Renal trauma during laparotomy for intra-abdominal injury.

The advantages of nonsurgical or surgical management of renal injuries are important when the renal trauma is found during a laparotomy for intra-abdominal injury. Blunt external trauma caused 85.5 percent of the renal injuries found during laparotomy in 194 patients. A large dose or infusion intravenous pyelogram on a modified operating table has allowed immediate evaluation of the renal injury during a laparotomy. When the degree of renal injury was more severe, renal tissue and function were saved by early surgical management. In this group, lowered morbidity and a sharp reduction in delayed renal operations followed the introduction of immediate surgical management. The nephrectomy rate was 11 percent, which compares favorably with that of nonsurgical management. Clamping of the renal vessels prior to opening Gerota fascia prevented reactivation of hemorrhage and allowed for a deliberate operation with conservation of undamaged renal tissue.

Nonstent or noncatheter extracorporeal shock-wave lithotripsy for ureteral stones.

OBJECTIVE: To determine if a ureteral stent or catheter was necessary to achieve satisfactory results with extracorporeal shock-wave lithotripsy (ESWL) for a stone in the ureter. METHOD: A retrospective review of 1,712 single ureteral stones treated in the ureter by ESWL using Dornier HM3 and Medstone STS lithotriptors was performed, 1,425 with a stent and 287 without a stent (in situ). Statistical analysis was performed using the chi-square test to determine the p value. RESULTS: The stone site, size, and treatment parameters (average shocks, kV, and estimated radiation to the patient) were similar in both groups. The retreatment rate, post-ESWL secondary procedure rate, and stone-free rate were 5 percent, 5 percent, and 79 percent, respectively, with a stent and 6 percent, 9 percent, and 79 percent, respectively, without a stent. CONCLUSION: The results of ESWL for single ureteral stones were similar with or without a stent, making the presence of a ureteral stent unnecessary.

Extracorporeal shock-wave lithotripsy for stones in middle third of ureter (overlying pelvic bone).

OBJECTIVE: To compare the results of using Dornier HM3 and Medstone STS lithotriptors to treat a ureteral stone overlying the pelvic bone (mid third of ureter) requiring the patient to be in the prone position. METHOD: The ease of use with each lithotriptor was evaluated and a retrospective review of the results using a Dornier HM3 in 53 patients and a Medstone STS in 143 patients was performed. The chi-square test was used to determine statistical difference. RESULTS: With single stones, the re-treatment rate, the post-ESWL secondary procedure rate, and the stone-free rate were 6 percent, 13 percent, and 75 percent, respectively, with the Dornier, and 6 percent, 8 percent, and 80 percent, respectively, with the Medstone. There was no statistically significant difference between these outcome results (p > 0.05). CONCLUSION: The prone position was difficult to achieve with the Dornier HM3, while the Medstone STS, a tubeless lithotriptor, allowed easy positioning of the patient in the prone position on its flat table. Satisfactory results were achieved using either machine.

Ureteral stenting with extracorporeal shock-wave lithotripsy.

We reviewed the results of ureteral stent use with extracorporeal shock-wave lithotripsy (ESWL) in 3,096 patients with renal calculi less than 3 cm in diameter. The 2,595 patients with indwelling ureteral stents required lower total power (shocks x voltage) and less radiation and had a lower secondary procedure rate but a higher retreatment rate than the 501 patients without stents. However, the only statistically significant difference was in the average radiation dose in patients with or without stents and single stones no larger than 10 mm (16 vs. 18 rad). The hospital stay was one day or less in 98 percent of the patients in both groups. With an 80 percent follow-up rate at three months indwelling ureteral stents were associated with a higher stone-free rate in patients with a single stone but a lower stone-free rate in patients with multiple stones, compared with those treated without a stent. An indwelling ureteral stent may result in urinary frequency and bladder discomfort in some patients, and with no statistical difference in the results with or without a ureteral stent it is questionable whether or not the high use of an indwelling ureteral stent is justified in patients admitted for one day or less.

Renal trauma in multiple-injured child.

