Prophylactic ureteral catheterization in gynecologic surgery

Objectives. To examine the frequency of ureteral catheter usage, its efficacy in preventing injury, and related complications, because the preoperative routine placement of ureteral catheters as a prophylactic measure to prevent ureteral injury is controversial.Methods. All major gynecologic operations performed between January 1992 and December 1994 were identified. All gynecologic procedures that were preceded by ureteral catheter placement were also identified. A data base maintained by the Department of Quality Management allowed identification of all urinary tract complications and ureteral injuries. Four categories of surgery were analyzed: exploratory laparotomy with catheters, exploratory laparotomy without catheters, operative laparoscopy with catheters, and operative laparoscopy without catheters. The medical records of all patients with urinary tract complications were reviewed.Results. Bilateral prophylactic ureteral catheterization was performed in 469 (15.3%) of 3071 patients. A ureteral injury occurred in 4 (0.13%) of 3071 patients. All four ureteral injuries (0.17%) occurred among 2338 patients who underwent exploratory laparotomy. None of the 733 patients who underwent operative laparoscopy suffered ureteral injury. The incidence of ureteral injury in patients who had ureteral catheters placed before exploratory laparotomy was 2 (0.62%) of 322. Two (0.10%) of 2016 patients who did not have prophylactic ureteral catheters suffered a ureteral injury. There was no statistically significant difference in the incidence of ureteral injury between patients who did and patients who did not undergo ureteral catheterization (P = 0.094).Conclusions. The use of prophylactic ureteral catheters did not affect the rate of ureteral injury in our patients. The very low incidence of ureteral injury among our patients is attributed mainly to meticulous surgical technique.     

Ureteral obstruction during pregnancy

We report on a woman with recurrent renal failure due to bilateral ureteral obstruction during the mid trimester of pregnancy. The first pregnancy was terminated due to obstructive renal failure. In the second pregnancy renal function again deteriorated due to bilateral ureteral obstruction. After successful placement of a right ureteral catheter and a left percutaneous nephrostomy, renal function normalized and the gestation was continued through 37 weeks. Recurrent ureteral obstruction during pregnancy was attributed to changes following bilateral ureteral reimplantation. Patients with a history of urologic surgery warrant surveillance for renal failure secondary to mechanical obstruction. Those with a history of proved obstruction during pregnancy might benefit from the prophylactic placement of ureteral catheters and chronic antimicrobial therapy during subsequent gestations.     

Obstructive anuria secondary to uterine prolapse

The prevalence of obstructive uropathy linked to uterine prolapse ranges between 4% and 80%, depending on the series, probably due to the varying degree of severity of the prolapses under consideration. Renal failure or anuria is an unusual complication. Several etiopathogenic theories regarding obstructive uropathy secondary to prolapse have been put forward: ureteral compression by the uterine vessels, severe urethral angulation, ureteral compression against levator ani muscles and the elongation and narrowing of the distal ureter. The major radiological exploration used in studying the urinary tract of these patients is intravenous urography in bipedestation. Emergency treatment for obstructive anuria resulting from a uterine prolapse consists of manually replacement of the prolapse. Surgery is considered to be the definitive ideal treatment, although in the case of surgical or anaesthetic high risk patients, inserting a permanent pessary may constitute a satisfactory solution. We present a case of obstructive anuria resulting from uterine prolapse, which was successfully treated with the insertion of a ring pessary.     

Subclavian aneurysm causing brachial plexus injury after removal of a subclavian catheter

The use of central venous catheters is associated with many different complications, some of which can be life threatening. Most complications associated with the use of central venous catheters are either immediate and occur around the time of catheter insertion, or are delayed and are related to the duration of catheter use. Complications occurring after removal of central venous catheters are reported infrequently but are still a cause of significant morbidity. The following case report illustrates a serious complication which occurred after a large gauge central venous catheter was removed from a patient and demonstrates the importance of close observation not only at the time of catheter placement but also when such devices are removed.      

The implications of lighted ureteral stenting in laparoscopic colectomy.

