Destroyed bladders: Characterization of progressive inflammatory cystitis.

PURPOSE: We identified a subset of patients with noninfectious cystitis who develop refractory symptoms marked by diffuse inflammatory changes, reduced bladder capacity, and vesicoureteral reflux (VUR), termed here as "progressive inflammatory cystitis" (PIC). Our objective was to describe the phenotype, disease outcomes, and pathologic findings of PIC. MATERIAL AND METHODS: A single institution retrospective cohort study of patients with PIC. Patients with a history of pelvic radiation, urologic malignancy, or neurogenic bladder were excluded. We describe cohort characteristics and use bivariate analyses to compare subgroups. Kaplan-Meier methods estimate time to urinary diversion. RESULTS: From 2008 to 2020, 46 patients with PIC were identified. The median age of symptom onset was 63 years old (interquartile range [IQR]: 56, 70) and the most common presenting symptoms were urinary urgency/frequency (54%) and incontinence (48%). Urodynamics showed a median maximum bladder capacity of 80 mL (IQR: 34, 152), commonly with VUR (68%) and hydronephrosis (59%). Ultimately 36 patients (78%) underwent urinary diversion at a median of 4.5 years (IQR: 2, 6.5) after symptom onset. Significant pathologic findings include presence of ulceration (52%), acute and chronic inflammation (68%), including eosinophils (80%), lymphoid follicles (56%), and mast cells in both lamina and muscularis propria (76%). CONCLUSIONS: PIC is a newly defined entity characterized by significantly diminished bladder capacity, upper tract changes, and relatively quick progression to urinary diversion. Larger prospective cohort studies are required to further characterize this severe phenotype of chronic noninfectious cystitis, aid earlier diagnosis, and guide management decisions.

The Utility of Radiologic and Symptomatic Surveillance After Minimally-invasive Adult Pyeloplasty.

OBJECTIVE: To evaluate different types of failure after minimally-invasive pyeloplasty (MIP) when stratified by initial radiologic study and symptoms after ureteral stent removal. METHODS: We retrospectively reviewed adults who underwent MIP (1996-2019) at a single academic center. Patients with at least 11 months of follow-up and patients who had a Mag3 scan as their initial postoperative imaging were included. Postprocedure, patients were categorized as having normal, equivocal, or obstructed imaging based on their initial radiologic test. Patients who were obstructed were excluded. Primary outcome was procedural failure, defined as the need for a procedure to treat recurrent obstruction. Secondary outcomes were radiologic failure and symptomatic failure. Groups were compared to assess for statistical significance (P <.05). RESULTS: Overall, 122 patients met inclusion criteria. On initial postoperative imaging, 108 (89%) patients had no obstruction and 14 (11%) had equivocal findings. The procedural failure rate was 6.5% in the unobstructed group and 28.6% in the equivocal group (P = .023). Seven unobstructed patients (6.5%) and 2 equivocal patients (14.3%) eventually experienced radiologic failure (P = .275). Among patients who had no obstruction on initial imaging and remained asymptomatic, only one (0.9%) required a salvage procedure. CONCLUSION: Recurrent obstruction after pyeloplasty varied based on the outcome of the initial radiologic study. These rates can be used to counsel patients and guide physicians' choice of surveillance schedules. The risk of future failure is very low in asymptomatic patients with normal initial imaging. The utility of routine radiologic surveillance in these patients may be limited.

Surveillance After Ureteroneocystostomy: Is it Necessary?

