Analgesic refractory colic pain: Is prolonged conservative management appropriate?

OBJECTIVES: To propose a clear definition and management pathway of patients with analgesic refractory colic pain (ARCP). PATIENTS AND METHODS: Prospective cohort study from February 2018 to February 2019 including patients with ARCP defined as ongoing renal colic pain after one dose of IV NSAID, IV paracetamol, and a parenteral opioid, given sequentially in that order. Patients were observed in-hospital under full parenteral analgesic management for 8-12 h, whenever patients had minimal or absent pain after conservative management (CM) they were discharged, and followed-up with new imaging within four weeks. If the pain was not controlled after CM, surgical management (double-J stent or ureteroscopy) was performed. We excluded patients with any other indication for urgent intervention or in cases where CM was deemed inappropriate (sepsis, acute renal failure, stones >10 mm in size, suspected concomitant urinary tract infection, bilateral ureteral stones, pregnancy, patients with a single kidney, kidney transplant recipients, difficult access to medical care or refusal to undergo CM). RESULTS: Data from 60 patients was collected. The only variable associated with an increased risk of failed CM was a history of previous renal colic (OR 3.98 [95% CI 1.14-13.84], p = 0.02). Neither gender, age, stone size, location, or hydronephrosis grade were able to predict CM failure. 41.6% of patients were successfully managed conservatively and only 8% of them required scheduled surgical management at follow-up. CONCLUSION: Our results show that a high proportion of patients with ARCP may be successfully managed conservatively with an extended observation period without complications at follow-up. These results should be replicated in a randomized controlled trial to confirm them.

Prevention of healthcare-associated infections (HAIs) in a surgical urology ward: observational study-analysis of the problem and strategies for implementation.

PURPOSE: Our purpose is to present the results of our working group, with a view to reduce the incidence and improve the management of healthcare-associated infections (HAIs) in a urology ward. METHODS: The study consists on an observational database designed with the view to analyse the incidence and characteristics of HAIs in Urology. Based on the results obtained, a critical evaluation was carried out and specific measures put in place to reduce HAIs. Finally, the impact and results of the implemented measures were periodically evaluated. RESULTS: The incidence of HAIs in urology decreased from 6.6 to 7.3% in 2012-2014 to 5.4-5.8% in 2016-2018. In patients with immunosuppression the incidence of HAIs decreased from 12.8 to 18% in 2012-2013 to 8.1-10.2% in 2017-2018, in those with a previous urinary infection fell from 13.6 to 4.8%, in those with a urinary catheter prior to admission from 12.6 to 10.8%, and in patients with a nephrostomy tube from 16 to 10.9%. The effect of the protocol also demonstrated a reduction in the percentage of patients with suspicion of HAIs for whom no culture was taken, from 6% in 2012 to zero in 2017 and 2018. Moreover, the implementation of protocols for empirical treatment has reduced the incidence of patients experiencing inadequate empirical antimicrobial therapy from 20 to 8.1%. CONCLUSION: It is essential to monitor the incidence of HAIs, and preventive measures play a useful role in reducing the rate of infection and in optimising their management.

Long surgical waiting list times are associated with an increased rate of negative ureteroscopies.

INTRODUCTION: Negative ureteroscopy (NURS) is "a ureteroscopy in which no stone is found during the procedure." We aimed to determine the association between the surgical waiting list time (WLT) and the NURS rate. METHODS: We retrospectively analyzed all patients scheduled for ureteroscopy in our center between January 2017 and July 2019. The inclusion criterion was unilateral, semirigid ureteroscopy for a single ureteral stone; exclusion criteria were renal-only stones, incomplete ureteroscopy, and stones >10 mm. We analyzed age; gender; body mass index; stone size, density, and location; presence of a temporary double-J (DJ) stent; use of medical expulsive therapy; and WLT. Complications while waiting for surgery were also collected and analyzed. RESULTS: We included 219 patients, 41 (18.7%) of whom had NURS. The median WLT was 74 days (interquartile range [IQR] 45-127). Variables protective against NURS were large stone size (odds ratio [OR] 0.78, 95% confidence interval [CI] 0.66-0.93), presence of a temporary DJ stent (OR 0.43, 95% CI 0.2-0.8), and radiopaque stones (OR 0.44, 95% CI 0.21-0.88). A long WLT ((≥60 days) increased the risk of NURS (OR 2.18, 95% CI 1.02-4.61). Complications requiring emergency department visits while waiting for surgery were documented in 58/137 (42.3%) patients with indwelling DJ stents; nonetheless, a WLT greater than the median was not associated with an increased risk of complications (p=0.38). CONCLUSIONS: Long WLT has an independent, direct, and linear correlation with NURS rates. Patients at higher risk of NURS, may be offered preoperative re-evaluation with a computed tomography scan in a resource-limited setting.

