Surgical strategies for placenta percreta invading the bladder and review of literature

Background Major obstetric hemorrhage is the leading cause of maternal morbidity and mortality. In rare cases, life-threatening hematuria in pregnant women may result from invasion of the bladder by the placenta. We present our experience with 18 cases of placenta percreta with suspected bladder invasion. Methods It is a retrospective single-center study conducted over a period of 3 years. Total 18 patients of radiologically diagnosed placenta percreta were included in the study. All patients who are at risk for placenta percreta underwent prenatal sonograms. Patients of Placenta Accreta Spectrum presenting electively also underwent MRI pelvis. Elective patients who were high risk of placenta percreta underwent bilateral placement of the balloon catheter in internal iliac artery. In case of doubt regarding bladder invasion, patient underwent anterior cystotomy and posterior wall of the bladder was examined and proximity of the ureteric orifice to the placenta and amount of involvement of bladder wall was assessed. Ureteric catheter placement was used as adjuncts depending on the proximity of placental invasion with ureteric orifice. Postoperative outcomes in the form of maternal morbidity, maternal mortality, fetal mortality, postoperative bleeding, bladder status, vesicovaginal fistula, bladder capacity were all evaluated. Results In our series, 17 cases all cases were diagnosed preoperatively by antenatal ultrasound and MRI. Only one patient presented with hematuria. Only in one patient, we attempted separation of placenta from bladder wall, and it resulted in profuse bleeding, and in rest, we excised the involved bladder. Partial cystectomy was done in 33.4% patients, 27% patients required bilateral placement of ureteric catheter due to proximity to the ureteric orifice. 33.4% patient underwent bilateral internal iliac artery ligation or balloon placement. Clot evaluation was needed in one patient. Intraoperatively—39% patients had uterus adhered to the bladder but no placental invasion into the bladder. One patient was managed with obstetric hysterectomy and methotrexate followed by clot evacuation and bilateral internal iliac artery ligation at a later date. One (5.6%) patient developed vesicovaginal fistula in postoperative period. There was one (5.6%) maternal mortality with no fetal mortality. On follow-up, patient had good bladder capacity, 3 weeks after the surgery. Conclusion MRI done preoperatively can help us guide regarding the extent or severity of placental invasion. Intraoperatively, anterior cystostomy should be done in suspected placenta percreta. Grade I or II accrete/percreta patients can be managed conservatively. Partial cystectomy with placement of bilateral ureteric catheter is safer and less morbid approach in tackling placenta percreta invading the bladder with mucosal involvement.

Povidone Iodine as Sclerotherapy Into the Renal Pelvis for the Management of Chyluria: Our Experience

Objective: To evaluate the effectiveness and safety of 0.2% povidone iodine renal pelvic instillation as minimally invasive therapy for chyluria resistant to conservative treatment. Methods: From July 2015 to December 2016, 9 patients with chyluria were treated. There were 2 males and 7 females ranging from 30-65 years of age. Cystoscopic localization of chylous efflux was done. On a day care basis under local anesthesia a 5 Fr open ended ureteric catheter was introduced on the affected side. Freshly prepared 10 ml 0.2% Povidone iodine solution was instilled as a sclerosing agent in the renal pelvis. A total of 3 doses were given at 8-hour intervals. Unilateral instillation was done in 8 cases, and bilateral instillation was done in 1 patient. Result: Eight of 9 patients showed complete clearance. In 1 patient, recurrence was noted and a repeat injection was given after 4 weeks, with success. Conclusion: Our experience shows that povidone iodine is a safe and effective sclerosing agent in the management of chyluria Bangladesh Journal of Urology, Vol. 20, No. 2, July 2017 p.78-81

Effectiveness of Single Dose Povidone Iodine Sclerotherapy for the Treatment of Chyluria

