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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE Table of Contents   
Year : 2007  |  Volume : 18  |  Issue : 4  |  Page : 532-535
Double Urinary Bladder Voiding Technique Post Removal of Urethral Catheter in Renal Allograft Recipients

Urology Department, Imam Hospital, Tabriz Medical Science University, Tabriz, Iran

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To evaluate the effect of urinary bladder double voiding technique on the incidence of urinary tract infection in the transplant patients with double J stents after the removal of the urethral catheters in the post-transplant period, we evaluated 65 recipients of live kidney transplant in whom we inserted double J stents and urethral catheters at the time of transplantation. After removing the urethral catheters on post-operation day six, we instructed a group of 30 patients to double void their bladders within five minutes after the first micturition. The rest of the patients served as controls. Urine cultures were repeated frequently before and at the time of removal of urethral catheters and double J stents to detect the incidence of urinary tract infection in both groups. All recipients received cotrimoxazol prophylactically. The group of patients who performed the double voiding technique had significantly lower incidence of positive urine cultures than the control group at the time of removing the double J stents (1 (3.3%) vs. 12 (34.2%) respectively). We conclude that double voiding may reduce risk of urine infection in patients with double J stents in renal allograft ureters.

Keywords: Catheters, Infection, Renal, Transplantation, Using

How to cite this article:
Zomorrodi A, Bohluli A. Double Urinary Bladder Voiding Technique Post Removal of Urethral Catheter in Renal Allograft Recipients. Saudi J Kidney Dis Transpl 2007;18:532-5

How to cite this URL:
Zomorrodi A, Bohluli A. Double Urinary Bladder Voiding Technique Post Removal of Urethral Catheter in Renal Allograft Recipients. Saudi J Kidney Dis Transpl [serial online] 2007 [cited 2022 Aug 13];18:532-5. Available from: https://www.sjkdt.org/text.asp?2007/18/4/532/36507

   Introduction Top

Kidney transplantation has revolutionized treatment of end-stage renal disease by proving to be more cost-effective than hemodialysis, [1] and with a lower morbidity and improved quality of life. [2] However, more than 50% of allograft recipients have evidence of active infection during the first six months post transplantation, and infection remains the second major cause of death at all stages of the post-transplant course. [3]

There are three general time frames during which infection can occur in the post-transplant period: first month, second through the sixth month, and beyond the sixth month. These time frames are influenced by surgical factors; the type and level of immunosuppression; and geo茆raphical location of, and environmental expo貞ure in, transplant centers. [4] In hospitalized patients, urinary infection associated with urethral catheterization is common. [5],[6] It is the main source of nosocomial infection [5],[7] and septicemia by gram-negative bacteria. [8] After renal transplant, urinary infection is the most frequent infection complication, [9],[10],[11] the principal source of bacteremia [11],[12] and septicemia. [13]

There is no standardization regarding the duration of the urethral catheterization after renal transplantation surgery. [9] The control of the rejection and the prevention and treatment of infection are the major problems involved in successful renal transplantation. [10],[14] Parenteral antimicrobial prophylaxis of the urinary infection associated with urethral catheterization in the post-'renal transplant' period has been employed by most transplant centers, though not by all. [3],[15],[16],[17],[18] Systemic antimicrobial prophylaxis has not been demonstrated to be of value for the prevention of this infection. [3]

Inserting double J stents in allograft ureters and Foley catheters in urethras is performed routinely at the time of transplant operation. After removing the urethral catheter after six days post transplantation, the remaining double J stents in the allograft ureters usually predispose to VUR. Vesicoureteral reflux (VUR) is a risk factor for acute pyelo-nephritis (APN). [19] Colonization of bacteria in bladder due to urethral catheterization may occur and predisposes with VUR to APN.

We evaluate in this study the incidence of urinary tract infection after requesting the transplanted patients to perform a double urinary bladder voiding technique after removal of the urethral catheter in order to decrease the incidence risk of VUR and APN.

   Material and Methods Top

We evaluated 65 recipients (age in the range of 20-55 years) who received live kidney trans計lants at Imam Hospital, Tabriz Medical Uni赳ersity Science, Tabriz, Iran. We inserted double J stents and urethral catheters at the time of operation in all the patients. All reci計ients received cotrimoxazol prophylactically. The maintenance immunosuppressive agents in all the patients included cyclosporine, myco計henolate mofetil and prednisolone.

