Christopher A. Haas

SELECTIVE NONOPERATIVE MANAGEMENT OF BLUNT GRADE 5 RENAL INJURY

PURPOSE We determined the feasibility of a nonoperative approach to blunt grade 5 renal injury. MATERIALS AND METHODS We retrospectively reviewed the records of all patients with grade 5 renal injury who presented to our level 1 trauma center from 1993 to 1998. Those treated nonoperatively and surgically were assigned to groups 1 and 2, respectively. Each group was compared with respect to the initial emergency department evaluation, computerized tomography findings, associated injuries, duration of hospital stay and intensive care unit stay, transfusion requirements, complications and followup imaging. RESULTS Of 218 renal injuries evaluated 13 were grade 5. In group 1, 6 patients were treated nonoperatively and in group 2, 7 underwent exploration. Each group had similar average hospitalization (12.0 and 12.8 days, respectively). Patients in group 1 had fewer intensive care unit days (4.3 versus 9.0), significantly lower transfusion requirements (2.7 versus 25.2 units, p = 0.0124) and fewer complications during the hospital course. Followup computerized tomography of nonoperatively managed cases revealed functioning renal parenchyma with resolution of retroperitoneal hematoma. CONCLUSIONS Conservative management of blunt grade 5 renal injury is feasible in patients who are hemodynamically stable at presentation.

Traumatic Renal Artery Occlusion: A 15-year Review

BACKGROUND To better define what constitutes appropriate treatment for traumatic renal artery occlusion, we report our 15-year experience in managing this injury. METHODS A retrospective chart review was performed to evaluate treatment outcomes and complications of 12 patients (13 injuries) who presented to our trauma centers with renal artery occlusion secondary to blunt injury. RESULTS Five of 12 patients underwent attempted surgical revascularization with a median warm ischemia time of 5 hours (range, 4.5-36 hours). Of these five patients, one required nephrectomy for inability to establish arterial flow, three demonstrated no function, and one had return to 9% differential function on postoperative renal scan. Seven patients did not have attempted revascularization, and none of them experienced immediate complications. Hypertension developed in three patients (43%) who required nephrectomy to control blood pressure at a mean of 5 months after injury (range, 3-7 months). Four patients remained asymptomatic and normotensive at a mean follow-up of 11 months (range, 4 weeks to 2.6 years). CONCLUSION Surgical revascularization for traumatic renal artery occlusion seldom results in a successful outcome. Patients who are observed must have close follow-up for hypertension.

Intraurethral alprostadil for treatment of erectile dysfunction in patients with spinal cord injury

OBJECTIVES To assess the efficacy of intraurethral prostaglandin E1 (alprostadil, MUSE) in treating erectile dysfunction in patients with spinal cord injury (SCI). METHODS Intraurethral alprostadil was tested in 15 patients with SCI to evaluate its effectiveness in treating SCI-associated erectile dysfunction. All patients were at least 1 year after injury, and all had previously used intracavernosal injections successfully (Schrameks grade 5 erection). The intraurethral drug was administered in the office, in the presence of a physician, with monitoring of blood pressure. If effective, the patient was then able to use MUSE at home. The first 3 patients underwent gradual dose escalation starting with 125 microg, without the use of a constriction ring. Because of hypotension, the remaining 12 patients all used a penile constriction ring prior to intraurethral drug administration using 1000 microg. The quality of the erection was compared with that achieved with intracavernosal injections using Schrameks grading. RESULTS The dose escalation (titration) in the first 3 patients demonstrated that the 1000-microg dose was the most effective in creating an erectile response. Transient hypotension was noted in these first 3 patients in whom the constricting band was not used. The highest dose of MUSE (1000 microg) was, therefore, used in the remaining 12 patients, with the constriction band. The quality of the erection varied and appeared to be less rigid in all patients (12 patients with grade 1 to 3; 3 patients with grade 4) than that noted with intracavernosal injection therapy (1 5 patients with grade 5). There was no incidence of priapism. The 3 patients with grade 4 erections tried the MUSE at home. All 3 patients were dissatisfied with the quality of the erection and did not continue to use the MUSE at home and returned to intracavernosal injection therapy. CONCLUSIONS MUSE appears to be somewhat effective in creating erections; however, these were less rigid erections than those obtained with intracavernosal therapy and provided less overall satisfaction. It should always be used in the patient with SCI after placement of a constriction ring to prevent hypotension. Its ultimate use depends on the patients level of satisfaction with the quality of the erection compared with intracavernosal injections.

Penile fracture and testicular rupture

Abstract Traumatic injuries to the penis and testicles are uncommon, likely due to the well-protected location and degree of mobility of these organs [10, 21]. Because of this the management of these injuries has historically been controversial. However, current literature supports immediate evaluation and surgical repair of these traumatic injuries to prevent complications such as erectile dysfunction or testicular loss [20, 27]. Herein the diagnostic and therapeutic options for both traumatic penile fracture and testicular rupture are reviewed with emphasis on immediate evaluation and repair.

