111
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Self-Retaining
lntraurethral
Stent:
An Alternative to Long-term Indwelling Catheters or Surgery in the Treatment Prostatism
Daniel Yachia1 Dov Lask1 Suzanna Rabinson2
The self-retaining severe
urethral
intraurethral
obstruction.
coil is a device
It allows
them
to stent
to empty
the urethra
their
of
in men who have
bladders
and
still remain
continent
and sexually active. The device can be used in place of long-term indwelling catheters or as an alternative to surgery. During 1 year, we inserted the stent in 26 men who were poor operative risks. The treatment was successful in 20 (77%). All 20 were able to void satisfactorily. Four of the 20 resumed sexual activity, which previously had been prevented by indwelling catheters. Two patients who had delayed prostatic surgery because of fear of impotence were able to empty their bladders properly and to remain sexually active. Three patients subsequently had surgery, two after anticoagulant therapy could be stopped and one after renal function improved. No difficulties caused by the stent were encountered during surgery. Follow-up was for 2-12 months. Four patients who had had the stent in place for 12 months had no difficulties. In 16 of the 18 patients who had indwelling catheters and infected urine before insertion of the stent, sterilization of the urine was obtained after relatively short courses of antibiotic treatment. Short-term complications associated with the stent were incontinence or urinary retention. These were treated by repositioning the stent. Frequency of urination after insertion of the stent either disappeared spontaneously or was treated with anticholinergic drugs. In six patients, frequency was so severe that removal of the stent and insertion of an indwelling catheter were necessary. Slight to mild dysuria occurred immediately after surgery in all patients but eventually disappeared. Our experience suggests that the self-retaining intraurethral stent has considerable promise for the treatment of prostatic obstruction of the urethra. AJR
154:111-113,
January
1990
An intraurethral coil for the treatment of severe urethral obstruction caused by enlargement of the prostate was developed by Fabian in 1 980 [1 ]. Since then, use of the coil has resulted in relatively high success rates (up to 80%) of overcoming urethral obstruction [2-6]. We used this procedure as an alternative to indwelling catheters for patients who were poor operative risks or who refused surgery because of fear of impotence.
Subjects
and Methods
We selected June 22, 1989; accepted after revision August 20, 1989. Received 1
Department
of Urology,
Hillel
Yafte
Medical
22 patients
who were
poor operative
risks who had had indwelling
treated
with
anticoagulants
embolism
had
urinary
retention that the become
Center, Hadera 381 01 , Israel.
prostatic
family
received
0361 -803X/90/1541-01 © American Roentgen
explanation All patients
about who
patients
and
the intraurethral had indwelling
stent,
catheters
ages 59 and 65, had chronic
that
last four patients until they would
All 26
two patients,
and
deterioration of renal function. It was explained to these not a permanent solution but a temporary treatment surgery.
Another
pulmonary
indwelling
11
catheters.
for
Center, Hadera 381 01 , Israel. Address reprint requests to D. Yachia. 2 Department of Radiology, Hillel Yaffe Medical
Ray Society
catheters
inserted 3-36 months before because of urinary retention caused by severe prostatism. mean age was 73 years (range, 68-86). Two other patients, ages 61 and 64, were
their
immediate
and all 26 patients had
infected
urine
urinary
members
signed despite
informed treatment
Their being
required
retention device eligible
a detailed
consent with
and was for
papers.
antibiotics.
YACHIA
112
All patients were admitted to the hospital before the procedure. who were receiving small doses of prophylactic antibiotics were given the full dosages, and those who were not on antibiotics were given oral cephalosporins. Small-caliber catheters were changed to 20-French ones. The two patients who had deterioration of renal function were catheterized with 20-French Foley catheters, and their bladders were emptied slowly over 3-6 hr. All anticoagulant therapy was stopped. The stent used (Fig. 1) was a modification of the device developed by Fabian [1 ], which originally was made of medical-grade stainless steel and was inserted endoscopically (Urologische Spirale, Uromed, Kassel, Germany). The device was redesigned by a team of Danish physicians and engineers. An introducing catheter temporarily locked to the stent was added to allow easier insertion under sonographic guidance, and the stainless-steel wire was plated with 24-karat gold to reduce contact allergy and incrustation (Prostakath, Engineers & Doctors A/S. Copenhagen, Denmark). The stent was inserted under sonographic guidance as follows: The bladder was filled with 300 ml saline or until the patient had a sensation of fullness. The Foley catheter was pulled gently until its balloon was seated at the neck of the bladder. The bladder was
Downloaded from www.ajronline.org by 41.76.122.150 on 11/12/15 from IP address 41.76.122.150. Copyright ARRS. For personal use only; all rights reserved
Those
scanned
sonographically
to rule out tumors
or stones,
which
are
contraindications for insertion of the stent, and the prostatic urethra was measured from the base of the balloon to the apex of the prostate. If the prostatic urethra could not be visualized, a 4- or 5French metal guidewire was inserted through the lumen of the Foley catheter. After the urethra was filled with anesthetic lubricating jelly, a stent of appropriate length, attached to its introducing catheter,
was inserted.