After removing the urethral catheters on post-operation day six, we instructed a group of 30 recipients (25 males and 5 females) to double void their bladders within five minutes after the first micturition. The rest of the patients (25 males and 10 females) served as controls. Urine cultures of carefully collected urine samples were repeated fre訂uently before and at the time of removal of urethral catheters and double J stents to detect the incidence of urinary tract infection in both groups. In addition, all the double J stents were sent for culture after removal.

   Statistics analysis Top

Statistical analysis was performed with Chi-square test to compare the incidence of positive urine cultures, and the significance was set at 'p' value <0.05.

   Results Top

In the group of patients who performed the double voiding techniques, the urine cultures were positive in 10 (33%) patients at the time of removal of urethral catheter versus 14 (40%) in the controls (p > 0.5). However, this incidence decreased significantly at the time of removal of the double J stents to 1 (3.33%) case versus 12 (34.2%) cases in the controls (p < 0.002) [Table - 1]

   Discussion Top

Urinary tract infections (UTIs) occur quite frequently in kidney transplant recipients, especially during the first three months after transplantation. [20] Most urinary infections after kidney transplantation occur during the first month after the surgery.[11],[15],[16],[17],[21],[22] Urethral catheterization for longer than one to four days may cause significant alteration of the normal urethral flora, [23],[24] which may result in higher incidence of UTI.[15],[24],[25] However, when the urethral catheters are removed within 1-4 days of the renal transplant, the development of urinary infection is unusual. [9],[7]

Immunosuppressive agents do not affect the natural defenses of the host during the first few days of induction of immuno貞uppression and therefore are unlikely to cause bladder bacterial colonization or asymptomatic bacteriuria. [18],[26]

The antimicrobial prophylaxis of the urinary infection should not be initiated until the urethral catheters have been removed since they may induce bacterial colonization. [3],[27],[28] In our study, all the renal transplant recipients received antibiotic prophylaxis, and almost 40% of them had positive urine culture at the time of removing the urethral catheters.

We considered the effect of double voiding in order to reduce the incidence of positive urine cultures; it could reduce the incidence signi苯icantly at the time of the removal of the double J stents. This simple technique was successful, as indicated by our results, in dec訃easing the incidence of positive urine cultures. We conclude that our study suggests that removing urethral catheter as soon as possible and double voiding technique post-removal of urethral catheter may reduce the incidence of early urinary tract infection post-'renal transplantation'.

