Hunter Wessells

Evaluation and management of renal injuries: consensus statement of the renal trauma subcommittee

The first in this series of five papers concerns the evaluation and management of renal injuries. The authors of this paper come from four continents and seven countries, and they reviewed all papers on renal injury published between 1966 and April 2002. The results of the authors’ deliberations are present here as a consensus document.

Smoking and erectile dysfunction: evidence based analysis.

PURPOSE We examined available evidence concerning the role of smoking in the development of erectile dysfunction. This task involved a complete review of the smoking literature as it pertained to erectile dysfunction and select endothelial diseases. MATERIALS AND METHODS We comprehensively reviewed the literature, including PubMed and recent abstract proceedings from national meetings relevant to smoking, erectile dysfunction and endothelial diseases. The quality of the evidence was assessed by methods used to develop clinical practice guidelines. Our review involved an objective evaluation of the basic science literature and clinical studies. When necessary, we examined studies of endothelial diseases other than erectile dysfunction because of obvious gaps in the literature. RESULTS There are strong parallels and shared risks among smoking, coronary artery disease, atherosclerosis and erectile dysfunction. Clinical and basic science studies provide strong indirect evidence that smoking may affect penile erection by the impairment of endothelium dependent smooth muscle relaxation. The association of erectile dysfunction with risk factors such as coronary artery disease and hypertension appears to be amplified by cigarette smoking. Smoking may increase the likelihood of moderate or complete erectile dysfunction 2-fold. The prevalence of erectile dysfunction in former smokers was no different from that in individuals who had never smoked, implying that smoking cessation may decrease the risk of erectile dysfunction. Case studies and retrospective series have shown an association of smoking with erectile dysfunction. CONCLUSIONS Available evidence on the association of smoking with erectile dysfunction is not complete insofar as association linking factors are concerned. However, the evidence of such an association is likely due to the consistency of the relationship of smoking and endothelial disease, and the strength of the association of erectile dysfunction with other endothelial diseases.

Sexual Dysfunction in Women With Type 1 Diabetes: Long-term findings from the DCCT/ EDIC study cohort

OBJECTIVE This study aimed to investigate the prevalence and risk factors associated with sexual dysfunction in a well-characterized cohort of women with type 1 diabetes. RESEARCH DESIGN AND METHODS The study was conducted in women enrolled in the long-term Epidemiology of Diabetes Interventions and Complications (EDIC) study, a North American study of men and women with type 1 diabetes. At year 10 of the EDIC study, 652 female participants were invited to complete a validated self-report measure of sexual function, standardized history and physical examinations, laboratory testing, and mood assessment. RESULTS Of the sexually active women with type 1 diabetes in the EDIC study, 35% met criteria for female sexual dysfunction (FSD). Women with FSD reported loss of libido (57%); problems with orgasm (51%), lubrication (47%), and arousal (38%); and pain (21%). Univariate analyses revealed a positive association between FSD and age (P = 0.0041), marital status (P = 0.0016), menopausal status (P = 0.0019), microvasculopathy (P = 0.0092), and depression (P = 0.0022). However, in a multivariate analysis, only depression (P = 0.004) and marital status (P = 0.003) were significant predictors of FSD. CONCLUSIONS FSD is common in women with type 1 diabetes and affects all aspects of sexual function and satisfaction. Depression is the major predictor of sexual dysfunction in women with type 1 diabetes. These findings suggest that women with type 1 diabetes should be routinely queried about the presence of sexual dysfunction and possible co-association with depression.

Renal injury and operative management in the United States: results of a population-based study.

BACKGROUND To evaluate the extent to which nonoperative renal trauma management has been adopted, we determined the incidence of renal injury and the rate of operative management across the United States. METHODS International Classification of Diseases, Ninth Revision diagnosis and procedure codes identified patients with renal injuries in an 18-state administrative database representing 62% of the U.S. population. RESULTS Of 523,870 patients hospitalized for trauma in 1997 or 1998, 6,231 (1.2%) had renal injuries (4.89 per 100,000 population). Sixty-four percent of patients with injuries that were classified had contusions/hematomas, 26.3% had lacerations, 5.3% had parenchymal disruption, and 4% had vascular injuries. Eleven percent of renal trauma patients required surgical management of their kidney injuries, of whom 61%, or 7% of patients with renal injuries overall, underwent nephrectomy. Injury Severity Score, mechanism, and renal injury severity were independent predictors of nephrectomy. CONCLUSION The nephrectomy rate in community and academic centers reflects renal and global injury severity. Prospective trials are indicated to determine whether, in the traumatized patient with severe kidney injury, renal preservation could lead to improved outcomes compared with nephrectomy.

