Frank Lin: Thank you, Dr. Wein, for having me. We wrote a review paper entitled Managing Neurogenic Bladder with a Suprapubic Catheter versus Urethral Foley - Which is Best? This is a topic that comes up in my clinical practice and I'm sure around the country in many of our practices, and we wanted to figure out which was best. We wrote this review paper and the presentation briefly goes over neurogenic lower urinary tract dysfunction, urethral catheters, suprapubic catheters. I think the big question and topic everyone has on their minds is urinary tract infections. And finally, a quick conclusions slide. So just briefly, the neurogenic bladder or officially the neurogenic lower urinary tract dysfunction is a group of conditions that encompasses a wide range of bladder dysfunction caused by a neurologic condition, and this really is a category that encompasses failure of the lower urinary tract. And Dr. Wein, this goes back to your idea of failure to store and failure to empty. There's a list that's not inclusive at the bottom of the screen that lists many of the conditions that we may manage that may affect voiding and storage function of the bladder. We're looking for options, really.
There's minimally invasive choices for bladder drainage including clean intermittent catheterization. The purpose of the review paper didn't take that into consideration. We're assuming the patient cannot do that themselves or doesn't have the care available to them, and so indwelling urethral catheters and suprapubic catheters are very common and effective. We know the consequences of inadequate urinary drainage, which can include infection, renal dysfunction or renal failure, hydronephrosis, reflux, and also stone formation. Our goals are to protect the upper urinary tract, achieving or maintaining continence and overall improving the quality of the life of our patients. We have to consider, of course, cost-effectiveness, technical complexity, and possible complications. And there's no right choice for every patient. And patient values, expectations, and ability are essential for optimizing both the medical and quality-of-life outcomes in these patients. The urethral catheter is straightforward. It's a transurethral indwelling catheter. Allows for constant urinary drainage. It eases the burden of repeat catheterization for patients who are unwilling or unable to perform clean intermittent catheterization, which is the gold standard. There's a diagram of that on the right side of the screen. And a suprapubic catheter.
This is a similar type catheter that actually enters the bladder directly through the skin suprapubically. These are procedures that can be done at the patient's bedside, in the operating room or in an interventional radiology suite under fluoroscopic guidance. There's relatively easy access to the lower abdomen and quoting a paper that's included in our review article, "Satisfaction rate is quite high, and most patients, when queried, will prefer the suprapubic catheter over a urethral catheter." Urinary tract infections, I think, are the number one thing that my clinic patients and I think most patients have concern about or are struggling with, with an indwelling catheter of any sort. And this paper from 2019 looked at a number of spinal cord injury patients. A quarter of them were female. All patients had an initial urethral catheter. And basically, these patients were followed, looking to see if intermittent catheterization or suprapubic catheterization had a lower rate of urinary tract infections when transitioned out of that urethral catheter. Indeed, they did. And if the urethral catheter had to be replaced, those patients ended up having more infections. You'd think, based on this data, that infections are just less common with intermittent or suprapubic catheterization. Another study here, this was just a cohort systematic review looking at 8 non-randomized observational cohort studies looking at over 2000 patients, and really, the comparisons gave some mixed results.
There wasn't a smoking gun better option in terms of indwelling urethral catheter versus suprapubic catheter, and certainly, a suprapubic catheter versus intermittent straight catheterization. We'd like to think that a suprapubic tube maybe is a slightly lower risk, but in this systematic review it was not totally clear. We have to consider some of the management that we perform for these patients. Urethral catheter is typically placed at the initial injury and is the first choice, such as the spinal cord injury in a trauma setting or if someone has multiple sclerosis and is progressively becoming more incontinent. Typically, the urethral catheter is the first option, and many times there's a decision to switch over to a suprapubic catheter as the clinical situation may dictate. The placement of a suprapubic catheter is more complex as the diagram had alluded to. You can have issues with that tract when exchanging the catheter or if that catheter becomes dislodged in some way. It may also require a higher-level specialized nursing care for exchanges depending on the facility or care situation the patient's in. And bladder spasms may still need to be managed, no matter the type of catheter they have in place, and so this may require anticholinergics, beta-3 agonists, or chemodenervation. Take-home messages from this paper essentially were that there are options for patients and they should be aware of these options including a suprapubic catheter.
Many of my patients come in not understanding or not knowing the differences. The choice of bladder management should be personalized, of course, to the individual patient and their clinical situation and the direction that they're headed. Rates of infection development are comparable between suprapubic catheters and urethral catheters. Taking in mind that these studies are based on certain types of patient populations, specifically spinal cord injuries. Therefore, risk of UTIs should not be the driving factor when choosing. And finally, suprapubic catheter may have lower rates of upper tract deterioration, genital complications, and higher patient satisfaction and comfort as compared to an indwelling urethral catheter.
