Geoffrey R. Nuss

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).

Are patients with hematuria appropriately referred to Urology? A multi-institutional questionnaire based survey.

INTRODUCTION Hematuria is a common finding that may be a sign of serious underlying urologic disease. Thus, the AUA guidelines (written in conjunction with the American Academy of Family Practice) recommend urologic evaluation for patients with both microscopic and gross hematuria. We sought to evaluate practice patterns of the evaluation of hematuria by primary care physicians (PCPs) in two locations in the United States. METHODS Anonymous questionnaires regarding use of urinalysis (UA) and evaluation of hematuria were mailed to 586 PCPs in Miami, Florida and 1,915 in Dallas, Texas. Surveys were mailed to physicians who identified themselves as practitioners of internal medicine, family practice, primary care, or obstetrics and gynecology. RESULTS Surveys were completed by 788 PCPs including 270 (46%) and 518 (26%) PCPs in Miami and Dallas, respectively. Screening UAs were obtained on all patients by 77% and 64%, of physicians in Miami and Dallas, respectively. In both Miami and Dallas, only 36% of PCPs reported referring patients with microscopic hematuria to an urologist. In patients with gross hematuria, referral rates were 77% and 69% in Miami and Dallas, respectively. CONCLUSIONS While many PCPs use UA in many of their patients routinely, few PCPs automatically refer their patients with microscopic hematuria to urology and not all patients with gross hematuria are referred. Further investigations regarding why and when patients are referred to urology is warranted. Increasing awareness of the complete and timely evaluation of hematuria may be beneficial in preventing a delay in bladder cancer.

Bladder Cancer Screening in a High Risk Asymptomatic Population Using a Point of Care Urine Based Protein Tumor Marker

PURPOSE We evaluated whether screening high risk asymptomatic individuals with a bladder tumor marker can lead to earlier detection and resultant down staging of bladder cancer. MATERIALS AND METHODS Subjects at high risk for bladder cancer based on age and smoking or occupational status were solicited from 2 well patient clinics from March 2006 to November 2007. NMP22 BladderChek testing was performed on voided urine samples. Those with positive test results underwent office cystoscopy and cytology testing. Participants were contacted for followup at 12 months after study enrollment to evaluate for unrecognized bladder cancer. RESULTS A total of 1,175 men and 327 women underwent BladderChek testing. Mean participant age was 62.5 years (range 46 to 92). Based on 10-year or greater smoking history 1,298 participants were enrolled while 513 were enrolled based on a greater than 15-year high risk occupation for bladder cancer. Positive BladderChek testing was observed in 85 (5.7%) participants and 69 agreed to undergo cystoscopy. Three types of lesions were diagnosed including multifocal, high grade Ta (1); Ta, low grade tumor (1) and marked atypia (1). Followup was available in 1,309 subjects. Mean followup was 12 months (range 0.9 to 25.5) and 2 of 1,309 participants had low grade noninvasive bladder cancer. Evaluation of patient records revealed that 73.4% of participants had urinalysis within 3 years before screening. CONCLUSIONS NMP22 BladderChek for screening an asymptomatic, high risk population can detect noninvasive cancers but the low prevalence of bladder cancer in this population did not permit assessment of intervention efficacy. Frequent use of urinalyses in high risk persons may attenuate future efforts to study the effects of bladder cancer screening tests.

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.

The Screening for Occult Renal Disease (SCORED) value is associated with a higher risk for having or developing chronic kidney disease in patients treated for small, unilateral renal masses

Patients with renal masses are at risk for having or developing chronic kidney disease (CKD) stage 3 (glomerular filtration rate [GFR] <60 mL per minute/1.73 m2). In this study, the authors investigated whether the Screening for Occult Renal Disease (SCORED) model could identify patients with renal masses who were at risk for having or developing CKD.

Management of elderly patients with urothelial carcinoma of the bladder: guideline concordance and predictors of overall survival.

