Co-Director, Virginia Tech Carilion School of Medicine and Research Institute
Stent placement before or after treatment of urolithiasis has been a subject of controversy antimicrobial overview order colcout 0.5mg overnight delivery. There was no difference in need for auxiliary treatments between the two groups in the meta-analysis antibiotic resistance hsc cheap 0.5mg colcout visa. Stenting has not conclusively demonstrated a beneficial effect on stone-free rates antibiotic injection for uti order colcout 0.5 mg line, and patients with a stent had more lower urinary tract symptoms (Ather et al, 2009; Shen et al, 2011a). Three meta-analyses over the following decade all confirmed that routine stenting has no beneficial effect on stone-free rate or ureteral stricture formation. The procedure takes longer and costs more, especially combined with the cost of subsequent cystoscopic stent extraction. Quality of life appears to be better in the non-stented group (Shen et al, 2011b; Tang et al, 2011; Song et al, 2012a). Even these commonly accepted indications for stent placement have been challenged in recent studies. Stented patients had more discomfort, and there was no beneficial effect on postoperative pain, stone-free rate, or short- or long-term complication rates (Baeskiolu et al, 2011). The authors suggest that indwelling time shorter than 14 days was associated with fewer adverse effects compared with having the stent in for 15 days or longer (Shigemura et al, 2012). Cetti and colleagues reported prestenting to be useful in 8% of patients in a tertiary referral center (Cetti et al, 2011). This passive dilative effect of an indwelling stent has also been demonstrated in the pediatric population (Hubert and Palmer, 2005; Corcoran et al, 2008). In addition, placement of a ureteral access sheath is easier in prestented patients (Kawahara et al, 2012b). This technique has also been successfully applied in ureteral anastomotic strictures in renal transplant patients (Miyaoka et al, 2011). Persistent urinary extravasation after blunt renal trauma can be treated by ureteral stent placement with high success rates (Matthews et al, 1997; Haas et al, 1998; Alsikafi et al, 2006; Long et al, 2013). Simultaneous bladder drainage is advised to maintain low intrarenal pressure and optimal drainage. Mokhmalji concluded nephrostomy tube placement to be superior compared with internal stents, based mainly on more discomfort and pain in the stented group (Mokhmalji et al, 2001). Although Joshi reported significantly more irritative symptoms in stented patients compared with those with nephrostomy tubes, a patient preference for either could not be demonstrated (Joshi et al, 2001). These patients are also more likely to be admitted to an intensive care unit (Goldsmith et al, 2013; Sammon et al, 2013). When considering the training and skill sets of most urologists, a "stent first where possible" policy has been suggested by Ramsey and associates (Ramsey et al, 2010). Stents are widely used in urologic reconstructive surgery for splinting the ureter. Stents have a dual role in this setting, the first being scaffolding the tissue to improve organized healing, and the second being to allow urine to flow unhindered past the operated field. Stents have shown usefulness in ureteral trauma treatment, ureteral realignment, pyeloplasty, ureteral reimplantation, ureteroureterostomy, and other reconstructive procedures. A particularly important and well-studied postoperative use of ureteral stents is after renal transplantation.