Alan Wein: Terrific. That was a great summary. So it sounds like, faced with a choice between the two, that your choice for chronic indwelling catheterization would be a suprapubic rather than a transurethral access route.
Frank Lin: That's correct, Dr. Wein. If it were my family member or even myself and I had to make that tough decision on bladder drainage, I think a suprapubic tube is preferred in almost all situations.
Alan Wein: So all these... Well, maybe not. I mean, all these are inserted with ultrasound guidance or do you need that, really?
Frank Lin: That's a great question. In my practice we send our patients to the interventional radiologist.
Alan Wein: Radiologist, yeah.
Frank Lin: And these are patients we meet with suboptimal body habitus that might require CT guidance or ultrasound guidance, and certainly, we've placed them in the operating room before under direct vision through a cut-down method. We've also done them in the trauma setting, just with a percutaneous Seldinger technique with a peel-away kit. So there's a lot of access sort of techniques that can be done in my practice in an ambulatory setting. I prefer the interventional radiology colleagues to be placing these. Typically, they'll place a small 10 French or 12 French pigtail, which will then be upsized, and finally, when they're an appropriate size, 14 or 16 French, they can get transitioned to myself or one of my advanced practice providers for routine exchanges every month.
Alan Wein: Yeah, I was going to ask you about that. So if the IR people do it, then your advice would be, basically if it's on a weekend, someone needs something acutely, the maybe lower level residents or in the ER, they'd be better off placing a temporary Foley and then getting one of the IR people to put in an SP tube if it looks like it's going to be long-term after the weekend passes, I guess.
Frank Lin: Yeah. A good urethral catheter is still an option for most of these patients, unless the urethra is obliterated or it's been closed. But yeah, urethral catheter is always a good bailout option, so it doesn't eliminate that route in the future.
Alan Wein: What's the time that it takes for the tract to close? Let's say somebody lives out in the middle of West Virginia and the next... I say that because that's where I'm originally from. And the next town, it's maybe 60 miles away that has a physician that really knows what a suprapubic tube is, may not be facile in putting them back in, but how long does it take one of those to close? Let's say if it's been in a month versus if it's long-term, been in a year, how much time does the patient have?
Frank Lin: A couple of hours at best. I think anything over 24 hours, I think that tract's going to be very hard to re-navigate. I think also it depends on the body habitus of the patient and the position they tend to be in also plays a role as those abdominal wall layers can shift a little bit, but I would try to get it in as quick as possible. Otherwise, I think that access is going to be lost. You could always, if there's a urologist around, try to scope that back in and certainly I've done my fair share of those to try and salvage a tract.
Alan Wein: Is there any body habitus that's particularly unsuitable for an SP-tube?
Frank Lin: I think the patients that have abdominal surgeries and maybe where that space of Retzius, that lower abdominal wall might've been disrupted and there might be small bowel in that location, those patients need to be evaluated with cross-sectional imaging prior and might be best for interventional radiology to place that. The other caveat to that is, of course, even if they get that catheter in place, the exchange in the future may be difficult if that tract is tortuous or not a good straight shot into the bladder.
Alan Wein: Now, I'm assuming that the patient satisfaction rate in favor of an SP would be the same for the non-neurogenic patients that require chronic catheterization. In other words, it's not just neurogenic patients, it's really anybody that needs a chronic drainage, that they would probably prefer that as well.
Frank Lin: Yeah, those studies are obviously a little bit more difficult to come by, but I think in a patient that has underactive detrusor, for example, that has hypotension, I think a suprapubic tube in that situation also is probably likely favorable. In many of those patients, they can perform self-catheterization as they still have good hand function and are ambulatory. So I think I see fewer of those patients with indwelling catheters at that point.
Alan Wein: Yeah. And those folks, the suprapubic allows you to do a void test without having to reinsert something if it doesn't work. So it's really a great thing that a lot of people have sort of forgotten about, I think, or neglected. I'm sure you, as well as I, see a whole bunch of patients that have the chronic indwelling transurethral Foley catheters, and they have all the urethral complications that you associate with that, and they're not very happy about it. They've got this gunk coming out around the catheter and they're pretty displeased. But listen, thank you so much, because I think the audience really needs to hear that from someone who sees a lot of neurogenic patients. And maybe they can transpose that to their non-neurogenic population, but we really appreciate your presence on the channel and your expertise, so thanks very much. Hope to see you at one of the other meetings.
Frank Lin: Great. Thank you very much, Dr. Wein.