Combined intra- and extra-peritoneal bladder perforation following rectal impalement injury.

A 62-year-old male presented with abdominal pain and hematuria following impalement of the rectum with a wooden foreign object. CT imaging showed air and fluid in the peritoneum prompting the patient to undergo abdominal exploration. An anterior rectal perforation was discovered along with dual bladder lacerations of the posterior wall and dome. The patient underwent a diverting colostomy and primary bladder repair. Post-operative course was uncomplicated and bladder repair was followed via cystograms with catheter removal 2 months post-operatively. Four months after the injury the patient underwent colostomy closure and remains with normal bladder and bowel function at 21-month follow-up.

Validation of the best practice policy statement on urodynamic antibiotic prophylaxis for the high-risk patient in the era of antibiotic stewardship.

AIMS: To validate the recommendations of the Society of Urodynamics, Female Pelvic Medicine, and Urogenital Reconstruction (SUFU) 2017 Best Practice Policy Statement (BPPS) for Urodynamic Antimicrobial Prophylaxis in high-risk patients. METHODS: After institutional review board approval, 489 patients who underwent urodynamics (UDS) in the absence of antibiotic prophylaxis were retrospectively reviewed. Patients were stratified according to the SUFU BPPS risk factors (neurogenic lower urinary tract dysfunction [NLUTD], elevated postvoid residual [PVR], immunosuppression, age over 70, catheter use, and orthopedic implants). χ2 , Fisher's exact test, Student t test, and univariate and multiple logistic regression analyses were used to assess the associations between these risk factors and postprocedural urinary tract infection (UTI). RESULTS: Twenty-two (4.5%) patients developed symptomatic postprocedural UTI. Univariate analysis revealed statistical differences in the incidence of UTI in patients with elevated PVR and NLUTD groups. The variables that were associated with UTI on multivariate analysis were elevated PVR (odds ratio [OR]: 4.91, 95% confidence interval [CI], 1.92-12.56, P = .001) and NLUTD (OR: 4.84, 95% CI, 1.75-3.37, P = .002). The data analysis for all other high-risk groups failed to show significant correlations with UTI on univariate or multivariate analysis. Patients with three risk factors were more likely to develop UTI than patients with 1 or 2 risk factors. No patient developed pyelonephritis, sepsis, or joint infection. CONCLUSIONS: Elevated PVR, NLUTD, and possessing three risk factors were significant predictors for post-UDS UTI. All other risk factors were not associated with postprocedural UTI. Morbidity associated with UTI was low. Antimicrobial prophylaxis for these conditions should be reconsidered.

Sepsis after elective ureteroscopy.

INTRODUCTION: We sought to determine our rate of postoperative sepsis after ureteroscopy as well as identifying associative factors, common antibiotic practices along with culture data. MATERIALS AND METHODS: Records of all patients who underwent elective ureteroscopy from 2010 to 2015 at an urban tertiary care facility were retrospectively reviewed. Factors thought to be associated with infection were collected, along with comorbidities depicted as Charlson Age-Adjusted Comorbidity Index (CAACI) and American Society of Anesthesia (ASA) score. Each patient's course was reviewed to determine if they were treated for postoperative sepsis as defined by standardized criteria. RESULTS: A total of 345 patients underwent elective ureteroscopy with 15 (4.3%) being treated for sepsis postoperatively. This resulted in an additional 5.33 ± 3.84 days of hospitalization per patient. The sepsis group grew three gram positive organisms and five multi-drug resistant (MDR) gram negatives while 7/15 (46.7%) had negative cultures. The most common preoperative antibiotics used in the sepsis group were cefazolin (60.0%), gentamicin (48.5%) and ciprofloxacin (20.0%). Univariate analysis showed prior endoscopic procedures, recent treatment for urinary tract infections (UTI), multiple comorbidities and longer operative times associated with sepsis. However, significant variables after multivariate analysis were treatment for UTI within the last month, (OR) 7.19 (2.25-22.99), p = 0.001. CONCLUSIONS: Patients with multiple comorbidities, prior endoscopic procedures, longer operative times and especially those recently treated for a urinary infection should be carefully monitored after ureteroscopy for signs of sepsis. Perioperative antibiotics in these patients should be selected to cover both MDR organisms and gram positives.

Aggressive Renal Angiomyolipoma of the Lipomatous Variant With Inferior Vena Cava Thrombus: A Case Report and Review of the Literature.

Two variants of renal angiomyolipoma (AML)-classic and epithelioid-have been described. Although the epithelioid variant has been reported to demonstrate an aggressive clinical behavior, classic AML is usually benign. Herein, we report a case of a 42-year-old asymptomatic woman with a lipomatous variant of renal AML associated with an inferior vena cava thrombus managed with radical nephrectomy and caval thrombectomy.