OBJECTIVE: The placement of indwelling ureteral catheters during colorectal surgery has been recommended for prevention of ureteral injuries. With the advent of laparoscopic colectomy (LCo), the role of preoperative placement of lighted ureteral stents (LUS) has also become commonplace. We sought to evaluate the value of lighted ureteral stent placement in laparoscopic colectomy. METHODS: Sixty-six patients underwent LCo with LUS inserted preoperatively. Stents were removed in the immediate postoperative period. Two surgeons performed all the colectomies; 32 patients were males and 34 were females. Fifty patients underwent sigmoid colectomy, 4 had abdominoperineal resection, 4 had right colectomy, and 1 each had transverse or subtotal colectomy. Eighteen patients had a diagnosis of cancer, 34 had diverticular disease, and 14 had neoplastic polyps. Forty patients had bilateral and 26 had unilateral stent placement. A review of the incidence of ureteral injuries, hematuria, and anuria as the cause of acute renal failure was accomplished, comparing the unilateral and bilateral stented groups. RESULTS: One (1.5%) patient suffered a left ureteral laceration during sigmoid colectomy. This was managed successfully with stent reinsertion. Sixty-five (98.4%) patients had gross hematuria lasting 2.93 days (1 to 6 days). The cost of bilateral stent placement was $1,504.32. A statistically significant difference occurred in the duration of hematuria (days) between patients who had unilateral (2.5 +/- 0.82) and bilateral stent placement (3.37 +/- 1.05), (P < 0.001). Four patients suffered from anuria, 2 required renal support needing hemodialysis for 3 to 6 days, 3 (75%) had bilateral stents, and 1 (25%) had a unilateral stent. CONCLUSIONS: We recommend the placement of lighted ureteral stents as a valuable adjunct to laparoscopic colectomy to safeguard ureteral integrity. Transient hematuria is common but requires no intervention. Reflux anuria occurs infrequently and is reversible.     

Infectious peritonitis complicating suprapubic catheter removal

Peritonitis following suprapubic catheter placement may result from inadvertent placement of the drain through the large and small bowel and bladder base. The author describes a case of infectious peritonitis which developed after suprapubic catheter removal. The patient, underwent suprapubic catheter placement after Burch Colposuspension for genuine stress incontinence. The catheter was removed with a full bladder after an uneventful postoperative course, but the patient subsequently developed acute infectious peritonitis due to extravasated urine from the cystostomy site. It was concluded that suprapubic catheters should be removed after the bladder is emptied, to prevent this complication. This may be most important in patients who void without residual prior to epithelialization of the cystostomy site.Editorial Comment: This paper illustrates another complication of suprapubic catheter use. In this case peritonitis developed secondary to infected urine entering the peritoneal cavity after removal of the catheter when the bladder was full. The peritoneum had not been closed at the time of the original Burch procedure. The authors make the point of planning removal when the bladder is empty. Another consideration would be to close the peritoneum when a suprapubic catheter is used.     

Stenturia: An unusual manifestation of spontaneous ureteral stent fragmentation.

Two patients presented with passage of worm-like stent fragments in the urine. The first had undergone attempted percutaneous removal of left renal calculus and ureteral stenting 4 months prior to presentation. The second had left-sided stent placement for obstructive anuria on account of bilateral renal calculi 3 months earlier. The stents had fragmented into multiple pieces over a mean indwelling time of only 3.5 months. Apart from calculus disease, both patients had documented urinary tract infection. Stent fragmentation is a relatively rare (0.3%) but major complication. However, spontaneous excretion of these fragments has not been hitherto reported. These cases of rapid stent disintegration highlight the need for closer monitoring of the indwelling stents, especially in patients with calculus disease and associated persistent infection. In such patients the stent should probably be changed within 3 months.     

Right ureteral injury after radiofrequency ablation for atrial fibrillation

Percutaneous radiofrequency ablation is a common procedure to treat atrial fibrillation. We describe a patient without a urologic history who had immediate abdominal pain after this treatment. Computed tomography scan and cystoscopy/retrograde pyelography confirmed a right proximal ureteral injury with urinary extravasation. The patient was treated with right ureteral stent placement and urethral catheter drainage. This case appears to be the first report of percutaneous radiofrequency ablation complicated by spontaneous ureteral injury related to blunt injury during manipulation of the transseptal sheaths or intracardiac catheters.     

急性上尿路梗阻性无尿应注意的临床问题

目的 提高对急性上尿路梗阻性无尿的认识,妥善处理相应的临床问题。方法 对55例急性上尿路梗阻性无尿患者的临床问题进行总结、分析。无尿、腰痛、水肿及血肌酐、尿素氮进行性增高是主要诊断依据;B超和腹部平片(KUB)是首选检查方法;治疗原则是尽快解除梗阻,有效防治感染,最大限度地保护肾功能。结果 肾功能恢复正常者43例(78．2％);治疗后3个月仍有氮质血症者10例(18．2％);患者放弃治疗者2例。结论 重视无尿症的肿瘤病因。治疗首选经膀胱镜输尿管插管,慎用利尿剂。     

Prophylactic placement of external iliac artery balloon catheter in a patient with intrapelvic prosthesis migration after hemiarthroplasty: A case report

Intrapelvic prosthesis migration is a rare but serious complication of bipolar hemiarthroplasty in femoral neck fractures. The external iliac artery is one of the most frequently damaged arteries during the removal of a migrated implant from the pelvic region. This report describes a case in which prophylactic placement of an external iliac artery balloon catheter was performed to reduce blood loss in the event of vascular injury during implant removal surgery in the pelvic region.     

