Jack W. McAninch

Organ injury scaling: spleen, liver, and kidney.

The Organ Injury Scaling (O.I.S.) Committee of the American Association for the Surgery of Trauma (A.A.S.T.) was appointed by President Trunkey at the 1987 Annual Meeting. The principal charge was to devise injury severity scores for individual organs to facilitate clinical research. The resultant classification scheme is fundamentally an anatomic description, scaled from 1 to 5, representing the least to the most severe injury. A number of similar scales have been developed in the past, but none has been uniformly adopted. In fact, this concept was introduced at the A.A.S.T. in 1979 as the Abdominal Trauma Index (A.T.I.) and has proved useful in several areas of clinical research. The enclosed O.I.S.s for spleen, liver, and kidney represent an amalgamation of previous scales applied for these organs, and a consensus of the O.I.S. Committee as well as the A.A.S.T. Board of Managers. The O.I.S. differs from the Abbreviated Injury Score (A.I.S.), which is also based on an anatomic scale but designed to reflect the impact of a specific organ injury on ultimate patient outcome. The individual A.I.S.s are, of course, the basic elements used to calculate the Injury Severity Score (I.S.S.) as well as T.R.I.S.S. methodology. To ensure that the O.I.S. interdiffuses with the A.I.S. and I.C.D.-9 codes, these are listed alongside the respective O.I.S. Both the currently used A.I.S. 85 and proposed A.I.S. 90 are provided because of the obligatory transition period. Indeed, A.I.S. 90 contains the identical descriptive text as the current O.I.S.s. The Abdominal Trauma Index and other similar indices using organ injury scoring can be easily modified by replacing older scores with the O.I.S.s.(ABSTRACT TRUNCATED AT 250 WORDS)

Organ injury scaling, II: Pancreas, duodenum, small bowel, colon, and rectum.

The Organ Injury Scaling (O.I.S.) Committee of the American Association for the Surgery of Trauma (A.A.S.T.) has been charged to devise injury severity scores for individual organs to facilitate clinical research. Our first report (1) addressed O.I.S.s for the Spleen, Liver, and Kidney; the following are proposed O.I.S.s for Pancreas (Table I), Duodenum (Table II), Small Bowel (Table III), Colon (Table IV), and Rectum (Table V). The grading scheme is fundamentally an anatomic description, scaled from 1 to 5, representing the least to the most severe injury. We emphasize that these O.I.S.s represent an initial classification system which must undergo continued refinement as clinical experience dictates.

Penile length in the flaccid and erect states: guidelines for penile augmentation.

PURPOSE We provide guidelines of penile length and circumference to assist in counseling patients considering penile augmentation. MATERIALS AND METHODS We prospectively measured flaccid and erect penile dimensions in 80 physically normal men before and after pharmacological erection. RESULTS Mean flaccid length was 8.8 cm., stretched length 12.4 cm. and erect length 12.9 cm. Neither patient age nor size of the flaccid penis accurately predicted erectile length. Stretched length most closely correlated with erect length. CONCLUSIONS Only men with a flaccid length of less than 4 cm., or a stretched or erect length of less than 7.5 cm. should be considered candidates for penile lengthening.

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.

Consensus statement on bladder injuries

The consensus on genitourinary trauma continues this month with the statement on bladder trauma from several internationally recognised experts on the subject. They describe blunt, penetrating and iatrogenic injuries and their management, considering paediatric injuries separately. They underline the importance of prompt diagnosis and treatment, stressing that problems raised when the diagnosis is delayed.

Reconstruction of Posterior Urethral Disruption Injuries: Outcome Analysis in 82 Patients

