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Letter from the Editor - October 2013

Dear Colleagues, 

We at UroToday International Journal hope all our current readers and authors have enjoyed a warm and nice early fall as we are fast approaching the Holiday season. In this issue of UIJ we are proud to announce the first ever article with videos included! The videos can be found on the homepage of UroToday,® the leading digital only, global urology website, where the first urology content dedicated Urology TUBE™ was recently launched. Urology TUBE™ is a rich media content distribution channel that offers a simplified interface providing easier access to video content channels.

The article by Nickles et al. present a technique for transvaginal removal of vesicular mesh erosion and the two accompanying videos demonstrate this technique in a step-by-step fashion in the Urology TUBE™ on urotoday.com

A review by Dr. Campeau shows thatsystemically administered cannabinoids may be able to become clinically useful for the control of lower urinary tract function. This review is a step towards understanding the potential in the development of novel cannabinoid drugs for the treatment of micturition disorders such as overactive bladder syndrome.

Newman and Strauss provide a synopsis of current practices and multimodal prevention strategies for catheter-associated urinary tract infections. These urinary catheter-related infections are associated with morbid events, such as delirium, and with longer lengths of stay and higher costs of medical care.

A retrospective review was completed by Dickstein et al. toevaluate the utility of computed tomography (CT) scanning in identifying patients with locally advanced bladder cancer.

An evaluation of the efficacy of alpha-adrenergic blockers with or without Deflazacort in the expulsion of a lower ureteric calculus ≤ 10 mm was performed by Phukan et al.

The ability to render patients tube and stent free after percutaneous nephrolithotomy (PNL) was studied by Al-Ba’adani et al. and they found that tubeless, stentless PNL decreases hospital stay, postoperative pain, and the need for analgesia, and subsequently lowered work abstinence.

Finally, Valentini et al. compared the geometric effect of the urethral catheter in regards to the effect of other mechanical parameters likely to influence the voiding phase during a urodynamic study. The geometric obstruction due to the catheter was almost negligible for non-obstructed individuals compared with the volume effect up to a 6 Fr catheter size.

We also present a series of case studies that include various topics, including the above mentioned study about Excision of Mesh Erosion, Crossed Renal Ectopia, Bladder Diverticulum, Colovesical Fistulae, Spontaneous Dissolution of a Double-J Ureteric Stent, Posterior Urethral Valve with a Bladder Stone, and Priapism as Unusual Sequalae of Malignant Melanoma.

We encourage our current readers and authors to continue to spread the word about UIJ, reminding potential submitters that submission, peer review, and publication are all free. I personally thank the authors and reviewers for their valuable contributions to this issue.

Warm Regards, 

Karl-Erik Andersson

 

Posterior Urethral Valve with a Bladder Stone: A Case Report

ABSTRACT

A posterior urethral (PU) valve and a bladder stone both may cause obstructive voiding symptoms. There are very few patients of a PU valve associated with bladder stones. We are presenting this case because of the rarity of its occurrence and for its unique way of management. 

Khalid Mahmood, Atul Kumar Khandelwal, Ahsan Ahmad, Mahendra Singh, Rajesh Tiwari, Vijoy Kumar

Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India

Submitted September 12, 2013 - Accepted for Publication October 24, 2013

KEYWORDS: Posterior urethral valve, bladder, stone

CORRESPONDENCE: Atul Kumar Khandelwal, MBBS, MS, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India ()

CITATION: UroToday Int J. 2013 October;6(5):art 66. http://dx.doi.org/10.3834/uij.1944-5784.2013.10.13

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Preventing Catheter-Associated Urinary Tract Infections

 ABSTRACT

Catheter-associated urinary tract infections, a worldwide, leading hospital-acquired infection, have substantial impact on patient safety and antibiotic consumption. These urinary catheter-related infections are associated with morbid events, such as delirium, and with longer lengths of stay and higher costs of medical care. It has been estimated that 65 to 70% of CAUTIs may be preventable with recommended evidence-based practices. For this reason, the Centers for Medicare & Medicaid Services no longer reimburses acute care and rehabilitation hospitals for the cost associated with treating these infections, and has a national goal to reduce these infections by 25% in 2014. An expanding body of literature has demonstrated methods for ensuring the practices and processes for decreasing these infections. This article will provide a synopsis of current practices and multimodal prevention strategies for catheter-associated urinary tract infections.

Diane K. Newman,1 Robyn Strauss2

1Division of Urology, Penn Medicine, University of Pennsylvania; 2Department of Nursing, Hospital of the University of Pennsylvania

Philadelphia, Pennsylvania

Submitted September 26, 2013 - Accepted for Publication October 20, 2013


KEYWORDS: catheter associated urinary tract infections, indwelling urinary catheter, prevention, evidence-based guidelines, bladder bundle

CORRESPONDENCE: Diane K. Newman, Adjunct Associate Professor of Urology in Surgery, Research Investigator Senior, Perelman School of Medicine, University of Pennsylvania; Co-Director, Penn Center for Continence and Pelvic Health, Division of Urology, Penn Medicine, 34th and Civic Center Boulevard, Philadelphia, PA 19104 ()

CITATION: UroToday Int J. 2013 October;6(5):art 64. http://dx.doi.org/10.3834/uij.1944-5784.2013.10.11


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Cannabinoid System Contribution to Control Micturition

ABSTRACT

Cannabinoid compounds, such as those that can be extracted from the Cannabis sativa plant (marijuana), produce a very wide array of central and peripheral effects, some of which may be of importance for the control of lower urinary tract function. Thus, stimulation of cannabinoid receptors, located both in the central nervous system and in different components of the lower urinary tract, has been shown to affect both normal micturition and various disturbances of bladder function. It is clear that systemically administered cannabinoids may be able to become clinically useful; however, a much greater understanding of the mechanisms of cannabinoid receptors in the control of the human lower urinary tract is necessary to facilitate development of novel cannabinoid drugs for the treatment of micturition disorders such as overactive bladder syndrome.


