Urinary Drainage Research Articles

Erosion of Inflatable Penile Prosthesis with Prolonged Foley Catheterization in the COVID-19 Era

IntroductionThe COVID-19 pandemic has changed the lives of many in the past year. As of writing this article, the virus has claimed over half a million American lives and has infected millions more. It has affected many people regardless of age, gender, race, religion, or medical history. We have noticed a unique sequence of events in urology patients with a prior history of inflatable penis prothesis implantation who have gotten critically ill from the SARS-CoV-2 virus.ObjectiveWe report our experience with patients with an inflatable penile prothesis who suffered respiratory failure due to the SARS-CoV-2 virus and findings that would help limit the risk of implant infection and/or erosion if prolonged urethral catherization is needed.MethodsWe have encountered 3 patients with a very similar history in the past year. They were all men aged 57-72 years old who had a functioning inflatable penile prothesis (IPP) for many years (3-13) and were intubated for a prolonged period of time (2-4 weeks) after suffering respiratory distress from the SARS-CoV-2 virus. During this time, they all had a prolonged urethral Foley catherization for urinary drainage while in the ICU. They were all subsequently found to have urethral erosion of a penile implant cylinder which was not present prior to hospitalization. Their charts were reviewed.ResultsTwo patients underwent explantation of their IPP during their hospital stay and one presented to our outpatient office 2 months after discharge with the complaint of urethral cylinder erosion and underwent subsequent explantation.ConclusionsUrethral catheterization is commonly used in the intensive care unit and spinal cord injury patients due to their convenience and efficacy. The friction and inflammation created by prolonged transurethral catheterization can be disastrous for IPPs by increasing the likelihood of infection and/or device erosion. In fact, Steidle and Mulcahy found that five out of their nine patients (55%) with IPPs who had an indwelling or intermittent transurethral catheterization were eventually found to have erosion of their IPP. In addition, indwelling transurethral catheters also confer a higher risk of urinary tract infection. Han et al. found that suprapubic tube placement conferred a statistically significantly lower risk of urinary tract infection when compared to indwelling transurethral catheterization for over five days at an odds ratio of 0.142 (95% CI 0.073-0.0276). Another alternative to bladder drainage in the intubated IPP patient is clean intermittent catherization (CIC), however this poses a unique challenge in the intubated COVID positive patient as it repeatedly exposes healthcare staff the virus-carrying patient. When compared to indwelling transurethral catherization, suprapubic tube placement has been shown to confer a lower risk of urinary tract infection and IPP infection/erosion. This can primarily be explained by its ability to drain the bladder without creating inflammation and friction in the urethra. Therefore, we propose that any team caring for a patient with an IPP and a planned, prolonged indwelling transurethral catheterization consult urology services to have a suprapubic tube temporarily placed. This will ensure that the risk of urinary tract infection and/or IPP erosion is kept as low as possible.DisclosureAny of the authors act as a consultant, employee or shareholder of an industry for: Coloplast, Boston Scientific, Neotract

Renal transplantasyonla eş zamanlı nativ nefrektomi: Deneyimlerimiz ve kısa bir literatür derlemesi

Objective: There is a need for native kidney nephrectomy to increase renal transplant surgery’s safety or improve postoperative function in some cases. The timing of the procedure is still controversial. This study aimed to present our native nephrectomy procedures performed simultaneously with the transplantation in light of the literature. Material and Methods: A retrospective analysis was performed on the data of 245 patients who underwent renal transplantation due to end-stage renal failure (ESRD) between September 2011 and February 2020. Patients who underwent unilateral or bilateral nephrectomy simultaneously with transplantation were included. Demographic characteristics of the patients, preoperative and postoperative laboratory data, primary disease, presence of comorbid diseases, duration of dialysis, duration of vascular anastomosis, surgical and clinical complications, duration of hospital stay, and graft functions were recorded. Results: 12 patients underwent ipsilateral or bilateral native nephrectomy simultaneously with renal transplantation. The primary diseases of the patients leading to ESRD were as follows; 6 (50%) patients with Polycystic Kidney Disease (PKD), 5 (41.6%) patients with vesicoureteral reflux (VUR), one (8.3%) patient with kidney stones. Postoperative fever in three patients, erythrocyte replacement therapy in three patients, urosepsis and urinary drainage catheter requirement in one patient due to lymphocele was recorded. Two patients developed humoral rejection, and two patients developed BK virus nephropathy. Conclusion: In the presence of appropriate indications, simultaneous native nephrectomy is a safe and effective method in patients preparing for renal transplantation. In centers with sufficient experience and equipment, it may be preferable to perform native nephrectomy simultaneously with renal transplantation. Keywords: Kidney transplantation, nephrectomy, bilateral nephrectomy, polycystic kidney disease, complications.

