Blood Clot Evacuation Research Articles

Very Delayed Surgical Bleeding after Coronary Artery Bypass Graft Causing Cardiac Tamponade and Cardiogenic Shock: A Rare Case Report

Delayed surgical bleeding from the left internal mammary artery (LIMA) bed following coronary artery bypass grafting (CABG) is a rare yet potentially fatal condition that can lead to cardiac tamponade and life-threatening cardiogenic shock. We present a case of extremely delayed active bleeding from the LIMA bed, occurring 5 weeks after conventional CABG, resulting in cardiac tamponade and cardiogenic shock. The 73-year-old patient presented to the emergency room with a 2-day history of general weakness and hypotension. He had undergone CABG 5 weeks ago. Optimal inotropic agents and vasopressors were used for the treatment of shock. In the emergency room, real-time bedside echocardiography showed severe external compression of the right ventricle by a homogeneous, hyperechoic mass. Veno-arterial (V-A) mode extracorporeal membrane oxygenation (ECMO) was promptly instituted to stabilize hemodynamics. Subsequent chest re-exploration, involving blood clot evacuation, was performed, and the bleed from the distal LIMA bed was ligated. Delayed LIMA bed bleeding causing cardiac tamponade and cardiogenic shock is an infrequent occurrence, and the use of V-A mode ECMO successfully provided a window of time for chest exploration.

Case report of high-grade pleomorphic sarcoma (rhabdomyosarcoma): a missed diagnosis in the non-healing post-traumatic wound of the elderly

Rhabdomyosarcoma (RMS) is known to be common childhood soft tissue sarcoma (STS). RMS is infrequent in adults. STS constitute <1% of all adult solid malignant sarcomas and RMS accounts for 3% of all STS. The tumor is divided into three main subtypes-embryonal, alveolar, and pleomorphic (most common in adults). The most common primary sites are extremities. It’s an aggressive lesion with a high rate of metastasis. The patient presented with a non-healing wound over a posterior-medial aspect of the right leg with features suggestive of cellulitis. The patient gave a history of fall 5 months ago for which he took treatment at a local doctor, he continued to have severe pain for which an orthopedic opinion was taken and advised conservative management for an un-displaced fracture of the fibula. He later developed swelling over the lower-middle part of his right leg 3 months ago for which an ultrasound was done suggestive of a large amount of fluid suspicious of hematoma secondary to A-V malformation, an attempt for drainage of fluid was made leading to an evacuation of blood clots further procedure was abandoned and the patient transferred to our center. CT-angio demonstrated it as a heterogeneously attenuating solid cystic lesion. After appropriate consents-wound exploration was done with the evacuation of soft gelatinous material with pus discharge and blood clots. HPE-suggestive of high-grade pleomorphic rhabdomyosarcoma. The patient was advised amputation but denied any further treatment. Post-operative recovery was uneventful with no recurrence for the first 6 months after which the patient did not follow up. Post-traumatic mass at extremities should be evaluated with a high index of suspicion of STS. In case of doubt, either a preoperative biopsy or an intraoperative frozen section is a safe practice.

Urethral Sheath to Evacuate Blood Clots through Mitrofanoff Appendicovesicostomy

Background: the Mitrofanoff appendicovesicostomy provides a catheterizable submucosal tunnel between umbilicus and bladder (or neobladder). In patients with a closed bladder neck, the Mitrofanoff channel is the only way to access the bladder. We describe our case of a 17 year-old girl with a Mitrofanoff appendicovesicostomy and a previous surgical closure of the bladder neck and who developed a large bladder clot due to hematuria after a surgical cystolithotomy in an augmented bladder; Methods: after an unsuccessful trans-appendicovesicostomy bladder washing, the endoscopic evaluation was performed using a 14 Ch rigid cystoscope and surrounded by its own urethral sheath. The clot was progressively fragmented through the cystoscope under direct vision. Clot fragments were aspirated to obtain a complete evacuation; Results: the urethral sheath prevented damages to the appendicovesicostomy, allowing at the same time repeated accesses of the cystoscope into the neobladder and ensuring the procedural success. The postoperative period was uneventful, and the neobladder catheter was removed after two days. Neither channel stenosis nor anastomosis dehiscence nor incontinence were reported after five months; Conclusions: the use of urethral sheath 14 Ch through an appendicovesicostomy preserves both the stoma and the channel, making possible endoscopic procedures such as blood clot evacuation into the neobladder.

