The reasons and countermeasures of Bladder Rupture caused by Transurethral Clot Evacuation

Objective: Bladder rupture caused by transurethral clot evacuation is rare in clinic, but an emergency operation is indeed needed in the patient with bladder rupture. We analyzed the reasons of bladder rupture caused by transurethral clot evacuation and provided the countermeasures to guide clinical surgeon to prevent the iatrogenic damage of bladder. Method: We retrospectively reviewed the records of 287 patients in our hospital, who had bladder tamponade resulting from clots of blood for various reasons and underwent transurethral clot evacuation from January 2007 to January 2019. Six male cases, aged from 28 to 76 years (mean 56.67±17.76) had bladder rupture. Four patients whose bladder ruptured intraperitoneally were changed to open surgery to repair bladder and clear the remanent blood clots. Two patients with extraperitoneal bladder rupture and a small bladder crevasse underwent a conservative therapy. Results: We observed that the incidence rate of bladder rupture was not associated with bladder tamponade and the age, but may be associated with gender, bladder paracentesis preoperative and urinary retention preoperative. All six cases were male.. They had different period of urinary retention before operation. No supra-pubis bladder paracentesis was made before operation. The bladder crevasses located in the triangle zone and posterior wall of bladder entirely, and the length of the bladder crevasses ranged from 3 to 7cm (mean 4.83cm). The bladder crevasses were all lengthways, and four cases were of’ bladders ruptured intraperitoneally while another two presented an extraperitoneal bladder rupture. Conclusions: The reasons of bladder rupture caused by transurethral clot evacuation may be related to gender, bladder paracentesis preoperative and urinary retention preoperative. We should decide to use expectant treatment or open surgery immediately according to the extent of the rupture when bladder rupture occurs. doi: https://doi.org/10.12669/pjms.37.3.3911 How to cite this:Liu KL, Wang X, Qu CB, Qi JC. The reasons and countermeasures of Bladder Rupture caused by Transurethral Clot Evacuation. Pak J Med Sci. 2021;37(3):---------. doi: https://doi.org/10.12669/pjms.37.3.3911 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

FRESH GRADUATE UROLOGIST IN EASTERN INDONESIA: FIRST YEAR SURGERY EXPERIENCE

Objective: In present days, endourology is the hallmark of urology, including in developing countries. This study reviews the surgical experiences of a urology practitioner in the first year of his practice in the underdeveloped province in Indonesia. Material & Methods: This research is a descriptive study that retrieval patients data from the medical record during June 2018 - May 2019. Results: Total of 401 operations were obtained. There were 328 male (81.8%) and 73 female (18.2%) with the average of patients age were 52+17.77 years old. The most common diagnoses were BPH 113 cases (28.2%). bladder stone 83 cases (20.7%), and ureteral stone 52 cases (13%). The most common surgical procedures performed were TURP 120 operations (29.9%), Ureterorenoscopy (URS) 64 operations (16%), and Vesicolithotripsy 58 operations (14.5%). The upper tract procedures were 84 operations (20.9%), mainly URS 64 operations (16%). Whereas the lower procedures were 317 operations (79.1%) mainly TURP 120 operations (29.9%). The complications were bleeding post-TURP 5 cases which require blood clot evacuation (1.2%), bleeding post open nephrolithotomy 1 case which requires blood transfusion (0.2%), and TURP syndrome 1 case (0.2%) with mortality 2 patient (0.4%). All kidney stones were handled by open surgery due to lack of PCNL and ESWL set devices. Conclusion: First year urologist who are interested in serving in such areas may benefit from prioritizing the availability of upper and lower set to performed basic standard care for surgical urology without leaving the hallmark of urology.

Uterine Evacuation before Operative Hysteroscopy in Patients with Active Uterine Bleeding: A randomized controlled trial

Background: Concurrent bleeding or existing clots usually obscure the vision field and decrease the hysteroscopy success rate. Therefore, any efforts made to have a clear view during the hysteroscopy will improve the diagnostic or treatment outcomes. In this study, we examined the effect of preoperative clot evacuation on hysteroscopy and patient outcomes.Methods: In this parallel-group clinical trial conducted from December 2018 to September 2019 at the Oncology Center of Alzahra Teaching Hospital in Tabriz, Iran, 114 patients with uterine bleeding were randomly assigned to receive either clot evacuation before standard operative hysteroscopy or standard hysteroscopy alone. The investigated endpoints were the clarity of vision, the volume of used distension media, duration of the procedure, amount of bleeding, and postoperative complications.Results: All 114 participants completed the study. There were statistically significant differences in the frequency of the clear vision (p<.001), the severity of bleeding (p=.0006), mean serum volume used (p<.001), mean procedure time (p<.001), and the postoperative hematocrit levels (p<.001) between groups, in favor of women with preprocedural intrauterine evacuation. There was no difference in in-hospital stay (p=0.081) and anesthetic complications among the patients (p=0.182). The procedure was successfully performed on all patients of both groups with zero postoperative complications.Conclusion: Removal of clots and other uterine contents before inserting hysteroscope rendered better and faster access to the uterine wall to observe existing abnormalities and reduce the hysteroscopy time. This additional surgical step could take a significant impact on surgical and clinical outcomes.Trial registration: Clinical trial registry name: Iranian Registry of Clinical Trials URL: https://en.irct.ir/trial/33369 The registration number: IRCT20101130005283N13 Date of trial registration: 2018-11-16