Retrospective Study of the Etiology, Laboratory Findings, and Management of Patients with Urinary Tract Infections and Urosepsis from a Urology Center in Silesia, Southern Poland Between 2017 and 2020.

BackgroundRecent studies have shown that up to 25% of sepsis cases originate in the urinary tract. Urosepsis can be associated with cystitis, lower urinary tract infections (UTIs), and upper UTIs and is most commonly caused by gram-negative bacteria. This retrospective study from a urology center in southern Poland, was conducted between 2017 and 2020 and aimed to investigate the causes, microbiology laboratory findings, and management in 138 patients with UTIs and urosepsis.Material/MethodsRecords of patients with UTIs with urosepsis admitted to the Urology Department of the hospital in Silesia, Poland, between 2017 and 2020 were analyzed retrospectively, and clinical and laboratory data were evaluated.ResultsThe 138 included patients were admitted to the hospital between 2017 and 2020. The median age of patients was 67 (20–94) years, and 59.9% (82/137) were men. The most common reasons for admission to the Urology Department were hydronephrosis due to dysfunction of urinary drainage in 36.5% (50/137) of patients and hydronephrosis due to urolithiasis in 22.6% (31/137) of patients. The main etiological agents responsible for the development of urosepsis were strains of Enterobacteriaceae in 85% of patients, of which 41.4% (48/116) produced extended-spectrum beta-lactamases (ESBL), accounting for 35.0% (48/137) of patients with urosepsis. In 83.3% (80/96) of patients, the pathogen cultured from the urine was identical to that cultured from the blood.ConclusionsThe identification of an increasing prevalence of urosepsis associated with ESBL-producing gram-negative rods from this single-center study highlights the importance of infection monitoring, rapid diagnosis, and multidisciplinary patient management.

A biogeographic 16S rRNA survey of bacterial communities of ureolytic biomineralization from California public restrooms.

In this study, we examined the total bacterial community associated with ureolytic biomineralization from urine drainage systems. Biomineral samples were obtained from 11 California Department of Transportation public restrooms fitted with waterless, low-flow, or conventional urinals in 2019. Following high throughput 16S rRNA Illumina sequences processed using the DADA2 pipeline, the microbial diversity assessment of 169 biomineral and urine samples resulted in 3,869 reference sequences aggregated as 598 operational taxonomic units (OTUs). Using PERMANOVA testing, we found strong, significant differences between biomineral samples grouped by intrasystem sampling location and urinal type. Biomineral microbial community profiles and alpha diversities differed significantly when controlling for sampling season. Observational statistics revealed that biomineral samples obtained from waterless urinals contained the largest ureC/16S gene copy ratios and were the least diverse urinal type in terms of Shannon indices. Waterless urinal biomineral samples were largely dominated by the Bacilli class (86.1%) compared to low-flow (41.3%) and conventional samples (20.5%), and had the fewest genera that account for less than 2.5% relative abundance per OTU. Our findings are useful for future microbial ecology studies of urine source-separation technologies, as we have established a comparative basis using a large sample size and study area.

Fungal urinary tract infection in outpatient practice: approaches to diagnosis and treatment

Introduction. In recent years, the role of fungal infection in inpatient and outpatient patients has been increasing. At the same time, there are currently no recommendations on the duration of treatment of outpatient patients with fungal urinary tract infection (UTI). Aim of the study. Optimization of methods of diagnosis and treatment of outpatient patients with fungal UTI.Materials and methods. To detect fungi in urine, the E. Koneman et al. (1997) method was improved. 56 patients with fungal UTI were examined. The efficacy of fluconazole in the treatment of fungal UTI was studied in 53 patients.Results. Candida albicans was detected in 37% of cases of fungal UTI in outpatient patients. Risk factors for fungal UTI in outpatient patients include: antibacterial therapy, infravesical obstruction, type 2 diabetes mellitus and the presence of urinary drainage. The microbiological efficacy of fluconazole therapy for 7, 10 and 14 days was 83.0%, 94.3% and 96.2%, respectively. The growth of fungi in the urine a month after treatment was absent in 86.7% of patients. In outpatient patients with fungal UTI without type 2 diabetes mellitus, the efficacy of fluconazole at a dose of 150 mg per day for 7 days was 94.9%. In patients with type 2 diabetes mellitus after 7 days of therapy, the efficacy was 50.0%.Conclusions. The most common causative agent of fungal UTI in outpatient patients is Candida albicans. To detect fungi in urine, samples should be seeded on selective media, while increasing the seeding volume to 0.1 ml and extending the incubation time to 96 hours. Fluconazole is a highly effective treatment for fungal UTI at a dose of 150 mg per day for 7 days, however, in patients with diabetes mellitus, therapy should last at least 10 days.

