Date of Award

January 2012

Document Type

Open Access Thesis

Degree Name

Medical Doctor (MD)

Department

Medicine

First Advisor

Harris E. Foster Jr.

Subject Area(s)

Medicine, Health sciences

Abstract

The main objective of this study was to retrospectively report our institutionaloutcomes with the long-term management of neurogenic bladder in spinal cord injurypatients. Specifically to: (A) report the association of recurrent urinary tract infection

(UTI) with the long-term use of clean intermittent catheterization (CIC) in our population of spinal cord injury (SCI) patients. (B) Secondly, to evaluate the use of retroperitoneal

ultrasound for long-term renal tract surveillance in injured patients. (C) And thirdly, to describe our experience with the use of the lowsley retractor method for suprapubic cystostmy in patients with neurogenic bladder.

Subjects were selected from patients followed by one physician at the Yale Urology Medical Group and their medical records were retrospectively reviewed. To address objectives (A) and (B), patients were identified after a search of the Financial Department's database with diagnosis codes for “neurgenic bladder” and “Spinal cord injury.” Patients seen between the years 2000 to 2010 were included in the study. For objective (C), patients were identified with diagnosis code for “cystostomy” and patients seen between 1995 and 2010 were included in the study.

For objective (A), 51 male and 10 female subjects were managed with CIC. 41 (67%) subjects were placed on medical prophylaxis (PRx) for symptomatic recurrent UTI. 28 (72%) subjects were started on PRx within 2 years after initiation of CIC. 48 SCI

patients were included in objective (B). Mean follow-up was 6.8 years. By final followup 7 (15%) subjects had moderate/minimal hydronephrosis. 4 (8%) cases were new compared to initial assessment. No severe cases of hydronephrosis were noted. For

objective (C), 49 primary catheter placements were performed on 44 patients. Operation time documented in 19 (39%) cases was 20.2 min (±5.5) (range: 11−31 min). Blood loss

was minimal and there were no intra-operative complications or cases of incorrect catheter placements.

The improved life expectancy of SCI patients in recent decades makes long-term complications of neurogenic bladder management more pertinent. Although CIC is the current standard of care following SCI, recurrent UTI remains a major complication in

patients using this technique. Due to a lack of standard guidelines for long-term renal tract monitoring in injured patients, there is wide variation in surveillance strategies. Our results suggest that annual retroperitoneal ultrasound is effective for renal tract monitoring rather than subjecting patients to annual urodynamic testing. Furthermore, the improved anticholinergic therapy makes suprapubic catheters an acceptable alternative to intermittent catheterization. Our findings support the use of the lowsley retractor method of suprapubic catheter placement as a safe and effective method for isolated suprapubic cystostomy in neurogenic bladder patients.

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