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Re: Urethral Stricture After Cardiovascular Surgery, a Retrospective and a Prospective Study
0022-534 7/84/1324-0778$0~.00/0 THE JOURNAL OF UROLOGY
Vol. 132, October
Copyright© 1984 by The Williams & Wilkins Co.
Printed in U.S.A.
Letters to the Editor DIAGNOSIS-RELATED GROUPS
RE: URETHRAL STRICTURE AFTER CARDIOVASCULAR SURGERY, A RETROSPECTIVE AND A PROSPECTIVE STUDY
A. Abdel-Hakim, J. Bernstein, J. Teijeira and M. M. Elhilali
J. Urol., 130: 1100-1102, 1983 To the Editor. The authors have done a nice job of documenting the incidence of strictures following a cardiovascular operation. The study was of interest to me because we see severe strictures in children after open heart operations. I agree with Doctor Engel's Editorial Comment concerning strictures after transurethral surgery. It might be worthwhile for the authors to study the influence of catheter position on the occurrence of strictures. In my experience urethral catheters placed after a cardiovascular operation usually are fastened securely to the upper thigh. This position puts an S-curve in the catheter that exerts pressure on the urethral wall in the bulbar and penoscrotal areas. In addition, these patients usually are turned frequently, undergo suction and otherwise are moved so that traction on the catheter creates almost constant friction with the penile urethra. One wonders whether the incidence of strictures would be decreased if the catheter were secured to the lower abdominal wall so that it follows a natural curve into the bladder. In such a position the catheter would be free of abnormal tension and movement. This clinical study surely would be easy and should resolve the issue fairly promptly. Respectfully, Peter S. Stevens Division of Pediatric Urology Jacksonville Wolfson Children's Hospital Jacksonville, Florida 32207
Reply by Authors. We fully agree with the comments regarding the possible influence of catheter position on the occurrence of strictures. We definitely believe that the etiology of stricture formation in these patients is multifactorial, including urethral ischemia, hypothermia during extracorporeal circulation (increasing the degree of vascular spasm), the trauma of the presence of the urethral catheter, the material of the urethral catheter, and there could well be a positional factor also. The team involved in this study were all aware of these factors and tried to minimize the effect of each. The positioning of the catheter was constant. We ensured a smooth curvature that did not eliminate the S-curve completely. The catheter was fixed to avoid traction during positioning or manipulation of the patient. We could not keep the catheter over the abdomen of the patient since the vascular surgeons required clear access to both saphenous veins, which would have been more difficult in that position.
778
The advent of the diagnosis-related groups has raised concerns among physicians, particularly concern over the possibility that a spate of patients with complications might deplete the hospital or their own resources. Urologists may not be reassured but at least will be interested to know that Dr. Hugh Hampton Young experienced a similar monetary loss through a similar payment plan. As Doctor Young related in his autobiography: "His prostate was extremely large and unusually soft. I thought he had simply a huge enlargement that could be shelled out by the usual method. I told him he would have to stay in the hospital about three weeks, and he agreed to pay me $500. 'I'll only be able to pay that,' he remarked, 'if I don't have to stay longer than three weeks. If I do, will you deduct my hospital expenses from your fee?' I agreed. "When the prostate was exposed, it was seen that instead of a simple enlargement the patient had a malignant tumor (sarcoma) of the prostate, a rare condition that I had never seen, and beyond hope of radical cure. All I could do was to remove the obstruction. The patient had taken one of the best rooms in the hospital, on a corner with a southern exposure, and costing $12 a day. At the end of three weeks he was far from well. The following week his board bill was on me, $84 was deducted from my bill, and the same amount the next week. During the third week, as I saw my fee rapidly disappearing, I suggested that he move into a cheaper room. But he said, 'No, I need the sunlight and I prefer to stay here,' so he stayed on and on at $12 a day (on me). When the wound had firmly healed, my work having been done, and he should have been ready to go home, pleurisy developed. I proposed transferring him to the medical department, but he would not have it. When my fee had been completely eaten up and I suggested that he had long since recovered from my operation and could easily be treated at home, he insisted that he preferred the treatment at the hospital and stayed on from week to week at my expense. When he left he owed me nothing and I owed the hospital $350, which he insisted upon my paying. He was deaf to my arguments that his case had proved entirely different from what I had contracted to operate for and that his stay had been unduly prolonged by complications of a medical character."' Respectfully, John F. Redman Department of Urology University of Arkansas College of Medicine Little Rock, Arkansas 72205
1. Young, H. H.: Hugh Young, a Surgeon's Autobiography. New York:
Harcourt, Brace and Co., p. 211, 1940.
