Douglas A. Husmann

Major Renal Lacerations with a Devitalized Fragment following Blunt Abdominal Trauma: A Comparison between Nonoperative (Expectant) Versus Surgical Management

Of 43 patients who sustained blunt trauma resulting in a major renal laceration with a devitalized fragment 27 had coexisting intraperitoneal and renal injuries for which emergency celiotomy and repair of the nonurological trauma were done. Management of the renal injuries consisted of simultaneous renal exploration with 23% urological morbidity in 13 cases or expectant management with 85% urological morbidity in 14 cases. In this latter patient population infected urinomas and perinephric abscesses seeded from coexisting enteric or pancreatic injuries were the most common complication (57%). The remaining 16 of the 43 patients sustained renal lacerations without associated intraperitoneal injuries and all were managed expectantly with 38% urological morbidity. These findings suggest that renal exploration and surgical repair significantly improve the prognosis only in patients with simultaneous intraperitoneal and renal injuries (p < 0.01).

Current concepts in the pathophysiology of testicular undescent

At present, we believe that descent of the testes within the human is a complex event mediated by both hormonal and mechanical factors. We hypothesize that descent of the testes occurs as a result of the secretion of an androgen-independent factor from a normal testis (descendin). This paracrine factor is responsible for the rapid proliferation (outgrowth) of the ipsilateral gubernaculum. The development of the gubernaculum results in creating a dilated inguinal canal, the width of which matches the testicular width. Descent of the testes through the inguinal canal is an interplay between abdominal pressure, a patent processus vaginalis, and androgen-induced gubernacular regression. We hypothesize that androgens (under control of an intact hypothalamic pituitary axis) alter the viscoelastic properties of the gubernaculum, reducing the turgidity of the gubernaculum and allowing intra-abdominal pressure to push the testis into the scrotum. Cryptorchidism can therefore result when any one or more of the involved factors malfunction.

Hydronephrosis in renal ectopia : incidence, etiology and significance

The incidence, cause and significance of hydronephrosis in patients with renal ectopia are unknown. Therefore, we conducted a retrospective review of 77 patients with 82 ectopic kidneys. Of 82 kidneys 46 (56%) had hydronephrosis. Dilatation of the renal pelvis was the result of primary ureteropelvic or ureterovesical obstruction in 52%, grade 3, 4 or 5 vesicoureteral reflux in 26% and extrarenal collecting systems with malrotation that produced apparent ureteropelvic junction obstruction in 22%. Surgery was performed in 41 patients, including primary nephrectomy in 18, ureteral reimplantation in 14 and ureteropelvic junction repair in 8. Hydronephrosis was present in 15 of 58 contralateral nonectopic kidneys, and 11 required surgery mostly for vesicoureteral reflux. Solitary ectopic kidneys with no associated obstruction or reflux demonstrated normal renal function. Our data indicate that the prognosis in renal ectopia relates directly to the associated urological disease and timely surgical intervention, not to ectopia alone.

Long-term follow up of enteric bladder augmentations: The risk for malignancy

OBJECTIVE To determine the risk of bladder cancer following enteric bladder augmentation. MATERIALS AND METHODS Patients followed for care after an enteric bladder augmentation have been entered into a registry; individuals followed for a minimum of 10 years were evaluated. RESULTS The study criteria were met by 153 patients. Indications for bladder augmentation were neurogenic bladder in 97, exstrophy in 38 and posterior urethral valves in 18. There was a median follow-up interval of 27 years (range 10-53). A total of seven cases of malignancy developed. Median time to tumor development following augmentation was 32 years (range 22-52). Two patients with neurogenic bladder developed transitional cell carcinoma; both were heavy smokers (>50 pack per year history). Two patients with a history of posterior urethral valves and renal transplantation developed adenocarcinoma of the enteric augment. Three patients with bladder exstrophy developed multifocal adenocarcinoma of the augmented bladder. Two patients remain alive, 5 and 6 years following radical cystoprostatectomy; five died of cancer-specific causes. CONCLUSIONS Malignancy following enteric bladder augmentation arose in 4.5% (7/153) of our patients and was associated with coexisting carcinogenic stimuli (prolonged tobacco/chronic immunosuppressive exposure), or alternatively with the inherent risk of malignancy existing with bladder exstrophy.

