The patient pathway for men with chronic urinary retention: treatments and their complications

Bos B1, Merode van N1, Steffens M1, Witte L1

Research Type

Clinical

Abstract Category

Male Lower Urinary Tract Symptoms (LUTS) / Voiding Dysfunction

Abstract 295
On Demand Male Lower Urinary Tract Symptoms (LUTS) / Voiding Dysfunction
Scientific Open Discussion Session 22
On-Demand
Underactive Bladder Male Retrospective Study Detrusor Hypocontractility Bladder Outlet Obstruction
1. Isala Clinics
Presenter
Links

Abstract

Hypothesis / aims of study
Different treatment options are available for patients with chronic urinary retention (CUR). The aim of this study was to explore the different treatments patients received from the urologist and the related complications.
Study design, materials and methods
For this retrospective study male patients were included who started treatment in 2014 for non-neurogenic CUR with a post-void residual (PVR) >150 ml. Patients were excluded because of urinary retention for a period shorter than four months, CUR with neurogenic origin, or the absence of clinical data. The follow-up began at the date of first treatment and ended on 1 September 2020. 
We analyzed all hospital contacts from the electronic patient records during the follow up period. These included different treatment steps, the related complications and the consequences thereof, such as additional diagnostics and additional treatments. Curative-intended options were de-obstructive prostate surgery, mostly transurethral resection of the prostate (TURP) or laser TURP, or sacral neuromodulation (SNM). Palliative options were clean intermittent catheterization (CIC), a urethral catheter (UC), a suprapubic catheter (SPC), and watchful waiting (WW).
Results
One hundred seventy-seven patients were included with a median age of 77 years (range 44-94) and a median follow-up of 68 months (range 1-319) during which they had a median of 8 hospital contacts (range 1-51). Four patients were excluded because of treatment with a percutaneous nephrostomy catheter due to another cause than CUR. 

Curative treatments
A part of patients was treated with a curative intent (n=50). Forty-nine patients (28%) had de-obstructive surgery of the prostate. Thirty-three percent of these patients could stop catheterization, compared to 6% of the patients in the group treated with catheterization . Patients treated with de-obstructive prostate surgery, were significantly more likely to end in the WW-group (OR 4.179). One patient received SNM in another hospital. Other baseline characteristics did not affect the final treatment outcome.
With regard to complications, the patient with SNM did not have any recorded complications. In the 30-days after prostate surgery, 36 complications were recorded. The most common were UTI’s (n=17) and haematuria (n=11). Other complications included frequency, urgency or urge incontinence (n=7) and a bladder perforation (n=1). 

Palliative treatments
The first and last treatment steps are displayed in Figure 1. Patients had a median of three (range 1-18) treatment steps until final treatment was attained. Most patients had a urethral catheter as first treatment (74%) and a form of catheterization as last treatment (87%). 

Complications
The incidence rate of the complications for catheterization and WW are presented in Table 1. An incidence rate of for example 1373 UTIs per 1000 patient-years can be explained as an average of 1.4 UTIs per patient per year. Catheterization (SPC, UC and CIC) gives a significantly higher chance of an UTI (incidence rate ratio (IRR) of 3.679, 95% CI: 2.920-4.686, p<0.001) and haematuria (IRR of 5.35, 95% CI: 2.292-15.12, p<0.001) compared to WW. However, patients in the WW-group have a much higher chance of post renal problems compared to catheterization (IRR of 25.36, 95% CI: 8.726-103.7, p<0.001). However, most post-renal problems (89%) were already present at the start of the first treatment. 
When comparing different forms of catheterization, CIC has a significantly lower incidence rate for all complications compared to UC and SPC (p<0.01), except for haematuria. SPC has a significantly lower incidence rate for all complications compared to UC (p<0.05), except for catheter pain.
Interpretation of results
Most male CUR-patients were treated with a form of catheterization, and these patients experience significant burden i.e. more UTIs, macroscopic haematuria, catheter problems and pain compared to the WW-group. Nevertheless, patients in the WW-group had a significantly higher chance of post-renal problems, mostly before onset of catheterisation.
In some patients, the burden of catheterization may be avoided by treating the underlying cause of urinary retention, such as bladder outlet obstruction (BOO) and/or detrusor underactivity (DU) (1). For a long time TURP has been the cornerstone of surgical treatment of BOO due to benign prostate hyperplasia (2), and some studies suggest that patients with DU might improve after TURP compared to doing nothing (3). In our study, 33% of the patients who had de-obstructive prostate surgery could stop catheterization.
Concluding message
This retrospective study demonstrates that men with CUR are most often treated with catheterization. This brings significant burden, such as UTIs, hematuria, catheter related problems, and pain. CIC is the most favourable form of catheterization. A selected group of men with CUR might benefit from de-obstructive prostate surgery.
Figure 1 Figure 1. First and last treatment step of different treatment options. CIC= clean intermittent catheterization, UC= urethral catheter, SPC= suprapubic catheter, WW= watchful waiting.
Figure 2 Table 1. Complications expressed as incidence rate per 1000 patients per year (95% confidence interval). CIC= clean intermittent catheterization, UC= urethral catheter, SPC= suprapubic catheter, WW= watchful waiting, UTI= urinary tract infection.
References
  1. Stoffel JT, Peterson AC, Sandhu JS, Suskind AM, Wei JT, Lightner DJ. AUA White Paper on Nonneurogenic Chronic Urinary Retention: Consensus Definition, Treatment Algorithm, and Outcome End Points. Journal of Urology 2017;198:153–60.
  2. Gravas S, Cornu J, Drake M, Gacci M, Gratzke C, Herrmann T. EAU Guidelines on Management of non-neurogenic male LUTS incl. benign prostatic obstruction. Arnhem: EAU Guidelines Office; 2018.
  3. Dobberfuhl AD, Chen A, Alkaram AF, De EJB. Spontaneous voiding is surprisingly recoverable via outlet procedure in men with underactive bladder and documented detrusor underactivity on urodynamics. Neurourology and Urodynamics 2019;38:2224–32.
Disclosures
Funding No funding Clinical Trial No Subjects Human Ethics Committee Local Ethical comittee of Isala Clinics, Zwolle, the Netherlands Helsinki Yes Informed Consent No
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