Noel A. Armenakas

Diagnosis and management of ureteric injury: an evidence-based analysis

The Consensus on Genitourinary Trauma continues this month with an evidence‐based analysis, by a team of experts under the chairmanship of Dr Jack McAninch, of current reports on the diagnosis and management of ureteric trauma. This is quite a unique document, and of interest to all urologists; not only as a consensus on how this condition should be managed, but also as a model of how to review current publications.

ERECTILE FUNCTION AFTER ANTERIOR URETHROPLASTY

PURPOSE We ascertained the impact of anterior urethroplasty on male sexual function. MATERIALS AND METHODS A validated questionnaire was mailed to 200 men who underwent anterior urethroplasty to evaluate postoperative sexual function. Questions addressed the change in erect penile length and angle, patient satisfaction with erection, preoperative and postoperative coital frequency, and change in erection noted by the sexual partner. Results were stratified by the urethral reconstruction method, namely anastomosis, buccal mucosal graft, penile flap and all others, and compared with those in a similar group of men who underwent circumcision only. RESULTS Of the 200 men who underwent urethroplasty 152 who were 17 to 83 years old (mean age 45.7) completed the questionnaire. Average followup was 36 months (range 3 to 149). Overall there was a similar incidence of sexual problems after urethroplasty and circumcision. Penile skin flap urethroplasty was associated with a slightly higher incidence of impaired sexual function than other procedures (p >0.05). Men with a longer stricture were most likely to report major changes in erectile function and penile length (p <0.05) but improvement was evident with time in 61.8%. CONCLUSIONS Overall anterior urethral reconstruction appears no more likely to cause long-term postoperative sexual dysfunction than circumcision. Men with a long stricture may be at increased risk for transient erectile changes.

Indications for nonoperative management of renal stab wounds

PURPOSE During the last 20 years 2,732 patients have presented to San Francisco General Hospital with renal trauma. Of these patients 198 sustained unilateral and 1 had bilateral stab wounds for a total of 200 renal injuries. We evaluated this subgroup of penetrating renal trauma cases to characterize the nature of the injuries and establish treatment guidelines for successful management. MATERIALS AND METHODS Preoperative staging was performed in 143 cases (71.5%) with excretory urography or computerized tomography. Based on radiographic and clinical findings the injuries were graded according to the organ injury scaling system. There were 75 grade I (37.5%), 33 grade II (16.5%), 52 grade III (26%), 38 grade IV (19%) and 2 grade V (1%) injuries. Associated organ injuries in 122 patients (61%) involved primarily the liver, pleura, diaphragm and spleen. Mean injury severity score was 20.6 (range 4 to 50). RESULTS Nonoperative treatment was selected in 108 patients (54%). In 3 patients initially treated nonoperatively delayed bleeding required surgical intervention. Of the 92 renal units explored 74 were reconstructed (80.4%) and 11 required nephrectomy (12%). The overall renal salvage rate was 94.5%. Complications included infection in 2 and hematoma in 2 patients each. Four patients died of nonurological complications. Followup imaging studies were obtained in 26 reconstructed kidneys (35.1%). None of the 107 patients who were followed demonstrated delayed sequelae of renal injuries or new onset of hypertension. CONCLUSIONS Stab wounds are the most common penetrating trauma to the kidney. More than half of these injuries can be selectively treated nonoperatively. Management criteria are based on aggressive radiographic, laboratory, clinical and when indicated surgical staging. Meticulous attention to reconstructive techniques in renal exploration can ensure an excellent renal salvage rate.

The Effect of Finasteride on the Expression of Vascular Endothelial Growth Factor and Microvessel Density: A Possible Mechanism for Decreased Prostatic Bleeding in Treated Patients

PURPOSE Several studies have confirmed the benefit of finasteride in limiting hematuria from benign prostatic hyperplasia. Vascular endothelial growth factor (VEGF), a potent stimulator of angiogenesis, and microvessel density have been independently evaluated in the mechanism of decreased bleeding observed in patients treated with finasteride. We evaluated the expression of VEGF and suburethral prostatic microvessel density in patients with benign prostatic hyperplasia treated with finasteride. MATERIALS AND METHODS The study included 24 patients undergoing prostatic surgery for benign disease, of whom 12 were given finasteride for a minimum of 6 weeks before surgery and the remaining 12 served as controls. Sections from the prostatic urothelium and hyperplastic prostate were individually stained for CD34 specific for nascent blood vessels and VEGF. Analysis of each specimen was performed in a blinded fashion. Microvessel density was calculated by counting the number of positively stained blood vessels on 10 consecutive, nonoverlapping, high power fields within the suburethral and hyperplastic prostate compartments. VEGF expression was examined by immunohistochemistry. Statistical analysis of the results was performed using Students t test. RESULTS Prostatic suburethral VEGF expression and microvessel density were significantly lower in the finasteride group compared to controls (p <0.05). Differences in VEGF expression and microvessel density at the level of the hyperplastic prostate were not found to be significantly different between the 2 groups. CONCLUSIONS Decreased expression of VEGF by finasteride inhibits angiogenesis and significantly decreases microvessel density in prostatic suburethral tissue. This sequential relationship provides histochemical insight into the mechanism by which finasteride reduces prostatic urethral bleeding.