Radiologic Evaluation of Pediatric Blunt Renal Trauma in Patients with Microscopic Hematuria

As a result of the rapid increase in medical costs, the efficacy of diagnostic imaging is under examination, and efforts have been made to identify patients who may safely be spared radiographic imaging. We reviewed the records of children who presented to our institution with suspected blunt renal injuries to determine if radiographic evaluation is necessary in children with microscopic hematuria and blunt renal trauma. We retrospectively reviewed the medical records of 1200 children (ages less than 18 years) who sustained blunt abdominal trauma and who presented to our level I pediatric trauma center between 1995 and 1997. Urinalysis was performed in 299 patients (25%). Urinalysis results were correlated with findings on abdominal computed tomography (CT). All patients had more than three red blood cells per high power field (RBC/hpf) or gross hematuria. Renal injuries were graded according to the injury scale defined by the American Association for the Surgery of Trauma. Sixty-five patients had microscopic hematuria. Thirty-five (54%) were evaluated with an abdominal CT scan. Three patients sustained significant renal injuries (grade II-V), and 32 patients had normal findings or renal contusions. Therefore only 3 of 65 patients (4.6%) sustained a significant renal injury. All three patients had other associated major organ injuries. Of the three patients with gross hematuria evaluated with abdominal CT, one (33%) sustained a significant renal injury and had no associated injuries. The degree of hematuria did not correlate with the grade of renal injury. Pediatric patients with blunt trauma, microscopic hematuria, and no associated injuries do not require radiologic evaluation, as significant renal injuries are unlikely. However, children who present with associated injuries and microscopic hematuria after blunt trauma may have significant renal injuries and should undergo radiologic evaluation.

Sclerosing lipogranuloma of the testis

Sclerosing lipogranuloma is an uncommon, benign condition that can affect several organs, particularly of the genitourinary system in males. We describe a patient who presented with an intratesticular mass on physical examination. Pathologic evaluation confirmed the diagnosis of testicular sclerosing lipogranuloma. Most case reports involve self-injection with a foreign substance that is pathognomonic. Treatment is often conservative after establishing the diagnosis.

Computed tomography three-dimensional reconstruction in the diagnosis of traumatic renal artery thrombosis

A woman was a restrained passenger in a high-speed motor vehicle accident. On initial evaluation, the patient was found to be hemodynamically stable and complaining of leftsided abdominal and flank pain. Her hematocrit was 38% (normal 36% to 46%) and serum creatinine 0.9 mg/dL (normal 0.7 to 1.5), and the urinalysis was normal. Computed tomography (CT) of the abdomen and pelvis with oral and intravenous contrast was performed (Fig. 1). CT demonstrated no perfusion to the left kidney, and the right kidney demonstrated prompt enhancement and excretion of contrast. Her only other injuries included a nasal fracture and left olecranon fracture. The patient was 5 hours postinjury and was treated nonoperatively because of the normally functioning right kidney. Her abdominal and flank pain resolved promptly and she was discharged 5 days after the injury with normal blood pressure and serum creatinine. A follow-up CT was performed 2 months later with three-dimensional reconstruction to image the renal vasculature (Fig. 2). Note the abrupt cutoff of the left main renal artery approximately 1 cm distal to its origin. At her 3-month follow-up visit, she was doing well with normal blood pressure.

Laparoscopic pelvic and para-aortic/retroperitoneal lymph node dissection

The application of laparoscopy in genitourinary surgery has broadened with recent advances in laparoscopic technique and instrumentation. Specifically, the laparoscopic pelvic lymph node dissection has become a viable alternative to open lymphadenectomy for the accurate staging of prostatic adenocarcinoma. The laparoscopic pelvic lymph node dissection is a less morbid method of determining nodal status and can potentially prevent a noncurative procedure in those patients with metastatic prostate cancer. Therefore, the laparoscopic pelvic lymph node dissection is limited to those patients with prostate cancer who have a high likelihood of metastatic disease as predicted by preoperative clinical staging, prostate-specific antigen, and Gleason grade. In contrast, the accuracy of the laparoscopic paraaortic/retroperitoneal lymph node dissection in the staging of nonseminomatous testis cancers has not yet been established. Although technically feasible, controversy over the increased morbidity and unproven accuracy of the laparoscopic retroperitoneal lymph node dissection exists when compared with its potentially curative, open counterpart. Therefore, the laparoscopic retroperitoneal lymph node dissection is performed only in those patients with nonseminomatous testis cancer who have a low likelihood of metastatic disease.

Transrectal Ultrasound and Prostate Biopsy in the Office

The medical application of ultrasonography is a relatively recent development that stems from advancements made in sonar technology during World War II. Initial ultrasound images of the prostate were of poor quality, and only with the introduction of transrectal B-Mode ultrasound did prostate imaging improve. Further advancements, including hand-held probes, gray-scale imaging, high-frequency biplanar transducers, and real-time imaging, have led to the development of the modern portable ultrasound unit. Today, ultrasound has become a critical part of the modern urologists’ office-based practice as a method for evaluating the prostate and guiding transrectal needle biopsies of the prostate.

Trends in Diagnosis, Biopsy, and Imaging

Prostate cancer is the most commonly diagnosed malignancy in men and has a mortality rate second only to lung carcinoma. It is estimated that 179,300 new cases of prostate cancer will be diagnosed and 37,000 deaths will be caused by prostate cancer in 1999 (1). Between 1980 and 1990, the prostate cancer incidence rate increased 65%. which is largely owing to improved detection (2). This increase in incidence reflects the widespread use of prostate specific antigen (PSA) combined with digital rectal examination (DRE) as a means to screen for prostate cancer. However, with the increased use of PSA came an increase in the number of biopsies, and further refinements in PSA testing were developed in an effort to decrease the number of unnecessary biopsies. Together with improvements in ultrasound technology, biopsy strategy, and advancements in other imaging modalities, the ability to detect and stage prostatic carcinoma has also improved. Herein, we will examine recent trends in the diagnosis of prostate cancer with particular emphasis on recent advancements in biopsy and imaging.