Vol. 132, October
Copyright© 1984 by The Williams & Wilkins Co.
Printed in U.S.A.
Letters to the Editor DIAGNOSIS-RELATED GROUPS
RE: URETHRAL STRICTURE AFTER CARDIOVASCULAR SURGERY, A RETROSPECTIVE AND A PROSPECTIVE STUDY
A. Abdel-Hakim, J. Bernstein, J. Teijeira and M. M. Elhilali
J. Urol., 130: 1100-1102, 1983 To the Editor. The authors have done a nice job of documenting the incidence of strictures following a cardiovascular operation. The study was of interest to me because we see severe strictures in children after open heart operations. I agree with Doctor Engel's Editorial Comment concerning strictures after transurethral surgery. It might be worthwhile for the authors to study the influence of catheter position on the occurrence of strictures. In my experience urethral catheters placed after a cardiovascular operation usually are fastened securely to the upper thigh. This position puts an S-curve in the catheter that exerts pressure on the urethral wall in the bulbar and penoscrotal areas. In addition, these patients usually are turned frequently, undergo suction and otherwise are moved so that traction on the catheter creates almost constant friction with the penile urethra. One wonders whether the incidence of strictures would be decreased if the catheter were secured to the lower abdominal wall so that it follows a natural curve into the bladder. In such a position the catheter would be free of abnormal tension and movement. This clinical study surely would be easy and should resolve the issue fairly promptly. Respectfully, Peter S. Stevens Division of Pediatric Urology Jacksonville Wolfson Children's Hospital Jacksonville, Florida 32207
Reply by Authors. We fully agree with the comments regarding the possible influence of catheter position on the occurrence of strictures. We definitely believe that the etiology of stricture formation in these patients is multifactorial, including urethral ischemia, hypothermia during extracorporeal circulation (increasing the degree of vascular spasm), the trauma of the presence of the urethral catheter, the material of the urethral catheter, and there could well be a positional factor also. The team involved in this study were all aware of these factors and tried to minimize the effect of each. The positioning of the catheter was constant. We ensured a smooth curvature that did not eliminate the S-curve completely. The catheter was fixed to avoid traction during positioning or manipulation of the patient. We could not keep the catheter over the abdomen of the patient since the vascular surgeons required clear access to both saphenous veins, which would have been more difficult in that position.
778
The advent of the diagnosis-related groups has raised concerns among physicians, particularly concern over the possibility that a spate of patients with complications might deplete the hospital or their own resources. Urologists may not be reassured but at least will be interested to know that Dr. Hugh Hampton Young experienced a similar monetary loss through a similar payment plan. As Doctor Young related in his autobiography: "His prostate was extremely large and unusually soft. I thought he had simply a huge enlargement that could be shelled out by the usual method. I told him he would have to stay in the hospital about three weeks, and he agreed to pay me $500. 'I'll only be able to pay that,' he remarked, 'if I don't have to stay longer than three weeks. If I do, will you deduct my hospital expenses from your fee?' I agreed. "When the prostate was exposed, it was seen that instead of a simple enlargement the patient had a malignant tumor (sarcoma) of the prostate, a rare condition that I had never seen, and beyond hope of radical cure. All I could do was to remove the obstruction. The patient had taken one of the best rooms in the hospital, on a corner with a southern exposure, and costing $12 a day. At the end of three weeks he was far from well. The following week his board bill was on me, $84 was deducted from my bill, and the same amount the next week. During the third week, as I saw my fee rapidly disappearing, I suggested that he move into a cheaper room. But he said, 'No, I need the sunlight and I prefer to stay here,' so he stayed on and on at $12 a day (on me). When the wound had firmly healed, my work having been done, and he should have been ready to go home, pleurisy developed. I proposed transferring him to the medical department, but he would not have it. When my fee had been completely eaten up and I suggested that he had long since recovered from my operation and could easily be treated at home, he insisted that he preferred the treatment at the hospital and stayed on from week to week at my expense. When he left he owed me nothing and I owed the hospital $350, which he insisted upon my paying. He was deaf to my arguments that his case had proved entirely different from what I had contracted to operate for and that his stay had been unduly prolonged by complications of a medical character."' Respectfully, John F. Redman Department of Urology University of Arkansas College of Medicine Little Rock, Arkansas 72205
1. Young, H. H.: Hugh Young, a Surgeon's Autobiography. New York:
Harcourt, Brace and Co., p. 211, 1940.