Iterative renal transplantation: our experience on third transplants.

PURPOSE: To report our experience on third kidney transplantation, analyzing the complications and graft survival rates as compared to previous transplants. METHODS: Retrospective study of third renal transplants performed at our center. Outcomes were compared with a cohort of first and second transplants. RESULTS: Of a total of 4143, we performed 72 third transplants in 46 men and 26 women with an average age of 46 years and mean time on dialysis of 70 months. Thirty-seven patients were hypersensitized [panel-reactive antibody (PRA) > 50%]. They were all from deceased donors, with a mean cold ischemia time of 19.2 h. The extraperitoneal heterotopic approach was used in 88.8%, transplantectomy was performed in 80.6% and vascular anastomoses were realized mostly to external iliac vessels, using the common iliac artery in 15 cases, and the inferior vena cava in 16. The main ureteral reimplantation technique was the Politano-Leadbetter (76.4%). Third transplantation reported a significantly higher incidence of lymphocele (13.9% vs. 3.2% in first and 4.5% in second transplants; p < 0.001), rejection (34.7% vs. 14.9% and 20.5%, p < 0.001) and urinary obstruction (11.1% vs. 3.6% and 6.3%, p 0.002). Graft survival rates for first, second and third transplants were 87%, 86% and 78% at 1 year, 83%, 82% and 74% at 3 years and 80%, 79% and 65% at 5 years, respectively. CONCLUSION: Iterative transplantation constitutes a valid therapeutic option with adequate surgical and survival results compared to previous transplants. It is a challenging procedure which must be performed by experienced surgeons.

Observational study over 8-year period evaluating microbiological characteristics and risk factor for isolation of multidrug-resistant organisms (MDRO) in patients with healthcare-associated infections (HAIs) hospitalized in a urology ward.

Objective: To analyze, in a urology ward, the prevalence and characteristics of healthcare-associated infections (HAIs) due to multidrug-resistant organisms (MDRO). Methods: We carried out an observational study from 2012 to 2019, evaluating MDRO among patients with HAIs, who were hospitalized in the urology ward. MDRO include Pseudomonas spp., resistant to at least three antibiotic groups, extended-spectrum beta-lactamase (ESBL) producing Enterobacteriaceae or those resistant to carbapenems, and Enterococcus spp. resistant to vancomycin. Results: Among patients with HAIs, MDRO were isolated in 100 out of 438 (22.8%) positive cultures. Univariate and multivariate analyses reported that prior urinary tract infection (UTI) [OR 2.45; 95% CI 1.14-5.36; p=0.021] and immunosuppression [OR 2.13; 95% CI 1.11-4.10; p=0.023] were risk factors for MDRO. A high prevalence of MRDO was found in patients with a catheter in the upper urinary tract; 27.6% for double J stent, 29.6% in those with a nephrostomy tube, and 50% in those with a percutaneous internal/external nephroureteral (PCNU) stent. MDRO were isolated in 28.4% of cultures with Enterobacteriaceae (23.8% and 44.7% in those with E. coli and Klebsiella spp.); 7% of Enterobacteriaceae showed resistance to carbapenems (1.3% and 10% for E. coli and Klebsiella spp., respectively). Three out of 80 Enterococcus spp. were vancomycin-resistant. The rate of Pseudomonas aeruginosa resistant to at least three antibiotic groups was 36.3%. Conclusions: The isolation of MDRO, in up to 25% of positive cultures in a urology ward, constitutes a challenge for the selection of antibiotics. MDRO are more common in immunosuppressed patients, those with previous UTIs, and those with a catheter in the upper urinary tract.