PURPOSE We sought to identify the long-term success rate of perineal anastomotic reconstruction for posterior urethral disruption. MATERIALS AND METHODS We reviewed the records of 82 patients with traumatic prostatomembranous urethral strictures who underwent perineal anastomotic urethroplasty by 1 surgeon. RESULTS Excision of fibrosis with simple perineal anastomosis was performed in 52 patients (63%), while pubectomy was required in 30 (37%) to obtain a tension-free anastomosis. Median followup was longer than 1 year. Potency improved from 46% before reconstruction to 62% postoperatively. Nine patients (11%) required 1 endoscopic urethrotomy after urethroplasty to improve flow rate and this procedure was successful in 8 (88%). In 3 patients (3%) urethroplasty ultimately failed and they remained untreated because of insurmountable co-morbidity. Overall, long-term success was observed in 79 patients (97%). CONCLUSIONS Excellent long-term results can be expected from anastomotic urethroplasty in patients with traumatic posterior urethral strictures. Subsequent urethrotomy, when required, has a high likelihood of success. A significant number of patients regain potency after urethral reconstruction. Persistent impotence probably reflects the severity of pelvic trauma.

Organ Injury Scaling

The Organ Injury Scaling (015) Committee of the American Association for the Surgery of Trauma has developed severity scores for spleen, liver, extrahepatic biliary, pancreas, duodenum, small bowel, colon, rectum, abdominal vascular, diaphragm, kidneys, ureter, bladder, urethra, chest wall, heart, lungs, and thoracic vascular injuries. These OISs are classification schemes based on an anatomic description, scaled from I to VI, representing the least to most severe injury. OISs are designed to facilitate clinical research as well as continuing quality improvement.

Priapism: a refined approach to diagnosis and treatment.

The recent introduction of intracorporeal injections of papaverine and phentolamine for the diagnosis and treatment of impotence has resulted in an increased incidence of iatrogenic priapism. Based on our research into penile hemodynamics we propose a refined approach to all types of priapism. Intracorporeal blood gas and pressure monitoring should be used to differentiate ischemic (low flow) from nonischemic (high flow) types. Most cases of papaverine-induced or phentolamine-induced priapism will respond to aspiration alone or in combination with intracorporeal instillation of a diluted alpha-adrenergic agent. In spontaneous priapism alpha-adrenergic agents can be tried first if patients have only mild or no ischemia. In patients with severe ischemia stagnant blood should be evacuated and a shunt procedure should be performed to allow metabolic replenishment of tissue. Intracorporeal pressure monitoring will help to determine the size and number of shunts needed to re-establish corporeal circulation.

Rupture of the corpus cavernosum: surgical management.

Rupture of the corpus cavernosum is an uncommon injury resulting from a direct blow to the erect penis. The injury is easy to recognize but treatment remains controversial. Our uniform operative plan, consisting of immediate exploration, identification, sharp débridement and primary repair of the tear in the tunica albuginea with absorbable sutures, resulted in preservation of normal penile erection in 7 patients. The hospital stay was brief (mean 3.8 days) and there were no complications. These results compare favorably to operative management as reported in the literature. Conservative management is associated with a 29 per cent complication rate and a mean hospital stay of 14 days. Therefore, early surgical repair of the rupture is advocated.

When and how to use buccal mucosal grafts in adult bulbar urethroplasty

OBJECTIVES To evaluate the efficacy of buccal mucosa in the repair of adult urethral stricture disease, we report our experience with its use as a nontubularized onlay graft during bulbar urethral reconstruction. METHODS From June 1993 to January 1996, 75 men underwent anterior urethral reconstruction for stricture disease. Single-stage urethroplasty with an onlay patch graft of buccal mucosa was performed in 13 patients with complex, refractory strictures of the bulbar urethra. In all cases, a two-team approach was used in which one team harvested the graft from the mouth while the perineal team simultaneously exposed and calibrated the stricture. RESULTS The length of buccal mucosa ranged from 3.5 to 17 cm (average length 6.2). In 8 patients, other reconstructive techniques were used concomitantly, including fasciocutaneous penile flap or stricture excision and primary anastomosis, depending on the length and severity of the scarred area. Median follow-up time was 18 months. Excellent results were obtained in all 13 patients, and none has required urethral dilation or instrumentation subsequently. Operative time was significantly less than with other forms of substitution urethroplasty. CONCLUSIONS Excellent results can be expected when buccal mucosa is used for urethral substitution in men with refractory bulbar strictures. For patients with long or dense strictures, buccal mucosal grafts may easily be combined with other reconstructive techniques. In patients with less complex stricture disease, the reduced operative time of this two-team approach may be beneficial.