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Fate of upper urinary tracts in patients with indwelling catheters after spinal cord injury
FATE OF UPPER URINARY TRACTS IN PATIENTS WITH INDWELLING CATHETERS AFTER SPINAL CORD INJURY ROBERTO CHAO, M.D. DIANE CLOWERS, R.N. MICHAEL E. MAYO. M.D. From the Department of Urology, University of Washington, and Department of Veterans Affairs Medical Center, Seattle, Washington
ABSTRACT-Several modes of urinary tract drainage exist for the spinal cord-injured (XI) patient, but the use of an indwelling catheter is discouraged. We retrospectively reviewed the charts of our traumatic SCI patients followed twenty years or more since initial injury to compare urinary tract preservation and the incidence of urologic complications in patients with neurogenic bladders voiding spontaneously with those using long-term indwelling catheters. Eighty-one patients with long-term injuries were identified; 73 of them fit the study criteria. Forty-one patients voided spontaneously having a balanced bladder or performing intermittent catheterization or have undergone sphincterotomy or vesicostomy, and 32 had indwelling suprapubic or Foley catheters. Renal function measured by creatinine clearance was similar in both groups: 81.3 + 20.2 mUmin for spontaneous voiders and 83.7 f 24.9 mUmin for catheterized patients. Review of urinary tract imaging and incidence of complications in both groups was very comparable, with the exception that the catheterized group had a higher prevalence of scarring and calicectasis on radiologic imaging of the upper urinary tracts which was statistically significant. Of the remaining population, in 6 of 81 patients, bladder cancer developed, and they underwent radical cystectomy and urinary diversion and 2 had proximal diversion alone. Of the 6 patients with bladder cancer, 2 were spontaneous voiders with transitional cell carcinoma (TCC) developing. Three of the 6 patients had indwelling catheters: in 1 patient TCC developed, in 1 adenocarcinoma, and in 1 squamous cell carcinoma. In 1 patient TCC developed in a defunctionalized bladder after ileal conduit formation. Based on this study, we can conclude that in select groups of SCI patients, the choice of an indwelling catheter may be made if other methods fail, provided patients undergo regular upper urinary tract imaging and cystoscopy.
Several modes of urinary tract drainage exist for the spinal cord-injured (SCI) patient. Ideal methods appear to be spontaneous voiding into a condom catheter, sometimes aided by sphincterocatheterization.3-6 Other tomy lx2 or intermittent patients, due either to convenience or necessity, will opt for indwelling catheter drainage via Foley or suprapubic tube (SPT). Indwelling catheter drainage has been held as inferior to the former methods in the current urologic literature.7-9 Our experience with both groups gave us the initial
impression that renal function and patient health is comparable in both groups. We retrospectively reviewed the charts of our traumatic spinal cordinjured patients followed twenty years or more since initial injury In this study we undertook the comparison of urinary tract preservation and incidence of urologic complications in patients with neurogenic bladders who were either voiding spontaneously or had long-term indwelling catheterization.
Submitted: March 24, 1993, accepted (with revisions): April 16, 1993
Eighty-one patients injured for twenty years or more, having their initial rehabilitation at other
UROLOGY /
SEPTEMBER 1993
I VOLUME42, NUMBER3
MATERIAL AND METHODS
259
TABLE I.
Patient population Number of Patients
Voiders (41) Paraplegics Quadriplegics Average (range) Age Years injured BUN Creatlnine Creatinine clearance
25 16
RESULTS Forty-one patients were spontaneous voiders, including 25 paraplegics and 16 quadriplegics (Table I). Mean group age was 61.6 years and time from injury 32.4 years. Mean creatinine clearance was 81.3 + 20.2 mL/min. Among spontaneous voiders, there was no statistically significant difference between the mean creatinine clearances of patients after sphincterotomy, having balanced bladders, or performing intermittent catheteriza-
(32)
16 16
61.6 (41-75) 32.4 (21-49) 12.6 0.9 81.3 k 20.2 (42-l
centers, have been followed in the spinal cord injury unit at the Seattle VAMC since 1986. Retrospective review of medical record charts and urinary tract imaging studies were performed on all the patients. Annual evaluation on all SC1 patients includes yearly history and physical examination, urinalysis, determination of serum blood urea nitrogen (BUN) and creatinine, twenty-four-hour urine collection for creatinine clearance, upper urinary tract imaging with intravenous pyelogram or renal ultrasound, and urodynamics as indicated. Urine culture and sensitivities are obtained and appropriate antibiotics are given only if the patient is symptomatic. Of 81 long-term injured patients, 73 patients have urinary tract drainage with either spontaneous voiding or indwelling catheterization. Forty-one spontaneous voiders included those who have undergone sphincterotomy (18), vesicostomy (11, balanced bladders (171, or perform intermittent catheterization (5). Thirty-two catheterized patients use a urethral Foley catheter (14) or suprapubic tube (18). The remaining 8 patients had undergone urinary diversion. Upper tract imaging included intravenous pyelogram or renal ultrasound, which were available for review. Previous studies were compared and note made of hydronephrosis, incidence of renal lithiasis, presence of scarring, and calicectasis. Reflux, if present, was noted on cystogram or urodynamics with fluoroscopy.
