Current Concepts in Urologic Management of Individuals with SCI: Making Sense of the Evidence

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Current Concepts in Urologic Management of
Individuals with SCI Making Sense of the Evidence
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Epidemiology 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

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Bladder 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

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Risk Factors for Bladder Cancer

• Smoking
• Male gender
• Exposure to aromatic amines
• Schistosomiasis infection
• UTI

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Challenges of Studying Bladder Cancer after SCI

• SCI is a rare condition
• Bladder cancer is relatively uncommon
• Bladder cancer may take decades to develop

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The Question Is there a heightened risk of
bladder cancer after spinal cord injury?
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Parachute 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

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The Evidence in SCI
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The Evidence in SCI
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Recent 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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Recent 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

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Recent 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

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Recommendations 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

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Risk Factors for Bladder Cancer
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Bladder 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)

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Bladder 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

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Bladder Cancer Surveillance

• Navon JD. J Urol 19971572109-11
• Screening revealed 14 patients
• No comparison group

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Next 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

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What do I do with this information?
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No Indwelling Catheter For You!
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From a HCP PerspectiveIntermittent Catheters
for All The Evidence
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From a Patients PerspectiveDoctor, which
catheter do YOU think I should use?
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The RealityWhat Insurance will Pay for.
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Types of Catheters

• Red, blue, orange, brown, rainbow
• Bendy, stiff, bendy stiff, stiff bendy
• Touchy vs DO NOT TOUCH
• vs vs

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The best intermittent cath system for your
patients..
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Priceless
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Reusable 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

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Catheterization 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

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No-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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The 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

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Microwave 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

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What 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

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Sterile 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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Urethral 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

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LoFric 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

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UTIs and Catheters

• Urinary Tract Infection in Spinal Cord Injured
  Patients A Prospective Randomized Parallel
  Comparative Trial (J Urol, 1995)
• Hydrophilic-coated catheters prevents UTI

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To 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

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Hydrophilic 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

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Does 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

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Urocath-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

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Single 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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To 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

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To 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

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How 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

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To 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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What will you recommend for your family and
friends?
Just because its cheaper doesnt mean its what
we all do.
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Ultimately, we do what is right for each of our
patients,just like we would treat our own family
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Yet To Be Released PVA Guideline Recommendations
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Recommendations 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.

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Recommendations 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

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Recommendations 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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• Everyone has personal preferences
• Its all about stiffness
• You should always be prepared
• Too infrequent is bad for your health
• Sometimes alcohol helps

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• 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