Augmentation Cystoplasty and Risk of Neoplasia: Fact, Fiction and Controversy

PURPOSE We determined if ileal/colonic bladder augmentation performed in patients with congenital bladder abnormalities is an independent risk factor for bladder malignancy. MATERIALS AND METHODS We reviewed a registry of patients with bladder dysfunction due to neurological abnormalities, exstrophy and posterior urethral valves. Individuals treated with augmentation cystoplasty were matched (1:1) to a control group treated with intermittent catheterization based on etiology of bladder dysfunction, gender and age (±2 years). RESULTS We evaluated 153 patients with an ileal/colonic cystoplasty and a matched control population. There was no difference (p=0.54) in the incidence of bladder cancer in patients with augmentation cystoplasty (7 patients [4.6%]) vs controls (4 [2.6%]). In addition, there was no difference between the 2 groups regarding age at diagnosis (51 vs 49.5 years, p>0.7), stage (3.4 vs 3.8, p>0.5), mortality rate (5 of 7 [71%] vs 4 of 4 [100%], p>0.4) or median survival (18 vs 17 months, p>0.8). Irrespective of augmentation status patients with a history of renal transplant on chronic immunosuppression had a significantly higher incidence of bladder cancer (3 of 20 [15%]), compared to patients who were not immunosuppressed (8 of 286 [2.8%], p=0.03). CONCLUSIONS In patients with congenital bladder dysfunction ileal/colonic bladder augmentation does not appear to increase the risk of bladder malignancy over the inherent cancer risk associated with the underlying congenital abnormality. In addition, immunosuppression irrespective of bladder treatment is an independent risk factor for malignancy in this patient population.

Intestinal metaplasia is not a strong risk factor for bladder cancer : Study of 53 cases with long-term follow-up

OBJECTIVES Intestinal metaplasia often coexists with adenocarcinoma of the urinary bladder, suggesting to some investigators that it is premalignant. However, the natural history and long-term outcome of intestinal metaplasia in isolation are unknown. We report 53 cases of intestinal metaplasia of the urinary bladder followed for more than 10 years. METHODS We reviewed the Mayo Clinic surgical pathology files between 1926 and 1996 and all patients with exstrophic bladder recorded in the files of the Hospital for Sick Children (Toronto, Ontario, Canada) and Dallas Childrens Hospital (Dallas, Texas) between 1953 and 1987, and identified all patients with intestinal metaplasia of the bladder. RESULTS A total of 53 cases were identified from both series, and none of the patients developed adenocarcinoma of the bladder. The Mayo Clinic series consisted of 24 patients. Nineteen of the 24 (79.1%) were alive without evidence of cancer (median follow-up 14 years, range 0.9 to 53), and 5 patients died of intercurrent disease (at 0.9, 4, 8, 11, and 53 years after diagnosis) without evidence of bladder cancer. The Dallas Childrens Hospital and the Hospital for Sick Children series consisted of 29 patients. Twenty-seven of the 29 (93.1%) were alive without evidence of cancer (median follow-up 13 years, range 3 to 23.9). Two patients died of trauma (at 10.9 and 12 years after diagnosis) and at autopsy had no evidence of bladder cancer. CONCLUSIONS Intestinal metaplasia of the urinary bladder is not a strong risk factor for adenocarcinoma or urothelial cancer.

Ureteropelvic Junction Disruption Following Blunt Abdominal Trauma

Disruptions of the ureteropelvic junction following blunt abdominal trauma are rare. Our recent management of 8 cases (7 patients) revealed that an immediate diagnosis of this entity was made in less than 50% of the patients. The majority of delayed diagnoses occurred when the patients experienced absence of hematuria associated with nonresponsive hypovolemic shock. The clinical instability of the patients required emergency celiotomy for stabilization and precluded our obtaining appropriate contrast enhanced radiographic studies. Retroperitoneal findings at operation failed to reveal evidence of a perinephric hematoma. The kidneys were palpably normal and, therefore, they were not directly examined. Despite these negative retroperitoneal findings the patients sustained disruption of the ureteropelvic junction. Therefore, we stress that a negative exploratory laparotomy without direct visualization of the kidney should not exclude radiographic evaluations for retroperitoneal injuries.

