A.S. Cass

Features of 164 Bladder Ruptures

We reviewed 164 cases of bladder rupture from external trauma. Of these patients 145 (88 per cent) suffered blunt trauma, and 59 (35.5 per cent) suffered intraperitoneal, 93 (57.5 per cent) extraperitoneal and 12 (7 per cent) both types of rupture. Bladder rupture owing to blunt trauma was caused by a compression (burst) type of injury in all patients with intraperitoneal rupture and in 24 per cent of those with extraperitoneal rupture. In the remaining instances of extraperitoneal rupture pelvic bone fragments corresponded to the site of the injury. Although surgical repair has been the traditional method of management of all bladder ruptures, nonoperative (catheter) management of extraperitoneal rupture was successful in most cases.

Immediate Exploration of the Unilateral Acute Scrotum in Young Male Subjects

Physical exertion, sexual activity or trauma can precipitate cremasteric contraction and result in torsion of a testicle with an underlying congenital anomaly. A high index of suspicion is required by the primary care doctor if acute torsion is to be diagnosed early for immediate reduction. The duration of torsion and the degree of twisting determine the long-term salvage rate of testicular tissue. An aggressive policy of immediate exploration of the unilateral acute scrotum in young men resulted in exploration of twice as many cases of acute epididymitis as torsion of the testis or its appendages but also resulted in an immediate orchiopexy (salvage) rate of 90 per cent and a long-term salvage rate of 73 per cent of patients with acute torsion of the testis.

Comparison of First Generation (Dornier HM3) and Second Generation (Medstone STS) Lithotriptors: Treatment Results With 13,864 Renal and Ureteral Calculi

Some reports have shown a decreased effectiveness of extracorporeal shock wave lithotripsy (ESWL*) with newer lithotriptors. We used a first generation unmodified Dornier HM3 lithotriptor to treat 5,698 patients with renal and ureteral calculi and a second generation Medstone STS device to treat 8,166 patients with renal and ureteral calculi. The treatment results were compared using the chi-square test to determine statistical significance. The stone-free rate, retreatment rate and post-ESWL secondary procedure rate were 69.5%, 4.4% and 3.1%, respectively, with the Dornier HM3 device and 72.1%, 4.9% and 2.3%, respectively, with the Medstone lithotriptor for single renal stones, and 81.5%, 5.2% and 5.5%, respectively, with the Dornier HM3 and 83.2%, 5.2% and 5.0%, respectively, with the Medstone device for single ureteral stones. There were no statistically significant different results between a second generation tubless Medstone STS lithotriptor and the gold standard unmodified Dornier HM3 instrument.

Self-inflicted foreign bodies involving lower urinary tract and male genitals

A great variety of self-inflicted foreign bodies have been removed from the lower urinary tract and male external genitalia. These foreign bodies were inserted or applied for autoerotic, psychiatric, therapeutic, or no definite reasons by the patient. Most patients were too ashamed to admit they had inserted or applied any object and usually presented when a complication had occurred from the foreign body such as difficulty voiding, hematuria, pain or swelling, extravasation, or abscess formation. Inspection and palpation diagnosed foreign bodies involving the male external genitalia in 3 patients and anterior urethra in 6. Radiographic studies with and without contrast medium and endoscopy were required to diagnose foreign bodies in the posterior urethra and bladder in 9 patients, and the exact location, shape, and orientation of the foreign bodies in all sites, radiolucent objects, and the complications of mucosal laceration and extravasation. All 16 foreign bodies in the anterior urethra (below urogenital diaphragm) were removed by endoscopic manipulation in the 6 patients. Nine foreign bodies in the posterior urethra or bladder (above the urogenital diaphragm) were removed by endoscopic manipulation in 2 females and 2 males, while suprapubic cystostomy was required in 1 female and 4 males. The 3 foreign bodies applied to the external genitalia of 3 males were removed carefully to avoid injury to the underlying skin. Foreign bodies lying below the urogenital diaphragm were palpable and readily removed endoscopically while foreign bodies above the urogenital diaphragm required greater endoscopic manipulation or open surgical procedures.

