Gender assignment, gonadectomy (as i cancer risk), screen for Wilms \200\231 tumor S E X D E V E L O P M E N T 46XX \200\230pure \200\231 gonadal dysgenesis 46XX Streak ovaries Female Normal stature, sexual infantilism, primary amenorrhoea Cyclic hormone replacement (Continued) 6 8 5 6 8 6 C H A P T E R 1 6 Table 16.7 (Continued) Disorder Karyotype Gonad Genitalia Other features Treatment P a e d i a t r i c 46XY DSD 3 -dydroxysteroid dehydrogenase Salt-wasting, d cortisol, d aldosterone 46XY Testes Ambiguous Glucocorticoid and mineralocorticoid replacement 17A-hydroxylase de \201 ciency d Cortisol (causing i ACTH), resulting in d steroids, hypokalaemia, hypertension 46XY Testes Ambiguous Glucocorticoid replacement u r o l o g y Complete androgen insensitivity syndrome 46XY Testes Female Androgen resistance, female phenotype, short blind-ending vagina, breasts at puberty Gonadectomy after puberty, estrogen replacement therapy Gender assignment surgery 9 gonadec tomy and hormone Incomplete androgen insensitivity syndrome 5A-reductase de \201 ciency 46XY Testes Ambiguous Wide spectrum, including hypospadias, infertility, gynaecomastia, pseudovagina Reconstructive surgery 9 hormonal support 46XY Testes Ambiguous Failure to convert testosterone to DHT in androgen-sensitive cells, hypospadias, small phal lus, short vagina, virilization at puberty 46XX DSD Glucocorticoid, mineralocorticoid replacement and surgery Congenital adrenal hyperplasia 46XX Ovaries Ambiguous Simple virilization or salt-wasting aldosterone de \201 ciency Virilization by maternal drug use in pregnancy or maternal adrenal tumors Transplacental androgens External genitalia reconstruction as required 46XX Ovaries Ambiguous D I S O R D E R S O F S E X D E V E L O P M E N T 6 8 7 CHAPTER 16 Pediatric urology 688 Exstrophy \200\223epispadias complex Exstrophy \200\223epispadias complex describes a spect rum of congenital malformations affecting the abdominal wall, pelvis, genitourinary tract, and sometimes also the spine and anus. It includes bladder exstrophy, epispa- dias, and clo acal exstrophy. Classic bladder exstrophy This is the most common manifestation and results from defective devel- opment of the anterior bladder and lower abdominal walls, resulting in the posterior bladder wall lying exposed on the abdomen. Virtually all cases are associated with epispad ias (see b p. 690). Epidemiology: incidence is 71 in 30 000 live births. Male to female ratio is 5:1. Increased risk in offspring of affected patients and with younger maternal age and increased parity. Embryology: classically described as an embryological malformation caus- ing abnormal overd evelopment of the cloacal membrane, which prevents in-growth of lower abdominal (mesenchyma l) tissues. The cloacal mem- brane normally perforates to form the urogenital and anal open ings, but in exstrophy, premature rupture results in a triangular defect below the umbilicu s. The timing of rupture determines the type of resulting defect (bladder exstrophy, cloaca l exstrophy, or epispadias). Other theories challenge this and suggest abnormal development of the bony pelvis or maldevelopment of the genital hillocks below their normal position, with midline fusion below rather than above the cloacal membrane (resulting in premature cl oacal rupture prior to mesenchymal in-growth). Associated anomalies - Bone defects outward rotation of the pelvic bones along the sacroiliac joints. Musculofasci al defects of rectus abdominis, abnormal pelvic \202 oor, low lying umbilicus. Genital de fects the corporal cavernosa, short urethral plate, epispadias, de \201 ciency of dorsal f oreskin. Females \200\224bi \201 d clitoris, stenotic vaginal ori \201 ce, short anterior ly placed vaginal canal, uterine prolapse in adult life. Urinary tract defects due to later al displacement of the ureteric ori \201 ces. GI anal sphincter contributes to fecal incon tinence. : diastasis (widening) of the symphysis pubis due to : umbilical hernias, inguinal hernias, divarication : Males \200\224short, broad penis with lateral splaying of : exposed bladder plate; majority suffer VUR tract defects: anteriorly displaced anus, rectal prolapse, abnormal Investigation Typical features seen on prenatal USS include a lower abdominal wall mass, ab sent bladder \201 lling, low-set umbilicus, small genitalia, abnormal iliac crest widenin g. Diagnosis can help planning of delivery in a center with facilities to perform early sur gical correction. EXSTROPHY \200\223EPISPADIAS COMPLEX 689 Management At birth, cover the bladder with plastic \201 lm and irrigate regularly with s terile saline. Trauma to the bladder mucosa can result in squamous meta- plasia, cystitis c ystica or adenocarcinoma, and squamous cell carcinoma after chronic exposure. Surgery: aims to provide a continent reservoir for urine storage, preserve renal function, and create functional and cosmetically acceptable external genitalia. Selected cases are su itable for a one-stage complete primary repair of bladder exstrophy (CPRE), involving closu re of the bladder plate and epispadias repair. However, many require staged procedures. - N ewborn : pelvic osteotomy (cutting bone to correct deformity) with external \201 xation a nd closure of bladder, abdominal wall, and posterior urethra. 