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JRRD Volume 45, Number 4, 2008 Volume 45, Number 4, 2008 JRRDJRRD Pages 639–646 Journal of Rehabilitation Research & Development A 24-hour feasibility study of intraurethral valved catheter for bladder management in males with spinal cord injury Bradley G. Orris, MD;1–2 Andrew E. Jahoda, MD;1–2 James S. Walter, PhD;2–3* Bernard N. Nemchausky, MD;4 Rafael Wurzel, MD;5 Harvey D. Homan, PhD;5 Sally Melloy, LPN;3 John S. Wheeler, MD1–2 1Department of Surgery, Edward Hines Jr Department of Veterans Affairs (VA) Hospital, Hines, IL; 2Department of Urology, Loyola University Medical Center, Maywood, IL; Departments of 3Research and 4Spinal Cord Injury, Edward Hines Jr VA Hospital, Hines, IL; 5Urovalve, Inc, Newark, NJ Abstract—This feasibility study was conducted to evaluate INTRODUCTION design features of the novel intraurethral valved catheter, Suri- nate (Urovalve, Inc; Newark, New Jersey). The device extends The most common methods of bladder management from the bladder neck to just beyond the external sphincter and following spinal cord injury (SCI) include indwelling contains a valve that can be activated by an external magnet for Foley catheters, external condom catheters, and clean bladder emptying. Five patients were recruited from the Edward intermittent catheterization (CIC) [1–6]. CIC is considered Hines Jr Department of Veterans Affairs Hospital spinal cord the standard of care because long-term outcomes with this injury population. We conducted cystometry and cystoscopy to evaluate the lower urinary tract. Then, the device was inserted method have been shown to be better than with the other for 24 hours with careful monitoring. The catheter was removed methods. However, all the methods have limitations for from the first patient because he developed autonomic dysre- some patients who may have problems in the areas of uri- flexia during implantation. The next four patients used the cathe- nary tract infections (UTIs), urethral trauma, and difficulty ter overnight and tolerated it well: one with independent use and with the use of anticholinergic medications as part of some two with increased abdominal pressure. Emptying time was of the methods [4,7–8]. Various surgical procedures have 208 +/– 99 s, residual was 42 +/– 33 mL, and the first-stream been developed to improve upon methods of bladder man- flow rate was 1.8 +/– 0.7 mL/s. The safety tether was used in agement, such as sacral nerve root stimulation, urinary three patients because the extraction device did not work. diversion, and suprapubic catheters, but all the surgical Results showed effective implantation and stability of the device methods are invasive and have limitations [9]. in the urethra. However, objectives for use and extraction were This study evaluated the feasibility of a new type of not met. This feasibility study provided important information internal urethral catheter that spans from the bladder neck that will help guide design improvements for the intraurethral valved catheter. to just distal to the striated urethral sphincter and contains Abbreviations: CIC = clean intermittent catheterization, SCI = spinal cord injury, TRUS = transrectal ultrasound, UTI = uri- nary tract infection. *Address all correspondence to James S. Walter, PhD; Edward Hines Jr VA Hospital (151), Research Service, Key words: catheterization, cystometry, cystoscopy, intra- Hines, IL 60141; 708-202-5805; fax: 708-202-2319. urethral valved catheter, neurogenic bladder, rehabilitation, spi- Email: [email protected] nal cord injury, urinary incontinence, urinary retention, UTI. DOI: 10.1682/JRRD.2007.07.0112 639 640 JRRD, Volume 45, Number 4, 2008 a magnetically actuated valve that allows for the controlled The objectives of this 24-hour feasibility study were flow of urine. This intraurethral valved catheter is the Suri- to (1) assess insertion and extraction instruments and nate® (Urovalve, Inc; Newark, New Jersey) (Figures 1–2). methods; (2) determine whether the device migrates from The device was designed to provide the following fea- the position of original placement; (3) assess function tures: (1) allow bladder emptying by the patient through and mechanical reliability of the device for bladder emp- the use of a magnetic valve and (2) avoid having a catheter tying based on measurement of urine flow rate, residual pass through the urethral meatus, a known risk for UTI. volume, and ease of operation by the patient; and The Ontario Neurotrauma Foundation (http://www.onf.org) (4) assess safety and tolerability during the period the has highlighted this area of research for funding of new device is in the urethra. approaches for SCI bladder care [10]. MATERIALS AND METHODS Five adult male patients with complete or incomplete third thoracic or lower SCI, a neurogenic bladder, and a documented history of chronic urinary retention or incon- tinence were recruited from the SCI service for this pro- spective study (see Table 1 for detailed medical history). This study was conducted under the approval of the Edward Hines Jr Department of Veterans