The Efficacy and Safety of a Conservative Management Approach to Radiation-Induced Male Urethral Strictures in Elderly Patients With Comorbidities

Objectives To assess the outcomes of a conservative management approach to radiation-induced urethral stricture disease (R-USD) in an elderly population with comorbidities. Methods Patients with R-USD managed with endoscopic procedures and/or clean intermittent catheterization (CIC) between 2007 and 2019 were included. Patients were excluded if they had an obliterative stricture, prior urethral reconstruction/urinary diversion surgery, or < 3 months follow-up. Primary outcome measures were urinary tract infection (UTI), acute urinary retention (AUR), serum creatinine, uroflowmetry/post-void residual, and urinary incontinence (UI). Failure was defined as progression to reconstructive surgery or permanent indwelling catheterization. Results Ninety-one men were analyzed with a median follow-up of 15.0 months (IQR 8.9 to 37.9). Median age was 75.4 years (IQR 70.0 to 80.0), body mass index was 26.5 kg/m2 (IQR 24.8 to 30.3), and Charlson comorbidity index was 6 (IQR 5 to 8). Median stricture length was 2.0 cm (IQR 2.0 to 3.0). Stricture location was bulbar (12%), bulbomembranous (75%), and prostatic (13%). A total of 90% underwent dilation, and 44% underwent direct visual internal urethrotomy (DVIU). For those that underwent these procedures, median number of dilations and DVIUs per patient was 2 (IQR 1 to 5) and 1 (IQR 1 to 3), respectively. Forty percent used CIC. Thirty-four percent developed a UTI, and 15% had an AUR episode requiring urgent treatment. Creatinine values, uroflowmetry measurements, and UI rates remained stable. Eighty percent avoided reconstructive surgery or indwelling catheterization. Conclusion Most elderly patients with comorbidities with R-USD appear to be effectively managed in the short-term with conservative strategies. Close observation is warranted because of the risk of UTIs and AUR. The potential long-term consequences of repetitive conservative interventions must be considered.

Bladder instillation for urinary tract infection prevention in neurogenic bladder patients practicing clean intermittent catheterization: A systematic review

Objective: To assess the efficacy and safety of different modalities of bladder instillation in patients with neurogenic bladder practicing intermittent catheterization. Methods: A systematic review of the literature were conducted using two databases: Medline via PubMed and Scopus. Articles evaluating bladder instillation in patients with neurogenic bladder, who are practicing intermittent catheterization, were collected and assessed for the efficacy and safety of the studied agent by two different reviewers. Results: Among the 1896 studies, eight involving 346 patients with neurogenic bladder, were included in this systematic review according to the PRISMA protocols. Gentamicin, Hyaluronic acid, and Lactobacillus rhamnosus was found to decrease the incidence of urinary tract infections, the former reduced multidrug-resistant organisms. Kanamycin-colistin, showed a drop in the mean incidence of bacteriuria in males only. Trisdine, the only studied antiseptic, significantly reduced bacteriuria. Neomycin, however, showed no efficacy in term of bacteriuria. Regarding safety, when evaluated, no major adverse events were reported with any of the studied modalities. Conclusion: Bladder instillations of either antibiotics, antiseptics, hyaluronic acid, or Lactobacillus rhamnosus GG are efficient and safe in patients having neurogenic bladder, with recurrent urinary tract infections and practicing clean intermittent catheterization, with gentamicin being the most recommended product among the different studied agents.

Latissimus dorsi detrusor myoplasty for bladder acontractility: a systematic review

Bladder acontractility affects several thousand patients in the United States, but the available therapies are limited. Latissimus dorsi detrusor myoplasty (LDDM) is a therapeutic option that allows patients with bladder acontractility to void voluntarily. Our goal was to conduct a systematic review of the literature to determine whether LDDM is a better option than clean intermittent catheterization (CIC) (standard treatment) in patients with bladder acontractility. On January 17, 2020, we conducted a systematic review of the PubMed/MEDLINE, Cochrane Clinical Answers, Cochrane Central Register of Controlled Trials, Embase, and ClinicalTrials.gov databases, without time frame limitations, to identify articles on the use of LDDM for bladder acontractility. Of 75 potential articles, 4 fulfilled the eligibility criteria. The use of LDDM to treat patients with bladder acontractility was reported in four case series by the same group in Europe. Fifty-eight patients were included, and no comparison groups were included. The most common cause of bladder acontractility was spinal cord injury (n=36). The mean (±standard deviation) operative time was 536 (±22) minutes, postoperative length of hospital stay ranged from 10 to 13 days, and follow-up ranged from 9 to 68 months. Most patients had complete response, were able to void voluntarily, and had post-void residual volume less than 100 mL. Although promising outcomes have been obtained, evidence is still weak regarding whether LDDM is better than CIC to avoid impairment of the urinary tract among patients with bladder acontractility. Further prospective studies with control groups are necessary.

The impact of constant antibiotic prophylaxis in children affected by spinal dysraphism performing clean intermittent catheterization: a 2-year monocentric retrospective analysis

Introduction Spinal dysraphism (SD) is a general term used to refer to developmental abnormalities of the spine that involves many clinical conditions including myelomeningocele (MMC). In these patients, neurogenic bladder (NB) is a common and predisposing factor for renal damage; the most frequently used approach to manage this situation is based on clean intermittent catheterization (CIC) and anticholinergic drugs. Urinary tract infections (UTIs) are a significant concern for these patients, and antibiotic prophylaxis is frequently used even if it is still a debated topic of literature. The purpose of this paper is to investigate the role and the real effectiveness of antibiotic prophylaxis in the reduction of incidence of UTIs in patients with spina bifida performing CIC. Methods We collected data of all patients performing CIC, who did their last follow-up visit in the period between January 2019 and January 2021, followed at the children multidisciplinary Spina Bifida Center of A. Gemelli Hospital in Rome. Data collected included age at referral, gender, type of SD lesion, serum creatinine and cystatin C levels, the use of anticholinergic medications, antibiotic prophylaxis and type of prophylaxis (oral/endovesical), age of starting prophylaxis with its duration/adherence, number of CIC/day and its duration, episodes of UTIs in the 2 years prior to the last follow-up, and presence and grade of vesical-ureteric reflux (VUR) on cystourethrogram. Results A total of 121 patients with SD performing CIC was included in the study; 66 (54%) presented ≥ 1 episode of UTIs in the last two years and 55 (46%) none. During the study period, 85 (70%) patients received antibiotic prophylaxis (ABP group) and 36 (30%) did not (NABP group): no statistically significative difference in terms of UTI development was observed between the two groups (p = 0.17). We also evaluated compliance to the therapy; 71 patients (59%) took antibiotic prophylaxis constantly (CABP group) and 50 (41%) did not do antibiotic prophylaxis constantly or did not do antibiotic prophylaxis at all (NCABP group): we observed a statistically significative difference in terms of UTIs with a 2.2 times higher risk of development at least one episode of UTIs in NCABP group. Conclusion In conclusion, antibiotic prophylaxis performed constantly, without interruption, is associated with a lower risk of developing urinary tract infections and consequently to develop renal failure in adulthood.