Congenital urinary tract obstruction.

Congenital bladder neck obstruction (or lower urinary tract obstruction [LUTO]) describes a heterogeneous group of congenital anomalies presenting with similar prenatal ultrasonographic findings of dilated posterior urethra, megacystis, hydronephrosis, oligohydramnios and often with associated renal dysplasia. Untreated LUTO has high rate of perinatal morbidity and mortality from associated pulmonary hypoplasia and early-onset renal failure in infancy. Ultrasonographic features and prospective fetal urinalysis may help in predicting the overall prognosis of congenital LUTO. Currently, fetal vesicoamniotic shunt (of various designs), and fetal cystoscopy and fulguration of the obstruction are potential prenatal interventions. Retrospective and prospective cohort studies and a relatively small randomized controlled trial have demonstrated these treatments may possibly improve perinatal survival. Despite this, concerns remain as to the high rates of renal impairment observed in paediatric survivors. A clinical prospective scoring/staging system may improve prenatal diagnostic criteria and case selection for fetal therapy.

[Primary prostatic sarcoma - a rare malignancy]. / Das primäre Prostatasarkom ­ ein seltenes Malignom.

Primary prostatic sarcomas are rare, reportedly comprising less than 1% of all prostate malignancies. Most patients present with lower urinary tract symptoms due to bladder outlet obstruction. Prostate-specific antigen (PSA) is typically normal. Histological confirmation and staging by a computed tomography (CT) or magnetic resonance imaging (MRI) scan of the pelvis and abdomen are essential for diagnosis and treatment planning. The differential diagnosis includes sarcomatoid prostate cancer or benign spindle cell tumors. Primary prostatic sarcomas are often aggressive and require multimodal treatment with surgery and (neo)adjuvant radiation and/or chemotherapy. The risk of local recurrence is high and the long-term prognosis is poor.

Defining and predicting 'intrauterine fetal renal failure' in congenital lower urinary tract obstruction.

BACKGROUND: The aim of this study was to identify predictors of 'intrauterine fetal renal failure' in fetuses with severe congenital lower urinary tract obstruction (LUTO). METHODS: We undertook a retrospective study of 31 consecutive fetuses with a diagnosis of LUTO in a tertiary Fetal Center between April 2013 and April 2015. Predictors of 'intrauterine fetal renal failure' were evaluated in those infants with severe LUTO who had either a primary composite outcome measure of neonatal death in the first 24 h of life due to severe pulmonary hypoplasia or a need for renal replacement therapy within 7 days of life. The following variables were analyzed: fetal bladder re-expansion 48 h after vesicocentesis, fetal renal ultrasound characteristics, fetal urinary indices, and amniotic fluid volume. RESULTS: Of the 31 fetuses included in the study, eight met the criteria for 'intrauterine fetal renal failure'. All of the latter had composite poor postnatal outcomes based on death within 24 h of life (n = 6) or need for dialysis within 1 week of life (n = 2). The percentage of fetal bladder refilling after vesicocentesis at time of initial evaluation was the only predictor of 'intrauterine fetal renal failure' (cut-off <27 %, area under the time-concentration curve 0.86, 95 % confidence interval 0.68-0.99; p = 0.009). CONCLUSION: We propose the concept of 'intrauterine fetal renal failure' in fetuses with the most severe forms of LUTO. Fetal bladder refilling can be used to reliably predict 'intrauterine fetal renal failure', which is associated with severe pulmonary hypoplasia or the need for dialysis within a few days of life.

Prostatic urethral lift: a novel approach for managing symptomatic BPH in the aging man.

INTRODUCTION: Benign prostatic hyperplasia (BPH) is an obligate disorder of the aging male prostate with close associations to other metabolic conditions of aging including obesity. Clinical manifestations of this chronic disorder increase as men age suggesting that a growing number of older men will require intervention for progressive voiding symptoms or bladder dysfunction. MATERIALS AND METHODS: The Prostatic Urethral Lift (PUL) procedure represents a new endoscopic approach in which small permanent intraprostatic implants are positioned to correct bladder outlet obstruction without tissue destruction. An overview of the treatment modality, review of recent literature, and analysis of data in the context of cost considerations is presented. RESULTS: The mean symptom score improvement of the prospective, sham controlled, pivotal trial was 11 points, 88% greater than sham controls. Multiple studies have confirmed symptom score improvement of at least 52%. Durability has been established out to 3 years. A randomized comparison between PUL and transurethral resection of the prostate (TURP) established PUL as superior to TURP in terms of a composite BPH6 endpoint which incorporated symptom relief, quality of recovery, erectile function preservation, ejaculatory function preservation, continence preservation, and safety. The National Institute for Health and Care Excellence of the United Kingdom conducted an analysis that found PUL is less costly than TURP. Earlier management with PUL may even reduce overall cost for those patients managed with medication. CONCLUSION: Current reports have demonstrated rapid voiding symptom improvement with a low risk of adverse events suggesting that this procedure represents a safe and cost effective new paradigm for the early therapy for BPH/ LUTS.

