Peter R. Carroll

Major Bladder Trauma: Mechanisms of Injury and a Unified Method of Diagnosis and Repair

We reviewed 51 cases of bladder trauma seen at our hospital between 1976 and 1981. There were 32 nonpenetrating, 13 penetrating, 1 spontaneous and 5 iatrogenic injuries. Rupture of the bladder was confirmed at operation in all but 1 case. Extraperitoneal rupture was noted in 32 patients (62 per cent), intraperitoneal rupture in 13 (25 per cent), and combined intraperitoneal and extraperitoneal rupture in 6 (12 per cent). The most frequent clinical features were gross hematuria, abdominal tenderness and shock. Associated pelvic fractures were present in 30 of the 31 nonpenetrating ruptures. The most common area of bladder rupture was the dome in nonpenetrating injuries (35 per cent) and the lateral wall in penetrating injuries (42 per cent). Associated organ injuries were common (62 per cent of penetrating injuries and 93 per cent of nonpenetrating injuries). Cystography, including the use of drainage films, was accurate in all cases for which it was used. Mortality in this series was 22 per cent and reflects the severity of associated organ injury. Risk factors include older age status, pedestrian injuries and extensive associated organ injury rather than type of bladder rupture. To minimize mortality and morbidity in this high risk group of patients strict attention should be directed to rapid resuscitation, early diagnosis including cystography with drainage films and anticipation of associated organ injury at operation.

Renal Reconstruction After Injury

During an 11-year period 1,363 patients presented to our institution with renal trauma. Renal exploration was performed in 127 patients (133 renal units). Most patients had multiple organ injuries, as indicated by a mean blood loss of 4,160 ml. and a mean injury severity score of 25.8. Absolute indications for exploration were bleeding and pulsatile perirenal hematoma and relative indications included urinary extravasation, nonviable renal tissue and incomplete staging. Renal surgery was required in 2.4% of the blunt injuries, 45% of the stab wounds and 76% of the gunshot wounds. Salvage was successful in 88.7% of the kidneys explored and total nephrectomy was required in 11.3%. The success rate was based on early vascular control and reconstructive techniques of renorrhaphy, partial nephrectomy, vascular repair and coverage with omental pedicle flaps. Complications occurred in 9.9% of the cases but none resulted in renal loss. When indicated, renal exploration after trauma is safe and in a high percentage of cases reconstruction will be successful.

Radiographic Assessment of Renal Trauma: A 10-Year Prospective Study of Patient Selection

To develop criteria to determine which patients require radiographic assessment after blunt renal trauma, we studied prospectively 1,146 consecutive patients with either blunt (1,007) or penetrating (139) renal trauma between 1977 and 1987. Based on our preliminary results from 1977 to 1983, in which none of the 221 patients with blunt trauma and microscopic hematuria without shock had significant renal injuries, we designed a prospective study to determine if such patients could be managed safely without radiographic staging. During the last 10 years significant renal injuries were found in 44 patients (4.4 per cent) with blunt trauma and gross hematuria or microscopic hematuria associated with shock, and in 88 patients (63 per cent) with penetrating trauma. No significant injuries occurred in the 812 patients with blunt trauma and microscopic hematuria without shock, 404 of whom had complete radiographic assessment and 408 of whom did not. There were no delayed operations or significant sequelae related to the renal injury in these patients. We conclude that complete radiographic staging is mandatory in patients with penetrating trauma to the flank or abdomen and in patients with blunt trauma associated with either gross hematuria or microscopic hematuria and shock. However, patients with blunt trauma, microscopic hematuria and no shock who do not have associated major intra-abdominal injuries can be managed safely without excretory urography.

Single shot intraoperative excretory urography for the immediate evaluation of renal trauma.

PURPOSEnWe reviewed the quality and usefulness of single shot intraoperative excretory urography (IVP) for evaluating suspected upper urinary tract trauma at our trauma center.nnnMATERIALS AND METHODSnBetween 1990 and 1997 single shot intraoperative IVP for staging renal injuries was performed in 50 patients in whom clinical instability and/or major associated injuries mandated an intraoperative study. Contrast material (2 ml/kg) was injected intravenously and images were obtained after 10 minutes. The quality and usefulness of each study were scored by a single attending urologist on a scale of 1-worst to 5-best.nnnRESULTSnIntraoperative study quality was generally good (average score 3.84). The information obtained was generally considered useful for determining urological treatment (average score 3.96). In 16 patients (32%) intraoperative IVP findings safely obviated renal exploration. No contrast medium reactions were noted and no complications developed that were attributable to intraoperative IVP.nnnCONCLUSIONSnIntraoperative single shot, high dose IVP is safe, efficient and of high quality in the majority of cases when performed as recommended. This study often provides important information that facilitates rapid and accurate decision-making. Intraoperative IVP is a useful tool for guiding the exploration of penetrating renal injuries and confirming blunt renal injuries that may be safely observed.

Major Bladder Trauma: The Accuracy of Cystography

We studied 51 cases of traumatic bladder rupture. Extravasation was noted in 32 cases for which retrograde cystograms were available, including 3 (9 per cent) in which additional infusion of contrast medium was required to demonstrate extravasation. Of the 32 cystograms 4 (13 per cent) showed rupture on the drainage film only. If drainage films and adequate distension of the bladder with contrast medium had been omitted in our study the rate of diagnostic accuracy of the cystogram would have been reduced to 79 per cent. If strict attention is paid to adequate distension of the bladder with contrast material and to obtaining drainage films, diagnostic retrograde cystography for trauma should be almost totally accurate and delays or errors in diagnosis should be rare.

