Point
of
Focus
Debate:
Con
–
Neuro-urology
Multiuse
Catheters
for
Clean
Intermittent
Catheterization
in
Urinary
Retention:
Is
There
Evidence
of
Inferiority?
Tess
van
Doorn,
Bertil
F.M.
Blok
*
DepartmentofUrology,ErasmusMedicalCenter,Rotterdam,TheNetherlands
Atpresent,Europeanpatientswhoperformclean intermit-tentcatheterization(CIC)forurinaryretentioncanonlyuse single-use catheters. This is in contrast to many non-Europeancountries,suchasAustralia,Canada, Japan,and theUSA,wherereuseofacatheteriscommonpractice in morethan50%ofcases[1,2].Accordingtothedefinitionof CICacleantechniqueisused,includingbothdisposableand cleanedreusablecatheters.Asepticintermittent catheteri-zation(IC)consistsofantisepticpreparationandtheuseof sterile(single-use)cathetersandgloves[3].TheEuropean Association of Urology neurourology guidelines suggest thatasepticICshouldbeusedwheneverpossible,butthat superioritycomparedtoCICisnotestablished[3].
The literature on differences in safety and efficacybetween single-andmultiusecathetersisconflictingandcomprisesa lowlevelofevidence.Ontheonehand,ithasbeensuggested thatreuseof catheters introducesunwanted bacteria and increasestherisk ofsymptomatic urinary tractinfections (UTIs),stoneformation,andurethralstrictures[4].On the otherhand,evidencesuggeststhatreusablecathetersareas safeandeffectiveasdisposablecatheters[5].
Arecent randomized clinical trial on CIC comparing single-useandreusedpoly(vinylchloride)cathetersamong75 pedi-atricpatientswithspinabifidashowednodifferenceinthe incidenceofUTIsorbacteriuria[6].InaCochraneanalysis, Prietoetal[7]foundnodifferencesinUTIincidencebetween patientsusingmultiusecathetersandthoseusingsingle-use catheters.Thisreviewwaswithdrawnin2017after reassess-mentofdatareportedbyChristisonetal[8].
Achallengingaspectofcomparingandmergingdatais thevariation in, orlack of,definitionofUTIs intrials, as pointedoutbyChristisonetal[8].Afterdataanalysisofthe Cochrane review was adjusted using the most recent
InfectiousDiseasesSocietyofAmerica criteria,no signifi-cant differences between single- and multiuse catheters werefound.However,finalconclusionsweredrawn accord-ing tothepreviouslyused(outdated)criteria,revealinga trendfavoringhydrophilicoverothercatheters[8].
Anotherdifficultyisthelackofconsensusonthemost efficientmethodforcleaningcatheters.Differentcleaning techniqueshavebeenstudiedandthisdiversitymakesthe available data even less generalizable [2]. The optimal cleaningmethodshouldbeidentifiedinfuturetrials.
Thecurrentliteraturemostlyfocusesonpatientswitha spinalcordinjury.Thisgroupaccountsforonlyapercentage ofallpatientsonchronicCIC.Idiopathiccausesofurinary retentionaremuchlessstudied.Theidiopathicand neuro-genicpopulationsdifferinvariousways,suchas presenta-tionandcomplaintsatthetimeofaUTIandmobilityand/or handfunction.
Thepossibleadvantagesofreusingcathetersareevident. Fromapatientperspective,theseincludegreatermobility becauseofhavingtocarryonlyonecatheter,havingtostore fewercathetersathome,havinglessbaggagewhen travel-ingandthereforelowercostswhenflying,andno fearof runningoutofcatheters.Fromanenvironmental perspec-tive,Sunetal[9]reportedthatsingle-usecathetersinthe USAalonewereresponsiblefor206millionlofwasteayear, equivalentto80Olympic-sizedswimmingpools,andthat catheters laid end-to-end would circumscribe the earth more than 5.5 times. These calculations were solely for catheters used by patients with neurogenic conditions; theidiopathicpopulationwasnotconsidered.Inaddition, most catheters are made of nonbiodegradable material
[9].The reductionin environmental burdenfor multiuse catheters shouldbetakeninto accountwhenconsidering EUROPEANUROLOGYFOCUS XXX(2019)XXX–XXX
a v ai l a b l e a t w w w . s c i e n c e d i r e c t . c o m
j o u r n al h o m e p a g e : w w w . e u r o p e an u r o l o g y . c o m / e u f o c u s
*Correspondingauthor.DepartmentofUrology,DrMolewaterplein40,Rotterdam3015GD,TheNetherlands.Tel.:+31107032414. E-mailaddress:b.blok@erasmusmc.nl(BertilF.M.Blok).