OBJECTIVE: To determine the utility of post-operative imaging after ureteroneocystostomy and whether long-term symptom or radiographic surveillance aided in the detection of recurrent obstruction. MATERIALS AND METHODS: Adult patients were identified who underwent a ureteroneocystostomy with or without psoas hitch or Boari flap between January 2012 and June 2021. Patients who underwent a bilateral procedure, had active malignancy or immediate failure, or did not have 6 months of follow-up with 2 imaging studies were excluded. Using the initial imaging study after stent removal, patients were categorized into normal and equivocal groups according to predefined radiologic criteria. Patients were followed longitudinally to determine whether they subsequently developed radiographic evidence of obstruction. Follow up visits were reviewed for patient symptoms suggestive of post-operative obstruction, defined as flank pain, hematuria, or pyelonephritis. RESULTS: One hundred and twelve patients met criteria. Normal and equivocal initial imaging was seen in 99 and 13 patients, respectively. At a mean radiologic follow-up of 32 months, stricture recurrence was identified in 3 patients with normal initial imaging. No patients with initial equivocal imaging demonstrated recurrent obstruction at mean radiologic follow-up of 29 months. All patients with recurrent stricture presented with symptoms of obstruction. Of patients who developed symptoms after ureteroneocystostomy, 13.6% had recurrent stricture. CONCLUSION: Asymptomatic patients after ureteroneocystostomy who had either normal or equivocal post-operative imaging did not benefit from additional radiologic testing in this cohort. All patients that demonstrated failure presented with symptomatic obstruction that warranted imaging. Surgeons may consider restricting surveillance imaging to symptomatic patients after the initial post-operative period.

Including Medical Management in the Urologic Approach to Idiopathic Retroperitoneal Fibrosis.

OBJECTIVE: To characterize the timing and effectiveness of medical management in resolving stent-dependent ureteral compression secondary to idiopathic retroperitoneal fibrosis (RPF), the long-term relevant outcomes, and the side effects of treatment. METHODS: A retrospective review of RPF patients diagnosed from 2002-2018 was performed. Patients with hydronephrosis due to ureteral involvement that were managed with medication and with temporary stenting as needed, but without initial ureterolysis, were included. Patient demographics and RPF management details were obtained, including the following subsequent events: ureterolysis, nephrectomy, recurrent upper tract obstruction, and medication side effects. RESULTS: Fifty-two patients met inclusion criteria. Resolution of ureteral obstruction with medical management and temporary renal drainage as needed occurred in 36 (69%) patients with a median stent duration of 16 months, and median clinical and radiographic follow up of 4.2 and 3.3 years, respectively. Recurrent obstruction after a stent-free period occurred in 9 (18%) patients. Ureterolysis was performed in 8 (15%) patients at a median of 2.2 years for medication intolerance, lack of radiographic response to medication, or persisting pain. Potential medication side effects occurred in 6 (12%) patients. CONCLUSIONS: Medical management supported successful resolution of ureteral obstruction in 69% of patients without the need for ureterolysis after temporary renal drainage using stents, with rare incidence of worsening renal dysfunction or medication side effect. To date, this is the largest reported series of systematically managed RPF patients with obstructive uropathy receiving initial medical therapy and serves to counsel patients and advise urologists and nephrologists of the expected course and advantages and disadvantages of medical versus surgical management.

Risk factors for orgasmic and concomitant erectile dysfunction in men with type 1 diabetes: a cross-sectional study.

In this study, we sought to determine the burden and characteristics of orgasmic dysfunction (OD) and concomitant erectile dysfunction (ED) in men with type 1 diabetes (T1D) enrolled in the Epidemiology of Diabetes Interventions and Complications (EDIC) study. In 2010, we assessed orgasmic and erectile function using the International Index of Erectile Function (IIEF). Sociodemographic, clinical, and diabetes characteristics were compared by OD status (OD only, OD and ED, no ED or OD). Age-adjusted associations between risk factors and OD status were examined. OD and ED information was available from 563 men. Eighty-three men (14.7%) reported OD of whom 21 reported OD only and 62 reported OD and ED. Age-adjusted odds ratios demonstrated that men who reported OD only had higher odds of depression, low sexual desire, and decreased alcohol use compared with men reporting no dysfunction. Men with OD concomitant with ED had greater odds of elevated hemoglobin A1C, peripheral and autonomic neuropathy, and nephropathy. Men reporting both dysfunctions were also more likely to report smoking, lower urinary tract symptoms, and had greater odds of androgen deficiency than men with no sexual dysfunction. Men with longstanding T1D suffer from an increased burden of OD. Psychogenic factors predominate in men reporting OD only while men who present with concomitant ED report increased burden of diabetes severity, characteristics previously observed with incident ED. ED may be the central impediment to sexual function in men with OD and ED. Longitudinal studies to characterize OD and ED experience over time are warranted.

