Daniel Dugi

American Association for the Surgery of Trauma grade 4 renal injury substratification into grades 4a (low risk) and 4b (high risk).

PURPOSE We identified computerized tomography findings associated with the need for urgent intervention for hemostasis after traumatic renal injury to update and refine the American Association for the Surgery of Trauma Organ Injury Scale for renal trauma. MATERIALS AND METHODS We retrospectively reviewed the records of consecutive patients presenting to our level I trauma center from 1999 to 2008 with American Association for the Surgery of Trauma grades 3 and 4 renal injury. In all patients initial abdominal computerized tomography was done soon after presentation to the emergency department before renal intervention. All images were interpreted by a staff radiologist and urologist blinded to clinical outcomes. Novel radiographic features (perirenal hematoma size, intravascular contrast extravasation and renal laceration site) were analyzed and correlated with the invasive intervention rate to control life threatening bleeding. RESULTS Of 299 patients hospitalized with renal injury 102 met study inclusion criteria. Increased perirenal hematoma size (perirenal hematoma rim distance greater than 3.5 cm), intravascular contrast extravasation and a medial renal laceration site were important radiographic risk factors significantly associated with intervention for bleeding after renal trauma. Analyzing these radiographic characteristics collectively showed that patients with 0 or 1 risk factor were at 7.1% risk for intervention and those with 2 or 3 were at remarkably higher risk, that is 66.7% (OR 26.0, 95% CI 7.20-93.9, p <0.0001). CONCLUSIONS On radiography a large perirenal hematoma, intravascular contrast extravasation and medial renal laceration are important risk factors associated with the need for urgent hemostatic intervention after renal trauma. Assessing these computerized tomography characteristics collectively shows that American Association for the Surgery of Trauma grade 4 renal injuries can and should be substratified into grades 4a (low risk) and 4b (high risk).

Penoscrotal plication as a uniform approach to reconstruction of penile curvature

Study Type – Therapy (case series)
Level of Evidence 4

Radiographic predictors of need for angiographic embolization after traumatic renal injury

BACKGROUND Although the American Association of the Surgery for Trauma Organ Injury Scale is the gold standard for staging renal trauma, it does not address characteristics of perirenal hematomas that may indicate significant hemorrhage. Angiographic embolization has become well established as an effective method for achieving hemostasis. We evaluated two novel radiographic indicators--perirenal hematoma size and intravascular contrast extravasation (ICE)--to test their association with subsequent angiographic embolization. METHODS Among 194 patients with renal trauma between 1999 and 2004, 52 having a grade 3 (n = 33) or grade 4 (n = 19) renal laceration were identified. Computed tomography scans were reviewed by a staff radiologist and urologist blinded to outcomes. ICE was defined as contrast within the perirenal hematoma during the portal venous phase having signal density matching contrast in the renal artery. Hematoma size was determined in four ways: hematoma area (HA), hematoma to kidney area ratio (HKR), difference between hematoma and kidney area (HKD), and perirenal hematoma rim distance (PRD). RESULTS Of the 52 patients, 8 had ICE and 4 of these (50%) required embolization, whereas none of the 42 (0%) patients without ICE needed embolization (p = 0.001). Likewise, all four measures of perirenal hematoma size assessed were significantly greater in patients receiving embolization [HA (128.3 vs. 75.4 cm, p = 0.009), HKR (2.75 vs. 1.65, p = 0.008), HKD (76.5 vs. 30.2 cm, p = 0.006), and PRD (4.0 vs. 2.5 cm, p = 0.041)]. CONCLUSION Perirenal hematoma size and ICE are readily detectible radiographic features and are associated with the need for angiographic embolization.

Skin Grafting of the Penis

Penile skin loss may occur after trauma, infection, or as a result of surgical resection. This article reviews indications for reconstruction of the penile skin, skin anatomy, and skin graft physiology. Choice of reconstructive options, skin grafting techniques, and complications of skin grafting are also discussed.

Does topical haemostatic agent have an adverse effect on the function of the prostatic neurovascular bundle

To assess the functional and histological effects of a bovine thrombin topical haemostatic agent used clinically to aid in surgical haemostasis (FloSealTM, Baxter International Inc., Deerfield, IL, USA) on the cavernous nerves in a canine model of survival, as there are concerns that the fibrotic/inflammatory response to this product could affect neural function.

Correlation of Penile and Bulbospongiosus Measurements: Implications for Artificial Urinary Sphincter Cuff Placement

PURPOSE We assessed penile and bulbospongiosus measurements to develop a quantitative guide to select the surgical approach (perineal vs transscrotal vs transcorporeal) to artificial urinary sphincter cuff placement. MATERIALS AND METHODS We retrospectively reviewed the intraoperative records of 100 men who underwent artificial urinary sphincter placement (43) or anastomotic urethroplasty (57) from February 2008 to June 2009. Correlations between penile (stretched length and circumference at the shaft base) and bulbospongiosus (distal and proximal circumference) measurements were assessed. Cases were analyzed according to 2 penile circumference groups, including group 1-8.0 cm or less and group 2-8.5 or more. RESULTS Mean proximal bulbospongiosus circumference was uniformly larger than distal bulbospongiosus circumference (4.5 vs 3.9 cm). It was about 50% of the penile shaft circumference (mean 8.9 cm, r = 0.70). In group 1 men the average distal bulbospongiosus circumference was 3.4 cm. They were more likely to undergo transcorporeal artificial urinary sphincter cuff placement than those in group 2, who had an average distal bulbospongiosus circumference of 4.1 cm (8 of 22 or 36% vs 1 of 21 or 5%, OR 11.4). Penile length correlated less robustly with distal and proximal bulbospongiosus circumference (r = 0.39 and 0.43, respectively). Patients with urethroplasty had significantly larger urethral measurements than those with the artificial urinary sphincter (proximal and distal bulbospongiosus circumference 4.9 vs 3.7 and 4.1 vs 3.2, respectively) but were significantly younger (47 vs 67 years), and less likely to have erectile dysfunction (11 of 57 vs 34 of 43) or to have undergone radical prostatectomy (0 of 57 vs 37 of 43). CONCLUSIONS Bulbospongiosus circumference appears to be proportional to penile circumference. The distal bulbospongiosus is uniformly smaller than the proximal bulbospongiosus. The potential need for a perineal or transcorporeal approach to artificial urinary sphincter placement can be anticipated by penile circumference measurements and a combination of clinical factors, such as older patient age, history of radical prostatectomy and impotence.

