Nathan Hale

Mechanistic Relationship of All-terrain Vehicles and Pediatric Renal Trauma

OBJECTIVE To identify and discuss the mechanistic risk factors associated with genitourinary (GU) trauma in pediatric all-terrain vehicle (ATV) accidents. MATERIALS AND METHODS A retrospective analysis of all pediatric trauma admissions to a level 1 trauma center from 2005 to August 2011 was performed. We identified all pediatric patients who presented with GU trauma related to an ATV accident. The demographics, injury data, mechanism of injury, and treatment records of these children were investigated. RESULTS A total of 304 pediatric patients were admitted with ATV-related injuries during the study period. Of these 304 patients, 10 (3.2%) had experienced GU injuries. An analysis of the mechanism revealed that 9 of the 10 had been thrown from the ATV; 1 event was described as a rollover accident. All 10 patients sustained renal trauma: 9 renal lacerations of various grades and 1 renal pedicle injury. Hematuria was observed in all cases. Spleen and liver lacerations were commonly associated injuries (40% and 30%, respectively). CONCLUSION Pediatric ATV-related GU injuries remain an uncommon, yet serious, problem. Renal trauma is the most commonly encountered GU injury and can be suspected by the presence of hematuria. Analysis of the mechanism of injury suggests that ejection from the ATV places pediatric patients at the greatest risk of renal injury. Additional research is recommended concerning the mechanistic relationship of ATV-related GU trauma.

Mid-ureteral rupture: a rare complication of urethral catheterization.

To our knowledge, there are only a few published cases of ureteral injuries secondary to urethral catheterization. We present a case of a ureteral rupture that occurred by placement of a standard 16-Fr urethral catheter. The ureteral injury was identified by computed tomography of the abdomen and pelvis and managed with ureteroureteral anastamosis.

Primary Care Evaluation and Treatment of Men With Lower Urinary Tract Symptoms

Lower urinary tract symptoms (LUTS) affect 50% to 90% of men aged 50 years or older. Primary care physicians should be knowledgeable about the diagnosis and management of this condition. The authors performed detailed PubMed searches using the terms lower urinary tract symptoms, benign prostatic hyperplasia, benign prostatic enlargement, and overactive bladder. The authors then reviewed the relevant literature on the evaluation and treatment of men with LUTS. According to the literature, accurate recognition of LUTS is predicated on a focused history and physical examination, as well as serum prostate-specific antigen measurement and urinalysis. For patients with mild symptoms, watchful waiting with ongoing monitoring and lifestyle modifications may be appropriate. For patients with moderate to severe symptoms, pharmacologic therapy is effective. When substantial LUTS persist despite appropriate pharmacologic therapy, specialty urologic evaluation and treatment is warranted.

Excessive Opioid Prescribing After Major Urologic Procedures

OBJECTIVE To examine the use of prescription opioids in patients undergoing major prostate and kidney operations. METHODS This is a prospective observational study that includes opioid naïve patients who underwent a major prostate or kidney operation from January 2017-May 2017. A telephone survey was conducted 3-4 weeks postoperatively. The survey assessed the number of 5 mg oxycodone-equivalents prescribed, opioid use, and disposal. RESULTS A total of 155 patients were included in our analysis. Most patients were male (86%), most were married (74%), the median was age 64 (interquartile range 59-70), and the majority were Caucasian (84%). Most patients reported social alcohol use (56%), but most denied current tobacco use (77%) or current and/or previous drug use (76%). Opioid prescribing exceeded use from 1.9- to 6.8-fold for all procedural categories. Overall, a total of 4065 oxycodone-equivalents were prescribed during this study and 60% of pills prescribed went unused. This resulted in 2622 excess pills in the community. CONCLUSION Opioids are prescribed far in excess of need following major open and minimally invasive urologic procedures. Overall, 60% of prescribed opioids were unused. These data provide initial benchmarks for appropriate opioid prescribing after major prostate and kidney procedures. Future work to validate this initial guideline and improve patient counseling regarding appropriate perioperative opioid use and disposal is needed.

Nephroblastoma Arising in a Primary Testicular Teratoma in a Nonatrophic Testis of a 50-Year-Old Man

Extrarenal nephroblastoma is an extremely rare tumor thought to be related to teratoid tumors of germ cell origin. Because few cases have been reported, no standard method for categorizing and managing these tumors exists. To our knowledge, there have only been 3 adult cases of nephroblastoma arising in a germ cell tumor of testicular origin in a nonatrophic testis, all in men aged 19 to 22 years and with aggressive clinical courses. We report a case of nephroblastoma in a nonatrophic testis, with nephroblastoma being the only non-germ cell component, in an older patient and with a more indolent clinical course that was responsive to localized treatment.

