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Managing Instillation Side Effects & Prevention Methods by Sandor Lovasz MD, PhD

Learn about side effects of instillation procedures & how to prevent them, including mucosal lesions, infections, and pain. Explore innovative catheter-free instillation techniques for higher success rates. Understand the impact of bladder cocktail components on irritation & methods to prevent discomfort.

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Managing Instillation Side Effects & Prevention Methods by Sandor Lovasz MD, PhD

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  1. Side effects of instillation and how to prevent them Sandor Lovasz MD. PhD. Rózsakert Medical Center, Budapest, Hungary

  2. Side effects of instillation • Most sideeffectsarecausedbythecatheterization • Mucosallesions (superficial, sometimesdeeperlesions: urethralrupture, perforation) • Infections (partiallyalsoduetothelesions) • Painduringtheprocedure (painfulurethra) • Irritation and painfollowingtheinstillation • Somecomponents of the „bladdercocktail” are irritative (low pH values, hyperosmoticsolutions)

  3. How to prevent them? • All available description of the bladder instillation starts with similar sentences: … An outpatient procedure during which a tube (catheter) is first inserted into the bladder, and a medication is infused through… The medications are given to you via a small catheter that is inserted into your bladder. Intravesical Medications (instillations) are placed directly into the bladder via a small catheter.  … Treatment involves guiding a narrow tube called a catheter up the urethra into the bladder…

  4. Is theuse of a catheterreallymandatory? • Retrograde urethrography • We know from the clinical Praxis that the retrograde filling of the urethra can be best performed by using a controlled hydrostatic filling pressure through a small size balloon catheter blocked in the fossa navicularis urethrae. • Retrograde sphincter opening pressure (RSOP) • At a defined level of the intraurethral pressure contrast agent flows back into the bladder. • In females: RSOP = 30 cmH2O • In males: RSOP = 60 cmH2O

  5. The solution:Instillationwithout a catheter Male patients Female patients

  6. The syringe adapter (ver. 1-3) • FitsbothonLuer-lock and Luer-slipsyringes • Roundednosetip • Made of inelastic, hardmaterial

  7. The rigid adapter was used in 62 femaleand 2 male patients in the first 6 months In 7 of 62 patients (11%) the instillation failed due to deep located urethral orifice or urethral kinking. These patients had to be treated by conventional catheterization. 55 of 62 patients (89%) were easily treatable by using the new catheter free method. Repeated instillations in 2 male patients suggest the applicability of the method in both genders.

  8. Improvedform and material ver. No. 3-6 • FitsbothonLuer-lock and Luer-slipsyringes • Roundednosetip • Elongatedneck, bettergrasping • Concaveisolatingcollar • Made of elastic, softermaterial – drop-free fitting Patent pending

  9. Catheterfreeinstillation of a femalepatient

  10. Catheterfreeinstillation of a malepatient

  11. Improvedskillatcatheter-free instillationin femalepatients Elevation of the orifice elongates and straightens the urethra The failureratecansignificantly be reducedbyusingthesetechniquesatcatheter-free instillation. Enhance the pressureagainst the orifice Correction of angle to catch the rightdirection

  12. The elastic adapter was used in 260 femaleand 14 male patients more than 1500 times in the last 1,5 years The failure rate dropped from previous 11% on 1,5% (4 female patients) due to deep located urethral orifice and/or cicatricosed, narrow introitus. These patients get the instillations by conventional catheterization. 98,5% of the female patients were easily treatable by using the new catheter-free method. 14 of 14 male patients (100%) were successfully instilled by using the modified adapter. Serious stricture of the meatus and cases of hypospadiasis can prevent using this method.

  13. Irritation and pain following the instillation • Somecomponents of the „bladdercocktail” maycauseirritation. • Great individualdifferences. • Causes: • Dexamethasone is more irritating than methyl-prednisolon, • Na-hyaluronate solutions are more irritating than Zn-hyaluronate solutions • Prevention: adding buffered Lidocain to the cocktail • Most solutions are acidic (low pH values, ranges 4.1 – 6.2) • Prevention: adding buffering solution (Na bicarbonate) to reach pH 7 • Hyperosmotic solution (high concentration, high specific weight) • Prevention: adding isotonic NaCl solution to dilute the cocktail

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