Utilidad del Renograma Diurético tras la Pieloplastia en la Población Pediátrica. ¿Es Necesario de Rutina?

The diuretic renal scan (MAG3) continues being the gold standard to test the improvement of the urinary drainage after pyeloplasty. Recent researches suggest that there are certain parameters of ultrasound (US) that may indicate an adequate urinary drainage during the follow-up. Our aim is to prove if the measurement of the anteroposterior diameter (APD) of renal pelvis by USS after the pyeloplasty may be a valid screening method to select those patients who also require a MAG3. We retrospectively study the patients who underwent pyeloplasty between 2010 and 2019. The sample was divided in two groups depending of the increase or non-increase in the pelvic APD on postoperative US. The results of the MAG3 and the US of both groups were compared in relation to the presence or absence of obstruction and the need for repyeloplasty. We included a total of 124 pyeloplasty, with a median age of 6 months (IQR 4-36); 12 patients showed an increase in pelvic APD, of those 5 had an obstructive MAG3 and renal function >10%, requiring reoperation. Of the 112 patients in whom the pelvic APD did not increase, only one patient needed reoperation due to obstruction in the MAG3, showing the same pre and postoperative pelvic APD. The sensitivity (S) of the US was 83.33% and the specificity (E) was 94.07%. A decrease of the renal pelvic APD between US before and after surgery appears to be enough to exclude those patients who will not to develop a recurrence of ureteropelvic junction obstruction (UPJO). In the rest of the patients, it would be necessary study the urinary drainage using MAG3, avoiding its inherent drawbacks in all patients undergoing pyeloplasty.

Practice Alert: New ICD-10 Codes for MASD.

Practice Alert: New ICD-10 Codes for MASD.

Periurethral Abscess Following Urethral Reconstruction: Clinical Features and Prognosis

ObjectiveTo evaluate the clinical and prognostic details of periurethral abscess (PUA) formation following urethroplasty (UP). MethodsA retrospective review was performed to identify men who developed PUA after UP between 2007 and 2019 at a single tertiary care referral center. Patient demographics, stricture characteristics, and UP technique were recorded. Outcomes included time to PUA, presenting symptoms, wound cultures, imaging, and ultimate management. Comparative analysis between PUA and non-PUA patients was performed using Fisher's Exact test and Student's t-test. ResultsAmong 1499 UP cases, 9 (0.6%) developed PUA. Mean stricture length was 4.6 cm with most located in the bulbar urethra (5/9, 56%), while 4/9 (44%) had undergone prior UP. PUA rates were 7/288 (2.4%) and 2/815 (0.3%) for substitution and anastomotic UP respectively. Voiding cystourethrogram (VCUG) demonstrated extravasation in 67% (4/6) of available UP cases imaged. Subsequent VCUG confirmed leak improvement or resolution in all cases. Wound cultures were frequently polymicrobial (4/6, 67%). Management included antibiotics with (6/9) and without (3/9) incision and drainage (I/D). Urinary drainage was performed in 5 patients using suprapubic tube (3/5) and foley placement (2/5). PUA resolution was observed in all patients while stricture symptom recurrence was observed in 2/9 (22%) patients with mean time to recurrence of 15 months. Overall mean follow-up time was 22 months. ConclusionPUA is a rare complication of UP that may be more common in setting of postoperative urine leak. PUA is safely managed with I/D, urethral rest, and antibiotics, with low risk of recurrent stricture formation thereafter.

Novel Coaxial Technique of Percutaneous Nephrostomy in Young Children: A Feasibility Study.

