Autonomic dysreflexia in urological practice: pathophysiology, prevention and treatment considerations.

PURPOSE: Spinal cord injury (SCI) leads to sensorimotor impairments; however, it can also be complicated by significant autonomic dysfunction, including cardiovascular and lower urinary tract (LUT) dysfunctions. Autonomic dysreflexia (AD) is a dangerous cardiovascular complication of SCI often overlooked by healthcare professionals. AD is characterized by a sudden increase in blood pressure (BP) that can result in severe cardiovascular and cerebrovascular complications. In this review, we provide an overview on the clinical manifestations, risk factors, underlying mechanisms, and current approaches in prevention and management of AD. METHODS: After conducting a literature research, we summarized relevant information regarding the clinical and pathophysiological aspects in the context of urological clinical practice CONCLUSIONS: The most common triggers of AD are those arising from LUT, such as bladder distention and urinary tract infections. Furthermore, AD is commonly observed in individuals with SCI during urological procedures, including catheterization, cystoscopy and urodynamics. Although significant progress in the clinical assessment of AD has been made in recent decades, effective approaches for its prevention and treatment are currently lacking.

Factores relacionados con la práctica de sondaje vesical en urgencias en pacientes ancianos y su relación con el pronóstico: resultados del estudio EDEN-30 / Factors related to bladder catheterization in older patients and its possible association with prognosis: results of the EDEN-30 study

Objetivos. Estudiar las variables de estado basal y de situación clínica a la llegada a urgencias relacionadas con la práctica de sondaje vesical (SV) en pacientes mayores, y si el SV está asociado a una evolución más compleja o grave. Método. Se incluyeron todos los pacientes de edad $ 65 años atendidos durante una semana en 52 servicios de urgencias (SU) españoles, que fueron clasificados en función de si se practicó o no SV en el SU. Se investigó la relación de SV con edad, sexo, 10 variables de comorbilidad, 7 de estado basal y 6 de situación clínica mediante un modelo de regresión logística multivariable. Se consideró la evolución como grave o compleja si existió necesidad de hospitalización, estancia prolongada, necesidad de residencia al alta o muerte. La relación entre edad y SV se exploró también mediante curvas spline cúbicas restringidas (SCR) ajustadas, tomando la edad de 65 años como referencia. (AU)

Objectives. The aims of this study in the Emergency Department and Elder Needs (EDEN) series were to explore associations between clinical variables on arrival at the ED (baseline) and the insertion of a bladder catheter, and the relation between catheterization and deterioration to a more complex or serious clinical state. Methods. Included were all patients aged 65 years or older attended during 1 week in 52 Spanish EDs. Patients were grouped according to whether a bladder catheter was or was not inserted in the ED. We used multivariable logistical regression to explore associations between catheterization and patient age, sex, 10 comorbidities, 7 baseline status variables, and 6 clinical variables. Progression was considered serious or complex if the patient died or required hospitalization, a prolonged hospital stay, or discharge to a care facility. We also explored the association between age and catheterization using adjusted restricted cubic spline (RCS) curves with a cutoff value of 65 years. (AU)

Factors related to bladder catheterization in older patients and its possible association with prognosis: results of the EDEN-30 study. / Factores relacionados con la práctica de sondaje vesical en urgencias en pacientes ancianos y su relación con el pronóstico: resultados del estudio EDEN-30.

OBJECTIVES: The aims of this study in the Emergency Department and Elder Needs (EDEN) series were to explore associations between clinical variables on arrival at the ED (baseline) and the insertion of a bladder catheter, and the relation between catheterization and deterioration to a more complex or serious clinical state. MATERIAL AND METHODS: Included were all patients aged 65 years or older attended during 1 week in 52 Spanish EDs. Patients were grouped according to whether a bladder catheter was or was not inserted in the ED. We used multivariable logistical regression to explore associations between catheterization and patient age, sex, 10 comorbidities, 7 baseline status variables, and 6 clinical variables. Progression was considered serious or complex if the patient died or required hospitalization, a prolonged hospital stay, or discharge to a care facility. We also explored the association between age and catheterization using adjusted restricted cubic spline (RCS) curves with a cutoff value of 65 years. RESULTS: Participating hospitals enrolled 24 573 patients; bladder catheters were inserted in 976 (4%). Of these, 44.3% were discharged from the ED. Fifteen of the 24 variables were independently associated with bladder catheterization. Factors with the strongest associations according to odds ratios (ORs) were impaired consciousness (OR, 2.50; 95% CI, 1.90-3.30), dehydration (OR, 2.24; 95% CI, 1.85-2.72), and male sex (OR, 2.12; 95% CI, 1.84- 2.44). Age 80 years or older was also associated with bladder catheterization (OR, 1.17; 95% CI, 1.01-1.358). The adjusted RCS curves showed a progressive linear increase in the probability of catheterization with age. The increase was constant in men and stabilized after the age of 85 years in women (P-interaction .001). Bladder catheterization was associated with hospitalization (OR, 2.31; 95% CI, 1.99-2.68), intensive care unit admission (OR, 4.64; 95% CI, 3.04-7.09), prolonged stay in the ED for discharged patients (OR, 2.28; 95% CI, 1.75-2.96), in-hospital death (OR, 1.99; 95% CI, 1.54-2.57), and 30-day death (OR, 1.66; 95% CI, 1.33-2.08). No associations were found between catheterization and prolonged hospital stay (OR, 1.11; 95% CI, 0.92-1.34) or need for a care facility on discharge (OR, 1.50; 95% CI, 0.98-2.29). CONCLUSION: Certain patient characteristics and baseline clinical conditions are associated with bladder catheterization in patients of advanced age. The main factors were decreased consciousness, dehydration, and male sex. Even after adjustment for related factors, catheterization is independently associated with progression to more complex or serious clinical states.