Pilot study of changes in stretched penile length 3 months after radical retropubic prostatectomy

OBJECTIVES To evaluate changes in stretched penile length after radical retropubic prostatectomy (RRP) in a prospective penile measurement study because an occasional complaint from patients after RRP is that their penis is shortened. METHODS Thirty-one patients undergoing RRP by one surgeon were enrolled. The same physician completed measurements with a paper ruler to the nearest 0.5 cm. The stretched penile length was measured from the tip of the glans to the pubopenile skin junction. The measurements were taken in the preoperative holding area before the patient received anesthetic medication for the RRP and again 3 months postoperatively. The reliability and reproducibility of this measurement were confirmed. RESULTS All 31 patients were measured at 3 months postoperatively. Of the 31 patients, 22 (71%) had a decrease in stretched penile length (range 0.5 to 4.0 cm). Seven were shortened 0.5 cm, 11 were shortened 1.0 to 2.0 cm, and 4 were shortened more than 2.0 cm. Five patients had no change, and in four the penile length was longer (range 0.5 to 1.0 cm). CONCLUSIONS The results of this pilot study appear to show that the stretched penile length decreases after RRP at 3 months of follow-up in most men; 48% (15 of 31) had considerable shortening greater than 1.0 cm. If confirmed by other investigators, the cause of this change needs to be elucidated.

Fournier’s Gangrene: Population Based Epidemiology and Outcomes

PURPOSE Case series have shown a Fourniers gangrene mortality rate of 20% to 40% with an incidence of as high as 88% in some studies. Because to our knowledge there are no population based data, we used a national database to investigate the epidemiology of Fourniers gangrene. MATERIALS AND METHODS We used the State Inpatient Databases, the largest hospital based database available in the United States, which includes 100% of hospital discharges from participating states. Inpatients diagnosed with Fourniers gangrene (ICD-9 CM 608.83) who underwent genital/perineal débridement or died in the hospital were identified from 13 participating states in 2001 and from 21 in 2004. Population based incidence, regional trends and case fatality rates were estimated. RESULTS We identified 1,641 males and 39 females with Fourniers gangrene. Cases represented less than 0.02% of hospital admissions. The overall incidence was 1.6/100,000 males, which peaked in males who were 50 to 79 years old (3.3/100,000) with the highest rate in the South (1.9/100,000). The overall case fatality rate was 7.5%. Patients with Fourniers gangrene were rarely treated at hospitals (mean +/- SD 0.6 +/- 1.2 per year, median 0, range 0 to 23). Overall 0 to 4 and 5 or greater cases were treated at 66%, 17%, 10%, 4%, 1% and 1% of hospitals, respectively. CONCLUSIONS Patients with Fourniers gangrene are rarely treated at most hospitals. The population based mortality rate of 7.5% was substantially lower than that reported in case series from tertiary care centers.

Incidence and severity of sexual adverse experiences in finasteride and placebo-treated men with benign prostatic hyperplasia.

OBJECTIVES To evaluate the incidence and resolution of sexual adverse experiences (AEs) in men with benign prostatic hyperplasia treated with finasteride 5 mg compared with placebo. METHODS The Proscar Long-term Efficacy and Safety Study (PLESS) was a 4-year, randomized, double-blind, placebo-controlled trial assessing the efficacy and safety of finasteride 5 mg in 3040 men, aged 45 to 78 years, with symptomatic benign prostatic hyperplasia, enlarged prostates, and no evidence of prostate cancer. Patients completed a questionnaire at screening regarding their history of sexual dysfunction. During treatment, spontaneously self-reported sexual AEs were recorded. RESULTS At screening, 46% of patients in each treatment group reported some history of sexual dysfunction. During year 1 of the study, 15% of finasteride-treated patients and 7% of placebo-treated patients had sexual AEs that were considered drug related by the investigator (P <0.001). During years 2 to 4, no between-group difference was noted in the incidence of new sexual AEs (7% in each group). The drug-related sexual AE profile for finasteride was similar for men with or without a history of sexual dysfunction. Sexual AEs resolved while continuing therapy in 12% of finasteride patients and 19% of placebo patients. Only 4% of finasteride and 2% of placebo patients discontinued the study because of sexual AEs. In men who discontinued with a sexual AE, 50% and 41% experienced resolution of their sexual AE after discontinuing finasteride or placebo therapy, respectively. CONCLUSIONS Compared with placebo, men treated with finasteride experienced new drug-related sexual AEs with an increased incidence only during the first year of therapy.

Renal and Extrarenal Predictors of Nephrectomy from the National Trauma Data Bank