The conventional Seldinger and trocar techniques of percutaneous nephrostomy (PCN) have inherent limitations in infants and younger children. We studied the role of a novel coaxial technique of PCN in children under the age of 5 years in comparison to the conventional techniques. This was a single-center feasibility trial based on 24 consecutive patients (n = 24 kidneys) under the age of 5 years, conducted over 12 months, substratified into Group I (n = 10): PCN with conventional Seldinger (n = 2) and trocar (n = 8) techniques and Group II (n = 14): PCN with proposed coaxial technique. In the proposed technique, catheter was inserted through the bore of a 14-G needle. The observation parameters included successful placement of PCN into the renal pelvis with free drainage of urine, number of needle punctures, duration of procedure, need for fluoroscopy, and procedural complications. Proposed technique was successful in all cases with single-needle puncture, while conventional techniques were successful in 8/10 (80%) cases with multiple needle punctures required in 3/10 (33.3%) cases (P = 0.163 and 0.059, respectively). Proposed technique was associated with lower median procedure time (6 min vs. 10.5 min; P < 0.001) and lower incidence of fluoroscopy use (0/14, 0% vs. 5/10, 50%; P = 0.006) than the conventional techniques. No complications were seen with either technique. The proposed coaxial technique is a feasible alternative to the conventional techniques of PCN in young children. It reduces the procedure time and the need for fluoroscopy in these patients.

Prospective Study on Clinical Outcomes of Laparoscopic Repair of Vesicovaginal Fistula with V-Loc 90 Suture

1.1. Objective To study feasibility , efficacy and postoperative outcomes of laparoscopic vesicovaginal repair with barbed, resorbable 3-0 V-Loc 90 sutures. 1.2. Methods Patients presented with vesicovaginal fistula and failed with more than 3 weeks of bladder drainage using a foley catheter are selected for study. The cases where the fistula can be approached via vaginal route adequately without episiotomy or moderate to heavy traction, recurrent cases, complex fistulas , post radiation and malignant fistula are excluded from this study. 1.3. Results In our study from March 2019 to November 2021, total 15 patients were enlisted for laparoscopic VVF repair using V-Loc suture. The main objective of laparoscopic repair of VVF is rapid cessation of urinary leakage with early return of normal and complete urinary and genital function. The most common cause of VVF in our studies was hysterectomy 12 (80%), caesarean section 3 cases (20%) . In our study in all cases laparoscopic transperitoneal transvesical mini-O’ Conor approach with an interposition of omental graft or appendices epiploicae were adopted. In our study all fistulas were supratrigonal with average size of 1.8 cm (range 0.8 to 3.4 cm). Mean age of patients undergoing VVF repair was 39.9 years (range 26 to 48years) . Estimated blood loss was 63 ml (range 30 ml to 160 ml) , and mean operative time 130 minutes (range 100 to 190 minutes). There was no serious intraoperative or postoperative complications including: conversion to open procedure, denying operative procedure, vascular, bowel or ureteric injury, blood transfusion, blood clots, pulmonary embolism, cardiac events or strokes. Length of hospital stay was mean 5.2 days (range 3 to 8 days). Patients were instructed to return our outpatient department 14 to 21 days after surgery for cystogram, cystoscopic and vaginal inspection to confirm successful VVF repair and subsequent suprapubic catheter removal. At a mean of 14.7 months (range 6 to 37 months) no recurrence of VVF occurred with success rate is 100% (15 out of 15 patients). 1.4. Conclusions In the era of minimally invasive surgery, it is difficult to deny its role in the management of VVF. It can be performed safely and effectively with shorter operative time. It seems to offer patients a shorter hospital stay, less morbidity , quicker convalescence, better cosmesis and equal efficacy. Technically, laparoscopy provides better visualization through magnification, but is more difficult to learn, as is intracorporeal suturing. Use of resorbable continuous barbed sutures (V-Loc) simplify the technique and reduce the time of surgery while avoiding implementation of knots. Successful treatment using a laparoscopic approach in VVF is highly dependent on the surgeon’s experience, tissue conditions around fistulae, tension-free watertight closure, and adequate postoperative urinary drainage