Objective: To evaluate the effectiveness of single dose 5 % povidone iodine renal pelvic instillation sclerotherapy for the treatment for chyluria. Methods: In a prospective study from January 2009 and till June 2013, 47 patients presenting with milky urine (chyluria and hematochyluria) were included. Patients with other co-morbid illness like diabetes, urinary infection, renal stone disease, chronic pyelonehritis were excluded from the study. Apart from ether test, the presence of lymphocytes in urine and urine triglycerides levels were also done to confirm chyluria. Under local anesthesia, cystoscopic evaluation revealed right-sided efflux in 11 (23.4%), left-sided in 36 (76.6%), and no bilateral involvement was detected. 5F open-ended ureteric catheter was introduced in the ureteric orifice of affected side. Freshly prepared 10 ml of 5 % povidone iodine solution was instilled over a minute with the patient in Trendelenburg position. Results: Total of 47 patients were enrolled (26 males and 21 females; mean age 41 years, SD 8.4, range 29–71) with a mean follow-up of 12 months. Immediate clearance was seen in all patients and recurrence in 9 (19.15 %). Overall success rate 80.85%. Mean diseasefree duration was 12 months. Three patients had moderate to severe flank pain. Conclusion: Single dose 5 % povidone iodine sclerotherapy is a effective treatment for chyluria. As the patients discharged on the next day after procedure, it can be offered as a day care basis, so continuous ureteral and urethral catheterizations can be avoided. Bangladesh Journal of Urology, Vol. 18, No. 2, July 2015 p.74-78

Variation of Fluoroscopic Radiation Dose during Endourological Procedures for Renal Stones

Introduction: Fluoroscopic guidance is routine for endourological procedures like percutaneous nephrolithotomy and retrograde intrarenal surgery in vast majority of centers. It is used for the initial retrograde ureteral access to define the pelvicalyceal system, puncture of the desired calyx and dilatation of the tract, aid navigation of stones and calyces, and placement of guide wires and stents. Both the patient and operating staffs are exposed to the radiation during surgery. The purpose of this study is to measure that exposed fluoroscopic radiation dose during these procedures and make operating surgeons aware of their fluoroscopic habit. Materials and Methods: This is prospective observational study, who underwent percutaneous nephrolithotomy (n=60) and retrograde intrarenal surgery (n=43) in our institute between December 2017 and August 2018. Percutaneous nephrolithotomy was done in prone position with prior insertion of ureteric catheter. Retrograde intrarenal surgery was carried out with or without insertion of ureteral access sheath. Fluoroscopic time was taken from the insertion of the ureteric catheter or UAS to the completion of the procedure with double J stenting. Results: For percutaneous nephrolithotomy and retrograde intrarenal surgery group, mean stone size were 21.89 mm and 10.56 mm; mean fluoroscopic time were 117.95 s (range 24-350) and 31.83 s (range 3-103); mean fluoroscopic dose were 29.71 mGy and 6.19 mGy respectively. Introduction: Fluoroscopic guidance is routine for endourological procedures like percutaneous nephrolithotomy and retrograde intrarenal surgery in vast majority of centers. It is used for the initial retrograde ureteral access to define the pelvicalyceal system, puncture of the desired calyx and dilatation of the tract, aid navigation of stones and calyces, and placement of guide wires and stents. Both the patient and operating staffs are exposed to the radiation during surgery. The purpose of this study is to measure that exposed fluoroscopic radiation dose during these procedures and make operating surgeons aware of their fluoroscopic habit. Materials and Methods: This is prospective observational study, who underwent percutaneous nephrolithotomy (n=60) and retrograde intrarenal surgery (n=43) in our institute between December 2017 and August 2018. Percutaneous nephrolithotomy was done in prone position with prior insertion of ureteric catheter. Retrograde intrarenal surgery was carried out with or without insertion of ureteral access sheath. Fluoroscopic time was taken from the insertion of the ureteric catheter or UAS to the completion of the procedure with double J stenting. Results: For percutaneous nephrolithotomy and retrograde intrarenal surgery group, mean stone size were 21.89 mm and 10.56 mm; mean fluoroscopic time were 117.95 s (range 24-350) and 31.83 s (range 3-103); mean fluoroscopic dose were 29.71 mGy and 6.19 mGy respectively. Conclusions: Among the endourological procedures for renal stones, retrograde intrarenal surgery was associated with less fluoroscopic hazard than percutaneous nephrolithotomy. Awareness of fluoroscopic exposure duration and experience of a surgeon can minimize the radiation hazard during endourological procedures.

