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 Treatment of established PE Fixed dose of SC LMWH seems to be as effective as adjusted dose IV unfractionated heparin for the treatment of PE found in conjunction with a symptomatic DVT.3 Rates of hemorrhage are similar with both forms of heparin treatment. Start warfarin at the same time and stop heparin when INR is 2 \200\2233. Continue warfarin for 3 months. CHAPTER 17 Urological surgery and equipment 708 Options for prevention of VTE \200 \200 Early mobilization. AK-TEDs \200\224provide graduated, static compression of the calves, th ereby reducing venous stasis. More effective than below-knee TEDS for DVT prevention.5 SC h eparin (low-dose unfractionated heparin (LDUH) or LMWH). In unfractionated preparations, he parin molecules are polymerized \200\224 molecular weights from 5000 \200\22330 000Da. LMWH is depolymerized \200\224 molecular weight 4000 \200\2235000Da. IPC boots, which are place d around the calves, are intermittently in \202 ated and de \202 ated, thereby increasing the \202 ow of blood in calf veins.6 For patients undergoing major urological surgery (r adical prostatectomy, cystectomy, nephrectomy), AK-TEDS with IPC intra- operatively, follow ed by SC heparin (LDUH or LMWH) should be used. For TURP, many urologists use a combination of AK-TEDS and IPCs; relatively few use SC heparin.7 Contraindications to AK-TEDS \200 Any local leg conditions with which stockings would interfere, such as dermatitis, vein lig ation, gangrene, recent skin grafts. Peripheral artery occlusive disease (PAOD). Massive oe dema of legs or pulmonary oedema from congestive cardiac failure. Extreme deformity of the legs. \200 Contraindications to heparin \200 \200 \200 \200 \200 Allergy to heparin. History of haemorrhagic stroke. Active bleeding. Signi \201 cant liver impairment \200\224check clotting \201 rst. 9/L). Thrombocytopenia (platelet count <100 x 10 Management of anticoagulation in the perioperative period Liaise with whoever is responsibl e for the patient \200\231s anticoagulation (e.g. anticoagulant clinic). Warfarin should be stopped either 4 days (if the target INR is 2.5) or 5 days (if the target INR is higher) b efore surgery. Determine the INR the day before surgery to reduce the risk of cancella- tio n. Administer oral vitamin K (2.5mg) if the INR is \211 2.0. Check the INR on the day of s urgery. The main decision is whether to give bridging therapy with treatment dose heparin (unfracti onated heparin or LMWH) and if not, whether preoperative prophylactic LMWH is advised when the INR is <2.0. For pragmatic purposes, to save monitoring the INR as an outpatient, this could be instituted 2 \200\2233 days after warfarin is stopped, i.e. on the morning after t wo doses have been omitted. A controversial group of patients are those with a prosthetic (non- caged) aortic valve and no other risk factor. It is acceptable not to use bridging therapy with treatment dose hep arin in these patients particularly if the bleeding risk is high.8,9 COMPLICATIONS OF SURGERY IN GENERAL: DVT AND PE 709 Table 17.2 Pre- and post-operative risks Pre-operative Post-operative* Treatment dose heparin (either IV UFH or SC LMWH) Treatment dose heparin (either IV UFH or SC LMWH)** High risk, e.g. VTE within 1 month. Prosthetic mitral valve, AF, and history of stroke Non-high Risk, e.g. AF without previous stroke Nil/prophylactic LMWH*** Prophylactic LMWH Continue until INR >2.0 for two consecutive days. ** Stop full dose IV UFH 6h preoperativel y and check APTT, omit full dose SC LMWH on day of surgery. *** For patients with VTE withi n 1 \200\2233 months or cancer, we would suggest prophylactic LMWH preoperatively. 1 Donat R, Mancey \200\223Jones B (2002) Incidence of thromboembolism after transurethral r esection of the prostate (TURP). Scan J Urol Nephrol 36:119 \200\22323. 2 Geerts WH, Heit JA, Clagett PG, et al. (2001) Prevention of venous thromboembolism. (Amer ican College of Chest Physicians (ACCP) Guidelines on prevention of venous thrombo- embolis m) Chest 119:132S \200\223175S. 3 Quinlan DJ, McQuillan A, Eikelboom JW (2004) Low molecular weight heparin compared with i ntravenous unfractionated heparin for treatment of pulmonary embolism. Ann Intern Med 140:1 75 \200\22383. 4 Lowe GDO, Greer IA, Cooke TG, et al. (1992) Risk of and prophylaxis for venous thrombo- e mbolism in hospital patients. Thromboembolic Risk Factors (THRIFT) Consensus Group. BMJ 305 :567 \200\22374. 