Minimally invasive retrieval of a retained Jackson--Pratt drainage tube using the Sachse urethrotome.

OBJECTIVE: A retained postoperative drain tube, trapped by one or more of the sutures of the abdominal wall closure, is a rare complication of frustrating consequences and potential legal repercussions. There are few reports of techniques for minimally invasive removal of an anchored postoperative drain tube, which not infrequently has been treated by reopening the wound. METHOD/RESULT: A 75 years-old man with a left T2-T3N0M0 renal carcinoma was treated with transperitoneal laparoscopic nephrectomy and a Jackson-Pratt drain was left in place. Drain removal the day after revealed impossible, as if being caught with fascial suture. With the patient under sedation, we introduced a Sachse urethrotome parallel to the drain, and the abdominal fascia was identified, then the polyglycolic stitch anchoring it to the wall could be severed, freeing the drain. CONCLUSIONS: Percutaneous extraction with the Sachse urethrotome of an anchored postoperative drain, should be the first option, before trying a forced traction or using more complex options. This technique is for the first time published in the Spanish bibliography, and we think this possibility should be disclosed to abdominal surgeons.

Retirada mínimamente invasiva con el uretromo de Sasche de un drenaje de Jackson-Pratt retenido / Minimally invasive retrieval of a retained Jackson - Pratt drainage tube using the sachse urethrotome

OBJETIVO: La retención de un drenaje postoperatorio, atrapado por una o más de las suturas del cierre de la pared abdominal, es una complicación infrecuente, de consecuencias frustantes y potenciales repercusiones legales. Existen en la bibliografía pocos informes de técnicas para la retirada poco invasiva de un drenaje postquirúrgico anclado, que en no pocas ocasiones se ha tratado mediante la reapertura de la herida. Un varón de 75 años con un carcinoma renal izquierdo T2-T3 N0 M0 fue tratado mediante una nefrectomía laparoscópica intraperitoneal y se dejó implantado un drenaje de Jackson-Pratt. A las 24 horas se puso de manifiesto que la retirada del drenaje era imposible por encontrarse atrapado con la sutura fascial. MÉTODO/RESULTADO: Con el paciente bajo sedación, se introdujo un uretrotomo de Sachse paralelamente al drenaje y se identificó primero la aponeurosis abdominal y a continuación el punto de poliglicólico que lo anclaba a la pared, y que pudo ser seccionado, liberando el drenaje. CONCLUSIONES: La extracción percutánea, mediante el uretrotomo de Sachse, de un drenaje de Jackson-Pratt anclado, debería ser la primera opción, antes de probar una tracción forzada o de recurrir a opciones más complejas. Es la primera vez que se publicita esta técnica en la bibliografía española, y esta posibilidad debería ser divulgada entre los cirujanos abdominales(AU)

OBJECTIVE: A retained postoperative drain tube, trapped by one or more of the sutures of the abdominal wall closure, is a rare complication of frustrating consequences and potential legal repercussions. There are few reports of techniques for minimally invasive removal of an anchored postoperative drain tube, which not infrequently has been treated by reopening the wound. METHOD/RESULT: A 75 years-old man with a left T2-T3N0M0 renal carcinoma was treated with transperitoneal laparoscopic nephrectomy and a Jackson-Pratt drain was left in place. Drain removal the day after revealed impossible, as if being caught with fascial suture. With the patient under sedation, we introduced a Sachse urethrotome parallel to the drain, and the abdominal fascia was identified, then the polyglycolic stitch anchoring it to the wall could be severed, freeing the drain. CONCLUSIONS: Percutaneous extraction with the Sachse urethrotome of an anchored postoperative drain, should be the first option, before trying a forced traction or using more complex options. This technique is for the first time published in the Spanish bibliography, and we think this possibility should be disclosed to abdominal surgeons(AU)

[Extraperitoneal bladder rupture coinciding with bone fragments: the case for surgical treatment]. / Rotura vesical extraperitoneal coincidiendo con esquirlas óseas: necesidad de tratamiento quirúrgico.

