Systematic voiding programme in adults with urinary incontinence following acute stroke: the ICONS-II RCT.

BACKGROUND: Urinary incontinence affects around half of stroke survivors in the acute phase, and it often presents as a new problem after stroke or, if pre-existing, worsens significantly, adding to the disability and helplessness caused by neurological deficits. New management programmes after stroke are needed to address urinary incontinence early and effectively. OBJECTIVE: The Identifying Continence OptioNs after Stroke (ICONS)-II trial aimed to evaluate the clinical effectiveness and cost-effectiveness of a systematic voiding programme for urinary incontinence after stroke in hospital. DESIGN: This was a pragmatic, multicentre, individual-patient-randomised (1 : 1), parallel-group trial with an internal pilot. SETTING: Eighteen NHS stroke services with stroke units took part. PARTICIPANTS: Participants were adult men and women with acute stroke and urinary incontinence, including those with cognitive impairment. INTERVENTION: Participants were randomised to the intervention, a systematic voiding programme, or to usual care. The systematic voiding programme comprised assessment, behavioural interventions (bladder training or prompted voiding) and review. The assessment included evaluation of the need for and possible removal of an indwelling urinary catheter. The intervention began within 24 hours of recruitment and continued until discharge from the stroke unit. MAIN OUTCOME MEASURES: The primary outcome measure was severity of urinary incontinence (measured using the International Consultation on Incontinence Questionnaire) at 3 months post randomisation. Secondary outcome measures were taken at 3 and 6 months after randomisation and on discharge from the stroke unit. They included severity of urinary incontinence (at discharge and at 6 months), urinary symptoms, number of urinary tract infections, number of days indwelling urinary catheter was in situ, functional independence, quality of life, falls, mortality rate and costs. The trial statistician remained blinded until clinical effectiveness analysis was complete. RESULTS: The planned sample size was 1024 participants, with 512 allocated to each of the intervention and the usual-care groups. The internal pilot did not meet the target for recruitment and was extended to March 2020, with changes made to address low recruitment. The trial was paused in March 2020 because of COVID-19, and was later stopped, at which point 157 participants had been randomised (intervention, n = 79; usual care, n = 78). There were major issues with attrition, with 45% of the primary outcome data missing: 56% of the intervention group data and 35% of the usual-care group data. In terms of the primary outcome, patients allocated to the intervention group had a lower score for severity of urinary incontinence (higher scores indicate greater severity in urinary incontinence) than those allocated to the usual-care group, with means (standard deviations) of 8.1 (7.4) and 9.1 (7.8), respectively. LIMITATIONS: The trial was unable to recruit sufficient participants and had very high attrition, which resulted in seriously underpowered results. CONCLUSIONS: The internal pilot did not meet its target for recruitment and, despite recruitment subsequently being more promising, it was concluded that the trial was not feasible owing to the combined problems of poor recruitment, poor retention and COVID-19. The intervention group had a slightly lower score for severity of urinary incontinence at 3 months post randomisation, but this result should be interpreted with caution. FUTURE WORK: Further studies to assess the effectiveness of an intervention starting in or continuing into the community are required. TRIAL REGISTRATION: This trial is registered as ISRCTN14005026. FUNDING: This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 31. See the NIHR Journals Library website for further project information.

Urinary incontinence affects around half of stroke survivors. It causes embarrassment and distress, affecting patients' ability to take part in rehabilitation. It also has a major impact on families and may determine whether or not patients are able to return home. Finding the underlying cause and addressing it can prevent, cure or reduce problems. Doing this in a systematic way for everyone with incontinence problems as early as possible after the stroke, while they are still in hospital, may work best. We also wanted to avoid using catheters in the bladder to drain the urine away, as these are often unnecessary and can cause urinary tract infections. This study aimed to test whether or not continence problems and the use of urinary catheters could be reduced if everyone with incontinence was fully assessed and given the right management and support early after hospital admission. We also wanted to find out if the benefits outweighed the costs. We planned to involve 1024 men and women with incontinence from 18 stroke units in the study, with 512 people receiving the intervention and 512 receiving usual care. However, the trial was paused because of COVID-19, at which time only 157 participants had been recruited. When we were thinking about restarting the study and looked at its progress, we found that not enough people had agreed to take part and, of those who had agreed, many had not returned their outcome questionnaires. This indicated that the trial was not feasible and should not restart. We could not make any firm conclusions about whether or not the intervention worked, as not enough people were involved. We found that stays in hospital after stroke are shorter than they were in the past. This suggests that future studies investigating ways of treating incontinence should consider interventions with management and support for incontinence that continue after patients leave the hospital.