6 \200\22318 months 4 \200 \2235y : bladder neck reconstruction (Young \200\223Dees \200\223Leadbetter procedure) and anti-re \202 ux surgery (ureteric re-implantation) is performed when there is adequate bla dder capacity and children can participate in voiding protocols. Where bladder capacity is too small, bladder augmentation and/or urinary diversion is required. : epispadias repair (see b p. 689). Surgical complications: increased risk of malignancy in urinary or ortho- topic bladder, \201 stula, hypospadias, bladder stones, infection (UTI, epidi- dymitis), incontinence. Cloacal exstrophy This is the most severe form of exstrophy \200\223epispadias complex. Cha racterized by an exomphalos (midline abdominal defect with bowel covered in a thin sac of a mnion and peritoneum), below which are two halves of an exstrophied bladder separated by an exstrophied bowel seg- ment. It is associated with a bi \201 d or micro-penis and the abs ence of one or both testes. The incidence is between 1 in 200 000 and 1 in 400 000; male to female ratio is 6:1. There is a high risk of associated congenital anomalies. Surgical rec onstruction may require terminal colostomy, pelvic osteotomy, anterior bladder reconstructi on augmentation cystoplasty. Gender assignment may need to be considered in males. CHAPTER 16 Pediatric urology 690 Primary epispadias In epispadias, the urethra opens onto the dorsal surface of the penis, a ny- where from the glans, penile shaft, or most commonly, the penopubic region. An incomple te urethral sphincter mechanism (seen with posterior urethral epispadias) results in a high risk of incontinence. Epispadias is also associated with dorsal chordee (causing an upward curvature of the penis) and with incomplete foreskin dorsally. Epispadias is part of the e xstrophy \200\223 epispadias complex (see b p. 688). Primary epispadias (without exstro- ph y) is rare. Associated anomalies Diastasis of the symphysis pubis results in splaying and rotation of t he corpora cavernosa, laterally placed neurovascular bundles, and shortening of the penile shaft. There is reduced male fertility, with paternity rates of 736%. Females have a bi \201 d clitoris, poorly developed labia, and demon- strate a spectrum of urethral deformiti es, ranging from a patulous urethral ori \201 ce to a urethral cleft affecting the entire length of the urethra and sphincter. There is >40% risk of VUR which commonly requires uret eric re-implantation. Incidence: affects 1 in 117 000 males; rarely seen in females (1 in 400 000). Management Males: urethroplasty with functional and cosmetic reconstruction of the external genitalia (penile lengthening and correction of chordee) at 6 \200\22318 months. The modi \201 ed Cantwell \200\223Ransley technique is commonly used in males. It describes mobiliz ing the urethra to the ventral aspect of the penis, with advancement of the urethral meatus onto the glans with a reverse meatal advancement glanuloplasty. The corporal bodies are se pa- rated and rotated medially above the urethra and re-approximated. From age 4 \200\2235y , when children can be toilet-trained, bladder neck reconstruction can be performed (Youngs \200\223Dees \200\223Leadbetter procedure). This achieves continence and any bladder resid uals may then be emptied by urethral catheterization. If this surgery fails, insertion of a rti \201 cial urinary sphinc- ters may be tried. Some patients may require bladder augment ation and Mitrofanoff reconstruction to achieve continence. Females: surgery involves urethral repair reinforced with pubic fat, along with clitoral re construction 9 bladder neck repair. This page intentionally left blank CHAPTER 16 Pediatric urology 692 Urinary incontinence in children Normal bladder control - Neonates is full. Infants and voiding frequency is reduced. 