Israel Nissenkorn

The indwelling ureteric stent: a ‘friendly’ procedure with unfriendly high morbidity

Objective To review the morbidity and complications of ureteric stent insertion and to evaluate specifically the effect of an indwelling ureteric stent on the changes in hydronephrosis after stenting.

Expression of cytokeratin 20 in urinary cytology of patients with bladder carcinoma

Of the 20 known cytokeratins, CK‐19 is expressed in normal urothelium, whereas the recently identified CK‐20 is expressed in urothelial carcinoma cells but not in normal urothelial cells. The aim of this study was to examine whether CK‐20 expression could serve as a noninvasive test in which malignant urothelial cells in urine are detected and monitored.

Late Complications of Ureteral Stents

Objective: To review morbidity and late complications of ureteral stent insertion and to specifically evaluate hydronephrosis as a radiologic finding of obstruction in the presence of an indwelling ureteral stent.Methods: In this prospective study, we evaluated 110 stented kidneys in a group of 90 patients. Of 110 stents, 52 were left in place for 3 months, 23 for 6 months, 11 for 9 months, and 24 for up to 12 months. With the stent in place, patients were followed by plain abdominal X–ray 1 and 30 days after stenting. Further follow–up was performed through ultrasound and plain film every 3 months until scheduled date for stent removal or the appearance of complications.Results: In 11 of 110 cases (10%) there was stent fragmentation and in 9 (8.2%) stent migration. In 10 cases (9.1%), there was no change in the severity of the hydronephrosis, but because of flank pain or urinary tract infection with fever, the stents had to be removed. In 6 cases (5.4%) hydronephrosis developed or worsened after stenting. Of the 110 ureteral stents, 32.7% had to be removed because of late complications.Conclusions: Although ureteral stenting is undoubtedly an important procedure for the release of ureteral obstruction, the indications for stent insertion should be carefully considered in each patient. Late complications of ureteral stents are frequent and appear in one third of the patients. Close follow–up of stented patients is valuable in early detection of morbidity or complications, and in such cases the stent should be removed or exchanged as soon as possible.

NEPHROVESICAL SUBCUTANEOUS STENT: AN ALTERNATIVE TO PERMANENT NEPHROSTOMY

PURPOSE We studied whether a subcutaneous ureteral bypass may be an alternative to a permanent nephrostomy tube in patients with ureteral obstruction caused by pelvic malignancy. MATERIALS AND METHODS Using local anesthesia we inserted an especially designed nephrovesical stent into subcutaneous tissue. The stent consists of 2 J stents that are joined by a connector after insertion into the renal pelvis and bladder. RESULTS In 8 patients 10 subcutaneous stents were inserted instead of a permanent nephrostomy tube. Nephrostomy was required because of obstructed ureters caused by metastatic prostate or invasive bladder cancer. Attempted Double-J stent insertion into the obstructed ureter had previously failed. The bypass has functioned well in all cases during 6 weeks to 18 months of followup (mean 5.5 months). CONCLUSIONS The high complication rate of a permanent nephrostomy tube and frequent rehospitalization render the subcutaneous stent an important alternative to nephrostomy. The subcutaneous stent eliminates external devices for urine drainage and improves patient quality of life.

LONG-TERM INCIDENCE OF ACUTE MYOCARDIAL INFARCTION AFTER OPEN AND TRANSURETHRAL RESECTION OF THE PROSTATE FOR BENIGN PROSTATIC HYPERPLASIA

PURPOSE Acute myocardial infarction was found to be the main cause of increased long-term mortality in patients after transurethral compared to open prostatectomy in various retrospective studies. We performed a randomized prospective study to compare morbidity and incidence of acute myocardial infarction in patients after transurethral compared to open prostatectomy for benign prostatic hyperplasia. MATERIALS AND METHODS We studied 365 patients who were assigned to transurethral (236) or open (129) prostatectomy only according to the size of the prostate and who were followed for 7 to 8 years. The clinical status of the patients in both groups before and after the operation was compared, and the rate of myocardial infarction and long-term mortality was studied. RESULTS More patients with a history of cerebrovascular accident (5.4 versus 0.8%) and indwelling catheters (16.3 versus 7.6%) before the operation were in the open prostatectomy group. Among the 236 patients operated on transurethrally 31 were reoperated on (6 more than once) during followup compared to 4 of the 129 patients who underwent open prostatectomy. In 15 patients from the transurethral prostatectomy group myocardial infarction developed compared to 9 patients in the open prostatectomy group. This difference was not statistically significant. The rate of acute myocardial infarction after prostatectomy, no matter which approach was used, was greater than 6% and it appeared to be higher when compared to the rate of infarction in the general population of the same age group, which is approximately 2.5% in our county. There was no statistically significant difference in the overall mortality rate between the transurethral and open prostatectomy groups, which was 14.4 and 8.5% respectively. CONCLUSIONS Open prostatectomy is more effective in overcoming urinary obstruction than the transurethral approach. No significant differences in myocardial infarction or overall mortality rates were found between the 2 groups.

