Every Urologist, during the course of fulguration treatment of bladder tumours, has at some time or another experienced small intravesical explosions usually manifesting as a "pop". Major intravesical explosions are rare but potentially devastating complications of transurethral endoscopic resections. The damage to the bladder can range from small mucosal tears to bladder rupture, which can either be intraperitoneal (requiring laparotomy and open bladder repair) or extraperitoneal. We review the literature on intravesical explosions to determine the aetiology of these explosions and suggest strategies to prevent these. A comprehensive literature search was performed using Medline and Ovid to obtain information using search terms: intravesical explosions, transurethral procedures, endoscopic procedures, diathermyIntravesical explosions occur due to the production of explosive gases during use of diathermy on human tissues. The most dangerous combination is hydrogen and oxygen. Hydrogen alone is not explosive and it only becomes explosive when admixed with oxygen. Oxygen is not produced in sufficient quantity during diathermy to cause explosions but can enter into the bladder from the atmosphere during endoscopic procedures. Careful operative technique (correct use of the Ellick evacuator bulb and reducing the frequency of manual irrigations of the bladder) with minimisation of the operative time and using the coagulation current at moderate power as well as judicious coagulation of tissues can reduce the risk of this dangerous complication arising.
Objectives: To review the potential challenges a urologist may encounter when embarking on simple/partial/radical nephrectomy in patients with long-term spinal cord injury and propose strategies to pre-empt and manage these. Materials and methods: Comprehensive literature review via PubMed, MEDLINE® and Google™ Scholar searching for relevant scientific articles published to date in English. Recommendations for strategies to safeguard surgical outcomes discussed with a panel of experienced upper-tract urologists. Results: Pre-operative considerations: - urethral assessment via flexible cystoscopy due to higher incidence of urethral pathology in spinal cord injury; - assessing for chronic constipation and distended bowel; and - considering glomerular filtration rate assessment by radio-isotope techniques, such as 51chromium-EDTA Peri-operative considerations: - adequate theatre staffing for safe patient transfer; and - planned choice of incision, due to higher incidence of previous abdominal surgery, stoma bags and/or foreign body devices. Post-operative considerations: - ensuring attending medical staff are trained to recognise autonomic dysreflexia; - early re-mobilisation with physiotherapists experienced in treating spinal cord injury; and - attentive antibiotic stewardship due to higher risk of hospital-acquired or urinary infections Conclusions: Patients with long-term spinal cord injury pose significant potential challenges in the pre-, peri- and post-operative stages of nephrectomy. Familiarisation and optimisation of such factors is recommended to safeguard outcomes. Level of evidence: Not applicable for this multicentre audit.
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