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A simple guidewire and angiocatheter technique for urinary catheter placement

Luangkhot, Robert MD; Cheng, Einstein PA-C; Yuan, Meilong PA-C; Rashidzada, Mariam PA-C; Chen, Yi PA-C; Yakubov, Yevgeniy PA-C; Babayev, Jonathan PA-C; Franco, Elizabeth PA-C; Prithiani, Rinku PA-C

Journal of the American Academy of PAs: August 2019 - Volume 32 - Issue 8 - p 39–42
doi: 10.1097/01.JAA.0000569800.52435.71
Original Research
Free

Objective: To report on a simple technique of inserting any difficult urinary catheter using a hydrophilic guidewire and an angiocatheter.

Materials and methods: A total of 764 requests were made to the urology team for assistance with a difficult urinary catheter placement. For all patients, either a regular or bent-tip catheter was attempted first. If the initial placement attempt failed, our technique using an angiocatheter, a hydrophilic guidewire, and a urinary catheter of choice was then employed.

Results: We were able to successfully insert 526 regular or bent-tip indwelling urinary catheters on first attempt (68.8%). Two hundred and four (26.7%) placements required the use of our described technique. No complication was encountered from the bedside maneuver.

Conclusions: Our method is safe, easily learned, and performed. The technique saves time, effort, and resources, as it averts the necessity of rare use of expensive equipment, bedside flexible cystoscopy, and cystotomy.

Robert Luangkhot is an attending physician at Pinnacle Urology in Flushing, N.Y. Einstein Cheng, Meilong Yuan, Mariam Rashidzada, Yi Chen, Yevgeniy Yakubov, Jonathan Babayev, and Elizabeth Franco practice at New York Presbyterian in Queens, N.Y. Rinku Prithiani practices psychiatry at Queens Hospital in New York City. The authors have disclosed no potential conflicts of interest, financial or otherwise.

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Figure

New York Presbyterian Queens, located in Flushing, N.Y., is a community teaching hospital affiliated with Weill Cornell Medical Center in Manhattan. The 535-bed tertiary care facility is serviced by 12 clinical departments and 62 subspecialties. The urology service is entirely triaged and managed by eight full-time physician assistants (PAs), with the support of a urology chief resident rotating from Weill Cornell, under the supervision of six full-time faculty and 20 voluntary attendings. Initial urology consultations usually are channeled to the PAs. A significant number of requests are for help when the primary service cannot successfully place an indwelling urinary catheter. We describe a simple technique for a PA to manage a difficult urinary catheter placement with the use of standard equipment routinely available on any medical unit or urology practice.

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MATERIALS AND METHODS

After reviewing the patient's history and performing a urology-focused examination, the clinician obtains the two crucial supplies: a hydrophilic guidewire and a 16-gauge angiocatheter. The PA in urology then reattempts to insert a regular or bent-tip indwelling urinary catheter, after introducing a generous amount of lubricating jelly into the urethra via a 10- to 20-mL syringe. If a gentle first attempt at indwelling urinary catheter placement is unsuccessful, the use of a hydrophilic guidewire is warranted. Prime the wire by injecting 10 mL of 0.9% sodium chloride solution into the housing chamber to activate the hydrophilic coating, then gently advance it into the urethra and bladder. More than one attempt may be needed if the patient has a challenging obstruction from false passages or strictures. Entrance into the bladder is assumed from smooth passage of the wire, without the distal tip coiling and reappearing at the urethral meatus. Clinicians who are still concerned about proper positioning of the wire in the bladder can advance a 6 Fr ureteral catheter over the wire and attempt to aspirate urine. If urine is aspirated, the guidewire is assumed to have been positioned correctly. Alternatively, the catheter can be irrigated with a syringe.