The Percutaneous shunting in Lower Urinary Tract Obstruction (PLUTO) study and randomised controlled trial: evaluation of the effectiveness, cost-effectiveness and acceptability of percutaneous vesicoamniotic shunting for lower urinary tract obstruction.

BACKGROUND: Congenital lower urinary tract obstruction (LUTO) is a disease associated with high perinatal mortality and childhood morbidity. Fetal vesicoamniotic shunting (VAS) bypasses the obstruction with the potential to improve outcome. OBJECTIVE: To determine the effectiveness, cost-effectiveness and patient acceptability of VAS for fetal LUTO. DESIGN: A multicentre, randomised controlled trial incorporating a prospective registry, decision-analytic health economic model and preplanned Bayesian analysis using elicited opinions. Patient acceptability was evaluated by interview in a qualitative study. SETTING: Fetal medicine departments in the UK, Ireland and the Netherlands. PARTICIPANTS: Pregnant women with a male singleton fetus with LUTO. INTERVENTIONS: In utero percutaneous VAS compared with conservative care. MAIN OUTCOME MEASURES: The primary outcome was survival to 28 days. Secondary outcome measures were survival and renal function at 1 year of age, cost of care and cost per additional life-year and per disability-free survival at the end of 1 year. RESULTS: The trial stopped early with 31 women randomised because of difficulties in recruitment. Of those randomised to VAS and conservative management, 3/16 (19%) and 2/15 (13%), respectively, did not receive their allocated intervention. Based on intention-to-treat analysis, survival at 28 days was higher if allocated VAS (50%) than conservative management (27%) [relative risk (RR) 1.88, 95% confidence interval (CI) 0.71 to 4.96, p = 0.27]. At 12 months survival was 44% in the VAS arm and 20% in the conservative arm (RR 2.19, 95% CI 0.69 to 6.94, p = 0.25). Neither difference was statistically significant. Of survivors at 1 year, two in the VAS arm had no evidence of renal impairment and four in the VAS arm and two in the conservative arm required medical management. One baby in the conservative arm had end-stage renal failure at 1 year. VAS was more expensive because of additional surgery and intensive care. VAS cost £15,500 per survivor at 1 year and £43,900 per disability-free year. Elicited expert opinions showed uncertainty in the effect of VAS at 28 days. In a Bayesian analysis combining elicited opinion with the results, uncertainty of the benefit of VAS remained (RR 1.31, 95% credible interval 0.84 to 2.18). The acceptability study identified visualisation of the fetus during ultrasound scanning, perceiving a personal benefit, and altruism as positive influences on recruitment. Fear of the VAS procedure and the perceived severity of LUTO influenced non-participation. The need for more detailed information about the condition and its implications during pregnancy and following delivery was a further important finding of this research. Recruitment was hampered by logistical and regulatory difficulties, a lower incidence of LUTO and lower antenatal diagnosis rate [estimated to be 3.34 (95% CI 2.95 to 3.72) per 10,000 total births and 47%, respectively, in an associated epidemiological study] and high termination of pregnancy rates. In the registry women also demonstrated a clear preference for conservative management. CONCLUSIONS: Survival to 28 days and 1 year appears to be higher with VAS than with conservative management, but it is not possible to prove benefit beyond reasonable doubt. Notably, prognosis in both arms for survival and renal function is poor. VAS was substantially more costly and unlikely to be regarded as cost-effective based on the 1-year data. Parents should be counselled about the risks of pregnancy loss with or without VAS insertion. The National Institute for Health and Care Excellence interventional procedures guidance (IPG 202) should be updated to reflect this new evidence. Babies in the PLUTO trial should be followed up long term for the different outcomes. TRIAL REGISTRATION: ISRCTN53328556. FUNDING: This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment ; Vol. 17, No. 59. See the NIHR Journals Library website for further project information.

