Scott L. Brown

LIMITATIONS OF COMPUTERIZED TOMOGRAPHY IN STAGING INVASIVE BLADDER CANCER BEFORE RADICAL CYSTECTOMY

PURPOSE Computerized tomography (CT) of the abdomen and pelvis is often routine in the preoperative staging assessment of invasive transitional cell carcinoma of the bladder. We determine the accuracy of staging CT findings, usefulness before planned extirpative surgery and impact on surgical management of this disease. MATERIALS AND METHODS We retrospectively reviewed the medical records, including radiographic, operative and pathological reports, of 82 consecutive cases. All patients presented with muscle invasive bladder tumors, were considered candidates for radical cystectomy and underwent preoperative staging CT of the abdomen and pelvis between July 1994 and June 1998. The ability of CT to provide additional staging information in terms of depth of tumor invasion, local extent of tumor, pelvic lymph node involvement and distant metastases was examined. We determined whether CT findings altered surgical management for individual patients. RESULTS CT was able to discriminate depth of invasion in only 1 patient (1.2%) and correctly identified extravesical tumor spread in 4 (4.9%). Lymph node and distant metastases were accurately determined in 4 (4.9%) and 2 (2.4%) cases, respectively. The overall accuracy of CT was 54. 9%, with an under staging and over staging rate of 39.0% and 6.1%, respectively. CT provided accurate, additional staging information in only 8 cases (9.8%). Surgical management was altered in 3 cases (3.7%) and only 1 (1.2%) avoided an unnecessary operation as a result of CT findings. CONCLUSIONS Staging CT of the abdomen and pelvis in patients with invasive bladder carcinoma has limited accuracy, mainly because of its inability to detect microscopic or small volume extravesical tumor extension and lymph node metastases. CT tends to under stage advanced disease and failed to alter surgical management in nearly all of our cases.

Limitations of computed tomography in the preoperative staging of upper tract urothelial carcinoma

OBJECTIVES Computed tomography (CT) of the abdomen and pelvis has been used for staging of upper tract urothelial carcinoma. This study was initiated to evaluate the utility of this modality in guiding the management of patients with upper tract urothelial malignancies. METHODS We performed a retrospective chart review of 37 consecutive patients with urothelial carcinoma of the upper urinary tract (21 renal pelvic, 16 ureteral) who underwent preoperative CT staging of the abdomen and pelvis before open surgical management. RESULTS CT was not required to establish the diagnosis in any of the patients, but in 16.2% helped to confirm the diagnosis when the disease was suspected based on other studies. CT accurately provided evidence of metastatic disease in only 3% of the patients. CT was accurate in predicting pathologic TNM stage in 59. 5% of patients. The study understaged or did not detect in 16.2% and 24.3%, respectively. Most importantly, CT did not alter the management of any patient. CONCLUSIONS CT was rarely helpful in establishing the diagnosis of the upper tract urothelial carcinoma and did not influence the management of any patient. We conclude that preoperative CT scan in those patients who are to undergo open surgical management of confirmed urothelial malignancies of the upper urinary tract without suspicion of advanced disease will rarely influence the management of the disease and its use should be selective and not routine.

ARE PEDIATRIC PATIENTS MORE SUSCEPTIBLE TO MAJOR RENAL INJURY FROM BLUNT TRAUMA? A COMPARATIVE STUDY

PURPOSE We determine whether pediatric patients are more susceptible to major renal injury than adults. MATERIALS AND METHODS We retrospectively reviewed the medical records of 34 consecutive children 2 to 17 years old (mean age 10) and 35 consecutive adults 19 to 59 years old (mean age 32) with blunt renal trauma who presented to our 2 level I trauma centers between 1990 and 1996. Patients with incomplete charts were excluded from study. According to the organ injury scaling committee of the American Association for the Surgery of Trauma renal injuries were graded based on computerized tomography results or laparotomy findings (4 adults) with major injuries classified as grade IV or V. Vascular injuries were excluded from study. Injury severity scores were calculated using the abbreviated injury scale. RESULTS Injury severity scores ranged from 4 to 75 (mean 16) in the pediatric and 5 to 50 (mean 22) in the adult populations (p <0.01). Overall 16 of the 34 children (47%) and 8 of the 35 adults (23%) sustained major renal injuries (p <0.04). In 4 children who required surgical exploration for hemodynamic instability injury severity score ranged from 17 to 42 (mean 26) and all had major renal injuries. In 7 of the 35 adults (20%) who underwent surgical exploration because of hemodynamic instability and/or positive diagnostic peritoneal lavage injury severity score ranged from 22 to 50 (mean 34). Three of these 7 adults (42%) had major renal injuries and all had other visceral injuries at exploration. CONCLUSIONS Children are more likely than adults to sustain renal injury from blunt abdominal trauma.

