Efficacy of Tamsulosin as Compared to Placebo, in Reducing Post Operative Flank Pain during Voiding, in Patients with Ureteric Stent

Objective: To evaluate the efficacy of tamsulosin in reducing post operative flank pain during voiding, in patients with ureteric stent. Study Design: This is a Randomized control trial (RCT) study. Place and Duration: Study carried out at Department of Urology, Jinnah Post Graduate Medical Centre, Hospital, Karachi, Pakistan, from June 2016 to November 2016. Methodology: 60 patients aged between 15 – 45years, undergone placement of ureteric stent to treat ureteric and renal calculi and have pain score >4, were included in the study. Divided into two groups ‘group A’ and ‘group B’. In group ‘A’ and group ‘B’ Tamsulosin and Placebo was given respectively in patients with ureteric stent and reduction in post-operative flank pain was measured and compared. Tamsulosin was given post operatively when NPO is broken after 2 hours – 6 hours. Patients having uretral trauma, patients having BPH, patient underwent TURP or TURBT, patent having urinary tract infection and patients with pregnancy or lactating females were excluded. All patients were received intravenous antibiotic (Ceftrixone 1gr). Also all patients were receive oral analgesic (diclofenic sodium 50mg BID) and antispasmodics (Drotaverine 80mg BID). Patients were discharged after 24 hours. Postoperatively stent related flank pain during voiding was assessed via Pain Scale. Results: 60 Patients who got operated for ureteric stent. In group ‘A’ there were 21 males (70%) and 9 females (30%), the mean age of group A was 35.67±5.99 as In group ‘B’ there were of 21 males (70%) and 9 females (30%) and mean age of group B was 35.04±6.42 (Table 1). Mean Pain score in ‘Group A’ (Tamsulosin) in week 1, 2, 3, 4, 5, 6 was 4.1, 3.5, 2.9, 2.3, 1.9, 1.3 respectively as shown in Table 2. Mean Pain score in ‘group B’ (Placebo) in week1, 2, 3, 4, 5, 6 was 6.9, 6.3, 5.9, 5.6, 5, 4.2 respectively as shown in Table 2. Average pain score in ‘group A’ and ‘group B’ came out to be 2.67 and 5.64 respectively (P value 0.005). Conclusion: Alpha blockers reduces the post-operative flank pain and voiding complaints in patients with ureteric stent. Our study shows that the efficacy of Tamsulosin in reducing post-operatice flank pain in patients with uretercic stent is better than placebo.

Ureteric Stone-Related Escherichia coli Bacteraemia Associated with Spondylodiscitis

Escherichia coli (E. coli)-related urosepsis associated with a ureteric stone has been shown to cause a systemic bacteraemia that can spread to other parts of the body. Hematogenous spread of infection is the most common cause of pyogenic spondylodiscitis. A 74-year-old female presented with acute left-sided flank pain and was found to have an obstructing 9 mm distal ureteric stone. After initial management involving ureteric stent insertion, the patient deteriorated and developed an E. coli associated bacteraemia, which proved difficult to treat. Further investigations revealed a subsequent spondylodiscitis, which required a 6-week course of antibiotics and no additional intervention. This case presents the likely association of stone-related bacteraemia, complicated by urinary tract instrumentation leading to spondylodiscitis, and demonstrates the importance of clinicians’ awareness of other causes of unresolving sepsis in an elderly patient.

Intrathoracic ureteric stent migration through a reno-pleural fistula: a case report of rare antegrade ureteric stenting complication

Background Malignant obstruction and associated hydronephrosis is a common complication of advanced cervical cancer. Percutaneous nephrostomy (PCN) followed by antegrade stenting is often required to relieve obstruction as retrograde access fails in considerable proportion of such patients. Reno-pleural fistula is a rare complication of PCN which creates a patent connection between the renal collecting system and the thoracic cavity, and urine accumulation in the pleural space can cause pleural effusion (i.e., urinothorax). Upward or downward migration is a complication of indwelling ureteric stents. Further migration with extrusion outside of the urinary tract is uncommon. Herein we present an unprecedented case in adult of ureteric stent upward migration through a reno-pleural fistula into the thoracic cavity managed by thoracoscopy. Case presentation A 66-year-old female was diagnosed of advanced stage cervical cancer with suspicious bladder invasion. Given her bilateral hydronephrosis with impaired renal function, she underwent bilateral PCN and subsequent antegrade ureteric stenting. However, she presented with dyspnea, right back pain, and oliguria four days after bilateral PCN catheter removal. Computed tomography reported massive right pleural effusion and an intrathoracic ureteric stent within reno-pleural fistula. Thoracoscopy with thoracostomy was performed to remove the ureteric stent and urine in right pleural space. A week later, urinothorax had resolved and right PCN was performed again. She was discharged after regaining normal renal function with right PCN and a left ureteric stent in place. Conclusions A reno-pleural fistula can serve as a route for ureteric stent migration and that continuous drainage of urine can cause urinothorax once the stent reaches the thoracic cavity. Anytime a supracostal approach is used for PCN, even when using small caliber catheters, clinicians should pay special attention given the risk of pleural injury and subsequent complications.

