Objective To evaluate the efficacy and safety of a low-priced temporary prostatic stent (intraurethral catheter) for the treatment of BPH patients with urine retention on a temporary basis.
Patients and Methods We studied the outcome of using an intraurethral catheter (IUC) in patients needing temporary drain-age. The stent was fixed under local anaesthesia with the use of flexible cysto-scopy. Cystoscopy was used to localize the distal end of the stent just proximal to the external sphincter. The procedure was done on an outpatient basis. A total of 43 IUCs were fixed in 42 patients (median age 73.5 years) and intended to be in place for 6 – 12 weeks. The efficacy of the stent was evaluated in terms of return of micturition, side effects, flowmetry and postvoiding residual urine.

Results Stent fixation was successful in all patients. All stents were kept in place for the intended time except for four which had to be removed early due to complications. Voiding was satisfactory in all patients, and all patients were continent after fixation with no significant residual urine. Symptomatic urinary tract infection (UTI) occurred in only three patients and was controlled with antibiotics. No IUC needed to be removed.
Conclusion The use of an IUC can be recommended in any patient requiring temporary drainage. It is cost effective, shows a high success rate and has the advantage of an easy fixation and removal. It can, thus, improve the quality of life in such patients.
Key Words intraurethral catheter, stent, temporary drainage, urinary retention, prostate

INTRODUCTION

With increasing medical and interventional management of benign prostatic hyperplasia (BPH), the need for drainage of the bladder during an acute and temporary retention for the duration of few weeks has increased. In many patients who do not need or do not fit for operative intervention, acute retention can be managed conservatively to give time for either medical treatment or a period of stress (e.g. after diagnostic cystoscopy or thermotherapy) to pass. A Foley's catheter or suprapubic bladder drainage is usually used but both are invasive, inconvenient and have high complica-tion rates.

The idea of stenting the bladder neck and the prostatic urethra in order to maintain continence without external appliances is ap-pealing.

In this study, we report the outcome of using an intraurethral catheter (IUC) as a temporary method of drainage.

Fig. 1: Disposable IUC and the insertion kit

Fig. 2: The position of the distal end of the IUC after insertion seen by cystoscopy
PIC

Fig. 3: KUB showing the IUC in place

tion sheath, the IUC partially hidden in a cart-ridge and a pusher. The insertion is simple, as it is performed under local anaesthesia in the outpatient clinic. To ensure that the proximal basket was just proximal to the bladder neck, an IUC 10 mm longer than the prostatic urethra was chosen. The prostatic urethral length should be known beforehand (e.g. by urethro-

PATIENTS AND METHODS

This study was conducted on 42 patients aged between 32 and 106 years (median age 73.5 years) needing temporary urethral cathe-terization. These included patients with BPH requiring operative intervention during the wait-ing time, patients with acute retention who were not relieved by in-and-out catheter drain-age in a trial of conservative and medical the-rapy and patients who had developed retention after diagnostic or interventional (thermo-therapy) procedures. Patients with stricture urethra and neurogenic bladder were excluded from this study.

The device used is a polyurethane double Malecot stent (16 Fr.) available in lengths of 35-70 mm to accommodate varying prostatic urethral lengths. This device called intraureth-ral catheter (IUC) is produced by Angiomed Germany. A nylon thread is attached to the IUC to be used in pulling out the device. The device is provided in an insertion set (Figure 1) containing a Tiemann-like catheter in the inser-

gram or cystoscopy using a graduated ureteric catheter).

Insertion is done by placing the patient in the lithotomy position. The urethra is lubricated with Xylocaine jelly which is kept in place for 10 minutes. The insertion sheath with the Tiemann catheter is then inserted into the blad-der and the catheter pulled out leaving the sheath in place. The cartridge is approximated to the insertion sheath. Then, using the pusher, the IUC is advanced from the cartridge into the insertion sheath to be placed inside the blad-der. The sheath is pulled back, leaving the IUC partially in the bladder and partially in the urethra. Cystoscopy is used for the proper adjustment of the IUC through the urethra to keep the distal end of the stent just proximal to the external sphincter (Fig. 2).

