Brandi Miller

Contemporary management of high-grade renal trauma: Results from the American Association for the Surgery of Trauma Genitourinary Trauma study

BACKGROUND The rarity of renal trauma limits its study and the strength of evidence-based guidelines. Although management of renal injuries has shifted toward a nonoperative approach, nephrectomy remains the most common intervention for high-grade renal trauma (HGRT). We aimed to describe the contemporary management of HGRT in the United States and also evaluate clinical factors associated with nephrectomy after HGRT. METHODS From 2014 to 2017, data on HGRT (American Association for the Surgery of Trauma grades III-V) were collected from 14 participating Level-1 trauma centers. Data were gathered on demographics, injury characteristics, management, and short-term outcomes. Management was classified into three groups—expectant, conservative/minimally invasive, and open operative. Descriptive statistics were used to report management of renal trauma. Univariate and multivariate logistic mixed effect models with clustering by facility were used to look at associations between proposed risk factors and nephrectomy. RESULTS A total of 431 adult HGRT were recorded; 79% were male, and mechanism of injury was blunt in 71%. Injuries were graded as III, IV, and V in 236 (55%), 142 (33%), and 53 (12%), respectively. Laparotomy was performed in 169 (39%) patients. Overall, 300 (70%) patients were managed expectantly and 47 (11%) underwent conservative/minimally invasive management. Eighty-four (19%) underwent renal-related open operative management with 55 (67%) of them undergoing nephrectomy. Nephrectomy rates were 15% and 62% for grades IV and V, respectively. Penetrating injuries had significantly higher American Association for the Surgery of Trauma grades and higher rates of nephrectomy. In multivariable analysis, only renal injury grade and penetrating mechanism of injury were significantly associated with undergoing nephrectomy. CONCLUSION Expectant and conservative management is currently utilized in 80% of HGRT; however, the rate of nephrectomy remains high. Clinical factors, such as surrogates of hemodynamic instability and metabolic acidosis, are associated with nephrectomy for HGRT; however, higher renal injury grade and penetrating trauma remain the strongest associations. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III; Therapeutic study, level IV.

A Simplified Adult Acquired Buried Penis Repair Classification System with an Analysis of Perioperative Complications and Urethral Stricture Disease

OBJECTIVE To propose a simple classification system for buried penis repairs and present an analysis of perioperative data based on category. METHODS Patients undergoing buried penis repair at a single institution were examined. Classification was as follows: Category I-penile unburying with local flap; II-skin graft; III-scrotal surgery; IV-escutcheonectomy; V-abdominal panniculectomy. Complex repairs were Category III or above. Success was defined as an unburied penis without additional unburying surgery. RESULTS Between 2007 and 2017, 64 patients underwent repair with 44 (69%) considered complex. Patients undergoing complex repairs had a higher body mass index (median 48 vs 36 kg/m2, P < .01). A total of 30 patients (47%) had urethral strictures, with no association to buried penis complexity (P = .43). High-grade complications (Clavien ≥ 3) occurred in 10 patients (23%) in the high-complexity group with none in the low-complexity group (P = .02). Seven of 10 (70%) of high-grade complications were wound related. Successful unburying was seen in 58 patients (91%). All failures occurred in the high-complexity group. Median follow-up was 209 days. CONCLUSION Buried penis repairs are highly successful. We propose a classification based on surgical complexity. Patients requiring complex repairs have higher body mass index and increased risk of high-grade complications. While urethral strictures are found in nearly half of patients, there is no association with the severity of disease. Ongoing modifications of technique and perioperative care may improve outcomes.

An American Association for the Surgery of Trauma (AAST) prospective multi-center research protocol: outcomes of urethral realignment versus suprapubic cystostomy after pelvic fracture urethral injury

Background Pelvic fracture urethral injuries (PFUI) occur in up to 10% of pelvic fractures. It remains controversial whether initial primary urethral realignment (PR) after PFUI decreases the incidence of urethral obstruction and the need for subsequent urethral procedures. We present methodology for a prospective cohort study analyzing the outcomes of PR versus suprapubic cystostomy tube (SPT) after PFUI. Methods A prospective cohort trial was designed to compare outcomes between PR (group 1) and SPT placement (group 2). Centers are assigned to a group upon entry into the study. All patients will undergo retrograde attempted catheter placement; if this fails a cystoscopy exam is done to confirm a complete urethral disruption and attempt at gentle retrograde catheter placement. If catheter placement fails, group 1 will undergo urethral realignment and group 2 will undergo SPT. The primary outcome measure will be the rate of urethral obstruction preventing atraumatic passage of a flexible cystoscope. Secondary outcome measures include: subsequent urethral interventions, post-injury complications, urethroplasty complexity, erectile dysfunction (ED) and urinary incontinence rates. Results Prior studies demonstrate PR is associated with a 15% to 50% reduction in urethral obstruction. Ninety-six men (48 per treatment group) are required to detect a 15% treatment effect (80% power, 0.05 significance level, 20% loss to follow up/death rate). Busy trauma centers treat complete PFUI approximately 1–6 times per year, thus our goal is to recruit 25 trauma centers and enroll patients for 3 years with a goal of 100 or more total patients with complete urethral disruption. Conclusions The proposed prospective multi-institutional cohort study should determine the utility of acute urethral realignment after PFUI.

