Chris F. Heyns

Evaluation and management of renal injuries: consensus statement of the renal trauma subcommittee

The first in this series of five papers concerns the evaluation and management of renal injuries. The authors of this paper come from four continents and seven countries, and they reviewed all papers on renal injury published between 1966 and April 2002. The results of the authors’ deliberations are present here as a consensus document.

Internal Urethrotomy Versus Dilation as Treatment for Male Urethral Strictures: A Prospective, Randomized Comparison

PURPOSE We compared the efficacy of dilation versus internal urethrotomy as initial outpatient treatment for male urethral stricture disease. MATERIALS AND METHODS A total of 210 men with proved urethral strictures was randomized to undergo filiform dilation (106) or optical internal urethrotomy (104) with local anesthesia on an outpatient basis. RESULTS Life table survival analysis showed no significant difference between the 2 treatments with regard to stricture recurrence. Hazard function analysis showed that the risk of stricture recurrence was greatest at 6 months, whereas the risk of failure after 12 months was slight. The recurrence rate at 12 months was approximately 40% for strictures shorter than 2 cm. and 80% for those longer than 4 cm., whereas the recurrence rate for strictures 2 to 4 cm. long increased from approximately 50% at 12 months to approximately 75% at 48 months. Cox regression analysis showed that for each 1 cm. increase in length of the stricture the risk of recurrence was increased by 1.22 (95% confidence interval 1.05 to 1.43). CONCLUSIONS There is no significant difference in efficacy between dilation and internal urethrotomy as initial treatment for strictures. Both methods become less effective with increasing stricture length. We recommend dilation or internal urethrotomy for strictures shorter than 2 cm., primary urethroplasty for those longer than 4 cm. and a trial of dilation or urethrotomy for those 2 to 4 cm. long.

Testicular function after torsion of the spermatic cord

We calculated the early salvage rate (testis viable at exploration) and late atrophy rate in two meta-analyses of 1140 patients in 22 series and 535 patients in eight series, respectively (Fig. 1). In one report the immediate orchidectomy rate before 1960 was 80%, from 1960 to 1984 it was 38%, and in the later part of this period (1980–84) testicular loss was 33% [4]. To salvage the testis three factors are needed: prompt presentation, prompt diagnosis and referral, and immediate surgery. According to one study the cause of testicular loss is a delay in seeking medical attention in 58% of cases, a wrong initial diagnosis by the GP in 29%, and delayed treatment at the referral hospital in 13% [8]. Earlier diagnosis and treatment can be achieved by educating medical students and physicians, but earlier presentation also requires educating the general population.

Management of radiation cystitis

Acute radiation cystitis occurs during or soon after radiation treatment. It is usually self-limiting, and is generally managed conservatively. Late radiation cystitis, on the other hand, can develop from 6 months to 20 years after radiation therapy. The main presenting symptom is hematuria, which may vary from mild to severe, life-threatening hemorrhage. Initial management includes intravenous fluid replacement, blood transfusion if indicated and transurethral catheterization with bladder washout and irrigation. Oral or parenteral agents that can be used to control hematuria include conjugated estrogens, pentosan polysulfate or WF10. Cystoscopy with laser fulguration or electrocoagulation of bleeding points is sometimes effective. Injection of botulinum toxin A in the bladder wall may relieve irritative bladder symptoms. Intravesical instillation of aluminum, placental extract, prostaglandins or formalin can also be effective. More-aggressive treatment options include selective embolization or ligation of the internal iliac arteries. Surgical options include urinary diversion by percutaneous nephrostomy or intestinal conduit, with or without cystectomy. Hyperbaric oxygen therapy (HBOT) involves the administration of 100% oxygen at higher than atmospheric pressure. The reported success rate of HBOT for radiation cystitis varies from 60% to 92%. An important multicenter, double-blind, randomized, sham-controlled trial to evaluate the effectiveness of HBOT for refractory radiation cystitis is currently being conducted.

