Risk factors for postoperative urinary retention in fragility hip fracture patients: a prospective study.

BACKGROUND: Postoperative urinary retention (POUR) among older patients with hip fractures is common and may result in delayed ambulation, prolonged hospital stays, and urinary tract infections. Although preoperative urinary catheter indwelling and early postoperative removal can prevent perioperative urinary retention, this condition may occur in some patients after catheter removal, which requires urinary catheter re-indwelling or intermittent catheterization. Therefore, this study aims to identify risk factors and develop a screening tool for postoperative urinary retention in patients who have undergone operative treatment for fragility hip fractures subsequent to urinary catheter removal. METHODS: A prospective cohort study of 145 fragility hip fracture in older patients who were operatively treated between September 2020 and May 2022 was conducted. All patients were evaluated for urine retention after urinary catheter removal using a bladder scan. In addition, factors related to urinary retention were collected and utilized for screening tool development. RESULTS: Of the included patients, 22 (15.2%) were diagnosed with POUR. A multivariable logistic regression model using a stepwise backward elimination algorithm identified the current use of drugs with anticholinergic effect (OR = 11.9, p = 0.012), international prostate symptom score (IPSS) ≥ 8 (OR = 9.3, p < 0.001), and inability to independently get out of bed within 24 h postoperatively (OR = 6.5, p = 0.051) as risk factors of POUR. The screening tool that has been developed revealed an excellent performance (AuROC = 0.85, 95%CI 0.75 to 0.91) with good calibration and minimal optimism. CONCLUSIONS: Current use of drugs with anticholinergic effects, IPSS ≥ 8, and inability to independently get out of bed within 24 h postoperatively are significant variables of POUR. For additional external validation, a proposed scoring system for POUR screening was developed. TRIAL REGISTRATION: The study protocol was retrospectively registered in The Thai Clinical Trials Registry (TCTR20220502001: 2 May 2022).

In vitro Comparison of the Mechanical and Optical Characteristics of 5 Disposable Flexible Ureteroscopes.

INTRODUCTION: Disposable (single-use) flexible ureteroscopes are alternatives to reusable ureteroscopes. With their superior surgical efficacy and safety in the presence of upper urinary calculi, disposable ureteroscopes aim to overcome the main limitations of conventional reusable ureteroscopes. However, studies on the performance of the most recently developed models of single-use flexible ureteroscopes are scarce. This study aimed to compare the in vitro performance of several recently introduced, single-use, flexible ureteroscopes. METHODS: Five disposable flexible ureteroscopes were tested in vitro to evaluate their mechanical and optical characteristics. To this end, their degrees of deflection, irrigation flow rates, and image qualities were investigated. The models examined were Innovex US31-B12, OTU-100RR, Redpine RP-U-C12, Sciavita SUV-2A-B, and Seplou URS3016E. Their performance was also compared with that of a reusable flexible ureteroscope, Olympus URV-F. RESULTS: The OTU device had the highest degrees of deflection and the smallest loop diameter of the disposable ureteroscopes. The single-use ureteroscopes had identical image resolutions at a distance of 1 cm. The Innovex and Redpine devices had the best color representation. CONCLUSIONS: Of the tested disposable ureteroscopes, the OTU device had the best mechanical attributes, given its small loop diameter, high deflection angles, and low irrigation flow loss. As to their optical properties, the resolutions of all 5 single-use models were identical at an image distance of 1 cm.

Management of rectal injury and rectourinary fistula from radical prostatectomy.

Objective: This study aimed to demonstrate our management of rectal injury (RI) and rectourinary fistula (RUF) from radical prostatectomy (RP) and identify a possible factor that increased the chance of developing RUF. Materials and Methods: Between January 2011 and December 2019, a total of 14 cases of RI were retrospectively reviewed and analyzed, including preoperative, perioperative, and postoperative information. Results: In all 14 cases of RI, the average age at RP was 66.3 years (54-77). During the study period, 8 of 14 cases of RI occurred in our hospital, and the incidence of RI was 0.42%. RI was intraoperative recognition in 8 cases and delayed diagnosis in 6 cases. For immediate recognition, 4 of 8 cases were primarily repaired without developing RUF and did not require diverting colostomy and suprapubic cystostomy. RUF occurred in 10 cases including 4 cases of intraoperative recognition and all cases of delayed diagnosis. In a subgroup analysis of RI that occurred in our hospital, the timing for diagnosis was clinically and statistically significant difference (P = 0.029). Instantly detected RI during RP and intraoperative rectal repair resulted in no postoperative complication. Among all 10 cases of RUF, 5 cases were successfully repaired by modified York-Mason procedure with dartos tissue flap interposition. No major complications were reported. Conclusions: Incidence of RI was 0.42% and intraoperative recognition of RI was a key to prevent the development of RUF. Modified York-Mason procedure with dartos tissue flap interposition was an effective treatment for RUF.

