Santiago Richter

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.

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.

Fast-track eligibility of geriatric patients undergoing short urologic surgery procedures.

Our primary objective was to assess the feasibility of geriatric patients (>65 yr) bypassing the postanesthesia care unit (PACU) after ambulatory surgery. A secondary objective was to compare recovery profiles when using three different maintenance anesthetics. Ninety ASA physical status I–III consenting outpatients (>65 yr) undergoing short urologic procedures were randomly assigned to one of three anesthetic treatment groups. After a standardized induction with fentanyl and propofol, anesthesia was maintained with propofol (75–150 &mgr;g · kg−1 · min−1 IV), isoflurane (0.7%–1.2% end tidal), or desflurane (3%–6% end tidal), in combination with nitrous oxide 70% in oxygen. In all three groups, the primary anesthetic was titrated to maintain an electroencephalographic-bispectral index value of 60–65. Recovery times, postanesthesia recovery scores, and therapeutic interventions in the PACU were recorded. Although emergence times were similar in the three groups, the time to achieve a fast-track discharge score of 14 was significantly shorter in patients receiving desflurane compared with propofol and isoflurane (22 ± 23 vs 33 ± 25 and 44 ± 36 min, respectively). On arrival in the PACU, a significantly larger percentage of patients receiving desflurane were judged to be fast-track eligible compared with those receiving either isoflurane and propofol (73% vs 43% and 44%, respectively). The number of therapeutic interventions in the PACU was also significantly larger in the Isoflurane group when compared with the Propofol and Desflurane groups (21 vs 11 and 7, respectively). In conclusion, use of desflurane for maintenance of anesthesia should facilitate PACU bypass (“fast-tracking”) of geriatric patients undergoing short urologic procedures.

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.

Combined cystolithotomy and transurethral resection of prostate: best management of infravesical obstruction and massive or multiple bladder stones.

OBJECTIVES To investigate the results of combined suprapubic cystolithotomy followed by transurethral resection (TUR) of the prostate (TURP) or TUR of the bladder neck in patients with infravesical obstruction and massive or numerous bladder stones. We also reviewed the medical literature and compared the success, morbidity, and mortality rates of the treatment modality presented here and the nonsurgical modality of transurethral lithotripsy and resection of the prostate or bladder neck. METHODS Through a 10-year period, 20 men with benign prostatic hyperplasia or bladder neck obstruction and massive or numerous bladder stones underwent cystolithotomy for stone clearance followed by TURP or TUR of the bladder neck. A second group of 20 randomly selected men who underwent TURP alone was studied retrospectively for time of surgery, number of days of postoperative indwelling catheter use, and hospital stay. RESULTS No deaths occurred. All stones were successfully evacuated (100% stone-free rate). The operative time and number of days of postoperative indwelling catheter use and hospital stay were notoriously shorter in the present series compared with the transurethral lithotripsy and TURP modality. A single case of fever (5% complication rate) occurred in each group. When comparing the data of the present series with a group of 20 men who underwent TURP only, no differences were found in the times of postoperative indwelling catheter use and hospital stay. Cystolithotomy performed before TURP prolonged the total time of surgery an average of 18.4 minutes. CONCLUSIONS In the era of endoscopic and minimally invasive surgery, a small suprapubic cystostomy followed by TURP is still the treatment of choice in cases of infravesical obstruction and very large or numerous bladder stones. The procedure is quick and easy to perform and bears a low morbidity rate compared with transurethral lithotripsy and TURP. A small cystotomy does not prolong the time of indwelling catheter use and hospital stay.

A simple, self-retaining intraurethral catheter for treatment of prostatic obstruction

An intraurethral catheter was successfully used in 38 of 47 (80.9%) patients with benign prostatic hyperplasia who were awaiting surgery or in whom surgery constituted a high risk. All patients had indwelling catheters due to urinary retention. The device was inserted via a cystoscope or a specially designed insertion set. The insertion was performed in the outpatient clinic under local anesthesia and did not require more time than the cystoscopy itself. The intraurethral catheter remained in place for up to 41 weeks. None of the patients developed clinically evident urinary tract infections. Voiding and continence were satisfactory in all, although 8 (21%) suffered some degree of frequency of micturition. There are apparently no limitations in the use of the intraurethral catheter. Compared to other techniques and devices for treatment of urinary retention, the intraurethral catheter appears to be more physiological, easier to insert and remove, and more economical. We recommend intraurethral catheter insertion for up to 6 months in patients who are awaiting surgery and as an alternative for high-risk patients. In the latter, the intraurethral catheter should be changed after 6 months.

Safety of transrectal prostatic biopsy through double-glove technique without antibiotic prophylaxis

We studied 143 men who underwent transrectal prostatic biopsies using the double-glove technique. No patient received any antimicrobial therapy before the procedure. Clean catch urine cultures were obtained at admission and two, four, and twenty-four hours, and two weeks after biopsy. Aerobic and anaerobic blood cultures were performed at admission, and at thirty minutes and four hours after the procedure. In addition, clinical parameters were monitored closely in the hospital for twenty-four hours after the biopsy. A total of 132 patients were considered evaluable. Temperatures of 37.6 degrees C or higher occurred in 3.8 percent of the patients. In no case was rigors recorded. In 4 of the patients studied (3%) post-biopsy urine cultures were infected with Escherichia coli. All post-biopsy blood cultures, both aerobic and anaerobic, were negative. Our data indicate that with the use of the double-glove technique, prophylactic administration of antibiotics is not necessary to prevent the infectious complications following transrectal biopsy of the prostate.

Supratrigonal Ectopic Prostate: Case Report and Review of the Literature

A 76-year-old man with a 6-month history of dysuria and frequency had a sessile tumor at the bladder dome containing benign prostatic glandular tissue. The presence of benign prostatic polyps in the prostatic urethra and bladder neck is a common finding. Ectopic prostatic tissue elsewhere is rare, it has been described previously in a few cases in the trigonum and only once in the supratrigonal area. The origin of prostate glands in this unlikely location is not yet fully understood. Prostatic tissue at any ectopic location is benign, although local recurrence has been reported.

Single preoperative bladder instillation of povidone-iodine for the prevention of postprostatectomy bacteriuria and wound infection.

OBJECTIVE To study the effectiveness of preoperative bladder washing with povidone-iodine to prevent postprostatectomy wound infection. DESIGN Patients with an indwelling catheter and scheduled for prostatectomy were divided into two groups. In patients in group 1 (n = 76) the indwelling catheter was simply removed without bladder irrigation. Patients in group 2 (n = 80) had their bladder washed with a nondiluted solution of povidone-iodine before surgery. PATIENTS One hundred fifty-six consecutive patients with an indwelling catheter and bacteriuria. Mean age was 64 years. All patients had an open prostatectomy during the 12-month study period. Patients undergoing open prostatectomy during the first 6 months of the study had no bladder irrigation and served as the control group. Patients undergoing open prostatectomy during the following 6 months had a bladder instillation with povidone-iodine. RESULTS Wound infection appeared in 17 of 76 patients (22.4%) without bladder washing and in 4 of 80 patients (5%) when 50 to 60 ml of the solution was retained in the bladder for 10 to 13 minutes (p = .001). The incidence of postoperative bacteriuria remained unchanged in the control group (100%) but was reduced to 22.5% in the treated group (p = .001). Statistical comparisons of incidence were done using the chi square test. CONCLUSIONS It has been demonstrated that the use of preoperative bladder instillation of povidone-iodine may be highly effective in the prevention of postprostatectomy wound infection and in reducing the incidence of bacteriuria in patients with an indwelling catheter and urine colonization.