A case of adrenal cortical carcinoma with inferior vena cava thrombus extending into the right atrium: a two staged procedure

We present a case of adrenal cortical carcinoma (ACC) with tumor thrombus involving the inferior vena cava (IVC) and right atrium in a morbidly obese, middle-aged female. ACC is a rare type of cancer with a poor outcome. Most cases present with metastasis at the time of initial presentation. This patient presented with breathing difficulty and flank pain. With endocrinology evaluation and collaborative effort of multidisciplinary teams, the patient successfully underwent staged procedures of atrial clot evacuation after thoracotomy with cardiopulmonary bypass (CBP) along with inferior vena cava thrombectomy (IVCT) and left radical nephroadrenalectomy. The two staged procedure reduces the mortality when compared with a single staged procedure. The patient underwent atrial clot evacuation, performed by cardiothoracic surgery team under CBP and deployment of IVC filter by interventional radiologist as a first staged procedure. At six months of follow-up, the patient had locoregional disease spread but with good functional status. This case report highlights that even a high-volume disease, with proper planning by an experienced surgical team, can be operated successfully with an acceptable post-surgery quality of life for the patients.

Incidence and risk factors associated with reoperation for sellar hematoma following endoscopic transsphenoidal pituitary surgery

OBJECTIVEPostoperative sellar hematoma is an uncommon complication of endonasal endoscopic transsphenoidal surgery (EETS) for pituitary adenoma that often requires emergency surgical evacuation. Sellar hematomas can cause mass effect and compress parasellar structures, leading to clinically significant symptoms such as visual impairment and severe headache. The objective of this study was to determine the incidence and risk factors associated with reoperation for postoperative hematoma after EETS for pituitary adenoma.METHODSThe authors reviewed a prospectively acquired database of EETS for pituitary adenoma over 13 years at Weill Cornell Medicine, NewYork-Presbyterian Hospital and identified cases that required reoperation for confirmed hematoma. They also reviewed clinical and radiographic data of a consecutive series of patients undergoing EETS for pituitary adenoma who did not have postoperative hematoma, which served as the control group. Demographic data and risk factors were compared between the groups using univariate and multivariate analyses via binary logistic regression.RESULTSAmong a cohort of 583 patients undergoing EETS for pituitary adenoma, 9 patients (1.5%) required operation for sellar hematoma evacuation. All 9 patients with reoperation for sellar hematoma presented with worsening in their vision, and severe headache was present in 67%. New postoperative endocrine dysfunction developed in 78%. Clot evacuation improved vision in 88%. The mean time to hematoma evacuation was 4.5 days. The median length of stay for patients with sellar hematoma was 8 days (range 4–210 days) compared with a median length of stay of 3 days (range 1–32 days) for the control patients (p < 0.005). Significant risk factors in univariate analysis were tumor diameter ≥ 30 mm (p < 0.005), suprasellar extension (p < 0.005), tumor volume (p < 0.005), cavernous sinus invasion (p < 0.05), gonadotroph histology (p < 0.05), antiplatelet use (p < 0.05), and elevated BMI (p < 0.05). On multivariate analysis, tumor diameter ≥ 30 mm (OR 4.555, CI 1.30–28.90; p < 0.05) and suprasellar extension (OR 1.048, CI 1.01–1.10; p < 0.05) were found to be the only independent predictors of sellar hematoma. The incidence of hematoma in tumors ≥ 30 mm was 5% (7/139).CONCLUSIONSPostoperative sellar hematoma requiring reoperation is a rare phenomenon after transsphenoidal surgery, often presenting with visual loss and headache. Clot evacuation results in improvement in vision, but long-term endocrinopathy often ensues. Tumor diameter ≥ 30 mm and suprasellar extent are the most reliable risk factors. Close postoperative scrutiny should be given to patients at high risk.

