When a pregnant patient presents with a urinary calculus, the customary investigations and management must change in order to take into account the well-being of the developing fetus. Transabdominal or endovaginal ultrasound should be the initial imaging modality used in order to establish the diagnosis. A plain abdominal X-ray, limited intravenous pyelography, or retrograde pyelography is used secondarily if a definitive diagnosis is lacking. The treatment of first choice for urolithiasis in pregnancy is conservative, because 70-80% of stones will pass spontaneously. If conservative management fails, or in cases of sepsis, obstruction of a solitary kidney, or bilateral ureteric obstruction, then surgical intervention is indicated. Traditional surgical management consists of draining the obstructed collecting system with a ureteral stent or percutaneous nephrostomy tube with definitive treatment of the stone in the post-partum period. Ureteroscopic lithotripsy and stone extraction is another option that has been used safely and reliably with increasing frequency in many centers. Despite recent reports of using extracorporeal shock-wave lithotripsy, this treatment is still considered contraindicated in pregnancy.
Background Ileus is common after elective colorectal surgery, and is associated with increased adverse events and prolonged hospital stay. The aim was to assess the role of non‐steroidal anti‐inflammatory drugs (NSAIDs) for reducing ileus after surgery. Methods A prospective multicentre cohort study was delivered by an international, student‐ and trainee‐led collaborative group. Adult patients undergoing elective colorectal resection between January and April 2018 were included. The primary outcome was time to gastrointestinal recovery, measured using a composite measure of bowel function and tolerance to oral intake. The impact of NSAIDs was explored using Cox regression analyses, including the results of a centre‐specific survey of compliance to enhanced recovery principles. Secondary safety outcomes included anastomotic leak rate and acute kidney injury. Results A total of 4164 patients were included, with a median age of 68 (i.q.r. 57–75) years (54·9 per cent men). Some 1153 (27·7 per cent) received NSAIDs on postoperative days 1–3, of whom 1061 (92·0 per cent) received non‐selective cyclo‐oxygenase inhibitors. After adjustment for baseline differences, the mean time to gastrointestinal recovery did not differ significantly between patients who received NSAIDs and those who did not (4·6 versus 4·8 days; hazard ratio 1·04, 95 per cent c.i. 0·96 to 1·12; P = 0·360). There were no significant differences in anastomotic leak rate (5·4 versus 4·6 per cent; P = 0·349) or acute kidney injury (14·3 versus 13·8 per cent; P = 0·666) between the groups. Significantly fewer patients receiving NSAIDs required strong opioid analgesia (35·3 versus 56·7 per cent; P < 0·001). Conclusion NSAIDs did not reduce the time for gastrointestinal recovery after colorectal surgery, but they were safe and associated with reduced postoperative opioid requirement.
Intravesical foreign bodies are an uncommon, but significant, cause of urologic consultation. We present 3 patients who all inserted magnetic beads per urethra into the urinary bladder, which subsequently became retained. Endoscopic attempts were unsuccessfully tried in the first 2 cases, necessitating open cystotomy to remove the beads. The third went straight to open removal. Given the failure of minimally invasive techniques, we believe that open removal should be the first-line treatment for these types of foreign bodies.
Clear cell myomelanocytic tumours are extremely rare neoplastic growths considered to be members of the family of perivascular epithelioid cell tumours (PEComas), which have in common the coexpression of melanocytic and smooth muscle immunohistochemical markers. These tumours are known to be ubiquitous with uncertain tumour biology and to have unpredictable clinical behaviour. They have been reported in the genitourinary tract, including the kidney and prostate. There are only 3 reported cases of clear cell myomelanocytic tumours originating in the urinary bladder. We report a case of a 24-year-old woman with chronic pelvic pain who underwent laparoscopic partial cystectomy and total excision of a bladder mass. Pathological examination revealed primary PEComa of the urinary bladder. Subsequent follow-up procedures, including cystoscopy and imaging, have not revealed any evidence of disease recurrence. The patient remains clinically free of disease 3 months after surgery.