5 Howard A, Zaccagnini D, Ellis M, Williams A, Davies AH, Greenhalgh RM (2004) Randomized c linical trial of low molecular weight heparin with thigh-length or knee-length antiembolism stock- ings for patients undergoing surgery. Br J Surg 91:842 \200\2237. 6 Soderdahl DW, Henderson SR, Hansberry KL (1997) A comparison of intermittent pneumatic co mpression of the calf and whole leg in preventing deep venous thrombosis in urological surg ery. J Urol 157:1774 \200\2236. 7 Golash A, Collins PW, Kynaston HG, Jenkins BJ (2002) Venous thromboembolic prophylaxis fo r transurethral prostatectomy: practice among British urologists. J R Soc Med 95:130 \200 \2231. 8 Dunn AS, Turpie AG (2003) Perioperative management of patients receiving oral anticoagu- lants: a systematic review. Arch Intern Med 163:901 \200\2238. 9 Kearon C (2003) Managment of anticoagulation before and after elective surgery. Am Soc He matol Educat Program Book, pp. 528 \200\22334. CHAPTER 17 Urological surgery and equipment 710 Fluid balance and the management of shock in the surgical patient Daily \202 uid requirement Can be calculated according to patient \200\231s weight: \200 \200 \200 For the \201 rst 10kg: 100mL/kg per 24h (= 1000mL). For the next 10kg (i.e. from 10 \200 \22320kg): 50mL/kg per 24h (= 500mL). For every kg above 20kg: 20mL/kg per 24h (= 1000mL fo r a patient weighing 70kg). Thus, for every 24h, a 70kg adult will require 1000mL for their \201 rst 10kg of weight, plus 500mL for their next 10kg of weight, and 1000mL for their last 50kg of weight = total 24h \202 uid requirement, 2500mL. Daily sodium requirement is 100mmol and for potassium, 70mmol. Thus, a standard 24h \202 uid regimen is 2L of 5% dextrose + 1L of normal saline (equivalent to about 150mmol Na+), w ith 20mmol K+ for every liter of infused \202 uid. Fluid losses from drains or nasogastric aspirate are similar in composi- tion to plasma and should be replaced principally with normal saline. Shock due to blood loss Inadequate organ perfusion and tissue oxygenation. The causes are h ypo- volaemia, cardiogenic, septic, anaphylactic, and neurogenic. The most com- mon cause i n the surgical patient is hypovolaemia due to blood and other \202 uid loss. Hemorrhage i s an acute loss of circulating blood volume. Haemorrhagic shock may be classi \201 ed as: Class I: up to 750mL of blood loss (15% of bl ood volume); normal pulse rate (PR), respiratory rate (RR), BP, urine output, and mental st atus. Class II: 750 \200\2231500mL (15 \200\22330% of blood volume); PR >100; decreased pul se pressure due to increased diastolic pressure; RR 20 \200\22330; urinary output 20 \200 \22330mL/h. Class III: 1500 \200\2232000mL (30 \200\22340% of blood volume); PR >120; decre ased BP and pulse pressure due to decreased systolic pressure; RR 30 \200\22340; urine outp ut 5 \200\22315mL/h; confusion. Class IV: pressure and BP; RR >35; urine output <5mL/h; col d, clammy skin. >2000mL (>40% of blood volume); PR >140; decreased pulse FLUID BALANCE AND THE MANAGEMENT OF SHOCK 711 Management \200 \200 \200 Remember \200\230ABC \200\231: 100% oxygen to improve tissue oxygenation. ECG, cardiac mon itor, pulse oximetry. Insert two short and wide IV cannulae in the antecubital fossa (e.g. 16 G). A central venous line may be required. Infuse 1L of warm Hartmann \200\231s solution or if severe hemorrhage, then start a colloid instead (e.g. Gelofusin ). Aim for a urinar y output of 0.5mL/kg/h and maintenance of BP. Check FBC, coagulation screen, U & E, and car diac enzymes. Cross-match 6U of blood. Arterial blood gasses to assess oxygenation and pH. Obvious and excessive blood loss may be seen from drains, but drains can block so assume th ere is covert bleeding if there is a tachycardia (and low BP). If this regimen fails to sta bilize pulse and BP, return the patient to the operating room for exploratory surgery. \200 \200 \200 CHAPTER 17 Urological surgery and equipment 712 Patient safety in the urology theater It is a fundamental part of safe surgical practice to cross-check that the fol- lowing have been done prior to starting an operation or procedur e. The process of cross-checking should be done with another member of staff, using several sources of information (e.g. the notes, consent form, X-ray images) to con \201 rm the fo llowing. \200 Patient identi \201 cation: by a process of \200\230active \200\231 identi \201 cation ( i.e. ask the patient their name, date of birth, and their address to con \201 rm that you are talking to the correct patient). Ensure you