   References Top

1.Blommers T, Schabacher B, Corry RJ. Transplant and Dialysis: The cost/benefit question. Iowa Med 1984:15-7.  Back to cited text no. 1    
2.Landsberg DN, Shackleton CR, Keown PA, Cameron EC, Manson D. Renal Trans計lantation. BC Med J 1993;35:801-4.  Back to cited text no. 2    
3.Fox BC, Sollinger HW, Belzer FO, Maki DG. A prospective, randomized, double-blind study of trimethoprim-sulfamethoxazole for pro計hylaxis of infection in renal transplantation: clinical efficacy, absorption of trimethoprim貞ulfamethoxazole, effects on the microflora, and the cost-benefit of prophylaxis. Am J Med 1990;89:225-74.  Back to cited text no. 3    
4.Hamshere RJ, Chisholm GD, Shackman R. Late urinary - tract infection after renal trans計lantation. Lancet 1974;5:7884-5.  Back to cited text no. 4    
5.Andriole VT. Hospital acquired urinary tract infections and the indwelling catheter. Uro Clin North Am 1975;2:451-69.  Back to cited text no. 5    
6.Centers for Disease Control Nosocomial Infection Surveillance 1984. Surveillance Summaries 1986;35(Suppl):17-29.  Back to cited text no. 6    
7.Haley RW, Culver DH, White JW, Morgam WM, Emori TG. The nationwide nosocomial infection rate. A new need for vital statistics. Am J Epidemiol 1985;121:159-67.  Back to cited text no. 7    
8.Kreger BE, Craven DE, Carling PC, McCabe WR. Gram-negative bacteremia. III. Reassess衫ent of etiology, epidemiology and ecology in 612 patients. Am J Med 1980; 68:332-43.  Back to cited text no. 8    
9.Rubin RH. Infection in the organ transplant recipient. In: Rubin RH, Young LS, eds. Clinical approach to infection in the compromised host. New York: Plenum Medical, 1994. p.629-705.  Back to cited text no. 9    
10.Ianhez LE, Sabbaga E. Transplante renal In: Praxedes JN, Cruz HMM, eds. Nefrlogia. Sao Paulo: Sarvier; 1995:227-39.  Back to cited text no. 10    
11.Murphy JF, McDonald FD, Dawson M. Factors affecting frequency of infection in renal transplant recipient. Arch Intern Med 1976;136:670-7.  Back to cited text no. 11    
12.Myerowitz RL, Medeiros AA, O' Brien TF. Bacterial infection in renal homotransplant recipient. A study of fifty-three bacteremic episodes. Am J Med 1972;53:308-14.  Back to cited text no. 12    
13.Mchenry MC, Braun WE, Popowniak K. Septicemia in transplant recipients. Urol Clin North Am 1976;3:647-66.  Back to cited text no. 13    
14.Ramos E, Karmi S, Alongi SV, Dagher FJ. Infectious complications in renal transplant recipient. South Med 1980;73:751-4.  Back to cited text no. 14    
15.Krieger JN, Tapia L, Stubenbord WT, Stenzel KH, Rubin AL. Urinary infection in kidney transplantation. Urology 1977;9: 130-6.  Back to cited text no. 15    
16.Belitsky P, Lannon SG, McDonald AD, Cohen AD. Urinary tract infectious (UTI) after kidney transplantation. Transplant Proc 1982;14:696-701.  Back to cited text no. 16    
17.Sussman M, Russell RB. Infection after cadaver renal transplantation. Proc Roy Soc Med 1972;65:471-3.  Back to cited text no. 17    
18.Rubin RH, Tolkoff-Rubin NE. Antimicrobial strategies in the care of organ transplant recipients. Antimicrob Agents Chemother 1993;37:619-24.  Back to cited text no. 18    
19.Rushton HG, Belman AB. Vesicoureteral reflux and renal scarring. In: Holliday MA, Barratt TM, Avner ED, eds. Pediatric Nephrology (3rd edn). Williams & Wilkins, Baltimore, 1994; 963-86  Back to cited text no. 19    
20.Takai K, Tollemar J, Wilczek HE, Groth CG. Urinary tract infections following renal transplantation. Clin Transplant 1998;12:19-23.  Back to cited text no. 20    
21.Ramsey DE, Finch WT, Birtch AG. Urinary tract infections in kidney transplant recipients. Arch Surg 1979;114:1022-5.  Back to cited text no. 21    
22.Bell PR, Briggs JD, Kyle K, at al. Renal transplantation: an analysis of 33 cases. Br Med J 1972;4:408-13.  Back to cited text no. 22    
23.Kunin CM, Steel C. Culture of the surfaces of urinary catheters to sample urethral flora and study the effect of antimicrobial therapy. J Clin Microbiol 1985;21:902-8.  Back to cited text no. 23    
24.Schaeffer AJ, Chimiel J. Urethral meatal colonization in the pathogenesis of catheter苔ssociated bacteriuria.J Urol 1983;130:1096-9.  Back to cited text no. 24    
25.Garibaldi RA, Burke JP, Dickman ML, Smith CB. Factors predisposing to bacteriuria during indwelling urethral catheterization. N Engl J Med 1974;291:215-9.  Back to cited text no. 25    
26.Kim JH, Perfect JR. Infection and cyclosporine. Rev Infect Dis 1989;11:677-90.  Back to cited text no. 26    
27.Britt MR, Garibaldi RA, Miller WA, Hebertson RM, Burke JP. Antimicrobial prophylaxis for catheter-associated bacteriuria. Antimicrob. Agents Chemother. 1977;11:240-3.  Back to cited text no. 27    
28.Martin CM, Brookrajlan EN. Bacteriuria prevention after indwelling urinary catheterization. Arch Intern Med 1962;10:703-71.  Back to cited text no. 28    

Correspondence Address:
Afshar Zomorrodi
Associate Professor of Urology, Imam Hospital, Tabriz Medical Science University, Tabriz
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Source of Support: None, Conflict of Interest: None

PMID: 17951938

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