INFECTED URINE AS A RISK FACTOR FOR POSTPROSTATECTOMY WOUND INFECTION

OBJECTIVE To study the relation of preoperative infected urine and postprostatectomy wound infection in patients with and without indwelling bladder catheters. DESIGN Patients undergoing prostatectomy were evaluated for the presence of infected urine prior to prostatectomy and postoperative wound infection. They were further divided into patients with indwelling urinary catheter and catheter-free patients. All had received antibiotic prophylaxis. PATIENTS One hundred fifty consecutive patients undergoing open prostatectomy--mean age was 67 years; 100 patients with an indwelling catheter for a mean period of 50 days; 50 catheter-free patients. RESULTS Wound infection was found in 19 of 81 (23.5%) and in 6 of 69 (8.7%) patients with infected and sterile urine, respectively (p = .028). In patients with indwelling catheters prior to operation, wound infection was 22.4% when urine was infected and 8.3% when it was not. In patients without catheters, infected urine was associated with 40% of wound infections, as compared with 8.9% of wound infections in patients with sterile urine. Organisms obtained from infected wound and urine were identical in 84% of cases. These results were obtained despite antibiotic prophylaxis. CONCLUSIONS Wound infection has been demonstrated to be a postprostatectomy complication directly related to the presence of urinary infection at surgery; thus, elective prostatectomy should be deferred until urine becomes sterile.

A SIMPLE NONMETAL STENT FOR TREATMENT OF URETHRAL STRICTURES: A PRELIMINARY REPORT

PURPOSE A polyurethane temporary stent has been designed for urethral strictures in patients who are unfit or unwilling to undergo surgery. MATERIALS AND METHODS The stent resembles a Malecot catheter and is inserted easily through the urethrotome sheath immediately after urethrotomy. The stent was used in 22 patients with recurrent urethral strictures and was left in the urethra for 3 to 24 months. RESULTS Mean followup was 11.2 months. All patients were treated successfully and had improved urine flow rates (maximum 15 to 21 ml. per second). In no patient was the stent obstructed by incrustation for up to 2 years. CONCLUSIONS This simple stent may offer effective treatment for many urethral strictures.

Spontaneous rupture of renal and ureteral tumors presenting as acute abdominal condition.

We report on 3 patients who presented with an acute onset of abdominal pain, a palpable abdominal mass and a rapid decrease in hemoglobin. In 2 patients a spontaneously ruptured hypernephroma was found and the other patient had a squamous cell carcinoma of the ureter with bleeding into the tumor. Although in all 3 cases the tumors were at an advanced stage of development, the patients had been entirely free of urological symptoms until shortly before hospitalization. The importance of considering the possibility of spontaneous rupture of such a tumor in the evaluation of cases of an acute abdomen is stressed.

Occult progressive renal damage in the elderly male due to benign prostatic hypertrophy.

A review of the case histories of 345 patients who underwent prostatectomy showed that 1.7 percent (6 patients) had “occult and progressive renal damage” secondary to prostatic hypertrophy. All these men were over the age of 60 and the disturbances in micturition were so mild that the patients were unaware of, or chose to ignore them. The presenting symptoms were nonspecific and included generalized weakness, anorexia, nausea, constipation, and weight loss. Investigation revealed imparied renal function of varying degrees. Prostatectomy was associated with a dramatic improvement in all 6 patients. Physicians should be aware of the clinical entity of occult and progressive renal damage secondary to obstruction of the bladder outlet, especially in the elderly male. Uremia can develop with minimal urinary symptoms. Elderly men often suppress or deny their symptoms because of the fear of operation.

Use of an intraurethral catheter instead of a Foley catheter after laser treatment of benign prostatic hyperplasia

OBJECTIVE Our study describes the results obtained in 15 patients in whom an intraurethral catheter (IUC) instead of an indwelling catheter was used after visual laser ablation of the prostate (VLAP). METHODS The 15 patients were treated by VLAP for benign prostatic hyperplasia. The IUC was inserted through the cytoscope sheath immediately after completion of surgery, and left in the prostatic urethra for 3 weeks. RESULTS Twelve of the 15 patients (80%) voided through the urethra without need of an indwelling catheter. In the remaining 3 patients the IUC had to be removed and a Foley catheter inserted. CONCLUSION Our results reveal that the IUC stent may be used as an alternative for an indwelling catheter in patients treated by VLAP.