Fatal collapse due to autonomic dysreflexia during manual self-evacuation of bowel in a tetraplegic patient living alone: lessons to learn.

BACKGROUND: To identify areas for improvement, the National Health Service in England mandates the review of case reports of patients who have died, which should be translated into improved care for other patients. CASE REPORT: A 49-year-old Caucasian man sustained C-7 tetraplegia in a motorcycle accident in 1992. In 2009, he developed seizures and collapsed in the lavatory on a number of occasions during manual self-evacuation of his bowel. A 24-hour electrocardiogram recording at that time showed sinus rhythm with a maximum heart rate of 97 and a minimum of 39 beats per minute; there were no significant arrhythmias that could have contributed to his episodes of collapse. In 2015, the patient again collapsed while performing manual evacuation of his bowel; on this occasion, he did not suffer a seizure. He was found unresponsive in the bathroom by his daughter, who contacted the emergency services. He recovered consciousness on arrival at the Accident and Emergency Department. A noncontrast computed tomography scan of his head revealed no acute intracranial pathology. In 2016, he suffered a fatal collapse in the lavatory, again while performing manual bowel evacuation. At autopsy, no other significant disease was found that might have caused death, and given the clinical history, the cause of death was recorded as autonomic dysreflexia. CONCLUSION: There were delays in 1) recognizing that his episodes of collapse in the lavatory were due to autonomic dysreflexia induced by manual bowel evacuation; 2) recommending the prior application of topical 2% lidocaine jelly to prevent or limit autonomic dysreflexia occurring during manual bowel evacuation; and 3) considering alternative bowel management such as stimulant laxatives, transanal irrigation, or colostomy, which could have prevented the occurrence of autonomic dysreflexia caused by manual evacuation.

Candida albicans Fungaemia following Traumatic Urethral Catheterisation in a Paraplegic Patient with Diabetes Mellitus and Candiduria Treated by Caspofungin.

A 58-year-old paraplegic male, with long-term indwelling urethral catheter, developed catheter block. The catheter was changed, but blood-stained urine was drained intermittently. A long segment of the catheter was seen lying outside his penis, which indicated that the balloon of Foley catheter had been inflated in urethra. The misplaced catheter was removed and a new catheter was inserted correctly. Gentamicin 160 mg was given intravenously; meropenem 1 gram every eight hours was prescribed; antifungals were not given. Twenty hours later, this patient developed distension of abdomen, tachycardia, and hypotension; he was not arousable. Computed tomography of abdomen revealed inflamed uroepithelium of right renal pelvis and ureter, 4 mm lower ureteric calculus with gas in right ureter proximally, and vesical calculus containing gas in its matrix. Urine and blood culture yielded Candida albicans. Identical sensitivity pattern of both isolates suggested that the source of the bloodstream infection was most likely urine. Both isolates formed consistently high levels of biofilm formation in vitro as assessed using a biofilm biomass stain, and high levels of resistance to voriconazole were observed. Both amphotericin B and caspofungin showed good activity against the biofilms. HbA1c was 111 mmol/mol. This patient was prescribed human soluble insulin and caspofungin 70 mg followed by 50 mg daily intravenously. He recovered fully from candidemia.

Failure of Urological Implants in Spinal Cord Injury Patients due to Infection, Malfunction, and Implants Becoming Obsolete due to Medical Progress and Age-Related Changes in Human Body Making Implant Futile: Report of Three Cases.