Female urinary retention from a huge periurethral mass caused by immunoglobulin G4-related disease (IgG4-RD).

Immunoglobulin G4-related disease is a systemic disease, recognized as extensive T-lymphocyte and IgG4-positive plasma cells. It can present as inflammatory pseudotumor in various organs. A female 75 years old, diagnosed IgG4-related autoimmune pancreatitis, presented with urinary retention. Pelvic examination showed well-defined, soft tissue mass, bulging from anterior vaginal wall. MRI pelvis demonstrated a huge periurethral mass, size 6.2 × 4.4 × 4.2 cm, encasing the urethra, extending from bladder neck to distal urethra, and mimicking the prostate gland. Tissue biopsy showed compatible with IgG4-related disease. Immunosuppresive drugs were given for few months and the patient could void normally.

The Impact of Arterial Clamping Technique in Robot-Assisted Partial Nephrectomy on Renal Function and Surgical Outcomes: Six-Year Experience at Siriraj Hospital, Thailand.

INTRODUCTION: Robot-assisted partial nephrectomy (RAPN) with different arterial clamping techniques has increasingly been performed to avoid ischemic injury to nephron. However, postoperative renal function remains controversial. We determine the impact of each renal arterial clamping on surgical and renal outcomes after RAPN. MATERIALS AND METHODS: Patients who underwent RAPN at Siriraj Hospital from 2010 to 2016 were retrospectively reviewed and stratified into 3 cohorts: main-clamp (MAC), selective-clamp, and off-clamp. RESULTS: Main, selective, and off-clamping were performed in 27, 38, and 12, respectively. Median tumor size and Radius, Exophytic or endophytic, Nearness to collecting system or sinus, Anterior or posterior, and Location relative to polar lines (RENAL) score were 3 cm and 7, respectively. Longer operative time was observed in MAC (p = 0.002) although estimated blood loss, transfusion rate, and complication were comparable. Warm ischemia time was not different between cohorts. However, number of patients with prolonged ischemia time in MAC were greater (p ≤ 0.01). All margins were negative. Median postoperative and latest glomerular filtration rate reduction were 3.8 and 5.3 mL/min/1.73 m2, respectively without significant difference between cohorts. On multivariable analysis, hypertension independently associated with reduced renal function preserved (p = 0.03). Median follow-up was 18 months. CONCLUSIONS: Our study is the first to report surgical and renal functional outcomes after RAPN in Southeast-Asian population. Based on our experience, clamping techniques does not impact on renal functions and complication rate was low even in small-volume center.

Incarcerated prolapsed ureterocele after midurethral sling in women.

Stress urinary incontinence (SUI) is a common problem in women. Successful treatment is now mid urethral sling but it would be a cause of urethral obstruction. In this case report, a 50 years old woman presented with a huge introitus mass after 3 months of midurethral sling. The mass protruded from the urethra and could not be reduced. Emergency MRI of pelvis was demonstrated prolapsed ureterocele, single system of right ureter. Preoperative planning was cystoscopy and mass excision. The patient was preoperatively counseled that right ureteric reimplantation may be required. Finally, the mass could be excised externally without reimplantation.

Clinical predictors and risk factors for vaginal mesh extrusion.

