Reynaldo Gomez

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.

Adrenal gland trauma: diagnosis and management.

We describe 14 patients with adrenal injuries from penetrating (ten) or blunt (four) trauma. The severity of their injuries was evidenced by the high incidence of hypovolemic shock (57%), mean Trauma Score (11), mean transfusion requirement (18 Units), number of associated injuries (4.9 per patient), complication rate (57%), and deaths (14%). Twelve patients required surgical exploration; adrenal repair, rather than removal, was possible in seven. Although adrenal insufficiency was suspected in three patients, it was not documented and no patient required corticosteroid replacement.

Hematuria as a predictor of abdominal injury after blunt trauma

Among the 1,484 patients included in the Renal Trauma Project with evidence of blunt trauma and hematuria, 160 patients were found to have both hematuria and a significant intra-abdominal injury not related to the genitourinary system. The incidence of abdominal injury generally increased with the degree of hematuria, approaching 24% in patients with gross hematuria. For each category of degree of hematuria, patients with shock had a significantly higher incidence of abdominal injury (p < 0.05) than patients without shock. The incidence of abdominal injury in patients with microscopic hematuria and shock was 29%, and it was 65% for patients with both gross hematuria and shock. All patients with gross hematuria after blunt abdominal trauma and all patients with microscopic hematuria and a history of shock should be evaluated for both urologic and extra-renal abdominal injuries.

A Multi-institutional Evaluation of the Management and Outcomes of Long-segment Urethral Strictures.

OBJECTIVE To evaluate the treatment options and surgical outcomes of long-segment urethral strictures-a review of the largest, international, multi-institutional series. METHODS A retrospective review was performed of patients treated with strictures ≥8 cm at 8 international centers. Endpoints analyzed included surgical complications and recurrence. RESULTS Four hundred sixty-six patients were identified. Treatment intervals ranged from December 27, 1984 to November 9, 2013. Dorsal onlay buccal mucosal graft (BMG) was the most common procedure (223, 47.9%); others included first- and second-stage Johanson urethroplasty (162 [34.8%] and 56 [12%], respectively), fasciocutaneous (FC) flaps (8, 1.7%), and a combination flap and graft (17, 3.6%). Overall success was achieved in 361 patients (77.5%) with a mean follow-up of 20 months. Second-stage Johanson urethroplasty was found to have a higher recurrence rate compared with that of 1-stage BMG urethroplasty (35.7% vs 17.5%, respectively; P <.01). This was also true in cases of lichen sclerosus (14.0% vs 47.8%, respectively; P <.01). Otherwise, success rates were similar. Urethroplasties performed with FC flaps had a higher complication rate compared with those without (32% vs 14%, respectively; P = .02). Prior dilation or urethrotomy, higher number of prior dilations or urethrotomies, abnormal voiding cystourethrogram, and skin grafts all portend a higher recurrence rate. On logistic regression analysis, only second-stage Johanson had an increased odds ratio of recurrence compared with that of BMG (2.82 [1.41-5.86]). CONCLUSION Long-segment strictures can be treated with high success rates in experienced hands. BMG was more successful than second-stage Johanson urethroplasty. FC flaps, although successful, had high complication rates.

Effects of Nerve Stimulation on Blood Flow in the Urinary Bladder, Urethra and Pelvic Floor in the Dog

Pelvic organs have triple innervation from the pelvic, sympathetic and pudendal nerves. Peripheral effects can be studied by neurostimulation of the nerves, whereas the topography of the spinal cord neurons can be determined by horseradish peroxidase tracing. We have evaluated the neurophysiologic effects of the nerves at their target organs by intraoperative electric stimulation and compared the effects to the anatomical innervation areas. These zonal areas were determined by blood flow alterations, measured with nine different microspheres. Pelvic nerve stimulation showed bladder contraction with no significant blood flow changes during stimulation. Sympathetic nerve stimulation caused moderate detrusor contraction and pressure increase in the bladder neck and intraprostatic area. Regional blood flow showed a four-fold increase in the bladder neck area during neurostimulation. Pudendal nerve stimulation revealed an intraurethral pressure increase with a 3.5-fold increase of blood flow in the sphincteric area and in the pelvic floor musculature.

Motility and intraluminal pressure of the ileocolonic junctional zone and adjacent bowel in a canine model

SummaryThe exact role of the ileocecal valve (ICV) at the junction of small and large bowel is not well understood. Bowel segments used for the construction of urinary reservoirs incorporate the ICV. In the Indiana pouch its natural continence is used as one principle for achieving continence of the efferent limb. Motor activity and pressure in the ICV, the ileum and colon were registered in eight dogs. Myogenic activity of the bowel consisted of slow weves, irregular spontaneous contractions and superimposed spikes. Pressures of 7.2±0.3 cmH2O were recorded in the ileum and of 5.6±0.4 cmH2O in the colon. The pressure in the ICV was 12.7±0.4 cmH2O rising to 26.4±2.2 cmH2O during spontaneous depolarization. Balloon dilatation of the ileum resulted in relaxation of the ICV in 76% of experiments, whereas colonic distension was followed by a pressure increase in the ICV region in 80% of experiments. In 16% of cases a relaxation of the ICV area and a weaker response after repeated dilatation was noted. These findings make the ICV an unreliable continence mechanism as its long-term continence can not be predicted despite intraoperative evaluation. Additional measures to ensure consistent continence at the ICV (e.g. electric stimulation) need to be studied.