INTRODUCTION: In closed traumatic bladder ruptures, a surgical treatment of the intraperitoneal rupture, and a conservative approach to the extraperitoneal one, with bladder catheter, antibiotics and confirmation of bladder wound closure after two to three weeks-, was recommended. Only recently, attention was paid to the importance of the presence of bone fragments of the pelvic fractures, that in the vecinity of a bladder catheter or urinary infection may give raise to either severe pelvic infection or permanent urinary fistula. PATIENTS AND METHOD: The two cases of extraperitoneal bladder rupture here presented, demonstrate the difficulties of a secure diagnosis by CT, and the potential severity of the existence of bone fragments impronting the bladder disruption. COMMENT: Recent consensus on genitourinary trauma emphasizes the need to pay attention to the presence of bone fragments of the pelvic ring fractures in cases of closed bladder rupture. In cases of extraperitoneal bladder rupture with bone fragments in the vecinity, bladder endoscopic examination and surgical treatment may be needed.

[Spontaneous transuretero-ureterostomy after complete stenosis of an ileal conduit, with four years of conservative follow-up]. / Transuretero-ureterostomía espontánea después de estenosis completa de un conducto ileal, con cuatro años de seguimiento conservador.

INTRODUCTION: Stenosis of an ileal conduit is a rare complication of this urinary diversion. In the case here described, such a complication was neglected for some weeks and left the patient in a high risk situation. After implantation of a bilateral nephrostomy, a spontaneous transuretero-ureterostomy was found. CLINICAL CASE: A 70-year-old man with an ileal conduit performed 15 years before because of bladder tumour, was admitted with signs of severe intraabdominal infection and oliguria. The image studies shown intraabdominal abscess, and an almost complete stenosis of the ileal conduit, that was conservatively treated with a bilateral percutaneous nephostomy. After discharged, he reported an accidental falling-out of the right nephrostomy, collecting normal diuresis from the only left nephrostomy. The spontaneous appearance of a transuretero-ureterostomy was demonstrated. The patient refused surgery and remained with a nephrostomy that is periodically changed, and after four years of follow-up he has neither significant kidney dysfunction nor other incidences. COMMENT: The origin of this ileal conduit stenosis is related to the inflammatory or immunologic changes induced by the chronic presence of the urine on the wall of the intestinal segment. This case is singular because of the curious result of an in situ transuretero-ureterostomy, and because of the long conservative follow-up, without significant complications, in a patient that keeps a good quality of life.

Rotura vesical extraperitoneal coincidiendo con esquirlas óseas: necesidad de tratamiento quirúrgico / Extraperitoneal bladder rupture coinciding with bone fragments: the case for surgical treatment

Introducción: En las roturas vesicales traumáticas cerradas, se ha recomendado reparar quirúrgicamente la rotura intraperitoneal y tratar de manera conservadora la extraperitoneal, mediante sonda, antibióticos y comprobación del cierre de la herida vesical a las dos o tres semanas. Sólo recientemente, se ha prestado importancia a la existencia de esquirlas óseas de las fracturas pelvianas vecinas a la lesión vesical, que en presencia de una sonda permanente o de una orina infectada pueden dar lugar a fístulas persistentes o infecciones pelvianas graves. Pacientes y Método: Los dos casos de rotura vesical extraperitoneal que presentamos ponen de manifiesto la dificultad del diagnóstico seguro mediante TAC, y la gravedad de la existencia de esquirlas óseas improntando en la disrupción de la vejiga. Comentario: Los consensos recientes en traumatismo genitourinario destacan la necesidad de prestar atención a la presencia de esquirlas óseas de las facturas del anillo pelviano en los traumatismos vesicales cerrados. En caso de rotura vesical extraperitoneal con fragmentos óseos en la vecindad, la exploración endoscópica y la reparación quirúrgicas pueden ser necesarias (AU)