LIMITATIONS OF ROUTINE SPIRAL COMPUTERIZED TOMOGRAPHY IN THE EVALUATION OF BLUNT RENAL TRAUMA

PURPOSE We have observed that injury to the renal collecting system may be missed during routine abdominal spiral computerized tomography (CT) for trauma. A definitive protocol for spiral CT has been established to identify all cases of renal collecting system injury. MATERIALS AND METHODS A retrospective review of 35 consecutive cases of blunt renal trauma evaluated with spiral CT between 1994 and 1997 at our Level I trauma center was performed. Each patient received 100 cc intravenous contrast at 2 cc per second. There was a 60-second delay after the start of contrast infusion before scanning was initiated. RESULTS Of the 35 cases 3 (8.6%) injuries to the renal collecting system were detected on delayed scans obtained after the initial CT failed to demonstrate contrast extravasation. Therefore, at our institution we have modified the protocol for spiral CT for abdominal trauma by repeating scans of the kidneys after the initial scans are completed. CONCLUSIONS Injury to the renal collecting system may be missed during routine spiral CT, thereby incorrectly under staging renal trauma. In all cases of suspected blunt renal trauma evaluated with spiral CT repeat scans of the kidneys should be performed.

Penile fracture and testicular rupture

Abstract Traumatic injuries to the penis and testicles are uncommon, likely due to the well-protected location and degree of mobility of these organs [10, 21]. Because of this the management of these injuries has historically been controversial. However, current literature supports immediate evaluation and surgical repair of these traumatic injuries to prevent complications such as erectile dysfunction or testicular loss [20, 27]. Herein the diagnostic and therapeutic options for both traumatic penile fracture and testicular rupture are reviewed with emphasis on immediate evaluation and repair.

Radiologic Evaluation of Pediatric Blunt Renal Trauma in Patients with Microscopic Hematuria

As a result of the rapid increase in medical costs, the efficacy of diagnostic imaging is under examination, and efforts have been made to identify patients who may safely be spared radiographic imaging. We reviewed the records of children who presented to our institution with suspected blunt renal injuries to determine if radiographic evaluation is necessary in children with microscopic hematuria and blunt renal trauma. We retrospectively reviewed the medical records of 1200 children (ages less than 18 years) who sustained blunt abdominal trauma and who presented to our level I pediatric trauma center between 1995 and 1997. Urinalysis was performed in 299 patients (25%). Urinalysis results were correlated with findings on abdominal computed tomography (CT). All patients had more than three red blood cells per high power field (RBC/hpf) or gross hematuria. Renal injuries were graded according to the injury scale defined by the American Association for the Surgery of Trauma. Sixty-five patients had microscopic hematuria. Thirty-five (54%) were evaluated with an abdominal CT scan. Three patients sustained significant renal injuries (grade II-V), and 32 patients had normal findings or renal contusions. Therefore only 3 of 65 patients (4.6%) sustained a significant renal injury. All three patients had other associated major organ injuries. Of the three patients with gross hematuria evaluated with abdominal CT, one (33%) sustained a significant renal injury and had no associated injuries. The degree of hematuria did not correlate with the grade of renal injury. Pediatric patients with blunt trauma, microscopic hematuria, and no associated injuries do not require radiologic evaluation, as significant renal injuries are unlikely. However, children who present with associated injuries and microscopic hematuria after blunt trauma may have significant renal injuries and should undergo radiologic evaluation.

COCAINE ASSOCIATED PRIAPISM

PURPOSE Cocaine abuse is an ongoing epidemic in the United States. Priapism associated with cocaine use has been reported only twice in the urological literature. To our knowledge we report the first series of priapism associated with cocaine use and the first case associated with the use of this drug in its solid form, known as crack. MATERIALS AND METHODS We retrospectively reviewed the presentation of 3 patients to our emergency department within the last year. Each patient presented with priapism and no identifiable predisposition other than the use of cocaine within 24 hours, as evident on positive urine toxicology. RESULTS Each patient delayed seeking treatment, which added to the complexity of therapy. Intracavernosal aspiration and irrigations failed in all 3 cases. Cavernous spongiosal shunting failed in the first 2 cases. Cases 2 and 3 were complicated by the high flow variant of priapism. Case 1 ultimately required partial penectomy for infected, gangrenous, distal penile tissue. CONCLUSIONS It appears that cocaine can be a cause of refractory priapism and treatment can be challenging. We suggest that urine toxicology screening be considered in such cases. The identification of underlying cocaine abuse is important in preventing priapism recurrence in these patients.