Tissue Bonding Cystostomy(TBC)

Traumatic spinal cord injury (SCI) results in permanent paraplegia or quadriplegia in approximately 10,000 Americans annually. All patients with SCI have neuropathic dysfunction of the urinary bladder. Progressive neurological syndromes such as multiple sclerosis, Parkinson's disease, Stroke, hemiplegia and dementia also induce progressive neuropathic bladder dysfunction. Neurologic impairment of the bladder causes or contributes to chronic urinary retention or urinary incontinence or both. Several million Americans suffer chronic neuropathic urinary retention or incontinence or both. Males tend to develop urinary retention and females tend to develop urinary incontinence but both genders commonly develop elements of both.

Current management includes [a] indwelling tubes (urethral catheterization or [b] suprapubic (abdominal) catheterization, [c] intermittent urethral catheterization [4+times per day], and surgical rehabilitation [e.g. use of autogenous intestinal conduits or reservoirs]. No single form of management is ideal. A high percentage of elder and disabled patients are poor candidates or non-candidates for surgical rehabilitation because of co-morbidities or limited life expectancy. A majority of neurologically impaired patients are managed with chronic tube drainage of their bladders [e.g. a-c, above].

Traditional tube drainage of the bladder may be either via the urethra or via an intubated fistula in the lower abdomen. Intermittent catheterization-by the patient or a care giver--via the urethra is a well accepted and sometimes used method. This technique is occasionally used [by an attendant] in cognitively impaired patients or quadriplegics with impairment of the upper extremities. Intermittent catheterization is expensive when provided by a professional care giver and is a social and domestic burden when provided by a family member. In most chronically impaired [cognitively or physically] patients chronic indwelling urethral or suprapubic tubes evolve as the most practical and widely used treatment option.

Chronic urinary infection and bladder stones are recurrent problems in patients who use indwelling tubes. Foley urethral catheters [which are also commonly used as suprapubic tubes] are licensed for 30 day use by FDA.

Indwelling urethral catheters and suprapubic tubes are "open eco-systems' and provide easy access to skin flora. Skin microbes migrate along the tubes and gain access to bladder urine which becomes colonized in 100% of cases. Both gram-stain positive [gram +] and gram-stain negative [gram-] organisms easily gain access to bladder urine. Both type of microbes form biofilms on the catheters within 48 hours of colonization. The biofilms are microbial sanctuaries that are highly resistant to eradication with antibiotics. Use of antimicrobial agents [often for non-urinary indications] may eradicate common urinary pathogens and thereby 'select' more resistant organisms. Multiple organisms and resistant organisms are commonly grown from the bladders of neurologically impaired patients who utilize indwelling urethral or suprapubic tubes. Both types of tubes tend to induce bladder spasms and urinary leakage thereby soiling under-garments and bed clothes. A majority of such patients smell of urine-chronically.

Urine is normally supersaturated with dissolved salts, notably physiologic concentrations of calcium, phosphorus, oxalic acid, and magnesium. Foreign bodies [e.g. the indwelling tube'] initiate nucleation of the salts which then precipitate and form stones on the catheters. A high percentage of neurologically impaired patients have Proteus species of chronic bacteriuria. These urea-splitting [urease producing] organisms greatly accelerate formation of struvite [magnesium-ammonium-phosphate] stones on the catheters; rapid stone formation may necessitate catheter exchanges more frequently than monthly.

Significant expense attends the chronic use of traditional urinary catheters. Monthly travel to clinics and monthly replacement of the drainage catheter and management of febrile reactions which may be precipitated by tube changes are routine and expensive. Surgical procedures are commonly required to remove bladder, kidney or ureteral stones that develop as a consequence of the chronic bacteriuria. Soiled garments and beds and the prevailing order of urine cause many disabled patients to be put in to assisted care facilities.