Vesico-vaginal fistula post Right radical nephroureterectomy with bladder cuff excision

Case: 61 years, female presented at KMH OPD with involuntary urinary leakage per vaginum for seven months following Right radical nephreureterectomy with bladder cuff excision for urinary bladder carcinoma at other centre. Dye test was positive. Cystoscopy revealed VVF defect around 2 cm (Goh’s stage 3biii) at right posterior wall of urinary bladder. Ureteric catheter was placed in left ureter and VVF repair was done. Dye test following 14 days of Foley’s catheterization was negative and patient went home dry. We present here a case of successful repair of VVF following Right radical nephreureterectomy with bladder cuff excision. Key words: dye test, Goh’s stage, pelvic surgeries, urinary tract injuries, vesico-vaginal fistula

A Novel Technique for Performing Retrograde Pyelogram through a Ureteric Stent

We describe a novel technique of performing a retrograde pyelogram through a 4.8 French multi-length stent. This was used in a female with an upper ureteric pinhole stricture which was impassable with a standard 6 French ureteric catheter, who required a retrograde pyelogram to confirm correct stent position. This technique was effective and conferred no additional cost to the procedure.

Sclerotherapy with Povidone Iodine Instillation into the Renal Pelvis in the Management of Non-Parasitic Chyluria: Our Experience

Background & objective: To evaluate the effectiveness and safety of 0.2% povidone iodine renal pelvic instillation as minimally invasive therapy for chyluria resistant to conservative treatment. Materials & Methods: From July 2015 to December 2016, 9 patients with chyluria were treated. There were 2 males and 7 females ranging from 30-65 years age. Cystoscopic localization of chylous efflux was done. On a day care basis under local anesthesia a 5 Fr open-ended ureteric catheter was introduced on the affected side. Freshly prepared 10 ml 0.2% Povidone iodine solution was instilled as a sclerosing agent in the renal pelvis. A total of 3 doses were given at 8-hour intervals. Unilateral instillation was done in 8 cases, and bilateral instillation was done in 1 patient. Results: Eight of 9 patients showed complete clearance. In 1 patient, recurrence was noted and a repeat injection was given after 4 weeks, with success. Conclusion: Our experience shows that povidone iodine is a safe and effective sclerosing agent in the management of chyluria. Ibrahim Card Med J 2016; 6 (1&2): 41-44

Partial nephrectomy without vessel clamping and hypothermia with conservative management of post-operative bleed in a rural setup: a case report

Hemorrhage is a well-known complication of partial nephrectomy. The bleeding is usually suspected when a patient presents with haematuria or bloody drain discharge following the procedure. This study’s primary objective is to discuss case of 63-year-old-man incidentally diagnosed with left lower pole kidney mass. USG abdomen was done and a suspicious mass in lower pole of kidney is noticed. CT-urography was done and assessment was made for further management. Patient details were collected by patient’s IPD file. Complete detailed history, patient vitals, hemogram, ABO, with USG abdomen and CT urography was done. Post op CT angiogram was done to evaluate for drain leak. Treatment diagnosis was left lower pole malignant mass. Pre-operative left ureteric catheter placement was done. 11th rib cutting incision was given. The tumour was resected with 1 cm margin. The renal defect was closed with interrupted sutures to the parenchyma. Gerota’s fascia was closed. A Robinson drain was placed and the abdominal wall closed. The case was managed without vessel clamping and hypothermia for clear renal cell carcinoma with post op bleed, successfully identified and managed conservatively, giving another potential management option in non-torrential haemorrhage.