Treatment of urethral stricture disease in women: A multi-institutional collaborative project from the SUFU research network.

AIM: Female urethral stricture disease is rare and has several surgical approaches including endoscopic dilations (ENDO), urethroplasty with local vaginal tissue flap (ULT) or urethroplasty with free graft (UFG). This study aims to describe the contemporary management of female urethral stricture disease and to evaluate the outcomes of these three surgical approaches. METHODS: This is a multi-institutional, retrospective cohort study evaluating operative treatment for female urethral stricture. Surgeries were grouped into three categories: ENDO, ULT, and UFG. Time from surgery to stricture recurrence by surgery type was analyzed using a Kaplan-Meier time to event analysis. To adjust for confounders, a Cox proportional hazard model was fit for time to stricture recurrence. RESULTS: Two-hundred and ten patients met the inclusion criteria across 23 sites. Overall, 64% (n = 115/180) of women remained recurrence free at median follow-up of 14.6 months (IQR, 3-37). In unadjusted analysis, recurrence-free rates differed between surgery categories with 68% ENDO, 77% UFG and 83% ULT patients being recurrence free at 12 months. In the Cox model, recurrence rates also differed between surgery categories; women undergoing ULT and UFG having had 66% and 49% less risk of recurrence, respectively, compared to those undergoing ENDO. When comparing ULT to UFG directly, there was no significant difference of recurrence. CONCLUSION: This retrospective multi-institutional study of female urethral stricture demonstrates that patients undergoing endoscopic management have a higher risk of recurrence compared to those undergoing either urethroplasty with local flap or free graft.

Patient-reported outcomes from a single-centre prospective post-marketing study on Collagenase Clostridium Histolyticum injections for Peyronie's disease.

The aim of this study was to evaluate patient-reported outcomes of Collagenase Clostridium Histolyticum (CCHi) for Peyronie's Disease. Patients treated with 2-4 cycles of CCHi between 01/2016 and 08/2018 were asked to fill out the "bother domain" of the Peyronie's Disease Questionnaire (PDQ) at scheduled appointments for injections. CCHi cycles involved two injections (0.58 mg) separated by 48-72 hr. During the study, 34 patients were treated, seven patients were excluded due to incomplete baseline values. Mean (standard deviation) PDQ bother domain baseline score was 11.1 (2.6). ANOVA demonstrated statistically significant effects of injections (p < .001) with a decrease in PDQ bother domain scores 6 weeks after the 1st cycle (9.9 [3.3], p = .013), 6 weeks after the 2nd cycle (8.2 [4.0], p = .009) and 6 weeks after the 3rd cycle (6.5 [3.6], p < .001). After 2-4 cycles of CCHi treatment, patients reported changes in penile curvature as "Worse" (0), "No Change" (2), "Little decrease" (10), Decrease (10) and "Significant decrease" (4). After completion of CCHi treatment, 82% of patients still reported that vaginal intercourse was difficult or impossible. Patients with Peyronie's Disease undergoing CCHi treatment reported statistically significant decreases in PDQ bother domain scores. However, most patients still report difficulty with intercourse after treatment.

Robotic Versus Open Ureteroneocystostomy: Is There a Robotic Benefit?

