Urological Emergencies in Clinical Practice - part 10 doc

172 J. REYNARD AND N. COWAN F IGURE 10.1. a: A flexible cystoscope has been passed into the bladder and a guidewire is manipulated into the ureter under direct vision. (See this figure in full color in the insert.) b: Under fluoroscopic control, the guidewire is advanced up the ureter and into the renal pelvis. c: The lower end of the stent is seen deployed in the bladder. (See this figure in full color in the insert.) d: Previously instilled contrast medium can be used to confirm that the stent is in the correct position. a FIGURE 10.1. Continued b 174 J. REYNARD AND N. COWAN FIGURE 10.1. Continued c FIGURE 10.1. Continued d PERCUTANEOUS NEPHROSTOMY INSERTION Indications in Urological Emergencies Preparation of the Patient for Nephrostomy Insertion Patients should have their blood clotting checked and serum should be grouped and saved in case heavy bleeding occurs and blood transfusion is required. Verbal consent should be taken and the discussion about risks documented in the patient’s notes (see Complications, below). Technique This procedure is performed under local anaesthetic with or without sedation, and with antibiotic cover (depending on urine culture; cefuroxime and gentamicin if no culture result is avail- able). The patient lies prone. A nephrostomy needle is inserted into the renal pelvis and contrast is instilled to outline the col- lecting system of the kidney (Fig. 10.2a). A guidewire is passed into the renal pelvis (Fig. 10.2b), and over this the nephrostomy tube is advanced (Fig. 10.2c). Complications These will depend on how experienced the radiologist is and on how many nephrostomies he or she inserts per year. The com- plication rate of dedicated uroradiologists is lower than that which is generally regarded as acceptable (Ramchandani et al. 2001). Quoted complication rates should be those relevant to your hospital. In the U.K., acceptable complication rates are haemorrhage requiring embolisation or surgery 1%, septic shock 4%, damage to adjacent organs <1%, and failure to drain the kidney approximately 5% (Ramchandani et al. 2001), but some series report complication rates that are below these (Ho and Cowan 2001). Failure to Deflate Catheter Balloon for Removal of a Urethral Catheter From time to time an inflated catheter balloon will not deflate when the time comes for removal of the catheter. No amount of drawing back on the balloon channel with a syringe will make the balloon go down, and attempts to burst the balloon by inflat- ing the balloon with air or flushing the balloon inflation channel with water fail to work. 176 J. REYNARD AND N. COWAN 10. COMMON EMERGENCY UROLOGICAL PROCEDURES 177 FIGURE 10.2 a: Nephrostomy insertion. A needle has been inserted into the renal pelvis and contrast has been instilled. b: A guidewire has been passed into the renal pelvis. c: The nephrostomy tube is advanced over the guidewire into the renal pelvis. a 178 J. REYNARD AND N. COWAN FIGURE 10.2. Continued b 10. COMMON EMERGENCY UROLOGICAL PROCEDURES 179 FIGURE 10.2. Continued c A little patience is required. Leave a 10-mL syringe firmly inserted in the balloon channel and come back an hour or so later. Sometimes, for no apparent reason, the balloon will have deflated and the catheter will be lying in the bed, having fallen out. If this does not work, and the patient is female, then it is quite easy to burst the balloon using a needle introduced alongside your finger into the vagina (Fig. 10.3). Ask the patient to lie on her back, place a needle on your finger, apply copious lubrica- tion, and gently insert the finger into the vagina. Pull down on the catheter with your other hand (or ask an assistant to do so), until you can feel the balloon of the catheter sitting at the bladder neck. By pulling the balloon onto the needle (which should be advanced a little so it advances just beyond the tip of your finger), the balloon can be deflated. In male patients, balloon deflation with a needle can also be done, but ultrasound-guided balloon puncture will be required. Either the catheter should be clamped to allow the bladder to fill up, or the bladder can be filled with saline using a bladder syringe. As the bladder is so inflated, the bowel is pushed upward, 180 J. REYNARD AND N. COWAN Catheter balloon vagina Needle on finger in vagina pubic symphysis F IGURE 10.3. Technique for bursting a catheter balloon in a woman. out of harm’s way, so that the needle can be introduced percuta- neously and directly, by ultrasound, toward the balloon of the catheter. References Birch BRP, Ratan P, Morley R, et al. Felxible cystoscopy in men: is topical anaesthesia with lignocaine gel worthwhile? Br J Urol 1994;73: 155–159. Hellawell GO, Cowan NC, Holt SJ, Mutch SJ. A radiation perspective for treating loin pain in pregnancy by double-pigtail stents. Br J Urol Int 2002;90:801–808. Ho S, Cowan NC. Eur J Radiol (ESUR) 2002. McFarlane J, Cowan N, Holt S, Cowan M. Outpatient ureteric proce- dures: a new method for retrograde ureteropyelography and ureteric stent placement. Br J Urol Int 2001;87:172–176. Ramchandani P, et al. Quality improvement guidelines for percutaneous nephrostomy. J Vasc Interv Radiol 2001;12:1247–1251. 