Value of Early Operation in Blunt Testicular Contusion with Hematocele

The use of ultrasound for evaluation of blunt testicular injury with hematocele allows contusion to be differentiated from rupture, and some authors advocate reserving surgical management for rupture. Our experience with the conservative management of 20 men with testicular contusion and hematocele was not encouraging. Of the patients 8 (40 per cent) required delayed exploration that involved orchiectomy in 3 (15 per cent) because of unresorbed hematoma or infection despite antibiotic use. In contrast, early surgical exploration in 19 patients reduced the morbidity and duration of disability, and resulted in an orchiectomy rate of 0.

Management of urinary calculi in pregnancy

When a calculus is present in the upper urinary tract during pregnancy, the upper tract dilatation seen on radiography and ultrasonography can be due to the calculus or to the pregnancy. This makes the decision on management difficult unless there are associated clinical findings of pain or sepsis. The records of 24 pregnant patients with proved urinary calculi were reviewed. The stone passed spontaneously in 18 patients, and procedures to remove the stone were required in 6 for pain and/or sepsis. With an upper urinary tract calculus and dilatation during pregnancy the deciding factors for intervention were the clinical findings of pain and/or sepsis and not the dilatation alone.

URETHRAL INJURY DUE TO EXTERNAL TRAUMA

Fifty-six patients with urethral injuries comprised 35 involving the posterior urethra and 21 involving the anterior urethra. Immediate retrograde urethrography confirmed the clinical diagnosis made when blood was found at the external urinary meatus after external trauma. Traffic accidents caused most of the posterior urethral injuries and were associated with severe injuries to multiple systems and a significant mortality rate (34 per cent). Primary realignment of the urethral injury by a urethral catheter in all cases of urethral rupture (plus a suprapubic cystostomy in most of these cases) resulted in a stricture rate of 62 per cent on follow-up. However, only half of these strictures required surgical correction. The incidence of incontinence was 10 per cent and of impotence 38 per cent.

Clinical Indications for Radiographic Evaluation of Blunt Renal Trauma

The evaluation of patients with blunt renal trauma has become controversial. We tested the hypothesis that renal contusion can be diagnosed clinically and that these patients do not require radiographic evaluation. To evaluate the association of microhematuria without shock and with renal contusion, we reviewed the medical records of 831 patients with hematuria following blunt renal trauma. Microscopic hematuria without shock was noted in 160 of 241 patients without and 334 of 590 with associated injuries. Of the former 160 patients 159 had renal contusion and 1 had a renal laceration, while of the latter 334 patients 329 had renal contusion, 3 had renal laceration, 1 had renal rupture and 1 had a pedicle injury. Most patients with microscopic hematuria and no shock after blunt renal trauma had a renal contusion, especially those with no associated injury. All of the patients with renal contusions experienced no complications from nonoperative management. However, avoiding a radiographic evaluation in patients with blunt renal trauma plus microhematuria and no shock would miss a few cases of severe renal injury.

Conservative or immediate surgical management of Blunt renal injuries

From 1969 to 1981, 1,176 blunt renal injuries were recorded in 1,166 patients (10 patients had bilateral injuries). Conservative management of 27 patients with severe renal injuries resulted in a delayed renal operation in 30 per cent and total renal loss in 22 per cent. A review of the published series of the conservative management of patients with severe renal injuries (laceration, rupture and pedicle injury) shows a renal surgery rate of 13 to 68 per cent, a renal loss rate of 3 to 33 per cent and a significant complication/renal surgery rate of 13 to 76 per cent. In our patients 88 per cent with severe renal injuries had associated injuries and 73 per cent of these underwent immediate laparotomy for intra-abdominal injury. Immediate renal surgery in 59 patients with severe renal injuries resulted in a nephrectomy rate of 6.5 per cent of 31 renal lacerations, 100 per cent of 14 renal ruptures and 50 per cent of 14 pedicle injuries. Of the 14 patients with pedicle injuries 6 (43 per cent) had immediate vascular repair, with salvage of the kidney. Immediate surgical management of the patients with severe renal injuries obviated the need for a second exploration in a severely injured patient, reduced morbidity and resulted in increased renal salvage.

Immediate Radiological Evaluation and Early Surgical Management of Genitourinary Injuries from External Trauma

An immediate diagnostic evaluation of genitourinary trauma is mandatory for an early operation. A method of immediate radiological evaluation is presented and the accuracy rate in the diagnosis of the type and site of injury is detailed. The advantages of early surgical management are compared to the results with expectant management.