EVALUATION OF THE EFFECTIVENESS OF PYELOVESICAL BYPASS IN THE TREATMENT OF PYELONEPHRITIS

Based on the widespread incidence of acute pyelonephritis, which is one of the most common inflammatory diseases of the urinary system, it is important to conduct searching for improved treatment methods, which would ensure higher effectiveness of clinical regression of the process and minimize the extent of manipulations and pharmacotherapy. Pyelovesical bypass is one of these methods. The aim of this study is to investigate the efficacy of pyelovesical drainage of the urinary tract in the course of acute pyelonephritis in comparison with conservative methods of treatment in order to identify its advantages and disadvantages. To assess the effect of urinary tract drainage, we analyzed the clinical findings of patients with acute obstructive pyelonephritis, who underwent pyelovesical stenting and compared them with standard conservative treatment methods. According to the data obtained, we can conclude that pyelovesical stenting procedure in cases of acute obstructive pyelonephritis provides a statistically significant acceleration of the regression of clinical manifestations of kidney inflammation, such as hyperthermic reaction, pain syndrome, inflammatory changes in the blood and urine, parameters of ultrasonic dynamics. Thus, in the presence of clinical indications, appropriate technical conditions, devices and qualified surgeons to perform stenting, we can recommend this method as an effective means of integrated treatment for this renal pathology.

Enhanced recovery after surgery: operation-related factors

Background: The enhanced recovery after surgery (ERAS) program, which has been recently introduced in the field of perioperative care, represents a multimodal strategy to attenuate the loss, and improve the restoration, of functional capacity after surgery. This program aims to reduce morbidity and enhance recovery by reducing surgical stress, optimizing pain control, and facilitating early resumption of an oral diet and early mobilization. Considering this perspective, protocols for enhanced recovery should include comprehensive and evidence-based guidelines for best perioperative care. Appropriate protocol implementation may reduce complication rates and enhance functional recovery and thereby reduce the duration of hospitalization.Current Concepts: In major abdominal surgeries, the recommended ERAS protocols involve common items such as preoperative counseling, preoperative optimization, prehabilitation, preoperative nutrition, fasting and carbohydrate loading, bowel preparation, thromboprophylaxis, antimicrobial prophylaxis, surgical access, drainage, nasogastric intubation, urinary drainage, early mobilization and prevention of postoperative ileus, postoperative glycemic control, and postoperative nutritional care. These items have been briefly reviewed with the relevant evidence.Discussion and Conclusion: ERAS is a comprehensive and evidence-based guideline for optimal perioperative care. Although a number of ERAS items still require high-level evidence through well-designed randomized controlled trials, the ERAS guidelines can serve as adequate recommendations for our practice. Thus, these items can be introduced and adopted with evidence. In addition, it is important to remove items that are not supported by evidence from routine procedures.

Bilateral staged ureteral stenosis secondary to Wegener’s disease: A case report

Wegener’s disease is a rare vasculitis characterized by inflammation of the endometrium of blood vessels. Ureteral stenosis is a rare manifestation of granulomatosis with polyangiitis (formerly known as Wegener’s granulomatosis). We report the case of a 38-year-old woman with acute renal failure in which bilateral hydronephrosis due to staged ureteral stenosis was the second manifestation of the disease after necrotico-inflammatory skin lesions. Our patient had high titers of anti-proteinase 3 c-ANCA, but no upper or lower respiratory tract damage was demonstrated. Hydronephrosis and renal function improved rapidly under immunosuppressive therapy with high dose of corticosteroids. We reviewed the literature and found only ten other reported cases of Wegener’s granulomatosis and intrinsic ureteral stenosis: in two cases the presenting clinical manifestation was unilateral hydronephrosis and in only three others bilateral hydronephrosis. All of these complications have developed on disease relapse except in one case where the first manifestation of vasculitis is bilateral ureteral stenosis. This case highlights the importance of including ANCA-related vasculitis in the differential diagnosis of unusual cases of unilateral or bilateral ureteral stenosis. Keywords: Wegener’s disease; ureteral stenosis; hydronephrosis; urinary drainage.

Ultrasound guided direct puncture percutaneous nephrostomy: a single tertiary centre observational study

Background: Percutaneous nephrostomy (PCN) is indicated to drain the upper urinary tract collecting system in cases of obstruction. Objective of our study is to evaluate the safety and efficacy of Ultrasound guided direct puncture PCN in our populations.Methods: This observational study was conducted from May 2020 to April 2021in department of urology and renal transplant. The total 65 patients with upper urinary tract obstruction requiring PCN were enrolled. All parameters were recorded and statistical analysis was performed using the Statistical package for the social sciences (SPSS 16.0) for windows.Results: In our study Ca Cervix with ureteric infiltration (35%) was the most common indication for PCN tube placement. Majority of patients (83%) had Grade IV and Grade III hydroneprosis. Single attempt for tube placement was sufficient most of the time in (86% cases). Direct Puncture PCN tube placement was successful in 62 (95.4%) cases. The mean duration of procedure was 12.4 minutes. Loin pain was the most common procedure related complication observed in 58 patients. There was no evidence of visceral injury, no need of blood transfusion in post procedural duration in our study.Conclusions: USG guided direct puncture PCN technique is simple, low cost, less time consuming, less chance of loss of tract and effective procedure for drainage of urine in case of upper urinary tract obstruction. We recommended this procedure in grade III and IV hydronephrosis and this procedure suitable for developing countries like India because of procedure related low cost.