Any new clinical data, whether positive or negative, generated about a medical device should be published because health professionals should know which devices do not work, as well as those which do. We report three spinal cord injury patients in whom urological implants failed to work. In the first, paraplegic, patient, a sacral anterior root stimulator failed to produce erection, and a drug delivery system for intracavernosal administration of vasoactive drugs was therefore implanted; however, this implant never functioned (and, furthermore, such penile drug delivery systems to produce erection had effectively become obsolete following the advent of phosphodiesterase type 5 inhibitors). Subsequently, the sacral anterior root stimulator developed a malfunction and the patient therefore learned to perform self-catheterisation. In the second patient, also paraplegic, an artificial urinary sphincter was implanted but the patient developed a postoperative sacral pressure sore. Eight months later, a suprapubic cystostomy was performed as urethral catheterisation was very difficult. The pressure sore had not healed completely even after five years. In the third case, a sacral anterior root stimulator was implanted in a tetraplegic patient in whom, after five years, a penile sheath could not be fitted because of penile retraction. This patient was therefore established on urethral catheter drainage. Later, infection with Staphylococcus aureus around the receiver block necessitated its removal. In conclusion, spinal cord injury patients are at risk of developing pressure sores, wound infections, malfunction of implants, and the inability to use implants because of age-related changes, as well as running the risk of their implants becoming obsolete due to advances in medicine. Some surgical procedures such as dorsal rhizotomy are irreversible. Alternative treatments such as intermittent catheterisations may be less damaging than bladder stimulator in the long term.

Incidental paraganglioma of the urinary bladder in a 66-year-old woman.

A 66-year-old female patient was referred to drology department when a bladder mass was incidentally found on a transvaginal ultrasound scan. Cystoscopy revealed a small, smooth mass just above the trigone which appeared to be covered with normal urothelium. The histology from this growth after transurethral resection revealed a paraganglioma of the bladder. We will discuss the management of this case and literature review of this finding in this study.

Challenges in diagnosis and treatment of a cervical spinal cord injury patient with melanoma, adenocarcinoma, and hepatic and osteolytic metastases: need to implement strategies for prevention and early detection of cancer in spinal cord injury patients.

A male tetraplegic patient with, who had been taking warfarin, developed haematuria. Ultrasound scan revealed no masses, stones, or hydronephrosis. Urinary bladder had normal configuration with no evidence of masses or organised haematoma. Urine cytology revealed no malignant cells. Four months later, CT urography revealed an irregular mass at the base of urinary bladder. Cystoscopic biopsy revealed moderately differentiated adenocarcinoma, which contained goblet cells and pools of mucin showing strongly positive immunostaining for prostatic acid hosphatase and patchy staining for prostate specific antigen. Computed Tomography revealed multiple hypodense hepatic lesions and several osteolytic areas in femoral heads and iliac bone. With a presumptive diagnosis of prostatic carcinoma, leuprorelin acetate 3.75 mg was prescribed. This patient expired a month later. Conclusion. (i) Spinal cord injury patient, who passed blood in urine while taking warfarin, requires repeated investigations to look for urinary tract neoplasm. (ii) Anti-androgen therapy should be prescribed for 2 weeks prior to administration of gonadorelin analogue to prevent tumour flare causing bone pain, bladder outlet obstruction, uraemia, and cardiovascular risk due to hypercoagulability associated with a rapid increase in tumour burden. (iii) Spinal cord physicians should adopt a caring and compassionate approach while managing tetraplegic patients with several co-morbidities, as aggressive diagnostic tests and therapeutic procedures may lead to deterioration in the quality of life.

Bilateral recurrent wrist flexor tenosynovitis and rice body formation in a patient with sero-negative rheumatoid arthritis: A case report and review of literature.

INTRODUCTION: Rice body formation has been traditionally observed in the joint and tendon sheaths of patients with tuberculosis. Few case reports exist that describe rice body formation in patients with rheumatoid arthritis. We describe a case report of bilateral recurrent wrist flexor tenosynovitis with rice body formation in a patient with sero-negative rheumatoid arthritis. PRESENTATION OF CASE: This case report describes a 72 year old lady presenting with severe bilateral, flexor tenosynovitis of the wrists. Ultrasonography revealed significant echogenic fluid on the palmer aspect of wrist joint surrounding flexor tendons with intact neurovascular bundles and no bony erosion. Laboratory tests demonstrated elevated erythrocyte sedimentation rate (50 mm/h) and negative rheumatoid factor. A sequential subtotal flexor tenosynovectomy was carried out with decompression of the carpal tunnel. During the operation, multiple rice bodies among the flexor tendons with adherent synovitis were found. Histology revealed disrupted synovial tissue containing several areas of fibrinoid necrosis, bounded by a layer of vaguely pallisaded histiocytes but no epitheloid granulomata or germinal centre. A revision surgery with debulking of the fibro-osseous canal was undertaken following recurrence. The patient presently has complete resolution of symptoms at one year follow-up. DISCUSSION: The combined clinical, laboratory, ultrasound and histology findings of the patient indicated that the cause of the rice body formation was due to a sero-negative arthritis rather than tuberculosis. CONCLUSION: Rice body formation can be caused by sero-negative arthritis. Bilateral wrist flexor tensosynovitis can recur within five months of a previous synovectomy in a patient with sero-negative arthritis.

