Irrigation of Continent Catheterizable Ileal Pouches: Tap Water Can Replace Sterile Solutions Because It Is Safe, Easy, and Economical

doi:10.1016/j.eururo.2011.01.003

European Urology

Volume 59, Issue 4, April 2011, Pages 518-523

https://doi.org/10.1016/j.eururo.2011.01.003 Get rights and content

Abstract

Background

Continent catheterizable ileal pouches require regular irrigations to reduce the risk of bacteriuria and urinary tract infections (UTIs).

Objective

Our aim was to compare the UTI rate, patient friendliness, and costs of standard sterile irrigation versus irrigation with tap water.

Design, setting, and participants

Twenty-three patients participated in a prospective randomized two-arm crossover single-center trial. Aseptic intermittent self-catheterization (ISC) combined with sterile sodium chloride (NaCl) 0.9% irrigation was compared with clean ISC and irrigation with tap water (H₂O) during two study periods of 90 d each.

Intervention

Patients underwent daily pouch irrigations with NaCl 0.9% solution or tap water.

Measurements

Urine nitrite dipstick tests were evaluated daily; urine culture (UC) and patient friendliness were evaluated monthly. Costs were documented.

Results and limitations

A total of 3916 study days with nitrite testing and irrigation were analyzed, 1876 (48%) in the NaCl arm and 2040 (52%) in the H₂O arm. In the NaCl arm, 418 study days (22%) with nitrite-positive dipsticks were recorded, 219 d (11%) in the H₂O arm, significantly fewer (p = 0.01). Of the 149 UCs, 96 (64%) were positive, 48 in each arm, revealing a total of 16 different germs. All patients preferred the H₂O method. Monthly costs were up to 20 times lower in the H₂O arm.

Conclusions

Pouch irrigation with sterile NaCl 0.9% solution and tap water had comparable rates of positive UC. Irrigation with tap water significantly lowered the incidence of nitrite-positive study days and was substantially less costly and more patient friendly than NaCl irrigation. We therefore recommend the use of tap water (or bottled water) instead of sterile NaCl 0.9% solution for daily irrigation of continent catheterizable ileal pouches.

Trial registration

Australian New Zealand Clinical Trials Registry, ACTRN12610000618055, http://www.ANZCTR.org.au/ACTRN12610000618055.aspx.

Introduction

For patients requiring urinary diversion, a continent catheterizable urinary reservoir can allow near normal physical integrity and a good quality of life. The need for intermittent self-catheterization (ISC), however, leads to an increased risk of bacteriuria [1]. To reduce the risk of urinary tract infections (UTIs) and mucus plug formation, daily pouch irrigation is recommended to eliminate microbes and evacuate the intestinal mucus [2]. Several studies have shown that the presence of mucus correlates with bacteriuria in patients with bladder substitutes or ileal conduits [3], [4]. Pouch irrigation with a sterile solution (eg, isotonic saline or Ringer lactate solution) is considered standard.

A potential advantage of irrigation with tap water is its hypo-osmolarity. Levina et al showed that the exposure of Escherichia coli to a hypo-osmolar medium results in loss of viability and lysis of the microbes [5]. If tap water would prove to be as efficient at pouch irrigation as sterile solutions, it would likely be more patient friendly and less costly than sterile solutions. The aim of this study was to test this hypothesis.

Section snippets

Materials and methods

A consecutive series of 23 patients (3 men, 20 women; median age: 61 yr; range: 29–71 yr) with a continent catheterizable ileal pouch and no known preexisting chronic infection was randomized in a prospective two-arm crossover study. Patients were enrolled in the study a median of 38 mo (range: 3–121 mo) after pouch construction (Table 1). All patients gave written informed consent.

The surgical technique employed to construct the ileal pouch is similar to that used for orthotopic bladder

Results

All 23 patients completed both 90-d study periods except for 2 patients who refused the crossover to NaCl after the first study period with H₂O.

A total of 3916 (100%) study days were analyzed, 1876 d (48%) in the NaCl arm and 2040 d (52%) in the H₂O arm. There were 418 (22%) nitrite-positive days in the NaCl arm and 219 (11%) in the H₂O arm, a significant difference (p = 0.01; 95% confidence interval, 0.03–0.26) (Fig. 2).

Of the 149 (100%) routinely collected UCs, 96 (64%) tested positive and 53

Discussion

Patients with a continent urinary diversion are at high risk for UTI [1], [10], [11] and are therefore advised to irrigate their pouches regularly for their lifetime. They are usually instructed to irrigate the pouch with sterile NaCl 0.9% solution. This prospective study demonstrates that patients using sterile NaCl 0.9% solution had significantly more nitrite-positive study days (22%) than the same patients using tap water (11%). The ratio of positive UCs to number of study days did not

Conclusions

Using tap water for ileal pouch irrigation significantly reduced the incidence of nitrite-positive study days while not changing the positive UC rate compared with that of NaCl 0.9% irrigation with comparable microbiologic spectra. Similarly, a trend towards fewer antibiotic treatments for symptomatic UTI was observed in the H₂O arm versus the NaCl arm. All patients preferred the use of tap water as easier, more patient friendly, and considerably less expensive. We therefore recommend the use

Naresh

Author contributions: Urs E. Studer had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Studer, Birkhäuser, Schürch, Burkhard, Willener, Ochsner, Zehnder, Thalmann.