[Benign prostatic hyperplasia management during COVID-19 pandemia.] / Manejo de la hiperplasia benigna de próstata durante la pandemia COVID-19.

OBJECTIVES: The pandemic caused by the new SARS / Cov-2 Coronavirus represents an unprecedented scenario in modern medicine that affects many aspects of daily healthcare. Lower urinary tract symptoms (LUTS) and benign prostatic hyperplasia (BPH) has a high prevalence and is related to high consumption of health resources. For this reason, we performed a revision of the management of LUTS and HBP during and after COVID-19 pandemic. MATERIAL AND METHODS: A group of experts in benign prostatic hyperplasia from different regions of Spain were selected to design a strategy to reorganize the management of benign prostatic hyperplasia and lower urinary tract symptoms during the pandemic. A comprehensive review of the literature was undertaken and a set of recommendations are generated. RESULTS: Recommendations for the management of LUTS-BPH during and after the SARS/CoV2 coronavirus pandemic outbreak consist of promoting telemedicine and developing joint protocols with Primary Care Attention .Clear diagnostic and treatment criteria and referral criteria must be established. Referral of patients for risk complications such as kidney failure, recurrent hematuria and obstructive uropathy are a priority. Surgeries due to BPH are generally potentially delayed until phases I and II of the pandemic, in which the percentage of hospitalized patients with COVID-19 does not exceed 25%, and it is necessary to determine COVID19 negativity. The surgical technique that associates the least complications and the shortest stay should be selected. CONCLUSIONS: The diagnosis and prescription of treatment for BPH during the COVID-19 pandemic should be based on telemedicine and joint protocols for primary care attention and urology. Elective surgical treatment can be delayed until we are in phases I or II, individualizing the surgical and anaesthetic technique of choice to minimize risks.

OBJETIVOS: La pandemia causada por el nuevo Coronavirus SARS/Cov-2 supone un escenario sin precedentes en la medicina moderna que afecta de manera indirecta en numerosos aspectos de nuestra actividad diaria como sanitarios. La hiperplasia benigna de próstata (HBP) es una patología con una elevada prevalencia y consumo de recursos sanitarios. Por ello, es necesaria una revisión en el manejo de la misma con el fin de adecuarlo a las necesidades impuestas por los acontecimientos recientes.MATERIAL Y MÉTODOS: Un grupo de expertos en hiperplasia benigna de próstata de distintas comunidades autónomas de España fueron contactados para diseñar una estrategia para reorganizar el manejo de la hiperplasia benigna de próstata y los síntomas del tracto urinario inferior durante la pandemia. Se realiza una revisión narrativa de la literatura publicada y se generan una serie de recomendaciones de manejo. RESULTADOS: Entre las recomendaciones para el manejo de HBP en tiempos de pandemia por coronavirus SARS/CoV2 se incluyen la promoción de teleconsulta y la realización de protocolos conjuntos con Atención Primaria estableciendo criterios de diagnóstico, tratamiento y derivación claros y homogéneos. Deben priorizarse las derivaciones pacientes complicaciones de riesgo tales como insuficiencia renal, hematuria recidivante y uropatía obstructiva. Desde el punto de vista quirúrgico, se trata generalmente de cirugías potencialmente demorables hasta fases I y II de la pandemia, donde el porcentaje de pacientes hospitalizados con Covid-19 no supera el 25%, siendo preciso determinar negatividad de COVID19. Debe seleccionarse la técnica quirúrgica que asocie una menor tasa de complicaciones así como una estancia más baja. CONCLUSIONES: El diagnóstico y el inicio del tratamiento médico de la HBP durante la pandemia debe basarse en la instauración de la telemedicina y protocolos conjuntos con atención primaria y urología. El tratamiento quirúrgico electivo se puede demorar hasta encontrarnos en fases I o II, individualizando la técnica quirúrgica y anestésica de elección para minimizar riesgos.