Using a 16-gauge angiocatheter, puncture the tip of the intended catheter antegrade via the distal side hole (Figure 1). Retract the needle, leaving behind its plastic sheath (Figure 2). Thread the proximal end of guidewire through the sheath in a retrograde fashion (Figure 3). Remove the sheath (Figure 4) and reroute the guidewire retrograde (Figure 5), through the lumen of the intended catheter, until the guidewire exits the proximal end of the urinary catheter (Figure 6). With good traction on the guidewire, liberally lubricate the indwelling urinary catheter and advance it over the guidewire into the bladder. Remove the guidewire. Confirm proper positioning of the indwelling urinary catheter in the bladder either with spontaneous or aspirated return of urine from the catheter, or with easy irrigation of the catheter with sterile 0.9% sodium chloride solution. Easy inflation of the balloon port of the indwelling urinary catheter also confirms proper placement. After correct placement is confirmed, connect the catheter to sterile drainage or continuous bladder irrigation, as the situation requires. The primary team should monitor the patient for decompression hematuria, postobstructive diuresis, and hypotension. Log the details of the consultation and the procedure into the urology service database.

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RESULTS

We initiated the technique in 2011, and started compiling data 4 years later. From January 2015 to April 2018, a total of 764 consultations were called into the urology service for assistance, due to the inability of the primary team to successfully insert an indwelling urinary catheter. Of these, the urology service was able to successfully insert 526 catheters on the first attempt (68.8%); another 204 patients (26.7%) required the use of our described protocol; 29 (3.8%) needed the assistance of bedside flexible cystoscopy for the guidewire placement; and 5 (0.7%) needed to go to the OR for suprapubic tube placements or endoscopic manipulations, due to failure of our procedure. No complications such as bleeding, additional false passages, or bladder or rectal injuries were encountered from the bedside maneuver.

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DISCUSSION

As the US population ages, the number of patients with urologic conditions has increased dramatically.1,2 In contradistinction, the number of practicing urologists is forecasted to diminish, based on the average practitioner age of 55 years and the decreasing number of graduating urology residents.3,4 Hospitals and medical practices have come to rely on PAs and NPs to fill the gap between the increased demand and shrinking urologist workforce.5,6 New York Presbyterian Queens has recorded a significant increase in the number of inpatient consultations requesting assistance with difficult indwelling urinary catheter placement, from 114 in 2015 to 315 in 2017. Clinicians must have a method that is simple, can be taught to PAs, and does not require advanced surgical experience or equipment.

Little is taught about urinary catheter placement in nursing, PA, or medical schools. Indwelling urinary catheters are needed to address urinary retention or monitor a patient's urine output. Often, the task is delegated to the nurse, medical student, PA, or resident in training. Typically, by the time the urology service is consulted, several attempts at catheter placement have failed. Repeated and unsuccessful trials at blind urinary catheterization result in psychologic and physical stress for the patient, urethral injury, potential urethral stricture, and challenging subsequent management.7,8 Improper insertion of catheters also can significantly increase healthcare costs because of increased interventions and added days of hospitalization. Complications from improper catheter placement include bleeding, sepsis, Fournier gangrene, and bladder and rectal perforations, and can lead to medical malpractice lawsuits.7-10

Failure at initial catheterization of a normal urethra may simply be the result of poor or improper technique, or anxious and combative patients.7,8 This is evidenced by the success of our experienced PAs in urology, who can insert a 16 Fr bent-tip catheter on first attempt 68.8% of the time.7,8,11 Verbal reassurance to the patient, along with asking the patient to “blow out a candle” as the catheter tip traverses the external sphincter, are two tricks of the trade. Lower urinary tract pathology that will necessitate use of our simple technique includes phimosis, anasarca, meatal stenosis, urethral strictures and false passages, bladder neck contracture from prior surgeries or urethral manipulations, bulky benign prostatic hyperplasia, or prostate cancer.12 Ostensibly, all our PAs are trained and certified to perform these more challenging procedures, regardless of the urethral barriers.

Several methods have been described in the medical literature and on YouTube channels to tackle difficult indwelling urinary catheter insertions.7-18 These include use of a vaginal speculum to visualize the glans penis in a patient with anasarca, perineal pressure, rubber or metal ureteral dilators; use of flexible or rigid cystoscopes and ureteroscopes in combination with guidewires; open-ended ureteral catheters; catheter punch devices; or slitting or cutting the tip of the urethral catheter to accommodate the guidewire.7-12,14 We have found the last technique to be detrimental to the contour of the catheter tip, impeding the eventual smooth passage of the catheter, and damaging to the anchoring balloon.

