Bladder infusion versus standard catheter removal for trial of void: a systematic review and meta-analysis.

PURPOSE: To compare the efficacy and time-to-discharge of two methods of trial of void (TOV): bladder infusion versus standard catheter removal. METHODS: Electronic searches for randomized controlled trials (RCTs) comparing bladder infusion versus standard catheter removal were performed using multiple electronic databases from dates of inception to June 2020. Participants underwent TOV after acute urinary retention or postoperatively after intraoperative indwelling catheter (IDC) placement. Quality assessment and meta-analyses were performed, with odds ratio and mean time difference used as the outcome measures. RESULTS: Eight studies, comprising 977 patients, were included in the final analysis. Pooled meta-analysis demonstrated that successful TOV was significantly higher in the bladder infusion group compared to standard TOV (OR 2.41, 95% CI 1.53-3.8, p = 0.0005), without significant heterogeneity (I2=19%). The bladder infusion group had a significantly shorter time-to-decision in comparison to standard TOV (weighted mean difference (WMD)-148.96 min, 95% CI - 242.29, - 55.63, p = 0.002) and shorter time-to-discharge (WMD - 89.68 min, 95% CI - 160.55, - 18.88, p = 0.01). There was no significant difference in complication rates between the two groups. CONCLUSION: The bladder infusion technique of TOV may be associated with a significantly increased likelihood of successful TOV and reduced time to discharge compared to standard TOV practices.

Incidence, Management, and Outcomes of Aortic Graft Infection.

BACKGROUND: Infection complicates 1% of aortic grafts, and although uncommon, the associated morbidity and mortality are significant. We sought to determine risk factors for aortic graft infection (AGI), the long-term outcomes in patients managed both nonoperatively and via explantation. METHODS: This observational study reviewed sequential aortic grafts (thoracic or abdominal) inserted via open or endovascular means between 2000 and 2017. We used Cox proportional hazards regression analyses to compare risk factors between groups who did and did not acquire an AGI and recorded method of management, morbidity, mortality, and duration to adverse event. RESULTS: There were 883 aortic repairs, 49% were endovascular. 17.2% were for ruptured aneurysms, 1.1% for symptomatic aneurysms, 1.4% for type B dissections, and 0.5% for occlusive disease. Twelve patients presented with AGI, of which ten had their index procedure performed at our institution (AGI incidence of 1.1%). There was no difference in rates of AGI between open and endovascular repairs (0.9 vs. 1.4%, P = 0.24). AGI was significantly associated with emergency aortic repair (HR 3.63, 95% CI 1.13-11.57, P = 0.03), septic process requiring in-patient management during follow-up (HR 5.44, 95% CI 1.21-24.26, P = 0.02), and suprarenal clamping during open repair (HR 5.21, 95% CI 1.00-26.99, P = 0.05). Four patients were managed with explantation and revascularization (3 extra-anatomical bypasses) and remained well at a median follow-up of 46 months. Of the 8 patients managed nonoperatively, 4 died at an average of 13.5 days after representation, and the other 4 remained well on oral antibiotics at a median follow-up of 26.5 months. No patient suffered limb loss, and there was no change in the rate of infection over the period. CONCLUSIONS: Incidence of AGI remains low but is associated with significant mortality. Patients with aortic grafts in situ require aggressive treatment of septic foci to prevent graft infection.

An unusual site of gallstones five years after laparoscopic cholecystectomy.

INTRODUCTION: Gallstone spillage during laparoscopic cholecystectomy is a common occurrence. Complications due to spilled gallstones occur in up to 5% of laparoscopic cholecystectomy cases, with complications having been reported up to 20 years after laparoscopic cholecystectomy. CASE REPORT: We report the case of a 70 year old male who presented for elective right inguinal hernia repair. At the time of repair he was found to have multiple foreign bodies embedded within an indirect hernia sac. Subsequent pathology confirmed these to be gallstones, having been spilled during emergency laparoscopic cholecystectomy 5 years prior. DISCUSSION: Gallbladder perforation and gallstone spillage during laparoscopic cholecystectomy occurs frequently, complications due to spilled gallstones are estimated to occur in less than 5% of cases. The most common complications is abscess formation and infection. Though spilled gallstones have been implicated in the formation of colocutaneous, colovesical, and biliocutaneous fistulae. Following gallbladder perforation during cholecystectomy, closure of the hole should be attempted with laparoscopic graspers, surgical clips, or a laparoscopic ligature. Meticulous collection of all visible spilled gallstones should then take place, followed by intraperitoneal lavage ensuring care is taken not to disperse gallstones throughout the peritoneal cavity. CONCLUSION: Gallbladder perforation during in laparoscopic cholecystectomy is common. Prevention of gallstone spillage, and retrieval of spilled gallstones is essential in minimising the risk of complications due to spillage.

Is 14 the new 40: trends in gallstone disease and cholecystectomy in Australian children.

BACKGROUNDS: Gallstone disease and cholecystectomy have been uncommon in paediatric patients and associated with haemolytic disease and prematurity. Many countries have observed an increase in the prevalence of paediatric gallstones and cholecystectomy with increasing childhood obesity. The purpose of this study was to determine any trend in prevalence in Australian children and the role of obesity. METHODS: Chart review was conducted for patients undergoing cholecystectomy under 18 in 25 years between 1992 and 2016. Patients were grouped based on year of operation into five groups of 5 years each. Patient demographics including age and gender were noted, as were weight, height, and percentiles. Also noted were comorbidities, indication for surgery, whether elective or emergent, and procedure performed. Statistical analysis was performed using logistic regression on R-Studio®. RESULTS: Seventy-nine patients were included, 9, 15, 18, 18, and 19 in Groups 1-5, respectively. A trend was noted of increasing frequency which did not reach statistical significance. Nineteen patients had alternative explanations for gallstone disease, decreasing over time, coefficient - 10.5. A trend was also noted of increasing proportion of patients in higher percentiles for weight, which was statistically significant for those above the 98th percentile. CONCLUSIONS: The changing profile of paediatric cholecystectomy is a little recognised aspect of the 'obesity epidemic'. This has implications when considering the impact of childhood overweight and obesity, and for clinicians involved in the diagnosis and management of these children.

Clear cell papillary renal cell carcinoma: a potential mimic of conventional clear cell renal carcinoma on core biopsy.

Clear cell papillary renal cell carcinoma (CCP-RCC) is a recently described, relatively uncommon variant of renal cell carcinoma (RCC) with a reported incidence of 4.1%. Thought to only arise in those with end stage renal disease, CCP-RCC is increasingly identified in those without renal impairment. CCP-RCCs have unique morphologic, genetic, and immunohistochemical features distinguishing them from both conventional clear cell renal cell carcinomas and papillary renal cell carcinomas. Immunohistochemically, these tumors are positive for CK7 and negative for CD10 and racemase. This is in contrast to conventional cell renal cell carcinomas (CK7 negative, CD10 positive) and papillary cell carcinomas (CK7, CD10, and racemase positive). These tumours appear to be indolent in nature, with no current documented cases of metastatic spread. We present the case of a 42-year-old female who presented with an incidental finding of a renal mass that on a core biopsy was reported as clear cell carcinoma, Fuhrman grade 1. She subsequently underwent a radical nephrectomy and further histological examination revealed the tumor to be a clear cell papillary renal cell carcinoma, Fuhrman grade 1.