2 \200\2234y control. : sacral spinal cord re \202 ex triggers voiding when the bladder : primitive re \202 exes are suppressed, bladder capacity increases, : development of conscious bladder sensation and voluntary Lower urinary tract symptoms and types of incontinence1 Urinary incontinence can be divided into primary types (never been dry) or secondary (re-emergence of incontinence after being dry for 6 months). - Overactive bladder syndrome urgency 9 urge incontinence, usually with frequency and nocturi a. The symptoms are usually caused by detrusor overactivity, but can be due to other forms of voiding dysfunction. Extraordinary daytime urinary frequency voiding during the daytime (after bladder control is achieved). It is usually self-limiting. Stress urinary incontinen ce patients with cystic \201 brosis, but otherwise is rare in non-neuropaths. Giggle inco ntinence urinary incontinence triggered by laughing. Bladder function is normal between epi sodes. Vaginal re \202 ux the underwear on standing. Improved by correcting toilet posture . Occasionally, it may be caused by labial adhesions which can be treated with topical estr ogen cream or divided, if necessary. Voiding postponement : children with incontinence may demonstrate holding maneuvers (leg crossing, squatting, Vincent \200\231s curtsey) to defer micturition and increase voiding intervals. It may be associated with behavioral and psych ological disturbances. Underactive bladder infrequent voids, and may need to strain to empt y the bladder. Nocturnal enuresis Dysfunctional voiding or non-neurogenic neurogenic bladde r): it results from external urethral sphincter contraction during voiding, leading to a st accato \202 ow pattern on uro \202 owmetry. It has a multifactorial etiology which inclu des abnormal learned voiding patterns. It can result in incomplete bladder emptying, UTI, u rge incontinence, and is associated with bowel dysfunction (constipation). Severe cases may results in a small, trabeculated bladder, VUR, hydronephrosis, and renal damage. : like adults, this is manifest as : small volume, frequent : leak of urine with exertion. It is seen in : a rare condition mainly affecting girls, with : urine re \202 uxes into the vagina, then dribbles into : large capacity bladder, poor contractility, (see b p. 694). (previously called Hinman \200\231s syndrome URINARY INCONTINENCE IN CHILDREN 693 Evaluation - History primary or secondary incontinence, daytime and/or night-time symptoms) , family history, bowel problems, social history, behavioral and psychosocial problems. Exa mination enlarged kidneys. Inspect external genitalia for congenital anomalies (i.e. epispa dias). Exclude any neurological causes (hairy patch, lipoma, dimple on lower back may indic ate lumbosacral spine abnormalities; examine lower limb re \202 exes). Investigations \202 ow rate, PVR. In selected cases \200\224USS renal tract (to assess for hydronephrosis, bladder size), MCUG (to assess for VUR, PVR), videourodynamics (if suspicion of neuropathi c bladder or sphincter dysfunction, or dif \201 culty in clinical diagnosis), MRI spine (i f clinical suspicion of neurological cause). : enquire about UTIs; voiding habits (frequency, urgency, : palpate the abdomen for distended bladder or : urinalysis (infection, protein, glucose), voiding diary, Management Conservative Education of the family and child are essential. Children may need blad- der retraining, timed voiding, change of voiding posture, and avoidance of bladder ir ritants. Diet should be modi \201 ed to avoid constipation, and use laxatives if it does o ccur. Psychological counseling and support should be available. Many conditions respond and improve with these measures alone. Speci \201 c management - Overactive bladder syndrome : where conservative methods have failed, anticholinergic medic ation (i.e. oxybutynin) is indicated. Some patients also respond well to neuromodulation of the bladder with transcutaneous electrical nerve stimulation (TENS). More invasive methods usually reserved for neuropathic patients include botulinum toxin A injection into the bla dder and ileocystoplasty. Giggle incontinence medications, imipramine and Ritalin (methyphe dinate). Underactive bladder UTI and ISC, if tolerated. It can be self-limiting and resolve . Nocturnal enuresis enuresis alarms and desmopressin. Dysfunctional voiding: in addition t o conservative techniques, anticholinergic medication may be useful and TENS can be used to neuromodulate the overactive bladder. ISC 9 A-blockers may be needed for patients with und eractive bladder and incomplete emptying. Antibiotics prophylaxis may be required for recur rent UTI. The condition tends to resolve spontaneously. : treatment options include anticholinergic : symptomatic children may need antibiotics for (see b p. 694): \201 rst-line active treatments are 1 Hoebeke P, Bower W, Combs A. et al. (2010) Diagnostic evaluation of children with daytime incontinence. J Urol 183:699 \200\223703. CHAPTER 16 Pediatric urology 694 Nocturnal enuresis Nocturnal enuresis (NE) is de \201 ned as intermittent incontinence whi lst sleeping.1 Monosymptomatic nocturnal enuresis (MNE) is de \201 ned as (nocturnal) enur esis in children without any other LUTS and without a history of bladder dysfunction.1 MNE accounts for <50% of children with bedwetting. Non-monosymptomatic nocturnal enuresis (NMNE ) includes children with associated voiding dysfunction. Primary NE refers to children that have never been dry for more than a 6-month period; Secondary NE refers to the re-emergenc e of bedwetting after a period of being dry for