Traumatic testicular dislocation.

IntroductionTraumatic testicular dislocation is a rare entity. It occurs after a direct blunt scrotal trauma causing the testicle to migrate outside the scrotum, most frequently to the superficial inguinal region.Materials and methodsA review of the diagnostic database of our two institutions was performed searching for complex genital trauma between 1990 and 2012.ResultsSeven cases of traumatic testicular dislocation were identified (four on the left side; one on the right side and two bilateral) for a total of nine testicles. Six were motorcycle accidents, and the other case suffered a pelvic crush injury. All victims had significant associated injuries, one case had an open dislocation and two were killed by the accident. The testicle was located at the inguinal region in four cases at the suprapubic area in four, and the other was an open dislocation. Diagnosis was suspected with the physical examination and confirmed by Doppler ultrasound; however, in one case, the diagnosis was missed during several weeks. In one case, the testicle was reduced into the scrotum immediately at the emergency department. Two cases were operated shortly after admission, performing testicular reduction into the scrotum and standard orchidopexy. Two other cases underwent delayed intervention, and both needed release of peri-testicular adhesions. Two cases (both bilateral) died at the accident site and were diagnosed by autopsy. In all surviving cases, it was possible to obtain a satisfactory orchidopexy with gonadal preservation.ConclusionsTraumatic testicular dislocation is rare and diagnosis can be elusive. It should be suspected in motorcycle and high-energy accidents around the groin area and depends on a careful physical examination. With proper management, prognosis is excellent.

STIMULATED PRESSURE RESPONSE OF THE ILEOCOLONIC JUNCTIONAL ZONE AND ITS USE AS A CONTINENCE MECHANISM IN A CANINE MODEL

SummaryMechanisms for maintaining passive continence in the efferent limb of urinary diversions include compression of tissue, peristalsis, equilibration of pressure and use of valves. Motor activity and pressure in the ileum, ileocecal valve (ICV) and the colon were evaluated in dogs. Spontaneous activity and pressure were compared with stimulated pressure response and activity. Stimulation was performed at the pelvic nerve and the small nerves in the mesenterium, as well as direct neurostimulation of the bowel. Resting pressure at the ICV was 12.7±0.4 cmH2O rising to 26.4±2.2 cmH2O during spontaneous depolarization. Stimulation of the pelvic nerve resulted in increased colonic motor activity with unchanged pressure. Electric stimulation of small mesenterical nerves to the ICV increased pressure in the ICV to 35.0±4.1 cmH2O, while direct myoelectric stimulation of the ICV zone increased the intraluminal pressure to 75.0±3.2 cmH2O. Termination of the electric stimulation was followed by a slow decrease of pressure to the resting level a period of 30–45 s. Maintaining continence at the ICV with long-term constant or intermittent stimulation seems feasible.

PD34-03 POST-TURP URETHRAL STRICTURES CAN BE MANAGED SUCCESSFULLY WITH URETHROPLASTY

INTRODUCTION AND OBJECTIVES: Anastomotic urethroplasty is an effective but occasionally controversial treatment for short bulbar urethral strictures. Non-transecting variations of anastomotic urethroplasty were created in part to address this controversy. The objective of this study is to assess current outcomes of anastomotic urethroplasty and compare outcomes of transecting and non-transecting techniques. METHODS: 171 patients with complete follow-up underwent anastomotic bulbar urethroplasty from September 2003 to May 2016. Patient age, stricture length, location, etiology, 90-day complications and semi-quantitative assessment of sexual dysfunction were recorded. The primary (objective) outcome was success defined as urethral patency >16Fr on routine follow-up cystoscopy. Secondary outcome measures included 90-day complications (Clavien 2) and de novo sexual dysfunction assessed at 6 months. Statistical comparison between transecting and non-transecting cohorts was made using Cox Regression Analysis and Chi-square when appropriate. RESULTS: One hundred and thirty patients underwent transecting anastomotic urethroplasty while 41 had a non-transecting anastomotic urethroplasty. Mean stricture length was 1.5 0.5cm (range 1-3) with a mean patient age of 43.0 18.0 years. 78.9% of patients failed prior endoscopic treatment (135/171) and 2.4% failed prior urethroplasty (4). Overall there was a 98.2% (168/171) success rate with a mean follow-up of 74.9( 46.7) months. 7.0% (12/171) of patients experienced a 90-day postoperative complication of Clavien 2 including 2.9% wound-related complications (5), 1.8% scrotal hematomas (3), 1.8% UTI (3), and 0.6% urethral bleeding (1). 9.9% reported an adverse change in sexual function including 6.4% erectile dysfunction (11), 1.8% ejaculatory dysfunction (3), 1.2% painful erection (2), and 0.6% chordee (1). When comparing transecting and non-transecting technique success using Cox Regression analysis there was no difference in urethroplasty success (97.7% vs. 100%; p1⁄40.63) and no difference in postoperative complications (7.7% vs. 4.9%; p1⁄40.73) but patients undergoing transecting anastomotic urethroplasty were more likely to report an adverse change in sexual function (13.1%; vs. 0%; p1⁄40.013). CONCLUSIONS: Anastomotic urethroplasty remains a highly effective treatment for short-segment bulbar urethral strictures with relatively minimal associated morbidity. Newer non-transecting anastomotic urethroplasty techniques appear to compare favorably in the short-term and may reduce the risk of associated sexual dysfunction.