Between 1959 and 1981, 251 renal injuries occurred in 248 children up to the age of sixteen years. Of the 36 children with renal laceration, rupture, or pedicle injury, 35 (97%) had associated injuries; 31 of these children (89%) with associated injuries required an immediate laparotomy by general surgeons for intra-abdominal injury. Immediate surgical management was performed on 27 severe renal injuries and resulted in nephrectomy in 3 of 20 renal lacerations (15%), in 4 of 4 ruptures (100%), and in 1 of 3 pedicle injuries (33%). Two of the 3 pedicle injuries (67%) had immediate repair with salvage of the kidney. Conservative management was carried out in 10 severe renal injuries. Delayed renal surgery was required in 3 cases (30%) and total renal loss (nephrectomy plus main renal artery injury) occurred in 5 of the 10 cases (50%). The severe degrees of renal injury did not all settle by themselves. Immediate surgical management of the patient with a severe renal injury resulted in a nephrectomy rate comparable with that of conservatively managed renal injuries.

Blunt renal pelvic and ureteral injury in multiple-injured patients.

The presence of multiple severe injuries influences the management and results with blunt renal pelvic and ureteral injury. Our 9 patients had an average of 4.5 associated injuries per patient and associated renal pedicle injuries in 4 patients. The poor general condition of the multiple-injured patient precluded the optimal management of the blunt renal pelvic and ureteral injury in 5 of the 9 patients. Delayed repair was performed in 4 patients with a successful result in 3. The fourth patient had a complicated course resulting in nephrectomy. The delay in presentation and diagnosis of the renal pelvic or ureteral injury did not preclude a successful result with delayed repair.

Unsatisfactory psychosocial results of vasectomy resulting in modification of preoperative counseling.

Psychosocial problems after vasectomy resulted in a change in preoperative counseling. Psychologic instability, marital problems, sexual difficulty, and anxiety because of religion became contraindications to vasectomy. Psychosocial problems after vasectomy were then reduced. Patient age under twenty years was also a contraindication. Five hundred sixty patients in the twenty to twenty-nine age group (31 per cent of the total 1,784 vasectomise performed) had vasectomies, with psychosocial problems in only 1 patient due to the young age. This was believed not to warrant a change in the age groups having vasectomy.

Ureteral contusion and delayed necrosis from gunshot injury.

The blast effect surrounding the path of a gunshot wound near the ureter can cause ureteral contusion with hematuria, no extravasation on the intravenous pyelogram, and an intact ureter found at laparotomy. Subsequent progression of the ureteral contusion to delayed necrosis and urine leakage can occur.

Testicular injuries.

We reviewed 91 testicular injuries in 86 patients (5 bilateral) as a result of blunt trauma in 72 patients and gunshot wounds in 14 patients. In 90 percent of the patients the injury was solitary. With blunt trauma initially conservative management led to the loss of the entire testis in 21 percent in comparison with only 6 percent of those explored promptly. The recent use of testicular ultrasonography has not differentiated intratesticular hematoma from rupture in the majority of cases of blunt trauma. Bilateral testicular injury occurred in 1 of 72 patients (1.4%) with blunt trauma versus 4 of 14 (29%) with penetrating trauma and affected the fertility in 3 of 4 patients on follow-up.

Nontraumatic rupture of varicocele.

A case of a nontraumatic scrotal hematoma thought to result from a ruptured varicocele is reported. It is postulated that a high venous pressure generated during a Valsalva maneuver while defecating may have precipitated the variceal hemorrhage.

Comparison of IVP and CT findings in patients with suspected severe renal injury.

Excretory urography (IVP) is the primary diagnostic tool for renal injury but has been indeterminate in diagnosing severe renal injuries in most cases. Computed tomography (CT) provides precise anatomic detail of renal injuries. The IVP and CT findings were compared in 22 patients with suspected severe renal injuries suggested by clinical examination and initial screening IVP. CT provided determinate diagnoses in all the cases of severe renal injury, while the IVP diagnoses were indeterminate in 82 per cent of these cases. Although clarification is needed on the accuracy of CT in diagnosing renal vascular injury, the CT diagnoses were accurate in all other types of severe renal injury (as well as minor renal injuries).

Psychosocial aspects of micturition.