Azygos arch cannulation by central venous catheters for hemodialysis

Cannulation of central veins and placement of catheters for temporary haemodialysis is a common procedure in the management of patients with end stage renal failure. The internal jugular vein is the site of choice for central venous catheter placement, being associated with the lowest complication rate. This procedure can be associated with a variety of malpositions of the catheter and rarely, can lead to significant morbidity and even mortality, if this is not recognised and corrected early. For anatomical reasons, the risk of azygos arch cannulation is substantially increased if catheters are inserted via left-sided veins. We report a case with a rare complication associated with the insertion of a catheter for temporary haemodialysis.     

Complications of peripheral nerve catheter removal at home: case series of five ambulatory interscalene blocks

Purpose

The placement of continuous peripheral nerve catheters on an ambulatory basis is increasing and is routine at our institution. There are few reports of complications associated with peripheral nerve catheter removal in the literature. Described herein is a case series of five patients where complications related to catheter withdrawal were observed.

Clinical features

A stimulating catheter with a stainless steel coil surrounded by polyurethane (19-G, 60-cm) exhibited shearing when removal proved difficult in five patients. In four cases, catheter removal by the patients was not possible, requiring them to return to hospital for management. No long-term sequelae were observed in any patient.

Conclusions

There can be various causes for difficulty with catheter removal, such as a technical aspect of catheter placement, catheter design, tissue reaction at the catheter site, or a combination thereof. The majority of complications related to outpatient perineural catheters can be handled over the telephone, but our case series may highlight a potential management dilemma in placing continuous stimulating perineural catheters on an ambulatory basis.     

Perforation der V. cava superior bei unerkannter Stenose Fallbericht einer letalen Komplikation einer zentralvenösen Katheterisierung

We report on a case of fatal perforation of the superior vena cava. The perforation occurred after catheterization of the left internal jugular vein with a hemodialysis catheter, due to an unrecognised stenosis of the superior vena cava. Vascular trauma induced by a previous, also left-sided, subclavian vein-hemodialysis catheter (in place for 14 days), seemed to be the most likely pathomechanism of the stenotic lesion. It should be emphasised that this is a frequent complication especially of left-sided dialysis catheters. In the case described a stenosis was complicated by a misdirected second hemodialysis catheter. Although being repositioned under fluoroscopic control via a guide wire, an extravasal placement occurred but was unrecognised. In order to rule out catheter misplacement, the position of every central venous catheter has to be controlled. Standard methods are either chest X-ray or right atrial electrocardiography. Additionally, confirmation of correct intravenous placement requires a combination of free venous backflow of all lumen and/or blood gas analysis or venous pressure monitoring. Only a combination of tests gives ample certainty as each test for itself has its pitfalls. After placement of hemodialysis catheters, in particular left-sided catheters, we demand chest X-ray in order to verify that the catheter runs parallel with the long axis of the superior vena cava. In doubtful cases the threshold for contrast-enhanced angiographic control of the catheter should be low. If a perforation by the catheter is suspected it should be ruled out by computed tomographic scanning or transesophageal echocardiography.     

Detection of intravascular epidural catheter placement: a review

Intravascular placement of an epidural catheter is recognised as a potentially fatal complication of epidural anaesthesia and analgesia. Up to 10% of epidural catheters may be inserted into an epidural vessel, the majority of which will be recognised; however, a proportion (1% of all epidural catheters inserted) may not be identified as lying intravascularly. Opinions differ on the optimal method for identifying intravascular catheters and no perfect method exists. Some debate the need for a test of correct location, as a lack of specificity may mean that a proportion of correctly located catheters are withdrawn and resited. This review outlines the incidence and risk factors associated with intravascular placement and aims to evaluate the detection methods that have been described, in an attempt to answer the question: "What is the optimal way of detecting intravascular placement of an epidural catheter?"     

Indwelling interscalene catheter use in an outpatient setting for shoulder surgery: technique, efficacy, and complications

Indwelling interscalene catheters are utilized for inpatient postoperative pain control after shoulder surgery. Improved medical equipment and advanced techniques may allow safe and efficacious outpatient use. One hundred and forty-four consecutive indwelling interscalene catheter placements were reviewed to determine adverse events, complications, and efficacy. Real-time ultrasound-guided catheter placement technique is described. Post-anesthesia care unit (PACU) narcotic consumption and last recorded pain score were reviewed to gauge efficacy. The catheter placement technique was 98% successful. There were 14 (9.7%) minor adverse events including inadequate analgesia (8), accidental catheter removal (4) of disconnection (1), and shortness of breath (1). The single complication (0.7%) was a small apical pneumothorax. The average PACU narcotic consumption in intravenous morphine equivalents was 1.7 mg. The average last recorded PACU pain score on a scale of 1 to 10 was 0.6. Catheter placement under real-time ultrasound guidance is accurate. Outpatient use of indwelling interscalene catheters is safe and efficacious.     

