Title: Current Concepts in Urologic Management of Individuals with SCI: Making Sense of the Evidence
1Current Concepts in Urologic Management of
Individuals with SCI Making Sense of the Evidence
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3Epidemiology Basics
- Incidence new cases in the population during
a defined time period - Reported as a rate (person-yrs) or risk
- Ex 21 new bladder cancer cases in 10,000 people
followed for 2 years - 21/20,000 person-years or 10.5/100,000p-y
- Prevalence cases with disease (new and
existing) in a population at a point in time or
during a given period of time - Ex 45 bladder cancer cases/10,000 people in 2005
4Bladder Cancer Epidemiology
- 5th most common cancer
- 12th leading cause cancer mortality
- Adjusted yearly incidence 17/100,000 py
- 54,400 new cases per year
- Males at greater risk
- Majority are transitional cell carcinoma
5Risk Factors for Bladder Cancer
- Smoking
- Male gender
- Exposure to aromatic amines
- Schistosomiasis infection
- UTI
6Challenges of Studying Bladder Cancer after SCI
- SCI is a rare condition
- Bladder cancer is relatively uncommon
- Bladder cancer may take decades to develop
7The Question Is there a heightened risk of
bladder cancer after spinal cord injury?
8Parachute use to prevent death and major trauma
related to gravitational challenge systematic
review of RCTs
- Gordon C S Smith, Jill P Pell
- BMJ 20033271459-1461 (20 December),
doi10.1136/bmj.327.7429.1459 - Individuals who insist that all interventions
need to be validated by a randomized controlled
trial need to come down to earth with a bump
9The Evidence in SCI
10The Evidence in SCI
11Recent Evidence
- Groah SL. Arch Phys Med Rehabil 2002
- 3,670 subjects contributed 39,729 p-y
- Stratified by bladder management method
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13Recent Evidence
- Groah SL. Arch Phys Med Rehabil 2002
- Age-adjusted incidence
- Indwelling catheter 77/100,000 py
- Mixed methods 56.1/100,000 py
- Non-indwelling catheter 18.6/100,000 py
- Using cox regression, only bladder management
method and age predicted disease
14Recent Evidence
- Subramonian et al. BJU Int, 2004.
- 4 cases/1334 people followed
- 30.7/100,000 person-years
- Risk reported as not statistically different from
general population and lower than reported in
other studies
15Recommendations from the PVA Guidelines
- Recommendation 6 Patient should be advised of
long-term complications of indwelling
catheterization, including - Bladder stones
- Kidney stones
- Urethral erosions
- Bladder cancer
- Epididymitis
- Recurrent symptomatic urinary tract infections
16Risk Factors for Bladder Cancer
17Bladder Cancer Surveillance
- Yang CC. Spinal Cord 199937204-7
- Cysto if gt10yrs catheter, smoker cath (5yrs)
- 59 subjects had 156 cystos
- No cancer diagnosed
- 4 other cases diagnosed during same period (2 did
not meet criteria1 not unit patient1 had screen
4 months prior)
18Bladder Cancer Surveillance
- Groah SL. JSCIM 200326339-44
- 8 survivors with bladder cancer compared with 13
deceased - Surveillance cystoscopy identified cancer in
- 14 survivors
- 11 deceased
- Survivors had fewer surveillance cystoscopies and
biopsies than deceased group
19Bladder Cancer Surveillance
- Navon JD. J Urol 19971572109-11
- Screening revealed 14 patients
- No comparison group
20Next Steps
- Determine best practice for surveillance of
bladder cancer - May include newer tests, such as urinary markers
- Microsatellite analysis
- ImmunoCyt
- NMP22
- CYFRA21-1
- LewisX
- FISH
- BTA Stat
- Survivin
21What do I do with this information?
22No Indwelling Catheter For You!
23From a HCP PerspectiveIntermittent Catheters
for All The Evidence
24From a Patients PerspectiveDoctor, which
catheter do YOU think I should use?
25The RealityWhat Insurance will Pay for.
