Prophylactic pre-operative bilateral ureteric catheters for major gynaecological surgery.

PURPOSE: The use of prophylactic pre-operative bilateral ureteric catheters for major gynaecological surgery is controversial. The aim of this study was to investigate the frequency of ureteric catheter-associated morbidity in our Unit, where systematic pre-operative ureteric catheterisation is performed. METHODS: We conducted a retrospective casenote review of 337 gynaecology patients undergoing laparotomy at Salford Royal Hospital between January 2007 and September 2010. RESULTS: The mean age was 56.36 (range 17-89). Procedures included TAH BSO (n = 249, 74 %), BSO (n = 17, 5 %), radical hysterectomy (n = 36, 11 %), and other (n = 35, 10 %), for indications of ovarian (n = 189, 56 %), uterine (n = 88, 26 %) or cervical cancer (n = 18, 5.3 %), massive fibroids (n = 27, 8 %), severe endometriosis (n = 6, 1.78 %), or other (n = 9, 2.67 %). Bilateral ureteric catheters were attempted in most patients and successfully placed in 315/337 (93 %) patients. In 22 patients (7 %), either no ureteric catheters or a single ureteric catheter was placed due to pre-existing ureteric anomaly, technical difficulty, or surgeon choice. Bilateral ureteric catheterisation took an average of 5.4 min (SD 2.0, range 3.2-9.2) for an experienced consultant or 8.4 min (SD 3.9, range 6.4-18.6) for an SpR trainee to complete. There were no intra-operative ureteric complications. Post-operative complications included urinary tract infection (5/337 patients, 1.48 %), acute renal failure (2/337, 0.6 %), and uretero-vaginal fistulae (1/337 patients, 0.3 %). CONCLUSIONS: Prophylactic pre-operative ureteric catheters are quick and easy to insert and associated with low complication rates. Routine use before major gynaecological surgery can expedite intra-operative identification of the ureters and may reduce accidental ureteric injury.

The surgical rectus sheath block for post-operative analgesia: a modern approach to an established technique.

OBJECTIVE: To describe the surgical rectus sheath block for post-operative pain relief following major gynaecological surgery. TECHNIQUE: Local anaesthetic (20 ml 0.25% bupivacaine bilaterally) is administered under direct vision to the rectus sheath space at the time of closure of the anterior abdominal wall. STUDY DESIGN: We conducted a retrospective case note review of 98 consecutive patients undergoing major gynaecological surgery for benign or malignant disease who received either standard subcutaneous infiltration of the wound with local anaesthetic (LA, n=51) or the surgical rectus sheath block (n=47) for post-operative pain relief. MAIN OUTCOME MEASURES: (1) Pain scores on waking, (2) duration of morphine-based patient controlled analgesia (PCA), (3) quantity of morphine used during the first 48 post-operative hours and (4) length of post-operative stay. RESULTS: The groups were similar in age, the range of procedures performed and the type of pathology observed. Patients who received the surgical rectus sheath block had lower pain scores on waking [0 (0-1) vs. 2 (1-3), p<0.001], required less morphine post-operatively [12 mg (9-26) vs. 36 mg (30-48), p<0.001], had their PCAs discontinued earlier [24h (18-34) vs. 37 h (28-48), p<0.001] and went home earlier [4 days (3-4) vs. 5 days post-op (4-8), p<0.001] [median (interquartile range)] than patients receiving standard subcutaneous local anaesthetic into the wound. CONCLUSIONS: The surgical rectus sheath block appears to provide effective post-operative analgesia for patients undergoing major gynaecological surgery. A randomised controlled clinical trial is required to assess its efficacy further.