Increasing role of angiography and segmental artery embolization in the management of renal stab wounds

During a 5-year period 93 patients with stab wounds involving the upper urinary tract were treated. Of these patients 79 were treated initially at our department (group 1) and 14 were referred with complications after initial treatment elsewhere (group 2). In group 1, 26 patients (33%) were selected for surgery on the basis of signs of severe blood loss or associated intra-abdominal injury, or major abnormality on the excretory urogram. At operation a major renal injury and/or associated intra-abdominal laceration was found in 23 patients (88%) and nephrectomy was required in 7 (27%) of them. Nonoperative management was selected in 53 patients (67%) in group 1 and secondary hemorrhage occurred in 8 (15%). Of the patients in group 2, 4 had undergone an operation elsewhere and 10 had been managed nonoperatively. Renal arteriography was performed in 14 patients who had been managed nonoperatively (6 from group 1 and 8 from group 2) and demonstrated a traumatic pseudoaneurysm in 6, an arteriovenous fistula in 5 and no large vessel injury in 3. Selective embolization of the involved segmental artery was successful in 9 of 11 patients (82%) when angiography showed a vascular lesion. This study demonstrates the increasingly important role of renal angiography and selective embolization in the selective nonoperative management of patients with stab wounds of the kidney.

Comparative efficacy of triptorelin pamoate and leuprolide acetate in men with advanced prostate cancer

To compare the efficacy of monthly administrations of the luteinizing hormone‐releasing hormone agonists triptorelin pamoate and leuprolide acetate to induce and maintain castrate levels of serum testosterone in men with advanced prostate cancer.

Management of the lymph nodes in penile cancer

A comprehensive literature study was conducted to evaluate the levels of evidence (LEs) in publications on the diagnosis and staging of penile cancer. Recommendations from the available evidence were formulated and discussed by the full panel of the International Consultation on Penile Cancer in November 2008. The final grades of recommendation (GRs) were assigned according to the LE of the relevant publications. The following consensus recommendations were accepted. Fine needle aspiration cytology should be performed in all patients (with ultrasound guidance in those with nonpalpable nodes). If the findings are positive, therapeutic, rather than diagnostic, inguinal lymph node dissection (ILND) can be performed (GR B). Antibiotic treatment for 3-6 weeks before ILND in patients with palpable inguinal nodes is not recommended (GR B). Abdominopelvic computed tomography (CT) and magnetic resonance imaging (MRI) are not useful in patients with nonpalpable nodes. However, they can be used in those with large, palpable inguinal nodes (GR B). The statistical probability of inguinal micrometastases can be estimated using risk group stratification or a risk calculation nomogram (GR B). Surveillance is recommended if the nomogram probability of positive nodes is <0.1 (10%). Surveillance is also recommended if the primary lesion is grade 1, pTis, pTa (verrucous carcinoma), or pT1, with no lymphovascular invasion, and clinically nonpalpable inguinal nodes, but only provided the patient is willing to comply with regular follow-up (GR B). In the presence of factors that impede reliable surveillance (obesity, previous inguinal surgery, or radiotherapy) prophylactic ILND might be a preferable option (GR C). In the intermediate-risk group (nomogram probability .1-.5 [10%-50%] or primary tumor grade 1-2, T1-T2, cN0, no lymphovascular invasion), surveillance is acceptable, provided the patient is informed of the risks and is willing and able to comply. If not, sentinel node biopsy (SNB) or limited (modified) ILND should be performed (GR B). In the high-risk group (nomogram probability >.5 [50%] or primary tumor grade 2-3 or T2-T4 or cN1-N2, or with lymphovascular invasion), bilateral ILND should be performed (GR B). ILND can be performed at the same time as penectomy, instead of 2-6 weeks later (GR C). SNB based on the anatomic position can be performed, provided the patient is willing to accept the potential false-negative rate of </=25% (GR C). Dynamic SNB with lymphoscintigraphic and blue dye localization can be performed if the technology and expertise are available (GR C). Limited ILND can be performed instead of complete ILND to reduce the complication rate, although the false-negative rate might be similar to that of anatomic SNB (GR C). Frozen section histologic examination can be used during SNB or limited ILND. If the results are positive, complete ILND can be performed immediately (GR C). In patients with cytologically or histologically proven inguinal metastases, complete ILND should be performed ipsilaterally (GR B). In patients with histologically confirmed inguinal metastases involving >/=2 nodes on one side, contralateral limited ILND with frozen section analysis can be performed, with complete ILND if the frozen section analysis findings are positive (GR B). If clinically suspicious inguinal metastases develop during surveillance, complete ILND should be performed on that side only (GR B), and SNB or limited ILND with frozen section analysis on the contralateral side can be considered (GR C). Endoscopic ILND requires additional study to determine the complication and long-term survival rates (GR C). Pelvic lymph node dissection is recommended if >/=2 proven inguinal metastases, grade 3 tumor in the lymph nodes, extranodal extension (ENE), or large (2-4 cm) inguinal nodes are present, or if the femoral (Cloquets) node is involved (GR C). Performing ILND before pelvic lymph node dissection is preferable, because pelvic lymph node dissection can be avoided in patients with minimal inguinal metastases, thus avoiding the greater risk of chronic lymphedema (GR B). In patients with numerous or large inguinal metastases, CT or MRI should be performed. If grossly enlarged iliac nodes are present, neoadjuvant chemotherapy should be given and the response assessed before proceeding with pelvic lymph node dissection (GR C). Antibiotic treatment should be started before surgery to minimize the risk of wound infection (GR C). Perioperative low-dose heparin to prevent thromboembolic complications can be used, although it might increase lymph leakage (GR C). The skin incision for ILND should be parallel to the inguinal ligament, and sufficient subcutaneous tissue should be preserved to minimize the risk of skin flap necrosis (GR B). Sartorius muscle transposition to cover the femoral vessels can be used in radical ILND (GR C). Closed suction drainage can be used after ILND to prevent fluid accumulation and wound breakdown (GR B). Early mobilization after ILND is recommended, unless a myocutaneous flap has been used (GR B). Elastic stockings or sequential compression devices are advisable to minimize the risk of lymphedema and thromboembolism (GR C). Radiotherapy to the inguinal areas is not recommended in patients without cytologically or histologically proven metastases nor in those with micrometastases, but it can be considered for bulky metastases as neoadjuvant therapy to surgery (GR B). Adjuvant radiotherapy after complete ILND can be considered in patients with multiple or large inguinal metastases or ENE (GR C). Adjuvant chemotherapy after complete ILND can be used instead of radiotherapy in patients with >/=2 inguinal metastases, large nodes, ENE, or pelvic metastases (GR C). Follow-up should be individualized according to the histopathologic features and the management chosen for the primary tumor and inguinal nodes (GR B).