The IUC is removed by lubricating the urethra with xylocaine jelly and pulling out the device by the attached thread.

Antibiotics were given for 48 hours starting 12 hours before the date of insertion. Urine culture was taken weekly throughout the time of fixation (2-6 weeks). All patients were subjected to flowmetry and assessment of post voiding residual urine to evaluate the efficiency of the device.

RESULTS

A total of 43 IUCs were inserted in 42 pa-tients aged between 32 and 106 years. (median age 73.5 years). The indications for temporary catheterization are presented in Table 1. Stent-fixation was done succesfully in all attempted cases. The IUC was left in place for a period ranging from 2 to 12 weeks. Most patients had the device in place for 3-6 weeks (Fig. 3). All stents were kept in place for the scheduled time, except in four patients where the stents had to be removed because of marked perineal pain and urgency after 1 week in one case, migration after 2 weeks in one case, and urethral bleeding after 2 weeks in one patient (Table 2). The remaining patient pulled the stent out causing bleeding from the urethra, and a suprapubic catheter was fixed in place.

In 40 patients voiding was satisfactory after removal of the device. Only one patient who had presented with retention following high-energy TUMT could not void when the device

was removed after two weeks which made re-insertion necessary for another two weeks.

On removal, one stent was covered by encrustation, and on culture of this encrusta-tion Proteus mirabilis was grown.

The complications encountered are presented in Table 3.

All patients were continent except one who needed re-adjustment under local anaesthesia on the same day. The results of flowmetry showed a maximum flow rate (Qmax) ranging from 6.2 to 9.5 ml/s with a mean of 7.1 ml/s (Fig. 4). No significant residual urine was present in any patient. The results of urine culture done weekly are illustrated in Table 4. Three patients had symptomatic UTI (fre-quency, urgency and dysuria) (one patient twice), but no stent had to be removed. The symptoms of the patients were controlled within 48 hours with antibiotics and symp-tomatic treatment.

DISCUSSION

The intraurethral catheter as a temporary stent represents a new concept in patient management since Fabian1 introduced a stain-less-steel prostatic urospiral. When using this spiral there is no contact with the extra-corporeal surroundings, thus reducing the danger of an ascending infection to a mini-mum. In addition, it improves the quality of life of the patients as there are no external appliances and the patients void the way they are used to.

In our study, the correct insertion of the stent done in the outpatient clinic under local anaesthesia was successful in all patients. This means that the procedure was easy and did not add a significant burden on the patients or the department workload. In 37 patients the stents were left in place until the scheduled time of removal. This means that 88% of our patients could lead a normal daily life. This compares favorably with the success rate of

Table 2: Causes of Unscheduled Removal

74% reported by Nissenkorn. However, Nis-senkorn used the stent for a longer time, and the 74% success rate was seen at 6 months of follow up.

The removal of the IUC is easy and can be done anytime either by pulling a nylon thread attached to it after lubricating the urethra or by means of a biopsy forceps through flexible cystoscopy. This makes it safe and easy to remove in case of migration or complication without any sequelae on the disease process.

It also provides a satisfactory stream with no residual urine.

An additional advantage of the IUC is that is is made of Polyurethane and is, therefore, cost effective, especially compared with an indwel-ling catheter if one considers the price of treatment of its complications. It is well known that the use of an indwelling catheter is asso-ciated with an increasing rate of infection with every day the catheter is left in place. A rate of bacteruria of 7.4% during the first 24 hour after

Table 4: Results of Urine Culture on Weekly Follow-Up

* = symptomatic UTI, ** = bacteriuria
stent migrated, 10% had recurrent urinary tract infection and 4% had encrustation5. In this study lower complication rates were seen (Table 3).