Periprostatic nerve blockade for transrectal ultrasound guided biopsy of the prostate: a randomized, double-blind, placebo controlled study.

PURPOSE We performed a randomized, double-blind, placebo controlled study to assess the safety and efficacy of periprostatic anesthesia administration during prostate biopsy. MATERIALS AND METHODS From May to November 2000 transrectal ultrasound guided prostate biopsy was performed in 132 consecutive men due to an abnormal digital rectal examination and/or elevated prostate specific antigen. During biopsy 66 patients each were randomly assigned to receive an injection of 1% lidocaine or normal saline. Immediately after biopsy the pain score was recorded independently by patients and the physician using a 10-point linear scale. In addition, patients were given a descriptive questionnaire to be completed at home and mailed back within 2 weeks of biopsy. RESULTS Mean patient perceived pain scores plus or minus standard deviation of 2.7 +/- 0.21 in the lidocaine and 4.7 +/- 0.26 in the saline groups were significantly different (p <0.0001), as were mean physician perceived scores of 2.9 +/- 0.27 and 5.1 +/- 0.34, respectively (p = 0.0001). Mean questionnaire scores for pain during biopsy of 2.3 +/- 0.13 in the lidocaine and 3.1 +/- 0.18 in the saline groups were also significantly different (p = 0.0006), as were mean questionnaire scores for pain after biopsy of 1.8 +/- 0.11 and 2.3 +/- 0.13, respectively (p <0.006). There were no adverse effects of injection. CONCLUSIONS Our results show a significant benefit of periprostatic anesthesia over placebo in a randomized double-blind trial. This safe, simple and rapid technique should be applied at transrectal ultrasound guided prostate biopsy to limit undue patient discomfort.

Carcinosarcoma of the prostate

Carcinosarcoma of the prostate is a biphasic tumor containing adenocarcinoma (ACA) and recognizable sarcomatous components. It is a rare neoplasm with only 12 previous reported cases. We describe three additional cases arising between 4 and 6 years after initial diagnosis of prostatic ACA. Two patients were initially treated by prostatectomy, pelvic external beam radiotherapy, and hormonal manipulation. The third patient was treated by pelvic lymphadenectomy and 125I implants. After the development of the sarcomatous component, the first two are still alive with distant metastases and residual pelvic disease at 9 and 17 months. The third patient died with disease 7 months after diagnosis. Histologically, prostatic ACA was recognized in all three cases, as well as a neoplastic mesenchymal component that appeared later. Foci of osteosarcomatous, chondrosarcomatous, and myosarcomatous differentiation were recognized in two of the three cases. Based on the chronologic and the histologic evolution of the neoplasm, we favor sarcomatoid transformation of the ACA as the most likely histogenesis. It appears that radiotherapy and hormonal therapy may be important in the development of at least some of these tumors

RENAL GUNSHOT WOUNDS: METHODS OF SALVAGE AND RECONSTRUCTION

Over the past 14 years, 2079 patients have been seen at our institution with renal trauma. Of these, 84 sustained gunshot wounds (81 unilateral, 3 bilateral; a total of 87 renal units). We evaluated this group to characterize the nature of their injuries and establish a methodology for renal salvage and reconstruction. Preoperative radiographic staging was performed with excretory urography (IVP) or computed tomographic (CT) scanning. The injuries were classified into five categories: 16 contusions (18.4%), 12 minor lacerations (13.8%), 44 major lacerations (50.5%), six vascular injuries (6.9%), and nine combination laceration and vascular injury (10.3%). Most patients had multiple organ injuries, with 79 requiring associated surgical procedures (94%). The mean injury Severity Score (ISS) was 26.7 (range, 4-59). Based on radiographic and clinical staging criteria, 69 renal injuries were surgically explored (79.3%), and 12 patients underwent nephrectomy (13.8%). Forty-six renal units were reconstructed (66.6%) by various methods, including renorrhaphy, omental pedical flaps, mesh or peritoneal patch grafts, partial nephrectomy, and vascular repair. Overall, 75 renal units were salvaged (86.2%). Early renal vascular control was achieved in all patients who underwent renal exploration. Follow-up functional studies were done in 24 (28.5%): none had delayed nephrectomy or postinjury hypertension. Overall, 79 patients survived (94%); however, mortality was not related to renal injury. These findings suggest that aggressive radiographic staging coupled with early vascular control and careful selection of reconstructive techniques can ensure a high renal salvage rate in patients with renal gunshot injuries.

