One discussion this week involved the removal of foreign bodies.

Reference: Smith PM, et al. Isiris: a novel method of removing foreign bodies from the lower urinary tract to avoid unnecessary hospitalization and anesthesia. Journal of Endourology Case Reports. 2016 Aug 1;2(1):144-147. doi: 10.1089/cren.2016.0086.

Summary: Polyembolokoilamania refers to the practice of inserting foreign bodies (FBs) into natural orifices. A FB within the urethra is a relatively rare phenomenon with 646 cases recorded last year in the United Kingdom. Management of these patients presents technical challenges and complexities because of underlying psychiatric disorders that are often associated. This case illustrates a novel way of removing FBs from the genitourinary tract, requiring less resources, preventing hospital admission, and attempts to break the cycle of behavior, leading to recurrent attendance with polyembolokoilamania.

A 38-year-old Caucasian male prisoner, with psychiatric history presented to the emergency department (ED) with a history of inserting FBs into his urethra on 12 different occasions over a 6-week period. Of these 12 attendances, 3 resulted in admission and 2 required emergency intervention in theater under general anesthesia. After the third attendance in 5 days, it was decided to use Isiris™, a single-use flexible cystoscopy device with a built-in ureteral stent grasper, to remove the FBs and check the integrity of the urethra. The procedure was performed within the ED, without the need for admission to a ward bed or general anesthesia. Furthermore, only two members of staff were required to remove all of the urethral FBs.

Isiris, although marketed as a stent removal device, enabled us to remove all the patient’s FBs in one procedure. Isiris is an easy to use device, similar to a flexible cystoscope, that a specialist nurse or resident would be familiar using. It allows efficient and safe removal of lower urinary tract FBs, even out of hours. It requires minimal staffing support and can be done in the ED. It has the potential to reduce associated sequela of urethral polyembolokoilamania, saving resources while preserving the availability of the emergency theater.

One discussion this week included the rate of bleeding complications after pharmacologic DVT prophylaxis.

Reference: Leonardi MJ, McGory ML, Ko CY. The rate of bleeding complications after pharmacologic deep venous thrombosis prophylaxis: a systematic review of 33 randomized controlled trials. Archives of Surgery. 2006 Aug;141(8):790-797.

Summary: In a systematic review of 33 RCTs with 33,813 patients, Leonardi et al (2006) concluded that there is a small, but measurable, rate of minor bleeding complications associated with pharmacologic DVT prophylaxis: injection site bruising (6.9%), wound hematoma (5.7%), drain site bleeding (2.0%), and hematuria (1.6%).

The rate of major complications, such as GI tract (0.2%) or RP (<0.1%) bleeding, was extremely low in this review. Complications requiring a change in care, such as subsequent operation (0.7%) or discontinuation of prophylaxis (2.0%), were also infrequent. The subsequent operation rate for bleeding problems for pharmacologic prophylaxis vs placebo was identical, at 0.7%.

(p.795)

Additional Reading: Leonardi MJ, McGory ML, Ko CY. A systematic review of deep venous thrombosis prophylaxis in cancer patients: implications for improving quality. Annals of Surgical Oncology. 2007 Feb;14(2):929-936.