urinary retention [keywords]
- Severe Hydronephrosis and Perinephric Urinoma with Rupture of Renal Fornix Secondary to Postoperative Urinary Retention following Laparoscopic Umbilical Hernia Repair. [Journal Article]
- Case Rep Urol 2016.:6754843.
Postoperative urinary retention (POUR) is a known complication following a variety of procedures, with a reported incidence of 2.1-3.8% in general surgery and up to 52% in anorectal surgery. We report a case of POUR in a female resulting in severe unilateral hydronephrosis with a perinephric urinoma due to a ruptured fornix. The extent of hydroureter caused an axial rotation upon itself producing further outflow obstruction. This phenomenon of an anatomical ureter deformity secondary to urinary retention resulting in a ruptured fornix is an unusual occurrence. The patient underwent a percutaneous nephrogram where a stiff guidewire was successfully passed into the bladder by interventional radiology (IR) and allowed for placement of an indwelling ureteral stent. The case presentation, diagnostic evaluation, and therapeutic intervention are discussed.
- Concomitant repair of stress urinary incontinence with proximal urethrovaginal fistula: Our experience. [Journal Article]
- Indian J Urol 2016 Jul-Sep; 32(3):229-31.
Proximal urethrovaginal fistula (UVF) located close to the bladder neck may cause extensive sphincter damage and is usually associated with continuous incontinence, which may mask the associated stress urinary incontinence (SUI). Simultaneous correction of SUI avoids a second surgery for SUI, which needs dissection in ischemic fields and carries a high risk of failure. The aim of this study is to describe our technique of concomitant repair of SUI with proximal UVF and our results.Between July 2010 and August 2014, 14 patients underwent UVF repair in Jackknife position by the interposition of a Martius flap and simultaneous correction of SUI by modified McGuire pubovaginal autologous fascial sling. The procedure was carried out a minimum of 3 months of presentation and after detailed preoperative evaluation.After a mean follow-up of 28 months, all 14 patients were continent. None of the patients developed recurrence of the UVF. Two patients presented with retention immediately after catheter removal and clean intermittent catheterization training was given to both of them. Two patients became pregnant during the follow-up period and were advised cesarean section near term.Repair of proximal UVF and correction of SUI can be performed in the same session to avoid the operation in an ischemic field.
- The challenges in the diagnosis of detrusor underactivity in clinical practice: A mini-review. [Journal Article, Review]
- Arab J Urol 2016 Sep; 14(3):223-7.
To review the current definitions, terminology, epidemiology and aetiology of detrusor underactivity (DU), with specific attention to the diagnostic criteria in use. In addition, we address the relation and the overlap between DU and bladder outlet obstruction (BOO). In this mini-review, we hope to help identify DU patients and facilitate structured clinical evaluation and research.We searched the English literature using ScienceDirect and PubMed for relevant articles. We used the following terms: 'detrusor underactivity', 'underactive bladder', 'post voiding residual', 'post micturition residual', 'acontractile bladder', 'detrusor failure', and 'detrusor areflexia'.DU is one of the most common conditions causing lower urinary tract symptoms (LUTS). Unfortunately, it is also the most poorly understood bladder dysfunction with scant research. To our knowledge there is no clear definition and no non-invasive method to characterise this important clinical condition. DU may result from the normal ageing process; however, it has multiple aetiologies including neurogenic and myogenic dysfunction. In many cases the symptoms of DU are similar to those of BOO and it usually requires invasive urodynamic study (UDS) for diagnosis to differentiate the two diagnoses. A number of diagnostic tests may be used including: UDS testing, the Schafer pressure/flow nomogram, linear passive urethral resistance relation, Watts factor, and the bladder contractility index. Of these, UDS testing is the most practical as it determines both the maximum urinary flow rate and the pressure exerted by the detrusor muscle relative to the maximal flow of urine, allowing for precise characterisation of detrusor function.Currently, the diagnosis of DU is based on invasive urodynamic parameters as defined by the International Continence Society in 2002. There is no consensus for the definition of DU prior to 2002. As there is significant overlap between the symptoms of DU and BOO, it is difficult to diagnose DU clinically.