Renal trauma: indications for imaging and surgical exploration

Complications such as persistent urinary leakage and infected urinoma or perinephric abscess can be managed with percutaneous catheter drainage and/or ureteric stenting. Secondary haemorrhage from a pseudoaneurysm or arteriovenous fistula (AVF) can be managed successfully with selective arteriography and segmental arterial embolization in most cases, thus avoiding the need for open surgery. Hypertension directly attributable to renal injury is probably rare, and is most commonly managed with nephrectomy. There is a lack of data on renal insufficiency after trauma, but the severity of injury, renovascular trauma and associated injuries may compromise renal function.

The glycosaminoglycans of the gubernaculum during testicular descent in the fetus

Tissues were obtained from 387 male pig fetuses ranging from 60 to 120 days of gestation. The relative wet mass and water content of the gubernaculum increased during and decreased after the period of testicular descent. The extracellular glycosaminoglycans (GAG) were assayed to determine whether these polyanionic macromolecules are responsible for the increased water content of the gubernaculum. The total GAG/wet tissue mass in the gubernaculum decreased during and increased after descent, while the total GAG/dry mass decreased during and after descent, indicating an accumulation of water during descent, with a loss of water and an increase in less hydrated tissue components after descent. The major GAG fraction in the gubernaculum was dermatan sulfate, but the percentage hyaluronate in the gubernaculum was two times higher than in striated muscle or umbilical cord, indicating that this GAG fraction may be responsible for the increased water content of the gubernaculum, which probably serves to dilate the inguinal canal and scrotum, thus facilitating descent.

Nonoperative Management of Renal Stab Wounds

A prospective clinical study of 54 patients with stab wounds and hematuria was conducted to evaluate the safety of selective nonoperative management compared to mandatory surgical exploration of these patients. In the absence of signs of severe blood loss, associated intra-abdominal injury or major abnormality on the excretory urogram patients were randomized to undergo mandatory surgery (group 1) or nonoperative management (group 2). Patients with signs of severe blood loss, associated intra-abdominal injury or gross abnormality on excretory urography were selected for an operation (group 3). The rate of probably needless operations (defined as minor renal injury without associated intra-abdominal lacerations) was 78 per cent in group 1 and 0 per cent in group 3. Pulmonary complications occurred in 33 per cent of the patients in group 1, 4 per cent in group 2 and 38 per cent in group 3. Despite an operation delayed renal hemorrhage occurred in 1 patient (5 per cent) in group 1 and 2 (15 per cent) in group 3, and resulted in nephrectomy in 2 of these patients. No instance of secondary hemorrhage occurred in group 2 patients. The mean length of hospitalization was 9, 5 and 11 days in groups 1 to 3, respectively. Our results indicate that the selective nonoperative management of patients with renal stab wounds can lead to a decrease in the rate of unnecessary operations, postoperative complications and length of hospitalization compared to a policy of mandatory surgical intervention.