Self-perceived health and functional status of older people: Telephone-based lifestyle survey of older adults in Tehran province.

Background: The prevalence study of health conditions can help policy makers to document base policymaking. This study aimed to reveal the health status, including the prevalence of geriatric syndrome health conditions such as activity of daily livings, pain, and physical and mental health of older adults in Tehran province. Methods: This cross-sectional study was a telephone survey with older people ≥60 years old using a systematic random sampling of telephone numbers in Tehran province. The Persian version of the Katz' activity of daily living (ADL) and the Lawton's instrumental activity of daily living (IADL) questionnaires were used to evaluate the functional status. Pain, history of chronic diseases, continence, hospital admission, sensory problems, and self-perceived health (SPH) were asked by trained nurses or gerontologists thorough telephone interviews. Results: In this study, 1251 older adults with the mean age of 67.03±7.51 years have been recruited. About 64.50% (95% CI: 64.4-64.6) of them were totally independent according to ADL (female=60.02% and male=68.50%), and about 40.50% (95% CI: 40.4-40.5) were independent based on IADL domains (female=39.41% and male=41.80). The dependency rates in ADL increased with the aging of population. Joint pain was the most prevalent type of pains and near to 26.00% (95% CI: 64.4-64.6) of the participants suffered moderate joint pains. About 71.5% (95% CI: 71.4-71.5) of the participants were urinary continent (female=67.66% and male=76.06%), and 91.9% (95% CI: 91.9-92.0) had bowel control (female=91.47% and male=92.94%) and the prevalence of incontinence increased by advancing age. Only 26.70% (95% CI: 26.6-26.8) of the participants reported excellent and good levels of perceived health status (female=21.98% and male=31.48%) and about 26.2% (95% CI: 26.1-26.2) of them reported some degree of visual impairment. Conclusion: The results of the present study can provide a good view about the health profile of older adults, including pain, functional status, sphincter control, chronic diseases, sensory status, and SPH. Future studies should prioritize SPH as an important predictor of mortality rates.

[Bladder wall neourethra technique improves early urinary continence after laparoscopic radical prostatectomy].

OBJECTIVE: To study the effect of the bladder wall neourethra (BWN) technique on early urinary continence after laparoscopic radical prostatectomy (LRP). METHODS: We prospectively selected 40 cases of LRP performed in our hospital from August 2020 to August 2021 and randomly divided them into a BWN group (n = 20) and a control group (n = 20). We recorded the urinary continence rate of the two groups of patients at 7, 30, 90 and 180 days, and measured the maximum urethral pressure (MUP), functional urethral length (FUL) and functional urethral area (UFA) and observed the shape of the neourethra closure by MRI at 1 month after catheter removal. RESULTS: The urinary continence rates were significantly higher in the BWN than in the control group at 7 days (90.0% vs 25.0%, P < 0.001), 30 days (95.0% vs 35.0%, P < 0.001), 90 days (100% vs 60.0%, P < 0.05) and 180 days (100% vs 90.0%, P > 0.05) after catheter removal. No statistically significant difference was observed in MUP between the two groups (P > 0.05). FUL and FUA were remarkably higher in the BWN than in the control group (P < 0.01). MRI showed tight closure of the neourethra in the BWN group in the urine storage period. CONCLUSION: The BWN technique can significantly prolong FUL and improve early urinary continence after LRP.