260
Catheterized
59.8 (42-76) 36.9 (2 l-47) 12.9 0.9 83.7 f 24.98 (40-l
17)
25)
tion. Twenty patients in the group underwent urodynamics tests and showed mean total bladder capacity of 350 cc, with 55 cm water of mean maximum voiding pressure (range 30-120 cm water) and a mean residual of 85 mL. Thirty-two patients evenly divided between paraplegics and quadriplegics were catheterized (Table I); 14 patients used intraurethral Foley catheters and 18 had suprapubic tubes. Mean group age was 59.8 years, with an average time from injury of 36.9 years. Average creatinine clearance was 83.7 f 24.9 mumin. The creatinine clearances were not statistically different between the two catheterized groups. Comparing the creatinine clearance of patients who were spontaneous voiders with those who had long-term indwelling catheters, there was no statistically significant difference between the two. Review of urinary tract imaging and prevalence of complications in both groups showed no significant difference with regard to hydronephrosis, renal lithiasis, reflux, or incidence of nephrectomy (Table II). The catheterized group had a higher
TABLE II.
Complications in voiders and catheterized patients Voiders
Complication Upper urinary tracts Hydronephrosis Renal lithiasis Scarringicalicectasis Reflux Nephrectomy Staghorn Cancer Renal failure Bladder Lithiasis Perineal fistulas Epididymitis
UROLOGY
79
Catheterized
8 7 2 3 2 1 1
62 2 8 14 3 2 2 0 0
3 0 0
7 1 1
1
/ SEPTEMBER 1993
Pts.
/ VOLUME42, NUMBER3
prevalence of scarring and calicectasis on upper urinary tract imaging (statistically significant by chi-square test, p = 0.02). The prevalence of bladder stone formation also was higher in the catheterized group, but this was not statistically significant (Fischer’s exact test). The incidence of urinary tract infections, defined as bacteriuria with symptoms requiring antibiotic treatment, was infrequent in both groups. Six spontaneous voiders and 4 catheterized patients had one to two bacteriuric episodes treated per year. Two spontaneous voiders and 1 catheterized patient were taking suppressive antibiotics. There was no documented problem with multiresistant organisms. Of 8 patients undergoing urinary diversion, 2 had ileal loop construction for urinary drainage. Six patients underwent radical cystectomy and urinary diversion for bladder cancer including 1 patient for squamous cell carcinoma (SCC), 4 patients for transitional cell carcinoma (TCC), and 1 patient for adenocarcinoma. This group included 2 patients who were spontaneous voiders with TCC developing after sphincterotomy, and 3 patients who had indwelling catheters with development of TCC in 1 patient, SCC in 1 patient, and adenocarcinoma in 1 patient. In 1 patient TCC developed in a defunctionalized bladder seven years after having an ileal conduit formed for urinary control. This patient’s previous bladder drainage could not be ascertained from chart review. The average time from injury to bladder cancer development was 25.7 years (range 9 to 34 years). All were free of metastases at the time of follow-up. COMMENT Deterioration of renal function continues to be a significant source of SC1 patient morbidity and mortality lo Catheter-free states are touted as the ideal management schemes. Previously reported series have proclaimed a high rate of success in maintaining SC1 patients catheter-free after sphincterotomy or using intermittent catheterization.1-6~11~‘However, 2 a small, but significant number of patients will fail one or the other and careful, long-term follow-up of the renal function of these patients is not available.3~“-‘3 Our retrospective study shows very comparable rates of urinary tract preservation and complications among both spontaneous voiders and long-term indwelling catheter users. These results appear to be contrary to previous investigators’ findings.7-9 However, in reviewing the findings of Jacobs and Kaufman in 1978,8 they also did not detect a statistically significant difference in frequency of upper urinary
UROLOGY
/ SEPTEMBER 1993
/ VOLUME42, NUMBER3