PD63-02 COMPLIANCE WITH AUA GUIDELINES WITH EXCRETORY PHASE IMAGING FOR EVALUATION OF HIGH-GRADE RENAL TRAUMA: RESULTS FROM THE AMERICAN ASSOCIATION FOR SURGERY OF TRAUMA (AAST) GENITOURINARY TRAUMA STUDY

INTRODUCTION AND OBJECTIVES: In our initial review of the Trauma Outcomes and Urogenital Health (TOUGH) cohort, we identified 423 male US service members (SMs) who sustained penile injuries (PI) while deployed in support of Operations Iraqi Freedom and Enduring Freedom (OIF/OEF). Conventional penile reconstruction is challenged by the unique structure and function of the penile tissues. Thus, penile transplantation is being investigated as a potential means for penile replacement after severe PI. We have made the clinical observation that many SMs who sustained severe PI during OIF/OEF presented with complex polytrauma which may have excluded them from enrollment in existing penile transplantation protocols. The objective of this study was to evaluate the injury patterns among members of the TOUGH cohort who sustained PI with a focus on comorbid conditions which may impact candidacy for penile transplantation. METHODS: The previously identified members of the TOUGH cohort who sustained PI were further characterized based on injury severity as well as the presence of comorbid conditions which may impact eligibility for penile transplantation. Severe PI was defined as an Abbreviated Injury Scale severity of 3 or greater (cutaneous avulsion, laceration through glans/cavernosum/urethra, or partial/total penectomy). Five comorbid conditions were identified which may negatively impact penile transplant candidacy: traumatic brain injury (TBI), massive blood transfusion, colorectal injury, pelvic fracture, and extremity amputation(s). SMs with severe PI were stratified by the number of comorbid conditions diagnosed. RESULTS: Among the 423 men with PI identified in the TOUGH cohort, 86 (20.3%) sustained severe PI. SMs with severe PI were largely young (median age: 23) and injured during battle (n1⁄481; 94%) by explosive mechanisms (n1⁄477; 90%) resulting in severe polytrauma (median ISS1⁄429). Comorbid conditions which could impact penile transplantation candidacy were common, including massive transfusion (n1⁄456; 65%), lower extremity amputation(s) (n1⁄455; 64%), TBI (n1⁄434; 40%), colorectal injury (n1⁄429; 34%), and pelvic fracture (n1⁄427; 31%). Overall, 83% of SMs (n1⁄471) had at least one of these conditions and 47% (n1⁄441) had 3. CONCLUSIONS: Severe PI was relatively rare during OIF/OEF. Life-threatening polytrauma was common and nearly all SMs with severe PI had comorbid immunologic, physical, and/or neurologic diagnoses which could disqualify them from penile transplantation given the current restrictions identified in existing transplant protocols. Source of Funding: none; The view(s) expressed herein are those of the author(s) and do not reflect the official policy or position of Brooke Army Medical Center, the U.S. Army Medical Department, the U.S. Army Office of the Surgeon General, the Department of the Army or the Department of Defense or the U.S. Government.

MP79-01 NEPHRECTOMY AFTER HIGH-GRADE RENAL TRAUMA: RESULTS FROM THE AMERICAN ASSOCIATION FOR THE SURGERY OF TRAUMA (AAST) GENITOURINARY TRAUMA STUDY

Health Network. Dr Rupal Gupta, medical editor at Kids Health, Dr Carlos Estrada from Boston Children’s Hospital, and Dr T. Ernesto Figueroa from Nemours/AI duPont Hospital for Children were the facilitators of the chat. The search tags included #khchat and #TesticularTorsion. It lasted one hour, and was joined by 90 people producing 660 tweets and 33,750,157 impressions on this subject. Throughout the chat, various questions were posed by Kids Health that were answered by the facilitators to provide information and generate discussion. CONCLUSIONS: Social media provides an outlet to discuss significant healthcare topics and serves as a unique way to reach a younger audience. Tweet chats in particular are a successful way in pediatric urology to promote awareness of important topics.