OBJETIVO: Estudiar las variables de estado basal y de situación clínica a la llegada a urgencias relacionadas con la práctica de sondaje vesical (SV) en pacientes mayores, y si el SV está asociado a una evolución más compleja o grave. METODO: Se incluyeron todos los pacientes de edad 65 años atendidos durante una semana en 52 servicios de urgencias (SU) españoles, que fueron clasificados en función de si se practicó o no SV en el SU. Se investigó la relación de SV con edad, sexo, 10 variables de comorbilidad, 7 de estado basal y 6 de situación clínica mediante un modelo de regresión logística multivariable. Se consideró la evolución como grave o compleja si existió necesidad de hospitalización, estancia prolongada, necesidad de residencia al alta o muerte. La relación entre edad y SV se exploró también mediante curvas spline cúbicas restringidas (SCR) ajustadas, tomando la edad de 65 años como referencia. RESULTADOS: Se incluyeron 24.573 pacientes, de los que 976 (4%) recibieron SV. De éstos, el 44,3% fueron dados de alta desde urgencias. De las 25 variables exploradas, 15 se relacionaron independientemente con el SV, y las más manifiestas fueron disminución de consciencia (OR = 2,50, IC 95% = 1,90-3,30), deshidratación (OR = 2,24, IC 95% = 1,85-2,72) y sexo masculino (OR = 2,12, IC 95% = 1,84-2,44). La edad 80 años también se asoció a SV (OR = 1,17, IC 95% = 1,01-1,358), y las curvas SCR ajustadas mostraron un incremento progresivo y lineal de la probabilidad de SV con la edad, constante en hombres y que se estabilizaba a partir de los 85 años en mujeres (p interacción 0,001). El SV se asoció a necesidad de hospitalización (OR = 2,31, IC 95% = 1,99-2,68), hospitalización en intensivos (OR = 4,64, IC 95% = 3,04-7,09), estancia prolongada en urgencias en los pacientes dados de alta (OR = 2,28, IC 95% = 1,75-2,96) y mortalidad intrahospitalaria (OR = 1,99, IC 95% = 1,54-2,57) y a 30 días (OR=1,66, IC 95% = 1,33-2,08), pero no con hospitalización prolongada (OR = 1,11, IC 95% = 0,92-1,34) ni con necesidad de residencia al alta (OR = 1,50, IC 95% = 0,98-2,29). CONCLUSIONES: Determinadas características del paciente mayor y de su estado clínico se asocian con realizar un SV en urgencias, entre las que destacan la disminución de consciencia, la deshidratación y el sexo masculino. Aun teniendo en cuenta los factores asociados a SV en urgencias, este procedimiento se asocia independientemente con evoluciones más complejas o graves.

Investigating Catheter-Related Infections in Southern Benin Hospitals: Identification, Susceptibility, and Resistance Genes of Involved Bacterial Strains.

The use of catheters and bladder catheters in hospitals can increase the risk of bacterial infections. This study aimed to identify the bacterial strains involved in catheter-related infections (CRI) in southern Benin hospitals. The study included 407 samples, including 95 catheter tip samples and 312 urine samples collected from bladder catheters from patients on the first day and 48 h after admission. The catheter tip samples were analyzed using traditional bacterial isolation and identification methods, while the urine samples were analyzed using VITEK-2. Antibiotic sensitivity was tested using the Kirby Bauer method, and virulence and resistance genes were detected through standard PCR. The results showed a predominance of Escherichia coli (53.5%), Klebsiella pneumoniae (23.3%), and Enterobacter aerogenes (7.0%) among Gram-negative bacilli, and coagulase-negative Staphylococcus as the most identified cocci. Bacterial susceptibility to antibiotics showed variable levels of resistance, with blaTEM being detected in 42.9% of identified bacterial species, followed by blaSHV (26.2%) and blaCTX-M-15 (16.7%). The blaNDM gene was only found in three identified bacterial strains, while vanA and vanB genes were detected in 3.2% of strains with a prevalence of 55% for the mecA gene. A prevalence of 18.8% for fimH was noted for the virulence genes. In conclusion, this study highlights the importance of following proper hygiene and aseptic practices during catheterization to effectively prevent CRIs. These findings should be used to improve interventions in hospitals and reduce healthcare-associated infections in developing countries.