32 - A big blood clot evacuation through an urethral sheath in a Mitrofanoff appendicovesicostomy

32 - A big blood clot evacuation through an urethral sheath in a Mitrofanoff appendicovesicostomy

Enterovesical Fistula Presenting with Gross Hematuria and Fecaluria after Pelvic Radiation Therapy and Transurethral Resection of Bladder Tumor: A Case Report and Literature Review

<p>本案例為一名75歲女性表現為肉眼可見的血尿兩天，過去病史有10年前子宮頸癌第四期接受過骨盆腔放射治療、高血壓及第2型糖尿病。病人到本院急診就醫後住院接受進一步檢查，住院後第2天膀胱鏡發現出血性膀胱炎，住院後第4天接受經尿道膀胱腫瘤切除術，病理報告顯示為膀胱急慢性發炎併出血。病人於手術後第四天出院。病人於手術後第10天出現下腹痛、肉眼可見的血尿及糞尿，安排腹部電腦斷層及腸胃道鋇劑攝影均顯示迴腸膀胱廔管。後續安排住院接受剖腹探查、廔管及迴腸切除術及膀胱修補術。病理報告顯示為迴腸憩室和潰瘍伴有急性和慢性發炎。病人於術後第7天併發膀胱出血及膀胱滲漏，經膀胱鏡清血塊及腹腔引流後，於術後第36天出院。本文討論腸道膀胱廔管的病態生理學、危險因子、常見症狀、診斷及治療、手術併發症處理等。此案例提醒基層醫師若病人有肉眼可見的血尿合併骨盆腔放射線治療的病史應鑑別診斷腸道膀胱廔管，需儘早安排腸胃道鋇劑攝影或腹部電腦斷層，以免延誤診斷時機。</p> <p> </p><p>The patient was a 75-year-old woman who presented with gross hematuria for two days. Her medical history included cervical cancer, stage IV treated with pelvic radiation therapy (RT) 10 years ago, hypertension, and type 2 diabetes mellitus. The patient visited the emergency department of our hospital on May 29, 2016, and was hospitalized for further evaluation. Cystoscopy on the 2nd day after admission revealed hemorrhagic cystitis. Transurethral resection of bladder tumor (TURBT) was performed on the 4th day after admission. The pathology report revealed acute and chronic bladder inflammation and bleeding. The patient was discharged on the 8th day after admission. However, the patient developed lower abdominal pain, gross hematuria, and fecaluria on the 10th postoperative day. Abdominal computed tomography (CT) and gastrointestinal tract (GI) series were performed, all of which showed an ileum-vesical fistula. Exploratory laparotomy, resection of the fistula and ileum, and bladder repair, were performed on June 17, 2016, fifteen days after her first operation. The surgeries were successful and uneventful. Pathological examination revealed a diverticulum and ulcer with transmural mixed acute and chronic inflammation. Unfortunately, the patient developed intraperitoneal bladder perforation on the 7th postoperative day. After adequate abdominal drainage and cystoscopy-assisted blood clot evacuation, she was discharged from the hospital on the 36th postoperative day. This article discusses the pathophysiology of enterovesical fistula, risk factors, common symptoms, diagnosis and treatment, and the management of surgical complications. Clinicians should keep this clinical scenario in mind if the patient has gross hematuria combined with a history of pelvic RT. This combination of symptoms and history should suggest a differential diagnosis of enterovesical fistula and arrangement of GI series or abdominal CT should be performed as soon as possible to avoid delaying the diagnosis.</p> <p> </p>

Penatalaksanaan Anestesi Tindakan Bedah Endoskopi Evakuasi Perdarahan Intraserebral karena Stroke Hemoragik