Introduction: In closed traumatic bladder ruptures, a surgical treatment of the intraperitoneal rupture, and a conservative approach to the extraperitoneal one, with bladder catheter, antibiotics and confirmation of bladder wound closure after two to three weeks-, was recommended. Only recently, attention was paid to the importance of the presence of bone fragments of the pelvic fractures, that in the vicinity of a bladder catheter or urinary infection may give raise to either severe pelvic infection or permanent urinary fistula. Patients and Method: The two cases of extraperitoneal bladder rupture here presented, demonstrate the difficulties of a secure diagnosis by CT, and the potential severity of the existence of bone fragments impronting the bladder disruption. Comment: Recent consensus on genitourinary trauma emphasizes the need to pay attention to the presence of bone fragments of the pelvicring fractures in cases of closed bladder rupture. In cases of extraperitoneal bladder rupture with bone fragments in the vecinity, bladderendoscopic examination and surgical treatment may be needed (AU)

Transuretero-ureterostomía espontánea después de estenosis completa de un conducto ileal, con cuatro años de seguimiento conservador / Spontaneous transuretero-ureterostomy after complete stenosis of an ileal conduit, with four years of conservative follow-up

Introducción: La estenosis del conducto ileal es una complicación infrecuente de esta derivación urinaria. En el caso que describimos pasó durante un tiempo inadvertida y llevó al paciente a una situación de riesgo. Después de implantar una nefrostomía bilateral, se encontró una transuretero-ureterostomia espontánea. Caso Clínico: Un varón de 70 años con un conducto ileal realizado 15 años antes por tener tumor vesical, ingresó con signos de infección intraabdominal grave y oliguria. Los estudios radiológicos mostraron absceso intraabdominal, y se encontró estenosis casi completa del conducto ileal, que se trató conservadoramente mediante una nefrostomia bilateral. Después de ser dado de alta ocurrió la caída accidental de la nefrostomía derecha, recogiendo cantidades normales de orina por la única nefrostomía izquierda. Se comprobó la existencia de una transuretero-ureterostomía espontánea, con estenosis de la porción distal del conducto ileal. Desde entonces permanece con la nefrostomía, que se cambia periódicamente y en cuatro años de seguimiento no ha tenido deterioro renal significativo. Comentario: El origen de esta estenosis se atribuye a los cambios inflamatorios o inmunológicos en la pared del segmento intestinal, inducidos por la presencia crónica de la orina. Nuestro caso es singular por el curioso resultado de una transuretero- ureterostomía in situ y por el largo seguimiento conservador que se hizo, en un paciente que mantiene una calidad de vida buena (AU)

Introduction: Stenosis of an ileal conduit is a rare complication of this urinary diversion. In the case here described, such a complication was neglected for some weeks and left the patient in a high risk situation. After implantation of a bilateral nephrostomy, a spontaneous transuretero-ureterostomy was found. Clinical case: A 70-year-old man with an ileal conduit performed 15 years before because of bladder tumour, was admitted with signs of severe intraabdominal infection and oliguria. The image studies shown intraabdominal abscess, and an almost complete stenosis of the ileal conduit, that was conservatively treated with a bilateral percutaneous nephostomy. After discharged, he reported an accidental falling-out of the right nephrostomy, collecting normal diuresis from the only left nephrostomy. The spontaneous appearance of a transuretero-ureterostomy was demonstrated. The patient refused surgery and remained with a nephrostomy that is periodically changed, and after four years of follow-up he has neither significant kidney dysfunction nor other incidences. Comment: The origin of this ileal conduit stenosis is related to the inflammatory or immunologic changes induced by the chronic presence of the urine on the wall of the intestinal segment. This case is singular because of the curious result of an in situ transuretero-ureterostomy, and because of the long conservative follow-up, without significant complications, in a patient that keeps a good quality of life (AU)