Infección urinaria producida por enterococo faecalis y enterococo faecium asociada a sonda vesical: factores de riesgo y evaluación de los patrones de resistencia / Urinary infection produced by enterococcus faecalis and enterococcus faecium associated with bladder catheterization: risk factors and evaluation of resistance patterns

Background and objectives: Urinary tract infection (UTI) is one of the most common infections in hospitalized and outpatients. Bladder catheterization is an important risk factor. The increase in antibiotic resistance can make the treatment of these infections a challenge. The main objective of this study is to analize the resistance and sensitivity rates of UTIs in catheterized patients caused by Enterococcus (E.faecium and E.faecalis). Associated riskfactors were also studied. Materials and methods: Retrospective observational study of patients with urinary infection associated to catheterization caused by E.faecium and E.faecalis during 2020 in al Internal Medicina Unit. Results: Ampicillin was the antibiotic with the highest resistance rate in the case of E.faecium (94.4%), while 93.05% of E.faecalis presented resistance to Gentamicin. Teicoplanin and Vancomycin were the ones with the lowest rates. Regarding risk factors, dementia, catheterization > 5 days, previous antibiotic therapy, immunosuppresion, and institutionalized patients were statistically significant. Conclusions: It is important to know the epidemiology of UTIs in each area, as well as the raties of resistance and risk factors in order to provide the most adequate treatment possible, and to avoid the increase in resistance. (AU)

Introducción y objetivos: La infección urinaria es una de las infecciones intra y extrahospitalarias más frecuentes, siendo el sondaje vesical uno de los principales factores de riesgo. El aumento de resistencias antibióticas al que estamos asistiendo hace que su tratamiento a veces suponga un reto. El objetivo principal del estudio pretende analizar las tasas de resistencia y sensibilidad de las principales infecciones urinarias producidas por Enterococos (E.faecium y E.faecalis) en pacientes sondados. También se estudiaron los factores de riesgo asociados. Material y métodos: Estudio retrospectivo observacional de pacientes con infección urinaria asociada a sondaje por E.faecium y E.faecalis durante el año 2020 en un servicio de Medicina Interna. Resultados: La ampicilina fue el antibiótico que mayor tasa de resistencia obtuvo en el caso de E.faecium (94.4%), mientras que el 93.05% de casos por E.faecalis presentó resistencias a gentamicina. Teicoplanina y vancomicina fueron los que menores tasas tuvieron. En cuanto a los factores de riesgo, la demencia, el sondaje > 5 días, la antibioterapia previa, la inmunodepresión y los pacientes institucionalizados fueron estadísticamente significativos. Conclusiones: Es importante conocer la epidemiología de las infecciones urinarias de la zona por áreas geográficas, así como las tasas de resistencias y los factores de riesgo con el fin de un tratamiento lo más adecuado posible, y evitar el aumento de resistencias. (AU)

Reacción anafilactoide a látex tras colocación de malla transvaginal para corrección de cistocele / Anaphylactoid latex reaction after transvaginal mesh placement for cystocele correction

La incidencia de alergia al látex en la población general es del 1-2%, siendo las reacciones más frecuentemente descritas de hipersensibilidad inmediata o tipo i y tardía o tipo iv, aunque también han sido descritas reacciones de hipersensibilidad no mediadas por IgE.Presentamos el caso de una mujer de 71 años con factores de riesgo cardiovascular (HTA y DLP) e intervenida previamente de colecistectomía y cistocele que ingresa de forma programada para intervención de recidiva de cistocele grado iv tras 4 años de la primera intervención.En el postoperatorio inmediato presenta fracaso renal agudo, por lo que se retira la malla a las 24h, persistiendo deterioro progresivo del estado general con dificultad respiratoria, disminución del nivel de conciencia y empeoramiento de la función renal. Tras una exploración exhaustiva se visualiza eritema en región vulvar e inguinal, por lo que se sospecha reacción anafiláctica a sonda de látex, que se recambia por una sonda de silicona, iniciándose tratamiento con metilprednisolona intravenosa y se consulta con el servicio de Alergología, que establece finalmente el diagnóstico.La paciente requirió ingreso en la unidad de cuidados intensivos durante 10 días por insuficiencia renal aguda e insuficiencia respiratoria aguda asociadas a íleo paralítico y coagulopatía.La anafilaxia es una reacción sistémica aguda que resulta en la liberación brusca de mediadores de los mastocitos y basófilos, mediada o no por IgE. Se admite que es una reacción de hipersensibilidad sistémica grave, de inicio repentino y potencialmente mortal. Clínicamente se asocia a la aparición de manifestaciones cutáneas relacionadas con alteraciones cardiovasculares, respiratorias o gastrointestinales.

Allergy to latex in the general population is 1-2%, the most frequent reactions described being immediate or type i and late or type iv hypersensitivity, although non-IgE-mediated hypersensitivity reactions have also been described.We present the case of a 71-year-old woman with cardiovascular risk factors (HTN and PLD) and previously operated on for cholecystectomy and cystocele who was admitted on a scheduled basis for intervention for grade iv cystocele recurrence, 4 years after the first intervention.In the immediate postoperative period, she presented acute renal failure, for which the mesh was removed after 24h, her general condition progressively deteriorated with respiratory distress, decreased level of consciousness, and worsening of renal function. After an exhaustive examination, erythema was visualized in the vulvar and inguinal region, hence the suspicion of an anaphylactic reaction to a latex catheter, which was replaced by a silicone catheter. Treatment was started with intravenous methylprednisolone, and the Allergology service was consulted who finally established the diagnosis.The patient required admission to the intensive care unit for 10 days due to acute renal failure and acute respiratory failure, associated with paralytic ileus and coagulopathy.Anaphylaxis is an acute systemic reaction that results in the abrupt release of mediators from mast cells and basophils, mediated or not by IgE. It is recognized to be a severe, sudden onset, and life-threatening systemic hypersensitivity reaction. Clinically, it is associated with the appearance of skin manifestations related to cardiovascular, respiratory, or gastrointestinal disorders.

