Urological day case surgery in elderly and medically unfit patients using sedoanalgesia: what are the limits?

OBJECTIVE: To assess how elderly and medically unfit patients cope with day case surgery in a urological unit using sedoanalgesia. PATIENTS AND METHODS: One hundred patients (mean age 78 years, range 59-97) either over the age of 75 years, or with an American Society of Anesthesiologists (ASA) status of 3 or 4 (58 patients) were studied before and after surgery to assess their medical condition, home circumstances and how they coped with their first day after the operation. RESULTS: Ninety patients found the procedure good or acceptable and 86 thought having their operation and going home on the same day was a good idea. CONCLUSION: Elderly and medically unfit patients can be treated safely with no serious complications using sedoanalgesia in a well organized Day Unit equipped with full monitoring facilities.

Temporary prostatic stenting and androgen suppression: a new minimally invasive approach to malignant prostatic retention.

Urinary retention secondary to carcinoma of the prostate is usually treated by 'channel' transurethral resection of the prostate either performed alone or in combination with hormone manipulation. The combination of temporary prostatic stenting and androgen suppression may reduce the morbidity and mortality associated with this treatment. We report on our initial experience using the combination of a temporary prostatic stent with the oral anti-androgen Flutamide in 10 patients with urinary retention or severe bladder outflow obstruction secondary to prostatic carcinoma. Eight of the ten patients successfully voided and maintained normal voiding after stent removal. There were two treatment failures requiring prostatic resection. We believe the cost of stenting and medication is entirely justified by patient preference and clearance of hospital beds.

Continuous flow resectoscopes. Are the theory and design wrong?

The optical design of rod-lens telescopes has now reached a zenith. The only way of improving the resectoscope is to investigate the ergonomics and flow dynamics. We present a comparative analysis of the flow mechanics of continuous flow resectoscopes. The morphology, flow characteristics and irrigating potential (washout gradient) of several instruments were examined. It was found that when used with balanced continuous flow (inflow and outflow balanced), all of the endoscopes had poor visibility compared with unbalanced continuous flow (inflow > outflow). Possible changes in the design of the instruments are discussed.

Does too much urology damage your eyesight? Study of macular function.

A study comparing the macular function of both eyes of 130 urological surgeons was carried out to investigate whether the increased light exposure to the endoscoping eye caused any deterioration of macular function. The non-endoscoping eye was used as a control. A sophisticated computer test of colour contrast sensitivity was used. The computer assesses the degree of brightness at which the subject is just able to detect a coloured grating, and for each eye this is expressed as a threshold for the red/green axis and the blue/yellow (tritan) axis. The subjects also completed a questionnaire about their working patterns and their general and ophthalmic history and had a brief examination of the fundus. The results do not suggest that urologists are suffering any significant macular damage as a result of their work with endoscopes.

Blue light emission from urological equipment. Can it damage the eyes?

Blue light present in the visible spectrum at the lower wavelengths can cause damage to the retinas of monkeys and rats. In the present study the light sources and instrumentation available to the urologist were evaluated to see whether they posed a hazard. The light emitting directly from the sources, cables and telescopes was tested and these levels were found to be dangerous to the eye when compared with the safety limit recommended by the American Conference of Governmental Industrial Hygienists (ACGIH). When the light at the eyepiece of the telescopes which had been reflected off a surface was measured, the blue light levels did not appear to be harmful when compared with the ACGIH safety limit. The use of filters is discussed and the transmission of 2 types of filters shown. While the level of blue light emission from the eyepiece remains within the ACGIH level, there are no data on long-term exposure. The addition of a blue light filter may be beneficial until such time as videoendoscopy becomes the norm. The light from light sources should be protected by a shutter and more care taken with the emission from cables and telescopes.

Guillain-Barré syndrome following cardiopulmonary bypass.

Two cases of Guillain-Barré syndrome occurring after otherwise uneventful cardiac surgery using cardiopulmonary bypass are presented. Although Guillain-Barré syndrome has been reported after surgical procedures, it has never been reported after cardiopulmonary bypass. Recent literature supports an immune mediated process for Guillain-Barré. Cardiopulmonary bypass may act as the trigger for this immune mediated response.

Dynamic clearance: mathematical assessment of flow mechanics in prostatic resection.

The understanding of flow mechanics in endoscopy is poor. In prostatic surgery, emphasis has been placed on limiting the rise of intravesical pressure with little regard to the effect on flow mechanics and visibility. A model has been developed using dynamic clearance to compare different methods of prostatic resection. The results show that in a 0.95-cm glass urethra, continuous flow irrigation has slower clearance at all flow rates when compared with intermittent irrigation and suprapubic suction. Although intravesical pressure is important, attention should also be paid to flow dynamics and more emphasis should be placed on this when new instruments and fluid delivery systems are developed.

Flow visualization in uroendoscopy: the steal effect.

Balanced continuous flow resection has been offered as the best form of irrigation in uroendoscopy. Although it will keep the bladder pressure low, using flow visualization techniques it has been demonstrated that it does not fulfil the requirements of an irrigating fluid when used in a confined environment such as the prostatic urethra. The outflowing irrigating fluid has been shown to be taken directly from the inflowing jet ('steal effect') thereby reducing the effectiveness of the irrigating jet on the working area of the resectoscope.

Beds or day case unit: your choice?

The aim of this study was to assess the amount of day case surgery and potential day case surgery being performed in the main theatre block of a District General Hospital, which had a thriving Day Case Unit. Our results revealed that as well as large numbers of potential day cases being performed as inpatients, many patients (both potential day cases and long-stay elective surgery patients) are spending a day(s) in hospital prior to the day of surgery. We believe that by performing all day case surgery in our Day Case Unit and by using the Day Case Unit to perform pre-admission screening on all surgical patients, a large number of bed days will become available. These beds may be used for elective or emergency admissions. Alternatively, cutting surgical beds will free monies which can be spent on the Day Case Unit.

Gastric abscess--an unusual presentation. Case report.

Gastric abscess is a rare inflammatory condition of the gastric wall. It is seldom diagnosed preoperatively because of the variety of clinical presentations mimicking the more common conditions. We report a case of a gastric abscess thought preoperatively to be a strangulated epigastric hernia. This prompted early and appropriate surgery.

Fluid delivery systems: high flow, low pressure, the key to safe resection.

The transurethral resection of the prostate (TURP) syndrome has been attributed to the effects of the excess absorption of irrigating fluid. Absorption may be reduced by preventing bladder distension using continuous irrigating resectoscopes or suprapubic trocar drainage. Pressure rises should be limited by the head of pressure in the fluid delivery systems. The flow pressure characteristics of two competing systems, Flowfusor (Kendall-McGaw) and Uromatic (Baxter), were evaluated. We have demonstrated that the Kendall-McGaw Flowfusor V4537 system provides adequate flow at a reduced head of pressure by virtue of the rigid container system and intrinsic negative pressure. The safety of TURPs is increased by reducing the risk of absorption.