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27Types of Catheters
- Red, blue, orange, brown, rainbow
- Bendy, stiff, bendy stiff, stiff bendy
- Touchy vs DO NOT TOUCH
- vs vs
28The best intermittent cath system for your
patients..
29Priceless
30Reusable Sterile IC
- Reusable catheter for long-term sterile
intermittent catheterization. Wu Y, Hamilton BB,
Boyink MA, Nanninga JB - Arch Phys Med Rehabil. 1981 Jan62(1)39-42.
- Average self cath time 2 minutes
- 10-20 cents/catheter
31Catheterization methods in hospitalized patients
with SCI
- King RB, Carlson CE, Mervine J, Wu Y, Yarkony GM
- Arch Phys Med Rehabil. 1992 Sep73(9)798-802.
- Included use of a sterile catheter each day
- Method of catheterization not associated with
infections or bacteuria
32No-touch catheterization and infection rates in a
select SCI population
- Charbonneau-Smith R.
- Rehabil Nurs. 1993 Sep-Oct18(5)296-9, 305
- Total infections significantly less with
no-touch - But, this benefit comes with a price
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34The Microwave and IC
- Microwave sterilization of polyethylene catheters
for intermittent self-catheterization - Griffith D, Nacey J, Robinson R, Delahunt B.
- Household 650 W microwave oven was used to
sterilize polyethylene catheters - 6 minutes microwaving required to achieve
sterility
35Microwave vs. Immersion
- Immersion of catheters that are reused for clean
intermittent catheterisation (Eur Urol. 2004) - Microwave
- 12 minutes at 750 W caused only minimal changes
in the physical qualities of all the catheters - Antimicrobial effect of the microwave heating
- Effective against E. coli
- NOT effective against P. aeruginosa or S. aureus
- Immersion in 70 alcohol solution for 5 minutes
- Complete antimicrobial effect on E. coli, P.
aeruginosa and S. aureus in all catheters
36What Really Happens?
- Variability in catheter microwave sterilization
techniques in a single clinic population (J Urol.
2002) - Despite uniform written and verbal instructions,
significant variation in exists in - Cleaning techniques
- Sterilizing techniques
37Sterile or Not?
- A study comparing sterile and nonsterile urethral
catheterization in patients with SCI (Rehabil
Nurs 1997) - Sterile catheterization
- 28.6 UTI
- Nonsterile cath
- 42.2 UTI, and.
- of antibiotics for sterile cath group was 43
of the cost of antibiotics for the nonsterile
group, however - Sterile kits cost nearly 4x that of the
catheterization kits for those in the nonsterile
program
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39Urethral Introducer Tips
- Effect of urethral introducer tip catheters on
the incidence of UTI in SCI (J Urol, 1997) - Introducer tip catheter bypasses the colonized
1.5 cm. of the distal urethra - Decreased UTIs in hospitalized men with SCI
- 2-4/cath
40LoFric Catheters
- Patient satisfaction and the LoFric catheter for
clean intermittent catheterization (J Urol, 1995) - Experienced patients on the disposable cath
- 81 more favorable opinion of disposable cath
- 81 found disposable cath to be more convenient
- 88 thought it was easier to handle
- 4
41UTIs and Catheters
- Urinary Tract Infection in Spinal Cord Injured
Patients A Prospective Randomized Parallel
Comparative Trial (J Urol, 1995) - Hydrophilic-coated catheters prevents UTI
42To Lube or Not
- A comparison of prelubricated hydrophilic and
non-hydrophilic polyvinyl chloride catheters for
urethral catheterization (BJU Int, 1999) - No significant difference in
- Frequency of CISC
- Discomfort
- Opinion on handling the catheters
- Preference toward one of the catheters
- Infection
- 4-4.50
43Hydrophilic Catheters
- Hydrophilic-Coated Catheters for Intermittent
Catheterisation Reduce Urethral Micro Trauma A
Prospective, Randomised, Participant-Blinded,
Crossover Study of Three Different Types of
Catheters (Eur Urol, 2005) - Hydrophilic-coated catheters better than uncoated
catheters - Hematuria
- Preference (93)
- SpeediCath (not LoFric) exerts less withdrawal
friction force than InCare((R)) Advance Plus
44Does SpeediCath Decrease UTI?