If such measures are not sufficient to control bleeding antibiotic expiration 0.5mg colcout sale, patients should be taken for endoscopic management under anesthesia antibiotic 93 3196 buy colcout 0.5 mg lowest price, with clot evacuation and electric or laser cauterization infection process order colcout mastercard. Although the variety of nonspecific intravesical therapies as are used in hemorrhagic cystitis. Although alternative forms of such endoscopic prostate tissue removal/destruction are available. The mechanism of hematuria in prostatitis is unclear and may be related to inflammation (Borth and Nickel, 2006). Management in this setting should consist of antibiotics when culturedocumented bacterial prostatitis is present. Significant recurrent hematuria in the setting of nonbacterial prostatitis is relatively uncommon, and it has been suggested that such cases should be treated with antibiotics in addition to standard supportive measures (Borth and Nickel, 2006). Meanwhile, hematuria from prostate cancer typically results in cases of significantly locally advanced tumors, often with bladder base/trigonal invasion. Indeed, hematuria has been noted to be the most common local symptom among patients with advanced symptomatic prostate cancers (Din et al, 2009). A careful history and physical examination may help elucidate whether the source of bleeding is truly from the urethra as opposed to other sites within the lower urinary tract. For example, blood at the urethral meatus in the absence of volitional micturition, initial hematuria, or blood at the start of urination frequently implies pathologic processes distal to the external urinary sphincter. Of note, in women, differentiating urethral bleeding from that of gynecologic origin based on history alone may be challenging and pelvic examination is typically necessary to clarify the site of origin (Sandhu et al, 2009). Importantly, retrograde urethrogram and cystourethroscopy remain the mainstays for diagnosis in patients with suspected urethral bleeding, because direct visualization permits identification of pathologic processes in the urethra and biopsy and fulguration allow for histologic characterization and cessation of bleeding. In men, trauma to the urethral epithelium represents the most common cause of urethral bleeding. For example, blunt trauma via straddle injury, kick to the perineum, or pelvic fracture often manifests with bleeding and concurrent urinary retention (Mundy and Andrich, 2011). Perineal or penile bruising, accompanied by a hematoma, often is a clear indication of injury related to trauma. Retrograde urethrography is essential in instances of trauma when a urethral injury is suspected (Avery and Scheinfeld, 2012). Meanwhile, a history of foreign body insertion in patients with hematuria may necessitate imaging to ensure no residual foreign elements remain that could perpetuate bleeding or result in subsequent calculus formation (Rahman et al, 2004). Particular mention should be made to the evaluation of bloody urethral discharge and/or hematuria occurring in patients with a penile fracture. In this setting, prompt evaluation via retrograde urethrography or cystoscopy should be undertaken to evaluate for a urethral injury and to identify the nature and location of the injury before surgical exploration (Avery and Scheinfeld, 2012). Urethritis refers to infection or inflammation of the epithelial lining of the urethra and has been reported secondary to bacterial or viral infection, chemical irritants. Urine microscopy and cultures, as well as urethral swabs for causative organisms, represent essential components of the evaluation. Urethral tumors are rare, although blood per meatus may be a manifesting sign in patients with urothelial carcinoma, specifically in men who have undergone a radical cystectomy with urethra still in situ (White and Malkowicz, 2010). At the same time, urethral caruncles are benign urethral lesions typically originating from the posterior lip of the urethra, most commonly found in postmenopausal women (Conces et al, 2012). These lesions are thought to arise from prolapse of distal urethra as a consequence of estrogen deficiency. In addition to the classic presentation Chapter9 EvaluationandManagementofHematuria 193 of dysuria, dyspareunia, and dribbling, women with a urethral diverticulum also may report intermittent episodes of bleeding, and urethral discharge may be noted on examination. Most often, hematuria from the upper tract manifests as total hematuria, or bleeding throughout the duration of the urinary stream (Mazhari and Kimmel, 2002), and may be characterized by wormlike clots passed per urethra.