Delay in diagnosis of cancer as a patient safety issue - a root cause analysis based on a representative case report.

BACKGROUND: It is well known in the literature that imaging has almost no value for diagnosis of superficial bladder cancer. However, wide gap exists between knowledge on diagnosis of bladder cancer and actual clinical practice. CASE PRESENTATION: Delay in diagnosis of bladder cancer in a male person with tetraplegia occurred because of reliance on negative flexible cystoscopy and single biopsy, negative ultrasound examination of urinary bladder, and computerised tomography of pelvis. Difficulties in scheduling cystoscopy also contributed to a delay of nearly ten months between the onset of haematuria and establishing a histological diagnosis of vesical malignancy in this patient. The time interval between transurethral resection and cystectomy was 42 days. This delay was mainly due to scheduling of surgery. CONCLUSION: We learn from this case that doctors should be aware of the limitations of negative flexible cystoscopy and single biopsy, cytology of urine, ultrasound examination of urinary bladder, and computed tomography of pelvis for diagnosis of bladder cancer in spinal cord injury patients. Random bladder biopsies must be considered under general anaesthesia when there is high suspicion of bladder cancer. Spinal cord injury patients with lesions above T-6 may develop autonomic dysreflexia; therefore, one should be extremely well prepared to prevent or manage autonomic dysreflexia when performing cystoscopy and bladder biopsy. Spinal cord injury patients, who pass blood in urine, should be accorded top priority in scheduling of investigations and surgical procedures.

Marked hydronephrosis and hydroureter after distigmine therapy in an adult male patient with paraplegia due to spinal cord injury: a case report.

INTRODUCTION: Distigmine, a long-acting anti-cholinesterase, is associated with side effects such as Parkinsonism, cholinergic crisis, and rhabdomyolysis. We report a spinal cord injury patient, who developed marked hydronephrosis and hydroureter after distigmine therapy, which led to a series of complications over subsequent years. CASE PRESENTATION: A 38-year-old male developed T-9 paraplegia in 1989. Intravenous urography, performed in 1989, showed normal kidneys, ureters and bladder. He was prescribed distigmine bromide orally and was allowed to pass urine spontaneously. In 1992, intravenous urography showed bilateral marked hydronephrosis and hydroureter. Distigmine was discontinued. He continued to pass urine spontaneously. In 2006, intravenous urography showed moderate dilatation of both pelvicalyceal systems and ureters down to the level of urinary bladder. This patient was performing self-catheterisation only once a day. He was advised to do catheterisations at least three times a day. In December 2008, this patient developed haematuriawhich lasted for nearly four months.. He received trimethoprim, then cephalexin, followed by Macrodantin, amoxicillin and ciprofloxacin. In February 2009, intravenous urography showed calculus at the lower pole of left kidney. Both kidneys were moderately hydronephrotic. Ureters were dilated down to the bladder. Dilute contrast was seen in the bladder due to residual urine. This patient was advised to perform six catheterisations a day, and take propiverine hydrochloride 15 mg, three times a day. Microbiology of urine showed Klebsiella oxytoca, Pseudomonas aeruginosa, and Enterococcus faecalis. Cystoscopy revealed papillary lesions in bladder neck and trigone. Transurethral resection was performed. Histology showed marked chronic cystitis including follicular cystitis and papillary/polypoid cystitis. There was no evidence of malignancy. CONCLUSION: Distigmine therapy resulted in marked bilateral hydronephrosis and hydroureter. Persistence of hydronephrosis after omitting distigmine, and presence of residual urine in bladder over many years probably predisposed to formation of polypoid cystitis and follicular cystitis, and contributed to prolonged haematuria, which occurred after an episode of urine infection. This case illustrates the dangers of prescribing distigmine to promote spontaneous voiding in spinal cord injury patients. Instead of using distigmine, spinal cord injury patients should be advised to consider intermittent catheterisation together with oxybutynin or propiverine to achieve complete, low-pressure emptying of urinary bladder.

