Christopher Dixon

Renal Reconstruction After Injury

During an 11-year period 1,363 patients presented to our institution with renal trauma. Renal exploration was performed in 127 patients (133 renal units). Most patients had multiple organ injuries, as indicated by a mean blood loss of 4,160 ml. and a mean injury severity score of 25.8. Absolute indications for exploration were bleeding and pulsatile perirenal hematoma and relative indications included urinary extravasation, nonviable renal tissue and incomplete staging. Renal surgery was required in 2.4% of the blunt injuries, 45% of the stab wounds and 76% of the gunshot wounds. Salvage was successful in 88.7% of the kidneys explored and total nephrectomy was required in 11.3%. The success rate was based on early vascular control and reconstructive techniques of renorrhaphy, partial nephrectomy, vascular repair and coverage with omental pedicle flaps. Complications occurred in 9.9% of the cases but none resulted in renal loss. When indicated, renal exploration after trauma is safe and in a high percentage of cases reconstruction will be successful.

Posttraumatic Impotence: Magnetic Resonance Imaging and Duplex Ultrasound in Diagnosis and Management

In 15 patients, impotent as a result of prostatomembranous urethral disruption consequent to pelvic crush injuries, magnetic resonance imaging (MRI) and duplex ultrasound were used to establish anatomical and pathophysiological criteria for accurate diagnosis and appropriate management. All patients were initially treated by suprapubic cystostomy diversion for at least 3 months, after which urethral reconstruction was performed. All men were potent before the pelvic trauma, with loss of sexual function immediately thereafter. Preoperative MRI demonstrated prostatic displacement in 13 cases (86.7%) and cavernous injury in 12 (80%). Duplex ultrasound revealed the cause of erectile failure as vasculogenic in 12 patients (80%) and neurogenic in 3 (20%). Treatment of impotence was deferred for at least 18 months after injury. Of the neurogenic group 2 patients were started on intracavernous injection therapy and 1 refused treatment. Of the vasculogenic group 3 patients underwent successful revascularization, 2 are on injection therapy and 1 had a penile prosthesis inserted. The detailed anatomical information obtainable with pelvic MRI and the functional data provided by duplex ultrasonography enabled us to identify the individual organic components of posttraumatic impotence and to select effective cause-specific therapy.

Magnetic Resonance Imaging of Traumatic Posterior Urethral Defects and Pelvic Crush Injuries

A total of 18 patients 4 to 71 years old with complete occlusion of the prostatomembranous urethra from pelvic crush injury underwent magnetic resonance imaging (MRI) of the pelvis just before open urethroplasty. MRI studies included T2-weighted sagittal and coronal images as well as transaxial T1 and T2-weighted spin-echo images. Operative findings and erectile function were correlated with MRI findings. All patients underwent conventional cystography and retrograde urethrography. The mean interval from injury to operation was 5.5 months (range 3 to 12 months) and followup averaged 12 months (range 3 to 40 months). Posttraumatic pelvic anatomy can be distorted and imaging in all 3 planes was needed. The severity and direction of prostatourethral dislocation, and the length of the urethral defect could be accurately determined, which often is not possible with conventional radiographic studies. MRI also demonstrated injuries at many locations along the erectile pathway, including sacral and ischial fractures as well as fractures and avulsions of the cavernous bodies. Pelvic MRI can accurately define the pelvic anatomy after crush injury and, therefore, it can provide useful preoperative information that cannot be obtained by conventional radiographic studies. Our results correlating MRI findings of cavernous avulsion with clinical impotence require further study.

Substance abuse-related spontaneous bladder rupture: report of 2 cases and review of the literature.

Spontaneous rupture of the normal bladder associated with alcohol abuse is rare, with only 20 cases reported in the English literature to which we add 2 cases. Heavy alcohol ingestion predisposes the bladder to rupture by the large volume of fluid intake, its diuretic effect and the mental obtusion it produces, clouding sensory cues to void. alpha-Sympathomimetic drugs, such as cocaine and methamphetamine, increase the resistance at the urethral sphincter and exacerbate the effects of alcohol. Cystography will be diagnostic, and prompt operative repair of intraperitoneal rupture is mandatory. Complete evaluation of the bladder, including urodynamic study, is important to eliminate underlying bladder pathological conditions. Substance abuse-related rupture demonstrates a typical constellation of clinical features that necessitate considering it a syndrome separate from other causes of spontaneous bladder rupture.

Transurethral convective water vapor as a treatment for lower urinary tract symptomatology due to benign prostatic hyperplasia using the Rezūm ® system: evaluation of acute ablative capabilities in the human prostate

Background The purpose of this study was to assess the acute ablative characteristics of transurethral convective water vapor (steam) using the Rezūm® system in men with benign prostatic hyperplasia through histologic and radiographic studies. Methods Seven patients were treated with transurethral intraprostatic injections of sterile steam under endoscopic visualization followed by previously scheduled adenectomies. The extirpated adenomas were grossly examined followed by whole mount sectioning and staining with triphenyl-tetrazolium chloride (TTC) to evaluate thermal ablation. Histology was performed after hematoxylin and eosin staining on one prostate. After review of results from the first patient cohort, an additional 15 patients with clinical benign prostatic hyperplasia were treated followed by gadolinium-enhanced magnetic resonance imaging (MRI) at one week. Results In the first patient cohort, gross examination of TTC-stained tissue showed thermal ablation in the transition zone. In addition, there was a distinct interface between viable and necrotic prostatic parenchyma. Histopathologic examination revealed TTC staining-outlined necrotic versus viable tissue. Gadolinium-enhanced MRIs in the cohort of 15 patients demonstrated lesion defects in all patients at 1 week post-procedure. Coalesced lesions were noted with a mean (± standard deviation) lesion volume of 9.6±8.5 cm3. The largest lesion volume was 35.1 cm3. Ablation using vapor was rapid and remained confined to the transition zone, consistent with the thermodynamic principles of convective thermal energy transfer. Conclusion Thermal ablation was observed in all specimens. The resulting coalescing ablative lesions, as seen on MRI, were confined to the transition zone. These studies confirm the ablative capabilities of vapor, validate the thermodynamic principles of convective heating, and allow for further clinical studies.

PD56-11 DEVELOPMENT OF CONVECTIVE WATER VAPOR ENERGY FOR TREATING LOCALIZED PROSTATE CANCER: FIRST-IN-MAN EARLY CLINICAL EXPERIENCES.

CONCLUSIONS: Only a quarter of our respondents utilize FT in their practice with surgeon’s experience being the only independent predictor for utilizing FT. Majority of respondents though consider FT to be beneficial in prostate cancer management and would use it more often if provided more reliable and cost effective options. Over time, experience and accessibility to reliable methods to perform FT may lead to further utilization of this novel treatment strategy.