Affairs Hospital Investigational Review Board, with investigational device Figure 1. exemption from the U.S. Food and Drug Administration. Intraurethral valved catheter, Surinate. Malecot tip is shown in upper Following enrollment and informed consent, we right corner and magnetic valve in lower left with safety tether screened all patients with medical history, physical attached. examination, and urine dipstick analysis to evaluate for UTI. Additionally, all patients were given a 4-day course of a prophylactic oral antibiotic beginning on the morn- ing of the study. Adverse events are reported as well as function and any difficulty with the device. Cystometry Next, we conducted cystometry with a rectal balloon and recorded abdominal pressure with a dual lumen uro- dynamic catheter (model DLC-6D, 6 French, Life-Tech, Inc; Stafford, Texas) in the bladder. Vesical pressure is an important pressure to report because it is the total pressure that promotes urine flow. Vesical pressure is defined as detrusor pressure (pressure due to the bladder wall) plus abdominal pressure; it is the pressure recorded in the bladder after a hydrostatic zero pressure is set external to the patient and at the top of the suprapubic bone. We can obtain detrusor pressures by subtracting abdominal pressure from vesical pressure. Filling was conducted at 50 mL/min to a volume of 300 mL or until a detrusor pressure of 50 cmH2O. A filling volume of 150 Figure 2. mL with a detrusor pressure of 50 cmH2O or lower was Intraurethral valved catheter, Surinate, with activator magnet in required for continuation in the study. During cystome- position for bladder emptying. try, the patient’s head was elevated on average 20°. One 641 ORRIS et al. Intraurethral valved catheter for chronic urinary retention Table 1. Patient medical history. Years Weight† Primary Bladder Autonomic Level of Injury No. UTIs Patient Age Hypertensive* Injured (BMI) Management Dysreflexia‡ & Completeness (last yr) 1 47 26 Treated, Controlled Overweight CIC Yes Motor & Sensory T5 4 (25.8) Complete 2 56 5 Treated, Controlled Obese CIC No Motor & Sensory T7 6 (32) Complete 36017NoObeseCIC (& external No Motor & Sensory L4 0 (32) catheter drainage) Complete 4 30 3 Treated, Uncontrolled Normal CIC Yes Motor T12 3 (24.7) Sensory S5 Incomplete 5 34 1 No Normal CIC No Motor & Sensory T3 2 (21.3) Complete Mean ± 45 ± 13 10.4 ± 10.7 — 27.16 ± 4.7 — — — 3 SD *Controlled defined as blood pressure <140/90 mmHg. †Normal = BMI 18.5–24.9, overweight = BMI 25.0–29.9, obese = BMI 30.0 and above. ‡Defined as one or more episodes noted in chart or per patient history. BMI = body mass index, CIC = clean intermittent catheterization, L = lumbar, S = sacral, SD = standard deviation, T = thoracic, UTI = urinary tract infection. patient was prone (0°) because of recent surgery on a (TRUS) of the malecot in the bladder. Once the device decubitus ulcer. Blood pressure and pulse were moni- was properly positioned, we disengaged the insertion tored throughout the entire procedure. stylet to expand the malecot wings and inserted a nylon 2,0 tether that extended from the urethra to aid in Cystoscopy removal of the catheter if any difficulties arose with the Following cystometry, we performed cystoscopy using extraction device. a 15 French flexible cystoscope to assess the lower urinary We activated the valve by placing a magnet in the tract and measure the length of the urethra. Measurements patient’s perineum and collected the urine in a handheld were taken from the bladder neck to the urethral meatus as urinal, a bedside urinal, or a cup (Figure 2). We deter- well as from the external sphincter to the urethral meatus. mined three different flow rates (ratio of volume col- We subtracted these values to determine the length of the lected to collection time). First, we determined the urethra from the bladder neck to the external sphincter and average flow rate of the first stream of urine with the first to determine the proper size device. The implantable magnet activation. This average did not include time device was available in 60 and 80 mm lengths. Criteria for searching with the magnet before bladder draining determining the device length to insert changed during the started. Second, we calculated the peak flow rate. For this study. Initially we inserted the shortest one that could rate, we placed a cup in the urine stream for collection extend beyond the measured length. But, we changed our once the peak flow rate was observed. The collection protocol after our initial experience to only implant the period for this rate was 10 or 20 s. Third, we calculated 80 mm length. an average for the entire procedure and included the total volume voided and the total time taken to empty the blad- Insertion and Use of Surinate der, including time searching with the magnet. This cal- We employed a specially designed mandarin stylet culation did not include the short rest periods between that engaged the tip of the catheter and collapsed the male- attempts to empty the bladder with the magnet.
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