These guidelines are directed toward the typical male patient over 50 years of age, presenting with LUTS and benign prostatic enlargement (BPE) and/or benign prostatic obstruction (BPO). It is recognized that men with LUTS associated with causes other than BPO may require more extensive diagnostic workup and different treatment considerations. We acknowledge that not all patients identify as male. These guidelines should also be applicable to non-binary people, transwomen, and any patients who may have anatomical features of a cis-male genitourinary tract such as a prostate. It is our intent to make these guidelines inclusive to all persons experiencing lower urinary tract symptoms or an enlarged prostate.In this document, we will address both diagnostic and treatment issues. Diagnostic guidelines are described in the following terms as: mandatory, recommended, optional, or not recommended. The recommendations for diagnostic guidelines and principles of treatment were developed on the basis of clinical principle (widely agreed upon by Canadian urologists) and/or expert opinion (consensus of committee and reviewers). The grade of recommendation will not be offered for diagnostic recommendations. Guidelines for treatment are described using the GRADE approach 4 for summarizing the evidence and making recommendations Diagnostic guidelinesThe committee recommended minor revisions in regard to diagnostic considerations as outlined in the 2018 CUA BPH guideline. 1 MandatoryIn the initial evaluation of a man presenting with LUTS, the evaluation of symptom severity and bother is essential. Medical history should include relevant prior and current illnesses, as well as prior surgery and trauma. Current medication, including over-the-counter drugs and phytotherapeutic agents, must be reviewed. A focused physical examination, including a digital rectal exam (DRE), is also mandatory. Urinalysis is required to rule out diagnoses other than BPH that may cause LUTS and may require additional diagnostic tests. [1][2][3]5,6,7 -History -Physical examination including DRE -Urinalysis Recommended Symptom inventory (should include bother assessment)A formal symptom inventory (e.g., International Prostate Symptom Score [IPSS] or AUA Symptom Index [AUA-SI]) is recommended for an objective assessment of symptoms at CUAJ -CUA Guideline Elterman et al CUA guideline: BPH/LUTS 3
Introduction: Partial nephrectomy remains the gold standard in the management of small renal masses. However, minimally invasive partial nephrectomy (MIPN) is associated with a steep learning curve, and optimal, standardized techniques for time-efficient hemostasis are poorly described. Given the relative lack of evidence, the goal was to describe a set of actionable guiding principles, through an expert working panel, for urologists to approach hemostasis without compromising warm ischemia or oncological outcomes. Methods: A three-step modified Delphi method was used to achieve expert agreement on the best practices for hemostasis in MIPN. Panelists were recruited from the Canadian Update on Surgical Procedures (CUSP) Urology Group, which represent all provinces, academic and community practices, and fellowship- and non-fellowship-trained surgeons. Thirty-two (round 1) and 46 (round 2) panellists participated in survey questionnaires, and 22 attended the in-person consensus meeting. Results: An initial literature search of 945 articles (230 abstracts) underwent screening and yielded 24 preliminary techniques. Through sequential survey assessment and in-person discussion, a total of 11 strategies were approved. These are temporally distributed prior to tumor resection (five principles), during tumor resection (two principles), and during renorrhaphy (four principles). Conclusions: Given the variability in tumor size, depth, location, and vascularity, coupled with limitations of laparoscopic equipment, achieving consistent hemostasis in MIPN may be challenging. Despite over two decades of MIPN experience, limited evidence exists to guide clinicians. Through a three-step Delphi method and rigorous iterative review with a panel of experts, we ascertained a guiding checklist of principles for newly beginning and practicing urologists to reference.
Introduction: Non-muscle-invasive bladder cancer is the most expensive malignancy to treat. Current Canadian guidelines recommend repeat transurethral resection of bladder tumour (TURBT) within six weeks after initial resection of T1 high-grade (T1HG) urothelial carcinoma, prior to initiation of intravesical bacillus Calmette-Guerin treatment. This is a burden on operating room usage and adds further cost and risk of complications. Internationally, major cancer centres report significant rates of recurrence and upstaging on repeat resection, however minimal Canadian data is available. We aimed to determine the rate of recurrence and upstaging in a resource-limited, Canadian healthcare system. Methods: A retrospective review of patients receiving TURBT between November 2009 and November 2014 was performed. Patients were included if they had all three of the following: a pathological diagnosis of T1HG, adequate muscularis propria present in the specimen, and a repeat resection. Results: We reviewed 3166 patients who underwent TURBT and found 173 to meet our inclusion criteria. The overall recurrence and upstaging rates were 57.2% and 9.2%, respectively. Tumour recurrence and upstaging occurred more often in patients who had repeat resection after 12-24 weeks compared to those patients whose repeat resection occurred within 12 weeks. Conclusions: Although recurrence rates are similar, we have found upstaging rates to be three-to four-fold lower than those previously reported. Despite this, one in 10 patients will be upstaged, justifying use of this resource within our
Background Postoperative acute kidney injury (AKI) is a common complication of major gastrointestinal surgery with an impact on short- and long-term survival. No validated system for risk stratification exists for this patient group. This study aimed to validate externally a prognostic model for AKI after major gastrointestinal surgery in two multicentre cohort studies. Methods The Outcomes After Kidney injury in Surgery (OAKS) prognostic model was developed to predict risk of AKI in the 7 days after surgery using six routine datapoints (age, sex, ASA grade, preoperative estimated glomerular filtration rate, planned open surgery and preoperative use of either an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker). Validation was performed within two independent cohorts: a prospective multicentre, international study (‘IMAGINE’) of patients undergoing elective colorectal surgery (2018); and a retrospective regional cohort study (‘Tayside’) in major abdominal surgery (2011–2015). Multivariable logistic regression was used to predict risk of AKI, with multiple imputation used to account for data missing at random. Prognostic accuracy was assessed for patients at high risk (greater than 20 per cent) of postoperative AKI. Results In the validation cohorts, 12.9 per cent of patients (661 of 5106) in IMAGINE and 14.7 per cent (106 of 719 patients) in Tayside developed 7-day postoperative AKI. Using the OAKS model, 558 patients (9.6 per cent) were classified as high risk. Less than 10 per cent of patients classified as low-risk developed AKI in either cohort (negative predictive value greater than 0.9). Upon external validation, the OAKS model retained an area under the receiver operating characteristic (AUC) curve of range 0.655–0.681 (Tayside 95 per cent c.i. 0.596 to 0.714; IMAGINE 95 per cent c.i. 0.659 to 0.703), sensitivity values range 0.323–0.352 (IMAGINE 95 per cent c.i. 0.281 to 0.368; Tayside 95 per cent c.i. 0.253 to 0.461), and specificity range 0.881–0.890 (Tayside 95 per cent c.i. 0.853 to 0.905; IMAGINE 95 per cent c.i. 0.881 to 0.899). Conclusion The OAKS prognostic model can identify patients who are not at high risk of postoperative AKI after gastrointestinal surgery with high specificity. Presented to Association of Surgeons in Training (ASiT) International Conference 2018 (Edinburgh, UK), European Society of Coloproctology (ESCP) International Conference 2018 (Nice, France), SARS (Society of Academic and Research Surgery) 2020 (Virtual, UK).
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