Prospective determination of the incidence and severity of hyponatraemia in older hospitalised patients with acute urinary tract obstruction.

INTRODUCTION: acute urinary tract obstruction (aUTO) is a common finding in older hospitalised patients. Anecdotal reports described hyponatraemia in patients with aUTO, which subsides rapidly with relief of the obstruction.The aim of this study was to determine the incidence, severity and subsequent correction of hyponatraemia in patients with aUTO. METHODS: this is a prospective, single-centre, observational study including inpatients in the internal medicine and geriatric wards. A total of 204 patients were investigated, 104 with aUTO and 100 controls. The prevalence, severity and associations of hyponatraemia between aUTO and control patients were compared. RESULTS: the incidence of hyponatraemia was similar in aUTO and control groups 28% versus 22%, respectively (P = 0.42). However, the incidence of severe hyponatraemia was significantly higher in the study group 7% versus 1% (P = 0.04). Mean sodium level was lower in hyponatremic patients with aUTO 127.7 ± 5.9 mEq/l versus 130.8 ± 3 mEq/l (P = 0.013). Serum sodium remained largely unchanged in the control group (∆Na 1.5 ± 2.3 mEq/l) but increased significantly within 48 hours following catheter insertion in patients with urinary retention (∆Na 5.3 ± 4.2 mEq/l overall in the aUTO group and 9.6 ± 3 mEq/l in those with urinary retention and severe hyponatraemia (P = 0.002)).

Chronic bladder catheterization for precise urine collection in awake mice.

Metabolic chambers are routinely used for urine collection in rodents. In mice, due to small urination volume, evaporation in the metabolic chambers (≈50%) distorts diuresis and urinalysis parameters. We have developed a new technique of bladder catheterization enabling long-term accurate and contamination-free urine collection in awake male and female mice for 30 days or longer. Daily diuresis in catheterized mice was twice higher as compared to metabolic cages. The twofold difference in urine recovery was preserved when the circadian variation of diuresis, the effects of furosemide, desmopressin and water load were estimated using the two techniques. Urine osmolarity, urinalysis, and microbiological parameters evidence higher quality of the catheter-collected urine. Using phenol red, we demonstrate utility of our technique for pharmacokinetic studies. 30 days after the surgery the catheters were patent and had minimal impact on the animals' heath. Bladder catheterization is a useful tool for physiological, pharmacological, and toxicological studies.

Quality of Life and Autonomy in Patients with Intermittent Bladder Catheterization Trained by Specialized Nurses.

Intermittent bladder catheterization (IBC) involves regular urine draining using a catheter, which is removed immediately after urinary elimination. It allows for the patient's urological health to be managed and their renal function to be preserved, and it promotes autonomy. Compliance with the prescribed number of daily catheterizations, which must be conducted by the patient, and infection prevention measures are crucial. To identify the patients requiring IBC, and to determine their adherence (whether they followed the prescribed guidelines and their difficulty in carrying out the procedure, as well as to assess how the IBC influences their quality of life and state of mind after receiving self-care training from a specialized nurse), we carried out a prospective, multicenter observational study in 24 Spanish hospitals with one month of monitoring and a sample of 99 patients. The sources of information were the patients' clinical records, the King's Health Questionnaire, the Mini-Mental State Examination (MMSE), and the hospital anxiety and depression scale (HADS). Descriptive and bivariate statistics were used to analyses the paired data. After recruitment (n = 99), 79 patients completed the questionnaire at a mean age of 35.2 years (SD = 20.5 years). In total, 53.5% (53) of the sample consisted of men and 32.3% (32) had neurological damage as the reason for prescription; 67% (67.7) performed self-catheterization and 86.7% adhered to the IBC. After one month of monitoring, a statistically significant improvement in quality of life was observed in all criteria, with the exception of personal relationships (p < 0.005), as well as an improvement in anxiety and depression levels (p < 0.001). Patients who require IBC show good adherence to the IBC with a significant percentage of self-catheterization. After one month of IBC, a significant improvement in the patients' quality of life and mood was observed. These results could be attributed to adequate patient training and adequate personalization of the IBC materials by the specialized nurses.

A randomized double-blind trial comparing the effect on pain of an oral sucrose solution versus placebo in children 1-3 months old needing bladder catheterization.