tract damage between voiders and catheterized patients followed for ten years or more. The major difference was found in the incidence of urethral and bladder complications. We believe that the improvement seen in our catheterized group with regard to bladder and urethral complications is in part due to the improved materials used in the catheter’s construction and subsequent reduced reactivity of today’s catheters. In a recent study by Dewire et a1.,14 the incidence of urologic complications in quadriplegics averaging twelve years from injury was not significantly different between voiders and patients with catheters. They were able to follow this group from initial rehabilitation until time of evaluation, which allows commentary on mortality from catheter-related complications, which our study does not. Of the original 57 patients followed by the Dewire group, 19 patients died. Of these, 3 of 32 patients with an indwelling catheter died of a urologic problem-urosepsis or renal failure. Of 25 patients without a catheter, 1 patient died of urosepsis. The death rates from urologic complications in both groups are not significantly different. Our study found no significant difference in renal function or in the prevalence of urologic complications in long-term SC1 patients classified as spontaneous voiders or using indwelling urethral catheters. There was a significantly higher prevalence of scarring and calicectasis of the upper urinary tracts in catheterized patients. This may represent clinically undetected reflux, pyelonephritis, or stone formation which may have led to the radiographic changes. Since these changes are not seen at twelve years post injury by Dewire et a1.,14 they may represent changes requiring twenty to thirty years to become evident. In 6 patients bladder cancer developed, and they underwent cystectomy. It has been theorized that chronic bladder infection and irritation can promote the development of bladder cancer in the SC1 patient. 15-18Squamous cell carcinoma tends to predominate in other series, although transitional cell carcinoma can be seen as in our study; adenocarcinoma is rare. Bladder cancer can arise in both spontaneous voiders or catheterized patients. Our present regimen for bladder cancer surveillance in our SC1 population includes cystoscopy and cup biopsy after ten years of indwelling catheter drainage. This workup is also necessary in any patient with an episode of gross hematuria, chronic symptomatic urinary tract infection refractory to conventional therapy, or particular predisposition secondary to chemical exposure.
261
To summarize, in a retrospective review of the medical records of 81 long-term SC1 patients, there was an overall decrease in renal function as measured by creatinine clearance. However, we found no significant difference in creatinine clearance or in the incidence of lower urinary tract complications between the 41 patients classified as spontaneous voiders and 32 patients using catheters. There was no significant difference in upper urinary tract complications except for a higher prevalence of scarring and calicectasis in catheterized patients. This study strengthens the conclusion that in a select group of SC1 patients the choice of an indwelling catheter may be dictated by convenience or preference of patients if methods to achieve spontaneous voiding have failed, as long as upper urinary tract imaging and cystoscopy are performed regularly Roberto Chao, M.D. Cleveland Clinic Florida Department of Urology 3000 w Cypress Creek Rd. Ft. Lauderdale. Florida 33309 REFERENCES 1. Perkash I: Modified approach to sphincterotomy in spinal cord injury patients. Indications, technique and results in 32 patients. Paraplegia 13: 247-260, 1976. 2. Perkash I: Problems of decatheterization in long-term spinal cord injury patients. J Ural 124: 249-253, 1980. 3. Yarnell SK, and Checkles NS: Intermittent catheterization: long-term follow-up. Arch Phys Med Rehabil 59: 491496,1978. 4. Barkin M, Dolfin D, Herschorn S, Bharatwal N, and Comisarow R: The urologic care of the spinal cord injury patient. J Urol 129: 335-339, 1983. 5. Diokno AC, Sonda LP, Hollander JB, and Lapides J:
262
Fate of patients started on clean intermittent self-catheterization therapy 10 years ago. J Urol 129: 1120-1122, 1983. 6. Maynard FM, and Glass J: Management of the neuropathic bladder by clean intermittent catheterisation: 5-Year outcomes. Paraplegia 25: 106-110, 1987. 7. Hackler RH: Spinal cord injuries, urologic care. Urology 2: 13-18, 1973. 8. Jacobs SC, and Kaufman JM: Complications of permanent bladder catheter drainage in spinal cord injury patients. J Uroll19: 740-741,1978. 9. Hackler RH: Long-term suprapubic cystostomy drainage in spinal cord injury patients. Br J Urol 54: 120-121,1982. 10. Whiteneck GG, Charlifue SW, Frankel HL, Fraser MH, Gardner BP Gerhart KA, Krishnan KR, Menter RR, Nuseibeh I, Short DJ, et al: Mortality, morbidity and psychosocial outcomes of persons SC1 more than 20 years ago. Paraplegia 30: 617-630,1992. 11. O’Flynn JD: An assessment of surgical treatment of vesical outlet obstruction in spinal cord injury: a review of 471 cases. Br J Uro148: 657-662, 1976. 12. Ross JC, Gibbon NOK, and Sunder GS: Division of the external urethral sphincter in the neuropathic bladder: a twenty years review. Br J Uro148: 649-656, 1976. 13. Lockhart JL, Vorstman B, Weinstein D, and Politano VA: Sphincterotomy failure in neurogenic bladder disease. J Ural 135: 86689, 1986. 14. Dewire DM, Owens RS, Anderson GA, Gottlieb MS, and Lepor H: A comparison of the urological complications associated with long-term management of quadriplegics with and without chronic indwelling urinary catheters. J Urol 147: 1069-1072,1992. 15. Melzak J: The incidence of bladder cancer in paraplegia. Paraplegia 4: 85-96, 1966. 16. Kaufman JM, Fam B, Jacobs SC, Gabilondo F, Yalla S, Kane JP and Rossier AB: Bladder cancer and squamous metaplasia in spinal cord injury patients. J Urol 118: 967-971, 1977. 17. Broecker BH, Klein FA, and Hackler RH: Cancer of the bladder in spinal cord injury patients. J Urol 125: 196-197,198l. 18. Bejany DE, Lockhart JL, and Rhamy RK: Malignant vesical tumors following spinal cord injury. J Urol 138: 1390-1392, 1987.
UROLOGY
/ SEPTEMBER 1993
/ VOLUME42, NUMBER3
ABSTRACT-Several modes of urinary tract drainage exist for the spinal cord-injured (XI) patient, but the use of an indwelling catheter is discouraged. We retrospectively reviewed the charts of our traumatic SCI patients followed twenty years or more since initial injury to compare urinary tract preservation and the incidence of urologic complications in patients with neurogenic bladders voiding spontaneously with those using long-term indwelling catheters. Eighty-one patients with long-term injuries were identified; 73 of them fit the study criteria. Forty-one patients voided spontaneously having a balanced bladder or performing intermittent catheterization or have undergone sphincterotomy or vesicostomy, and 32 had indwelling suprapubic or Foley catheters. Renal function measured by creatinine clearance was similar in both groups: 81.3 + 20.2 mUmin for spontaneous voiders and 83.7 f 24.9 mUmin for catheterized patients. Review of urinary tract imaging and incidence of complications in both groups was very comparable, with the exception that the catheterized group had a higher prevalence of scarring and calicectasis on radiologic imaging of the upper urinary tracts which was statistically significant. Of the remaining population, in 6 of 81 patients, bladder cancer developed, and they underwent radical cystectomy and urinary diversion and 2 had proximal diversion alone. Of the 6 patients with bladder cancer, 2 were spontaneous voiders with transitional cell carcinoma (TCC) developing. Three of the 6 patients had indwelling catheters: in 1 patient TCC developed, in 1 adenocarcinoma, and in 1 squamous cell carcinoma. In 1 patient TCC developed in a defunctionalized bladder after ileal conduit formation. Based on this study, we can conclude that in select groups of SCI patients, the choice of an indwelling catheter may be made if other methods fail, provided patients undergo regular upper urinary tract imaging and cystoscopy.
