Chapter 11

The ability to manipulate the urinary tract without the need for an open surgical incision differentiates urology from other disciplines. Such intervention may be required for diagnostic or therapeutic purposes (or both). Understanding the various catheters, guidewires, stents, endoscopes, and associated instrumentation is key in helping physicians accomplish their desired tasks. Manipulation of the urinary tract should be performed in a gentle fashion; instruments need not be forced. An understanding of anatomy and alternative instrumentation should allow physicians to accomplish their tasks with finesse. The patient should understand the proposed procedure and potential complications. For example, the attempt to place a retrograde ureteral catheter to drain an infected kidney may ultimately lead to a percutaneous nephrostomy if the surgeon is unable to achieve retrograde drainage. Knowing when to stop is as important as knowing when to start.

Many procedures are performed at the bedside or in a cystoscopy suite under local anesthesia. A patient who is comfortable, informed, and assured will more likely cooperate and tolerate the procedure. A physician who is familiar with the proposed instrumentation and understands its limitations and alternatives will win the patient's confidence.

Manipulation of the urinary tract can result in significant injury. Anticipated prolonged procedures should be covered with appropriate antibiotics directed by preoperative urine cultures and sensitivities. Generous use of a water-soluble lubricant and low-pressure irrigation decreases the likelihood of significant iatrogenic infections. Patient positioning is as important as proper choice of instrumentation. Pressure points must be identified and adequately padded, especially when the patient is placed in the dorsal lithotomy position. In addition, the legs should be secured in their stirrups to prevent accidental injury, such as those that might result from a leg hitting the surgeon after an unexpected obturator reflex during endoelectric surgery.

Urethral catheterization is the most frequent retrograde manipulation performed on the urinary tract. Catheters are placed to drain the bladder during and after surgical procedures requiring anesthetics, to assess urinary output in critically ill patients, to collect reliable urine specimens, for urodynamic evaluation, for radiographic studies (eg, cystograms), and to assess residual urine. Such catheters can be left indwelling with a self-retaining balloon, as is done with a Foley catheter. An in-and-out procedure to drain a bladder does not require a self-retaining device. Adequate lubrication and sufficient frequency to keep the bladder at reasonable volumes are critical and must be emphasized to the patient performing self-intermittent catheterization; sterility is secondary. In contrast, when a catheter is left indwelling it is important to use sterile technique.

### Technique of Catheterization

#### In Men

The penis should be positioned pointing toward the umbilicus to decrease the acute angulation as the catheter traverses the bulbar urethra. On most occasions, the catheter passes without difficulty. When difficulties arise, a careful history relating to previous urologic manipulations is critical. Strictures are not infrequent and can occur after endourologic surgery. Urethral strictures ...

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