OBJECTIVE: The efficacy of oral sweet solutions to decrease pain in infants during painful procedures remains uncertain. This study aimed to compare the efficacy of an oral sucrose solution versus placebo in reducing pain during bladder catheterization in infants in the Emergency Department (ED). METHODS: A randomized, double-blind clinical trial was conducted in a pediatric university-affiliated hospital ED. Infants 1-3 months old were recruited and randomly allocated to receive 2 ml of sucrose or placebo, 2 min before bladder catheterization. The primary outcome measure was the difference in pain scores as assessed by the Face, Legs, Activity, Cry and Consolability (FLACC) Pain Scale during procedure. Secondary outcome measures were the difference in pain scores using the Neonatal Infant Pain Scale (NIPS), crying time, variations in heart rate and adverse events. RESULTS: Eighty-three participants were recruited and completed the study, 41 and 42 in the sucrose and placebo groups, respectively. The mean difference in FLACC scores compared to baseline was 5.3 in the sucrose group vs. 6.4 in the placebo group during catheterization. There were no differences in FLACC scores or NIPS scores measured at 1, 3 and 5 min post procedure. Mean crying times were similar: 97 vs. 110 s. No significant difference was found in participants' heart rate variations. No adverse events were reported. CONCLUSIONS: In infants undergoing bladder catheterization in the ED, administration of an oral sweet solution was not associated with lower pain as measured by the FLACC and NIPS scales. Participants' heart rate variations and crying times did not change when sucrose was provided.

RéSUMé: OBJECTIF: L'efficacité des solutions sucrées orales pour diminuer la douleur chez les nourrissons pendant les procédures douloureuses reste incertaine. Cette étude visait à comparer l'efficacité d'une solution de saccharose orale par rapport à un placebo pour réduire la douleur pendant le cathétérisme vésical chez les nourrissons dans le service d'urgence. MéTHODES: Un essai clinique randomisé en double aveugle a été mené dans les urgences d'un hôpital universitaire pédiatrique. Des nourrissons âgés de 1 à 3 mois ont été recrutés et répartis au hasard pour recevoir 2 ml de sucrose ou de placebo, 2 minutes avant le cathétérisme vésical. La principale mesure des résultats était la différence dans les scores de douleur évalués par l'échelle de douleur FLACC (Face, Legs, Activity, Cry and Consolability) pendant la procédure. Les mesures de résultats secondaires étaient la différence des scores de douleur en utilisant l'échelle de douleur du nourrisson néonatal (NIPS), la durée des pleurs, les variations de la fréquence cardiaque et les événements indésirables. RéSULTATS: Quatre-vingt-trois participants ont été recrutés et ont terminé l'étude, 41 et 42 dans les groupes sucrose et placebo, respectivement. La différence moyenne des scores FLACC par rapport à la ligne de base était de 5,3 dans le groupe sucrose contre 6,4 dans le groupe placebo pendant le cathétérisme. Il n'y avait aucune différence dans les scores FLACC ou NIPS mesurés à 1, 3 et 5 minutes après la procédure. La durée moyenne des pleurs était similaire : 97 contre 110 secondes. Aucune différence significative n'a été constatée dans les variations de la fréquence cardiaque des participants. Aucun événement indésirable n'a été signalé. CONCLUSIONS: Chez les nourrissons soumis à un cathétérisme vésical aux urgences, l'administration d'une solution sucrée orale n'était pas associée à une douleur moindre, telle que mesurée par les échelles FLACC et NIPS. Les variations de la fréquence cardiaque et les temps de pleurs des participants ne changeaient pas lorsque du saccharose était administré.

Evidence-based labor management: first stage of labor (part 3).

There are several interventions during the first stage of labor that have been studied. Vaginal disinfection with chlorhexidine cannot be recommended. Intrapartum antibiotic prophylaxis is recommended for group B streptococcus-positive women. Antibiotic therapy can be considered in women with term prelabor rupture of membranes whose latency is expected to be >12 hours. Aromatherapy with essential oils through inhalation or back massage can be considered. Immersion in water can be considered. Oral restriction of fluid or solid food is not recommended. In the setting of oral restriction, intravenous fluid containing dextrose at a rate of 250 mL/h is recommended. Upright positions and ambulation are recommended in women without regional anesthesia, and women with regional anesthesia can adopt whatever position they find most comfortable and choose to ambulate or not ambulate. Continuous bladder catheterization cannot be recommended. There is no recommended frequency of cervical examinations or sweeping of membranes. The use of a partogram cannot be recommended as a routine intervention. Routine use of the peanut ball cannot be recommended. Antispasmodic agents cannot be recommended. Routine amniotomy alone in normally progressing spontaneous first stage of labor cannot be recommended. Oxytocin augmentation is recommended to shorten the time to delivery for women making slow progress in spontaneous labor, and higher doses of oxytocin can be considered. Early intervention with oxytocin and amniotomy for the prevention and treatment of dysfunctional or slow labor is recommended. Routine use of intrauterine pressure catheter and ultrasound cannot be recommended. Cesarean delivery for arrest should not be performed unless labor has arrested for a minimum of 4 hours with adequate uterine activity or 6 hours with inadequate uterine activity in a woman with rupture of membranes, adequate oxytocin, and ≥6 cm cervical dilation.

[Socio-economic aspects of neurogenic dysfunctions in urology].