High-energy thermotherapy (HETUMT) is usually associated with a period of retention for 1-3 weeks6. In one series the problem of catheterization after treatment was avoided by using a biodegradable (temporary) stent7. As this type of temporary prostatic stenting is expensive, we preferred to use the poly-urethane IUC in our patients who had undergone HETUMT.

In this study there was one case of encrustation which was associated with infec-tion. Sassine and Schulman8 described one case of encrustation with the same type of IUC but did not report whether it was associated with infection. Twelve percent of the patients in their series developed urinary tract infection.

Two stents migrated in this study (2.3%). Nissenkorn et al.9 reported a 5.7% migration rate for temporary stenting using the same type of IUC, while Djavan et al.10 reported a migration rate of 5.6% with another type of temporary stent.

In conclusion, this preliminary study has shown satisfactory results in view of a relative-ly low price, a high success rate and an easy

All correspondence to be sent to:

Ammar Ghobish, M.D.; P.O. Box 67, Ismailia 41511, Egypt

Table 3: Complications of IUC

catheterization has been reported, with an additional daily risk of 8.1%3. In this series the infection rate after IUC was very small. Only 7/42 patients (16%) had a positive culture 6 weeks after the insertion of the stent with only three clinical urinary tract infections (7%). All cases were controlled by antibiotics and no stent was removed to control the infection. This compares favourably with the infection rate seen with indwelling catheters. As no external appliances are needed, the patients continue with their normal life, go to work and even are sexually active4. This improves the quality of life of these patients in spite of the disease process.

Another two temporary prostatic stents are the prostakath and the urospiral. Both are metalic stents and more expensive with higher complication rates. With these stents success-ful outcomes were reportedly obtained in 89% of patients. 5% developed bleeding, in 15% the
removal. The use of an IUC can be recom-mended in any male patient in need of a temporary indwelling catheter for a period of more than a few days.

1. Fabian KM. Der intraprostatische “Partielle Katheter”. Urologische Spirale. Urologe 1980, 19A:236-238.

2. Nissenkorn I. A self retaining intraurethral catheter (IUC) for treatment of prostatic obstruction. In: Fitzpatrick JM (Ed.): Non surgical treatment of BPH. Edinburgh, London:Churchill Livingstone, ch. 16, p. 155, 1992.

3. Garibaldi RA, Burke JP, Dickman ML. Factors predisposing to bacteriuria during indwelling urethral catheterization. N Engl J Med 1984, 291:215-219.

4. Richter S, Slutzker D, Nissenkorn I. Preservation of normal sexual activity in patients with urinary retention through the use of a self-retaining intraurethral catheter. Int J Impot Research 1990, 2:314-318.

5. Thomas PJ, Britton JP, Harrison NW. The prostakath stent. Four years experience. Br J Urol 1993, 71:430.

6. De la Rosette J, de Wildt M, Hofner K. High energy TUMT (Prostasoft 2.5) in the treatment of BPH: Results of the European BPH study group. J Urol 1995, 153:A822.

7. Dahlstrand D, Grundtman S, Petterssons S. High energy TUMT for large severely obstructing prostates and the use of biodegradable stents to avoid catheterization after treatment. Brit J Urol 1997, 79:907-909.

8. Sassine AM, Schulman CC. Intraurethral catheter in high risk patients with urinary retention. Eur Urol 1994, 25:131-134.

9. Nissenkorn I, Slutzker D, Shalev M. Use of an intraurethral catheter instead of a Foley catheter after laser treatment of benign prostatic hyper-plasia. Eur Urol 1996, 29:341-344.

10. Djavan B, Fakhari M, Shariat S, Ghawidel K, Marberger M. A novel intraurethral prostatic bridge catheter for prevention of temporary prostatic obstruction following high-energy transurethral microwave thermotherapy in patients with benign prostatic hyperplasia. J Urol 1999, 161:144.151.