- Extracorporeal shockwave lithotripsy monotherapy for treating patients with bladder stones. [Journal Article]
- Arab J Urol 2016 Sep; 14(3):207-10.
To describe our experience with extracorporeal shockwave lithotripsy (ESWL) for the treatment of bladder stones of <20 mm.This study was prospectively performed in two hospitals (Althawrah Modern General Hospital, and Ibn Sina Specialized Hospital) between November 2012 and November 2015. In all, 44 patients presented with urethral or bladder stones. The location and size of the stones was assessed by abdominal ultrasonography and plain abdominal radiography of the kidneys, ureters and bladder. All patients with radiopaque stones of <20 mm underwent ESWL monotherapy after fixation of a Foley catheter in a supine position under intravenous analgesia.The mean size of the stones was 15.8 mm and spontaneous evacuation occurred after removal of the Foley catheter without the need for adjuvant procedures in 40 patients (90.9%). Four patients (9%) developed acute urinary retention due to urethral impaction of large stone fragments. In two of them, the urethral catheter was successfully re-inserted pushing the fragments back to the bladder and a complementary session of ESWL resulted in more fragmentation of the stones, with spontaneous passage after catheter removal. In the other two patients (4.5%), the catheter could not be re-inserted and urgent endoscopic intervention was required.ESWL monotherapy is safe and effective method for treatment of bladder stones with no other causes of infra-vesical obstruction. Several indications can be met including patients with high anaesthetic risk, patients fearing anaesthesia or endoscopic procedures, and patients who have difficulty in positioning.
- Holmium laser cystolithotripsy under local anaesthesia: Our experience. [Journal Article]
- Arab J Urol 2016 Sep; 14(3):203-6.
To investigate the feasibility and effectiveness of transurethral holmium laser cystolithotripsy (HLC) under local anaesthesia using a flexible cystoscope.A prospective study was undertaken from January 2013 to June 2015. In all, 37 men with bladder calculi underwent HLC under local anaesthesia, preferably in a lithotomy position using a flexible cystoscope, followed by per urethral Foley catheter placement postoperatively.The mean (SD; range) patient age was 46.6 (5.6; 32-76) years. All patients were rendered stone-free, regardless of stone size. The mean (SD; range) stone size was 2.1 (1.2; 1.4-4.1) cm and operative time was 35 (6; 26-52) min. The whole procedure was well tolerated and there were no major intraoperative complications. The mean (SD; range) hospital stay was 2.4 (1.5; 1-5) days. After a mean follow-up of 6 months, no recurrent stones, urinary retention or urethral strictures had developed.Transurethral HLC using a flexible cystoscope under local anaesthesia is a safe and effective technique for the treatment of bladder calculi and can be used as an alternative treatment option.
- Holmium laser for the surgical treatment of benign prostatic hyperplasia. [Journal Article]
- Can J Urol 2016 Aug; 23(4):8356-62.
Holmium laser ablation of the prostate (HoLAP) is a surgical approach for treatment of benign prostatic hyperplasia (BPH). Limited evidence suggests laser ablation/vaporization is inferior to enucleation with respect to reoperation rates. Our objective was to determine if properly performed laser ablation results in outcomes similar to enucleation.A total of 198 patients with moderate to severe lower urinary tract symptoms and/or acute urinary retention had holmium laser enucleation of the prostate (HoLEP) or HoLAP between 2008 and 2014. Patients with metastatic prostate cancer, prior pelvic radiation, or bladder cancer involving the bladder neck or prostatic urethra were excluded. All procedures involved residents and were supervised by one experienced surgeon. The decision to perform HoLAP versus HoLEP was made intraoperatively. Demographics, pre, peri and postoperative data were collected.A total of 169 men were analyzed: 54 had HoLAP and 115 had HoLEP. Mean follow up was 27.16 months for HoLAP, and 38.18 months for HoLEP. As expected, the HoLEP group had larger prostates, longer mean operative times, and greater reduction in total PSA. There was no difference in the net change of flow rate between groups.Both HoLEP and HoLAP are appropriate surgical interventions for the management of BPH, when properly performed. Our findings suggest that adequate ablation of prostatic adenoma results in similar 2 year outcomes as enucleation.