AIM: to evaluate the medico-economic significance of neurogenic lower urinary tract dysfunction (NLUTD) in the Russian Federation, to calculate the economic burden of NLUTD in patients with targeted entities and to prepare suggestions for improving the methods of payment for the provision of medical care to patients with NLUTD in inpatient practice. MATERIALS AND METHODS: an analysis of the literature and an expert assessment of the prevalence of NLUTD in the Russian Federation were performed. Due to the various etiology of NLUTD, the following entities were considered: craniocerebral trauma, acute stroke, multiple sclerosis, spinal cord injury (hereinafter referred to as targeted entities), characterized by the highest rate of NLUTD and high social significance (damage to the working-age population): traumatic brain injury, acute stroke, multiple sclerosis, spinal cord injury. The calculations of the economic burden of NLUTD and its main complications (stage 5 of chronic kidney disease (CKD), urinary tract infection) in the Russian Federation (using mainly the normative method) were carried out, based on national statistics, regulatory legal acts and expert assessments of healthcare specialists. Proposals have been prepared for improving the reimbursement (tariffs of the KSG) for payment of NLUTD in the inpatient practice. RESULTS: according to the study, the number of patients with NLUTD due to the group of targeted entities is estimated at 910 000. The economic burden (excluding indirect and unaccounted costs) of the NLUTD is 33.3 billion rubles per year. The burden associated with secondary complications (stage 5 CKD, urogenital infection) due to ineffective diagnosis and treatment of NLUTD is 51.6 billion rubles. The total costs on the NLUTD is estimated at 84.9 billion rubles. Direct costs, calculated by the normative method based on the analysis of standards of medical care per patient are 36,546 rubles per year. Provision of medical care to patients with NLUTD in accordance with federal guarantees within the framework of the compulsory medical insurance is provided in accordance with the tariffs of KSG st30.005 (profile "urology"). The KSG tariff for 2019 (taking into account the established standards of financial costs for one case of hospitalization in the inpatient department and the established cost-intensity coefficients (CZ) established by the CG is 21,495.07 rubles, which is 58% of the minimum need, excluding the cost of treatment of complications, according to the normative method of calculation. The real estimate of the tariff for the payment of treatment of NLUTD in the constituent entities of the Russian Federation is 35-38% of the minimum need, excluding the cost of treatment of complications, according to the normative method of calculation. The real estimate of the costs for the treatment of NLUTD in regions is 35-38% of the minimum need, excluding the cost of treatment of complications, according to the normative method of calculation. To provide effective specialized urological care in the framework of compulsory medical insurance at the rates of the CSG for neuro-urological care (st30.005), expert calculations of the actual cost of NLUTD therapy were made. The proposed average cost of the CSG and the values of the cost intensity factors: CSG (min) st30.005.1 - 39,936 rubles, CZ - 1.65; CSG (max) st30.005.2 - 68,531 rubles, CZ - 2.75. The weighted average savings while expanding the availability of complex neuro-urological care for patients with NLUTD in accordance with the proposed payment rates is 9.4 billion rubles per year. CONCLUSIONS: Evaluation of the prevalence and burden of NLUTD showed the high medical and economic significance of NLUTD in the Russian Federation. The results of the study indicate a significant discrepancy between the requirements and the real costs within federal guarantees for the organization of medical care for patients with NLUTD. To provide effective specialized urological care in the compulsory medical insurance at the rates of CSG for neuro-urological care, it is necessary to increase funding, through the correction at the federal level of the cost-intensity coefficient from 1.65 to 2.75 for the CSG st30.005, which will ensure the increase in the cost for a case of treatment in inpatient department in form 39 936 to 68 531 rubles. The weighted average savings while expanding the availability of complex neuro-urological care for patients with NLUTD in accordance with the proposed payment rates is 9.4 billion rubles per year.

No drains in thoracic surgery with ERAS program.

Enhanced recovery after lobectomy surgery (ERAS) concept has been greatly developed between clinical implementation and minimally invasive surgery. In addition to the minimally invasive surgery, the management of the perioperative catheter has also attracted everyone's attention. Tubeless minimally invasive treatment includes no urinary catheter placement during the operation and no chest tube after the operation. Here, we summarized all the reports on no urinary catheterization and no chest tube in patients with thoracic surgery and the impact of postoperative length of stay (LOS) and postoperative complications. We find that avoiding chest drain and urinary catheter placement after the surgery appears to be safe and beneficial for patients.

Extended bladder catheterization for women with positive dye tests after obstetric vesicovaginal fistula repair surgery.

OBJECTIVE: To determine the success rate and factors that result in a negative dye test after extended bladder catheterization after surgery for obstetric fistula. METHODS: A retrospective cohort study was carried out on women who underwent obstetric fistula repair in Malawi and had ≥14 days of bladder catherization. Variables such as age, class of fistula, previous repairs, menopausal status, and HIV status were examined for association with successful healing at the end of the catheterization period. RESULTS: Fifty-two patients had a positive dye test after the intended period of catheterization and the catheterization period was extended by 7 days. Of these patients, 29 (55.7%) had a subsequent negative dye test. Older women (mean age 28.4 years) who developed a fistula were more likely to have a negative dye test after extended catheterization, compared to their younger counterparts (mean age 20 years) (P=0.0018). Other variables were not found to be significantly different between the two groups. CONCLUSION: More than half of the patients with a positive dye test had complete closure of the fistula defect after an extension of bladder decompression. It is reasonable to consider an extension of bladder catheterization for 7 days after an initial positive dye test.