A review of the literature revealed that our method was first described by Blitz in 1995.13 He used the technique after performing cystoscopy on patients who were difficult to catheterize. He also found the maneuver useful for exchanging previously difficult-to-place urethral catheters. Variations of the procedure were subsequently referenced by others.7-18 Blitz also concurred that a hydrophilic guidewire is superior to a standard guidewire for the successful execution of the maneuver (telephone communication with Barry F. Blitz, MD, April 6, 2018). The difference between our technique and the rest is our reliance on our PAs, and on equipment readily available on the medical or surgical units and physician offices, without having to depend on any expensive tools or surgical expertise. This enables the individual PA to independently tackle the difficult situation with minimal training, assistance, and supervision. Equally important, it also lets the PA insert any catheter of choice to manage the patient's urologic requirement.

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LIMITATIONS

We do not have patient demographic details due to the retrospective nature of our data analysis. Another shortfall is our inability to perform a controlled comparison of the outcomes, before and after the institution of our technique. A cursory examination of our technique also may lead to the conclusion that the maneuver is similar to other previously published procedures. Nonetheless, we can highlight the fact that the technique can be performed on any patient, without any complications, regardless of cause of the urethral impediment. A more close-up inspection of the data also reveals that almost a third of the patients consulted (238/764 = 31.2%) would have required a trip to the OR if not for the application of our maneuver. The main strength of our simple technique showcases the capability of our PAs to make use of available simple tools to insert any type of indwelling urinary catheter, regardless of patient characteristics.

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CONCLUSION

Considering the large number of consultations for difficult urethral catheter placement and the rarity of available literature on the topic, this issue truly is underappreciated. When problems arise, they create significant financial consequences to the hospital, and at times disastrous complications to the patient and legal implications for providers. We believe that our simple technique lets PAs and NPs in hospital and office settings manage this vexing problem after a short period of training, with all the catheter options and inexpensive tools available at every medical facility.

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REFERENCES

1. Grayson VK, Velkoff VA. The Next Four Decades, The Older Population in the United States: 2010 to 2050. US Department of Commerce, May 2010.
2. Miller DC, Saigal CS, Litwin MS. The Urologic Diseases in America Project. The demographic burden of urologic diseases in America. Urol Clin North Am. 2009;36(1):11–27.
3. American Urological Association. The State of urology workforce and practice in the United States 2016. http://www.auanet.org/Documents/research/census/AUA-Census-2016-State-of-the-Urology-Workforce-and-Practice-in-the-United-States.pdf. Accessed May 28, 2019.
4. Miller DC, Link RE, Olsson CA. Trends in urology graduate medical education: a brief update from the Urology Residency Review Committee. J Urol. 2004;172(3):1062–1064.
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11. Villanueva C, Hemstreet GP III. Difficult catheterization: tricks of the trade. AUA Update Series. 2013;30:41.
12. Abbott JE, Heinemann A, Badalament R, Davalos JG. A clever technique for placement of a urinary catheter over a wire. Urol Ann. 2015;7(3):367–370.
13. Blitz BF. A simple method using hydrophilic guide wires for the difficult urethral catheterization. Urology. 1995;46(1):99–100.
14. Chiou RK, Aggarwal H, Chen W. Glidewire-assisted Foley catheter placement: a simple and safe technique for difficult male catheterization. Can Urol Assoc J. 2009;3(3):189–192.
15. Freid RM, Smith AD. The glidewire technique for overcoming urethral obstruction. J Urol. 1996;156(1):164–165.
16. Zammit PA, German K. The difficult urethral catheterization: use of a hydrophilic guidewire. BJU Int. 2004;93(6):883–884.
17. Lezrek M. Difficult catheterization: insertion of a bladder catheter over a guidewire. http://www.youtube.com/watch?v=zSyhAC-cmbQ. Accessed May 14, 2019.
    18. Yuminaga Y. Difficult catheter insertion: Seldinger technique. http://www.youtube.com/channel/UCOXawC480ITy99LI81nROyw. Accessed May 14, 2019.
    Keywords:

    physician assistant; indwelling urinary catheter; guidewire; urethral stricture; difficult placement; urology

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