Purple urine bag syndrome is an uncommon condition that describes the purple discolouration of a catheter bag and tubing. It mainly affects patients with limited mobility who have long-term catheters. Although benign in nature per se, its presence can alarm both patient and practitioner unfamiliar with the syndrome. Here, we describe two cases of asymptomatic patients who both presented to outpatient clinic with the characteristic purple discolouration of their long-term catheters and tubing. The report discusses the pathophysiology of the syndrome and initial investigation and management. Although the syndrome is considered benign, it may signify occult urine tract infection. This should not be ignored even if the patient is asymptomatic, given the likely co-morbidities of the patients affected. Healthcare professionals - particularly urologists and geriatricians - need to be aware of this unusual syndrome so as to initiate appropriate investigation and possible treatment as soon as possible.

Background: Ureteric colic is a major clinical and economic burden on the National Health Service. There has been a recent paradigm shift to consider definitive surgery as the primary intervention at the time of initial presentation. Objective: To systematically evaluate the outcomes of primary/emergency ureteroscopy versus delayed/elective ureteroscopy. Methods: We performed a critical review of MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials–CENTRAL, CINAHL, Clinicaltrials.gov, Google Scholar and individual urological journals in April 2020. A robust database search was performed using a combination of the terms ‘primary ureteroscopy’, ‘immediate ureteroscopy’, ‘delayed ureteroscopy’ and ‘emergency ureteroscopy’. Adult patients (> 16 years) with ureteric stones presenting as an emergency were included. Results: Twelve studies met the inclusion criteria, with 4 studies directly comparing primary/emergency to delayed/elective ureteroscopy for an acute presentation of ureteric colic. Across the studies, 1708 patients underwent primary/emergency ureteroscopy for ureteric calculi and 990 underwent delayed ureteroscopy. No significant differences in stone-free rates were found between both groups with primary/emergency achieving 85% and delayed/elective 91% ( p = 0.68). The majority of stones treated were located in the distal ureter in both groups. Overall, there were no differences in complications between the groups ( p = 0.42) or major complications (0.17). However, there were fewer minor complications in the primary URS group ( p = 0.02). Ureteral catheter or double-J stent insertion was used in 71% of delayed/elective ureteroscopy cases, compared to 46.8% of primary/emergency cases (p = 0.001). For patients undergoing primary/emergency ureteroscopy, 6.4% patients required auxiliary procedures. In the delayed/elective group, 7.6% required further definitive treatment (NS). Conclusion: Primary ureteroscopy is a safe and feasible procedure, when performed in suitable patients in the acute setting. It is associated with significantly lower stent usage, equivalent stone clearance, no increase in overall or major complications including sepsis, and fewer minor complications when compared to delayed/elective ureteroscopy. Prospective studies will do well to explore this area further but on current evidence, primary ureteroscopy is the safe procedure. Level of evidence: Not applicable

Special access techniques during percutaneous nephrolithotomy (PCNL) are indicated for challenging stones. Various techniques have been described to inferiorly displace the kidney to facilitate optimal percutaneous access whilst minimizing thoracic complications associated with the supracostal approach. We describe our institution’s technique of using a ureteric balloon catheter to inferiorly distract and immobilize the kidney (UBC Technique) to achieve the optimal calyceal access infracostally during PCNL. This permits effective and safe access in a single puncture whilst additionally stabilizing the renal unit during respiration and reducing the skin-to-calyceal distance by mobilizing the desired calyx in line with the axis of the puncture needle.  We reviewed the literature regarding alternative inferior renal displacement techniques permitting infracostal approaches.  From May 2012 to October 2017 150 PCNLs were performed in our institution. Out of these, the UBC technique was used in 18 cases during both prone and supine PCNLs. In all cases, the UBC technique was used successfully to access the most desirable calyx. No complications associated with renal distraction were reported. Post operatively, 1 patient required a blood transfusion, 1 patient had a pyrexia of >38 degrees resulting in a longer admission and 1 patient developed sepsis requiring HDU admission for monitoring only. 15 out the 18 patients had complete stone clearance from their PCNL. The UBC technique provides a safe alternative to the supracostal approach in percutaneous renal surgery. It is less traumatic than alternative infracostal access techniques and has a very short learning curve.  

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