10. COMMON EMERGENCY UROLOGICAL PROCEDURES 181 [...]... Urethral injuries anterior, 109 pelvic fractures and, 90–91 posterior, 109 Urethral rupture, bladder imaging in, 95–97 Urethral tears, 112 Urethrogram, retrograde, 93, 94 Urinary retention, acute, 9–15 Urinary septicaemia, 45–48 Urinary system, injuries to, 83–92 Urinary tract infection, 5 Urinary tract obstruction, 4 Urine culture, 34 Urinoma, 66 Urological disease, spinal cord compression with, 163–165 INDEX... surgical repair of, 108 109 types of perforation in, 98 Bladder outlet obstruction, 9 Bladder perforation, 98 extraperitoneal, 100 102 iatrogenic, delayed diagnosis of, 104 intraperitoneal, 102 103 during transurethral resection of prostate, 104 105 types, 98 Bladder rupture, spontaneous rupture after augmentation, 107 108 Bleeding after transurethral resection of prostate, 146–147 following circumcision,... loss, 83 shock due to, 141–142 Blunt renal injuries, 54, 55 Boari flap, 77, 80, 81 Buck’s fascia, rupture of, 110 111 Bulbocavernosus reflex, and spinal cord and cauda equina compression, 11 184 INDEX ‘Butterfly-wing’ bruising, due to rupture of Buck’s fascia, 109 – 110 C Caesarean section, bladder injuries during, 107 Catheterisable stoma, difficulty in catheterizing, 15 Catheterisation suprapubic, see Suprapubic... Methylene blue, for demonstrating ureteric injuries, 68 Mitrofanoff stoma, difficulties catheterising, 15 Myectomy, detrusor, spontaneous rupture of bladder and, 108 I ‘Iced-glove’ method, for reduction of paraphimosis, 135–136 Ileus, 66 Intraperitoneal bladder perforation, 102 103 Intravaginal torsion, of testis, 127 Intravenous urogram (IVU), 19–21 Intravenous urography for renal imaging, 58–59 N Neobladder,... acute, 48–49 Bed-wetting, and high pressure chronic retention, 12 Bladder augmentation, spontaneous rupture after, 107 blocked catheter after, 170–171 Bladder cancer, TURBT and bladder perforation, 99, 101 , 104 Bladder imaging, in urethral rupture, 95–97 Bladder injuries, 97 109 associated with pelvic fractures, 89–90 during caesarean section, 107 causes of, 97–98 diagnosing, 98–99 imaging studies for,... compression with, 163–165 INDEX Urological emergencies common procedures for, 167–181 infective, 45–53 lower urinary tract, 9–15 postoperative, 141–150 presenting symptoms of, 1–7 scrotal and genital, 125–139 traumatic, 54–121 urological neoplastic conditions presenting as, 160–165 189 Urological neoplastic conditions presenting as urological emergencies, 160–165 W Wound dehiscence leading to burst abdomen,... Oliguria, 4–5 Open-book pelvic fractures, 85, 86 Open suprapubic cystostomy, for pelvic fracture, 92–93 P Pain back, 6–7, 11 flank, 1–2, 17–18 scrotal, 5–6 suprapubic, 5 Paraphimosis, 135–138 186 INDEX Partial transection of ureter, primary closure of, 75 Pelvic fractures, 10, 83–92 abdominal and pelvic imaging in, 91–92 bladder injuries associated with, 89–90 closed-book, 85, 87, 88 open-book, 85, 86 radiologic... 48–49 Psoas hitch, ureteric injury and, 77–80 Psoas hitch stitches, ureteric injury and, 79 Pyelonephritis acute, 32–35 emphysematous, 38–41 xanthogranulomatous, 42–43 Pyonephrosis, 35, 36–37 INDEX R Radiation levels in urinary tract imaging in pregnancy, 152–153 Rectal perforation, following pelvic fracture, 105 Recurrent urinary retention, 14–15 Renal colic, 17–18 Renal emergencies, nontraumatic,... Extraperitoneal bladder perforation, 100 102 Extravaginal torsion, of testis, 125 F Fascial layers of penis, and urethral injury, 111 Fasciotomy, for lower limb compartment syndrome, 150 Flank pain, 1–2, 17–18 Foreign bodies attached to penis, 139 in urethra, 138–139 Fournier’s gangrene, 49–51 Fowler’s syndrome, urinary retention and, 10 G Genital emergencies, 125–139 H Haematocele, following testicular trauma,...Index A Abdomen, burst, wound dehiscence leading to, 145–146 Abdominal imaging in pelvic fractures, 91–92 Acute-on-chronic highpressure retention, 12–13 Amiodarone, epididymitis and, 52 Anaemia, 2 Anaphylaxis, 142–144 Aneurysm repair, ureteric injury during, 83 Anuria, 4 Appendix epididymis, torsion of, 127 Appendix testis, torsion of, 127 Arteriovenous fistulae, post PCNL, 62 B Back pain, and urological . perforation, 99, 101 , 104 184 INDEX ‘Butterfly-wing’ bruising, due to rupture of Buck’s fascia, 109 – 110 C Caesarean section, bladder injuries during, 107 Catheterisable stoma, difficulty in catheterizing, 15 Catheterisation suprapubic,. stent is in the correct position. a FIGURE 10. 1. Continued b 174 J. REYNARD AND N. COWAN FIGURE 10. 1. Continued c FIGURE 10. 1. Continued d PERCUTANEOUS NEPHROSTOMY INSERTION Indications in Urological. 100 102 iatrogenic, delayed diagnosis of, 104 intraperitoneal, 102 103 during transurethral resection of prostate, 104 105 types, 98 Bladder rupture, spontaneous rupture after augmentation, 107 108 Bleeding after