[Posterior urethral valves--diagnosis and primary treatment considerations]. / Considerente privind diagnosticul si tratamentul primar al valvelor de uretra posterioara.

Posterior Urethral Valves--PUV are the most common cause of bladder outflow obstruction in male infants, representig about 10% of prenatally detected hydronephrosis. The medical records of 27 patients, admitted and treated in the pediatric urology department of "Maria Sklodowska Curie" Emergency Hospital for Children, Bucharest, between 2001-2010 where reviewed. The aim of the study is to discuss the endoscopic valve ablation as the first choice treatment of PUV. Twenty-six, (96%) of ouer patients are alive, having now different ages, with serum creatinine levels < 0.8 mg/dl, at successive controls. One patient, lyear 11 mounths old, died in the pediatric nephrology department after right nephrec-tomy and left ureterostomy, 9 mounth before. Mortality rate in PUV patients has significantly decreased in the last 30 years, from 50% to less than 10% of patients. Nonetheless, morbidity related to PUV still represent an heavy burden for these patients and their doctors. Urodynamic studies help in understanding the pathophysiology of valve bladder and its effect on the urinary tract at long term follow-up.

Systematic review of the effectiveness of antenatal intervention for the treatment of congenital lower urinary tract obstruction.

BACKGROUND: Congenital lower urinary tract obstruction is associated with high mortality and morbidity. Antenatal detection has improved with advances in ultrasound technology, and has allowed the option of antenatal intervention. OBJECTIVES: To systematically review the literature to evaluate the effectiveness of antenatal interventions to improve perinatal survival and postnatal renal function in congenital lower urinary tract obstruction. SEARCH STRATEGY: Extensive electronic searches (database inception 2009) using Medical Subject Headings (MeSH) and keywords, without restrictions. Reference lists of included studies were checked, and all authors were contacted. SELECTION CRITERIA: Studies were selected according to a predefined protocol. The included studies were observational or randomised trials, where an intervention was performed in utero to treat congenital lower urinary tract obstruction, compared with another intervention or no treatment. DATA COLLECTION AND ANALYSIS: Data were extracted on study design, quality and results to construct 2 x 2 tables. Meta-analysis was performed where possible. Peto ORs with 95% CIs were computed. MAIN RESULTS: Prenatal bladder drainage improved perinatal survival compared with no treatment (OR 3.86, 95% CI 2.00-7.45). This effect was amplified in a subgroup with poor predicted prognosis (OR 12.85, 95% CI 1.25-153.03). However, although treatment increases survival, it appears that the residual risk of poor long-term postnatal renal function is uncertain (OR 0.50, 95% CI 0.13-1.90). AUTHOR'S CONCLUSIONS: Antenatal bladder drainage appears to improve perinatal survival in cases of congenital lower urinary tract obstruction, but may confer a high residual risk of poor postnatal renal function, based on observational studies. Randomised research with long-term follow up is necessary to determine the role of antenatal treatment in clinical practice.

The natural history of lower urinary tract dysfunction in men: minimum 10-year urodynamic followup of transurethral resection of prostate for bladder outlet obstruction.

PURPOSE: Despite long-term symptomatic and uroflowmetry studies following transurethral prostate resection (TURP) there are sparse pressure flow data. Consequently there is minimal information to account for the long-term symptomatic failure and flow rate decrease seen with time following early improvements after surgery. MATERIALS AND METHODS: Men older than 45 years who were investigated at our department between 1972 and 1986, diagnosed with bladder outlet obstruction and elected surgical intervention were invited for repeat symptomatic and urodynamic assessment. Identical methods were used, allowing direct comparison of results. RESULTS: A total of 1,068 men were initially diagnosed with bladder outlet obstruction, of whom 428 (40%) died in the interim. Of the men who were followed 217 underwent TURP with a mean followup since surgery of 13.0 years. A significant, sustained decrease in the majority of symptoms and improvements of urodynamic parameters was seen. Long-term symptomatic failure and decreased flow rate were principally associated with detrusor under activity (DUA) rather than obstruction. Presentation predictive factors for the future development of DUA were decreased detrusor contractility and a lesser degree of obstruction. CONCLUSIONS: This unique long-term study provides valuable information on surgically treated bladder outlet obstruction. The association of long-term failure following surgery with DUA emphasizes the importance of pressure flow studies before repeat surgery. However, our faith in the long-term efficacy of TURP is justified.

