Eur J Vasc Surg 4, 535-538 (1990)

Urethral Strictures and Aortic Surgery. Suprapubic rather than Urethral Catheters M. D. Dinneen, L. A. Wetter and A. R. L. May

Department of Surgery, Colchester General Hospital, Colchester, Essex, U.K. Urethral strictures associated with the use of a urethral catheter may be more common after cardiac and aortic surgery when compared with other surgical procedures. The reasonsfor this are obscure. Fifty-two aortic procedures in males from 1980-1983 were reviewed with an incidence of urethral stricture of21%. Forty anterior resections of the rectum in which a urethral catheter was used were also reviewed with an incidence of urethral stricture of only 5%. Since 1985 supra-pubic catheters have been used now in over 200 aortic procedures with no morbidity and no urethral stricture. Bacteruria has been significantly reduced by the use of supra-pubic catheters and there would appear to be considerable advantages in the use of this technique. Key Words: Urethral stricture; Aortic surgery; Suprapubic catheter.

Introduction

Urethral stricture is a well recognised complication of urethral catheterisation. There are m a n y factors involved in the aetiology, and the incidence m a y be higher w h e n urethral catheters are u s e d in cardiac a n d aortic surgery. A minor epidemic of urethral strictures in males u n d e r g o i n g aortic surgery in the early part of the last d e c a d e p r o m p t e d a review of these cases and of the literature. Since this problem was identified in patients u n d e r g o i n g aortic surgery, supra-pubic catheters h a v e been u s e d and no further strictures have b e e n seen.

Materials and Methods Fifty-two males (Group 1) w h o u n d e r w e n t aortic surgery b e t w e e n 1980 and 1983 inclusive were studied. The ages of patients r a n g e d from 49-83 years at the time of s u r g e r y with a m e a n of 68.7 years. All patients were catheterised electively after induction of anaesPlease address all correspondence to: Mr M. D. Dinneen, Department of Paediatric Urology, Hospital for Sick Children, Great Ormond St, London WC1N 3JH, UK. 0950-821X/90/050535+04 $03.00/0 © 1990 Grune & Stratton Ltd.

thesia with a size 16 French gauge, latex urethral catheter, using K-Y jelly as a lubricant. In no case was any difficulty experienced. Post-operatively the catheter was left in situ for b e t w e e n 3 and 5 days in all patients. Seven patients h a d had previous prostatic surgery. O v e r the same period 40 patients, all male (Group 2), u n d e r g o i n g anterior resection for rectal carcinoma w e r e studied for comparison. Age range was similar. All patients w e r e catheterised again with a size 16 French gauge, latex catheter. N o patient had h a d previous prostatic surgery. Finally, from January 1985, 100 consecutive male patients (Group 3) u n d e r g o i n g aortic surgery have been studied (this has n o w risen to over 200 patients). All patients had a Bonano suprapubic catheter inserted d u r i n g surgery. This consists of a flexible p o l y p r o p y l e n e catheter, t h r e a d e d over a long needle and inserted t h r o u g h a stab incision suprapubically. This was d o n e at the e n d of the proc e d u r e with a full bladder and the retaining flange s u t u r e d to the skin. The catheter was left in situ for 5 days. In the majority of cases a catheter specimen of urine was taken just prior to the removal of the catheter. All three g r o u p s were studied for the incidence of urethral stricture and bacteruria.

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Results Urethral stricture

In Group 1, 11 patients developed an urethral stricture (21%). Their ages ranged from 53-78 years with a mean of 69 years. Two patients had had a previous prostatectomy. The site of stricture was as follows, three sub-meatal, five peno-scrotal and three membranous. The two patients w h o had had previous prostatic surgery had membranous urethral strictures. Of the 11 strictures, three developed within one month of surgery, six between one and three months and two after three months of surgery. Seven patients had elective abdominal aortic aneurysm repair and four had aorto-femoral bypass. In no case was either internal iliac artery ligated and no patient developed intestinal ischaemia post-operatively. In Group 2 only two patients (5%) developed an urethral stricture. The difference between these two groups is significant (P < 0.001, Table 1). In Group 3 there have been no Table 1. Urethral stricture v. type of surgery Surgery

Number of patients

Number of strictures

Aortic Anterior resection of rectum

52

11 (21%)

40

2

(5%)

urethral strictures. All strictures have be~n confirmed by urethrography.

