chronic bacterial colonization of the bladders of spinal patients, due to encrustation of the lumen of the catheter , necessitating surgical removal (endoscopic or dif \201 cultly , either around the suprapubic site or per urethra. (SCC of the bladder): there is con \202 icting evidence CHAPTER 4 Bladder outlet obstruction 114 whether managed with indwelling catheters, ISC, or sheath drainage and so the presence of t he catheter per se is not enough to induce development of a cancer. Screening cystoscopy st udies have either failed to result in a downstaging of bladder cancer when compared with no n-screened patients or have simply not detected any cases of bladder cancer. Screening cyst oscopy remains a subject of debate.5 Catheter care \200 When should the \201 rst change be done and who should do it? BAUS suprapubic catheter pr actice guidelines state \200\230It is not necessary for the \201 rst catheter change to be carried out by the team who inserted the catheter; the \201 rst change is generally de ferred for at least 2 weeks (and typically 6 \200\22312 weeks) after catheter insertion to allow the track to \200\230mature \200\231. How often should the catheter be changed? Usua lly 6 weekly to 3 monthly, but there is no hard and fast rule that a catheter must be chang ed at a given interval. To maintain bladder capacity over the long term, should the cathete r be clamped and should long-term anticholinergic medication be given? Nice idea in theory, but no evidence of ef \201 cacy of either method. Can a \202 ip- \202 ow valve be used to allow intermittent bladder emptying? Yes, as long as the patient does not get autonomic dysre \202 exia with bladder distension and does not leak urethrally with a full bladder. Can the patient or carer change the SPC? Yes, if adequately trained. What should I do for bypassing of urine (leakage of urine either per urethra or around the SPC)? Try anticholine rgics and if this fails bladder botox injections. If all else fails, a bladder neck or uret hral closure may be necessary. The catheter keeps blocking. What can I do? BAUS suprapubic catheter practice guidelines state that \200\230Repeated catheter blockages are frequently related to the development of bladder calculi \200\231. The author agrees that blockages a re \200\230related to \200\231 the same process that causes bladder stones, but catheter b lockages are not caused by bladder stones for in the authors \200\231 experience of managin g many, many hundreds of patients with bladder stones, such stones are often far too large to block the catheter eye-holes. Catheter blockages and bladder stones are caused by the sa me process \200\224chronic bacterial colonization of the bladder and any arti \201 cial de vice left within the bladder such as a catheter, followed by the development of a bio \201 lm around the colonies of bacteria, followed by in \201 ltration of this bio \201 lm wit h calcium and phosphate. This is the process of catheter encrustation (which blocks cathete rs) and it is also the process of bladder stone formation. Where blockages become problemat ic, increase the SPC size, increase \202 uid intake, and consider bladder washouts (daily or every few days) \200\224the evidence base for the ef \201 cacy of all of this is weak. The evidence base for in vivo use of a \202 ip- \202 ow valve to stop blockages is non- existent. In the authors \200\231 experience, full-dose courses of antibiotics or low-dose prophylactic antibiotics only very occasionally resolve this problem and more often than no t, lead to the emergence of multiresistant bacteria in the urine. \200 TECHNIQUE OF SUPRAPUBIC CATHETERIZATION 115 1 Ahluwalia RS, Johal N, Kouriefs C, et al. (2006) The surgical risk of suprapubic catheter insertion and long-term sequelae. Ann R Coll Surg Engl 88: 171 \200\2236. 2 Sheriff MK, Foley S, McFarlene J, et al. (1998) Long-term suprapubic catheterization: cli nical outcome and satisfaction survey. Spinal Cord 36:171 \200\2236. 3 Ord J, Lunn D, Reynard J (2003) Bladder management and risk of bladder stone formation in spinal cord injured patients. J Urol 170:1734 \200\2237. 4 Subramonian K, Cartwright RA, Harnden P, Harrison SCW (2004) Bladder cancer in patients w ith spinal cord injuries. Br J Urol Int 93:739 \200\22343. 5 Hamid R, Bycroft J, Arya M, Shah PJ (2003) Screening cystoscopy and biopsy in patients wi th neuropathic bladder and chronic suprapubic indwelling catheters: is it valid? J Urol 170 (2 Pt 1):425 \200\2237. Further reading Harrison SCW, Lawrence WT, Morley R, Pearce I, Taylor J (2011) British Association of Urolo gical Surgeons \200\231 (BAUS suprapubic catheter practice guidelines (BAUS) suprapubic cat heter practice guidelines. Br J Urol Int 107:77 \200\22385. Hamid R, Bycroft J, Arya M, Shah PJ (2003) Screening cystoscopy and biopsy in patients with neuropathic bladder and chronic suprapubic indwelling catheters: is it valid? J Urol 170(2 Pt 1):425 \200\2237. Ord J, Lunn D, Reynard J (2003) Bladder management and risk of bladder stone formation in s pinal cord injured patients. J Urol 170:1734 \200\2237. Sabbuba NA, Stickler DJ, Long M, et al. (2005) Does the valve-regulated release of urine fr om the bladder reduce the encrustation and blockage of indwelling catheters by crystalline Proteus mirabilis bio \201 lms? J Urol 173:262 \200\2236. Stickler DJ, Zimakoff J (1994) Complications of urinary tract infections associated with de vices for long-term bladder management. J Hosp Infect 28:177 \200\22394. Warren JW, Muncie HL, Hebel JR, Hall-Craggs M (1994) Long-term urethral catheterisation inc reases risk of chronic pyelonephritis and renal in \202 ammation. J Am Geriatr Soc 42:1286 \200\22390. CHAPTER 4 Bladder outlet obstruction 116 Management of nocturia and nocturnal polyuria Nocturia is often particularly resistant to t reatment. First, establish whether the patient is polyuric (>3L of urine/24h) by getting them to comp lete a frequency volume chart. If they are polyu- ric, this may account for their daytime a nd night-time voiding frequency. Establish whether they have a solute or water diuresis and the causes thereof (Box 4.1). If non-polyuric (<3L urine output/24h), determine the distribution of urine output over the 24h period. If >1/3 of urine output is between the hours of midnight and 8 a.m., then the patient has nocturnal polyuria (NP). If there is nocturnal polyuria, exclude other medical causes \200\224diabetes mellitus and inspidus, adrenal insuf \201 ciency; hypercalcaemia; liver failure; polyuric renal failure ; chronic heart failure; obstructive sleep apnoea, dependent oedema; chronic venous stasis; calcium channel blockers; diuretics; selective serotonin reuptake inhibitor antidepressant s. Non-polyuric nocturia BPH medical therapy The impact of alpha blockers, 5 -reductase inhib itors, and anticholinergics on nocturia is modest. TURP Nocturia persists in 20 \200\22340% of men after TURP.