Uropathic observations in mice expressing a constitutively active point mutation in the 5-HT3A receptor subunit.

Mutant mice with a hypersensitive serotonin (5-HT)3A receptor were generated through targeted exon replacement. A valine to serine mutation (V13'S) in the channel-lining M2 domain of the 5-HT3A receptor subunit rendered the 5-HT3 receptor 70-fold more sensitive to serotonin and produced constitutive activity when combined with the 5-HT3B subunit. Mice homozygous for the mutant allele (5-HT3Avs/vs) had decreased levels of 5-HT3A mRNA. Measurements on sympathetic ganglion cells in these mice showed that whole-cell serotonin responses were reduced, and that the remaining 5-HT3 receptors were hypersensitive. Male 5-HT3Avs/vs mice died at 2-3 months of age, and heterozygous (5-HT3Avs/+) males and homozygous mutant females died at 4-6 months of age from an obstructive uropathy. Both male and female 5-HT3A mutant mice had urinary bladder mucosal and smooth muscle hyperplasia and hypertrophy, whereas male mutant mice had additional prostatic smooth muscle and urethral hyperplasia. 5-HT3A mutant mice had marked voiding dysfunction characterized by a loss of micturition contractions with overflow incontinence. Detrusor strips from 5-HT3Avs/vs mice failed to contract to neurogenic stimulation, despite overall normal responses to a cholinergic agonist, suggestive of altered neuronal signaling in mutant mouse bladders. Consistent with this hypothesis, decreased nerve fiber immunoreactivity was observed in the urinary bladders of 5-HT3Avs/vs compared with 5-HT3A wild-type (5-HT3A+/+) mice. These data suggest that persistent activation of the hypersensitive and constitutively active 5-HT3A receptor in vivo may lead to excitotoxic neuronal cell death and functional changes in the urinary bladder, resulting in bladder hyperdistension, urinary retention, and overflow incontinence.

A randomized controlled trial comparing transurethral resection of the prostate, contact laser prostatectomy and electrovaporization in men with benign prostatic hyperplasia: analysis of subjective changes, morbidity and mortality.

PURPOSE: We analyze subjective changes, morbidity and mortality in men with lower urinary tract symptoms associated with benign prostatic hyperplasia (BPH) after transurethral resection of the prostate, contact laser prostatectomy and electrovaporization. MATERIALS AND METHODS: A prospective, randomized controlled trial was conducted on men with lower urinary tract symptoms, who met the criteria of the International Scientific Committee on BPH, had a prostate volume between 20 and 65 ml., and had Schäfer's obstruction grade 2 or greater. Objective morbidity was recorded for up to 12 months. Subjective morbidity was measured by a questionnaire completed by patients. Subjective changes were quantified using the International Prostate Symptom Score, Symptom Problem Index, Quality of Life question and BPH Impact Index. These indexes and the morbidity questionnaire were measured weekly for the first 6 weeks postoperatively and then at 3, 6 and 12 months. RESULTS: Transurethral prostatic resection was analyzed in 50 men, laser treatment in 45 and electrovaporization in 46. Baseline characteristics, and changes in the symptom scores up to 12 months postoperatively were similar. Perioperative blood loss and perforation were greatest in the resection group, and retention was greatest in the laser group. During the first 6 postoperative weeks there was less pain and less hematuria after resection, and less incontinence after laser prostatectomy. CONCLUSIONS: Subjective changes are similar for transurethral prostatic resection, contact laser and electrovaporization. In the first 6 weeks after treatment there are only slight differences in pain, hematuria and incontinence among the therapies.

Bladder neck involvement in pathological stage pT4 radical prostatectomy specimens is not an independent prognostic factor.