[Functional changes during the voiding phase in males with non-neurogenic detrusor underactivity undergoing bladder catheterization.] / Cambios funcionales en la fase miccional de varones diagnosticados de detrusor hipoactivo no neurogénico sometidos a cateterización vesical.

OBJECTIVES: To investigate urodynamic changes during the voiding phase in males with detrusor underactivity (DU) undergoing bladder catheterization for urinary retention. METHODS: From a total of 64 patients with urinary retention, a follow-up study was performed in 17 males with a mean age of 77 years. Patients received a urodynamic diagnosis of DU based on a Bladder Contractility Index (BCI) score of < 100 and underwent permanent bladder catheterization (16 cases) or clean intermittent catheterization (1 case) for acute urinary retention (14 cases), or post void residual urine (3 cases). Patients underwent a second urodynamic study after a mean 13 months of follow-up. Fisher's exact test was used with categorical variables and Student's t test with parametric variables. The level of significance was set at p < 0.05 for a two-sided test. RESULTS: The second urodynamic study showed a significant increase in maximal detrusor pressure, pressure at maximum flow rate, BCI score, Bladder Outlet Obstruction Index (BOOI) score, and number of patients who urinated during the pressure-flow study. CONCLUSIONS: Bladder catheterization in men with DU significantly improves bladder contractility and revealed obstructions of the lower urinary tract that were masked by insufficient detrusor pressure in relation to the DU of these patients. These findings could have diagnostic as well as prognostic and therapeutic applications.

OBJETIVOS: Determinar los cambios urodinámicos de la fase miccional en varones con hipocontractilidad del detrusor (DU) sometidos a cateterismo vesical por retención urinaria. MÉTODOS: De un total de 64 pacientes con retención urinaria, se realizó un estudio de seguimiento en 17 varones de edad media 77 años, diagnosticados urodinámicamente de DU por presentar un Índice de Contractilidad Vesical (BCI) menor de 100, sometidos a sonda vesical a permanencia (16 casos) o cateterismo vesical limpio intermitente (1 caso) por retención aguda de orina (14 casos), o residuo postmiccional patológico (3 casos). Los pacientes fueron sometidos a un segundo estudio urodinámico a los 13 meses de seguimiento de media. Las pruebas estadísticas utilizadas fueron el test exacto de Fisher para variables cualitativas y el test de comparación de media de la t de Student para variables paramétricas. El nivel de significación se fijó en p < 0,05 bilateral. RESULTADOS: En el segundo estudio urodinámico, se observó un aumento significativo de la presión máxima del detrusor, la presión a flujo máximo, el BCI y el Índice de Obstrucción de Salida Vesical (BOOI) y del número de pacientes que orinaron durante el estudio presión/ flujo. CONCLUSIONES: El cateterismo vesical en varones con DU mejora significativamente la contractilidad vesical y permiten desenmascarar obstrucciones del tracto urinario inferior que estaban ocultas por una insuficiente presión del detrusor en relación a la DU de estos pacientes. Esto podría tener no sólo aplicaciones diagnósticas, sino pronósticas y terapéuticas.

Non-invasive bladder volume measurement for the prevention of postoperative urinary retention: validation of two ultrasound devices in a clinical setting.

Ultrasound scanning of bladder volume is used for prevention of postoperative urinary retention (POUR). Accurate assessment of bladder volume is needed to allow clinical decision-making regarding the need for postoperative catheterization. Two commonly used ultrasound devices, the BladderScan® BVI 9400 and the newly released Prime® (Verathon Medical®, Bothell, WA, USA), with or without the 'pre-scan' option, have not been validated in clinical practice. The aim of this study was to assess the performance of these devices in daily clinical practice. Between June and September 2016 a prospective observational study was conducted in 318 surgical patients (18 years or older) who needed a urinary catheter perioperatively for clinical reasons. For acceptable performance, we required that the volume as estimated by the BladderScan® differs by no more than 5% from the actual urine volume after catheterization. The Schuirmann's two one-sided test was performed to assess equivalence between the BladderScan® estimate and catheterization. The BVI 9400® overestimated the actual bladder volume by + 17.5% (95% CI + 8.8 to + 26.3%). The Prime® without pre-scan underestimated by - 4.1% (95% CI - 8.8 to + 0.5%) and the Prime® with pre-scan underestimated by - 6.3% (95% CI - 11.6 to - 1.1%). This study shows that while both ultrasound devices were able to approximate current bladder volume, both BVI 9400® and Prime®-with and without pre-scan-were not able to measure the actual bladder volume within our predefined limit of ± 5%. Using the pre-scan feature of the Prime® did not further improve accuracy.

