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CASE REPORTS
Intravesical Intercatheter Knotting
Bibhuti Bhusan Nayak, Varun Dixit, Mohit Jain, Mukund Jagannathan
Intravesical catheter knotting is rare and only a few cases have been mentioned in literature with no mention of intercatheter knotting. All published reports mention involvement of infant feeding tubes of smaller diameter except one report of knotting of simple red rubber catheter.1 A rare case of intercatheter knotting managed successfully by a minimally invasive technique is discussed.
Fig. 1 :
Photograph showing intercatheter knotting after retrieval by gentle manual traction following percutaneous rupture of the olley’s balloon.
A three year old child with hypospadias had undergone Thiersch-Duplay procedure for which a suprapubic catheter (No 12 Foley) was used for urinary diversion and no. 9 infant feeding tube for urethral stenting. After one week of surgery when an attempt was made to remove the urethral catheter there was resistance, and it was not possible to pull out the catheter. Traction on the suprapubic catheter produced a tug on the urethral catheter, pointing towards possibility of some form of connection between the two catheters inside the bladder. The side channel of the Foley’s catheter was blocked and it was not possible to rupture the balloon by passing a guide wire through it. The patient was taken under general anaesthesia and the balloon was ruptured by a percutaneous needle after securing the balloon per rectally. When the suprapubic catheter was pulled out by gentle traction, our suspicion was confirmed as the infant feeding tube had knotted tightly proximal to the balloon preventing defiation (Fig. 1).DISCUSSION
There are a few reports of catheter knotting but no case of intercatheter knotting has been reported in literature. In most of the cases the culprit was the infant feeding tube. Suprapubic distension and pain, pericatheteric leak, difficulty in removal
point towards possibility of catheter knotting. This problem has been managed by various techniques like steady gentle traction,1,2 urethral dilatation,1,3 guide wire manipulation,4 surgical removal and endoscopic removal.2 In our case it may possibly have been due to bladder irritation and spasm. The knot was so precise that it was just proximal to the balloon and tight enough to occlude the side channel precluding a straight forward removal. This case is reported as it is an extremely rare occurrence.REFERENCES
1. Klein EA, Wood DP, Kay R. Retained straight catheter complication of clean intermittent catheterisation. J Urology 1986; 135 : 780.
2. Harris F, Ritchey M, David B. Adventitious knots in urethral catheters: report of 5 cases. J Urology 1992; 148 1496-98.
3. Pearson-Shaver AL, Anderson MH. Urethral catheter Knots. Pediatrics 1990; 85 : 852-3.
4. Harris VJ, Jose R. Guide wire manipulation of knot in a catheter used for cystourethrography. J Urology 1976;
It quickly became clear that although stents made the result of balloon angioplasty predictable and safe, clinically relevant.intimal hyperplasia could not be avoided.
In 1999, I suggested that brachytherapy was then the only means of reducing the rate of in-stent restenosis in a clinical setting. Meanwhile, long-term results after brachytherapy have revealed its shortcomings, the so-called edge effect: proliferation at the border zone of local irradiation. This edge effect and the legal hurdles associated with the clinical use of radioactive sources account for the decreasing popularity of this otherwise effective treatment.
The first impressive results with local delivery of a drug with antiproliferative properties from stents raised hopes
again, with the publication of the RAVEL study. The substance released from the stent in that trial was sirolimus (also
called rapamycin). Actinomycin D was the first casualty, being dropped after the clinical observation of edge effects
similar to those seen after brachytherapy. Batimastat, steroids, and two substances similar to sirolimus (ABT-578) and everolimus) are still being investigated.
Sirolimus is the drug with which most experience has been gathered so far. Restenosis occurred in only 5.9% of patients who received the sirolimus-eluting stent in E-SIRIUS compared with 8.9% in SIRIUS. The results of baremetal stenting were compared with those of sirolimus eluting stent placements in a consecutive real-world registry. Occlusion were not higher than in the corresponding baremetal stent group (more than 600 patients), with similar antithrombotic management.
Are these findings enough to assign bare-metal stenting to historyfi Maybe yes, but not until more homework is done, handed in, and reviewed.
Drug-eluting stents, at present are 3-4 times more expensive than bare-metal stents. The advocates of drug-eluting stents argue that in the long run this investment is worthwhile because of the reduced need for revascularisation. Healthcrare provdiers still have to be convinced that this calculation adds up.
The advent of drug delivery from intravascular stents is a major advance in medicine. With this technology, endoluminal
therapy is likely to produce similar or even better results than bypass surgery in most patients, not in a selected few. The vehicle for drug delivery, the stent, is clearly under-engineered at the moment. Bad stents should not be promulgated to patients as the ultimate achievement just because of their glossy paintwork.
Ulrich Sigwart, Lancet, 2003; 362 : 1088-89.
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