PURPOSE: Bladder neck invasion by prostate cancer in radical prostatectomy specimens is uncommon and, thus, its influence on disease recurrence has not been well defined. Consequently the classification of bladder neck invasion in the TNM staging system is controversial. We studied our cohort of patients with stage pT4 disease and bladder neck invasion to clarify the true clinical behavior and prognostic significance of bladder neck invasion in radical prostatectomy specimens. MATERIALS AND METHODS: The study group consisted of 4,090 consecutive patients treated with radical prostatectomy at one of our institutions between 1983 and 2001. Median followup was 53.1 months (range 1 to 189). After excluding from analysis patients treated with neoadjuvant androgen withdrawal or preoperative irradiation 72 of the remaining 2,571 (2.8%) with bladder neck invasion were classified with stage pT4 disease and their specimens were reviewed. Progression-free probability was determined by Kaplan-Meier analysis. Using the Cox proportional hazards model the independent prognostic significance of bladder neck invasion was assessed after controlling for pretreatment prostate specific antigen, final Gleason sum, extracapsular extension, surgical margins status, seminal vesicle invasion and lymph node involvement. RESULTS: Of the 72 patients categorized with stage pT4 disease 14 (19%) had poorly differentiated Gleason sum 8 to 10 cancer, 38 (53%) had established extracapsular extension, 24 (33%) had seminal vesicle invasion and 8 (11%) had lymph node involvement. However, 26 patients (36%) had cancer confined to the prostate and 28 (39%) had negative surgical margins except for the bladder neck site. The mean 5-year progression-free probability plus or minus SD in all stage pT4 cases was 68% +/- 7%, which was better than in cases of seminal vesicle invasion (52% +/- 5%, log rank test p = 0.0156) but worse than in those of extracapsular extension (84% +/- 4.1%). Univariate analysis of the stage pT4 cohort revealed that higher prostatectomy Gleason sum, more extensive extracapsular extension and seminal vesicle invasion were significantly associated with an adverse prognosis. However, in a multivariate model that included all radical prostatectomy cases the finding of bladder neck invasion or stage pT4 disease did not independently predict prostate specific antigen recurrence. CONCLUSIONS: Stage pT4 disease comprises a heterogeneous group of tumors with various pathological features and inconsistent outcomes. Assigning the pT4 stage to cases of microscopic bladder neck invasion provides no independent ability for predicting disease progression after adjusting for other adverse disease features. Due to this and previously reported data the definition of stage pT4 disease should be modified in the next version of the TNM staging system.

Fetal, perinatal, and infant death with congenital renal anomaly.

AIMS: To ascertain why 19.6% of pregnancies in which a fetal renal anomaly has been detected fail to produce a surviving child, and whether antenatal diagnostic accuracy has altered since specialised fetal medicine units were established in 1995. METHODS: An analysis of deaths was conducted among fetuses and babies with a congenital abnormality in the urinary tract notified to the Northern Region Congenital Abnormality Survey (NorCAS). There were 560 deaths among 2857 cases with an anomaly in the urinary tract delivered between 19 February 1984 and 21 March 2000. RESULTS: Renal anomaly was the cause of death in 323 (57.7%) cases. Excluding 10 which were not screened, 126 (60%) of 210 pre-1995 had been suspected antenatally and 81 (78.6%) of 103 post-1995. No abnormality had been suspected in 39 (18.6%) cases pre-1995 and four (3.9%) post-1995. Postnatal death occurred in 89 (41.4%) pre-1995 and in 13 (12%) post-1995. There were 209 cases of death caused by anomalies in other systems but with a renal anomaly present, of which 66 (31.6 %) were chromosomal and 36 (54.5%) had a horseshoe kidney. Of the cases with a horseshoe kidney, 56.3% had a chromosomal anomaly. CONCLUSIONS: The antenatal diagnosis of renal anomalies which cause death did not improve significantly in the second period of this study. However, the number of false positive antenatal diagnoses and the number of postnatal deaths were significantly lower and the number of pregnancy terminations were significantly higher. This reduced the risk of delivering a live baby with an unexpected fatal renal anomaly.

[Clinical relevance of incidental prostate carcinoma. A retrospective study]. / Klinische Relevanz des inzidentellen Prostatakarzinoms. Eine retrospektive Analyse.