Aim: We sought to compare the outcomes of patients who underwent an open vs robotic ureteroneocystostomy for ureteral obstruction. Methods: Retrospective review was performed on adult patients who underwent primary ureteroneocystostomy for obstruction from January 2012 to April 2018. Intraoperative outcomes of estimated blood loss (EBL) and operative time, as well as postoperative outcomes of catheter and stent duration, length of hospital stay, inpatient nurse-controlled opioid use, patient-controlled analgesia (PCA), and outpatient opioid prescription, complications, readmission, radiologic and clinical stricture recurrence, and follow-up, were compared. Among the open cohort, indications for an open approach were evaluated, identifying patients with prior complex open abdominal surgery that would make an open approach preferable. Results: Open ureteroneocystostomy was performed in 27 patients compared with 18 who underwent a robotic approach. The open and robotic cohorts were not significantly different in age, gender, Charlson comorbidity index, stricture location or side, abdominal surgery (laparoscopic or open), pelvic radiation, or preoperative urinary tract infection. The robotic group had a significantly lower rate of prior open abdominal surgery. The robotic cohort had significantly lower EBL, length of stay (LOS), catheter duration, prescribed morphine milliequivalents (MME) at discharge, and rate of PCA usage. Among the open cohort, 13 (48%) patients demonstrated indications making an open approach preferable. Comparing the robotic group with the remaining 14 open patients revealed a significantly lower rate of inpatient PCA use, prescribed MME at discharge, LOS, and catheter duration. Mean operative time was higher in the robotic group. EBL was not significantly different in this subanalysis. Conclusions: Robotic ureteroneocystostomy provides similar outcomes when compared with an open approach in well-selected patients when assessing for recurrent ureteral obstruction or adverse events. Robotic surgery is associated with lower postoperative narcotic pain prescriptions at discharge, lower PCA usage, and shorter LOS, which are important benefits when compared with open surgery.

Does Early Ureteroneocystostomy After Iatrogenic Ureteral Injury Jeopardize Outcome?

OBJECTIVE: To compare the outcomes of patients who underwent early repair (≤7 days) of iatrogenic ureteral injury with ureteroneocystostomy and compare them to those repaired in a delayed fashion (>7 days). METHODS: A retrospective review of billing data between 2012 and 2018 identified patients who underwent ureteroneocystostomy for a benign ureteral disease. Inclusion criteria included all ureteral injuries related to a laparoscopic, robotic, or open surgical injury. Patients with ureteral injury related to radiation, stones, or reconstructive surgery were excluded. Patients undergoing reconstruction during the initial injury or within ≤7 days were designated as having undergone early repair, while the remaining were considered delayed repair. Demographics, as well as inpatient and postdischarge data were acquired, and statistical analysis was performed comparing the 2 groups. RESULTS: Sixty-seven patients met inclusion criteria. Early repair was performed on 12 patients, while 55 underwent delayed repair. No significant difference in age, gender, Charlson Comorbidity Score, laterality, stricture location, or history of pelvic/abdominal radiation was noted. Inpatient complications were significantly higher in the immediate group (58 vs 18%, P =.004). Thirty- and 90-day complications were similar. Two patients in the delayed group and none in the immediate group demonstrated stricture recurrence (P =.710). A higher rate of Boari flap ureteral reconstruction was performed in the delayed cohort (P =.001). CONCLUSION: In this cohort, there was no detectable difference in outcomes when comparing early and delayed ureteroneocystostomy for iatrogenic ureteral injuries.

Extended Case Duration and Hypotension Are Associated With Higher-grade Postoperative Complications After Urinary Diversion for Non-oncological Disease.

OBJECTIVE: To report survival for patients who undergo urinary diversion for benign indications and to identify risk factors for morbidity at 90 days. METHODS: This is a retrospective review of consecutive urinary diversions with or without cystectomy for non-oncological indications at a single institution. The indication for diversion was intractable incontinence, upper tract deterioration, urinary fistula, and unmanageable bladder pain. Patients were categorized according to their most severe complication within 90 days of surgery, using the Clavien-Dindo system. Multivariable analysis was performed to identify factors associated with high-grade complications. Survival analysis was performed. RESULTS: Between 2007 and 2014, 141 patients underwent urinary diversion for non-oncological indications. The postoperative rate of high-grade adverse events (class III or greater) was 28%. Risk factors for class III or greater complications at 90 days included prolonged intraoperative mean arterial pressure below 75% of baseline, operative duration greater than 343 minutes, and postoperative vasopressor requirement. Kaplan-Meier survival analysis demonstrated a 1- and 5-year survival of 88.4% and 77.2%, respectively. The long-term survival of patients who experienced higher-grade complications was not statistically different from the survival of the rest of the group. The study was limited by a retrospective design and sample size in identifying additional variables associated with increased risk of long-term mortality. CONCLUSION: Urinary diversion for non-oncological conditions has a good 5-year survival in this cohort. Extended case duration and hemodynamic instability during or immediately after urinary diversion are associated with a high-grade complication within 90 days of the procedure.