at least 6 months. Prevalence Nocturnal enuresis is estimated to affect up to 15% of 5y olds2 and 10% of 7y ol d children (Table 16.8).3 There is 15% spontaneous resolution of symptoms per year.1 The pr evalence in adults is 70.5%. Table 16.8 Prevalence of nocturnal enuresis Age (y) Females (%) Males (%) 5 10 \200\22315 15 \200\22320 7 7 \200\22315 15 \200\22320 9 5 \200\22310 10 \200\22315 16 1 \200\2232 1 \200\2232 Pathophysiology Three main factors that interact to produce nocturnal enuresis are: - Altered night causes increased urine production (nocturnal polyuria). Altered sleep/arousal mechanism response to a full bladder. Reduced nocturnal functional bladder capacity detrus or overactivity). ADH secretion: an abnormal decrease in ADH levels at : impaired \200\230arousal from sleep \200\231 ( nocturnal Familial predisposition, psychological factors, UTI, and constipation are also considered t o contribute to nocturnal enuresis. History The aim is to establish the underlying pathophysiological factors to guide treatmen t. Enquire about the frequency of episodes and whether it is a new or recurrent problem. Sp eci \201 cally ask about daytime urinary symp- toms, urgency, holding maneuvers, symptoms of UTI, and daytime incon- tinence. Enquire about bowel habit (constipation, incontinence). Establish any underlying contributory medical conditions, a family history, and psy- choso cial history. NOCTURNAL ENURESIS 695 Examination Physical examination in a child with MNE is usually normal. Examination of the abdomen and genitals, neurological exam, lower limb sensation, and examination of the spine in children with associated voiding dysfunction (NMNE) is recommended. Investigations - Voiding diary capacity. Urinalysis or protein (UTI, renal disease). : to assess for nocturnal polyuria and functional bladder : to assess for infection, the presence of glucose (diabetes) Management General advice should be given to children and their parents. Active treat- ment is usually deferred until age 6y. First-line treatments are enuresis alarm and desmopressi n.4,5 Behavioral - Reassurance and counseling reward systems to improve the child \200\231s self-esteem. Bladd er training before bed, avoiding bladder stimulants (i.e. blackcurrant drinks, caffeine), r educed \202 uid intake in the hours before sleep. Adjust diet to avoid constipation and t reat it with laxatives if it occurs. Conditioning therapy underwear, which is triggered wit h the \201 rst few drops of urine, waking the child from sleep (60 \200\22370% successful response). : including motivational techniques and : regular daytime toileting, emptying the bladder : an enuretic alarm is connected to the child \200\231s Pharmacological - Desmopressin (synthetic analog of buccal melt) just before bedtime with no further drinks. It produces an antidiuretic response. Overall 730% achieve a full response to desmopressin and a further 40% have a partial response. Anticholinergics can be used to suppress detruso r overactivity when conservative methods have failed. Imipramine, a tricyclic antidepressan t with anticholinergic and antispasmodic properties (used only selectively in children). ADH) given orally (tablet or A full response to treatment is 14 consecutive dry nights or an 90% improvement in the numb er of wet pads.4 Patients with nocturnal polyuria (and normal bladder function) tend to hav e a good response to desmo- pressin. Patients with functionally reduced bladder capacity (w hich may be associated with occult bladder dysfunction) bene \201 t most from a com- binat ion of enuresis alarm, bladder training, and anticholinergic drugs (i.e. oxybutynin) des mopressin. Aged-based \200\230normal \200\231 bladder capacity in children is calculated as: child <2 y: bladder capacity (mL) is estimated as 7.5mL/kg; child >2y: bladder capacity in mL = 30 ( age + 2). CHAPTER 16 Pediatric urology 696 1 Neveus T, van Gontard A, Hoebeke P, et al. (2006) The standardization of terminology of l ower urinary tract function in children and adolescents: report from the standardization co mmit- tee of the International Children \200\231s Continence Society. J Urol 176:314 \200 \22324. 2 Forsythe WI, Redmond A (1974) Enuresis and spontaneous cure rate: study of 1129 patients. Arch Dis Child 49:259 \200\22363. 3 Hellstrom AL, Hansson E, Hansson S, et al. (1990) Micturition habits and incontinence in 7-year-old Swedish school entrants. Eur J Paediatr 149:434 \200\2237. 4 National Institute for Health and Clinical Excellence (2010) Nocturnal enuresis \200\224t he manage- ment of bedwetting in children and young people [online]. Available from: M http ://www.nice. org.uk/cg111. 5 Neveus T, Eggert P, Evans J, et al. (2010) Evaluation of and treatment for monosymptomati c enuresis: a standardization document from the International Children \200\231s Continence Society. J Urol 183:441 \200\2237. 