Several modes of urinary tract drainage exist for the spinal cord-injured (SCI) patient. Ideal methods appear to be spontaneous voiding into a condom catheter, sometimes aided by sphincterocatheterization.3-6 Other tomy lx2 or intermittent patients, due either to convenience or necessity, will opt for indwelling catheter drainage via Foley or suprapubic tube (SPT). Indwelling catheter drainage has been held as inferior to the former methods in the current urologic literature.7-9 Our experience with both groups gave us the initial
impression that renal function and patient health is comparable in both groups. We retrospectively reviewed the charts of our traumatic spinal cordinjured patients followed twenty years or more since initial injury In this study we undertook the comparison of urinary tract preservation and incidence of urologic complications in patients with neurogenic bladders who were either voiding spontaneously or had long-term indwelling catheterization.
Submitted: March 24, 1993, accepted (with revisions): April 16, 1993
Eighty-one patients injured for twenty years or more, having their initial rehabilitation at other
UROLOGY /
SEPTEMBER 1993
I VOLUME42, NUMBER3
MATERIAL AND METHODS
259
TABLE I.
Patient population Number of Patients
Voiders (41) Paraplegics Quadriplegics Average (range) Age Years injured BUN Creatlnine Creatinine clearance
25 16
RESULTS Forty-one patients were spontaneous voiders, including 25 paraplegics and 16 quadriplegics (Table I). Mean group age was 61.6 years and time from injury 32.4 years. Mean creatinine clearance was 81.3 + 20.2 mL/min. Among spontaneous voiders, there was no statistically significant difference between the mean creatinine clearances of patients after sphincterotomy, having balanced bladders, or performing intermittent catheteriza-
(32)
16 16
61.6 (41-75) 32.4 (21-49) 12.6 0.9 81.3 k 20.2 (42-l
centers, have been followed in the spinal cord injury unit at the Seattle VAMC since 1986. Retrospective review of medical record charts and urinary tract imaging studies were performed on all the patients. Annual evaluation on all SC1 patients includes yearly history and physical examination, urinalysis, determination of serum blood urea nitrogen (BUN) and creatinine, twenty-four-hour urine collection for creatinine clearance, upper urinary tract imaging with intravenous pyelogram or renal ultrasound, and urodynamics as indicated. Urine culture and sensitivities are obtained and appropriate antibiotics are given only if the patient is symptomatic. Of 81 long-term injured patients, 73 patients have urinary tract drainage with either spontaneous voiding or indwelling catheterization. Forty-one spontaneous voiders included those who have undergone sphincterotomy (18), vesicostomy (11, balanced bladders (171, or perform intermittent catheterization (5). Thirty-two catheterized patients use a urethral Foley catheter (14) or suprapubic tube (18). The remaining 8 patients had undergone urinary diversion. Upper tract imaging included intravenous pyelogram or renal ultrasound, which were available for review. Previous studies were compared and note made of hydronephrosis, incidence of renal lithiasis, presence of scarring, and calicectasis. Reflux, if present, was noted on cystogram or urodynamics with fluoroscopy.
260
Catheterized
59.8 (42-76) 36.9 (2 l-47) 12.9 0.9 83.7 f 24.98 (40-l
17)
25)
tion. Twenty patients in the group underwent urodynamics tests and showed mean total bladder capacity of 350 cc, with 55 cm water of mean maximum voiding pressure (range 30-120 cm water) and a mean residual of 85 mL. Thirty-two patients evenly divided between paraplegics and quadriplegics were catheterized (Table I); 14 patients used intraurethral Foley catheters and 18 had suprapubic tubes. Mean group age was 59.8 years, with an average time from injury of 36.9 years. Average creatinine clearance was 83.7 f 24.9 mumin. The creatinine clearances were not statistically different between the two catheterized groups. Comparing the creatinine clearance of patients who were spontaneous voiders with those who had long-term indwelling catheters, there was no statistically significant difference between the two. Review of urinary tract imaging and prevalence of complications in both groups showed no significant difference with regard to hydronephrosis, renal lithiasis, reflux, or incidence of nephrectomy (Table II). The catheterized group had a higher
TABLE II.
Complications in voiders and catheterized patients Voiders
Complication Upper urinary tracts Hydronephrosis Renal lithiasis Scarringicalicectasis Reflux Nephrectomy Staghorn Cancer Renal failure Bladder Lithiasis Perineal fistulas Epididymitis
UROLOGY
79
Catheterized
8 7 2 3 2 1 1
62 2 8 14 3 2 2 0 0
3 0 0
7 1 1
1
/ SEPTEMBER 1993
Pts.