Hourglass urinary bladder in a spinal cord injury patient - unusual late complication of suprapubic cystostomy: a case report.

INTRODUCTION: Suprapubic cystostomy is performed in spinal cord injury patients in order to prevent complications associated with long-term urethral catheter drainage. We report a patient in whom suprapubic catheter did not drain urine satisfactorily and imaging studies revealed hourglass bladder. CASE PRESENTATION: A female patient sustained paraplegia in a traffic accident in 1994 at the age of seventeen years. When she was discharged from spinal unit, she was performing self- catheterisations. In 1995, indwelling urethral catheter drainage was instituted, as she was not able to cope up with self-catheterisations. Intravenous urography, performed in 1994, 1997, 2000 and 2003 showed urinary bladder of normal shape. In 2004, this patient developed frequent blockages and bypassing of catheter; therefore, suprapubic cystostomy was performed. In 2005, she was leaking urine per urethra; therefore, an indwelling catheter was inserted; both suprapubic and urethral catheters drained urine. In 2008, suprapubic catheter failed to drain any urine. Cystogram revealed hourglass bladder. The balloon of suprapubic Foley catheter was located in the upper compartment of hourglass bladder whereas the urethral catheter was placed in the inferior compartment. Ultrasound examination of urinary bladder showed two compartments of hourglass bladder separated by a narrow waist. Computed tomography cystogram delineated smaller superior and larger inferior compartment of the hourglass bladder. At present this patient is happy to manage her bladder with suprapubic and urethral catheters. CONCLUSION: When prompt replacement of a mal-functioning suprapubic catheter fails to rectify the problem, computer tomography cystography should be performed to check precise location of suprapubic catheter and structural abnormalities of urinary bladder. In this patient, cystogram revealed hourglass bladder. Possible reasons for development of hourglass bladder in spinal cord injury patients are: traction applied to dome of urinary bladder by Foley balloon when suprapubic catheter is taped tightly to anterior abdominal wall for several months; uncoordinated contractions of detrusor muscle; chronic cystitis leading to hypertrophy of bladder wall.

Reducing laparoscopic radical prostatectomy false-positive margin rates using cyanoacrylate tissue glue.

BACKGROUND: Trauma to the prostate surface from laparoscopic instruments may have a role in creating false-positive margins during laparoscopic radical prostatectomy (LRP). OBJECTIVE: To determine the feasibility of using cyanoacrylate glue to repair iatrogenic lacerations and to evaluate the glue's effect on the positive surgical margin rates of LRP specimens. DESIGN, SETTING, AND PARTICIPANTS: We used porcine kidneys as a surrogate experimental tissue to help determine the quality, robustness, and adequacy of glued repairs in experimentally created lacerations. A matched control group of unrepaired kidney specimens and kidney specimens repaired with glue were subjected to full histopathologic processing. Exposure of a nephron to surface marker ink was considered to be a "positive margin." The efficacy and impact of glue repairs on LRP specimens that had sustained iatrogenic intraoperative surface trauma were also assessed. MEASUREMENTS: We evaluated the success of glue repair in preventing subcapsular renal parenchymal staining. We also compared the rate of positive margins in LRP specimens with and without routine glue repair of the surface of the prostate. RESULTS AND LIMITATIONS: The glue remained effective throughout the entire laboratory process and did not interfere with histopathologic assessment. As hypothesised, cyanoacrylate glue repair of the renal lacerations prevented staining of subcapsular tissues with marker dye and therefore prevented what might otherwise be considered false-positive staining. The rate of positive margins of the 40 LRP specimens without glue repair was 35%, compared with a rate of 10% for 40 glue-repaired specimens. The limitations of the study are that follow-up was short and that the prostatectomy specimens were compared with consecutive controls rather than with matched randomised controls. CONCLUSIONS: Cyanoacrylate glue is a novel, inexpensive, and very effective prostate repair agent that does not interfere with histologic processing. It is possible to accurately repair iatrogenic prostate lacerations with cyanoacrylate glue and, in doing so, to considerably reduce the rate of spurious false-positive surgical margins.