Testicular Carcinoma in Patients Positive and at Risk for Human Immunodeficiency Virus

Patients with the acquired immunodeficiency syndrome are at increased risk for certain malignancies. Because acquired immunodeficiency syndrome and testicular cancer affect primarily young men, the potential complications that acquired immunodeficiency syndrome might impose raise significant concern. To address this question we performed a retrospective review of all cases of testicular cancer during an 11-year period. Of 140 patients 6 had human immunodeficiency virus infection and 7 were from human immunodeficiency virus risk groups. All cases were either stage I or II disease with seminoma in 8, teratocarcinoma in 3, embryonal cell carcinoma in 1 and teratoma in 1. The clinical presentations of these patients were comparable to those of patients without human immunodeficiency virus risk factors. The majority of the patients received standard therapy, including orchiectomy followed by lymphadenectomy, radiation therapy or chemotherapy depending on stage and pathological subtype. Patients tolerated therapy well with only 1 course of radiation therapy complicated by Pneumocystis carinii pneumonia. All patients achieved complete remission and none died of testicular cancer. Since treatment of these patients may worsen the immunosuppression, surveillance is recommended after orchiectomy for acquired immunodeficiency syndrome patients with stage I disease. However, the majority of patients with human immunodeficiency virus infection should receive standard therapy.

Penile Replantation: Current Concepts

We describe the microvascular repair of a traumatically lacerated penis (the fifth such case in the literature) and outline a uniform plan of management with which one can expect restoration of function and an adequate cosmetic appearance. Microvascular repair represents the most physiological method of reconstruction, with a lower incidence of urethral stricture disease, skin loss and sensory impairment.

Early Vascular Control for Renal Trauma: A Critical Review

To determine the incidence of, indications for and sequelae of temporary vascular occlusion in the management of renal trauma the records of 90 patients with 92 renal injuries were reviewed. Patients who required temporary vascular occlusion were compared to patients with similar injuries who also required renal surgery but not vascular occlusion. Only 11 of 92 renal injuries (12 per cent) required temporary vascular occlusion for reconstruction and control of renal bleeding. Neither the type nor the extent of renal and associated injury was a significant predictor of the need for occlusion. Renal injuries associated with large or expanding retroperitoneal hematomas were more likely to require temporary vascular occlusion than injuries without such associated hematomas. Temporary vascular occlusion was not associated with an increase in postoperative azotemia or mortality. The procedure is safe and effective, and allows for confident inspection and reconstruction of the kidney in patients who otherwise would be at high risk for nephrectomy.

Outcome after Temporary Vascular Occlusion for the Management of Renal Trauma

To determine the impact of temporary vascular occlusion on patient outcome after surgery for renal trauma, we reviewed the records of 30 patients managed since 1977 whose injuries represented 17% of a total of 181 injuries in 175 patients. Reconstruction was judged to be adequate in 25 patients, while the remaining 5 underwent immediate nephrectomy. Compared with patients whose renal injuries did not require temporary occlusion, these 30 were more likely to have renovascular trauma, shock at presentation and higher transfusion requirements. Postoperatively, of 20 patients renal imaging (9) and radionuclide scanning (11) demonstrated preservation of significant renal parenchyma or function in 18 (90%). Although complications were more common in patients whose renal injuries required temporary vascular occlusion, only 2 were related to the renal injury or its method of repair (urinary extravasation in 1 patient and azotemia in 1 with bilateral injury). Temporary vascular occlusion can be performed expeditiously and safely, and may have an important role in preserving renal function. Our results support the routine use of early vascular control and the selective use of temporary vascular occlusion in renal injuries requiring exploration.

Functional Characteristics of the Continent Ileocecal Urinary Reservoir: Mechanisms of Urinary Continence

We evaluated urodynamically 14 patients with a continent ileocecal urinary reservoir. Reservoirs were constructed of detubularized right colon alone (4 patients), or augmented with ileum (2) or with a U-shaped ileal patch (8). All reservoirs were placed in the abdomen and used plicated terminal ileum as the efferent continence mechanism. Twelve patients are completely continent with intermittent catheterization at 4 to 8-hour intervals. Two patients suffer mild nighttime incontinence. Mean reservoir volume was 675 ml. Intermittent intestinal contractions were noted in the plicated ileal segment and reservoir but they occurred more frequently in the former and were either synchronous with or preceded those in the reservoir. Mean and maximal contraction pressures were 24 and 47 cm. water, respectively, in the reservoir and 40 and 151 cm. water, respectively, in the plicated ileal segment (p equals 0.043 and less than 0.001, respectively). The highest reservoir contractions occurred in the 2 patients with nocturnal incontinence. The method of construction bore no consistent correlation with mean or maximal contraction pressures, contraction frequency or continence. Careful urodynamic assessment suggests that the ileocecal urinary reservoir is a relatively low pressure, nonrefluxing and continent bladder substitute. The plicated terminal ileal segment acts as an effective sphincter that responds to pressure elevations in the reservoir. Its simple construction and easy catheterization make it an attractive alternative to intussuscepted ileal segments.