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

197 PROSPECTIVE ANALYSIS OF QUALITY OF LIFE AFTER ANTERIOR URETHROPLASTY

INTRODUCTION AND OBJECTIVES: Urethral stricture disease can negatively impact quality of life (QOL). We conducted a prospective study to determine baseline QOL and the change in QOL in men undergoing anterior urethroplasty for urethral stricture disease. METHODS: All men undergoing anterior urethroplasty by one surgeon at a single institution from 11/06 to 2/10 were offered enrollment. Men were asked to complete the 12-item Short Form Health Survey (SF-12) and the QOL component of the AUA Symptom Index (AUASI) pre-operatively and on all subsequent post-operative visits (1,3,6 and 12 months then yearly). SF-12 physical (PS) and mental scores (MS) were calculated according to the SAS SF-12v2.0 scoring algorithm. AUA SI Quality of Life was scored from a range of 0 (delighted) to 6 (terrible). Preand post-operative QOL scores were compared using two tailed T test. RESULTS: 51 men enrolled in the study, of which 13 (26%) were excluded because their post-operative questionnaires were not completed. Included men had a mean age of 41.8 14 years, stricture length of 4.25 2.31 cm and follow-up time of 136.74 146.44, all statistically similar to excluded men. Stricture locations were penile (n 11) or bulbar (n 27). Penile strictures were repaired in one stage with buccal graft (n 4) or abdominal wall skin (n 1) and in two stages with buccal (n 6). Bulbar repairs were either anastomotic (n 16) or buccal augmented anastomotic repairs (n 11). The overall SF-12 PS (47.44 9.91 v 48.03 11.11; p 0.91) and MS (49.5 12 v 53.2 9.5; p 0.15) scores did not change significantly post-operatively at a mean follow-up time of 4.56 months (Table 1), regardless of repair type or location. However, in all subgroups, significant improvements were measured on the AUA-SS QOL question (4.3 1.6 v 1.2 1.2). CONCLUSIONS: Significant improvements in overall quality of life were not appreciated in this study when assessed by the SF-12. However, urinary QOL, as assessed by the AUA-SI, improved dramatically, indicating that either urinary symptoms do not play a part in overall QOL, or that the SF-12 is not an appropriate tool to measure QOL in men undergoing anterior urethroplasty for urethral stricture disease.

1 HOW DO MEN PRESENT WITH URETHRAL STRICTURE DISEASE? THE CASE FOR A DISEASE SPECIFIC INSTRUMENT TO MEASURE OUTCOMES

INTRODUCTION AND OBJECTIVES: Available questionnaires evaluating lower urinary tract symptoms, such as the American Urological Association symptom index (AUASI) are not specific to urethral stricture disease (USD) and may not capture the spectrum of complaints of men with USD. Instruments specific to USD may be required for prospective research into outcomes of urethral reconstruction. We evaluated all symptoms of men with USD presenting for urethroplasty, both assessed and not assessed by the AUASI. METHODS: We performed a retrospective review of all patients who underwent urethroplasty by one surgeon at a single institution from 3/2001 to 6/2010. All presenting complaints related to urinary and sexual function were recorded. Obstructive symptoms were defined as weak stream, incomplete emptying, straining, and intermittency. Irritative symptoms were defined as frequency, urgency, and nocturia. Correlation of symptoms with respect to stricture etiology, length, and location was performed. RESULTS: Symptoms from 225 patients based on etiology are shown in table 1. The most common presenting complaints were weak stream (47%) and urinary retention (38%). Some 10% were asymptomatic. Over one-third (35%) presented with symptoms not addressed by the AUA SI; the most common symptoms were spraying (12%) and dysuria (10%). Age and stricture length did not correlate with specific symptoms. Men with penile USD were more likely to complain of spraying of urine stream (17% v 5.4%, p 0.006). Men with lichen sclerosis presented more frequently with obstructive symptoms (81% v 55%, p 0.04), erectile (ED) and/or ejaculatory (EjD) dysfunction (24% v 9.8%, p 0.05), and dysuria (33% vs 27%, p 0.01) but were less likely to present in urinary retention (0% v 20%, p 0.02). Men with strictures related to failed hypospadias repair were more likely to present with EjD or ED (23% v 9.3%, p 0.03) but less likely to present with dysuria (3.3% v 17%, p 0.04). CONCLUSIONS: While the AUA SI captures the most common complaints of men with USD, one-third of patients undergoing urethroplasty did not have symptoms assessed by the AUA SI, especially those related to urinary stream, dysuria, and sexual dysfunction. A validated, disease-specific instrument for USD is necessary to fully measure the symptoms and outcomes of urethral reconstruction.