are doing the correct procedure and on the correct side by cross-checking with the notes and X-rays: for lateralized procedures (e.g. nephrectomy, PCNL), the correct side of the operation should be con \201 rmed by cross-che cking with the X-rays and with the X-ray report as well as referring to the notes. Where it is possible for the sides of an IVU to be incorrectly labeled, this cannot happen with a C T scan where the location of the liver (right side) and the spleen (left side) provides con \201 rmation of what side is what. Appropriate antibiotic prophylaxis has been given. DVT prophylaxis has been administered boots). Blood is available, if appropriate. The patient is safely and securely positioned on the operating table: pressure points padded, not touch ing metal (to avoid diathermy burns), body straps securely in place. con \201 rm you are operating on the right patient \200 (e.g. heparin, AK-TEDS, IPC \200 Develop an approach to operating that involves members of your team. Listen to the opinions of staff who are junior to you. They may some- times be able to identify errors that are n ot obvious to you. Cultivate the respect of the recovery room staff. They may express conce rn about a patient under their care \200\224listen to their concerns, take them seriously, and if all is well, reassure them. It does no harm for your patients or for your reputation to develop the habit of visiting every patient in the recov- ery room to check that all is well. You may be able to identify a problem before it has developed into a crisis and at t he very least, you will gain a reputation for being a caring surgeon. TRANSURETHRAL RESECTION (TUR) SYNDROME 713 Transurethral resection (TUR) syndrome Arises from the infusion of a large volume of hypoto nic irrigating solution into the circulation during endoscopic procedures (e.g. TURP, TURBT , PCNL). Occurs in 0.5% of TURPs. Pathophysiology Biochemical, haemodynamic, and neurological disturbances occur. \200 Dilutional hyponatraemia is the most important \200\224and serious \200\224factor leading t o the symptoms and signs. The serum sodium usually has to fall to <125mmol/L before the pat ient becomes unwell. Hypertension \200\224due to \202 uid overload. Visual disturbances m ay be due to the fact that glycine is a neurotransmitter in the retina. \200 Diagnosis: symptoms, signs, and tests Confusion, nausea, vomiting, hypertension, bradycardi a, visual distur- bances, seizures. If the patient is awake (spinal anesthesia), they may r eport visual disturbances (e.g. \202 ashing lights). Preventing development of TUR syndrome and de \201 nitive treatment Use a continuous irrig ating cystoscope (provides low-pressure irrigation), limit resection time, avoid aggressive resection near the capsule, and reduce the height of the irrigant solution.1 For prolonged procedures, where a greater degree of \202 uid absorption may occur, measur e serum Na and give 20 \200\22340mg of IV furosemide to start of \202 oading the excess \202 uid that has been absorbed. If the serum sodium comes back as being normal, you will h ave done little harm by giving the furosemide, but if it comes back at <125mmol/L, you will have started treatment already and thereby may have prevented the development of severe TU R syndrome. Techniques for measuring \202 uid overload \200 \200 2 Weighing machines can be added to the ordinary operating table. Adding a little alcohol t o the irrigating \202 uid and constantly monitoring the expired air with a breathalyzer3 allows an estimation of the volume of excess \202 uid which has been absorbed. 1 Madsen PO, Naber KG (1973) The importance of the pressure in the prostatic fossa and abso rption of irrigating \202 uid during transurethral resection of the prostate. J Urol 109: 446 \200\22352. 2 Coppinger SW, Lewis CA, Milroy EJG (1995) A method of measuring \202 uid balance during trans- urethral resection of the prostate. Br J Urol 76:66 \200\22372. 