Passage of the stent through the prostatic
urethra was
observed sonographically. When the tip of the stent reached the bladder, and urine began to drip from the distal end of the introducing catheter, the stent was pushed in 1 0-1 5 mm farther. Then the stent was disconnected from the introducing catheter by turning the handle
of the locking mechanism
at least five times clockwise.
Under sono-
graphic guidance, first the locking wire and then the introducing catheter were pulled gently outward a few centimeters. Before the catheter was removed, the bladder was filled again slowly. After the introducing catheter was removed, for immediate assessment of stress incontinence, the patients were asked to cough, and then, for immediate assessment of continence, they were asked to urinate and then stop the stream voluntarily. Continuous dripping of urine when the patient is standing or coughing indicates that the stent or its short part is in the external sphincter area, preventing contraction of the sphincter. If the patient
1 3 Fig. 1.-Three main parts of intraurethral stent. Gold-plated urethral coil (1) is composed of body of coil (A), which sits along prostatic urethra with tip protruding into bladder short coil (B), which sits in bulbous urethra; and connecting wire (C), which passes along extemal sphincter. Other two parts are introducing catheter(2) and locking mechanism (3) that embraces connecting wire.
ET AL.
AJR:154,
cannot urinate until he starts
Repositioning
at all, percutaneous to void spontaneously
January
1990
cystostomy is used temporarily or the stent is repositioned.
can be done endoscopically
by using a direct-vision
urethroscope and a rigid foreign-body forceps for pulling or pushing the stent. During urethroscopy, the short part of the stent should be seen in the bulbar urethra, and the connecting wire should be seen
passing
through
ment during muscles.
the membranous
repositioning,
the patient
urethra.
In order to check place-
is asked
to contract
the perineal
Results Seven the
of the 26 patients
procedure.
the day required the stent ing and catheter
Urinary
were
retention
incontinent developed
immediately in two
others
after on
of surgery and in another the day after. All three temporary suprapubic cystostomy. In two patients, was removed because of severe frequency of voidurgency that did not respond to treatment, and a was inserted. Six of the incontinent patients became fully continent after the stent was repositioned. The seventh patient had severe dementia, and despite repeated repositioning of the stent, and without any obvious mechanical cause, he remained incontinent. The stent was removed, and a catheter was inserted. In two patients who had prostatic carcinoma, hyperreflexic bladder developed after radiation therapy. In one of these, the stent was ejected into the penile urethra after a blood clot blocked the lumen. The stent was reinserted, but it caused severe frequency and dysuria and so was removed 1 week later. In the second patient, despite repeated repositioning of the stent, urge incontinence could not be controlled, and the stent was removed. In one patient, frequency of voiding developed 1 2 days after discharge from the hospital, and he went to the emergency department of another institution, where a urethral catheter was inserted, pushing the stent into the bladder. Later attempts to remove the coil endoscopically failed because both ends of the stent entered the openings of several pseudodiverticula and became entrappped. Cystostomy under local anesthesia was performed to remove the stent. In another patient, urinary retention developed 1 week after discharge from the hospital. Because of severe scarring from repeated abdominal surgery, transurethral manipulation was preferred to suprapubic cystostomy. Under direct visual guidance, a guidewire was inserted alongside the coil, and an 8French ureteral catheter was introduced. Later the spiral was repositioned, and the patient was able to urinate and became fully continent. One patient with chronic retention urinated spontaneously with an increasing flow rate. The second patient with chronic retention required suprapubic cystostomy for 4 days until he started to urinate after treatment with 150 mg bethanechol chloride for a few days. Three and 4 months later, respectively, both patients had no residual urine after voiding and were able to perform sexually. Another three patients who had been sexually active before the insertion of an indwelling catheter, regained sexual functioning after the stent was inserted. Another was able to resume intercourse by using a vacuum device to produce artificial erections.