The Impact of Timing of Stent Removal on the Incidence of UTI, Recurrence, Symptomatology, Resistance, and Hospitalization in Renal Transplant Recipients

Purpose. To evaluate the impact of early (<3 weeks) versus late (>3 weeks) urinary stent removal on urinary tract infections (UTIs) post renal transplantation. Methods. A retrospective study was performed including all adult renal transplants who were transplanted between January 2017 and May 2020 with a minimum of 6-month follow-up at King Abdulaziz Medical City, Riyadh, Saudi Arabia. Results. A total of 279 kidney recipients included in the study were stratified into 114 in the early stent removal group (ESR) and 165 in the late stent removal group (LSR). Mean age was 43.4 ± 15.8; women: n: 114, 40.90%; and deceased donor transplant: n: 55, 19.70%. Mean stent removal time was 35.3 ± 28.0 days posttransplant (14.1 ± 4.6 days in the ESR versus 49.9 ± 28.1 days in LSR, p < 0.001 ). Seventy-four UTIs were diagnosed while the stents were in vivo or up to two weeks after the stent removal “UTIs related to the stent” (n = 20, 17.5% in ESR versus n = 54, 32.7% in LSR; p = 0.006 ). By six months after transplantation, there were 97 UTIs (n = 36, 31.6% UTIs in ESR versus n = 61, 37% in LSR; p = 0.373 ). Compared with UTIs diagnosed after stent removal, UTIs diagnosed while the stent was still in vivo tended to be complicated (17.9% versus 4.9%, p : 0.019), recurrent (66.1% versus 46.3%; p : 0.063), associated with bacteremia (10.7% versus 0%; p : 0.019), and requiring hospitalization (61% versus 24%, p : 0.024). Early stent removal decreased the need for expedited stent removal due to UTI reasons (rate of UTIs before stent removal) (n = 11, 9% in the early group versus n = 45, 27% in the late group; p = 0.001 ). The effect on the rate of multidrug-resistant organisms (MDRO) was less clear (33% versus 47%, p : 0.205). Early stent removal was associated with a statistically significant reduction in the incidence of UTIs related to the stent (HR = 0.505, 95% CI: 0.302-0.844, p = 0.009 ) without increasing the incidence of urological complications. Removing the stent before 21 days posttransplantation decreased UTIs related to stent (aOR: 0.403, CI: 0.218-0.744). Removing the stent before 14 days may even further decrease the risk of UTIs (aOR: 0.311, CI: 0.035- 2.726). Conclusion. Early ureteric stent removal defined as less than 21 days post renal transplantation reduced the incidence of UTIs related to stent without increasing the incidence of urological complications. UTIs occurring while the ureteric stent still in vivo were notably associated with bacteremia and hospitalization. A randomized trial will be required to further determine the best timing for stent removal.

Safely increasing nephro-ureteric stent exchange intervals, resulting in significant cost savings for the interventional radiology suite, a 2-year experience in a tertiary referral centre

Aim To evaluate the nephro-ureteric stent (NUS) insertion and exchange practice in a tertiary referral cancer centre, and determine the safety and compliance with current guidelines. We also reviewed if increasing exchange time interval from 6 to 12 weeks was safe, and if this could be adopted into our local guidelines. Methods A retrospective review was performed covering 24 months from January 2017 to December 2018. All NUS insertions and exchanges performed in that period were analysed, including the number of exchanges the patient underwent, the time between subsequent exchanges, and the screening time. We also reviewed the indications for stent insertion, possible causes for failed stent exchange, and factors which led to significant delays in stent exchanges for some patients. A scatterplot of screening time versus time in situ was derived and correlation analysis performed using the Pearson coefficient. Results Thirty-two patients underwent de novo NUS insertion during the period, and 102 NUS exchanges were performed. The interval between stent exchanges ranged from 1 to 40 weeks, with a mean of 12.3 weeks (SD = 8.96 weeks). Screening time ranged from 33 s to 17 min, with a mean of 3 min 50 s (SD = 3 min 35 s). There were 100 successful exchanges, and two failed exchanges, accounting for 1.9% of total exchanges. In both failed cases, the reason for failed exchange was due to a prolonged period between exchanges (6 months in both cases). The reason for delay for stent exchange was due to non-attendance for scheduled appointments. There was a weakly positive correlation coefficient of 0.06 (screening time versus time period between insertions); however, this was not statistically significant (p = 0.81). Conclusion In this retrospective review, we have demonstrated that the recommended 6-week period between stent exchanges is unnecessary in the vast majority of cases, and that a longer interval between NUS exchanges, e.g. 8–12 weeks, is safe for the patient, and reduces screening time. This reduction in procedures also provides a significant potential saving to the radiology department in both monetary expense and limited angiography suite time.