Recursos fisioterapêuticos nas disfunções miccionais em injúrias espinhais congênitas / Physiotherapeutic resources in voiding dysfunctions in congenital spinal injuries

Malformações congênitas são alterações morfológicas com origem no desenvolvimento embrionário e podem ser devido a causas genéticas, ambientais ou ambas. Em indivíduos que sofrem de injúrias espinhais congênitas, a bexiga neurogênica (BN) é um dos acometimentos com maior impacto na vida diária e o principal objetivo urológico é melhorar o manejo urinário e a continência social, para diminuir altas pressões vesicais e prevenir danos renais. Esta condição reflete diversas repercussões, como a diminuição na qualidade de vida, progressão para procedimentos invasivos, lesão renal e ao óbito. Objetivo: Revisar sistematicamente os estudos publicados nos últimos 10 anos a respeito da atuação da fisioterapia na incontinência urinária (IU) nas injúrias espinhais congênitas. Métodos: Revisão sistemática de literatura realizada através de busca, entre os anos de 2009 a 2019, nas bases de dados eletrônicas PubMed, Bireme e PEDro. Resultados: Não houve grande conformidade em relação às técnicas utilizadas, mas sim em relação aos desfechos analisados, sendo verificado estudos sobre IU na espinha bífida. Conclusão: A fisioterapia mostrou-se benéfica para os casos de IU nas injúrias espinhais congênitas, melhorando os parâmetros urodinâmicos e o desfecho no diário miccional. (AU)

Congenital malformations are morphological changes originating from embryonic development and can be due to genetic, environmental or both. In individuals suffering from congenital spinal injuries, the neurogenic bladder (BN) is one of the disorders with the greatest impact on daily life and the main urological objective is to improve urinary management and social continence, to decrease high bladder pressures and prevent kidney damage. This condition reflects several repercussions, such as a decrease in quality of life, progression to invasive procedures, kidney injury and death. Objective: To systematically review the studies published in the last 10 years regarding the role of physical therapy in urinary incontinence (UI) in congenital spinal injuries. Methods: Systematic literature, between the years 2009 to 2019, in the electronic databases Pubmed, Bireme and PEDro. Results: There was no great conformity in relation to the techniques used, but in relation to the analyzed outcomes, with studies on UI in spina bifida being verified. Conclusion: Physical therapy proved to be beneficial for cases of UI in congenital spinal injuries, improving urodynamic parameters and the outcome in the voiding diary. (AU)

Prevalência de incontinência urinária e perfil miccional de mulheres praticantes de Crossfit® / Prevalence of urinary incontinence and voiding pattern of Crossfit® practicing women

Introdução: A Incontinência Urinária (IU) afeta 200 milhões de pessoas de todas as idades, sendo a maioria mulheres. Segundo a International Continence Society (ICS) a IU é definida como qualquer perda involuntária de urina e consiste em uma patologia que leva a diversos efeitos sobre as atividades diárias, a interação social e percepção da própria saúde. Objetivo: Avaliar a prevalência de perda de urina involuntária e padrão miccional em mulheres praticantes de Crossfit® em de Patos de Minas/MG. Métodos: Estudo transversal, exploratório, com abordagem quantitativa em 3 academias de Patos de Minas, cuja amostra foi de 38 mulheres. O perfil da amostra foi traçado por questionário contendo informações sociodemográficas e antecedentes obstétricos elaborados pelas pesquisadoras. Aplicou-se questionário específico para investigar a presença de IU e situações relacionadas ao padrão miccional e outro para uma avaliação da incontinência atlética que identificou o perfil de treinamento da atleta e as atividades específicas do Crossfit®. Resultados: Observou-se que 78,9% eram nulíparas, 13,2% tiveram parto do tipo vaginal e 7,9% partos cesárea. Apenas 7,9% da amostra apresentou incontinência atlética. Conclusão: Apesar da queixa, houve baixa prevalência de Incontinência Atlética na amostra. (AU)

Introduction: Urinary Incontinence (UI) affects 200 million people of all ages, mostly women. According to the International Continence Society (ICS), UI is defined as any involuntary loss of urine and consists of pathology that leads to various effects on daily activities, social interaction and perception of one's own health. Objective: To evaluate the prevalence of involuntary urine loss and voiding pattern in women practicing Crossfit® in Patos de Minas/MG. Methods: Crosssectional, exploratory study with a quantitative approach in 2 Patos de Minas gyms, whose sample consisted of 38 women. The sample profile was traced by a questionnaire containing socio-demographic information and obstetric antecedents prepared by the researchers. A specific questionnaire was applied to investigate the presence of UI and situations related to voiding and other patterns and an assessment of athletic incontinence that identified the athlete's training profile and specific Crossfit® activities. Results: It was observed that 78.9% were nulliparous, 13.2% had vaginal delivery and 7.9% cesarean. Only 7.9% of the sample had athletic incontinence. Conclusion: Despite the complaint, there was a low prevalence of athletic incontinence in the sample. (AU)

[Laparoscopic robot-assisted artificial urinary sphincter in women: First approach]. / Sphincter urinaire artificiel robot chez la femme : début d'expérience.