Impact of enhanced recovery after surgery protocol compliance on patients\u2019 outcome in benign hysterectomy and establishment of a predictive nomogram model

BackgroundEnhanced recovery after surgery (ERAS) pathways have been shown to improve clinical outcomes after surgery. Considering the importance of patient experience for patients with benign surgery, this study evaluated whether improved compliance with ERAS protocol modified for gynecological surgery which recommended by the ERAS Society is associated with better clinical outcomes and patient experience, and to determine the influence of compliance with each ERAS element on patients’ outcome after benign hysterectomy.MethodsA prospective observational study was performed on the women who underwent hysterectomy between 2019 and 2020. A total of 475 women greater 18 years old were classified into three groups according to their per cent compliance with ERAS protocols: Group I: < 60% (148 cases); Group II:≥60 and < 80% (160 cases); Group III: ≥80% (167 cases). Primary outcome was the 30-day postoperative complications. Second outcomes included QoR-15 questionnaire scores, patient satisfaction on a scale from 1 to 7, and length of stay after operation. After multivariable binary logistic regression analyse, a nomogram model was established to predict the incidence of having a postoperative complication with individual ERAS element compliance.ResultsThe study enrolled 585 patients, and 475 completed the follow-up assessment. Patients with compliance over 80% had a significant reduction in postoperative complications (20.4% vs 41.2% vs 38.1%, P < 0.001) and length of stay after surgery (4 vs 5 vs 4, P < 0.001). Increased compliance was also associated with higher patient satisfaction and QoR-15 scores (P < 0.001),. Among the five dimensions of the QoR-15, physical comfort (P < 0.05), physical independence (P < 0.05), and pain dimension (P < 0.05) were better in the higher compliance groups. Minimally invasive surgery (MIS) (P < 0.001), postoperative nausea and vomiting (PONV) prophylaxis (P < 0.001), early mobilization (P = 0.031), early oral nutrition (P = 0.012), and early removal of urinary drainage (P < 0.001) were significantly associated with less complications. Having a postoperative complication was better predicted by the proposed nomogram model with high AUC value (0.906) and sensitivity (0.948) in the cohort.ConclusionsImproved compliance with the ERAS protocol was associated with improved recovery and better patient experience undergoing hysterectomy. MIS, PONV prophylaxis, early mobilization, early oral intake, and early removal of urinary drainage were of concern in reducing postoperative complications.Trial registrationChinese Clinical Trial Registry, ChiCTR1800019178. Registered on 30/10/2018.

Learning of self-catheterization: For whom? Why? How?

Since the 1970s, self-catheterization is the preferred method of urine drainage in case of urinary retention of neurological etiology (paraplegia, multiple sclerosis…) and non-neurological cause (benign prostatic hypertrophy, acontractile bladder of the elderly subject…). The main objective is to allow the physiological alternation of filling and complete emptying phases, in order to preserve the renal function and prevent urinary infections. The learning of self-catheterization is simple but requires a therapeutic education session with trained personnel, at home or in a specialized center. Cognitive disorders, poor vision, lack of dexterity or lack of knowledge of urogenital anatomy are the main limitations to their implementation. Their success depends on the frequency of catheterization (every 4h), which is performed in a clean but non-sterile manner. The benefit/risk ratio is largely in favor of using them to replace the indwelling probe whenever possible.