3 Hahn RG (1993) Ethanol monitoring of extravascular absorption of irrigating \202 uid. B r J Urol 72:766 \200\2239. CHAPTER 17 Urological surgery and equipment 714 Catheters and drains in urological surgery Catheters Made from latex or silastic (for patie nts with latex allergy or for long-term use \200\224better tolerated by the urethral mucosa ). Types \200 Self-retaining (also known as a Foley, balloon, or 2-way catheter) (Fig. 17.1). An in \202 ation channel can be used to in \202 ate and de \202 ate a balloon at the end of the cat heter, which prevents the catheter from falling out. A 3-way catheter (also known as an irr igating catheter). Has a third channel (in addition to the balloon in \202 ation and drain age channels) which allows \202 uid to be run into the bladder at the same time as it is drained from the bladder (Fig. 17.2). Size The size of a catheter is denoted by its circumference in mm. This is known as the \200\230French \200\231 or \200\230Charriere \200\231 (hence Ch) gauge. Thus a 12 Ch cathe ter has a circumference of 12mm. Uses \200 Relief of obstruction (e.g. BOO due to BPE causing urinary retention \200\224 use the small est catheter that you can pass; usually a 12 Ch or 14 Ch is suf \201 cient in an adult). I rrigation of the bladder for clot retention (use a 20 Ch or 22 Ch 3-way catheter). Drainage of urine to allow the bladder to heal if it has been opened (trauma or deliberately, as pa rt of a surgical operation). Prevention of ureteric re \202 ux, maintenance of a low bladd er pressure, where the ureter has been stented (post-pyeloplasty for PUJO). To empty the bl adder before an operation on the abdomen or pelvis (de \202 ating the bladder gets it out of harm \200\231s way). Monitoring of urine output post-operatively or in the unwell patien t. For delivery of bladder instillations (e.g. intravesical chemotherapy or immunotherapy). To allow identi \201 cation of the bladder neck during surgery (e.g. radical prostatectom y, operations on or around the bladder neck). \200 Drains Principally indicated for the prevention of accumulation of urine, blood, lymph, or other \202 uids. Particularly used after the urinary tract has been opened and closed by suture repair. A suture line takes some days to become completely watertight and during thi s time, urine leaks from the closure site. A drain prevents accumulation of urine (a urinom a), the very presence of which can cause an ileus and if it becomes infected, an abscess ca n develop. CATHETERS AND DRAINS IN UROLOGICAL SURGERY 715 Fig. 17.1 A Foley catheter with the balloon in \202 ated. Fig. 17.2 2- and 3-way catheters. CHAPTER 17 Urological surgery and equipment 716 Tube drains passive drainage (i.e. no applied pressure). Used to drain suture lines at a si te of repair or anastomosis of the urinary tract. Avoid placing the drain tip on the suture line as this may prevent healing of the repair. Suture it to adjacent tissues to prevent i t from being dislodged. Suction drains drainage (i.e. air in the drainage bottle is evacuat ed, producing a negative pressure when connected to the drain tube to encourage evacuation of \202 uid). Used for the prevention of accumulation of blood (a haematoma) in super \201 cial wounds. Avoid in proximity to a suture line in the urinary tract \200\224the suct ioning effect may encourage continued \202 ow of urine out of the hole, discouraging heal ing. (e.g. a Robinson \200\231s drain; Figs. 17.3 and 17.4): provide (e.g. Hemovac ; Figs. 17.5 and 17.6): provide active As a general principle, drains should be brought out through a separate stab wound, rather than through the main wound, since the latter may result in bacterial contamination of the main wound with subsequent risk of infection. Secure the drain with a thick suture to preve nt it from inad- vertently \200\230falling out \200\231. CATHETERS AND DRAINS IN UROLOGICAL SURGERY 717 Fig. 17.3 A Robinson \200\231s (passive) drainage system. Fig. 17.4 Note the eyeholes of the Robinson \200\231s catheter. CHAPTER 17 Urological surgery and equipment 718 Failure to de \202 ate catheter balloon for removal of a urethral catheter From time to ti me, an in \202 ated catheter balloon will not de \202 ate when the time comes for removal of the catheter. \200 Try in \202 ating the balloon with air or water \200\224this can dislodge an obstruction. Leave a 10mL syringe \201 rmly inserted in the balloon channel and come back an hour or s o later. Try bursting the balloon by overin \202 ation. Cut the end of the catheter off, p roximal to the in \202 ation valve \200\224the valve may be \200\230stuck \200\231 and th e water may drain out of the balloon. In the female patient, introduce a needle alongside y our \201 nger into the vagina and burst the balloon by advancing the needle through the a nterior vaginal and bladder wall. In male patients, balloon de \202 ation with a needle ca n also be done under USS guidance. Fill the bladder with saline using a bladder syringe so that the needle can be introduced percutaneously and directed towards