Inguinal Herniation of Perinephric Tissue: Case Report and Review of the Literature

Inguinal hernias containing a kidney or perinephric tissue are extremely rare and usually related to cases involving a kidney positioned in the pelvis. We report the case of a 79-year-old man who presented with abdominal pain and scrotal swelling. He was found on imaging to have an inferiorly displaced kidney with an inguinal herniation of Gerota fascia, as well as an obstructing ureteral stone with an associated forniceal rupture. The unusual renal anatomy, as well as the management of a forniceal rupture, is discussed.

MP96-07 PATIENT TRAVEL DISTANCES TO HIGH-VOLUME CYSTECTOMY CENTERS FOLLOW A COMPLEX RELATIONSHIP

INTRODUCTION AND OBJECTIVES: Regionalization of cystectomy has been associated with improved outcomes but it may exacerbate geographic disparity by increasing travel distance. We sought to examine the association between travel distance to a highvolume cystectomy center and the probability of receiving a cystectomy among patients with muscle-invasive bladder cancer. METHODS: Using Surveillance, Epidemiology, and End Results (SEER)-Medicare data, we identified patients diagnosed with non-metastatic muscle-invasive bladder cancer between 2004 and 2011. We further identified patient treatment (i.e, cystectomy, bladdersparing alternative) using the inpatient, outpatient, and carrier files. Patients were then grouped into quartiles according to travel distance to the nearest high-volume cystectomy center (<1⁄48, 9-22, 23-53, and >53 miles). High-volume cystectomy centers included those with cystectomy volumes in the top quartile. The relationship between distance to a high-volume cystectomy center and treatment was assessed using a multivariable logistic regression model, adjusting for age, sex, race, comorbidity, marital status, county population, education level and median household income in ZIP code of residence, grade, and stage. RESULTS: Among 5149 patients with non-metastatic muscleinvasive bladder cancer, 1998 (39%) underwent a radical cystectomy. The adjusted probability of receiving a cystectomy according to travel distance to a high-volume cystectomy center is summarized in Figure 1. Compared to patients with a travel distance of 8 miles or less, those with a travel distance of 9-22 miles were less likely to receive a cystectomy (adjusted OR 0.79, 95% CI 0.66-0.96). However, this difference was mitigated in those with travel distances beyond 22 miles CONCLUSIONS: Our findings demonstrated a complex relationship between travel distances to a high-volume cystectomy center and the probability of receiving a radical cystectomy. While increasing distance decreased the likelihood of receiving a cystectomy for patients that live easily commutable distance, this disparity dissipated once the travel distance increased beyond 22 miles.

Primary Melanoma of the Urinary Tract

© 2015 American Osteopathic Association An 83-year-old woman with a painful distal urethral mass presented to the urology department. Results of a cystoscopy revealed a 4-cm dark pigmented lesion in the bladder (image A). The patient was evaluated for a primary skin lesion or other primary malignancies, which was found to be negative. She underwent distal urethrectomy and transurethral resection of the bladder tumor, and HMB-45 and S-100 staining revealed melanoma of the urinary tract (image B). After this diagnosis, the patient underwent bladder preservation therapy with external beam radiation and close surveillance. This treatment delayed disease progression for 20 months, at which point the patient developed metastatic disease and elected to receive hospice care. Primary melanoma originating from the urinary tract is an extremely rare occurrence and Primary Melanoma of the Urinary Tract

Pelvic Hematoma With Suprapubic Distention

A 71-year-old woman was evaluated for abnormal urination, which occurred 2 weeks after left hip arthroplasty. Abdominal examination revealed suprapubic distention despite urethral catheterization with an 18F Foley catheter. Initially, a computed tomographic scan of the pelvis without intravenous contrast material indicated a grossly distended urinary bladder (image A, arrow). Hand irrigation of the Foley catheter was unable to resolve the suprapubic distention with minimal production of urine. A normal bladder without extravasation was appreciated with cystoscopy but incompletely filled during irrigation. A cystogram (image B) revealed a 15-cm pelvic hematoma (arrow) with compression of the bladder (star). Percutaneous drain was placed for the hematoma, and the patient was discharged to home 3 days later in stable condition. Kluger et al1 and Abdulwahab et al2 describe similar instances of urinary obstruction from pelvic hematomas. Physicians should consider pelvic hematomas in the differential diagnosis when treating patients with pelvic fractures. (doi:10.7556 /jaoa.2013.073)