AJR:154, January 1990
SELF-RETAINING
INTRAURETHRAL
Sterilization
of the urine was obtained after 1 -3 months of antibiotics in 1 6 of the 1 8 patients who had infected urine before the procedure. After sterilization was attained, no other prophylactic antibiotics were needed. The two patients with chronic retention and deterioration of renal function who had sterile urine before insertion of the stent had sterile urine afterward, and their renal function improved. The two patients who were receiving anticoagulants because of pulmonary emboli had prostatectomies 8 months after insertion of the stent and after treatment with anticoagulants was stopped. One patient with chronic retention had a transurethral incision of the prostate. In these three patients, the stents were removed endoscopically before surgery, and no intraoperative difficulties occurred that could be attributed to the stent.
Downloaded from www.ajronline.org by 41.76.122.150 on 11/12/15 from IP address 41.76.122.150. Copyright ARRS. For personal use only; all rights reserved
treatment
with
Discussion Insertion of a urethral catheter is the simplest form of urinary diversion, and it is used widely in chronic or acute obstructions of the lower urinary tract. However, complications associated with long-term catheterization are well known [7-10]. This alternative of inserting an intraurethral stent is a welcome development in urology and a new technique in interventional radiology. The modified stent we used was practical because of its ease of insertion. In 77% of the patients, it allowed passage of urine and solved the problem of infection almost always seen with indwelling catheters. Easy sterilization of the urine after replacing the indwelling catheter with the stent is one of the major advantages of this procedure. Insertion of the stent in uninfected patients did not cause infection. Having the indwelling catheter removed and regaining the ability to urinate eased the medical and psychological burden of the patient. Four of our patients in whom indwelling cath-
STENT
113
eters prevented sexual intercourse, and two others who delayed prostatic surgery because of fear of impotence were able to resume sexual activity after the stent was inserted. All six reported retrograde ejaculation. Our experience in 26 patients shows that the intraurethral stent is an acceptable alternative to indwelling catheters in most cases. Further experience will show if it can function properly over a long term. If so, this may increase indications for its use in patients who have prostatic enlargement without complete urethral obstruction and who fear or refuse or wish to delay surgery.
REFERENCES 1 . Fabian KW. Der intraprostatische “Partielle Katheter’ (urologische Spirale). Urologe [A] 1980;19:236-238 2. Fabricius PG, Matz M, zepnick H. Die Endourethralspirale: eine Alternative zum Dauerkatheter. Z Arztl Fortbild (Jena) 1983;77:482-485 3. Reuter HJ, Oettinger M. Las primeras experiencias con Ia espiral de acero en lugar del cat#{233}ter permanente. Arch Esp Urol 1986;39[suppl 1]:65-68 4. Langemeyer TNM. The prostatic coil, an altemative for an indwelling catheter. Presented at the 8th Congress of the European Association of Urology, London, May 1988 5. Vicente J, Salvador J. Urethral prosthesis as the substitution of urethral indwelling
catheter.
Association 6. Nordling intraurethral
at the
8th
Congress
of the
J, HoIm JJ, Nielsen KK, Hald T. Urinary retention treated spiral (Prostakath). Presented at the 8th Congress
European Association 7. Warren
Presented
European
of Urology, London, May 1988
JW,
Muncie
with an of the
of Urology, London, May 1988 HL Jr,
Bergquist
EJ,
Hoopes
JM.