PURPOSES: Our study aims to enhance the accuracy of the clinical diagnosis in patients with vaginal mesh extrusion following transvaginal mesh placement for pelvic organ prolapse using significant clinical parameters and risk factors. METHODS: All patients who underwent vaginal mesh removal were retrospectively reviewed from January 2000 to May 2014. Eligible patients were divided into two groups according to the presence of vaginal mesh extrusion. RESULTS: A total of 862 patients, 798 were included. 357 (44.7%) had evidence of vaginal mesh extrusion, and 441 (55.3%) had no evidence of vaginal mesh extrusion. The mean age of the vaginal mesh extrusion group was slightly higher than in the group without vaginal mesh extrusion (58.7 ± 11.2 vs. 56.4 ± 11.5, respectively; p = 0.002). From multivariate analysis, the significant clinical correlations for vaginal mesh extrusion were vaginal bleeding [60 (16.9) vs. 14 (3.2%), p < 0.001], hispareunia [48 (13.5) vs. 15 (3.4%), OR = 4.163, p < 0.001], and vaginal discharge [45 (12.6) vs. 18 (4.1%), p = 0.001]. The risk factors were multiple mesh implantations [218 (67.06) vs. 175 (39.68%), p < 0.001] and menopause [314 (88) vs. 364 (82.7%), p = 0.145]. Demographic data, including BMI, sexual activity, vaginal atrophy, both local and systemic hormonal use, smoking status, and hysterectomy status, were not significantly different, as well as the clinical symptoms including dyspareunia, vaginal infection, and symptomatic vaginal bulge. CONCLUSIONS: Vaginal bleeding, hispareunia, and vaginal discharge were the most significant clinical predictors for raising suspicion of vaginal mesh extrusion. Multiple mesh implantations were a significant risk factor for extrusion.

The Risk of Recurrent Urinary Incontinence Requiring Surgery After Suburethral Sling Removal for Mesh Complications.

OBJECTIVE: We sought to examine the risk of recurrent stress urinary incontinence (SUI) after suburethral sling mesh removal or excision. MATERIALS AND METHODS: We conducted a retrospective cohort study of patients who were continent before removal or excision of synthetic midurethral slings; this cohort of 278 subjects was much larger than seen in previous such studies. Patients with preoperative incontinence, additional vaginal mesh placements, prior mesh revision/excision, existing SUI, and prior pelvic radiation or fistula were excluded. Only patients with follow-up detailing continence status within 1 year of mesh removal were examined. RESULTS: Of 278 patients, 117 (70 retropubic and 47 transobturator) midurethral sling removals met inclusion criteria. Demographic data were comparable between groups. Presenting symptoms were also similar, with similar extrusion rates. Chronic pain was the reason for mesh removal in 80% of cases. In 1 year of follow-up, 38.6% (27/70) retropubic and 34.0% (16/47) transobturator sling removals had SUI requiring an anti-incontinence procedure. Total sling mesh removal was performed in 51.4% of retropubic vaginal mesh and 51.1% of transobturator mesh cases. CONCLUSION: In this continent population with sling complications, approximately 1/3 developed significant SUI within 1 year of mesh removal requiring anti-incontinence surgery, regardless of the amount or type of mesh removed. Total mesh removal did not increase SUI risk.

Accuracy of preoperative urinary symptoms, urinalysis, computed tomography and cystoscopic findings for the diagnosis of urinary bladder invasion in patients with colorectal cancer.

BACKGROUND: To determine the accuracy of preoperative urinary symptoms, urinalysis, computed tomography (CT) and cystoscopic findings for the diagnosis of urinary bladder invasion in patients with colorectal cancer. MATERIALS AND METHODS: Records of patients with colorectal cancer and a suspicion of bladder invasion, who underwent tumor resection with partial or total cystectomy between 2002 and 2013 at the Faculty of Medicine Siriraj Hospital, were reviewed. Correlations between preoperative urinary symptoms, urinalysis, cystoscopic finding, CT imaging and final pathological reports were analyzed. RESULTS: This study included 90 eligible cases (71% male). The most common site of primary colorectal cancer was the sigmoid colon (44%), followed by the rectum (33%). Final pathological reports showed definite bladder invasion in 53 cases (59%). Significant features for predicting definite tumor invasion were gross hematuria (OR 13.6, sensitivity 39%, specificity 73%), and visible tumor during cystoscopy (OR 5.33, sensitivity 50%, specificity 84%). Predictive signs in CT imaging were gross tumor invasion (OR 7.07, sensitivity 89%, specificity 46%), abnormal enhancing mass at bladder wall (OR 4.09, sensitivity 68%, specificity 66%), irregular bladder mucosa (OR 3.53, sensitivity 70%, specificity 60% ), and loss of perivesical fat plane (OR 3.17, sensitivity 81%, specificity 43%). However, urinary analysis and other urinary tract symptoms were poor predictors of bladder involvement. CONCLUSIONS: The present study demonstrated that the most relevant preoperative predictors of definite bladder invasion in patients with colorectal cancer are gross hematuria, a visible tumor during cystoscopy, and abnormal CT findings.