the balloon of the ca theter under USS control. Pass a ureteroscope alongside the catheter and de \202 ate the b alloon with the rigid end of a guidewire or with a laser \201 bre (the end of which is sh arp). \200 CATHETERS AND DRAINS IN UROLOGICAL SURGERY 719 Fig. 17.5 A Redivac suction drain showing the drain tubing attached to the needle used for insertion and the suction bottle. Fig. 17.6 The eyeholes at the tip of the suction drain. CHAPTER 17 Urological surgery and equipment 720 Guidewires An essential tool for endourological procedures. Uses As a track over which catheters or instruments can be passed into the ureter, collecti ng system of the kidney (retrograde or antegrade), or the bladder. Types Many different types of guidewire are available. They are classi \201 ed accord- ing to their size, tip design, rigidity, and surface coating. These speci \201 c properties d etermine their use. All are radio-opaque so X-ray screening can be used to determine their position. They come prepackaged in a coiled sheath to allow ease of handling and storage (F ig. 17.7). Size \200\230Size \200\231 refers to diameter measured in inches (length is usually around 150cm). Most common size are 0.035 inches (2.7 Ch) and 0.038 inches (2.9 Ch). Also availab le as 0.032 inches (2.5 Ch). Tip design Shape of tip \200\224straight or angle (Fig. 17.8); a straight tip is usually ad equate for most uses. Occasionally, an angled tip is useful for negotiating an impacted sto ne or for placing the guidewire in a speci \201 c position. Similarly, a J-shaped tip can negotiate an impacted stone \200\224the curved leading edge of this guidewire type can some times suddenly \202 ick past the stone (in this situation, a straight guidewire can inadv ertently perforate the ureter, thereby creating a false passage). Surface coating Most standard guidewires are coated with polytetra \202 uoroethylene (PTFE ) which has a low coef \201 cient of friction, thus allowing easy passage of the guidewire through the ureter and of instruments over them. Some guidewires are coated with a polymer which, when wet, is very slippery (hydrophilic coating). In some cases, the entire length of the guidewire is so coated (e.g. Terumo Glidewire) and in others, just the tip (e.g. Sen sor guidewire). The virtually friction-free surface of Glidewires makes them liable to slip out of the ureter and they, therefore, make unreliable safety wires (they can be exchanged for a wire with greater friction via a ureteric catheter). If allowed to become dry, these wires have a high coef \201 cient of friction, which makes them dif \201 cult to manipul ate. Tip rigidity The tip of all guidewires, over at least 3cm, is soft and, therefore, \202 e xible. This reduces \200\224although does not completely remove \200\224the risk of ureteri c perforation. GUIDEWIRES 721 Fig. 17.7 Guidewires come prepackaged in a sheath for ease of handling. Fig. 17.8 Examples of straight-tip and angled-tip guidewires. Shaft rigidity Stiff guidewires are easier to manipulate than \202 oppy ones and help to straighten a tortuous ureter (e.g. Amplatz Ultrastiff is particularly useful for this). Ver y malleable wires such as the Terumo Glidewire can be very useful for passing an impacted s tone (for the same reason as J tip wires). Some guidewires provide a combination of properties \200\224a soft, \202 oppy, hydrophili c-coated tip, with the remainder of the guidewire being stiff (e.g. Sensor guidewire). CHAPTER 17 Urological surgery and equipment 722 Irrigating \202 uids and techniques of bladder washout Glycine is used for endoscopic sur gery requiring application of diathermy Normal saline is used for: Irrigation of bladder following TURP, TURBT. Irrigation during u reteroscopy, PCNL. \200 Blocked catheter post-TURP and clot retention Avoiding catheter blockage following TURP \200\224keep the catheter bag empty; ensure a suf \201 cient supply of irrigant solution. The bladder will be painfully distended. Irrigant \202 ow will have stopped.A small clot may have blocked the catheter or a chip of prostate may have stuck in the eye of the cathet er. Attach a bladder syringe to the end of the catheter and pull back (Fig. 17.9). This may suck out the clot or chip of prostate and \202 ow may restart. If it does not, draw some irrigant up into the syringe until it is about half full and forcefully inject this \202 uid into the bladder. This may dislodge (and fragment) a clot that has stuck to the eye of the catheter. If the problem