Comparative evaluation of physical characteristics of different inflatable penile prostheses.

OBJECTIVE: The aim of this study was to describe and evaluate existing inflatable penile prostheses (IPPs) in an independent laboratory setting. MATERIALS AND METHODS: New IPPs were obtained from two manufacturers: American Medical Systems (AMS) and Coloplast. The AMS 700™ LGX (18 cm), CX (18 cm) and CXR (14 cm), and the Coloplast Titan® Touch (18 cm) and Titan Narrow (14 cm) were investigated. Internal pressure, length and girth of the cylinders were measured at 2 ml increments. A urodynamic individual transducer connected to an analogue amplifier and recording system was used to measure pressure. Rigidity and axial loading of the different IPPs were evaluated with a compression system. RESULTS: Regular-size prostheses were inflated to 22 ml and narrow prostheses to 16 ml. The Titan Touch had a girth of 17.8 mm at 22 ml compared to 15.6 mm for the AMS 700 LGX and 16.5 mm for CX. The AMS 700 LGX increased in length by 13 mm from baseline, a feature that was unique among all the tested prostheses. Rigidity curves as assessed by compression showed significant variability, with both Titan prostheses and the AMS CXR exhibiting similar patterns and requiring a higher load to reach 50% compression. The buckling experiment showed different patterns of deformity. CONCLUSIONS: The results suggest that these prostheses exhibit significant physical differences. The clinical impact of these differences is poorly elucidated. These variations in behavior of the prostheses could be considered by physicians and patients when objectively assessing the choice of prosthesis. These findings could aid in objective patient counseling.

The Value of Urodynamics in an Academic Specialty Referral Practice.

OBJECTIVE: To describe and evaluate the use of urodynamics (UDS) studies for all indications in an academic specialty referral urology practice. MATERIALS AND METHODS: This is a prospective questionnaire-based study wherein clinicians completed a pre- and post-UDS questionnaire on each UDS that they ordered for all clinical indications between May 2013 and August 2014. Questions pertained to patient demographics and history, the clinical indication for the UDS, the clinician's pre- and post-UDS clinical impressions, and changes in post-UDS management plans. Pre- and post-UDS diagnoses were compared using the McNemar test. RESULTS: Clinicians evaluated a total of 285 UDS studies during the study period. The average age of study participants was 56.0 (±16.4) years, 59.5% were female, and 29.3% had a neurologic diagnosis. The most common indication for performing UDS was to discern the predominant type of urinary incontinence (stress vs urgency) in patients with mixed incontinence symptoms (38.5%) and to assess the safety of the bladder during filling (38.2%). UDS statistically significantly changed the ordering clinician's clinical impression of the patient's lower urinary tract diagnosis for stress urinary incontinence and for urgency and urgency urinary incontinence (both had P values of <.05). Fluoroscopy was found to be helpful in 29.5% of urodynamic studies, and clinicians reported that UDS changed their treatment plans in 42.5% of the studies, most commonly pertaining to changes related to surgery (35.0%). CONCLUSION: Overall, UDS was a clinically useful tool that altered the clinical impression and treatment plan in a large percentage of carefully selected patients.

Diversity of patient profile, urethral stricture, and other disease manifestations in a cohort of adult men with lichen sclerosus.

PURPOSE: Lichen sclerosus (LS) in men is poorly understood. Though uncommon, it is often severe and leads to repeated surgical interventions and deterioration in quality of life. We highlight variability in disease presentation, diagnosis, and patient factors in male LS patients evaluated at a tertiary care center. MATERIALS AND METHODS: We retrospectively reviewed charts of male patients presenting to our reconstructive urology clinic with clinical or pathologic diagnosis of LS between 2004 and 2014. Relevant clinical and demographic information was abstracted and descriptive statistics calculated. Subgroup comparisons were made based on body mass index (BMI), urethral stricture, and pathologic confirmation of disease. RESULTS: We identified 94 patients with clinical diagnosis of LS. Seventy percent (70%) of patients in this cohort had BMI >30 kg/m(2), and average age was 51.5 years. Lower BMI patients were more likely to suffer from urethral stricture disease compared to overweight counterparts (p=0.037). Patients presenting with stricture disease were more likely to be younger (p=0.003). Thirty percent (30%) of this cohort had a pathologic diagnosis of LS. CONCLUSIONS: Urethral stricture is the most common presentation for men with LS. Many patients endure skin scarring and have numerous comorbidities. Patient profile is diverse, raising the concern that not all patients with clinical diagnosis of LS are suffering from identical disease processes. The rate of pathologic confirmation at a tertiary care institution is alarmingly low. Our findings support a role for increased focus on pathologic confirmation and further delineation of the subtype of disease based on location and clinical manifestations.

