Management of pediatric renal trauma - Results from the American Association for Surgery and Trauma Multi-Institutional Pediatric Acute Renal Trauma Study (Mi-PARTS).

BACKGROUND: Pediatric renal trauma is rare and lacks sufficient population-specific data to generate evidence-based management guidelines. A non-operative approach is preferred and has been shown to be safe. However, bleeding risk assessment and management of collecting system injury is not well understood. We introduce the Multi-institutional Pediatric Acute Renal Trauma Study (Mi-PARTS), a retrospective cohort study designed to address these questions. This manuscript describes the demographics and contemporary management of pediatric renal trauma at Level I trauma centers in the United States. METHODS: Retrospective data were collected at 13 participating Level I trauma centers on pediatric patients presenting with renal trauma between 2010-2019. Data were gathered on demographics, injury characteristics, management, and short-term outcomes. Descriptive statistics were used to report on demographics, acute management and outcomes. RESULTS: In total 1216 cases were included in this study. 67.2% were male, and 93.8% had a blunt injury mechanism. 29.3% had isolated renal injuries. 65.6% were high-grade (AAST Grade III-V) injuries. The mean Injury Severity Score (ISS) was 20.5. Most patients were managed non-operatively (86.4%) 3.9% had an open surgical intervention, including 2.7% having nephrectomy. Angioembolization was performed in 0.9%. Collecting system intervention was performed in 7.9%. Overall mortality was 3.3% and was only observed in polytrauma. The rate of avoidable transfer was 28.2%. CONCLUSION: The management and outcomes of pediatric renal trauma lacks data to inform evidence-based guidelines. Non-operative management of bleeding following renal injury is a well-established practice. Intervention for renal trauma is rare. Our findings reinforce differences from the adult population, and highlights opportunities for further investigation. With data made available through Mi-PARTS we aim to answer pediatric specific questions, including a pediatric-specific bleeding risk nomogram, and better understanding indications for interventions for collecting system injuries. LEVEL OF EVIDENCE: IV, Epidemiological (prognostic/epidemiological, therapeutic/care management, diagnostic test/criteria, economic/value-based evaluations, and Systematic Review and Meta-Analysis).

Validity of midday total testosterone levels in older men with erectile dysfunction.

PURPOSE: Based on studies showing the circadian rhythmicity of testosterone the optimal time of day to draw total testosterone in men has classically been reported as between 8 and 11 a.m. However, further studies demonstrated that the testosterone circadian rhythmicity becomes blunted with age. MATERIALS AND METHODS: We retrospectively reviewed the charts of 2,569 men who presented with erectile dysfunction for total testosterone and draw times. We compared the men by age group, including less than 40 years and 5-year groupings after age 40 years. Total testosterone was analyzed for variability during the most common draw time hours (7 a.m. to 2 p.m.). RESULTS: Mean total testosterone at 7 to 9 a.m. and 9 a.m. to 2 p.m. clinically and statistically differed only in men younger than 40 vs 40 to 44 years old (mean difference 207 ng/dl, 95% CI 98-315, p = 0.0004 vs 149 ng/dl, 95% CI 36-262, p = 0.01). No other group showed a clinically and statistically significant difference between those periods. CONCLUSIONS: Total testosterone in men with erectile dysfunction who are younger than 45 years should be drawn as close to 7 a.m. as possible because a statistically and clinically relevant decrease in testosterone will occur during the course of the day. Men older than 45 years with erectile dysfunction can have total testosterone drawn at any time before 2 p.m. without misleading results.

Alfuzosin to relieve ureteral stent discomfort: a prospective, randomized, placebo controlled study.