Bacteruria

Urine specimens were obtained in 45 of the 52 patients in Group 1, 32 of the 40 patients in Group 2 and in 86 of the 100 patients in Group 3. Bacteruria was defined as the occurrence of greater than 100,000 organisms per millilitre. Sixteen of the 45 patients in the first group Table 2, Incidence of bacteruria in patients with urethral and suprapubic catheters

Group

N u m b e r of CSU's available

Number of positive CSU's

% positive

1~ 2b 3~

45 32 86

16 13 7

35.5 40.6 8.1

aGroup 1: patients undergoing arotic surgery with a urethral catheter bGroup 2: patients undergoing rectal surgery with a urethral catheter CGroup 3: patients undergoing aortic surgery with a suprapubic catheter Eur J Vasc Surg Vol 4, October 1990

had significant bacteruria (35.5%). Thirteen of the 32 patients in the second group had significant bacteruria (40.6%) and only seven of the 86 patients (8.1%) in the third group with suprapubic catheters had significant bacteruria (Table 2). This difference is statistically significant (P < 0.05).

Discussion

There have been a number of reports of a high incidence of urethral stricture in male patients, both children and adults, undergoing elective cardiac surgery. 1-6 This complication has been noted but not as yet reported in association with peripheral vascular surgery. Such strictures occur exclusively in males at the narrowest points of the urethra, the external sphincter, the penoscrotal junction and just inside the external meatus. 7 Their development is multifactorial. It may of course be that the stricture predated the vascular surgery and therefore a previous history of urinary tract infection, trauma or surgery is important. In our elective aortic surgery group, of the 11 patients noted post-operatively to have strictures two had had a previous prostatectomy. Ruutu et al. noted that a "stricture epidemic" in their unit ceased after changing from latex to silicone catheters. 5 Edwards et al. found that latex catheters provoked moderate inflammatory infiltrate, epithelial loss and some haemorrhage in rat bladder mucosa, changes that may ultimately lead to stricture formation. 3 It has also been noted that these changes are more likely due to cytotoxic material in the catheters themselves than to the surface roughness of the catheter. s The only major cause found for an increase in incidence in urethral strictures after open heart surgery in Dublin was a change in lubricant. 2 This was reversed once use of the offending lubricant was discontinued. In the study by Edwards et al. it was noted that neither K-Y jelly nor tignocaine-chlorhexidine gel provoked any inflammatory or other response in rat bladder mucosa. 3 Urethral mucosal damage, whatever the cause, may lead to inflammation hence to healing by fibrosis and ultimately to stricture. Traumatic catheter insertion maybe incriminated, this is more likely to occur w h e n the patient is anaesthetised. 6 Drainage of clear urine is mandatory before the balloon is inflated. The use of large catheters may by pressure, block urethral glands thus causing irritation, inflammation and subsequent stricture. Avascular necrosis caused by large catheters may be further accentuated by bow-string-

Urethral Strictures and Aortic Surgery

ing if self retaining catheters are allowed to hang under traction. 3 The longer the patient is catheterised especially with a large catheter the more likely the above changes are to occur. Cystoscopically all urethras show some reaction even after 2-3 days with an indwelling catheter. 9 It has been suggested that urethral ischaemia may have a role in the aetiology of subsequent strictures.4" 6 This suggestion is supported by our finding of a 21% incidence of strictures in patients undergoing elective aortic surgery but only a 5% incidence in patients undergoing abdomino-pelvic surgery (anterior resection of the rectum) but where there is no aortic c r o s s clamping. This ischaemia may be associated with diminished perfUsion of the urethra during by-pass procedures or such manoeuvres as cross clamping of the aorta. Queral et al. monitored changes in blood flow to the pelvis by measurement of penile blood pressures. They found that those patients who had a decrease in penile blood pressure (21%) had a higher incidence postoperatively of clinical sequalae as measured by impotence, l° Urethral ischaemia therefore may well be important in the aetiology of strictures particularly w h e n aggravated by the presence of other detrimental factors such as a large catheter. Elhilali et al. go as far as to suggest that a penile vascular study be performed and the penile brachial index be evaluated in all patients who have erectile impotence or significant peripheral vascular disease before cardiovascular surgery, they recommend use of a cystocatheter rather than a urethral catheter in at risk cases. 11 It is well known that up to 50% of patients undergoing bladder catheterisation will develop a urinary tract infection. The longer the catheter is left in situ the higher the incidence. Although no direct correlation has been found between urinary tract infection and stricture formation, 5 such infections may have a deleterious effect on the health of the patient both in the short and long-term, they may increase the duration of hospitalisation and may even lead to death. 12 Such infections may also represent a risk in patients with prosthetic vascular grafts. In view of the high incidence of urethrM strictures (21%) noted in our series and the lack of a single identifiable correctable aetiological agent, it was decided to change the method of bladder drainage. A fine soft flexible polypropylene catheter, introduced under direct vision through the skin and into the bladder at the end of the operation was used. The catheter is sutured to the skin and remains in situ for 5 days. There are a number of advantages associated witl\its use. Since mid-1984 we have used this method exclusively and in over 200 cases have had no further urethral strictures in males and no morbidity a s s o -