Incidence of urinary infection among kidney-transplant recipients / Incidência de casos de infecção urinária em receptores pós-transplante renal

Urinary tract infection is the most common bacterial complication in renal transplant. This study investigated the number of urinary infection in renal transplant patients at a transplant center aimed at improving nursing care in order to minimize the incidence of urinary infection. We analyzed 59 medical records of patients subjected to renal transplant from May to June 2015 at a transplant center in a hospital in northwestern state of Paraná. The prevailing age of the patients was between 50 and 60 years (29%), and the hemodialysis time was up to 24 months (30%). In patients diagnosed with urinary tract infection (36%), the prevalent microorganisms were: Enterobacter cloacae (25%), occurring more frequently in the first month after transplantation (67%). It was concluded the nursing team may to act in the control and prevention of urinary tract infection.

A infecção do trato urinário é a intercorrência bacteriana mais comum em transplante renal. O presente trabalho objetivou investigar o número de infecções urinárias em pacientes transplantados renais em um centro transplantador, visando à melhoria dos cuidados de enfermagem a fim de amenizar a incidência de infecção urinária. Analisou-se 59 prontuários de pacientes que foram submetidos ao transplante renal entre janeiro 2012 à janeiro 2015 em um centro transplantador situado em um hospital no Noroeste do estado do Paraná. A idade prevalente dos pacientes foi entre 50 e 60 anos (29%), e o tempo de hemodiálise foi de até 24 meses (30%). Entre os pacientes diagnosticados com infecção urinária (36%) o microorganismo prevalente foi: Enterobacter cloacae (25%), ocorrendo com maior frequência no primeiro mês após o transplante (67%). Conclui-se que a equipe de enfermagem pode atuar satisfatoriamente no controle e prevenção da infecção urinária.

Prostatic Artery Embolization as an Alternative to Indwelling Bladder Catheterization to Manage Benign Prostatic Hyperplasia in Poor Surgical Candidates.

PURPOSE: To prospectively assess discontinuation of indwelling bladder catheterization (IBC) and relief of lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH) following prostate artery embolization (PAE) in poor surgical candidates. METHODS: Patients ineligible for surgical intervention were offered PAE after at least 1 month of IBC for management of urinary retention secondary to BPH; exclusion criteria for PAE included eligibility for surgery, active bladder cancer or known prostate cancer. Embolization technical and clinical success were defined as bilateral prostate embolization and removal of IBC, respectively. Patients were followed for at least 6 months and evaluated for International Prostate Symptom Score, quality of life, prostate size and uroflowmetric parameters. RESULTS: A total of 43 patients were enrolled; bilateral embolization was performed in 33 (76.7%), unilateral embolization was performed in 8 (18.6%), and two patients could not be embolized due to tortuous and atherosclerotic pelvic vasculature (4.7%). Among the patients who were embolized, mean prostate size decreased from 75.6 ± 33.2 to 63.0 ± 23.2 g (sign rank p = 0.0001, mean reduction of 19.6 ± 17.3%), and IBC removal was achieved in 33 patients (80.5%). Clavien II complications were reported in nine patients (21.9%) and included urinary tract infection (three patients, 7.3%) and recurrent acute urinary retention (six patients, 14.6%). Nine patients (22.0%) experienced post-embolization syndrome. CONCLUSIONS: PAE is a safe and feasible for the relief of LUTS and IBC in highly comorbid patients without surgical treatment options.

[Comparative evaluation of the efficacy of uncoated and coated with silver silicone urethral catheters for prevention of urinary tract infections among patients of the intensive care unit].

The goal of the research is to compare and evaluate the efficiency of using silver - coated silicone urinary catheters and catheters without coating for prevention urinary tract infections. MATERIALS AND METHODS: The study included 57 adult patients of intensive care unit, which have silicone bladder catheters "Foley" without coating, and 57 patients were catheterized using catheters coated with silver. We revealed symptomatic and asymptomatic urinary tract infections in our research. RESULTS: During the 14-day bladder catheterization period the preventive effect of urethral silicone catheters coated with silver for prevention of manifest and subclinical urinary tract infections was determined.

[Simulation training for urinary drainage improves skill retention]. / Simulation et rétention des acquisitions : application au drainage vésical.

INTRODUCTION: Urethral and suprapubic catheterizations are the two methods for urinary drainage. Systematic simulation training could improve the performance and reduce iatrogenic complications. The aim of the study was to evaluate the skills retention using simulation training. MATERIALS AND METHODS: It was an experimental study of the effect of urinary drainage simulation based skills on medical students in order to compare active and passive training methods. On the first session, randomization was proceeded. Then, the participant performed one of the two workshops (urethral or suprapubic catheterization) on a male mannequin. The maximal performance was 40 points on the assessment form. Both workshops were performed on the second (one month) and third sessions (six months). RESULTS: Eighteen participants were included. Main performance was 28.7/40 (23-34.2) at the first session. All the participants improved the performance on the second session with a significant difference (P<0.01) between passive 32.5 (26-36.5) and active participants 36.1/40 (34.5-39). On the third session, a similar difference was observed between passive and active participants (32.5 versus 30.4, P non significant). CONCLUSION: Simulation training seems to improve long-term skill retention of urinary drainage for inexperienced medical students. This preliminary study suggests to incorporate urinary drainage simulation training into all medical school curricula. LEVEL OF EVIDENCE: 4.