PURPOSE: We assessed the impact of alfuzosin on ureteral stent discomfort. MATERIALS AND METHODS: A total of 66 patients scheduled for unilateral retrograde ureteroscopy with stent placement provided consent for the study. Patients were randomized between placebo and the study medication, and investigators and patients were blinded to the randomization scheme. To evaluate pain and urinary symptoms patients were asked to complete the Ureteral Stent Symptom Questionnaire (Stone Management Unit, Southmead Hospital, Westbury-on-Trym, United Kingdom) before ureteroscopy and 3 days after the procedure to minimize the confounding impact of procedural discomfort due to surgery. Patients were also asked to maintain a use log of pain medication each day that the ureteral stent was in place. Procedure outcome and complications were recorded, as were patient study medication use and vital health information before the procedure and at the time of stent removal. Statistical analysis was performed using the Student t, chi-square and Wilcoxon rank sum tests, as appropriate, with p <0.05 considered significant. RESULTS: Of 66 patients who provided consent 55 successfully completed the study. In 3 of the 11 failed cases surgery was not done due to spontaneous stone passage, surgery was performed in 3 but no ureteral stent was placed, 4 were excluded from study after obtaining consent due to exclusion criteria and 1 was voluntarily removed from study after obtaining consent but before surgery. Regarding stent type, procedure complications and baseline questionnaire results there were no significant differences between the placebo and alfuzosin arms. When comparing post-procedure questionnaire results, patients in the alfuzosin arm reported less overall pain in the kidney/back/loin area and less pain in the kidney area while passing urine (p = 0.017 and 0.007, respectively). Men in the alfuzosin arm also reported a lesser incidence of excessive urination (p = 0.040). When comparing changes from baseline questionnaire results, the alfuzosin arm experienced a decrease in kidney pain during sleep (p = 0.017), less frequent use of painkillers to control kidney pain (p = 0.020) and a decrease in how much kidney associated pain interfered with life (p = 0.045). There was no significant difference in the amount of narcotics used per day, as reported in patient medication logs. CONCLUSIONS: Alfuzosin improves the patient discomfort associated with ureteral stents by decreasing urinary symptoms and kidney pain but it does not affect the amount of narcotics that patients use while the stent is in place.

Alfuzosin stone expulsion therapy for distal ureteral calculi: a double-blind, placebo controlled study.

PURPOSE: We evaluated the efficacy of alfuzosin as medical expulsive therapy for distal ureteral stone passage. MATERIALS AND METHODS: A total of 76 patients with a distal ureteral calculus provided consent for the study. Patients were randomized between placebo and study medication, and investigators and patients were blinded to the randomization scheme. Followup was done on a weekly basis and continued until the patient was rendered stone-free. The patient blood pressure, discomfort level, stone position on imaging, number of remaining pills and any adverse events were assessed. Statistical analysis was performed with the Student t test with p <0.05 considered significant. RESULTS: The overall spontaneous stone passage rate was 75%, including 77.1% for placebo and 73.5% for alfuzosin (p = 0.83). Mean +/- SD time needed to pass the stone was 8.54 +/- 6.99 days for placebo vs 5.19 +/- 4.82 days for alfuzosin. (p = 0.003). There was no difference in the size or volume of stones that passed spontaneously between the placebo and alfuzosin arms, as measured on baseline computerized tomography (4.08 +/- 1.17 and 3.83 +/- 0.95 mm, p = 0.46) and by a digital caliper after stone expulsion (3.86 +/- 1.76 and 3.91 +/- 1.06 mm, respectively, p = 0.57). When comparing the improvement from the baseline pain score, the alfuzosin arm experienced a greater decrease in pain score in the days after the initial emergency department visit to the date of stone passage (p = 0.0005). CONCLUSIONS: Alfuzosin improves the patient discomfort associated with stone passage and decreases the time to distal ureteral stone passage but it does not increase the rate of spontaneous stone passage.

Prevalence of androgen deficiency in men with erectile dysfunction.

OBJECTIVES: Erectile dysfunction (ED) and androgen deficiency in aging men are two separate clinical entities that often overlap. Controversy exists regarding the most appropriate total testosterone level that defines androgen deficiency in aging men, and its prevalence in men with ED is still uncertain. We evaluated the prevalence and risk factors of low and low-normal testosterone levels in men presenting for an initial ED evaluation. METHODS: The computerized charts from 1987 to 2002 of 2794 men aged 25 to 80 years and presenting with a primary complaint of ED who also had serum total testosterone levels measured were retrospectively reviewed. Multiple testosterone level cutpoints and a linear regression model (including age, diabetes, cholesterol, anemia, creatinine, and prostate-specific antigen) were used to analyze the factors that correlated with hypogonadism. RESULTS: The prevalence of androgen deficiency was 7%, 23%, 33%, and 47% for testosterone levels of less than 200, less than 300, less than 346, and less than 400 ng/dL, respectively. An abrupt increase in hypogonadism prevalence occurred in men aged 45 to 50, beyond which a plateau of prevalence was maintained until older than 80 years of age. Age, the presence of uncontrolled diabetes, high total cholesterol, and anemia all correlated with significantly decreased testosterone levels in men with ED. The prostate-specific antigen level and creatinine did not affect the testosterone levels. CONCLUSIONS: Androgen deficiency was quite common in men presenting with ED and correlated significantly with age, uncontrolled diabetes, hypercholesteremia, and anemia. Although additional prospective studies evaluating the effect of testosterone supplementation in this population are needed, clinicians, including urologists, should be keenly aware of the large overlap of patients with ED who might also have the entity, androgen deficiency in the aging male.