EUF-810;No.ofPages2
Pleasecitethisarticleinpressas:vanDoornT,Blok BFM,MultiuseCathetersforCleanIntermittentCatheterizationinUrinary Retention:IsThereEvidenceofInferiority?.EurUrolFocus(2019),https://doi.org/10.1016/j.euf.2019.09.018
https://doi.org/10.1016/j.euf.2019.09.018
reuse. In addition,if single- and multiusecatheters have equivalentsafety andefficacy,the potentialsavingsfrom reuse of catheters can contribute to mitigating growing healthcarecosts[10].
Thereisno multiuse catheter withUS Food and Drug Administrationor ConformitéEuropéenne approval com-merciallyavailable.Thus,reuseofcathetersisoutsidetheir intended use, whichcannotberecommended and isnot reimbursedbyhealthinsurancecompanies.Althoughthis argument is put forward against multiuse, it could be a reasontodevelopacatheterespeciallyforreuse,sincereuse isalreadycommon.
Theexclusiveadvocacyforsingle-usecathetersseemsto bebasedon biasedassumptionsratherthanexisting evi-dence. The only conclusion that can be drawn from the currentliteratureisthatahigh-gradelevelofevidencefrom arandomizedcontrolledtrialinvolvinganadequatesample size,asufficientcleaningmethod,andacleardefinitionof UTIisneeded.Suchatrialshouldconsistofpatientswith neurogenicandidiopathicconditionsrequiringCICsothat practicerecommendations canbeformulatedfor all indi-vidualsperformingCICforbladderdrainage.Untilthen,no conclusiononthesuperiorityofeithersingle-ormultiuse catheterscanbedrawn.
Conflictsofinterest:Theauthorshavenothingtodisclose.
Acknowledgement:FinancialsupportwasprovidedbytheDutch Orga-nization for Medical Sciences (ZonMW; B.F.M.B.), project number 853001104.Thefunderhadnoroleinthepreparationofthemanuscript.
References
[1] YoshidaM,IgawaY,HigashimuraS,SuzukiM,NiimiA,SanadaH. Translation and reliability and validity testing of a Japanese
version of the Intermittent Self-Catheterization Questionnaire amongdisposableandreusablecatheterusers.NeurourolUrodyn 2017;36:1356–62.
[2]HakanssonMA.Reuseversussingle-usecathetersforintermittent catheterization: whatis safe andpreferred? Review ofcurrent status.SpinalCord2014;52:511–6.
[3]BlokB,Castro-DiazD,DelPopoloG,etal.EAUguidelineson neuro-urology.Arnhem,TheNetherlands:EuropeanAssociationof Urol-ogy;2019.
[4]BogaertGA,GoemanL,deRidderD,WeversM,IvensJ,Schuermans A.Thephysicalandantimicrobialeffectsofmicrowaveheatingand alcoholimmersiononcathetersthatarereusedforclean intermit-tentcatheterisation.EurUrol2004;46:641–6.
[5]KovindhaA,MaiWN,MadersbacherH.Reusedsiliconecatheterfor cleanintermittentcatheterization(CIC):isitsafeforspinal cord-injured(SCI)men?SpinalCord2004;42:638–42.
[6]Madero-MoralesPA,Robles-TorresJI,Vizcarra-MataG,etal. Ran-domizedclinicaltrialusingsterilesingleuseandreused polyvi-nylchloridecathetersforintermittentcatheterizationwithaclean techniqueinspinabifidacases:short-termurinarytractinfection outcomes.JUrol2019;202:153–8.
[7]PrietoJA,MurphyC,MooreKN,FaderMJ.Intermittent catheterisa-tion for long-term bladder management (abridged Cochrane review).NeurourolUrodyn2015;34:648–53.
[8]ChristisonK,WalterM,WyndaeleJJM,etal.Intermittent cath-eterization: the devil is in the details. J Neurotrauma 2018;35:985–9.
[9]SunAJ,ComiterCV,ElliottCS.Thecostofacatheter:an environ-mentalperspectiveonsingleusecleanintermittentcatheterization. NeurourolUrodyn2018;37:2204–8.
[10] BerminghamSL,HodgkinsonS,WrightS,HayterE,SpinksJ,Pellowe C.Intermittentselfcatheterisationwithhydrophilic,gelreservoir, andnon-coatedcatheters:asystematicreviewandcost effective-nessanalysis.BrMedJ2013;346:e8639.
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EUF-810;No.ofPages2
Pleasecitethisarticleinpressas:vanDoornT,Blok BFM,MultiuseCathetersforCleanIntermittentCatheterizationinUrinary Retention:IsThereEvidenceofInferiority?.EurUrolFocus(2019),https://doi.org/10.1016/j.euf.2019.09.018