697 Chapter 17 Urological surgery and equipment Preparation of the patient for urological surgery 698 Antibiotic prophylaxis in urological surgery 702 Complications of surgery in general: DVT and PE 706 Fluid balance and the manag ement of shock in the surgical patient 710 Patient safety in the urology theater 712 Transurethral resection (TUR) syndrome 713 Cathet ers and drains in urological surgery 714 Guidewires 720 Irrigating \202 uids and techniqu es of bladder washout 722 JJ stents 724 Lasers in urological surgery 730 Diathermy 732 Ster ilization of urological equipment 736 Telescopes and light sources in urological endoscopy 738 Consent: general principles 740 Cystoscopy 742 Transurethral resection of the prostate (TURP) 744 Transurethral resection of bladder tumor (TURBT) 746 Optical urethrotomy 748 Cir cumcision 750 Hydrocele and epididymal cyst removal 752 Nesbit \200\231s procedure 754 Vase ctomy and vasovasostomy 756 Orchidectomy 758 Urological incisions 760 JJ stent insertion 76 2 Nephrectomy and nephro-ureterectomy 764 Radical prostatectomy 766 Radical cystectomy 768 Ileal conduit 772 Percutaneous nephrolithotomy (PCNL) 774 Ureteroscopes and ureteroscopy 77 8 Pyeloplasty 782 Laparoscopic surgery 784 Endoscopic cystolitholapaxy and (open) cystolith otomy 786 Scrotal exploration for torsion and orchidopexy 788 Electromotive drug administra tion (EMDA) 790 CHAPTER 17 Urological surgery and equipment 698 Preparation of the patient for urological surgery The degree of preparation is related to t he complexity of the procedure. Certain aspects of examination (pulse rate, BP) and certain tests (haemo- globin, electrolytes, creatinine) are important, not only to assess \201 t ness for surgery, but also as a baseline against which changes in the post-oper- ative peri od may be measured. \200 Assess cardiac status (angina, arrhythmias, previous MI, BP, ECG, CXR). We assess respirato ry function by pulmonary function tests (FVC, FEV1) for all major surgery and any surgery w here the patient has symptoms of respiratory problems or a history of chronic airways disea se (e.g. asthma). Arrange an anesthetic review where there is, for example, cardiac or resp iratory comorbidity. Culture urine, treat active (symptomatic) infection with an appropriat e antibiotic, starting a week before surgery, and give prophylactic antibiotics at the indu ction of anesthesia. Consider stopping aspirin and NSAIDs 10 days prior to surgery. Obtain consent. Measure hemoglobin and serum creatinine and investigate and correct anemia, electr olyte disturbance, and abnormal renal function. If blood loss is anticipated, group and sav e a sample of serum or cross- match several units of blood, the precise number depending on the speed with which your blood bank can deliver blood, if needed. In our own unit, our po licy is (other units may have a different policy) (Box 17.1): \200 \200 \200 The patient may choose to store their own blood prior to the procedure. Box 17.1 The Group and Save and Cross Match policy in Oxford (consult your local hospital p olicy) TURBT TURP Open prostatectomy Simple nephrectomy Radical nephrectomy (renal vein or IVC extension) Cystectomy Radical prostatectomy PCNL Group and save Group and save Cross-match 2 units Cross-match 2 units Cross-match 4 units C ross match 6 units Cross-match 4 units Cross-match 2 units Group and save PREPARATION OF THE PATIENT FOR UROLOGICAL SURGERY 699 Should aspirin and other antiplatelet drugs be stopped prior to minor urological procedures and urological surgery? Aspirin and TRUS biopsy In the UK, 65% of urologists routinely sto p aspirin prior to TRUS biopsy; 35% do not.1 Four of 297 urologists (1.3%) reported cerebro vascular side effects from stopping aspirin. There remains no consensus guidance on whether to stop or continue aspirin. Aspirin and TURP There is wide variation in the management of aspirin in men undergo- ing T URP. In a recent audit of UK urologists, 38% said they did not stop aspirin prior to TURP, but of those that said they did stop it, a substantial number still proceeded with TURP if the aspirin had inadvertently not been stopped.2 Overall, 75% either did not bother stoppin g aspirin or proceeded with TURP if patients were inadvertently still taking it, presum- ab ly because of a perceived increased risk of serious cardiovascular events. Some studies sug gest an increased risk of bleeding and the need for blood transfusion in those on aspirin w hile others report no increased risk. There is only one RCT and this showed that aspirin di d increase blood loss after TURP, but not enough to increase the requirement for blood tran sfusion.3 The risks of short-term withdrawal of aspirin prior to TURP have not been establi shed, although there are anecdotal reports of serious adverse cardiovascular events. So sho uld aspirin be stopped or continued prior to TURP? The short answer is that there is no sub stantial body of evidence