Sequelae
and
management of urinary infection in the patient requiring chronic catheterisation. J Urol 1981;125:1-8 8. Breitenbucher RB. Bacterial changes in the urine samples of patients with long-term indwelling catheters. Arch Intern Med 1984;144:1585-1588 9. Blacklock NJ. Catheters and urethral strictures. Br J Urol 1986;58:
475-478 10. Ouslander catheters
JG, Greengold B, Chen S. Complications of chronic indwelling among male nursing home patients: a prospective study. J Urol
1987;138:1191-1195
Downloaded from www.ajronline.org by 41.76.122.150 on 11/12/15 from IP address 41.76.122.150. Copyright ARRS. For personal use only; all rights reserved
Self-Retaining
lntraurethral
Stent:
An Alternative to Long-term Indwelling Catheters or Surgery in the Treatment Prostatism
Daniel Yachia1 Dov Lask1 Suzanna Rabinson2
The self-retaining severe
urethral
intraurethral
obstruction.
coil is a device
It allows
them
to stent
to empty
the urethra
their
of
in men who have
bladders
and
still remain
continent
and sexually active. The device can be used in place of long-term indwelling catheters or as an alternative to surgery. During 1 year, we inserted the stent in 26 men who were poor operative risks. The treatment was successful in 20 (77%). All 20 were able to void satisfactorily. Four of the 20 resumed sexual activity, which previously had been prevented by indwelling catheters. Two patients who had delayed prostatic surgery because of fear of impotence were able to empty their bladders properly and to remain sexually active. Three patients subsequently had surgery, two after anticoagulant therapy could be stopped and one after renal function improved. No difficulties caused by the stent were encountered during surgery. Follow-up was for 2-12 months. Four patients who had had the stent in place for 12 months had no difficulties. In 16 of the 18 patients who had indwelling catheters and infected urine before insertion of the stent, sterilization of the urine was obtained after relatively short courses of antibiotic treatment. Short-term complications associated with the stent were incontinence or urinary retention. These were treated by repositioning the stent. Frequency of urination after insertion of the stent either disappeared spontaneously or was treated with anticholinergic drugs. In six patients, frequency was so severe that removal of the stent and insertion of an indwelling catheter were necessary. Slight to mild dysuria occurred immediately after surgery in all patients but eventually disappeared. Our experience suggests that the self-retaining intraurethral stent has considerable promise for the treatment of prostatic obstruction of the urethra. AJR
154:111-113,
January
1990
An intraurethral coil for the treatment of severe urethral obstruction caused by enlargement of the prostate was developed by Fabian in 1 980 [1 ]. Since then, use of the coil has resulted in relatively high success rates (up to 80%) of overcoming urethral obstruction [2-6]. We used this procedure as an alternative to indwelling catheters for patients who were poor operative risks or who refused surgery because of fear of impotence.
Subjects
and Methods
We selected June 22, 1989; accepted after revision August 20, 1989. Received 1
Department
of Urology,
Hillel
Yafte
Medical
22 patients
who were
poor operative
risks who had had indwelling
treated
with
anticoagulants
embolism
had
urinary
retention that the become
Center, Hadera 381 01 , Israel.
prostatic
family
received
0361 -803X/90/1541-01 © American Roentgen
explanation All patients
about who
patients
and
the intraurethral had indwelling
stent,
catheters
ages 59 and 65, had chronic
that
last four patients until they would
All 26
two patients,
and
deterioration of renal function. It was explained to these not a permanent solution but a temporary treatment surgery.
Another
pulmonary
indwelling
11
catheters.
for
Center, Hadera 381 01 , Israel. Address reprint requests to D. Yachia. 2 Department of Radiology, Hillel Yaffe Medical
Ray Society
catheters
inserted 3-36 months before because of urinary retention caused by severe prostatism. mean age was 73 years (range, 68-86). Two other patients, ages 61 and 64, were
their
immediate
and all 26 patients had
infected
urine
urinary
members
signed despite
informed treatment
Their being
required
retention device eligible
a detailed
consent with
and was for
papers.
antibiotics.
