BLOCKED CATHETERS FOLLOWING BLADDER AUGMENTATION OR NEOBLADDER
Again, the suture line of these bladders is weak, and overvigor-ous irrigation with a bladder syringe can rupture the bladder. Gently fill the bladder with a 100 mL or so of saline, and very gently wash this fluid around the bladder with the syringe. This
10. COMMON EMERGENCY UROLOGICAL PROCEDURES 171
can help to dilute a mucus plug allowing spontaneous flow to be reestablished.
JJ STENT INSERTION
Indications in Urological Emergencies
Obstructing ureteric stones Ureteric injury
Malignant obstruction of the ureter
Preparation of the Patient for JJ Stent Insertion
Oral ciprofloxacin 250 mg; lignocaine gel for urethral anaesthesia and lubrication; sedoanalgesia (diazemuls 2.5-10 mg i.v., pethidine 50-100 mg i.v.). Monitor pulse and oxygen saturation with a pulse oximeter.
Technique (Hellawell et al. 2002, McFarlane et al. 2001)
A flexible cystoscope is passed into the bladder and rotated through 180 degrees. This allows greater deviation of the end of the cystoscope and makes identification of the ureteric orifice easier. A 0.9-mm hydrophilic guidewire (Terumo Corporation, Japan) is passed into the ureter under direct vision (Fig. 10.1a). The guidewire is manipulated into the renal pelvis using C-arm digital fluoroscopy (Fig. 10.1b). The cystoscope is placed close to the ureteric orifice and its position relative to bony landmarks in the pelvis is recorded by frame grabbing a fluoroscopic image. The flexible cystoscope is then removed and a 4-Ch ureteric catheter is passed over the guidewire, into the renal pelvis. A small quantity of nonionic contrast medium is injected into the renal collecting system, to outline its position and to dilate it. The Terumo guidewire is replaced with an ultrastiff guidewire (Cook UK Ltd., Letchworth, UK), and the 4-Ch ureteric catheter is removed. We use a variety of stent sizes depending on the patient's size (6-8 Ch, 20-26 cm) (Boston Scientific Ltd., St. Albans, UK). The stent is advanced to the renal pelvis under flu-oroscopic control, checking that the lower end of the stent is not inadvertently pushed up the ureter by checking the position of the ureteric orifice on the previously frame-grabbed image (Fig. 10.1c). The guidewire is then removed (Fig. 10.1d).