A lysine analogue virus medication order colcout without a prescription, aminocaproic acid is a competitive inhibitor of activators of plasminogen antibiotic history buy cheap colcout 0.5 mg on line, including urokinase antibiotics for sinus infection how long proven 0.5mg colcout, and thus interrupts fibrinolysis and the cascade that perpetuates hemorrhage (Garber and Wein, 1989; Stefanini et al, 1990; Abt et al, 2013). Symptom resolution has been reported in up to 92% of patients (Singh and Laungani, 1992). The risk for thromboembolic events may be increased with this treatment, and, importantly, aminocaproic acid must be given only after the bladder has been rendered clot-free, because the agent will otherwise lead to the formation of hard clots difficult to eradicate from the bladder (Rastinehad et al, 2007). That is, for clinically stable patients, intravesical formalin, a solution of formaldehyde that induces cellular protein precipitation and capillary occlusion (Choong et al, 2000), may be used. Control of bleeding has been reported in 80% to 90% of cases with formalin (Choong et al, 2000), which are relatively higher rates than what has been noted with other intravesical treatments. However, because formalin instillation may induce significant pain, administration under general or spinal anesthesia is recommended. Moreover, intravesical formalin therapy is associated with significant complications, including bladder fibrosis with associated decreased bladder capacity and ureteral stricturing with proximal hydronephrosis/ renal injury (Choong et al, 2000; Abt et al, 2013). Thus pretreatment cystogram is recommended to exclude the presence of vesicoureteral reflux and/or bladder perforation (Donahue and Frank, 1989). Both estrogens and antiandrogens have, in small case reports, been associated with decreased prostate bleeding, presumably through the repression of androgen-stimulated angiogenesis and the induction of programmed cell death within the prostate (Marshall and Narayan, 1993; Rittmaster et al, 1996). Unfortunately, these tumors are typically invasive of the bladder and/or pelvic sidewall (T4) and the patients are often elderly and unwell. Initial conservative measures, including catheter drainage with or without continuous bladder irrigation, suffice for most cases of mild prostatic bleeding. For patients in whom hematuria is not acutely lifethreatening, palliative external beam radiotherapy with or without androgen deprivation therapy may be administered. Indeed, one series reported that hematuria from advanced prostate cancer responded to palliative radiation in 81% of patients at 6 weeks after treatment; however, durable symptom control was limited, such that the response rate 7 months after treatment in these patients was only 29% (Din et al, 2009). Among patients who are not candidates for local therapy, as well as among patients in whom disease has recurred after previous local therapy, androgen deprivation therapy may resolve the hematuria (Marshall and Narayan, 1993) by decreasing prostate vascularity (Kaya et al, 2005). In the situation of persistent hematuria with prostate cancer, and in particular in the setting of bladder outlet obstruction, cystoscopy under anesthesia with fulguration and/or limited, or channel, transurethral resection of prostatic tissue should be undertaken. Ultimately, if bleeding persists or escalates, consideration should be given to urinary diversion, which initially may be attempted with percutaneous nephrostomy tube insertion. Symptom improvement or resolution has been consistently noted in approximately 90% of patients (Puchner and Miller, 1995; Carlin et al, 1997; Miller and Puchner, 1998; Sieber et al, 1998; Kearney et al, 2002). The onset of action for finasteride is variable, with improvement in bleeding noted from as short as 2 weeks to up to 9 months after initiating therapy. In addition, a randomized trial of finasteride versus cyproterone acetate versus watchful waiting demonstrated a significant decrease in recurrent hematuria in both the finasteride and in the cyproterone acetate cohorts, with no noted difference in efficacy between finasteride and cyproterone acetate in patients treated with this agent (Perimenis et al, 2002). Herein, we highlight several particularly salient, albeit less frequent, causes of upper tract hematuria. LateralizingEssentialHematuriaandtheEvaluationof UpperUrinaryTractBleeding Lateralizing essential hematuria, also termed benign essential hematuria or chronic unilateral essential hematuria, is defined as macroscopic hematuria cystoscopically localized to one side of the urinary system (Nakada, 2003). The differential diagnosis for this entity is as noted earlier for upper tract bleeding (see Box 9-4), although in many such cases no identifiable cause can be determined. Cystoscopy at the time of bleeding may allow lateralization of the source of hematuria. Subsequently, in the absence of a clear cause for bleeding localized to the upper tract in a patient with lateralizing essential hematuria, direct endoscopic inspection with ureteropyeloscopy is recommended as a diagnostic and potentially therapeutic modality (Nakada, 2003). Critical components of diagnostic ureteropyeloscopy include the judicious use of guidewires (to avoid inadvertent urothelial injury), low-pressure irrigation, and systematic evaluation of all calices from a superior-to-inferior approach (Ankem and Nakada, 2006). Biopsy samples can be obtained for lesions suspicious for malignancy, and fulguration of such tumors or other noted sources of bleeding.