- Complications After Systematic, Random, and Image-guided Prostate Biopsy. [REVIEW, JOURNAL ARTICLE]
- Eur Urol 2016 Aug 16.
Prostate biopsy (PB) represents the gold standard method to confirm the presence of cancer. In addition to traditional random or systematic approaches, a magnetic resonance imaging (MRI)-guided technique has been introduced recently.To perform a systematic review of complications after transrectal ultrasound (TRUS)-guided, transperineal, and MRI-guided PB.We performed a systematic literature search of Web of Science, Embase, and Scopus databases up to October 2015, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Complications and mortality following random, systematic, and image-guided PBs were reviewed. Eighty-five references were included.The most frequent complication after PB was minor and self-limiting bleeding (hematuria and hematospermia), regardless of the biopsy approach. Occurrence of rectal bleeding was comparable for traditional TRUS-guided and image-guided PBs. Almost 25% of patients experienced lower urinary tract symptoms, but only a few had urinary retention, with higher rates after a transperineal approach. Temporary erectile dysfunction was not negligible, with a return to baseline after 1-6 mo. The incidence of infective complications is increasing, with higher rates among men with medical comorbidities and older age. Transperineal and in-bore MRI-targeted biopsy may reduce the risk of severe infectious complications. Mortality after PB is uncommon, regardless of biopsy technique.Complications after PB are frequent but often self-limiting. The incidence of hospitalization due to severe infections is continuously increasing. The patient's general health status, risk factors, and likelihood of antimicrobial resistance should be carefully appraised before scheduling a PB.We reviewed the variety and incidence of complications after prostate biopsy. Even if frequent, complications seldom represent a problem for the patient. The most troublesome complications are infections. To minimize this risk, the patient's medical condition should be carefully evaluated before biopsy.
- AN AUDIT OF THE MANAGEMENT OF ACUTE PAIN IN CHILDREN. [Journal Article]
- Arch Dis Child 2016 Sep; 101(9):e2.
To evaluate clinical management of acute pain with respect to pain assessment, scoring and timing of analgesia and whether appropriate supportive medicines were prescribed alongside strong opiates. A previous pain audit found dosing of analgesia was appropriate but did not assess clinical management against pain scores. Our paediatric guideline does not currently stipulate guidance on appropriate time frames to administer analgesia and re-assess pain. Standards were developed with a multidisciplinary team to audit against.Data were collected over two weeks on paediatric wards excluding intensive care and day surgery.Pain score of ≥1 during admission, or clear documentation of pain prior to ward admission, and analgesia prescribed for the indication of pain relief. Pain assessment was audited based on recorded pain scores on observation charts. Analgesia prescribed and administered was audited from drug charts. Audit standards:(1) Following a pain score of ≥1 (out of 3), subsequent dosing and assessment of pain scores must be achieved in 80% of patients as follows:(a) Severe/worst pain (score 3): Should receive appropriate analgesia within 20 minutes of assessment and pain re-evaluated within 5-minute intervals for intravenous and intranasal route or within 30 minutes of receiving oral analgesia.(b) Mild/moderate pain (score 1-2): Should receive appropriate analgesia within 30 minutes of assessment and pain re-evaluated within 60 minutes of receiving analgesia.(2) 80% of patients prescribed regular analgesia should have their pain score assessed at least 4-hourly.(3) 90% of patients prescribed strong opioid analgesia should be co-prescribed naloxone prn for respiratory depression and pruritus/urinary retention.Twenty-five patients were audited. In total there were 59 severe pain scores and 92 mild/moderate. Observation charts allowed for documentation of pain scores at 15-minute intervals but only hourly recordings were observed throughout the audit period. 