The complex act of micturition is still insufficiently understood and a controversial neuromuscular phenomenon. In humans, the urinary bladder reflects the constant accommodation to physiologic, psychologic, and social aspects of micturition. This article deals with these additional dimensions of micturition of which the urologist should be aware.

Immediate surgical management of severe renal injuries in multiple-injured patients.

Between 1969 and 1980, 1,132 renal injuries were recorded in 1,120 patients. Of the 129 patients with a severe renal injury (laceration, rupture, pedicle injury), 118 (91%) had associated injuries and 101 (86%) required an immediate laparotomy by general surgeons for intra-abdominal injury. Immediate surgical management was performed on 90 severe renal injuries and resulted in a nephrectomy rate of 5 of 55 lacerations (9%), 16 of 17 ruptures (94%), and 10 of 18 pedicle injuries (56%). Seven of the 18 pedicle injuries (39%) had immediate repair with salvage of the kidney. Conservative management was done on 32 severe renal injuries. Autopsy revealed 10 severe renal injuries in 9 patients who died in the operating room or on admission. A delayed renal operation was required in 9 (28%), and total renal loss (nephrectomy plus main renal artery injury) occurred in 7 of the 32 cases (22%). The severe degrees of renal injury did not all resolve spontaneously. Immediate surgical management of the patient with a severe renal injury resulted in a nephrectomy rate comparable with that of conservatively managed renal injuries.

Late bladder complications with use of external fixator device for pelvic fractures.

The management of unstable, open-book fractures by reduction and immobilization with the external fixator device resulted in late bladder complications in 2 patients.

Urethral injury due to external trauma.

Fifty-six patients with urethral injuries comprised 35 involving the posterior urethra and 21 involving the anterior urethra. Immediate retrograde urethrography confirmed the clinical diagnosis made when blood was found at the external urinary meatus after external trauma. Traffic accidents caused most of the posterior urethral injuries and were associated with severe injuries to multiple systems and a significant mortality rate (34 per cent). Primary realignment of the urethral injury by a urethral catheter in all cases of urethral rupture (plus a suprapubic cystostomy in most of these cases) resulted in a stricture rate of 62 per cent on follow-up. However, only half of these strictures required surgical correction. The incidence of incontinence was 10 per cent and of impotence 38 per cent.

Crossed renal ectopia with familial occurrence.

A familial occurrence of crossed renal ectopia is presented. No genetic factor has been determined in this congenital anomaly so this familial occurrence is believed to be incidental.

Rapid and slow-fill gas cystometry. Influence on bladder capacity and diagnosis of hyperreflexic bladder.

Rapid-fill gas cystometry has been criticized for giving a falsely low value of bladder volume and for inducing an "artefact", the hyperreflexic bladder. This study in 72 patients revealed that the average capacity with slow-fill air cystometry was less than with rapid fill. The diagnosis of hyperreflexic bladder was made more often with slow fill than with rapid fill in these 72 patients.

Endoscopic removal of staghorn calculi in patient with high urinary diversion.

The treatment of recurrent renal calculi in patients after ureteroileal urinary diversion is difficult, especially when urinary stones are formed in the presence of urinary tract infection. In many cases, these patients already have undergone multiple renal operations and more surgery could pose difficult technical problems. We report on a patient with a high urinary diversion in whom bilateral staghorn renal calculi developed, and then were endoscopically removed. The conversion of ureteroileocutaneous diversion to a high pyeloileocutaneous diversion is recommended in selected cases as alternate treatment for patients with recurrent stone formation.

Simultaneous upper and lower urinary tract injury from external trauma.

We found simultaneous upper and lower urinary tract injury to be rare, being present in 10 of 2,310 patients (0.4%). Multiple associated injuries were present in all patients (average 4.4 per patient). In 3 patients both upper and lower urinary tract injuries were minor, and 1 patient died of associated injuries. In 4 patients one of the urinary injuries was significant and the other minor, and 2 of these patients died. In 3 patients both urinary injuries were significant, and all 3 died of associated injuries. A comprehensive urologic evaluation was required in all 10 patients because of their severe associated multiple injuries.

Management of postoperative fistula of upper urinary tract.

The simple procedure of passage and withdrawal of a ureteral catheter hastens the closure of a urinary fistula after surgery of the ureter or renal pelvis.