Urological Involvement in the Multidisciplinary Management of Placenta Accreta Spectrum in a Centralised, High-Volume Centre: A Retrospective Analysis

Objectives Placenta accreta spectrum (PAS) significantly increases the complexity of childbirth and frequently involves urologic organs. Multidisciplinary team (MDT) care is paramount to ensure optimal outcomes. We aimed to evaluate urologic interventions in patients with PAS at a centralised, tertiary referral centre. Methods An analysis of a prospectively collected data set, consisting of all women presenting with PAS at our institution between November 2013 and June 2019. Patients who required urological intervention were identified, and perioperative details were retrieved. Results Forty-two cases of PAS were identified. The mean maternal age was 35 years, and mean gestational age at delivery was 34 weeks. Thirty-seven cases were managed electively, with 5 cases managed conservatively (no hysterectomy) and 5 requiring emergency management. Fifteen patients (36%) had suspected bladder invasion on MRI. A total of 36 patients (86%) had ureteric catheters inserted, 14 (33%) required bladder repair, and 2 had ureteric injuries (5%). Conclusions PAS frequently requires urological intervention to prevent and repair injury to the urinary bladder and ureter. PAS is a rare condition that is best managed in an MDT setting in a centralised, tertiary, high-volume centre with access to a variety of medical and surgical sub-specialities.

Special Issue ‘Minimally Invasive Urological Procedures and Related Technological Developments’

The landscape of minimally invasive urological intervention is changing[...]

Empowerment-Based Education in Urological Patients: A Scoping Review

Prostate, kidney, and bladder cancer are the three most frequently diagnosed urological cancers. Educational programs could teach patients to become experts in disease management. The aim of this scoping review was to explore the literature to identify the educational requirements and strategies for improving and implementing educational processes for urological patients undergoing surgery. We searched several databases, including PubMed, CINAHL, Embase, Scopus, PsycINFO, and Cochrane Library. All adult patients undergoing urological educational interventions were included in the review. Of 3,197 initially identified articles, 42 were retained. Urological patients undergoing prostatectomy, cystectomy, and nephrectomy require cognitive, psychological, and functional support. For each level of support, several methods exist to provide support, including informational brochures, preoperative counseling, telephone support, online content, educational videos, support groups, individual stress management interventions, peer support, online interventions, partner support, and various educational programs that help the patient manage negative effects associated with the urological intervention.

Frank haematuria secondary to ruptured pseudoaneurysm of the inferior vesical artery: a case report and review of the literature

Background Pseudoaneurysm of a vesical artery is an extremely rare iatrogenic complication; however, it may cause fatal haematuria. Case presentation A 21-year-old Arab Jordanian male had multiple optical urethrotomies for an iatrogenic urethral stricture after he had rectal surgery for Hirschsprung’s disease at the age of 2 years. During one of his admissions to the Emergency Room (ER) with urinary retention, an attempt at suprapubic catheter insertion was complicated by massive bleeding at the insertion site of the catheter. Abdominal exploration showed a distended urinary bladder with clots and bleeding seen at the bladder neck that was controlled with multiple sutures. The patient rebled again two times; the first was controlled with cystoscopy and cautery for a pulsatile bleeder seen at the bladder neck. The second time, the patient required blood transfusion of three units of packed red blood cells. Angiography was performed, and a pseudoaneurysm at the base of the urinary bladder from the inferior vesical artery was diagnosed, which was controlled by embolization. Conclusion Pulsatile bladder haemorrhage following urological intervention is suggestive of pseudoaneurysm or arteriovesical fistula, and angiography with embolization is recommended.

Does Endourological Intervention a Suitable Treatment Options in Management of Iatrogenic Thermal Ureteral Injury?

Introduction This study aimed to evaluate the etiological factors and their effects on long-term clinical outcomes in patients with iatrogenic ureteral injury (IUI). Material and Method Twenty-seven patients who underwent surgery because of IUI were evaluated between January 2011 and April 2018. Patients were classified according to the time of diagnosis and the need for reoperation after the urologic intervention. The IUI cases detected during gynecological surgery were called ‘perioperative’ IUI, and those diagnosed late as ‘postoperative’ (delayed) IUI. The IUI type was categorized as ‘cold transection’ due to surgical dissection or ligation and ‘thermal injury’ if it depended on any energy-based surgical device. Results Postoperative diagnosed cases consisted of exclusively after laparoscopic surgery (p=.025). Patients with thermal injury to the ureter were mostly diagnosed postoperatively (p= .021). Patients who underwent endourological intervention, 31.25% (N = 5/16) were diagnosed during gynecologic surgery, and 68.75% (n = 11/16) were diagnosed postoperatively. For open reconstructive surgery, these rates were observed to be 72.72% (n = 8/11) and 27.28% (n = 3/11), respectively (p=.034). IUI was due to thermal injury in all patients who developed complications after the urological intervention (p = .046), and the first urological intervention was endoscopic double loop stenting (p = .005). One of these patients was diagnosed in the perioperative period and seven in the postoperatively (p = .016). Conclusion Treatment success rates are low in patients who underwent endourological intervention after thermal IUI. Therefore, surgical techniques in which the traumatic ureter segment is excised should be preferred to avoid complications. Key Words Ureter, Iatrogenic, Thermal Injury, Iatrogenic Ureteral Injury, Endourological Intervention.