Lysanne Campeau

Division of Urology, McGill University, Montreal, Quebec, Canada

Submitted September 1, 2013 - Accepted for Publication September 23, 2013


KEYWORDS: Cannabinoid, cannabinoid receptor, endocannabinoid, knockout mice, cystometry, bladder, urodynamics

CORRESPONDENCE: Lysanne Campeau, CM, MD, PhD, FRCSC, Assistant Professor, Division of Urology, Department of Surgery, Jewish General Hospital and Lady Davis Institute for Medical Research, McGill University, Montreal, Quebec, Canada

CITATION: UroToday Int J. 2013 October;6(5):art 59. http://dx.doi.org/10.3834/uij.1944-5784.2013.10.06

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Transvaginal Excision of Intravesical Mesh Erosion

ABSTRACT

Introduction and Objectives: Transvaginal mesh has been used in the management of a multitude of female urologic conditions; most commonly vaginal prolapse and stress urinary incontinence. However, in the event of a complication related to the use of such mesh, there is scant literature on its safe and efficacious removal. We present a technique for transvaginal removal of vesicular mesh erosion.

 

 

Excision of Intravesical Mesh Erosion

 

 

Transvaginal Removal of Intraurethral Mesh

Methods: The patient is placed in lithotomy position and cystoscopy is performed. Once bilateral ureteral catheters are in place, a Foley catheter is placed. Using a midline transvaginal approach, hydrodissection is performed. Allis clamps are used to grasp the vaginal epithelium, and vaginal flaps are developed. The sling is identified and the midline it is transected. A combination of sharp and blunt dissection is used to free the sling. The sling is dissected to the most lateral extent possible. Once the intravesical mesh is encountered, the entirety of the offending mesh is excised. Once the mesh has been removed, attention is then turned to the resultant cystotomy. The bladder is then closed in multiple layers. A urethral catheter is left indwelling postoperatively.

Results: The patient is discharged when ambulatory and tolerating a regular diet. A voiding cystourethrogram (VCUG) is obtained in 1 to 2 weeks and if urinary extravasation is not seen, the urethral catheter is removed.

Conclusion: Despite the use of mesh slings for stress urinary incontinence and pelvic organ prolapse, literature describing operative techniques to remove slings in the setting of urinary tract erosion is lacking. The described technique avoids significant manipulation of the urinary tract and further disruption of the periurethral and perivesical fascia while ensuring a watertight closure.


S. Walker Nickles, Lara MacLachlan, Eric Rovner

Medical University of South Carolina, Charleston, South Carolina, United States

Submitted September 27, 2013 - Accepted for Publication October 17, 2013


KEYWORDS: Mesh erosion, transvaginal surgery, mesh complication

CORRESPONDENCE: S. Walter Nickles, Medical University of South Carolina, Charleston, South Carolina, United States, ()

CITATION: UroToday Int J. 2013 October;6(5):art 63. http://dx.doi.org/10.3834/uij.1944-5784.2013.10.10

INTRODUCTION AND OBJECTIVES

Transvaginal mesh has been used in the management of a multitude of female urologic conditions; most commonly vaginal prolapse and stress urinary incontinence. However, in the event of a complication related to the use of such mesh, there is scant literature on its safe and efficacious removal. We present a technique for transvaginal removal of vesicular mesh erosion.

METHODS

The patient is placed in lithotomy position and cystoscopy is performed to identify the location of the mesh and to place ureteral catheters to aid in the identification of the ureters during the dissection of the offending mesh. Once bilateral ureteral catheters are in place, a Foley catheter is placed and gentle traction is placed on the catheter to aid in identification of the bladder neck by palpating the Foley balloon. Subsequently, using a midline transvaginal approach, hydrodissection is performed using injectable saline to infiltrate the length of the intended incision. Allis clamps are used to grasp the vaginal epithelium once incised, and vaginal flaps are developed in order to expose periurethral and perivesical fascia. Once the sling is identified in the midline it is transected, creating 2 arms. With traction on the edge of the transected sling, a combination of sharp and blunt dissection is used to free the sling from the medial to the lateral, working from known to unknown. The sling is dissected to the most lateral extent possible taking care to identify the location of the intravesical mesh. Once the intravesical mesh is encountered, the entirety of the offending mesh is excised, taking care to leave no eroded mesh in the bladder as a nidus for future infections or stones. Stay sutures can be placed upon encountering the intravesical portion of the mesh if there is concern the repair will be difficult to visualize. Once the mesh has been removed bilaterally at its most lateral aspect, attention is then turned to the resultant cystotomy. The bladder is then closed in multiple layers using delayed synthetic absorbable sutures, and stay sutures, if present, are removed. A urethral catheter is left indwelling postoperatively.

RESULTS

The patient is discharged when ambulatory and tolerating a regular diet. A voiding cystourethrogram (VCUG) is obtained in 1 to 2 weeks and if urinary extravasation is not seen, the urethral catheter is removed.

CONCLUSIONS

Despite the use of mesh slings for stress urinary incontinence and pelvic organ prolapse, literature describing operative techniques to remove slings in the setting of urinary tract erosion is lacking. The described technique avoids significant manipulation of the urinary tract and further disruption of the periurethral and perivesical fascia while ensuring a watertight closure.

 

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