Acquisition of data: Birkhäuser, Ochsner, Zehnder, Roth, Burkhard, Willener, Thalmann, Studer.

Analysis and interpretation of data: Birkhäuser, Studer, Zehnder, Roth.

Drafting of the manuscript: Birkhäuser, Zehnder, Studer.

References (19)

B. Wullt et al.
Microbial flora in ileal and colonic neobladders
Eur Urol
(2004)
P. Zehnder et al.
Effect of urinary tract infection on reservoir function in patients with ileal bladder substitute
J Urol
(2009)
V.G. Reeves-Darby et al.
Effect of cloned Salmonella typhimurium enterotoxin on rabbit intestinal motility
FEMS Microbiol Lett
(1995)
P.R. Monti et al.
New techniques for construction of efferent conduits based on the Mitrofanoff principle
Urology
(1997)
M.E. Falagas et al.
Urinary tract infections in patients with urinary diversion
Am J Kidney Dis
(2005)
U.E. Studer et al.
Twenty years experience with an ileal orthotopic low pressure bladder substitute—lessons to be learned
J Urol
(2006)
H.M. Pollock
Laboratory techniques for detection of urinary tract infection and assessment of value
Am J Med
(1983)
A. Tsapis et al.
Transient breakdown of the permeability barrier of the membrane of Escherichia coli upon hypoosmotic shock
Biochim Biophys Acta
(1977)
J. N’Dow et al.
Mucus production after transposition of intestinal segments into the urinary tract
World J Urol
(2004)

There are more references available in the full text version of this article.

Cited by (13)