Complications of Benchekroun vesicostomy in a spina bifida patient: severe stenosis requiring permanent suprapubic cystostomy, recurrent vesical calculi and abdominal hernia containing ileocystoplasty - a case report.

INTRODUCTION: In female patients with neuropathic bladder, the urethra is closed permanently in order to avoid urine leak. Then Benchekroun hydraulic ileal valve is attached to urinary bladder, thus providing a continent stoma for performing intermittent catheterisations. CASE PRESENTATION: We present a female patient with spina bifida who underwent Benchekroun continent vesicostomy in 1993. This patient developed severe stenosis of Benchekroun stoma and stones in urinary bladder. Dilatation of stoma and vesicolithotomy were carried out in 1995. Vesical calculi recurred; suprapubic cystolithotomy was performed in 1999. In March 2000, catheterisation of stoma was not possible and emergency suprapubic cystostomy was done. In April 2000, endoscopy was attempted through Benchekroun stoma. It was not possible to insert ureterorenoscope beyond two inches. The track was completely blocked. In November 2001, X-ray of abdomen showed several vesical calculi; suprapubic cystolithotomy was performed. In March 2005, this patient developed pain in abdomen. X-ray of abdomen showed a large vesical calculus. In June 2005, suprapubic catheter was removed and a cystoscope was introduced in to the bladder. Then electrohydraulic lithotripsy was performed. In 2007, this patient was concerned about the increasing swelling in lower abdomen. Computed tomography of abdomen revealed midline, lower abdominal wall hernia, which contained several loops of small bowel and ileal cystoplasty. The large hernia was uncomfortable and tender on coughing, but did not cause obstructive bowel symptoms. Surgical repair of hernia was considered. But this patient would require alternative way of urinary diversion because the current location of suprapubic catheter would almost lead to infection of prosthetic material used in reconstruction of the anterior abdominal wall. After discussing risks of operative procedures with patient and her husband, it was decided not to proceed with surgery. CONCLUSION: This case is a poignant reminder to spinal cord physicians that novel surgical techniques should be viewed cautiously, and patients should be informed of potential complications of surgical procedures some of which could be irreversible.

Effect of spinal cord injury upon prostate: adenocarcinoma of prostate in a spinal cord injury patient - a case report.

INTRODUCTION: Following spinal cord injury, prostate undergoes atrophy probably due to interruption of neuro-hormonal pathways. The incidence of carcinoma of prostate is lower in patients with spinal cord injury above T-10 than in those with lesion below T-10. CASE PRESENTATION: A Caucasian male sustained T-4 paraplegia in 1991 at the age of 59-years. He had long-term indwelling urethral catheter. In May 1995, routine blood test showed prostate-specific antigen to be 17.7 mg/ml. Prostate biopsy revealed moderately differentiated primary adenocarcinoma of prostate; Gleason score was 3+3. Bone scans showed no evidence of metastatic bone disease. Bilateral orchidectomy was performed in September 1995. MRI of pelvis revealed no evidence of spread beyond prostatic capsule. There was no pelvic lymphadenopathy. In October 1996, this patient got chest infection and recovered fully after taking amoxicillin. In February 2001, he developed pneumonia and was prescribed cefuroxime intravenously. In March 2001, cystoscopy and electrohydraulic lithotripsy of vesical calculi were carried out. In August 2001, this patient was admitted to spinal unit for management of pressure sores. He expired on 28 June 2002 in local hospital. Cause of death was recorded as acute ventricular failure, congestive heart failure, chronic respiratory failure and spinal cord injury. CONCLUSION: Although prostate gland undergoes atrophy in men who sustained spinal cord injury in early age, physicians should be vigilant and look for prostatic diseases particularly in men, who have sustained spinal cord injury during later period of life. Patients with cervical and upper dorsal lesions are at risk of developing potentially life-threatening chest complications after major surgical procedures including radical prostatectomy. Therefore, it may be advisable to consider chemoprevention of prostate cancer with Finasteride, especially in men, who sustained cervical and upper dorsal spinal cord injury during later part of their life.