Comparison of urinary continence outcome between robotic assisted laparoscopic prostatectomy versus laparoscopic radical prostatectomy.

OBJECTIVE: To compare urinary continent rate at six and 12-month postoperative period, and perioperative outcome between robotic-assisted laparoscopic radical prostatectomy (RALP) and laparoscopic radical prostatectomy (LRP) at Siriraj Hospital. MATERIAL AND METHOD: All medical records of patients performed RALP and LRP between 2005 and 2010 were reviewed. Data composed of demographic information, perioperative outcome, and oncologic outcome. Moreover, the urinary continence rate was also collected at six and 12-month postoperative period by questionnaires based research design. RESULTS: Between 2005 and 2010, we performed 548 cases of RALP and 613 cases of LRP. Only 486 cases of RALP (88.6%) and 561 cases of LRP (91.5%) had been followed-up more than 12 months. All demographic data including age, biopsy Gleason score, and preoperative PSA level in both groups were comparably. On the other hand, the perioperative outcome in RALP differed from LRP group significantly, including operative time (210 min vs. 255 min), blood loss (449 ml vs. 766 ml), blood transfusion rate (7.6% vs. 25.2%), and length of hospital stay (7 days vs. 8.6 days) (p < 0.001). The oncological outcome including pathologic tumor staging and Gleason score were comparably. Late complication such as anastamosis stricture was not different between the two groups (3.1% in RALP vs. 2.4% in LRP, p = 0.584). The continence rate of RALP and LRP groups at 6-month was 67.8% and 39% and at 12-month was 80% and 63.7%, respectively. The continence rate of RALP was better than LRP significantly. CONCLUSION: From our experience, perioperative outcome and continence rate at six and 12-month of RALP group was significantly better than LRP group. The demographic data, oncological outcome, and anastamosis stricture rate were comparably in both groups. The most relevant preoperative predictors of urinary continence were patient's age and prostatic weight.

Laparoscopic radical prostatectomy, Siriraj resident experiences: the first resident series in Thailand.

OBJECTIVE: To evaluate laparoscopic radical prostatectomy (LRP) performed by urological residents trained from Siriraj Hospital. MATERIAL AND METHOD: Twenty-four laparoscopic radical prostatectomies were performed by 12 urological residents between April 2007 and October 2009 (23 intraperitoneal approaches and one extraperitoneal approach). We used five to six ports. Vesico-urethral anastomosis was sutured by interrupted stitches in two cases and continuous technique in 22 cases. Bilateral pelvic lymphadenectomy were performed in all cases. Demographic data, operative outcome, and pathological outcomes were analyzed. Pathological reports were used with TNM stage following AJCC 2002. The peri-operative parameters and follow-up data were studied. RESULTS: Mean age was 71.3 years and mean serum PSA level was 18.34 ng/ml. Eighty seven percent was clinical localized disease. Most Gleason score was 7. Mean operative time was 208.9 minutes and mean blood loss was 295.8 ml. Blood transfusion rate was 16.7%. Mean hospital stay was 6.1 days and surgical drain was removed at mean time of 3.9 days. Mean catheter time was 12.5 days. Pathological report shows pT1, pT2, and pT3 at 4.2%, 20.8% and 75.0%, respectively No patients had lymph node metastasis. Positive surgical margin rate was 20.0% and 88.9% in pT2 and pT3, respectively Ten cases received adjuvant hormonal therapy because ofp T3. Twenty-three cases were followed at the mean time of 14.8 months and mean serum PSA level was 0.03 ng/ml. At the mean time of follow-up, patients had urinary incontinence in 10 cases. This group had only two cases that used pads, which were more than two pads per day. Two cases had anastomotic stricture that was treated by urethral dilatation. CONCLUSION: Laparoscopic radical prostatectomy is a difficult operation. Training from an experience surgeon is an important step to shorten the learning curve.