OBJECTIVE OF THE STUDY: To analyze the medium-term results and complications of the artificial urinary sphincter (AUS) AMS 800 implanted using laparoscopic robot surgery in women with stress urinary incontinence (SUI) due to intrinsic sphincter deficiency (ISD). DESIGN, SETTING, AND PARTICIPANTS: We conducted a prospective cohort study, which included all procedures done in the CHU of Nîmes from July 2015 to January 2017. Patients with SUI by ISD needing an AUS or patients with a malfunctioning AUS needing to be changed were included. We collected data on intraoperative complications, length of hospitalization, postoperative complications, continence rate at twelve months and satisfaction of patients. RESULTS: Nineteen patients were included, 10 for primo-implantation and 9 for AUS revision. There were 4 postoperative bladder injuries, of which 2 led to laparoconversions. The mean length of hospitalization was 4.1days. Three patients had postoperative complications, which needed an intervention without AUS removal. One patient with persisting SUI due to bladder weakness preferred AUS ablation rather than having a cuff change. There was a median follow-up of 22months (12 to 33months). Sixteen patients out of 19 were completely continent and were satisfied of their intervention and the improvement of their quality of life. CONCLUSION: The laparoscopic robot surgery for AUS implantation is safe and reproducible with good medium-term results. LEVEL OF EVIDENCE: 4.

Prevalência de incontinências anal e dupla em idosas e impacto na qualidade de vida / Prevalence of anal and double incontinence in elderly women and impact on their quality of life

Introdução: A prevalência das incontinências anal e urinária que são mais comuns em mulheres, aumenta com a idade. Tais disfunções podem ser encontradas isoladamente ou em associação (incontinência dupla) e podem provocar grande impacto na qualidade de vida. Objetivos: Avaliar a prevalência das incontinências anal e dupla e o impacto dessas condições sobre a qualidade de vida de mulheres idosas da comunidade. Casuística e Métodos: Estudo observacional descritivo, realizado em mulheres com mais de 60 anos que buscaram a unidade básica de saúde para vacinação. Para a triagem de incontinência urinária e anal, foram utilizadas versões brasileiras dos questionários International Consultation on Incontinence Questionnaire - Short Form e do Índice de Incontinência Anal. Mulheres que apresentaram escores diferentes de zero em ambos questionários receberam diagnóstico de incontinência dupla. A avaliação do impacto da incontinência anal na qualidade de vida foi feita por meio do questionário Fecal Incontinence Quality of Life Questionnaire. As variáveis foram estudadas de maneira descritiva, por meio do cálculo de frequências absolutas e relativas e, no caso da variável idade e dos escores de qualidade de vida, por meio do cálculo da média e desvio-padrão. Resultados: Participaram da pesquisa 66 mulheres, com média de idade de 69,6±7,2 anos. A prevalência de incontinência anal foi de 28,8% (n=19), e a prevalência de incontinência dupla foi de 18,1% (n=12). Pacientes com incontinência anal isolada e dupla apresentaram impacto negativo na qualidade de vida, conforme indicado pelos escores dos domínios avaliados. Conclusão: A prevalência de incontinência anal foi mais elevada do que a prevalência de incontinência fecal isolada ou de incontinência anal encontrada em outras populações. O mesmo foi observado em relação à prevalência de incontinência dupla. Houve impacto negativo de ambas as condições em todos os domínios de qualidade de vida avaliados.