Long-term nephrostomy in an adult male spinal cord injury patient who had normal upper urinary tracts but developed bilateral hydronephrosis following penile sheath drainage: pyeloplasty and balloon dilatation of ureteropelvic junction proved futile: a case report.

INTRODUCTION: The consequences of spinal cord injury upon urinary bladder are readily recognised by patients and health care professionals, since neuropathic bladder manifests itself as urinary incontinence, or retention of urine. But health care professionals and persons with spinal cord injury may not be conversant with neuropathic dysmotility affecting the ureter and renal pelvis. We report an adult male patient with spinal cord injury, who developed bilateral hydronephrosis after he started managing neuropathic bladder by penile sheath drainage. CASE PRESENTATION: A male patient, born in 1971, sustained spinal cord injury following a motorbike accident in September 1988. In November 1988, intravenous urography showed normal upper tracts. He was advised spontaneous voiding with 2-3 catheterisations a day. In February 1995, this patient developed fever, chills and vomiting. Blood urea: 23.7 mmol/L; creatinine: 334 umol/L. Ultrasound revealed marked hydronephrosis of right kidney and mild hydronephrosis of left kidney. Bilateral nephrostomy was performed in March 1995. Right pyeloplasty was performed in May 1998. In July 2005, this patient developed urine infection and was admitted to a local hospital with fever and rigors. He developed septicaemia and required ventilation. Ultrasound examination of abdomen revealed bilateral hydronephrosis and multiple stones in left kidney. Percutaneous nephrostomy was performed on both sides. Subsequently, extracorporeal shock wave lithotripsy of left renal calculi was carried out. Right nephrostomy tube slipped out in January 2006; percutaneous nephrostomy was performed again. In June 2006, left ureteric antegrade stenting was performed and nephrostomy tube was removed. Currently, right kidney is drained by percutaneous nephrostomy and left kidney is drained by ureteric stent. This patient has indwelling urethral catheter. CONCLUSION: It is possible that regular intermittent catheterisations along with anticholinergic medication right from the time of rehabilitation after this patient sustained paraplegia might have prevented the series of urological complications. Key components to successful management of external drainage of kidney in this patient are: [1] use of size 14 French pigtail catheter for long-term nephrostomy, [2] anchoring the catheter to skin to with Percufix catheter cuff to prevent accidental tug [3], replacing the nephrostomy dressing once a week by the same team in order to provide continuity of care, and [4] changing nephrostomy catheter every six months by a senior radiologist.

Lessons we learn from review of urological procedures performed during three decades in a spinal cord injury patient: a case report.

BACKGROUND: We review urological procedures performed on a spinal cord injury patient during three decades. CASE PRESENTATION: A 23-year-old male patient sustained T-12 paraplegia in 1971. In 1972, intravenous urography showed both kidneys functioning well; division of external urethral sphincter was performed. In 1976, reimplantation of left ureter (Lich-Gregoir) was carried out for vesicoureteric reflux. As reflux persisted, left ureter was reimplanted by psoas hitch-Boari flap technique in 1978. This patient suffered from severe pain in legs; intrathecal injection of phenol was performed twice in 1979. The segment bearing the scarred spinal cord was removed in September 1982. This patient required continuous catheter drainage. Deep median sphincterotomy was performed in 1984. As the left kidney showed little function, left nephroureterectomy was performed in 1986. In an attempt to obviate the need for an indwelling catheter, bladder neck resection and tri-radiate sphincterotomy were carried out in 1989; but these procedures proved futile. UroLume prosthesis was inserted and splinted the urethra from prostatic apex to bulb in October 1990. As mucosa was apposing distal to stent, in November 1990, second UroLume stent was hitched inside distal end of first. In March 1991, urethroscopy showed the distal end of the distal stent had fragmented; loose wires were removed. In April 1991, this patient developed sweating, shivering and haematuria. Urine showed Pseudomonas. Suprapubic cystostomy was performed. Suprapubic cystostomy was done again the next day, as the catheter was pulled out accidentally during night. Subsequently, a 16 Fr Silastic catheter was passed per urethra and suprapubic catheter was removed. In July 1993, Urocoil stent was put inside UroLume stent with distal end of Urocoil stent lying free in urethra. In September 1993, this patient was struggling to pass urine. Urocoil stent had migrated to bladder; therefore, Urocoil stent was removed and a Memotherm stent was deployed. This patient continued to experience trouble with micturition; therefore, Memotherm stent was removed. Currently, wires of UroLume stent protrude in to urethra, which tend to puncture the balloon of urethral Foley catheter, especially when the patient performs manual evacuation of bowels. CONCLUSION: We failed to implement intermittent catheterisation along with anti-cholinergic therapy. Instead, we performed several urological procedures with unsatisfactory outcome; the patient lost his left kidney. We believe that honest review of clinical practice will help towards learning from past mistakes.