58% (34/59) and 30% (28/92) of pain scores indicating severe or mild/moderate pain respectively received analgesia in the same hour the pain score was recorded. In total there were 71 analgesia administrations for severe pain and 92 for mild/moderate pain. 52% (37/71) and 34% (31/92) of analgesia administrations after severe or mild/moderate pain scores respectively had a pain score re-assessed within 60 minutes.Eighteen patients were prescribed regular analgesia of whom 15 (83%) had pain assessed a minimum of every 4 hrs. Eleven patients were prescribed strong opioid analgesia, 45% of whom were not prescribed any naloxone, 27% had naloxone fully prescribed (pruritus and respiratory depression), and 27% had naloxone prescribed for respiratory depression alone.Despite lack of guidance around timing of pain assessment and administration of drugs, pain scores were being recorded regularly and acted upon, although not within a structured time frame. Observation charts allowed for assessment of pain scores at 15-minute intervals but only 'on the hour' documentation were observed. Specific guidance around timing of analgesia administration and assessment will be introduced to the revised guideline with medical and nurse training sessions to standardise practice and improve management of pain, in addition to safe prescribing of opiates.
- Therapeutic Potential of Adipose-Derived Stem Cells-Based Micro-Tissues in a Rat Model of Stress Urinary Incontinence. [JOURNAL ARTICLE]
- Urology 2016 Aug 15.
To examine the potential and mechanism of three-dimensional (3D) cultures of ADSCs in the treatment of SUI in a rat model simulating menopause combined with preceding childbirth injury.ADSCs were used to generate microtissues (MTs) with a hanging drop method. 48 postpartum Sprague-Dawley rats were developed SUI models by 4 hours vagina dilation (VD) followed by bilateral ovariectomy (OV). 10 rats underwent sham OV without VD served as control group. The SUI rats were divided into 3 groups and received urethral injection of PBS, ADSCs and MTs. Specimens were harvested for histology examination and ADSCs tracking at day 1, 3, 7, 28 (n=3) post-injection. At day 28, the remaining rats were examined for voiding function. Western blot, immunofluorescence and immunohistochemistry staining were performed to examine histological changes and cytokines expression.The voiding function and histopathological structures were better recovered in MTs group than those in ADSCs group. Compared with ADSCs, MTs express higher level of vascular endothelia growth factor (VEGF), TNFα stimulated gene/protein 6 (TSG-6) in vitro and represented a higher retention rate in vivo.Urethral injection of MTs better restored the voiding function than ADSCs.
- Current Challenges in the Evaluation and Management of Hyponatremia. [Journal Article, Review]
- Kidney Dis (Basel) 2016 Jun; 2(2):56-63.
Hyponatremia is a common electrolyte imbalance that clinicians face on a regular basis.This review aims to discuss four current challenges that can arise when diagnosing and treating hyponatremia: low solute intake, heart failure, exercise-associated hyponatremia, and mild chronic hyponatremia. Low solute intake in a person who already has a urinary concentrating defect will lead to increased retention of free water. The free water retention will cause or worsen hyponatremia that is already present. Low solute intake is overlooked in patients with other disease processes that can cause hyponatremia, such as liver disease or heart failure. Heart failure and hyponatremia present their own set of challenges specifically with treatment as there are limited options. The newer class of aquaretics allows for the short-term treatment of hyponatremia. Exercise-associated hyponatremia is a phenomenon that has been described in ultra-endurance athletes. This happens when a person drinks a significant amount of water while exercising in the setting of antidiuretic hormone production from prolonged exercise. This acute drop in sodium must be treated with hypertonic saline. The term asymptomatic mild chronic hyponatremia is no longer valid. Mild chronic hyponatremia carries an increased risk of falls and fractures, specifically in the elderly populations.In summary, hyponatremia is a multifaceted disease and presents many challenges for physicians treating it.