Introduction: The prevalence of anal and urinary incontinence is more frequent in women, and it increases with age. Such dysfunctions may be found alone or in combination (double incontinence), and they may have a major impact on quality of life. Objectives: Evaluate the prevalence of anal and double incontinence, as well as the impact these conditions cause on the quality of life of elderly women residents in a community. Patients and Methods: We carried out an observational descriptive study involving women aged 60 and over who sought the Primary Health Care Unit for vaccination. For the urinary and anal incontinence screening, Brazilian versions of the International Consultation on Incontinence Questionnaire - Short Form and the Anal Incontinence Index were used.Women who presented scores different from zero in bothquestionnaires were diagnosed with double incontinence. Theevaluation on the impact of anal incontinence on quality of lifewas done through the Brazilian version of Fecal IncontinenceQuality of Life Questionnaire. We used descriptive statistics tocalculate relative and absolute frequencies. Age and Qualityof life domain scores were expressed using mean and standarddeviation. Results: Sixty-six women were included in thestudy. Mean age was 69.6±7.2 years. The prevalence of AnalIncontinence was 28.8% (n=19) and the prevalence of doubleincontinence was 18.1% (n=12). Patients with isolated anddouble anal incontinence had a negative impact on qualityof life, as indicated by the scores of the domains evaluated.Conclusions: The prevalence of anal incontinence was higherthan the prevalence of isolated fecal incontinence or analincontinence found in studies carried out in other populations.The same results were observed for the prevalence of doubleincontinence. We identified negative impact of both conditionson all domains of quality of life

[Stricture of the vesicourethral anastomosis after radical prostatectomy]. / Die Striktur der vesikourethralen Anastomose nach radikaler Prostatektomie.

BACKGROUND: The development of a stricture of the vesicourethral anastomosis is a serious complication after radical prostatectomy. Strictures occur in 5-8% of patients after radical prostatectomy. SYMPTOMS: Usually the clinical symptoms include an irritative and obstructive component similar to benign prostatic hyperplasia. In rare cases, patients suffer from partial or complete stress incontinence as a result of the anastomotic stricture. DIAGNOSTICS: The diagnostic workup is similar to the procedure for urethral strictures. In addition to uroflowmetry, a cystourethrogram (CUG) or, if necessary, a micturating cystourethrogram (MCU) can be performed. A urethrocystoscopy can be performed to ensure the diagnosis. THERAPY: In most cases, endoscopic procedures were performed for treatment. Beside a transurethral dilation of the stricture or the Sachse urethrotomy, the most common procedure is transurethral resection to treat the stricture. However, all procedures are associated with a high recurrence rate. In recurrent strictures, open surgical procedures, usually a perineal reanastomosis, should performed early. CONCLUSION: Endourological procedures like transurethral resection are a good treatment option, but due to the high recurrence rates, open surgical procedures should be discussed and if necessary should be performed early.

Anal incontinence and vesico-sphincter events in systemic sclerosis: An epidemiologic bicentric cohort study.

OBJECTIVE: To estimate the frequency and severity of anal incontinence and vesico-sphincter events, associated factors, and impact on the quality of life of patients with systemic sclerosis. METHODS: Questionnaires assessing anal incontinence (Miller score), vesico-sphincter events (Urogenital Distress Inventory) and quality of life [Short Form Health Survey 36v2 (SF-36), and Hospital Anxiety and Depression Scale] were mailed to 139 patients with systemic sclerosis at the university hospitals of Besançon and Poitiers, France. Clinical data were collected from the medical records to identify risk factors. RESULTS: Among the 121 (87%) responders, severe vesico-sphincter events or severe anal incontinence occurred in 3.4% and 12.4% of cases, respectively. Frequent urination (66.3%) and anal incontinence to gas (50.4%) were the most frequent symptoms. Anal incontinence was associated positively with vesico-sphincter events, unrelated to obstetrical factors. No correlations were seen with age, sex, or systemic sclerosis characteristics. In multivariate analysis, moderate or severe vesico-sphincter events was associated with higher anxiety and depression scores and lower SF-36 scores; the same results were observed for anal incontinence, but did not reach significance. CONCLUSION: Vesico-sphincter events and anal incontinence are common in systemic sclerosis, and sometimes severe, with a potential negative impact in quality of life. These results will be confirmed by a case-control study with dynamic and manometric assessment, and could legitimate a systematic screening to ensure early therapy and multidisciplinary individual management.

Lower urinary tract symptoms in children with anorectal malformations with rectoperineal fistulas.