to support stopping it or continuing it and as the majority conti nue to do TURP with patients on aspirin, but a substantial minority stop it, either behavio r is reasonable. Since bleeding times return to normal within 48h of stopping aspirin (the time taken for new platelets to reach suf \201 cient numbers to compensate for impaired fu nction of circulating platelets), it seems reasonable to stop it 2 days before surgery and to restart it within a few days of surgery when it is obvious that post-operative bleeding has stopped (usually when it is deemed safe to remove the catheter). Drug-eluting cardiac stents and antiplatelet agents Be careful in patients receiving the ne wer antiplatelet drugs such as clopi- dogrel or ticlopidine (with or without aspirin) since bleeding times can increase 3-fold.4 Severe intractable bleeding can occur following \200 \230minor \200\231 procedures such as prostate biopsy or bladder biopsy. Patients with coro nary artery stents are treated with dual anticoagulation with aspirin and clopidogrel for s everal months after stent insertion to reduce the risk of stent thrombosis. The precise dur ation of antiplatelet therapy has not been established, but 9 \200\22312 months is currentl y recommended by the American Heart Association. Seek advice from a cardiologist about the safety of stopping these drugs. Consider delaying invasive procedures (e.g. prostate or bla dder biopsy) if the risk of bleeding is deemed to be unac- ceptable in the presence of the continued need for anticoagulation. CHAPTER 17 Urological surgery and equipment 700 Bowel preparation Indicated if large bowel is to be used (bowel prep is not required if sma ll bowel alone is to be used, e.g. ileal conduit, ileal neo-bladder reconstruction). Use a simple mechanical prep (Citramag or Picolax \200\224magnesium salts), two doses startin g the morning before surgery with clear \202 uid-only diet. 1 Masood J, Hafeez, Calleary J, Barua JM (2007) Aspirin use and transrectal ultrasonography - guided prostate biopsy: a national survey. Br J Urol Int 99:965 \200\2236. 2 Enver MK, Hoh I, Chinegwundoh FI (2006) The management of aspirin in transurethral prosta - tectomy: current practice in the UK. Ann R Coll Surg Engl 88:280 \200\2233. 3 Nielsen JD, Holm-Nielsen A, Jespersen J, et al. (2000) The effect of low-dose acetylsalic ylic acid on bleeding after transurethral prostatectomy \200\224a prospective, randomized, double-blind, placebo- controlled study. Scan J Urol Nephrol 34:194 \200\2238. 4 Stephen Jones J (2007) Urologists: be aware of signi \201 cant risks of stopping anticoa gulants in patients with drug eluting coronary stents. BJU Int 99:1330 \200\2231. This page intentionally left blank CHAPTER 17 Urological surgery and equipment 702 Antibiotic prophylaxis in urological surgery The precise antibiotic prophylaxis policy that you use will depend on your local microbiological \202 ora. Your local microbiology depa rtment will pro- vide regular advice and updates on which antibiotics should be used, both for prophylaxis and treatment. The policy shown here and in Table 17.1 is our own local pol icy. Since the last edition of this book, there has been a move away from cefuroxime in an attem pt to reduce the risk of antibiotic-induced C. dif \201 cile colitis. There has also been a similar move away from the use of \202 uo- roquinolones (cipro \202 oxacin, nor \202 oxacin, o \202 oxacin, levo \202 oxacin) because they are a risk factor for the developme nt of C. dif \201 cile-associated diar- rhoea and pseudomembranous colitis (and also for M RSA since they are secreted onto the skin and many staphylococci are resistant to them).* T rimethoprim, gentamicin, penicillin, and co-amoxiclav are less likely to cause C. dif \201 cile-associated disease. Culture urine before any procedure and use speci \201 c prophylaxis (based on sensitivities) if culture positive. We avoid cipro \202 oxacin in inpatients because it is secreted onto the skin and causes M RSA colonization. For most purposes, nitrofurantoin pro- vides equivalent cover without bei ng secreted onto the skin. We do use cipro \202 oxacin if there is known Proteus infection (all Proteus species are resistant to nitrofurantoin). Patients with arti \201 cial heart valves Patients with heart murmurs and those with prost hetic heart valves: 1g of IV amoxicillin with 120mg of gentamicin should be given at induct ion of anesthesia, with an additional dose of oral amoxicillin, 500mg 6h later (substitutin g vancomycin 1g for those who are penicillin-allergic). Patients with joint replacements The advice is con \202 icting. C. dif \201 cile is a Gram-positive, anaerobic, spore-forming bacillus. Most common cause of nos- ocomial diarrhea and antibiotic-associated colitis. Disease arises as a consequence of faeco-oral transmission of C. dif \201 cile spores (Ribotype 027 seems to be particula rly pathogenic). Once