Medical conservative treatment is a mainstay of supratentorial intracerebral hemorrhage management, which include blood pressure and increased intracranial pressure management, as well as seizure and thromboembolic prevention. Surgical intervention is an option if the intracerebral hematoma is expanding significantly and increase morbidity and mortality. Neuroendoscopic procedure is an attractive option which is less invasive and also provides high hemorrhage evacuation rate, low incidence of complication, better protection of brain tissue, and fever surgery-related injuries compared to open craniotomy. In this report, we presented a case of a man 44 years old, obese with body mass index of 36.73 kg/m2, hypertensive, who suffered from intracerebral hemorrhage and underwent endoscopic intracerebral blood clot evacuation. Medical management was done and the patient regained full consciousness, with left hemiparesis and the left supranuclear nerve VII sequelae. Due to the expanding volume of the hematoma, the patient underwent endoscopic surgical blood clot evacuation. Minimally invasive intracerebral blood clot evacuation of expanding hemorrhagic stroke in patient gives the anesthesiologist enormous challenge during the perioperative periods to provide optimal surgical conditions, performing brain protection, and ensure patients have early excellent recovery.

Intravesical Blood Clot Retention? How We Manage It, a Tertiary Hospital Preference

Intravesical blood clot retention is one of the Urological emergencies. Ongoing haematuria and blood clot formation in the bladder obstruct the urine outflow and lead to urinary retention, abdominal pain, anemia, urinary tract infection (UTI), and renal function deterioration. Most of the cases required cystoscopy blood clot evacuation and definitive surgery to stop the ongoing bleeding. This study aimed to discover the demography, characteristics, management, and complication of patients with intravesical blood clot retention in Dr. Soetomo General Acadenic Hospital, Surabaya from January 2017 until April 2020. This is an observational study, a retrospective-descriptive design. We conducted a review on the medical records of 97 patients, 76 males and 21 females with an average age of 54.9 years old. Of all patients initially treated conservatively using normal saline irrigation with a large three-way catheter (22-24 fr), four were successfully treated without surgery, and 89 patients underwent cystoscopy and definitive surgery. The mean operation time was 69,6 minutes, with an average blood clot volume of 167,7 ml (25-600 ml). Sources of bleeding were mostly originated from malignancy (58%), Benign Prostatic Hyperplasia (BPH) (10%), and hemorrhagic cystitis (7%). The most common comorbidity found was hypertension (13) and chronic kidney disease (10). Based on our experience, managing intravesical blood clot retention with cystoscopy continued with definitive surgery in a one-step procedure is a good approach. Urological malignancy is the most frequent abnormality that causes intravesical blood clot retention.

FRESH GRADUATE UROLOGIST IN EASTERN INDONESIA: FIRST YEAR SURGERY EXPERIENCE

Objective: In present days, endourology is the hallmark of urology, including in developing countries. This study reviews the surgical experiences of a urology practitioner in the first year of his practice in the underdeveloped province in Indonesia. Material & Methods: This research is a descriptive study that retrieval patients data from the medical record during June 2018 - May 2019. Results: Total of 401 operations were obtained. There were 328 male (81.8%) and 73 female (18.2%) with the average of patients age were 52+17.77 years old. The most common diagnoses were BPH 113 cases (28.2%). bladder stone 83 cases (20.7%), and ureteral stone 52 cases (13%). The most common surgical procedures performed were TURP 120 operations (29.9%), Ureterorenoscopy (URS) 64 operations (16%), and Vesicolithotripsy 58 operations (14.5%). The upper tract procedures were 84 operations (20.9%), mainly URS 64 operations (16%). Whereas the lower procedures were 317 operations (79.1%) mainly TURP 120 operations (29.9%). The complications were bleeding post-TURP 5 cases which require blood clot evacuation (1.2%), bleeding post open nephrolithotomy 1 case which requires blood transfusion (0.2%), and TURP syndrome 1 case (0.2%) with mortality 2 patient (0.4%). All kidney stones were handled by open surgery due to lack of PCNL and ESWL set devices. Conclusion: First year urologist who are interested in serving in such areas may benefit from prioritizing the availability of upper and lower set to performed basic standard care for surgical urology without leaving the hallmark of urology.

A simple and effective method for bladder blood clot evacuation using hydrogen peroxide.