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ciated with the use of the catheter. The incidence of bacteruria has also been significantly reduced (P = 0.05) in patients undergoing aortic surgery with a suprapubic catheter w h e n compared with those undergoing both aortic and rectal surgery when a urethral catheter is used. A further advantage of this method of catheterisation is that it affords the patient a trial of micturition and simply unclamping the catheter should this fail. 13 A potential criticism of the use of such suprapubic catheters is cost. In general, fine gauge proprietary catheters are approximately 4.5 times as expensive as a standard Foley catheter. Considering the overall cost of an aortic operation plus the saving by avoidance of urethral strictures the additional expense is negligible.

Conclusion

Urethral strictures associated with urethral catheters may occur more frequently after aortic and cardiac surgery. The aetiology of this is obscure and is probably multi-factorial. Suprapubic catheters are a safe and convenient alternative and abolish the incidence of urethral stricture. Bacteruria is also significantly reduced by the use of suprapubic catheters and the additional cost is negligible.

References i RUUTUM, ALFTHAN O, HEIKKINEN L, et al. "Epidemic" of acute urethral stricture after open-heart surgery. Letter to the editor. Lancet 1982; 1: 218. 2 SMITH JM, NELIGAN M. Urethral strictures after open heart surgery. Letter to the editor. Lancet 1982; 1: 392. 3 EDWARDSLE, LOCK R, POWELL C, JONES P. Post-catheterisation urethral strictures. A clinical and experimental study. Br J Urol 1983; 55: 53-56. 4 ABDEL-HAKIMA, BERNSTEINJ, TEIJEIRAJ, ELHILALIMM. Urethral stricture after cardiovascular surgery, a retrospective and a prospective study. ] Uro11983; 130: 1100-1102. 5 RuuTU M, ALFTHAN O, HEIKKINEN L, et al. Unexpected urethral strictures after short-term catheterisation in open-heart surgery. Scand J Urol Nephrol 1984; 18: 9-12. 6 PRABHUS, COCHRAN W, RAINE PAM, a z i Y AF. Postcatheterisation urethral strictures following cardiac surgery in children. J Ped Surg 1985; 20: 69-71. 7 BLAND¥JP Urethral stricture. Postgrad Med J 1980; 56: 383418. 8 WILSCH J, VERNON-ROBERTS B, GARRETTR, SMITH K. The role of catheter surface morphology and extractable cytotoxic material in tissue reactions to urethral catheters. Br J Uro11983; 55: 48-52. 9 RAY PAINTERM, BORSKIa a , TREVINOGS, CLARKJR WE. Urethral reaction to foreign objects. J Uro11971; 106: 227-230. 10 QUERALLA, WHITEHOUSEJR WM, FLINN WR, et al. Pelvic hemodynamics after aortoiliac reconstruction. Surgery 1979; 86: 799-809. Eur J Vasc Surg Vol 4, October 1990

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11 ELHILALIMM, HASSOUNAM, ABDEL-HAKIMA,TE1JEIRAJ.Urethral stricture following cardiovascular surgery: role of urethral ischaemia. J Uro11986; 135: 275-277. 12 PLATT R, FOLK F, MURDOCK B, ROSNER B. Mortality associated with nosocornial urinary tract infection. Br J Surg 1987; 74: 624-625.

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13 SETHIA KK, SELKONJB, BERRYAR, et al. Prospective randomised controlled trial of urethral versus suprapubic catheterisation. Br J Surg 1987; 74: 624-625.

Accepted 17 May 1990

Urethral strictures and aortic surgery. Suprapubic rather than urethral catheters.

Urethral strictures associated with the use of a urethral catheter may be more common after cardiac and aortic surgery when compared with other surgic...
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