persists, change the catheter. You may see the obstructing ch ip of prostate on the end of the catheter as it is withdrawn. Blocked catheter post-TURBT Use the same technique as for post-TURP catheter blockage, but avoid vigorous pressure on the syringe \200\224the wall of the bladder will have been weake ned at the site of tumor resection and it is possible to perforate the bladder, particularl y in elderly women who have thin bladder walls. Blocked catheters following bladder augmentation or neo-bladder The suture line of the augm ented bladder is weak and overvigorous blad- der washouts can rupture the bladder. IRRIGATING FLUIDS AND TECHNIQUES OF BLADDER WASHOUT 723 Fig. 17.9 A bladder syringe \200\224the tip is designed to \201 t onto a catheter. CHAPTER 17 Urological surgery and equipment 724 JJ stents These are hollow tubes with a coil at each end, which are inserted through the bl adder (usually) into the ureter and thence into the renal pelvis. They are designed to bypa ss a ureteric obstruction (e.g. due to a stone) or drain the kidney (e.g. post-renal surger y). They have a coil at each end (hence, the alternative name of \200\230double pigtail \200\231 stent \200\224the coils have the con \201 gura- tion of a pig \200\231s tail \200 \224or the less accurate name of J stent). These prevent migration downwards (out of the ureter) or upwards (into the ureter). They ar e, therefore, \200\230self-retaining \200\231. Made of polymers of variable strength and b iodurability. Some stents have a hydrophilic coating which absorbs water and thereby, makes them more slippery and easier to insert. Stents are impregnated with barium- or bismuth-co ntaining metallic salts to make them radio-opaque so that they can be visualized radio- gra phically to ensure correct positioning. Types Classi \201 ed by size and length. Common sizes are 6 or 7 Ch (Fig. 17.10). Common l engths for adults are 22 \200\22328cm. Multilength stents are of vari- able length, allowin g them to accommodate to ureters of different length. A new stent design, the PolarisTM loo p (Boston Scienti \201 c), is said to reduce bladder irritation and to make removal easier . Stent materials Polyurethane; silicone; C- \202 ex; Silitek; Percu \202 ex; biodegradable (experi- mental \200\224obviates the need for stent removal and eliminates the possibil- i ty of the \200\230forgotten stent \200\231). Some are coated (by chemical bonding) with a hydrogel (e.g. HydroPlusTM) which provides a low friction surface so making insertion easie r, encrustation less likely, and in theory, makes the stent more comfortable (whether this is the case in practice has not been established). Indications and uses \200 Relief of obstruction: from ureteric stones; benign (i.e. ischaemic) ureteric strictures; m alignant ureteric strictures. The stent will relieve the pain caused by obstruction and rev erse renal impairment if present. Prevention of obstruction: post-ureteroscopy (routine ste nting after \200\230uncomplicated \200\231* ureteroscopy is not necessary). Indications fo r J stenting post-ureteroscopy: \200 \200 \200 \200 \200 Prevention of obstructio n post-ESWL. Indications for J stenting post-ESWL:1 \200 Ureteric injury. Solitary kidney. Large residual stone burden. Raised creatinine (implying overall impaired renal function). Ureteric stricture. \200 Stents reduce the incidence of steinstrasse with large renal calculi (1.5 \200\2233.5cm, 6% with a stent, and 13% without develop a steinstrasse post-ESWL). Solitary kidney. JJ STENTS 725 Fig. 17.10 A JJ stent. \200 Raised creatinine (implying overall impaired renal function). (The analysis by the Joint AU A/EAU Nephrolithiasis Guideline Panel 20072 found no improvement in stone fragmentation wit h stenting, i.e. stents do not enhance ESWL ef \201 cacy.) \200 \200\230Passive \200\231 dilatation of ureter prior to ureteroscopy. To ensure antegrade \202 ow of urine following surgery (e.g. pyeloplasty) or injury to ureter. Following endop yelotomy (endopyelotomy stents have a tapered end, from 14 to 7 Ch, to keep the incised ure ter \200\230open \200\231). Post-renal transplantation (stenting of re-implanted ureter). An alternative to the J stent A short-term 4 or 6 Ch ureteric catheter, attached to a 12 Ch urethral catheter (to stop the ureteric catheter from falling out), is an alternative form of post-ureteroscopy drainage. In an RCT of 24h of ureteric catheter drainage post-ureteroscopy com- pared with no drainag e, the non-catheterized group were more likely