A Rare Presentation of Renal Papillary Necrosis in a COVID-19-Positive Patient

In this case report we describe an unusual presentation of severe acute papillary necrosis in a COVID-19-positive patient. An emergency flexible ureteroscopy greatly helped in the establishment of the diagnosis. In the international literature, there is a paucity of intraoperative endoscopic images representing severe renal papillary necrosis. We present a case of severe acute renal papillary necrosis in a 49-year-old south-Asian, COVID-19-positive male patient who needed emergency urological intervention for macroscopic hematuria and urinary retention due to clot formation in the urinary bladder. The patient underwent emergency cystoscopy, clot evacuation, and by rigid and flexible ureteroscopy. The diagnosis was only confirmed in the postoperative period, retrospectively. Finally, the patient fully recovered due to the multidisciplinary management. Diagnosis of rare clinical entities can be sometimes challenging in the everyday routine practice. Having atypical clinical course, the surgeon should be prepared and sometimes must take responsible decisions promptly, even if needed intraoperatively, to manage unexpected findings in order to get the right diagnosis without compromising the patient’s safety.

Does Computed Tomography of Kidney, Ureter and Bladder (CTKUB) Affect The Management of Patients with Suspected Renal Colic in Emergency Department?

Introduction CTKUB use in patients presenting to Emergency Department (ED) with suspected renal colic has increased by 10-fold over last few years. However, its impact on the urological intervention is not fully known.Methods We performed a retrospective study of adult patients, presenting consecutively to ED with suspected renal colic who underwent CTKUB from January to June 2014. We calculated descriptive summary statistics for analysis to determine the association of predefined radiological and patients’ characteristics on the urological intervention.Results Of the 282 patients enrolled in the study, 38% had stones. Commonest locations of stone were ureter (15%), uretero-vesical junction (12.4%). Of the study participants, 2% of the patients underwent urological intervention. Chi Square analysis did not find any significant associations between radiological or patients related characteristics and urological interventionConclusion There was no significant correlation between CTKUB findings or patients’ characteristics and urological intervention in this study cohort.

Urological outcomes in nonagenarians with prostate cancer

Introduction: Nonagenarians represent a growing patient population. Herein, we report on the largest cohort of Canadian nonagenarian patients, to our knowledge, with prostate cancer. Methods: A retrospective chart of 44 nonagenarian men diagnosed with localized or metastatic prostate cancer between 2006 and 2019 was performed. Diagnoses were based on pathological specimens or the presence of a high prostate-specific antigen (PSA >20) or abnormal digital rectal exam (DRE) in the setting of metastatic disease on imaging. Patient demographics, presenting complaints, and treatments required were included in the analysis. A descriptive statistical analysis was performed. Results: The median patient age at time of referral was 91.1 years (interquartile range [IQR] 90.2–92.9). The median PSA at time of referral was 54.0 (IQR 18.2–142.6). Metastatic disease was present in 55% of patients at time of diagnosis (n=24). Most patients required at least one urological intervention (n=35). There were 56.8% of patients who received androgen deprivation therapy (ADT) as part of their treatment regime (n=25). Half (50%) of patients were managed with androgen receptor axis-targeted agents (ARAT), as well as ADT (n=22). Five patients (11.4%) underwent surgical castration. Death due to any cause was noted in 52.3% of patients (n=23) throughout the study period, with the median age at death being 94.4 years (IQR 92.3–97.0). Death due to prostate cancer was noted in 18.2% of patients (n=8). Conclusions: This study highlights common presenting complaints for nonagenarian patients with prostate cancer and that many require urological intervention despite advanced age. Future studies should address patient-reported quality of life outcomes in the nonagenarian population with prostate cancer.

Risk Factors Predicting the Necessity of Renal Ultrasound in the Emergency Department

Objectives: Renal ultrasound (US) is widely used for diagnosing renal pathologies, though few of them, such as obstructive uropathy, require emergent urological intervention. During on-call hours, when medical staff is limited, it is important to prioritize which renal US examinations will be done. The aim of this study was to evaluate patient risk factors to predict the necessity of emergent renal US in the emergency department (ED). Material and Methods: All adult patients referred for renal US from the ED, during on-call hours from May 2015 to April 2017, were retrospectively included. The mean age was 64 years (18–98). Data were collected from the patients’ medical records. Urological intervention performed within the first 24 h following the US examination was recorded. Multivariate analysis was performed. Results: About 66% of the patients did not have a permanent urethral catheter, history of renal stones, or known abdominal or pelvic mass. None of these patients required an urgent urological intervention. The receiver operating characteristic curve was calculated at 0.883, 95% CI (0.84–0.92). Conclusion: Using only three variables, we can greatly reduce the number of renal US examinations done at on-call hours allowing for prioritization of only the necessary examinations.