PURPOSE The kidney is injured in 1.4% to 3.0% of all trauma cases. The management of renal injuries is controversial, as reflected in regional and institutional variations in treatment preferences. Using a national trauma database we identified independent risk factors for nephrectomy. MATERIALS AND METHODS The population was selected from the National Trauma Data Bank, a voluntary data repository containing all trauma admissions to 268 participating trauma centers. Patients with renal injuries were identified by Abbreviated Injury Scale codes. Patient demographic, associated injuries and facility characteristics were recorded. Univariate and Poisson regression analysis with clustering by facility was performed. RESULTS Renal injury was present in 8,465 patients. Nephrectomy was performed in 4% of all blunt and 21% of all cases of penetrating renal injuries. Only 0.5% of blunt renal injury cases underwent repair compared with 15% of those of penetrating injuries. On multivariate analysis renal injury severity was the strongest predictor of nephrectomy. The relative risk of nephrectomy for grade V renal injuries was 146 (95% CI 74 to 289) and 33 (95% CI 13 to 89) in the blunt and penetrating models, respectively. The need for laparotomy and surgery on other intra-abdominal organs predicted nephrectomy in patients with blunt and penetrating injuries. Hospital trauma designation did not statistically impact nephrectomy rates. CONCLUSIONS The severity of renal injury based on the AAST organ injury scale for Renal Trauma is the strongest risk factor for nephrectomy. The need for surgery on other intra-abdominal injuries increases the risk of nephrectomy to a lesser extent. In cases of blunt trauma severe renal injury usually necessitates nephrectomy.

Reduced NO-cGMP Signaling Contributes to Vascular Inflammation and Insulin Resistance Induced by High-Fat Feeding

Objective—Diet-induced obesity (DIO) in mice causes vascular inflammation and insulin resistance that are accompanied by decreased endothelial-derived NO production. We sought to determine whether reduced NO-cGMP signaling contributes to the deleterious effects of DIO on the vasculature and, if so, whether these effects can be blocked by increased vascular NO-cGMP signaling. Methods and Results—By using an established endothelial cell culture model of insulin resistance, exposure to palmitate, 100 &mgr;mol/L, for 3 hours induced both cellular inflammation (activation of IKK&bgr;–nuclear factor-&kgr;B) and impaired insulin signaling via the insulin receptor substrate–phosphatidylinositol 3-kinase pathway. Sensitivity to palmitate-induced endothelial inflammation and insulin resistance was increased when NO signaling was reduced using an endothelial NO synthase inhibitor, whereas endothelial responses to palmitate were blocked by pretreatment with either an NO donor or a cGMP analogue. To investigate whether endogenous NO-cGMP signaling protects against vascular responses to nutrient excess in vivo, adult male mice lacking endothelial NO synthase were studied. As predicted, both vascular inflammation (phosphorylated I&kgr;B&agr; and intercellular adhesion molecule levels) and insulin resistance (phosphorylated Akt [pAkt] and phosphorylated eNOS [peNOS] levels) were increased in endothelial NO synthase−/− (eNOS−/−) mice, reminiscent of the effect of DIO in wild-type controls. Next, we asked whether the vascular response to DIO in wild-type mice can be reversed by a pharmacological increase of cGMP signaling. C57BL6 mice were either fed a high-fat diet or remained on a low-fat diet for 8 weeks. During the final 2 weeks of the study, mice on each diet received either placebo or the phosphodiesterase-5 inhibitor sildenafil, 10 mg/kg per day orally. In high-fat diet–fed mice, vascular inflammation and insulin resistance were completely prevented by sildenafil administration at a dose that had no effect in mice fed the low-fat diet. Conclusion—Reduced signaling via the NO-cGMP pathway is a mediator of vascular inflammation and insulin resistance during overnutrition induced by high-fat feeding. Therefore, phosphodiesterase-5, soluble guanylyl cyclase, and other molecules in the NO-cGMP pathway (eg, protein kinase G) constitute potential targets for the treatment of vascular dysfunction in the setting of obesity.

Analysis of Diagnostic Angiography and Angioembolization in the Acute Management of Renal Trauma Using a National Data Set

PURPOSE To our knowledge data on diagnostic angiography and angioembolization after renal trauma have been limited to single institution series with small numbers. We used the National Trauma Data Bank® to investigate national patterns of diagnostic angiography and angioembolization after blunt and penetrating renal trauma. MATERIALS AND METHODS All renal injuries treated between 2002 and 2007 were identified in the National Trauma Data Bank by Abbreviated Injury Scale codes and converted to American Association for the Surgery of Trauma renal injury grades. Diagnostic angiography and angioembolization were identified by ICD-9 codes and examined. Initial angioembolization was considered a failure if subsequent therapy was needed. Repeat diagnostic angiography was not considered a failure. RESULTS A total of 9,002 renal injuries were available for analysis. A total of 165 patients (2%) underwent diagnostic angiography after renal injury, including 77 (47%) who underwent concomitant angioembolization. Of the patients 78% sustained grade III-V renal injuries. Of the 77 patients with initial angioembolization 68 required successive therapy. Repeat angioembolization was the most common management choice (29% of patients). Secondary angioembolization was durable during the index hospitalization with success in 35 of 36 cases. Successive therapy was required after initial angioembolization for all grade IV and V renal injuries in 48 patients. The overall renal salvage rate was 92%, including 88% for grade IV and V injuries. CONCLUSIONS Successive therapy is common after initial management of renal injury by angioembolization. Close observation is highly recommended after initial angioembolization for grade IV-V renal injuries. National agreement on the use of diagnostic angiography and angioembolization is needed since these procedures may be overused after grade I-III renal injuries.