- IC with hydrophilic-coated catheters (SpeediCath)
reduces the risk of clinical UTI in SCI A
prospective randomized parallel comparative trial
(Urol, 2005) - Twice as many patients in the SpeediCath group
were free of UTI - No significant difference in bleeding episodes
- No overall difference in
- Hematuria
- Leukocyturia
- Bacteriuria
- 4.72
45Urocath-Gel Catheters
- Evaluation of the use of Urocath-Gel catheters
for intermittent self-catheterization by male
patients using conventional catheters for a long
time (Spinal Cord. 2000) - Urethritis and urethral bleeding less frequent
- Satisfaction better
- Negative satisfaction
- Availability and the use of water to lubricate
the catheter - Difficulty of manipulation
- Cost
46Single Use Catheters
- Effect of a single-use sterile catheter for each
void on the frequency of bacteriuria in children
with neurogenic bladder on intermittent
catheterization for bladder emptying (Pediatrics.
2001 Oct) - Frequency of bacteriuria
- Single-use sterile vs. reused clean catheters
- New, sterile catheter for each void did not
decrease the frequency bacteriuria
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48To Prophylax or Not
- Are prophylactic antibiotics necessary with clean
intermittent catheterization? A randomized
controlled trial (J Pediatr Surg. 2005) - Use of prophylactic antibiotics may result in
increased rates of infection because of the
development of resistant organisms
49To Reuse or Not?
- Reused silicone catheter for clean intermittent
catheterization is it safe for SCI men? (Spinal
Cord. 2004) - Electron microscopy of reused catheters for 2
years - Encrustation but no obstruction in the lumens
- 20 increase in stiffness
- Conclusion
- For SCI patients in developing countries, CIC
with a reusable silicone catheter may be a
suitable and safe choice if one cleans and
applies it properly to reduce infection
50How to Have a Pristine Bladder
- Twenty-seven years of complication-free life with
clean intermittent self-catheterization in a
patient with spinal cord injury A case report
(Arch Phys Med Rehabil. 2004) - Possible reasons for success
- Absence of incontinence because of underactive
and normal capacity bladder - Normal upper-extremity function
- Absence of marked spasticity of lower extremities
- Absence of sociovocational problems
51To Electrify or Not?
- An electrified catheter to resist encrustation by
Proteus mirabilis biofilm (J Urol. 2005) - Electrified catheters released ions in urine that
inhibit bacterial growth - Application of electric current to catheters
fitted with silver electrodes - Decreased encrustation by P. mirabilis
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53What will you recommend for your family and
friends?
Just because its cheaper doesnt mean its what
we all do.
54Ultimately, we do what is right for each of our
patients,just like we would treat our own family
55Yet To Be Released PVA Guideline Recommendations
56Recommendations from the PVA Guidelines
- Recommendation 1 Intermittent catheterization is
the preferable method for bladder emptying for
men and women who have adequate hand function or
a willing caregiver to perform the
catheterization and have bladders that do not
empty adequately. - Recommendation 2 Intermittent catheterization
should be ideally performed every 4 to 6 hours to
keep bladder volumes below 400ccs.
57Recommendations from the PVA Guidelines
- Recommendation 5 Consider sterile
catheterization for those individuals with
recurrent symptomatic infections occurring with
clean intermittent catheterization. Rationale
Lower infection rates can be achieved with
sterile techniques and with pre-lubricated self
contained catheter sets
58Recommendations from the PVA Guidelines
- Recommendation 5 Risk of symptomatic infection
is at least comparable and may be less in
individuals with indwelling catheters than those
managing their bladders with clean intermittent
catheterization.
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60- Everyone has personal preferences
- Its all about stiffness
- You should always be prepared
- Too infrequent is bad for your health
- Sometimes alcohol helps
61- Only certain devices are meant to be reused
- Too much jelly gets messy
- Some lubrication is useful
- You need pretty good hands
- You can do it on airplanes, but discretion is
advised