Decreased Suburethral Prostatic Microvessel Density In Finasteride Treated Prostates: A Possible Mechanism For Reduced Bleeding In Benign Prostatic Hyperplasia

PURPOSE We evaluated the influence of finasteride on prostatic microvessel density to elucidate a mechanism of decreased bleeding in finasteride treated patients with hematuria secondary to benign prostatic hyperplasia (BPH). MATERIALS AND METHODS A total of 22 patients with clinical BPH and gross hematuria who underwent prostate reductive surgery between 1998 and 2000 were prospectively evaluated. The prostate from 10 finasteride treated and 12 untreated patients was immunohistochemically stained for CD-34. Microvessel density analysis was performed by quantifying positive stained blood vessels located within the stroma of hyperplastic nodules as well as in the suburethral portion of the prostate. RESULTS Mean microvessel density plus or minus standard deviation in finasteride treated patients was significantly lower in the suburethral portion of the prostate versus untreated controls (14.0 +/- 2.8 versus 20.2 +/- 5.3 vessels per high power field, p <0.05). In the nodular hyperplasia there was no statistically significant difference in the treatment and control groups (mean 17.5 +/- 2.8 and 16.7 +/- 4.6 vessels per high power field, respectively). CONCLUSIONS Finasteride significantly decreases suburethral prostatic microvessel density in patients with BPH, which may explain its efficacy for decreasing BPH associated bleeding.

INDINAVIR UROLITHIASIS: AN EMERGING CAUSE OF RENAL COLIC IN PATIENTS WITH HUMAN IMMUNODEFICIENCY VIRUS

PURPOSE We evaluate the clinical, diagnostic and radiographic findings in patients on indinavir therapy who presented with renal colic, and propose appropriate treatment options for indinavir urolithiasis. MATERIALS AND METHODS A total of 16 patients positive for human immunodeficiency virus on indinavir were evaluated for 18 episodes of severe renal colic requiring hospitalization. Laboratory evaluation was performed in all patients followed by an imaging study. Conservative treatment included intravenous hydration, narcotic analgesics and temporary cessation of indinavir. Intervention was elected only in patients with persistent fever or intractable pain. A month after hospital discharge an excretory urogram and metabolic stone evaluation were performed. Mean followup was 9.3 months and 2 patients had recurrent symptoms. RESULTS All patients presented with nausea or vomiting and hematuria. Imaging studies confirmed obstruction in all patients with 13 radiolucent (indinavir) and 3 radiopaque (calcium oxalate) stones. Patients with radiolucent and radiopaque stones demonstrated significant differences in urinary pH (p = 0.002) and serum creatinine (p = 0.03). Conservative therapy was successful in 11 patients (68.8%) within 48 hours and 4 patients (25%) with radiolucent calculi required endoscopic stenting for persistent fever. Metabolic stone evaluation demonstrated significant hypocitruria (less than 50 mg./24 hours) in all patients with radiolucent calculi. CONCLUSIONS The urologist should be familiar with this growing cause of renal colic in patients on indinavir therapy. Pure indinavir stones are radiolucent and have a soft, gelatinous endoscopic appearance. Conservative treatment is successful in most patients and if intervention is deemed medically necessary, endoscopic stent placement should be the procedure of choice.

Evaluation of asymptomatic microhematuria

OBJECTIVES The purpose of this study was to evaluate a comprehensive urine cytodiagnostic assay to assist in localizing the site of origin and the etiology of asymptomatic microhematuria. This analysis, which assesses various qualitative and quantitative aspects of the voided urine, is compared simultaneously with controls obtained from the established routine urologic evaluation. METHODS One hundred consecutive subjects who presented solely for the evaluation of asymptomatic microhematuria were evaluated by the established routine urologic evaluation and a refined urine cytodiagnostic assay. For the purpose of this study, only calculi and neoplasms were considered significant findings. RESULTS The incidence of significant urologic disease was 13% (3 renal neoplasms, 2 urothelial bladder carcinomas, and 8 urinary calculi). The refined urine cytodiagnostic assay identified both uroepithelial vesical neoplasms, 7 of the 8 urinary calculi, and none of the 3 renal neoplasms. The presence of dysmorphic urinary red blood cells (RBCs) and RBC casts was strongly suggestive of renal parenchymal bleeding. Overall, 43 of 44 subjects (98%) with dysmorphic RBCs and RBC casts failed to demonstrate any significant urologic etiology. CONCLUSIONS These preliminary results suggest that the refined cytodiagnostic urine assay may be helpful in distinguishing whether a given patients microhematuria is of a significant urologic or a renal parenchymal cause. The addition of this specialized urinalysis may prove a useful adjunct in improving the diagnostic yield in patients with asymptomatic microhematuria.