ObjectiveUrinary retention caused by bladder clots can be frustrating because such blood clots are difficult to remove. We established a novel technique in which hydrogen peroxide is applied to evacuate bladder clots.MethodsIn this single-center retrospective study, we evaluated 31 patients with retention of blood clots in the bladder who underwent emergency evacuation using hydrogen peroxide.ResultsThe patients comprised 17 men and 14 women with mean age of 61.2 years (range, 42–82 years). Hydrogen peroxide solution and a 20-Fr three-cavity Foley catheter with large-diameter side holes were used for manual bladder irrigation in all patients. The bladder blood clots were successfully removed in 27 patients. The remaining four patients could not tolerate the symptoms of urinary retention and had to resort to surgery.ConclusionHydrogen peroxide solution for manual bladder irrigation can improve the efficiency of bladder blood clot evacuation. This is a simple and effective option for managing bladder clot retention.

Thulium Laser Vapoenucleation of the Prostate (ThuVEP) in Men at High Cardiovascular Risk and on Antithrombotic Therapy: A Single-Center Experience.

Bleeding is the most common complication of transurethral resection of the prostate and simple open prostatectomy, especially in men on antiplatelet/anticoagulant therapy. The present study aimed to evaluate the safety and effectiveness of thulium laser vapoenucleation of the prostate (ThuVEP) for benign prostatic hyperplasia in patients on chronic antithrombotic medications. Between January 2015 and December 2019, 88 men underwent the procedure under antithrombotic agents in our center. The mean age was 74.7 ± 6.1 years. Median prostate volume was 66.5 mL. Patients on oral anticoagulants were bridged to low-molecular-weight heparin (n = 35). Aspirin (n = 39), clopidogrel (n = 10), and ticlopidine (n = 4) were maintained. Of the patients, 69.3% had an American Society of Anesthesiologists score ≥ 3. Blood loss at 24 h was comparable in all groups. Median catheterization length and postoperative stays were 2 and 3 days respectively. Acute cardiovascular events occurred in 2 patients (2.3%). Of the patients, 4 required prolonged bladder irrigation, 2 required blood transfusions, 1 required a cystoscopy for bleeding control, and 1 required a suprapubic cystostomy for blood clot evacuation. No patients died within 30 days of being discharged. Late complications occurred in 3 (3.8%) patients (1 optical urethrotomy and 1 bladder neck incision for stenosis; 1 acute myocardial infarction). All follow-up visits (1, 6, and 12-month) showed a significant improvement in all urinary parameters compared to baseline. ThuVEP appears to be a feasible surgical option in high-risk patients on antithrombotic regimens, with acceptable postoperative morbidity, good functional outcome, and low incidence of medium-term reoperation rate.

The medial wall of the cavernous sinus. Part 2: Selective medial wall resection in 50 pituitary adenoma patients.

Pituitary adenomas often invade the medial wall of the cavernous sinus (CS), but this structure is generally not surgically removed because of the risk of vascular and cranial nerve injury. The purpose of this study was to report the surgical outcomes in a large series of cases of invasive pituitary adenoma in which the medial wall of the CS was selectively removed following an anatomically based, stepwise surgical technique. The authors' institutional database was reviewed to identify cases of pituitary adenoma with isolated invasion of the medial wall, based on an intraoperative evaluation, in which patients underwent an endoscopic endonasal approach with selective resection of the medial wall of the CS. Cases with CS invasion beyond the medial wall were excluded. Patient complications, resection, and remission rates were assessed. Fifty patients were eligible for this study, 15 (30%) with nonfunctional adenomas and 35 (70%) with functional adenomas, including 16 growth hormone-, 10 prolactin-, and 9 adrenocorticotropic hormone (ACTH)-secreting tumors. The average tumor size was 2.3 cm for nonfunctional and 1.3 cm for functional adenomas. Radiographically, 11 cases (22%) were Knosp grade 1, 23 (46%) Knosp grade 2, and 16 (32%) Knosp grade 3. Complete tumor resection, based on intraoperative impression and postoperative MRI, was achieved in all cases. The mean follow-up was 30 months (range 4-64 months) for patients with functional adenomas and 16 months (range 4-30 months) for those with nonfunctional adenomas. At last follow-up, complete biochemical remission (using current criteria) without adjuvant treatment was seen in 34 cases (97%) of functional adenoma. No imaging recurrences were seen in patients who had nonfunctional adenomas. A total of 57 medial walls were removed in 50 patients. Medial wall invasion was histologically confirmed in 93% of nonfunctional adenomas and 83% of functional adenomas. There were no deaths or internal carotid artery injuries, and the average blood loss was 378 ml. Four patients (8%) developed a new, transient cranial nerve palsy, and 2 of these patients required reoperation for blood clot evacuation and fat graft removal. There were no permanent cranial nerve palsies. The medial wall of the CS can be removed safely and effectively, with minimal morbidity and excellent resection and remission rates. Further follow-up is needed to determine the long-term results of this anatomically based technique, which should only be performed by very experienced endonasal skull base teams.

