Erik S. DeSoucy

Contemporary management of high-grade renal trauma: Results from the American Association for the Surgery of Trauma Genitourinary Trauma study

BACKGROUND The rarity of renal trauma limits its study and the strength of evidence-based guidelines. Although management of renal injuries has shifted toward a nonoperative approach, nephrectomy remains the most common intervention for high-grade renal trauma (HGRT). We aimed to describe the contemporary management of HGRT in the United States and also evaluate clinical factors associated with nephrectomy after HGRT. METHODS From 2014 to 2017, data on HGRT (American Association for the Surgery of Trauma grades III-V) were collected from 14 participating Level-1 trauma centers. Data were gathered on demographics, injury characteristics, management, and short-term outcomes. Management was classified into three groups—expectant, conservative/minimally invasive, and open operative. Descriptive statistics were used to report management of renal trauma. Univariate and multivariate logistic mixed effect models with clustering by facility were used to look at associations between proposed risk factors and nephrectomy. RESULTS A total of 431 adult HGRT were recorded; 79% were male, and mechanism of injury was blunt in 71%. Injuries were graded as III, IV, and V in 236 (55%), 142 (33%), and 53 (12%), respectively. Laparotomy was performed in 169 (39%) patients. Overall, 300 (70%) patients were managed expectantly and 47 (11%) underwent conservative/minimally invasive management. Eighty-four (19%) underwent renal-related open operative management with 55 (67%) of them undergoing nephrectomy. Nephrectomy rates were 15% and 62% for grades IV and V, respectively. Penetrating injuries had significantly higher American Association for the Surgery of Trauma grades and higher rates of nephrectomy. In multivariable analysis, only renal injury grade and penetrating mechanism of injury were significantly associated with undergoing nephrectomy. CONCLUSION Expectant and conservative management is currently utilized in 80% of HGRT; however, the rate of nephrectomy remains high. Clinical factors, such as surrogates of hemodynamic instability and metabolic acidosis, are associated with nephrectomy for HGRT; however, higher renal injury grade and penetrating trauma remain the strongest associations. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III; Therapeutic study, level IV.

PD63-02 COMPLIANCE WITH AUA GUIDELINES WITH EXCRETORY PHASE IMAGING FOR EVALUATION OF HIGH-GRADE RENAL TRAUMA: RESULTS FROM THE AMERICAN ASSOCIATION FOR SURGERY OF TRAUMA (AAST) GENITOURINARY TRAUMA STUDY

INTRODUCTION AND OBJECTIVES: In our initial review of the Trauma Outcomes and Urogenital Health (TOUGH) cohort, we identified 423 male US service members (SMs) who sustained penile injuries (PI) while deployed in support of Operations Iraqi Freedom and Enduring Freedom (OIF/OEF). Conventional penile reconstruction is challenged by the unique structure and function of the penile tissues. Thus, penile transplantation is being investigated as a potential means for penile replacement after severe PI. We have made the clinical observation that many SMs who sustained severe PI during OIF/OEF presented with complex polytrauma which may have excluded them from enrollment in existing penile transplantation protocols. The objective of this study was to evaluate the injury patterns among members of the TOUGH cohort who sustained PI with a focus on comorbid conditions which may impact candidacy for penile transplantation. METHODS: The previously identified members of the TOUGH cohort who sustained PI were further characterized based on injury severity as well as the presence of comorbid conditions which may impact eligibility for penile transplantation. Severe PI was defined as an Abbreviated Injury Scale severity of 3 or greater (cutaneous avulsion, laceration through glans/cavernosum/urethra, or partial/total penectomy). Five comorbid conditions were identified which may negatively impact penile transplant candidacy: traumatic brain injury (TBI), massive blood transfusion, colorectal injury, pelvic fracture, and extremity amputation(s). SMs with severe PI were stratified by the number of comorbid conditions diagnosed. RESULTS: Among the 423 men with PI identified in the TOUGH cohort, 86 (20.3%) sustained severe PI. SMs with severe PI were largely young (median age: 23) and injured during battle (n1⁄481; 94%) by explosive mechanisms (n1⁄477; 90%) resulting in severe polytrauma (median ISS1⁄429). Comorbid conditions which could impact penile transplantation candidacy were common, including massive transfusion (n1⁄456; 65%), lower extremity amputation(s) (n1⁄455; 64%), TBI (n1⁄434; 40%), colorectal injury (n1⁄429; 34%), and pelvic fracture (n1⁄427; 31%). Overall, 83% of SMs (n1⁄471) had at least one of these conditions and 47% (n1⁄441) had 3. CONCLUSIONS: Severe PI was relatively rare during OIF/OEF. Life-threatening polytrauma was common and nearly all SMs with severe PI had comorbid immunologic, physical, and/or neurologic diagnoses which could disqualify them from penile transplantation given the current restrictions identified in existing transplant protocols. Source of Funding: none; The view(s) expressed herein are those of the author(s) and do not reflect the official policy or position of Brooke Army Medical Center, the U.S. Army Medical Department, the U.S. Army Office of the Surgeon General, the Department of the Army or the Department of Defense or the U.S. Government.