/ VOLUME42, NUMBER3
prevalence of scarring and calicectasis on upper urinary tract imaging (statistically significant by chi-square test, p = 0.02). The prevalence of bladder stone formation also was higher in the catheterized group, but this was not statistically significant (Fischer’s exact test). The incidence of urinary tract infections, defined as bacteriuria with symptoms requiring antibiotic treatment, was infrequent in both groups. Six spontaneous voiders and 4 catheterized patients had one to two bacteriuric episodes treated per year. Two spontaneous voiders and 1 catheterized patient were taking suppressive antibiotics. There was no documented problem with multiresistant organisms. Of 8 patients undergoing urinary diversion, 2 had ileal loop construction for urinary drainage. Six patients underwent radical cystectomy and urinary diversion for bladder cancer including 1 patient for squamous cell carcinoma (SCC), 4 patients for transitional cell carcinoma (TCC), and 1 patient for adenocarcinoma. This group included 2 patients who were spontaneous voiders with TCC developing after sphincterotomy, and 3 patients who had indwelling catheters with development of TCC in 1 patient, SCC in 1 patient, and adenocarcinoma in 1 patient. In 1 patient TCC developed in a defunctionalized bladder seven years after having an ileal conduit formed for urinary control. This patient’s previous bladder drainage could not be ascertained from chart review. The average time from injury to bladder cancer development was 25.7 years (range 9 to 34 years). All were free of metastases at the time of follow-up. COMMENT Deterioration of renal function continues to be a significant source of SC1 patient morbidity and mortality lo Catheter-free states are touted as the ideal management schemes. Previously reported series have proclaimed a high rate of success in maintaining SC1 patients catheter-free after sphincterotomy or using intermittent catheterization.1-6~11~‘However, 2 a small, but significant number of patients will fail one or the other and careful, long-term follow-up of the renal function of these patients is not available.3~“-‘3 Our retrospective study shows very comparable rates of urinary tract preservation and complications among both spontaneous voiders and long-term indwelling catheter users. These results appear to be contrary to previous investigators’ findings.7-9 However, in reviewing the findings of Jacobs and Kaufman in 1978,8 they also did not detect a statistically significant difference in frequency of upper urinary
UROLOGY
/ SEPTEMBER 1993
/ VOLUME42, NUMBER3
tract damage between voiders and catheterized patients followed for ten years or more. The major difference was found in the incidence of urethral and bladder complications. We believe that the improvement seen in our catheterized group with regard to bladder and urethral complications is in part due to the improved materials used in the catheter’s construction and subsequent reduced reactivity of today’s catheters. In a recent study by Dewire et a1.,14 the incidence of urologic complications in quadriplegics averaging twelve years from injury was not significantly different between voiders and patients with catheters. They were able to follow this group from initial rehabilitation until time of evaluation, which allows commentary on mortality from catheter-related complications, which our study does not. Of the original 57 patients followed by the Dewire group, 19 patients died. Of these, 3 of 32 patients with an indwelling catheter died of a urologic problem-urosepsis or renal failure. Of 25 patients without a catheter, 1 patient died of urosepsis. The death rates from urologic complications in both groups are not significantly different. Our study found no significant difference in renal function or in the prevalence of urologic complications in long-term SC1 patients classified as spontaneous voiders or using indwelling urethral catheters. There was a significantly higher prevalence of scarring and calicectasis of the upper urinary tracts in catheterized patients. This may represent clinically undetected reflux, pyelonephritis, or stone formation which may have led to the radiographic changes. Since these changes are not seen at twelve years post injury by Dewire et a1.,14 they may represent changes requiring twenty to thirty years to become evident. In 6 patients bladder cancer developed, and they underwent cystectomy. It has been theorized that chronic bladder infection and irritation can promote the development of bladder cancer in the SC1 patient. 15-18Squamous cell carcinoma tends to predominate in other series, although transitional cell carcinoma can be seen as in our study; adenocarcinoma is rare. Bladder cancer can arise in both spontaneous voiders or catheterized patients. Our present regimen for bladder cancer surveillance in our SC1 population includes cystoscopy and cup biopsy after ten years of indwelling catheter drainage. This workup is also necessary in any patient with an episode of gross hematuria, chronic symptomatic urinary tract infection refractory to conventional therapy, or particular predisposition secondary to chemical exposure.