Осложнения гольмиевой лазерной энуклеации гиперплазии предстательной железы

With growing experience in the HoLEP, it can replace TURP as the "gold standard" for the surgical management of BPH, and therefore this technique is the most studied surgical modality. Despite the proven effectiveness of HoLEP in the treatment of patients with BPH, its widespread use has been associated with both intra- and postoperative complications. To improve the results of surgical management of patients with BPH. The study comprised 310 patients who underwent HoLEP for BPH. HoLEP was performed using the Gillings technique. presence of LUTS (Qmax<15 ml/s, Qav<10 ml/s, presence of residual urine, I-PSS score> 5, QoL score> 2), absence of an active inflammatory process of the urogenital organs. Intraoperative complications included severe hemorrhage in 16 (5.2%), the bladder wall injury in 17 (5.5%) and the ureteral orifice injury in 2 (0.6%) patients. 275 (88.7%) had no intraoperative complications. Early postoperative complications included fever in 4 (1.3%), the bladder tamponade that required cystoscopy and evacuation of blood clots in 7 (2.3%) and acute urinary retention in 36 (11.8%) patients. 263 (84.6%) patients had no postoperative complications. Long-term postoperative complications comprised urinary incontinence in 39 (12.6%) patients and urethral strictures requiring surgical treatment in 9 (2.9%) patients. There were no long-term complications in 262 (84.5%) patients. HoLEP is an effective and safe surgical modality for treating patients with BPH with minimal complications, suitable for any size of the prostate.

Preoperative treatment with 5α-reductase inhibitors and the risk of hemorrhagic events in patients undergoing transurethral resection of the prostate – A population-based cohort study

OBJECTIVES:To assess the associations between preoperative treatment with 5-alpha reductase inhibitors and the risks of blood transfusion during transurethral resection of the prostate and blood clot evacuation or emergency department visits for hematuria within 1 month after surgery.METHODS:We used data from the Taiwan National Health Insurance Research Database in this population-based cohort study. A total of 3,126 patients who underwent first-time transurethral resection of the prostate from 2004 to 2013 were identified. Adjusted odds ratios estimated by multiple logistic regression models were used to assess the independent effects of the preoperative use of 5-alpha reductase inhibitors on the risks of perioperative hemorrhagic events after adjustment for potential confounders.RESULTS:Two hundred and ninety-seven (9.4%) patients were treated with 5-alpha reductase inhibitors for <3 months, and 65 (2.1%) patients were treated for ≥3 months prior to undergoing transurethral resection of the prostate. The blood transfusion rates for patients who were not treated with 5-alpha reductase inhibitors (controls), patients who were treated with 5-alpha reductase inhibitors for <3 months, and patients who were treated with 5-alpha reductase inhibitors ≥3 months were 9.5%, 8.8%, and 3.1%, respectively. 5-alpha reductase inhibitors tended to decrease the risk of blood transfusion; however, this association was not statistically significant (adjusted odds ratio=0.14, 95% confidence interval: 0.02-1.01). Age ≥80 years, coagulopathy, and a resected prostate tissue weight >50 g were associated with significantly higher risks of blood transfusion than other parameters.CONCLUSIONS:This nationwide study did not show that significant associations exist between 5-alpha reductase inhibitor use before transurethral resection of the prostate and the risks of blood transfusion and blood clot evacuation or emergency visits for hematuria.

THE EFFICACY OF NASOGASTRIC TUBE IN A LARGE BLOOD CLOT EVACUATION DURING CYSTOSCOPY

Objective: In this study we introduce using nasogatric tube as an alternative to procure a safe and efficient way to remove large troublesome blood clots during cystoscopy procedure. Material &amp; methods: We prospectively perform blood clot evacuation using nasogastric tube suction (NGT) on 21 patients in Hasan Sadikin GeneralHospital Bandung,within 6 months period. A 24 fr sheath and 16 fr NGT connected to suction unit with a 300 mmhg negative pressure was set. A repetitive back and forth technique was set in motion during the procedure. Cystoscopy time and NGT suction time was documented. Results: All patients were successfully managed with this method without complication during the procedure. The average time for clot removal was 5 minutes 8 seconds with average cystoscopy time was 20 minutes 12 seconds and average estimated blood clots volume was 483 grams. Conclusion: Evacuation using NGT suction is effective, safe and an efficient way to remove a large bothersome clots.