Nonoperative Management of Nonvascular Grade IV Blunt Renal Trauma in Children: Meta-analysis and Systematic Review

OBJECTIVES To evaluate nonoperative management of grade IV blunt renal trauma in pediatric patients by performing a systematic review and meta-analysis of published studies. METHODS MEDLINE, EMBASE, Cochrane, and Scopus databases were searched between January 1992 and June 2008 for studies of pediatric renal trauma management. Inclusion criteria were patient age <or= 18 years and use of the American Association for the Surgery of Trauma renal injury scale. RESULTS A total of 95 children with grade IV injuries were identified. No intervention was required in 72% (68/95). Hemodynamic instability necessitated surgical exploration in 11% of patients (11/95). Of these, 46% (5/11) required a partial nephrectomy, 27% (3/11) underwent nephrectomy, and 27% (3/11) were salvaged. Angiographic infarction was not used for patients with delayed or persistent hemorrhage. Symptomatic urinoma developed in 17% (16/95). Of these patients, 81% (13/16) were successfully managed by percutaneous drainage or ureteral stent placement, and open intervention to manage complications became necessary in the remaining 19% (3/16). Partial renal preservation was possible in 95% of patients (90/95). CONCLUSIONS Nonoperative management of children with grade IV blunt renal injuries is highly successful, with at least partial renal preservation possible in 95% (90/95) of patients.

PENOSCROTAL TRANSPOSITION: REVIEW OF 53 PATIENTS

PURPOSE Penoscrotal transposition is a rare congenital abnormality of the external genitalia. We determine whether there is a genetic basis for this disorder, define the incidence of coexisting organ system anomalies, and compare the results of surgical techniques to correct transposition and hypospadias. MATERIALS AND METHODS We report the largest, single institution series of 53 patients 1 day to 30 years old with penoscrotal transposition. RESULTS Of the patients 13% had a family history of penoscrotal transposition. Interestingly, we identified 1 family in which inheritance occurred in an X-linked recessive manner. There were 17 (32%) patients who had abnormalities in other organ systems, with the genitourinary system in 9 affected most. A total of 79% of patients had hypospadias and 81% chordee. These anomalies were corrected with a single stage Thiersch-Duplay urethroplasty in 6 patients and complex repair with bladder or buccal mucosa, or a staged procedure in 34. Complication rates for urethroplasty were similar. Correction of the transposition included a Glenn-Anderson technique in 37 patients, Singapore rotational flaps in 7 and V-Y procedure in 6. The Glenn-Anderson repair produced the best cosmetic results and was associated with a significantly lower incidence of complications (p = 0.001). CONCLUSIONS We identified a subgroup of patients with a family history of penoscrotal transposition. Treatment requires an awareness of the association with other organ system anomalies. The Glenn-Anderson technique was the most successful method to correct transposition. Most patients required release of chordee and complex urethroplasty for hypospadias.

Ureteropelvic Junction Obstruction with a Simultaneous Renal Calculus: Long-Term Followup

We reviewed 111 patients who presented with simultaneous renal calculi and a ureteropelvic junction obstruction. Of 34 patients with ureteropelvic junction obstruction and a coexisting struvite stone 62% had recurrent calculi. The use of antibiotics significantly affected the incidence of recurrent struvite calculi. In particular, if prolonged prophylactic antibiotics (greater than 3 months) were used 15% of the patients had recurrent stones, compared to 90% if only perioperative antibiotics (less than 15 days) were used (p < 0.001). Patients with ureteropelvic junction obstruction and coexisting nonstruvite calculi were treated by either observation alone (53) or metabolic evaluation with appropriate intervention (24). Metabolic evaluation of patients with nonstruvite calculi revealed that 76% had an identifiable metabolic abnormality, treatment of which significantly decreased the incidence of recurrent renal calculi: 17% of the patients on interventional therapy had recurrent stones compared to 55% treated by observation alone (p < 0.001).