EP.TH.282Adherence to ERAS® Society recommendations following elective colonic surgery (2012) in regard to urinary drainage, postoperative nutritional care and intra-abdominal drainage

Abstract Aims Evaluating adherence to ERAS® recommendations for post-operative urinary drainage, nutritional care and intra-abdominal drain placement in elective colorectal surgery. Methods Approval was obtained by the audit department of a university teaching hospital. Data was collected prospectively over a seven-week period for nineteen (n = 19) patients. Results were compared against the standard set by the ERAS® Society (2012). Results Right colonic surgery (n = 5): catheter removed on post-operative day (POD) 1 n = 1 (20%), normal diet started on POD 0 or 1 n = 3 (60%), IV fluids discontinued on POD 1 n = 3 (60%) and n = 4 (80%) did not have a drain placed. High anterior resection or left/subtotal colectomy (n = 9): catheter removed on POD 1 n = 3 (33%), normal diet started on POD 0 or 1 n = 4 (44%), IV fluids discontinued on POD 1 n = 3 (33%) and n = 2 (22%) did not have a drain placed. Low rectal surgery (n = 4*, *one patient, n = 1, excluded from all domains except intra-abdominal drainage due to immediate post-op complication): catheter removed on POD 3 n = 4 (100%), normal diet started on POD 0 or 1 n = 2 (50%), IV fluids discontinued on POD 1 n = 1 (25%) and all patients had a drain placed n = 5 (100%). Conclusions Adherence for urinary drainage in low rectal surgery and intra-abdominal drainage for right colonic surgery was satisfactory. Multiple areas of improvement were identified, in order to optimise compliance, and recommendations were generated. The exception may be drains for lower rectal surgery where recent data has recommended selective drain placement.

PSI-2 A procedure for urine collection in pre-weaned heifer calves

Abstract Urine collection is a useful tool to analyze intestinal permeability in cattle for research and diagnostic purposes. However, urine sampling techniques often rely on total waste collection, which reduces the ability to perform more frequent sampling and obtain accurate and sterile urine volumes. A potential alternative is urethral catheters, which have been used in cows and weaned heifers. However, urethral catheters have not been thoroughly tested in pre-weaned dairy heifer calves. The study objective was to develop a urethral catheter placement procedure in pre-weaned heifer calves for continuous and accurate urine collection. Fifteen Holstein heifer calves had catheters placed at 8 ± 2 days (37.5 ± 3.38 kg BW) and 40 ± 2 days (59.3 ± 5.38 kg BW) of age. During the procedure, calves were individually housed (1.87 m2/calf) and restrained. The vulva was cleaned using betadine and 70% ethanol and then a sterile, lubricated 8.9 cm speculum was inserted into the vagina. A sterile guidewire (145 cm x 0.89 cm) was inserted into a lubricated sterile 10 FR catheter. The catheter was inserted into the urethral opening (~5–7 cm into vagina), guided into the bladder, and the catheter balloon was filled with water (10 mL). The guide wire was removed, and urine flow confirmed correct placement before a 4 L urinary drainage bag was attached to the catheter. Individual calf health observations were made twice over a 24-hour period and included vaginal discharge, bleeding, redness or inflammation, and tissue discharge in the urine. Occurrence rate was determined using PROC FREQ in SAS 9.4. Regardless of catheterization timing, bleeding and tissue discharge occurred at a rate of 3.33% ± 0.18, and vaginal discharge and inflammation occurred at a rate of 6.70% ± 0.25. In summary, this procedure is a viable method for total urine collection in pre-weaning heifer calves.

Systematic review and meta-analysis of early removal of urinary catheter after colorectal surgery with infraperitoneal anastomosis.

To review and to analyse the feasibility of using no urinary catheter or a catheter for less than 24h compared with longer post-operative catheter after colorectal surgery with infraperitoneal dissection. We performed a systematic review and meta-analysis of studies comparing no urinary catheter or a catheter for less than 24h (early removal, ER) and urinary catheter drainage for 2days or longer (late removal, LR) after colorectal surgery with infraperitoneal dissection. Primary endpoint was acute urinary retention (AUR) requiring a re-catheterization. Secondary endpoints were urinary tract infection (UTI), overall morbidity and hospital length of stay. Meta-analysis met the PRISMA criteria, with a random model. Out of 3659 articles found, 82 comparative studies on catheter duration were selected, of which five were in colorectal surgery: three randomized trials, one retrospective and one prospective series. There were 396 ER and 410 LR patients. All had undergone surgery with infraperitoneal dissection. There was no significant difference regarding AUR (OR = 2.09 [95%CI 0.97-4.52]) but significantly less UTI (OR = 0.39 [95%CI 0.22-0.67]) for early urinary catheter removal. The number needed to harm was much higher for AUR than for UTI (23.3 vs. 8). This meta-analysis suggests that, in terms of benefit/risk ratio, in colorectal surgery with infraperitoneal anastomosis, early removal (< 24h) of the urinary catheter would be beneficial (because of a more frequent UTI after LR than AUR after ER) and would reduce the occurrence of UTI if no AUR risk factors are present. However, these findings should be interpreted with caution because of the low quality of evidence.