261
To summarize, in a retrospective review of the medical records of 81 long-term SC1 patients, there was an overall decrease in renal function as measured by creatinine clearance. However, we found no significant difference in creatinine clearance or in the incidence of lower urinary tract complications between the 41 patients classified as spontaneous voiders and 32 patients using catheters. There was no significant difference in upper urinary tract complications except for a higher prevalence of scarring and calicectasis in catheterized patients. This study strengthens the conclusion that in a select group of SC1 patients the choice of an indwelling catheter may be dictated by convenience or preference of patients if methods to achieve spontaneous voiding have failed, as long as upper urinary tract imaging and cystoscopy are performed regularly Roberto Chao, M.D. Cleveland Clinic Florida Department of Urology 3000 w Cypress Creek Rd. Ft. Lauderdale. Florida 33309 REFERENCES 1. Perkash I: Modified approach to sphincterotomy in spinal cord injury patients. Indications, technique and results in 32 patients. Paraplegia 13: 247-260, 1976. 2. Perkash I: Problems of decatheterization in long-term spinal cord injury patients. J Ural 124: 249-253, 1980. 3. Yarnell SK, and Checkles NS: Intermittent catheterization: long-term follow-up. Arch Phys Med Rehabil 59: 491496,1978. 4. Barkin M, Dolfin D, Herschorn S, Bharatwal N, and Comisarow R: The urologic care of the spinal cord injury patient. J Urol 129: 335-339, 1983. 5. Diokno AC, Sonda LP, Hollander JB, and Lapides J:
262
Fate of patients started on clean intermittent self-catheterization therapy 10 years ago. J Urol 129: 1120-1122, 1983. 6. Maynard FM, and Glass J: Management of the neuropathic bladder by clean intermittent catheterisation: 5-Year outcomes. Paraplegia 25: 106-110, 1987. 7. Hackler RH: Spinal cord injuries, urologic care. Urology 2: 13-18, 1973. 8. Jacobs SC, and Kaufman JM: Complications of permanent bladder catheter drainage in spinal cord injury patients. J Uroll19: 740-741,1978. 9. Hackler RH: Long-term suprapubic cystostomy drainage in spinal cord injury patients. Br J Urol 54: 120-121,1982. 10. Whiteneck GG, Charlifue SW, Frankel HL, Fraser MH, Gardner BP Gerhart KA, Krishnan KR, Menter RR, Nuseibeh I, Short DJ, et al: Mortality, morbidity and psychosocial outcomes of persons SC1 more than 20 years ago. Paraplegia 30: 617-630,1992. 11. O’Flynn JD: An assessment of surgical treatment of vesical outlet obstruction in spinal cord injury: a review of 471 cases. Br J Uro148: 657-662, 1976. 12. Ross JC, Gibbon NOK, and Sunder GS: Division of the external urethral sphincter in the neuropathic bladder: a twenty years review. Br J Uro148: 649-656, 1976. 13. Lockhart JL, Vorstman B, Weinstein D, and Politano VA: Sphincterotomy failure in neurogenic bladder disease. J Ural 135: 86689, 1986. 14. Dewire DM, Owens RS, Anderson GA, Gottlieb MS, and Lepor H: A comparison of the urological complications associated with long-term management of quadriplegics with and without chronic indwelling urinary catheters. J Urol 147: 1069-1072,1992. 15. Melzak J: The incidence of bladder cancer in paraplegia. Paraplegia 4: 85-96, 1966. 16. Kaufman JM, Fam B, Jacobs SC, Gabilondo F, Yalla S, Kane JP and Rossier AB: Bladder cancer and squamous metaplasia in spinal cord injury patients. J Urol 118: 967-971, 1977. 17. Broecker BH, Klein FA, and Hackler RH: Cancer of the bladder in spinal cord injury patients. J Urol 125: 196-197,198l. 18. Bejany DE, Lockhart JL, and Rhamy RK: Malignant vesical tumors following spinal cord injury. J Urol 138: 1390-1392, 1987.
UROLOGY
/ SEPTEMBER 1993
/ VOLUME42, NUMBER3