AIM: The aim was to describe the frequency of lower urinary tract symptoms (LUTS) in children with anorectal malformations with rectoperineal fistulas (ARM-P), as compared with healthy controls based on gender. METHOD: LUTS were defined using the 2014 definitions of the International Children's Continence Society. Data were collected at 2 tertiary pediatric surgery centers in 2 countries from all children aged 4-12years who had undergone an operation for ARM-P. RESULTS: A total of 24 girls and 33 boys, with a median age of 8 (4-12)years, were eligible and compared with 165 controls. Of the patient group, 4 (17%) girls had 8 urinary tract anomalies (UTA), and 8 (24%) boys had 13 UTA. There were no gender differences in LUTS among the patients. The frequency of urinary tract infections was higher among the patients (5/24 girls and 7/55 boys) than the controls (1/55 and 4/110) (p=0.009). More patients (5/24 girls and 5/33 boys) than controls (1/55 and 2/110) used daily urinary medications (p=0.009 and p=0.007, respectively). Patients with UTA reported urinary infections more frequently (3/4 girls and 4/8 boys) than those without UTA (2/20 girls and 0/25 boys) (p=0.018 and p=0.002, respectively). CONCLUSION: Children with ARM-P had more LUTS than controls, and patients with concomitant UTA had more LUTS than patients without UTA. Therefore, children with ARM-P are suggested to have routine follow-up for both UTA and LUTS.

The Miniarc® sling system in the treatment of female stress urinary incontinence

AIMS: To assess the technical feasibility of a new mini-invasive sling procedure (MiniArc®) and present short-term results in the treatment of female urinary incontinence. MATERIAL AND METHODS: A total of 97 women with mixed or stress urinary incontinence (SUI) were treated by placement of the new single-incision sling. Pelvic organ prolapse was graded using the POP-Q system (pelvic organ prolapse quantification system). Preoperative workup included urodynamic evaluation, cough stress test and introital ultrasound. Postoperatively, introital ultrasound was performed to determine residual urine and check tape position. Quality of life was measured using King's Health Questionnaire. A voiding diary and pad count served to verify the patients' subjective complaints. RESULTS: The MiniArc® single-incision sling procedure was the initial intervention in 37 (38.2 percent) patients and the second intervention in 60 (61.7 percent) patients with recurrent incontinence. The cough stress test was negative in 79 (83.1 percent) women 6 weeks after the sling procedure and in 74 (77.8 percent) at 12 months. De novo urge occurred in 32 (36.8 percent) women. Quality of life was significantly improved at 12-month follow-up in 65 (69.1 percent) patients (p < 0.001). The number of pads decreased significantly from 2.2 to 0.6 (p < 0.001) after the procedure. One patient developed an hematoma and bladder perforation occurred in another. CONCLUSIONS: Our short-term clinical results suggest that the MiniArc® is a safe and effective minimally invasive sling procedure for treating female SUI. Randomized comparative controlled trials and long-term results are still required to define the role of the new sling system in comparison to established mid-urethral tape techniques for treating incontinence.

Voiding Pattern and Incontinence after Orthotopic Ileal Neobladder in Male Patients / 대한비뇨기과학회지

PURPOSE: To report the voiding pattern and continence stati in male patients having undergone a radical cystectomy and orthotopic bladder substitution. MATERIALS AND MATHODS: Between March 2000 and June 2005, 20 men with advanced bladder cancer had a radical cystoprostatectomy and urinary diversion via an ileal orthotopic bladder substitution. The voiding pattern and continence stati were assessed using patient interviews, frequency- volume charts and pad tests at 1, 3, 6, 9 and 12 months after catheter removal. RESULTS: The mean age and follow-up were 60.5 years (41-72) and 34.1 months (12-69), respectively. Neobladder substitution was performed with an ileum in all patients. 17 patients had reconstruction with a Studer neobladder and 3 with a W-pouch Hautmann. All patients had transitional cell carcinoma (TCC) and their tumor stages ranged from T1G3 to T4aN1M0. The frequency of voiding ranged from 4 to 12 times during the day, and 0 to 5 times during the night, with a mean maximum neobladder capacity of 336ml (200-620) and maximum flow rate of 24.6ml/sec (12-46) 12 months after removal of the catheter. No patient required intermittent self-catheterization. All-time continence rates were 15, 30, 65 and 85%, and all-time incontinence rates were 55, 25, 10 and 5% at 1, 3, 6 and 9 months after catheter removal, respectively. CONCLUSIONS: Orthotopic bladder substitution has an excellent functional outcome over time, resulting in high daytime and nighttime continence rates within 9 months of catheter removal.