Between July 1973 and December 1992, 5156 men underwent either TURP (n = 4259) or open prostatectomy (n = 897) because of infravesical obstruction supposedly due to benign prostatic hyperplasia (BPH). In this retrospective study, 86 men in whom an incidental carcinoma of the prostate had been found were followed up. Thirty-seven cases had been classified as pT1a tumor and 49 cases as pT1b tumor; 73 patients had undergone TURP and 13 open surgery. The mean age of the patients was 70.6 years (range 54-89). Twenty-seven patients (73%) with a pT1a tumor and 19 patients (38.8%) with a pT1b carcinoma received no further treatment. Radical prostatectomy was performed in four cases, one of pT1a and three of pT1b tumor. In all other cases the patients received androgen deprivation, and in four cases external radiotherapy was applied. With a mean follow-up of 5 years (range 17-229 months) 48 patients died (55.8%). The median survival was 73 months (95% CI: 52; 89). Compared to the overall population in the same age range, the standard mortality rate (SMR) was 1.72 and 2.05 (95% CI: 1.23; 2.21 and 1.46; 2.64 respectively) using the "Allgemeine Sterbetafel" of the Federal Republic of Germany (1949-1951 and 1986-1988). Using the log-rank test (P = 0.5, two-sided) no difference in survival was found between patients staged pT1a and pT1b. Ten of 48 patients dead at the time of evaluation died of prostate cancer. This means that 20.8% (pT1a n = 3; pT1b n = 7) of the patients succumbed to progressive disease during follow-up. All four patients who underwent radical prostatectomy are free of tumor at time of this evaluation. These results are in accordance with other studies. In younger men with incidental carcinoma of the prostate and life expectancy of more than 10 years, radical surgery of the prostate should be recommended.

Visual laser ablation of the prostate and transurethral resection of the prostate for benign prostatic hyperplasia.

For the past 50 years, transurethral resection of the prostate (TURP) has been the most common treatment for benign prostatic hyperplasia (BPH). The authors have conducted visual laser ablation of the prostate (VLAP) for BPH as a minimum invasive surgery. The results were compared with those of VLAP, VLAP+transurethral incision of the prostate (TUIP), and TURP as other treatments for BPH. In the VLAP group, 50 of 52 (96.2%), 36 of 40 (90.0%) and 31 of 36 (86.1%) were categorized as having more than a Fair Response (FR) at 3, 6 and 12 months, postoperatively. In the VLAP+TUIP group, 24 of 29 (82.8%), 19 of 22 (86.4%) and 9 of 11 (81.8%) were classed as having more than a FR at 3, 6 and 1 2 months, postoperatively. Forty-one of 42 (97.6%), 1 7 of 1 7 (100.0%) and 6 of 6 (100.0%) patients reaction to TURP was more than FR in overall response at 3, 6 and 12 months, postoperatively. The need for a blood transfusion, perforation of the prostate capsule and transit incontinence persisting for more than 1 month occurred in 1 of 45 (2.2%), 1 (2.2%) and 4 (8.9%) patients in the TURP group. Bladder neck contracture was seen in 4 of 52 (7.7%) in the VLAP group. Average postoperative catheter duration was shorter in the VLAP+TUIP (5.7 ± 8.4 days) than in the VLAP group (10.3 ± 10.4 days). Although TURP remains the standard treatment for BPH, VLAP results in less morbidity compared to TURP. VLAP with TUIP appears to lessen the risk of postoperative urinary retention and provide better results in longer follow-up studies.

Radical retropubic prostatectomy: our experience with the first 54 patients.

Complications were analysed in a contemporary series of the first 54 retropubic radical prostatectomies performed for carcinoma of the prostate at our Institution. The postoperative morbidity was notable; three life threatening and ten minor complications occurred within the first 30 postoperative days. Thus, more than 1 year after the operations 7 patients had severe stress incontinence and 17 noticed minor degree of incontinence. Twenty-six per cent of the patients who claimed to be potent before surgery maintained potency. The operative time averaged 195 min and the demand for transfusions averaged 2.98 units per patient. Our experience in this early series of radical prostatectomy is that the operation cannot be done without notable postoperative morbidity.

Fatal intra-peritoneal bladder rupture due to blocked catheter in a paraplegic.

A female paraplegic developed intraperitoneal rupture of urinary bladder seven weeks after institution of indwelling urethral catheter drainage. Blockage of the catheter precipitated this fatal event. Oliguria after an initial encouraging urinary output despite adequate fluid replacement led us to suspect bladder rupture which was confirmed by urgent cystography. Although emergency laparotomy to repair the rent in the bladder was performed, she succumbed to gram-negative septicemia. Other hazards of indwelling urethral catheter drainage even for short periods are highlighted (though the above complication itself is admittedly rare) with an oft re-emphasised plea to consider earlier the alternative modality of intermittent catheterisation or pharmacotherapy in female patients.