Infection of Brindley sacral anterior root stimulator by Pseudomonas aeruginosa requiring removal of the implant: long-term deleterious effects on bowel and urinary bladder function in a spinal cord injury patient with tetraplegia: a case report.

INTRODUCTION: We report infection of Brindley sacral anterior root stimulator in a spinal cord injury patient, who ultimately required removal of the implant. The consequences of failed implantation were severe constipation, and loss of reflex penile erection and bladder emptying. CASE PRESENTATION: A male patient, born in 1973, fell off the balcony while on holidays in Crete in 1993 and developed complete tetraplegia at C-5 level. In 1996, deafferentation of sacral nerve roots 2, 3 and 4 were carried out bilaterally. Brindley sacral anterior root stimulator was implanted. On eleventh post-operative day, blood stained fluid came out of sacral wound. Microbiology of exudates showed growth of Pseudomonas aeruginosa, sensitive to gentamicin. As discharge of serosanguinous fluid persisted, sacral wound was explored. In March 1997, induration and craggy swelling were noted at the site of receiver. There was discharge from the surgical wound in the back. Wound swab grew Pseudomonas aeruginosa. The receiver was taken out. Cables were retrieved and tunnelled in left flank. Laminectomy wound was left open. In May 1997, cables were removed from left flank through the laminectomy wound. Grommet was sliced down as much as possible without producing leak of cerebrospinal fluid. Histoacryl glue was used over the truncated grommet as a sealing agent. Microbiology of end of S-2 and S-3 cables showed growth of Pseudomonas aeruginosa, which was sensitive to gentamicin. End of S-4 cable showed scanty growth of Pseudomonas aeruginosa and Klebsiella aerogenes. Review of this patient in January 1999 revealed presence of sinuses in dorsal wound exuding purulent material. The wound was explored; grommet and electrodes were removed. The consequences of failed implantation were severe constipation and loss of reflex penile erection and bladder emptying. This patient had to spend increasing amount of time for bowels management. Faecal incontinence limited his mobility. The problem with his bowels was affecting his confidence in doing anything, as the slightest movement could cause his bowels to work. The inconvenience and embarrassment of a bowel accident caused distress to the patient and to his mother. CONCLUSION: This case illustrates that bacterial infection is a major problem in spinal cord injury patients who undergo implantation of medical devices. Further, this case underlines the need for honest discussion with spinal cord injury patients about possible complications of implantation of sacral anterior root stimulator and long-term consequences of an unsuccessful operation.

Incomplete renal tubular acidosis as a predisposing factor for calcium phosphate stones in neuropathic bladder: a case report.

We present a male tetraplegic patient, who developed stones in neuropathic bladder six times within a span of three years. Unusual features of this case are: (1) This patient started developing stones in urinary bladder thirteen years after sustaining spinal cord injury. (2) He was performing intermittent catheterisation and did not have an indwelling catheter. (3) The presenting symptom of vesical lithiasis was abdominal spasms and not urine infection. (4) The major component of the stones was calcium phosphate; magnesium ammonium phosphate was completely absent in the calculus on four occasions. (5) Proteus species were not grown from urine at any time. (6) This patient failed to acidify urine below a pH of 5.3 after taking simultaneously furosemide (40 mg) and fludrocortrisone (1 mg), which suggested incomplete renal tubular acidosis type 1.We learn from this case that biochemical analysis of stones removed from urinary bladder may be useful. If the major component of vesical calculus is calcium phosphate, complete or incomplete renal tubular acidosis type 1 should be excluded, as it may be possible to reduce the risk of recurrence of calcium phosphate stones by oral potassium citrate therapy or, vegetable and fruit rich diet.