URINOTHORAX FOLLOWING THE FORMATION OF A NEPHROPLEUROCUTANEOUS FISTULA AFTER PERCUTANEOUS NEPHROLITHOTOMY TO REMOVE STAGHORN CALCULI

TOPIC: Disorders of the Pleura TYPE: Medical Student/Resident Case Reports INTRODUCTION: Urinothorax is a rare cause of pleural effusion secondary to obstructive uropathy or a complication of a post urological procedure. Patients may present with respiratory and urinary symptoms. Pleural fluid analysis is traditionally transudative and the pleural fluid to serum (PF/S) creatinine ratio is greater than 1. Imaging can also be done to find the etiology while treatment of the underlying pathophysiology typically results in its resolution. CASE PRESENTATION: A 27-year-old female with history of nephrolithiasis secondary to proteus mirabilis infection presented to the emergency room with SOB and CP six days after undergoing a left ureteral stent placement alongside a left percutaneous nephrolithotomy (PCNL) in order to remove a staghorn calculi measuring 9.2cm x 3.2cm.Initial chest x-rays revealed a large, left-sided pleural effusion. A diagnostic thoracentesis was performed and 800cc of cloudy, yellow fluid was removed. Pleural fluid analysis revealed a PF/S creatinine ratio of 2.7 and pleural LDH of 208. Since these findings were consistent with an LDH-discordant urinothorax, a Foley catheter was placed; however, the patient began to develop fevers and left flank pain. A CT scan revealed left upper pole hydronephrosis, a newly-formed left renal pelvis stone causing stent obstruction, and the presence of a nephropleurocutaneous tract likely secondary to the PCNL. The patient was then taken to the OR for stent revision and chest tube placement. Within the next few days, her respiratory status improved and she was discharged home with close follow-up. DISCUSSION: Urine translocation into the pleural space occurs in two ways. The first comes from the lymphatic drainage of urine that has been extravasated into the retroperitoneal space because of increased pressure gradients from obstructive uropathy. The second, which is what our patient had, comes from the urine entering into the pleura through a fistula or an anatomical defect. A diagnostic thoracentesis of a urinothorax will reveal a cloudy, yellow fluid with the smell of urine, a PF/S creatinine ratio greater than 1, and a transudate. However, studies have shown that concomitant infections, such as our patient's proteus mirabilis infection, can cause the fluid to be exudative. Imaging can also be used to further identify the pleural effusion as well as any pathological or structural abnormalities. Treatment of a urinothorax depends on the underlying etiology. For obstructive cases, stents, nephrostomy tubes, and Foley catheters are utilized. For iatrogenic cases like our patient's, repairing the defect yields the best results. CONCLUSIONS: The identification of a urinothorax following a post urological procedure requires a high level of clinical suspicion in the correct clinical context. As such, it is important for clinicians to learn more about this rare cause of pleural effusions, its pathophysiology, and its treatment options. REFERENCE #1: Toubes, M., Lama, A., Ferreiro, L., Golpe, A., Álvarez-Dobaño, J., & González-Barcala, F. et al. (2017). Urinothorax: a systematic review. Journal Of Thoracic Disease, 9(5), 1209-1218. https://doi.org/10.21037/jtd.2017.04.22 REFERENCE #2: Austin, A., Jogani, S., Brasher, P., Argula, R., Huggins, J., & Chopra, A. (2017). The Urinothorax: A Comprehensive Review With Case Series. The American Journal Of The Medical Sciences, 354(1), 44-53. https://doi.org/10.1016/j.amjms.2017.03.034 REFERENCE #3: Ramahi, A., Aburayyan, K., Alqahtani, A., Said Ahmed, T., & Taleb, M. (2019). Shortness of Breath: An Unusual Presentation of Bladder Injury. A Case Report and Literature Review of Urinothorax. Cureus. https://doi.org/10.7759/cureus.4559 DISCLOSURES: No relevant relationships by Sanford Church, source=Web Response No relevant relationships by Timothy Vu, source=Web Response No relevant relationships by Bassam Yaghmour, source=Web Response, value=Honoraria Removed 04/30/2021 by Bassam Yaghmour, source=Web Response