col- onization has occurred, progression to diarrhea or colitis depen ds on coexisting conditions and host immune response. C. dif \201 cile toxins A and B are responsible for pathogenicity. They bind to intestinal epithelial receptors. In \202 ammat ory cytokines cause \202 uid secretion, mucosal destruction, and tissue necrosis. Other r isk factors for C. dif \201 cile-associated disease: age >65y. Use of proton pump inhibito rs, laxatives, nasogastric tubes, prolonged hospital stay. Treatment for diarrhea and colit is: stop causative antibiotics, isolate and barrier nurse (wash hands with soap and water a s al- cohol hand rubs are ineffective against spores), oral metronidazole (oral vancomycin reserved for serious or recurrent infection). ANTIBIOTIC PROPHYLAXIS IN UROLOGICAL SURGERY 703 AAOS/AUA advice Joint advice of the American Academy of Orthopedic Surgeons (AAOS) and the American Urological Association (AUA) \200\224antibiotic prophylaxis is not indicated for u rological patients with pins, plates, or screws or for most patients with total joint repla cements. It is recommended for all patients undergoing urological procedures, including TUR P within 2 years of a prosthetic joint replacement, for those who are immunocompromised (e. g. rheumatoid patients, those with SLE, drug-induced immunosuppres- sion, including steroid s), and for those with a history of previous joint infection, hemophilia, HIV infection, di abetes, and malignancy. Antibiotic regime: single dose of a quinolone, such as 500mg of cipro- \202 oxacin, 1 \200\2232h preoperatively + ampicillin 2g IV + gentamicin 1.5mg/kg 30 \200\22360min preoper atively (substituting vancomycin 1g IV for penicillin- allergic patients). UK advice In the UK, a Working Party of the British Society for Antimicrobial Chemotherapy has stated that patients with prosthetic joint implants (including total hip replacements) do not require antibiotic prophylaxis and consider that it is unacceptable to expose patien ts to the adverse effects of antibiotics when there is no evidence that such prophylaxis is of any bene \201 t. This advice is based on the rationale that joint infections are cause d by skin organisms that get onto the prosthesis at the time of the operation and that the role of bacteraemia as a cause of seeding outside the immediate post-operative period has n ever been established. We use the same antibiotic prophylaxis as for patients without joint prostheses. CHAPTER 17 Urological surgery and equipment 704 Table 17.1 Oxford Urology procedure: speci \201 c antibiotic prophylaxis protocol for urol ogical surgery Procedure Antibiotic prophylaxis Catheter removal Nitrofurantoin 100mg PO 30min before catheter removal Change of male long-term catheter Gentamicin 1.5mg/kg IM or IV 20min before* Flexible cystoscopy or GA cystoscopy Nitrofurantoin 100mg PO 30 \200\22360min before procedure Transrectal prostatic biopsy Cipro \202 oxacin 500mg PO and metronidazole 400mg 20min prebiopsy and for 48h post-biopsy (cipro \202 oxacin 500mg bd, metronidazole 400mg tds) ESWL 500mg PO cipro \202 oxacin 30min before treatment (nitrofurantoin does not cover Proteus, a common \200\230stone \200\231 bacterium) PCNL Co-amoxiclav 1.2g IV tds starting the day before, hours before operation, and 3 doses post- operatively; gentamicin (3 \200\2235mg/kg) commencing the day prior to surgery, with a furt her dose 24 hours later Ureteroscopy Gentamicin 1.5mg/kg IV at induction Urogynaecological procedures (e.g. colposuspension) Co-amoxiclav 1.2g IV and metronidazole 500mg IV at induction of anesthesia TURPs and TURBTs \200\224 both for non-catheterized patients (i.e. elective TURP for LUTS) and patients with catheters (undergoing TURP for retention) Nitrofurantoin 100mg + IV gentamicin at induction (1.5mg/kg); nitrofurantoin 100mg PO 30min before catheter removal Radical prostatectomy Co-amoxiclav 1.2g IV + 240mg IV gentamicin + 500mg IV metronidazole at induction 240mg of gentamicin 24h post-op; 48h IV co-amoxiclav 1.2g tds; cipro \202 oxacin PO 5 days ANTIBIOTIC PROPHYLAXIS IN UROLOGICAL SURGERY 705 Table 17.1 (Continued) Procedure Antibiotic prophylaxis Co-amoxiclav 1.2g IV + 500mg IV metronidazole at induction; further 2 doses of co-amoxiclav 1.2g and metronidazole 500mg post-operatively Cystectomy or other procedures involving the use of bowel (e.g. aug- mentation cystoplasty) Arti \201 cial urinary sphincter insertion Vancomycin 1g 1.5h before leaving the ward (infuse over 100min)** + co-amoxiclav 1.2g IV + 3mg/kg IV gentamicin at induction; continue IV cefuroxime, gentamicin, and vancomycin (1g b d) for 48h Sepsis rate (necessitating admission to hospital) may be as high as 1% without antibiotic c over. ** OR teicoplanin if vancomycin allergic \200\224400mg at induction and bd thereafter for a total of 48h; meropenem may be substituted for vancomycin in \200\230vancomycin-fre e \200\231 hospitals. About 