Meningioma-related subacute subdural hematoma: A case report

Background: Meningiomas are the most frequent benign head tumors, although spontaneous hemorrhage is a rare form of presentation of such lesions. Of all possible bleeding locations associated with them, the subdural space is one of the most uncommon, with very few cases reported worldwide. Case Description: A middle-aged woman presented with progressively worsening left-sided headache, initiated 2 weeks before, with no other complaints, denying any previous head trauma. Head computed tomography revealed a subacute left hemisphere subdural hematoma and left frontal, suggestive of meningioma on magnetic resonance imaging. Surgical treatment was performed with hematoma evacuation and lesion removal. Neuropathology showed a transitional meningioma with signs of hemorrhage. After surgery, no neurological deficits were registered, and headache abated. Conclusion: As we could not identify any other cause for the subacute subdural hematoma, hemorrhage from the meningioma was the most probable cause, and thus, we decided to remove it along with clot evacuation. Based on neuropathological findings, we propose an alternative mechanism for this spontaneous hemorrhage from the meningioma, involving the place where the periphery of the lesion insertion, the dura mater as the origin of the hemorrhage. Knowledge of this association could help define the best treatment in such cases.

Uterine Evacuation before Operative Hysteroscopy in Patients with Active Uterine Bleeding: A randomized controlled trial

Background: Concurrent bleeding or existing clots usually obscure the vision field and decrease the success rate of hysteroscopy. Therefore, any efforts made in order to have a clear view during the hysteroscopy will improve the diagnostic or treatment outcomes. We examined the effect of preoperative clot evacuation on hysteroscopy and patient outcomes. Methods: In this parallel-group trial, 114 patients with uterine bleeding were randomly assigned to receive either clot evacuation before standard operative hysteroscopy or standard hysteroscopy alone. The investigated endpoints were the clarity of vision, amount of bleeding, the volume of distension media, duration of the procedure, and postoperative complications. Results: All 114 participants completed the study. There were statistically significant differences in the frequency of the clear vision (p<.001), the severity of bleeding (p=.0006), mean procedure time (p<.001), mean serum volume used (p<.001), and the postoperative hematocrit levels (p<.001) between groups, in favor of women with preprocedural intrauterine evacuation. There was no difference related to in-hospital stay (p=0.081) and anesthetic complications among the patients (p=0.182). The procedure was successfully performed on all patients of both groups with zero postoperative complications. Conclusion: Removal of clots and other uterine contents before the insertion of the hysteroscope rendered better and faster access to the uterine wall to observe existing abnormalities. This additional surgical step could take a significant impact on surgical and clinical outcomes. Trial registration: Clinical trial registry name: Iranian Registry of Clinical Trials Url: https://en.irct.ir/trial/33369 The registration number: IRCT20101130005283N13 Date of trial registration: 2018-11-16

Papillary meningioma: a rare cause of massive supratentorial intracerebral hemorrhage

Papillary meningioma (PM) represents a very rare histological subtype, which may present with massive intracerebral hemorrhage. Gross total tumor resection results in a lower recurrence rate and mortality. A 69-year-old man had been experiencing headache for 6 months. After exacerbating right frontal headache, he was brought to the emergency room. His Glasgow Coma Scale (GCS) was 11/15 and he had a left-sided hemiparesis. A computed tomography brain scan revealed a massive right frontal intracerebral hematoma with transtentorial herniation. During right frontal craniotomy and blood clot evacuation, a fleshy, pigmented tissue was encountered. Histopathological findings were consistent with PM World Health Organization Grade III. Complete tumor resection, Simpson II was achieved with a second operation. The hemiparesis and GCS normalized subsequently. The diagnosis of PM relies largely on histopathology and is not commonly encountered preoperatively in emergency cases. Staged surgery in this case resulted in a good outcome.

Uterine Evacuation before Operative Hysteroscopy in Patients with Active Uterine Bleeding: A randomized controlled trial

BackgroundConcurrent bleeding or existing clots usually obscure the vision field and decrease the success rate in hysteroscopy. Therefore, any effort to have a clear view during the hysteroscopy will meliorate the diagnostic or treatment outcomes. We examined the effect of preoperative clot evacuation on hysteroscopy and patient outcomes.MethodsIn this parallel-group trial, 114 patients with uterine bleeding were randomly assigned to receive either clot evacuation before standard operative hysteroscopy or standard hysteroscopy alone. The primary endpoints were the clarity of vision, amount of bleeding, the volume of consumed media, duration of the procedure, and postoperative complications.ResultsAll 114 participants completed the study. There were statistically significant differences in the frequency of the clear vision (p < 0.001), the severity of bleeding (p = 0.0006), mean procedure time (p < 0.001), mean serum volume used (p < 0.001), and the postoperative hematocrit levels [95% CI (-3.00, -1.88)] (p < 0.001) between groups. There was no difference related to in-hospital stay (p = 0.081) and anesthetic complications among the patients (p = 0.182). The procedure was successfully performed on all patients of both groups with zero postoperative complications.ConclusionRemoval of clots and other uterine contents before the insertion of the hysteroscope rendered better and faster access to the uterine wall to observe existing abnormalities. This method of starting the hysteroscopy procedure has a significant impact on surgical outcomes.Trial registration: Clinical trial registry name: Iranian Registry of Clinical TrialsUrl: https://en.irct.ir/trial/33369The registration number: IRCT20101130005283N13Date of registration: 2018-11-16