Optimised Protocol for Managing Failed Catheterisation: Leveraging Bedside Retrograde Urethrography and Cystourethroscopy

Introduction Urethral catheterization is a routine procedure often required for many hospitalized patients. Various conditions, such as meatal stenosis, stricture urethra, false passage, benign prostatic hyperplasia, bladder neck contractures, and impacted urethral stones, can contribute to difficulty in catheterisation. In the setting of failed attempts at per urethral catheter placement, the subsequent intervention is suprapubic catheter (SPC) insertion. SPC placement has its associated complications and causes inconvenience to the patients. We framed an algorithm to minimise the need for SPC insertion in cases of difficult per urethral catheterisation in a non-trauma setting. This study aimed to evaluate the common causes of difficult per urethral catheterisation and establish the efficacy of our algorithm in managing difficult catheterisation with bedside retrograde urethrography (RGU) and cystoscopy while avoiding SPC placement. Materials and methods This prospective observational study was conducted from September 2022 to June 2024. Patients admitted with urinary retention or requiring routine catheterisation, with one failed attempt at catheterisation, were included in the study. Our algorithm for the management of difficult catheterisation in a non-trauma setting, to avoid SPC, integrates a bedside RGU and retrograde urethroscopy using either a 15.5 Fr cystoscope sheath or a 6 Fr ureteroscope to identify the urethral pathology, followed by dilatation and per urethral catheterisation. Results Among 55 patients (aged 34-82 years), 48 (87.27%) were male and seven (12.73%) were female. The most common indication for catheterisation was routine catheterisation for output monitoring (n = 30; 54.54%), followed by acute retention (n = 25; 45.45%). Bulbar urethral stricture (n = 28; 50.9%) was the most common cause of difficult catheterisation, followed by meatal/sub-meatal narrowing (n = 13; 23.63%), enlarged prostate or high bladder neck (n = 4; 7.27%), and impacted stones (n = 3; 5.45%). Successful catheterisation was achieved in 48 male patients following urethroscopy with a 6 Fr ureteroscope or 15.5 Fr cystoscope. In females, reducing the pelvic organ prolapse enabled catheterisation in two cases, while five required serial dilatation and catheterisation. Successful per-urethral catheterisation was achieved in all 55 (100%) patients, thus avoiding SPC. Conclusions Conventional blind catheterisation techniques have limited success in the setting of failed initial catheterisation. This approach, which employs bedside fluoroscopy and direct visualisation of the urethra using a cystoscope or ureteroscope, helped achieve higher success rates (n = 55; 100%) for difficult per-urethral catheterisation and avoided the need for SPC. Proper implementation of this protocol for dealing with difficult per-urethral catheterisation will reduce the unnecessary burden on the healthcare system by minimising the potential iatrogenic urethral injuries and reducing the need for SPC.