YACHIA
112
All patients were admitted to the hospital before the procedure. who were receiving small doses of prophylactic antibiotics were given the full dosages, and those who were not on antibiotics were given oral cephalosporins. Small-caliber catheters were changed to 20-French ones. The two patients who had deterioration of renal function were catheterized with 20-French Foley catheters, and their bladders were emptied slowly over 3-6 hr. All anticoagulant therapy was stopped. The stent used (Fig. 1) was a modification of the device developed by Fabian [1 ], which originally was made of medical-grade stainless steel and was inserted endoscopically (Urologische Spirale, Uromed, Kassel, Germany). The device was redesigned by a team of Danish physicians and engineers. An introducing catheter temporarily locked to the stent was added to allow easier insertion under sonographic guidance, and the stainless-steel wire was plated with 24-karat gold to reduce contact allergy and incrustation (Prostakath, Engineers & Doctors A/S. Copenhagen, Denmark). The stent was inserted under sonographic guidance as follows: The bladder was filled with 300 ml saline or until the patient had a sensation of fullness. The Foley catheter was pulled gently until its balloon was seated at the neck of the bladder. The bladder was
Downloaded from www.ajronline.org by 41.76.122.150 on 11/12/15 from IP address 41.76.122.150. Copyright ARRS. For personal use only; all rights reserved
Those
scanned
sonographically
to rule out tumors
or stones,
which
are
contraindications for insertion of the stent, and the prostatic urethra was measured from the base of the balloon to the apex of the prostate. If the prostatic urethra could not be visualized, a 4- or 5French metal guidewire was inserted through the lumen of the Foley catheter. After the urethra was filled with anesthetic lubricating jelly, a stent of appropriate length, attached to its introducing catheter,
was inserted.
Passage of the stent through the prostatic
urethra was
observed sonographically. When the tip of the stent reached the bladder, and urine began to drip from the distal end of the introducing catheter, the stent was pushed in 1 0-1 5 mm farther. Then the stent was disconnected from the introducing catheter by turning the handle
of the locking mechanism
at least five times clockwise.
Under sono-
graphic guidance, first the locking wire and then the introducing catheter were pulled gently outward a few centimeters. Before the catheter was removed, the bladder was filled again slowly. After the introducing catheter was removed, for immediate assessment of stress incontinence, the patients were asked to cough, and then, for immediate assessment of continence, they were asked to urinate and then stop the stream voluntarily. Continuous dripping of urine when the patient is standing or coughing indicates that the stent or its short part is in the external sphincter area, preventing contraction of the sphincter. If the patient
1 3 Fig. 1.-Three main parts of intraurethral stent. Gold-plated urethral coil (1) is composed of body of coil (A), which sits along prostatic urethra with tip protruding into bladder short coil (B), which sits in bulbous urethra; and connecting wire (C), which passes along extemal sphincter. Other two parts are introducing catheter(2) and locking mechanism (3) that embraces connecting wire.
ET AL.
AJR:154,
cannot urinate until he starts
Repositioning
at all, percutaneous to void spontaneously
January
1990
cystostomy is used temporarily or the stent is repositioned.
can be done endoscopically
by using a direct-vision
urethroscope and a rigid foreign-body forceps for pulling or pushing the stent. During urethroscopy, the short part of the stent should be seen in the bulbar urethra, and the connecting wire should be seen
passing
through
ment during muscles.
the membranous
repositioning,
the patient
urethra.
In order to check place-
is asked
to contract
the perineal
Results Seven the
of the 26 patients
procedure.
the day required the stent ing and catheter
Urinary
were
retention
incontinent developed
immediately in two
others
after on
of surgery and in another the day after. All three temporary suprapubic cystostomy. In two patients, was removed because of severe frequency of voidurgency that did not respond to treatment, and a was inserted. Six of the incontinent patients became fully continent after the stent was repositioned. The seventh patient had severe dementia, and despite repeated repositioning of the stent, and without any obvious mechanical cause, he remained incontinent. The stent was removed, and a catheter was inserted. In two patients who had prostatic carcinoma, hyperreflexic bladder developed after radiation therapy. In one of these, the stent was ejected into the penile urethra after a blood clot blocked the lumen. The stent was reinserted, but it caused severe frequency and dysuria and so was removed 1 week later. In the second patient, despite repeated repositioning of the stent, urge incontinence could not be controlled, and the stent was removed. In one patient, frequency of voiding developed 1 2 days after discharge from the hospital, and he went to the emergency department of another institution, where a urethral catheter was inserted, pushing the stent into the bladder. Later attempts to remove the coil endoscopically failed because both ends of the stent entered the openings of several pseudodiverticula and became entrappped. Cystostomy under local anesthesia was performed to remove the stent. In another patient, urinary retention developed 1 week after discharge from the hospital. Because of severe scarring from repeated abdominal surgery, transurethral manipulation was preferred to suprapubic cystostomy. Under direct visual guidance, a guidewire was inserted alongside the coil, and an 8French ureteral catheter was introduced. Later the spiral was repositioned, and the patient was able to urinate and became fully continent. One patient with chronic retention urinated spontaneously with an increasing flow rate. The second patient with chronic retention required suprapubic cystostomy for 4 days until he started to urinate after treatment with 150 mg bethanechol chloride for a few days. Three and 4 months later, respectively, both patients had no residual urine after voiding and were able to perform sexually. Another three patients who had been sexually active before the insertion of an indwelling catheter, regained sexual functioning after the stent was inserted. Another was able to resume intercourse by using a vacuum device to produce artificial erections.