9% of patients undergoing \202 exible cystoscopy develop bact eruria (>105 CFU/mL of urine). A randomized, placebo controlled trial of cipro \202 oxacin 500mg or trimethoprim 200mg in 2083 patients undergoing \202 exible cystoscopy showed a signi \201 cant reduction of bacteriuria to 3 and 5%, respectively. While both antibiotics reduce the risk of bacteriuria, cipro \202 oxacin is more effective \200\224after adjustm ent for baseline bacteriuria (774% had bacteriuria before cystoscopy), the odds of bacteriu ria for those taking trimethoprim were 4 times greater than those on cipro \202 oxacin (Jo hnson MI, Merrilees D, Robson WA et al. (2007) Oral cipro \202 oxacin or trimethoprim redu ces bacteriuria after \202 exible cystoscopy. Br J Urol Int 100:826 \200\2239). CHAPTER 17 Urological surgery and equipment 706 Complications of surgery in general: DVT and PE Venous thromboembolism (VTE) is uncommon af ter urological surgery, but it is considered the most important non-surgical complication o f major urological procedures. Following TURP, 0.1 \200\2230.2% of patients experience a pu lmonary embolus (PE)1 and 1 \200\2235% of patients undergoing major uro- logical surgery ex perience symptomatic VTE.2 The mortality of PE is in the order of 1%.3 Risk factors for DVT and PE Increased risk: open (vs endoscopic) procedures, malignancy, in creasing age, duration of procedure. Categorization of VTE risk American College of Chest Physicians (ACCP) Guidelines on the pr e- vention of VTE2 and British Thromboembolic Risk Factors (THRIFT) Consensus Group4 catego rize the risk of VTE: \200 Low-risk patients: those <40 undergoing minor surgery (surgery lasting <30min) and no addit ional risk factors. No speci \201 c measures to prevent DVT are required in such patients other than early mobilization. Increasing age and duration of surgery increases the risk of VTE. High-risk patients: include those undergoing non-major surgery (surgery lasting >30mi n) who are aged >60. Additional risk factors (that indicate the requirement for additional prophylactic measures , e.g. the addition of SC heparin and/or intermittent pneumatic calf compression (IPC) \200 \200 \200 \200 \200 \200 \200 \200 \200 \200 \200 \200 \200 \200 \200 \200 \200 \200 \200 \200 Active heart or respiratory failure. Active cancer or cancer treatment. Acute medical illne ss. Age >40y. Antiphospholipid syndrome. Behcet \200\231s disease. Central venous catheter in situ. Continuous travel >3h up to 4 weeks before surgery. Immobility (paralysis or limb in plaster). In \202 ammatory bowel disease (Crohn \200\231s disease/ulcerative colitis). Myeloproliferative diseases. Nephrotic syndrome. Obesity (BMI >30kg/m Paraproteinaemia. Par oxysmal nocturnal haemoglobinuria. Personal or family history of VTE. Recent myocardial inf arction or stroke. Severe infection. Use of oral contraceptive or hormone replacement thera py. Varicose veins with associated phlebitis. 2). COMPLICATIONS OF SURGERY IN GENERAL: DVT AND PE 707 \200 Inherited thrombophilia. Factor V Leiden. \200 \200 \200 \200 \200 Prothrombin 2021A gene mutation. Antithrombin de \201 ciency. Protein C or S de \201 cien cy. Hyperhomocysteinaemia. Elevated coagulation factors (e.g. Factor VIII). Prevention of DVT and PE See Table 17.2. Diagnosis of DVT Signs of DVT are non-speci \201 c (i.e. cellulitis and DVT share common s igns \200\224low-grade fever, calf swelling, and tenderness). If you suspect a DVT, arrange a Doppler USS. If the ultrasound probe can compress the popliteal and femoral veins, there is no DVT; if it cannot, there is a DVT. Diagnosis of PE Small PEs may be asymptomatic. Symptoms: include breathlessness, pleu- riti c chest pain, haemoptysis. Signs: tachycardia, tachypnoea, raised JVP, hypotension, pleural rub, pleural effusion. Tests \200 CXR: artery, oligaemia of affected segment, small pleural effusion. ECG: may be normal or s how tachycardia, right bundle branch block, inverted T waves in V1 \200\223V4 (evidence of right ventricular strain). The \200\230classic \200\231 SI, QIII, TIII pattern is rare. Ar terial blood gasses: Imaging: and sensitivity when compared with ventilation perfusion (VQ) radioisotope scan. Spiral CT: normal isotope lung scan or a negative pulmonary angiogram. may be normal or show linear atelectasis, dilated pulmonary \200 low PO2 and low PCO2. CT pulmonary angiogram (CTPA) \200\224superior speci \201 city a negative CTPA rules out a PE with similar accuracy to a Treatment of established DVT \200 Below-knee DVT: if no peripheral arterial disease (enquire for claudication and check pulse s) + unfractionated heparin 5000U SC 12-hourly. Above-knee DVT: warfarin and stop heparin w hen INR is between 2 and 3. Continue treatment for 6 weeks for post-surgical patient; lifel ong if underlying cause (e.g. malignancy). LMWH. above-knee thromboembolic stockings (AK-TEDs), start a low molecular weight heparin (LMWH) and