Nenad Djakovic

Review of the Current Management of Upper Urinary Tract Injuries by the EAU Trauma Guidelines Panel

CONTEXTnThe most recent European Association of Urology (EAU) guidelines on urological trauma were published in 2014.nnnOBJECTIVEnTo present a summary of the 2014 version of the EAU guidelines on upper urinary tract injuries with the emphasis upon diagnosis and treatment.nnnEVIDENCE ACQUISITIONnThe EAU trauma guidelines panel reviewed literature by a Medline search on upper urinary tract injuries; publication dates up to December 2013 were accepted. The focus was on newer publications and reviews, although older key references could be included.nnnEVIDENCE SYNTHESISnA full version of the guidelines is available in print and online. Blunt trauma is the main cause of renal injuries. The preferred diagnostic modality of renal trauma is computed tomography (CT) scan. Conservative management is the best approach in stable patients. Angiography and selective embolisation are the first-line treatments. Surgical exploration is primarily for the control of haemorrhage (which may necessitate nephrectomy) and renal salvage. Urinary extravasation is managed with endourologic or percutaneous techniques. Complications may require additional imaging or interventions. Follow-up is focused on renal function and blood pressure. Penetrating trauma is the main cause of noniatrogenic ureteral injuries. The diagnosis is often made by CT scanning or at laparotomy, and the mainstay of treatment is open repair. The type of repair depends upon the severity and location of the injury.nnnCONCLUSIONSnRenal injuries are best managed conservatively or with minimally invasive techniques. Preservation of renal units is feasible in most cases. This review, performed by the EAU trauma guidelines panel, summarises the current management of upper urinary tract injuries.nnnPATIENT SUMMARYnPatients with trauma benefit from being accurately diagnosed and treated appropriately, according to the nature and severity of their injury.

A NEW APPROACH TO THE TREATMENT OF PENILE CURVATURE

PURPOSEnTechniques for penile straightening generate the serious dilemma of which is most appropriate. We created and describe our penile disassembly technique to avoid penile shortening in curvature repair.nnnMATERIALS AND METHODSnFrom November 1995 to March 1997 we performed our penile disassembly technique in 87 patients 12 months to 47 years old (mean age 4.5 years). Indications for surgery were isolated penile curvature and chordee with or without hypospadias, curvature of the distal third of the corpora cavernosa and a small penis with curvature. Our method consists of separation of the penis into its entities, a glans cap with its neurovascular bundle dorsally, a nondivided or divided urethra, or urethral plate ventrally and corpora cavernosa that may be partially separated in the septal region. This maneuver achieves excellent correction of penile curvature. In addition, during this procedure a space is created between the glans cap and the tips of the corpora cavernosa into which various tissues may be inserted to avoid penile shortening due to corporoplasty or even to lengthen the penis.nnnRESULTSnMean followup was 16 months (range 6 months to 2 years). There were no injuries to the neurovascular bundle or urethra. Complications developed only in relation to onlay or tubularized urethroplasty in 4 patients.nnnCONCLUSIONSnOur penile disassembly technique seems to be the most effective procedure in select cases of severe curvature of the distal penile shaft, marked glans tilt and a small penis with curvature. In addition, the procedure provides the possibility of penile lengthening.

PENILE DISASSEMBLY TECHNIQUE FOR EPISPADIAS REPAIR: VARIANTS OF TECHNIQUE

PURPOSEnWe present 2 variants of the penile disassembly technique for epispadias repair that refine some details of the Mitchell technique. In some cases the urethral plate retracts and shortens, and there may be poor vascularization at the most distal portion. In addition, when the neurovascular bundles of the separated hemicorporeal glanular bodies are intact, it is difficult to achieve excellent correction of dorsal chordee.nnnMATERIALS AND METHODSnBetween 1995 and 1998 we performed the modified Mitchell technique in 11 boys 2 to 14 years old using 1 of 2 variants. For variant 1 the hemiglans and urethral plate remain connected by a small tissue bridge to avoid shortening the urethral plate and ensure a better blood supply. For variant 2 each corporeal body is dissected from the glans cap and neurovascular bundle to achieve complete mobility. This procedure enables ideal mobility of the corporeal bodies as well as curvature repair. When corporeal rotation was unsuccessful, we corrected persistent dorsal chordee using the Ransley corporotomy with corporostomy in 2 patients and with dermal grafting in 1.nnnRESULTSnMean followup was 17 months (range 6 to 30). Dorsal curvature was corrected in all cases. Cosmetic appearance was good. Complications included meatal stenosis and urethral fistula in 1 case each.nnnCONCLUSIONSnOur variants of epispadias repair may be good alternatives to the Ransley and Mitchell complete penile disassembly techniques.

Penile surgery and reconstruction.

This review will highlight recent advances in the field of penile reconstructive surgery in the paediatric and adult population. It is based on the work published during the year 2001. Besides the anatomical and histological studies of the penis, major contributions have been described in congenital and acquired penile anomalies. Also, a few new techniques and modifications of old procedures are described in order to improve the final functional and aesthetic outcome. The techniques for penile enlargement present a trend in the new millennium, but are still at the stage of investigation.

Grey Areas: Challenges of Developing Guidelines in Adult Urological Trauma

Urology Department, St George’s Healthcare NHS Trust, London, UK; Department of Urology, Asklipieion General Hospital, Athens, Greece; Department of Urology, University Hospital Groeninge, Kortrijk, Belgium; Department of Urology, Muhldorf General Hospital, Muhldorf am Inn, Germany; Department of Radiology, St George’s Healthcare NHS Trust, London, UK; f London Andrology Institute, London, UK; Department of Urology, Ghent University Hospital, Ghent, Belgium; Department of Urology, Chaim Sheba Medical Centre, Tel-Hashomer, Israel; Department of Urology, University Hospitals of Leicester NHS Trust, Leicester, UK E U R O P E A N U R O L O G Y F O C U S X X X ( 2 0 1 5 ) X X X – X X X

INLAY-ONLAY URETHROPLASTY IN SEVERE HYPOSPADIAS

INTRODUCTION AND OBJECTIVES: Scrotal Agenesis is an extremely rare anomaly with only a handful of case reports in the literature. METHODS: We present a patient with an UPJ obstruction, absence of the scrotum and undescended testicles that was noted during extensive workup for Genitopatellar syndrome. Genitopatellar syndrome encompasses a multitude of abnormalities, including: absent patella, imperforate anus, agenesis of the corpus callosum, hydronephrosis, and scrotal hypoplasia. RESULTS: The patient was followed until 6 months of age when adequate penile skin was available for repair. He was then taken back to the operating room for a complex scrotoplasty. After degloving the penis, a ventral penile U-shaped flap and a dorsal buttonhole pedicle were used for a neo scrotum. We elected to stage the procedure, with the 2nd stage entailing bilateral orchiopexy. CONCLUSIONS: We believe this video provides a unique learning opportunity to better understand the important steps in this very rare anomaly.