to report renal colic (45% vs 2%) and to hav e loin pain (76% vs 20%) than the ureteric catheterized group.3 Analgesic use was greater i n the non- catheterized group (67% vs 20%). Twenty percent of non-catheterized patients and 5% of catheterized returned to hospital for analgesia (but no patient required readmission ). The only disadvantage of this technique was a higher reported rate of urethral irritatio n (37% vs 4%) in the catheterized patients. It has the obvious advantage of ease of removal of the catheter The de \201 nition of \200\231uncomplicated \200\231 ureteroscopy is not precise. \200 \230Complicated \200\231 ureteroscopy has been variously de \201 ned as (a) ureteral perfo ration (i.e. mucosal injury); (b) severe ureteric oedema at the site of the stone; (c) impa ction (which means dif \201 culty getting a guidewire past the stone ( \200\230cork in a b ottle \200\231 stone); (d) prolonged operation (no precise de \201 nition of what \200 \230long \200\231 is); (e) one where ureteral dilatation was carried (to de \201 ne such u reteroscopies as \200\230complicated \200\231 is contentious because some urologists routi nely \200\230dilate \200\231 with a dual lumen catheter to allow double guidewire placemen t. Does this automatically make all their ureteroscopies \200\230complicated \200\231?). CHAPTER 17 Urological surgery and equipment 726 without the need for a second procedure and avoids the potential risk of the forgotten sten t. Symptoms and complications of stents \200 Stent symptoms: common (78%) \200\224suprapubic pain, LUTS (frequency, urgency \200\224sten t irritates trigone), haematuria, inability to work.4 More than 80% of patients have stent- related pain that affects daily activities, 32% report sexual dysfunction, and 58% report r educed work capacity and loss of income. A-blockers may help reduce pain with voiding and o verall analgesic use. development of bacteriuria after stenting is common. In a small UTI: proportion, sepsis can develop. In such cases, consider placement of a urethral catheter to lower the pressure in the collecting system and prevent re \202 ux of infected urine. Ste nts coated with the antibacterial triclosan are no better than non-coated stents in prevent ing stent- associated UTI. Incorrect placement: subsequent stent removal requires ureterosc opy; can be technically dif \201 cult; percutaneous removal may be required). Too low (pro ximal end not in renal pelvis; stent may not, therefore, relieve obstruction). (up the uret er or down the ureter and into bladder). Stent migration Stent blockage: catheters and sten ts become coated with a bio \201 lm when in contact with urine (a protein matrix secreted by bacteria- colonizing stent). Calcium, magnesium, and phosphate salts become deposited. B io \201 lm build-up can lead to stent blockage or stone formation on the stent (Fig. 17.11 ). Stents coated with heparin are no better than non-coated stents in preventing stent bio \201 lm formation or encrustation. The \200\230forgotten stent \200\231: may become encru sted with stone, making removal technically very dif \201 cult. If the proximal end only i s encrusted, PCNL may be required to remove the stone and then the stent. If the entire ste nt is encrusted, open removal via several incisions in the ureter may be necessary. too high (distal end of stent in ureter; \200 rare, but potentially very serious as the bio \201 lm JJ STENTS 727 Fig. 17.11 An encrusted stent. Commonly asked questions about stents Does urine pass though the center of the stent? No, i t passes around the outside of the stent. Re \202 ux of urine occurs through the center. Should I place a JJ stent after ureteroscopy? (see Indications and uses) A stent should be placed if: \200 There has been ureteric injury (e.g. perforation \200\224indicated by extravasation of cont rast). There are residual stones that might obstruct the ureter. The patient has had a uret eric stricture that required dilatation. Solitary kidney. Raised creatinine (implying overa ll impaired renal function). \200 \200 \200 Routine stenting after ureteroscopy for distal ureteric calculi is unneces- sary.5,6 Many u rologists will place a stent after ureteroscopy for proximal ureteric stones. Do stents cause obstruction? In normal kidneys, stents cause a signi \201 cant and substan tial increase in intrarenal pressure, which persists for up to 3 weeks.7 (This can be pre- vented by placing a urethral catheter.) CHAPTER 17 Urological surgery and equipment 728