Invasive carcinoma of urinary bladder in a patient with a spinal cord injury with non-functioning Brindley sacral anterior root stimulator: a case report.

BACKGROUND: Anterior sacral root stimulation combined with sacral posterior rhizotomy restores bladder function in spinal cord-injured patients suffering from hyperactive bladder. After successful implantation of bladder stimulator, urinary infection rate decreases, and patients are able to get rid of indwelling urinary catheters, which in turn reduce the risks for vesical malignancy. We present a spinal cord injury patient with non-functioning Brindley sacral anterior root stimulator, who developed carcinoma of urinary bladder. CASE PRESENTATION: A Caucasian male, who was born in 1943, sustained paraplegia at T-4 (ASIA-B) in 1981. This patient underwent implantation of sacral anterior root stimulator in September 1985. The bladder stimulator started giving trouble since 1996 and the patient went back to using indwelling urethral catheter. In August 2006, this patient passed blood in urine after a routine change of indwelling catheter. Cystoscopy showed unhealthy bladder mucosa. Bladder biopsy revealed carcinoma, which was infiltrating bundles of muscularis propria. Many of the nests showed evidence of squamous differentiation, while others could be transitional or squamous. This patient underwent cystectomy with lymphadenectomy in March 2007 in a hospital nearer his home. Histology showed three nodes involved. This patient has been doing well since the operation. CONCLUSION: Occurrence of vesical malignancy in this patient with non-functioning bladder stimulator is a timely reminder to all health professionals, and health care managers that concerted efforts should be made to rectify a non-functioning sacral anterior root stimulator as soon as possible. Otherwise, facilities should be made available in the community for the spinal cord injury patient to use intermittent catheterisation and thereby, avoid permanent indwelling catheter, vesical calculi and urine infections, which are risk factors for bladder cancer.

Burrowing of urinary bladder wall by the tip of a size 22 Fr silicone foley catheter in an adult male patient with multiple sclerosis and suprapubic cystostomy: should caution be exercised in using a size 22 Fr silicone foley catheter for long-term drainage of neuropathic bladder?

INTRODUCTION: Silicone Foley catheters tend to become stiffer as size of the catheter increases. Whereas the tip of a size 12 French silicone, Foley catheter is soft and flexible, a size 24 French silicone, Foley catheter is distinctly stiff. Chronically inflamed neuropathic bladders are susceptible to perforation by the tip of a Foley catheter. We report a patient with multiple sclerosis and moderately severe chronic cystitis, in whom a size 22 French Foley catheter burrowed through the dome of urinary bladder. CASE PRESENTATION: A 55-year-old, Caucasian male suffering from multiple sclerosis underwent suprapubic cystostomy in January 2007. Initially, a size 16 Fr. silicone, Foley, catheter was inserted. During subsequent catheter changes, silicone Foley catheters of progressively increasing sizes were inserted and in July 2007, a size 22 Fr. catheter was used in order to prevent blockages and consequent bypassing of urine. In April 2008, he had an uneventful change of suprapubic catheter; but a week later, this patient developed profuse bypassing. On examination, suprapubic catheter contained fresh blood; there was hardly any urine in the leg bag, which was attached to suprapubic catheter. Cystogram showed localised extravasation of contrast on the superior aspect of urinary bladder around the tip of Foley catheter, which protruded beyond the dome of urinary bladder. The size 22 Fr. catheter was removed and a size 20 Fr silicone, Foley, catheter was inserted ensuring that the tip of catheter pointed towards bladder neck. This patient received gentamicin intravenously and he was prescribed ciprofloxacin for five days. He did not develop temperature or other features of sepsis. Bypassing stopped completely. CONCLUSION: In this patient, bladder biopsy had shown moderately severe chronic inflammation and congestion. We learn from this case that we should have used a smaller size catheter, which has a softer texture and changed the catheter at shorter intervals rather than insert a larger bore catheter, and run the risk of perforation of neuropathic bladder by the tip of a stiff Foley catheter.