Neurogenic Bladder:: Assessment and Operative Management
2022, Urologic Clinics of North America
Citation Excerpt :
After catheter removal, we recommend once daily irrigation with tap water. Tap water is a safe, cheap, convenient, and environmentally friendly alternative to bottles of sterile saline.34 We perform a renal-bladder ultrasound on all patients with NGB on an annual basis.
Intravesical bacteriophages for treating urinary tract infections in patients undergoing transurethral resection of the prostate: a randomised, placebo-controlled, double-blind clinical trial
2021, The Lancet Infectious Diseases
Citation Excerpt :
More surprising was the similar primary outcome success for both bacteriophage and placebo instillation, which we hypothesise was due to a therapeutic effect of a mechanical reduction of the bacterial load following bladder irrigation. This is supported by Birkhäuser and colleagues,23 who reported that daily bladder irrigation with tap water reduces the bacterial load and the subsequent need for antibiotic treatment for UTI in a randomised controlled trial in patients with ileal pouches. The effect of mechanical reduction of the bacterial load would also have been expected for the Pyophage solution, thus bringing into question any inherent direct antibacterial activity of the applied bacteriophages.
Urinary tract infections (UTIs) are among the most prevalent microbial diseases and their financial burden on society is substantial. In the context of increasing antibiotic resistance, finding alternative treatments for UTIs is a top priority. We aimed to determine whether intravesical bacteriophage therapy with a commercial bacteriophage cocktail is effective in treating UTI.
We did a randomised, placebo-controlled, clinical trial, at the Alexander Tsulukidze National Centre of Urology, Tbilisi, Georgia. Men older than 18 years of age, who were scheduled for transurethral resection of the prostate (TURP), with complicated UTI or recurrent uncomplicated UTI but no signs of systemic infection, were allocated by block randomisation in a 1:1:1 ratio to receive intravesical Pyo bacteriophage (Pyophage; 20 mL) or intravesical placebo solution (20 mL) in a double-blind manner twice daily for 7 days, or systemically applied antibiotics (according to sensitivities) as an open-label standard-of-care comparator. Urine culture was taken via urinary catheter at the end of treatment (ie, day 7) or at withdrawal from the trial. The primary outcome was microbiological treatment response after 7 days of treatment, measured by urine culture; secondary outcomes included clinical and safety parameters during the treatment period. Analyses were done in a modified intention-to-treat population of patients having received at least one dose of the allocated treatment regimen. This trial is registered with ClinicalTrials.gov, NCT03140085.
Between June 2, 2017, and Dec 14, 2018, 474 patients were screened for eligibility and 113 (24%) patients were randomly assigned to treatment (37 to Pyophage, 38 to placebo, and 38 to antibiotic treatment). 97 patients (28 Pyophage, 32 placebo, 37 antibiotics) received at least one dose of their allocated treatment and were included in the primary analysis. Treatment success rates did not differ between groups. Normalisation of urine culture was achieved in five (18%) of 28 patients in the Pyophage group compared with nine (28%) of 32 patients in the placebo group (odds ratio [OR] 1·60 [95% CI 0·45–5·71]; p=0·47) and 13 (35%) of 37 patients in the antibiotic group (2·66 [0·79–8·82]; p=0·11). Adverse events occurred in six (21%) of 28 patients in the Pyophage group compared with 13 (41%) of 32 patients in the placebo group (OR 0·36 [95% CI 0·11–1·17]; p=0·089) and 11 (30%) of 37 patients in the antibiotic group (0·66 [0·21–2·07]; p=0·47).
Intravesical bacteriophage therapy was non-inferior to standard-of-care antibiotic treatment, but was not superior to placebo bladder irrigation, in terms of efficacy or safety in treating UTIs in patients undergoing TURP. Moreover, the bacteriophage safety profile seems to be favourable. Although bacteriophages are not yet a recognised or approved treatment option for UTIs, this trial provides new insight to optimise the design of further large-scale clinical studies to define the role of bacteriophages in UTI treatment.
Swiss Continence Foundation, the Swiss National Science Foundation, and the Swiss Agency for Development and Cooperation.
For the Georgian and German translations of the abstract see Supplementary Materials section.
Efficacy of Long-Acting Octreotide on Reducing Mucus Production in Patients With Ileal Neobladder
2017, Clinical Genitourinary Cancer
Citation Excerpt :
Some authors have suggested using single-J ureteral stents. Urethral catheters, cystostomy tubes, and external ureteral stents may be used simultaneously to irrigate the neobladder, thus preventing catheter obstruction caused by mucus secretion.8 By using cystostomy and external ureteral catheters at the same time, the patient would have 4 catheters in addition to drains in place for 2 to 3 weeks—a cumbersome situation for the patient.
To evaluate the efficacy of long-acting-release octreotide (trade name Sandostatin) on decreasing mucus secretion, thus reducing catheter obstruction after radical cystectomy and orthotopic reconstruction.
In this double-blind, placebo-controlled study, we treated 73 cases of radical cystectomy between the years 2008 and 2014; 65 were deemed eligible for the study. Cases were randomly divided into 2 groups. Group A (n = 32) received 2 doses of 20 mg intramuscular long-acting-release octreotide 4 weeks before and on the day of surgery, while group B (n = 33) received placebo. Catheter irrigation was only performed when there was an obstruction due to a mucus plug. The need for catheter irrigation and the volume of mucus produced by the neobladder were evaluated and compared between the 2 groups.
The average number of neobladder irrigations required to treat mucus plugs was 2.3 ± 1.5 in group A and 9.5 ± 4.3 in group B (P < .001) before hospital discharge. This number changed to 2.5 ± 1.5 versus 11.4 ± 2.7 in groups A and B, respectively (P < .001), after discharge from the hospital. The 24-hour mucus production at the end of the first week was 5.4 ± 2.7 mL versus 21.5 ± 5.6 mL in groups A and B, respectively (P < .001). At the end of the third week, this amount changed to 5.5 ± 2.3 mL versus 21.8 ± 5.6 mL in groups A and B, respectively (P < .001).
Two injections of long-acting-release octreotide can dramatically reduce mucus production and hence catheter obstruction due to mucus plugs after radical cystectomy and orthotopic reconstruction.
The quest for a better bladder from bowel
2011, European Urology
ELIMINATE Phase 2 Trial: Outcomes from the Part 1 Open-Label Dose Regimen Selection Portion of a 2-Part Trial Testing LBP-EC01, a CRISPR-Cas3-Enhanced Bacteriophage Cocktail, in Uncomplicated Urinary Tract Infections
2024, SSRN
Bladder irrigation with tap water to reduce antibiotic treatment for catheter-associated urinary tract infections: an evaluation of clinical practice
2023, Frontiers in Urology

View all citing articles on Scopus

View full text

Platinum Priority – Bladder CancerEditorial by Joseph L. Chin on pp. 524–525 of this issueIrrigation of Continent Catheterizable Ileal Pouches: Tap Water Can Replace Sterile Solutions Because It Is Safe, Easy, and Economical

Abstract

Background

Objective

Design, setting, and participants

Intervention

Measurements

Results and limitations

Conclusions

Trial registration

Introduction

Section snippets

Materials and methods

Results

Discussion

Conclusions

Naresh

Eur Urol

J Urol

FEMS Microbiol Lett

Urology

Am J Kidney Dis

J Urol

Am J Med

Biochim Biophys Acta

Mucus production after transposition of intestinal segments into the urinary tract

World J Urol

Platinum Priority – Bladder Cancer
Editorial by Joseph L. Chin on pp. 524–525 of this issue
Irrigation of Continent Catheterizable Ileal Pouches: Tap Water Can Replace Sterile Solutions Because It Is Safe, Easy, and Economical