AJR:154, January 1990
SELF-RETAINING
INTRAURETHRAL
Sterilization
of the urine was obtained after 1 -3 months of antibiotics in 1 6 of the 1 8 patients who had infected urine before the procedure. After sterilization was attained, no other prophylactic antibiotics were needed. The two patients with chronic retention and deterioration of renal function who had sterile urine before insertion of the stent had sterile urine afterward, and their renal function improved. The two patients who were receiving anticoagulants because of pulmonary emboli had prostatectomies 8 months after insertion of the stent and after treatment with anticoagulants was stopped. One patient with chronic retention had a transurethral incision of the prostate. In these three patients, the stents were removed endoscopically before surgery, and no intraoperative difficulties occurred that could be attributed to the stent.
Downloaded from www.ajronline.org by 41.76.122.150 on 11/12/15 from IP address 41.76.122.150. Copyright ARRS. For personal use only; all rights reserved
treatment
with
Discussion Insertion of a urethral catheter is the simplest form of urinary diversion, and it is used widely in chronic or acute obstructions of the lower urinary tract. However, complications associated with long-term catheterization are well known [7-10]. This alternative of inserting an intraurethral stent is a welcome development in urology and a new technique in interventional radiology. The modified stent we used was practical because of its ease of insertion. In 77% of the patients, it allowed passage of urine and solved the problem of infection almost always seen with indwelling catheters. Easy sterilization of the urine after replacing the indwelling catheter with the stent is one of the major advantages of this procedure. Insertion of the stent in uninfected patients did not cause infection. Having the indwelling catheter removed and regaining the ability to urinate eased the medical and psychological burden of the patient. Four of our patients in whom indwelling cath-
STENT
113
eters prevented sexual intercourse, and two others who delayed prostatic surgery because of fear of impotence were able to resume sexual activity after the stent was inserted. All six reported retrograde ejaculation. Our experience in 26 patients shows that the intraurethral stent is an acceptable alternative to indwelling catheters in most cases. Further experience will show if it can function properly over a long term. If so, this may increase indications for its use in patients who have prostatic enlargement without complete urethral obstruction and who fear or refuse or wish to delay surgery.
REFERENCES 1 . Fabian KW. Der intraprostatische “Partielle Katheter’ (urologische Spirale). Urologe [A] 1980;19:236-238 2. Fabricius PG, Matz M, zepnick H. Die Endourethralspirale: eine Alternative zum Dauerkatheter. Z Arztl Fortbild (Jena) 1983;77:482-485 3. Reuter HJ, Oettinger M. Las primeras experiencias con Ia espiral de acero en lugar del cat#{233}ter permanente. Arch Esp Urol 1986;39[suppl 1]:65-68 4. Langemeyer TNM. The prostatic coil, an altemative for an indwelling catheter. Presented at the 8th Congress of the European Association of Urology, London, May 1988 5. Vicente J, Salvador J. Urethral prosthesis as the substitution of urethral indwelling
catheter.
Association 6. Nordling intraurethral
at the
8th
Congress
of the
J, HoIm JJ, Nielsen KK, Hald T. Urinary retention treated spiral (Prostakath). Presented at the 8th Congress
European Association 7. Warren
Presented
European
of Urology, London, May 1988
JW,
Muncie
with an of the
of Urology, London, May 1988 HL Jr,
Bergquist
EJ,
Hoopes
JM.
Sequelae
and
management of urinary infection in the patient requiring chronic catheterisation. J Urol 1981;125:1-8 8. Breitenbucher RB. Bacterial changes in the urine samples of patients with long-term indwelling catheters. Arch Intern Med 1984;144:1585-1588 9. Blacklock NJ. Catheters and urethral strictures. Br J Urol 1986;58:
475-478 10. Ouslander catheters
JG, Greengold B, Chen S. Complications of chronic indwelling among male nursing home patients: a prospective study. J Urol
1987;138:1191-1195