Padding must be checked each time the table position is changed antibiotics for uti caused by e coli cheap colcout 0.5 mg otc, and the patient should be rechecked if he or she is suspected of sliding on the table virus - f colcout 0.5 mg for sale. Similar to open surgery treatment for gardnerella uti order 0.5 mg colcout amex, during laparoscopic or robotic surgical procedures the urinary tract, spleen, or pancreas may be injured. See the Expert Consult website for a discussion of the incidence, presentation, management and prevention. Either way, the additional port allows the surgeon to repair the bleeding site using two hands and with excellent visualization of the surgical field. Alternatively, the surgeon can convert from standard laparoscopy to a hand-assisted approach. The hand, in this case, is valuable because it can rapidly tamponade the bleeding site. In this regard it is recommended, if at all possible, to pinch the sidewalls of the vein. Larger aortic or renal artery injuries are much more difficult to resolve laparoscopically. Although the latter, if it occurs during a planned nephrectomy, can be handled by expeditiously taking the renal artery with a vascular stapler, the former may lead to immediate conversion and open repair. As mentioned earlier, addition of an additional 5-mm port can be very useful to help establish a clear field and provide the surgeon with two hands to control the injury. If conversion to an open procedure is necessary, the area of injury should be tamponaded with laparoscopic forceps and the surgeon can proceed to rapidly make a midline or subcostal incision by swinging one of the ports up to the underside of the abdominal wall and cutting down on the shaft of the port. The tamponading laparoscopic forceps are important to directing the surgeon immediately to the site of injury, which can then be properly repaired. As mentioned previously in this chapter, because most bleeding episodes are unexpected, it is wise to have in the room a hemorrhage tray equipped with all instruments necessary to control bleeding and for potential open conversion (see Box 10-3). Nerve injury is invariably a result of patient positioning in combination with the duration of the procedure. A survey of neuromuscular injuries associated with laparoscopic urologic surgery completed by 18 urologists from 15 institutions in the United States, published in 2000, found that of a total of 1651 procedures there were 46 neuromuscular injuries in 45 patients (2. This included abdominal wall neuralgia (14), extremity sensory deficit (12), extremity motor deficit (8), clinical rhabdomyolysis (6), shoulder contusion (4), and back spasm (2) (Wolf et al, 2000). If the patient is inadequately positioned and/or padded, nerve damage may result from abnormal nerve stretching or compression. Among position-related nerve injuries, the brachial plexus appears to be most at risk. Injury may be inflicted in several ways: (1) abduction of the arm beyond 90 degrees, (2) extreme outward rotation of the head of the humerus, and (3) compression damage when shoulder braces are used in the Trendelenburg position (Phong and Koh, 2007), which pushes the clavicle into the retroclavicular space. In particular, this has been reported as a problem with robotic radical prostatectomy when a steep Trendelenburg position is required and strapping the patient might be necessary to avoid slippage. Other nerves that can be affected by positioning include the femoral nerve, because of extreme lateral rotation and abduction of the hip joint, specifically in the lithotomy position, and the sciatic nerve, because of stretching along the superior leg when the patient is in the lateral decubitus position (Hershlag et al, 1990; AbdelMeguid and Gomella, 1996; Liss et al, 2013). In addition, nerves may be injured during the surgery itself because of either direct mechanical injury or monopolar electrosurgical current. Nerve palsy caused by positioning is recognized only postoperatively, often on the first postoperative day when the patient tries to ambulate. Neurologic examination with possible nerve conduction studies to document acute damage is important. However, recovery in these cases, if it does not occur within the first few postoperative days, is often slow, requiring months.
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