The Role of Fenestration of the Lamina Terminalis on Symptomatic Vasospasm After Aneurysmal Subarachnoid Hemorrhage: A Clinical Research.

To compare the beneficial effects of cisternal blood clot evacuation with or without microsurgical fenestration of the lamina terminalis (LT) on symptomatic vasospasm during the course of aneurysmal subarachnoid hemorrhage. This was a clinical, retrospective study that included 72 patients with aneurysmal subarachnoid hemorrhage (aSAH). The patient group that underwent aneurysm clipping with only extensive cisternal drainage of the subarachnoid blood clot was defined as the non fenestrated lamina terminalis group (NonFLT group, n=39). The patient group that underwent aneurysm clipping with extensive cisternal drainage of the subarachnoid blood clot combined with microsurgical fenestration of LT was defined as the fenestrated lamina terminalis group (FLT group, n=33). All patients were operated by the same experienced neurovascular surgeon, the senior author of this article (MEU), and his colleagues. New cerebral infarct development was determined with computed tomography, Glasgow Outcome Score (GOS), clinical vasospasm rate and Hunt-Hess scale (H&H) grade before and after surgery and duration of hospital stay of the patients were assessed and compared. A favorable clinical outcome was obtained from 51.2% of the NonFLT group patients and 72.66% of the FLT group patients. And FLT group patients have better GOS and H&H grade. Clinical vasospasm rate and duration of hospital stay were also significantly reduced in FLT group patients. Wide fenestration of lamina terminalis as a cerebrospinal fluid diversion technique may be very beneficial in the surgical treatment of aneurysmal SAH.

ClearPath-assisted underwater endoscopic mucosal resection of a laterally spreading tumor of the colon

A 50-year-old gentleman with a 4cm laterally spreading tumor of the sigmoid colon was referred to our institute for endoscopic resection. Biopsy of this lesion confirmed the presence of an adenomatous polyp with high-grade dysplasia. Based on the size and histology of the polyp, and in view of its location in the sigmoid colon, we opted to carry out underwater endoscopic mucosal resection (UEMR) [1]. This procedure was carried out with a high-definition narrowband endoscope (GIF-H190; Olympus Medical, Center Valley, PA, USA) equipped with a ClearPath cleaning device (EasyGlide Ltd., Kfar Truman, Israel) to facilitate water irrigation and aspiration during the procedure. With the help of the ClearPath, the colon was rapidly irrigated with water, allowing piecemeal UEMR. All the polyp fragments, regardless of size, were aspirated through the ClearPath suction channel into the central suction canister (● Fig.1,● Fig.2). The patient tolerated the procedure well with no adverse events recorded in the following days. UEMR of large sessile colorectal polyps without submucosal injection was described by Binmoeller et al. in 2012 [1]. In their experience, 60 consecutive patients with large sessile colorectal polyps undergoing UEMR had successful complete resection and no early complications. The ClearPath device has been developed for rapid luminal irrigation with high flow rates and efficient aspiration through its large suction channel (● Fig.2). This may allow evacuation of fluids, bile, and blood clots during upper gastrointestinal bleeding and has also been shown to be useful and safe for cleaning of poorly prepared porcine colon [2]. ClearPath-assisted underwater EMR allowed complete endoscopic resection while reducing procedure time due to fast colonic irrigation/aspiration and rapid polyp fragment retrieval. Although its efficacy cannot be fully demonstrated by a single report, this application of ClearPath appears useful and safe and may stimulate the development and manufacture of new, dedicated devices for UEMR.