Obstructive acute renal failure by a gravid uterus: a case report and review

Acute renal failure caused from an obstruction by the gravid uterus is a rare complication of pregnancy. Only 13 cases have been reported. We report a case of obstructive acute renal failure in a patient at 34 weeks' gestation with a twin pregnancy complicated by polyhydramnios. The serum creatinine peaked at 1,078 mumol/L (12.2 mg/dL), higher than in the previously reported patients. The striking feature of her clinical course was the immediate resolution of anuria following amniotomy, thus avoiding the need for dialysis, ureteral stenting, or immediate surgical delivery. This patient illustrates the potential importance of increased uterine pressure on the ureters as a cause of significant obstructive renal failure during pregnancy.     

Risk of bacteremia from temporary hemodialysis catheters by site of insertion and duration of use: a prospective study

BACKGROUND: Uncuffed, nontunneled hemodialysis catheters remain the preferred means to gain immediate access to the circulation for hemodialysis. Bacteremia is the primary complication that limits their use. The risk of bacteremia by site of insertion and duration of use has not been well studied. METHODS: Two hundred eighteen consecutive patients who required a temporary hemodialysis catheter were prospectively followed. RESULTS: Catheters were placed at 318 new insertion sites and remained in use for a total of 6235 days. The incidence of bacteremia was 5.4% after three weeks of placement in internal jugular vein and 10.7% after one week in femoral vein [relative risk for bacteremia 3.1 (95% CI, 1.8 to 5.2)]. The incidence of bacteremia was 1.9% one day after the onset of an exit site infection but increased to 13.4% by the second day if the catheter was not removed. Guidewire exchange for malfunction and patient factors did not significantly affect the risk of bacteremia. CONCLUSIONS: Internal jugular catheters may be left in place for up to three weeks without a high risk of bacteremia, but femoral catheters in bed-bound patients should be removed after one week. Catheter exchanges over a guidewire for catheter malfunction do not increase bacteremia rates. Temporary catheters should be removed immediately if an exit site infection occurs.     

Noncardiogenic pulmonary edema and acute kidney failure after withdrawal of a central venous catheter

A 17-year-old male suffered severe noncardiogenic pulmonary edema with arterial hypotension and acute renal insufficiency after withdrawal of a central venous catheter from the subclavian vein. The patient was in semirecumbent supine position with the head of the bed at a 40 degree angle. Resuscitation maneuvers, orotracheal intubation, and hemodynamic support were required. After 4 days in intensive care the patient had fully recovered. Fibrin tracts form around catheters and can create a way for air to enter a vein after catheter removal. The causes of pulmonary edema secondary to venous air embolism have been well studied: it seems that edema develops as a consequence of the sudden appearance of small air bubbles in pulmonary circulation, leading to an acute inflammatory response in pulmonary microvasculature. Experimental studies have shown that edema is associated with increased pulmonary vascular resistance that leads to pulmonary hypertension. Venous air embolism as a complication of central venous catheterization is too seldom detected and little stress is placed on this possibility in the care and removal of catheters.     

Value of double "J" ureteral stents in cancerology

Self-retaining silicone ureteral stents are used for prolonged urinary drainage in situ. Thanks to the exceptional patient tolerance, they appear to be the best indwelling catheters for the treatment of ureteral obstruction due to cancer. Eighteen catheters were placed in sixteen patients. Endoscopic insertion was carried out in 8 patients (9 catheters were inserted; one patient requiring bilateral catheterisation). An operative procedure was necessary in the remaining 8 cases: in 4 cases a simple ureteral dissection was necessary, whereas ureterostomy had to be carried out in the 5 remaining cases. During the treatment, the patient tolerance was excellent. Mean survival time, after catheterisation was 5,5 months and one patient had a functional catheter for 15 months. Obstruction of the catheter was observed in 3 cases but ureterostomy was avoided in 7 cases and 8 kidneys were protected in 6 cases. The palliative use of the double J catheter when no other treatment is possible for malignant ureteral obstruction precludes the need for ureterostomy. These catheters can be used for strategic curative treatment if nephrotoxic drugs are required to treat obstructive tumors of the ureters. Bladder disease is a contra-indication to the use of these catheters although their insertion is rarely impossible. In cases of acute obstruction, it is better to prepare the pathway with a traditional catheter, which is easier to manage, it is always possible to insert a double J catheter after some time has elapsed.     

Ureteral involvement in the Churg-Strauss syndrome: a case report

We report a case of the Churg-Strauss syndrome with bilateral ureteral stenosis, secondary obstructive uropathy and anuria. The literature regarding urological implications of this disease is reviewed, and the surgical and medical management of our case is detailed.