Clinical Risk Factors Associated With Urethral Atrophy

OBJECTIVE To analyze a series of clinical risk factors associated with pretreatment urethral atrophy. METHODS We retrospectively reviewed 301 patients who underwent artificial urinary sphincter (AUS) placement between September 2009 and November 2015; of these, 60 (19.9%) transcorporal cuff patients were excluded. Patients were stratified into 2 groups based on intraoperative spongiosal circumference measurements. Men with urethral atrophy (3.5 cm cuff size) were compared to controls (≥4 cm cuff size). Chi-square test, Mann-Whitney U test, and logistic regression analyses were performed to determine risk factors for urethral atrophy. RESULTS Among 241 AUS patients analyzed, urethral atrophy was present in 151 patients (62.7%) compared to 90 patients (37.3%) who received larger cuffs (range 4-5.5 cm). Patients with urethral atrophy were older (71.1years vs 68.3 years; P < .02), more likely to have received radiation (52.9% vs. 33.3%; P < .007), and had a longer time interval between prostate cancer treatment and AUS surgery (8.9 years vs. 6.6 years; P < .033). On multivariable analysis, radiation therapy was independently associated with risk of urethral atrophy (odds ratio 1.77, 95% confidence interval: 1.01-3.13; P = .046), whereas greater time between cancer therapy and incontinence surgery approached clinical significance (odds ratio 1.05, 95% confidence interval 1.00-1.09; P = .05). CONCLUSION History of radiation therapy and increasing length of time from prostate cancer treatment are associated with urethral atrophy before AUS placement.

Permanent Bulbar Urethral Ligation: Emerging Treatment Option for Incontinent Men With End-stage Urethra

OBJECTIVE To report our experience with permanent urethral ligation for severe incontinence among men with end-stage urethra. MATERIALS AND METHODS From our institutional artificial urinary sphincter database of 512 patients from 2010 to 2016, 10 men underwent permanent urethral ligation with concurrent suprapubic tube diversion following recurrent artificial urinary sphincter cuff erosion. Clinical characteristics and outcomes were evaluated. Quality of life was assessed using the Michigan Incontinence Symptom Index and the Patient Global Index of Improvement. RESULTS Urethral ligation resulted in resolution of incontinence in 8 men (80%), including 7 (70%) after 1 surgery and in 1 (10%) after a single revision. The average American Society of Anesthesiologists physical status rating was 2.7 (range 2-3). Seven patients (70%) experienced postoperative complications (4 Clavien-Dindo grade II complications [1 Clostridium difficile infection, 3 refractory bladder spasms) and 5 grade III complications (2 abscesses, 2 urethrocutaneous fistula, and 1 bladder stone formation]). Overall, satisfactory Michigan Incontinence Symptom Index urinary scores were reported in 8 (80%) men. On the Patient Global Index of Improvement, 6 (60%) men reported improvement in overall condition following surgery. All men (10/10) stated that they would recommend this procedure to others. CONCLUSION For debilitated men with end-stage urethra and severe refractory stress urinary incontinence, permanent urethral ligation with chronic suprapubic tube drainage can restore continence and improve quality of life without the need for more invasive formal urinary diversion, though with a high risk of complication.

Urethroplasty for Stricture Disease: Contemporary Techniques and Outcomes

Urethral reconstruction is now considered optimal therapy for most men presenting with symptomatic urethral strictures. The rapid development of innovative tissue transfer techniques over the past decade provides todays reconstructive urologist with a high probability of achieving excellent long-term outcomes after urethroplasty, even in the reoperative setting. Fundamental principles such as accurate initial stricture staging by urethrography, along with critical assessment of both stricture severity and tissue quality during urethroplasty are critical for success. This review illustrates the way in which stricture length, location, severity, and etiology influences the application of reconstructive techniques during contemporary urethroplasty.

Bone Saw for Calcified Peyronie's Disease Plaques

OBJECTIVES To determine the incidence of calcified Peyronies disease plaque that cannot be cut with a blade in a 100-case series and to describe the use of a soft tissue-protecting bone saw for plaque incision. METHODS Chart reviews were done of all surgically treated Peyronies disease patients at our center between October 1996 and December 2012. 100 cases were included. We evaluated our novel technique of tissue-protecting bone saw surgical use. RESULTS 100 consecutive patients underwent surgery for Peyronies disease, and 6 required transverse bone saw plaque incision due to the severity of calcification that could not be cut with a blade. Four of those 6 underwent grafting procedures with porcine submucosal intestinal substance (SIS) and 2 underwent placement of inflatable penile prosthesis (IPP) after plaque incision. There were no surgical complications. Both IPP patients had functioning prosthesis 4 and 7.3 years after surgery. One SIS-graft patient required re-operation for more proximal curvature 11 months later and ultimately required multiple plaque incisions and an IPP. CONCLUSION Densely calcified plaques occurred in 6% of a surgical series of Peyronies disease patients. The vibrating bone saw is a novel technique to incise calcified plaques before grafting or IPP placement.