Emergency surgical management strategy for extra dural hematoma with pre-existing undiagnosed hypothyroidism: A case report

Extra dural hematomas (EDH) are usually characterized by a rapidly progressing clinical course within several hours. Surgical management of EDH with hypothyroidism is a challenging issue in emergency hour, as the ultimate outcome depends on the time since trauma, the interval between admittance and operation, associated co-morbidities and the location of hematomas. We received a 55 yr old woman with Rt. Temporoparietal EDH with significant mass effect on examination revealed some of the clinical findings, but not the goiter, of hypothyroidism being confirmed on thyroid function test. Accordingly, we planned for craniotomy with evacuation of extra-dural blood clots ↓ local anesthesia (LA), with immediate post-operative l-Thyroxine supplementation through Ryle's tube. Thus, thorough clinical knowledge on general examination will help sensitize the neurosurgeon to exclude common co-morbidities, e.g. hypothyroidism in our case, while focusing on surgical and anesthetic aspects of relevance of the surgically planned traumatic brain injury cases.

Clinical outcome of primary small cell carcinoma of the urinary bladder

PurposePrimary small cell carcinoma of the urinary bladder is a rare malignant disease. It accounts for less than 1% of all urinary bladder carcinomas. The purpose of this study is to review the clinical features, the treatment modalities, and the overall survival of these patients. We also compare the clinical outcomes between patients of bladder small cell carcinoma (SCC) and bladder urothelial carcinoma (UC).Materials and methodsWe reviewed the charts of patients with bladder tumors from January 1995 to December 2012 in the Chang Gung Memorial Hospital. A total of 2421 malignant bladder tumor patients were reviewed and there were 18 patients who were diagnosed with primary bladder SCC. The patients’ characteristics, including age, gender, smoking history, presented symptoms, tumor size, locations, clinical stages, treatment modalities, pathology appearance, recurrence conditions, and survival conditions were all recorded. We also compared the clinical outcomes and the overall survival rates between patients with bladder SCC and those with UC.ResultsBladder SCC accounted for about 0.74% of all bladder malignancies in our institution. The mean age at diagnosis was 70.67 years, and the male-to-female ratio was 2.6:1. Thirteen patients had a history of cigarette smoking. All patients presented with symptoms of gross hematuria, and three of them had bladder tamponade requiring blood clot evacuation by cystoscopy. Only one patient had T1 disease, ten patients had stage III disease, and seven patients had lymph node or distant metastasis (stage IV disease). The mean tumor size was 4.29 cm in diameter. For the majority (61.11%) of patients, SCC coexisted with UC components. The average survival time was 10.92 months. Patients with bladder SCC had worse overall survival rates than those of stage III and stage IV bladder UC. Performing radical cystectomy does not significantly improve their overall survival rates. None of the clinicopathologic parameters, including the presence of coexisting nonsmall cell carcinoma component (P = 0.831), receiving radical cystectomy (P = 0.194), distant metastasis (P = 0.062), and gender (P = 0.564), were significantly associated with survival.ConclusionSCC of the urinary bladder is a rare condition, and standard treatment outlines have not been well established. Most of the presented cases have a very poor prognosis. Prospective, multi-institutional, randomized studies are required to assess better treatment modalities. To the best of our knowledge, this is the largest reported case analysis of primary bladder SCC in a Taiwanese population.

Conservative treatment of concomitant extraperitoneal bladder rupture and intrabladder blood clot formation: Case report of application of ureteral catheterization

Most extraperitoneal bladder ruptures can be treated conservatively with catheter drainage only. However, in patients with concomitant intra bladder blood clot formation and extraperitoneal bladder rupture, surgery for blood clot evacuation and bladder repair are usually needed due to occlusion of the urinary catheter. In our patient, we used a ureteral catheter to bypass the clots in the bladder to provide adequate urinary drainage. This procedure serves as a valuable tool in the conservative treatment of extraperitoneal bladder injury.

Conservative treatment of concomitant extraperitoneal bladder rupture and intrabladder blood clot formation: Case report of application of ureteral catheterization.

Most extraperitoneal bladder ruptures can be treated conservatively with catheter drainage only. However, in patients with concomitant intrabladder blood clot formation and extraperitoneal bladder rupture, surgery for blood clot evacuation and bladder repair are usually needed due to occlusion of the urinary catheter. In our patient, we used a ureteral catheter to bypass the clots in the bladder to provide adequate urinary drainage. This procedure serves as a valuable tool in the conservative treatment of extraperitoneal bladder injury.