MP79-01 NEPHRECTOMY AFTER HIGH-GRADE RENAL TRAUMA: RESULTS FROM THE AMERICAN ASSOCIATION FOR THE SURGERY OF TRAUMA (AAST) GENITOURINARY TRAUMA STUDY

Health Network. Dr Rupal Gupta, medical editor at Kids Health, Dr Carlos Estrada from Boston Children’s Hospital, and Dr T. Ernesto Figueroa from Nemours/AI duPont Hospital for Children were the facilitators of the chat. The search tags included #khchat and #TesticularTorsion. It lasted one hour, and was joined by 90 people producing 660 tweets and 33,750,157 impressions on this subject. Throughout the chat, various questions were posed by Kids Health that were answered by the facilitators to provide information and generate discussion. CONCLUSIONS: Social media provides an outlet to discuss significant healthcare topics and serves as a unique way to reach a younger audience. Tweet chats in particular are a successful way in pediatric urology to promote awareness of important topics.

Comparison of direct site endovascular repair utilizing expandable polytetrafluoroethylene stent grafts versus standard vascular shunts in a porcine (Sus scrofa) model

INTRODUCTION The small diameter of temporary vascular shunts for vascular trauma management may restrict flow and result in ischemia or early thrombosis. We have previously reported a clinical experience with direct, open surgical reconstruction using expandable polytetrafluoroethylene stent grafts to create a “sutureless” anastomosis as an alternative to standard temporary vascular shunts. We sought to characterize patency and flow characteristics of these grafts compared with standard shunts in a survival model of porcine vascular injury. METHODS Twelve Yorkshire-cross swine received a 2-cm-long near-circumferential defect in the bilateral iliac arteries. A 14 Fr Argyle shunt was inserted into one randomly assigned artery, with a self-expanding expandable polytetrafluoroethylene stent deployed in the other. At 72 hours, conduit patency was evaluated by angiography. Arterial flow measurements were obtained at baseline, immediately after intervention, and after 72 hours via direct measurement with perivascular flow meters. Blood pressure proximal and distal to the conduits and arterial samples for histopathology were obtained during the terminal procedure. RESULTS Angiography revealed no difference in patency at 72 hours (p = 1.0). While there was no difference in baseline arterial flow between arteries (p = 0.63), the stent grafts demonstrated significantly improved blood flow compared with shunts both immediately after intervention (390 ± 36 mL/min vs. 265 ± 25 mL/min, p = 0.002) and at 72 hours (261 ± 29 mL/min vs. 170 ± 36 mL/min, p = 0.005). The pressure gradient across the shunts was greater than that of the stent grafts (11.5 mm Hg [interquartile range, 3–19 mm Hg] vs. 3 mm Hg [interquartile range, 3–5 mm Hg], p = 0.013). The speed of deployment was similar between the two devices. CONCLUSIONS Open “sutureless” direct site repair using commercially available stent grafts to treat vascular injury is a technically feasible strategy for damage control management of peripheral vascular injury and offers increased blood flow when compared with temporary shunts. Furthermore, stent grafts may offer improved durability to extend the window until definitive vascular repair. The combination of these traits may improve outcomes after vascular injury. LEVEL OF EVIDENCE Epidemiologic/Prognostic, level III.

A novel flight surgeon training model at a joint military and civilian surgical residency program

BACKGROUND Graduating military preliminary interns are often required to fill flight surgeon billets. General surgery preliminary interns get experience evaluating surgical and trauma patients, but receive very little training in primary care and flight medicine. At a joint military and civilian training program, we developed a supplemental curriculum to help transition our interns into flight medicine. METHODS From 2013 to 2016, we developed a lecture series focused on aerospace medicine, primary care, and specialty topics including dermatology, ophthalmology, orthopedics, pediatrics, psychiatry, and womens health. During the 2016 iteration attended by 10 interns, pre- and post-participation 10-item Likert scale surveys were administered. Questions focused on perceived preparedness for primary care role and overall enthusiasm for flight medicine. Open-ended surveys from 2013 to 2016 were also used to gauge the effect of the curriculum. RESULTS The composite number of agreement responses (indicating increased comfort with presented material) increased 63% after course completion. Disagreement responses and neutral responses decreased 78% and 30%, respectively. Open-ended surveys from 14 participants showed an overall positive impression of the curriculum with all indicating it aided their transition to flight medicine. CONCLUSIONS Survey responses indicate an overall perceived benefit from participation in the curriculum with more confidence in primary care topics and improved transition to a flight medicine tour. This model for supplemental aerospace medicine and primary care didactics should be integrated into any residency program responsible for training military preliminary interns who may serve as flight surgeons.