Ureteral Involvement Within an Incarcerated Inguinal Hernia in a Patient With Crossed-fused Renal Ectopia.

Crossed-fused renal ectopy is an uncommon abnormality of the genitourinary tract that results from errors during embryological development. Ureteral herniation represents another rare anatomic event and can often occur from spontaneous, postoperative, and congenital causes (Allam, Johnson, Grewal & Johnson 2015; Pollack, Popky & Blumberg 1975). Here, we discuss the complex clinical course of a patient with crossed-fused renal ectopia who presents with symptoms due to ureteroinguinal herniation and provide a brief overview of the literature. We highlight the clinical considerations in the management of this patient and provide a potential anatomical and embryological explanation for his presentation.

Patient perceptions of physical and emotional discomfort related to urodynamic testing: a questionnaire-based study in men and women with and without neurologic conditions.

OBJECTIVE: To determine predictors of physical and emotional discomfort associated with urodynamic testing in men and women both with and without neurologic conditions. METHODS: An anonymous questionnaire-based study was completed by patients immediately after undergoing fluoroscopic urodynamic testing. Participants were asked questions pertaining to their perceptions of physical and emotional discomfort related to the study, their urologic and general health history, and demographics. Logistic regression was performed to determine predictors of physical and emotional discomfort. RESULTS: A total of 314 patients completed the questionnaire representing a response rate of 60%. Half of the respondents (50.7%) felt that the examination was neither physically nor emotionally uncomfortable, whereas 29.0% and 12.4% of respondents felt that the physical and emotional components of the examination were most uncomfortable, respectively. Placement of the urethral catheter was the most commonly reported component of physical discomfort (42.9%), whereas anxiety (27.7%) was the most commonly reported component of emotional discomfort. Presence of a neurologic problem (odds ratio, 0.273; 95% confidence interval, 0.121-0.617) and older age (odds ratio, 0.585; 95% confidence interval, 0.405-0.847) were factors associated with less physical discomfort. There were no significant predictors of emotional discomfort based on our model. CONCLUSION: Urodynamic studies were well tolerated regardless of gender. Presence of a neurologic condition and older age were predictors of less physical discomfort. These findings are useful in counseling patients regarding what to expect when having urodynamic procedures.

The S-CAHPS Survey in Urology.

INTRODUCTION: The S-CAHPS survey assesses patient experience and satisfaction with 1 episode of surgical care. We describe the initial implementation, results and experience using S-CAHPS in urology. METHODS: This was a prospective, institutional review board approved, observational study at a tertiary care academic medical center. Adult patients who underwent elective outpatient or 23-hour observation surgery during a 33-month period were mailed the survey. Survey content was separated into composites 1 to 6 and percent top box scoring (percent of most positive responses) was performed. Summary scores for each composite were correlated with the mean of a global surgeon rating question. RESULTS: A total of 430 surveys were returned for a 33.8% response rate. Respondents were statistically older than nonrespondents and more likely to reside in Michigan (p <0.05). Mean ± SD global surgeon rating was 9.50 ± 1.04 on a scale of 0-worst to 10-best surgeon possible. Global surgeon rating correlated most highly with the question composites for "How well surgeon communicates with patients after surgery" (composite 5, τ = 0.459), followed by "Information to help you recover from surgery" (composite 4, τ = 0.400). Conversely, there was lower correlation with composites pertaining to "Information to help you prepare for surgery" (composite 1, τ = 0.251). CONCLUSIONS: Survey results suggest that patient satisfaction with the surgeon is more influenced by postoperative communication and information than by preoperative counseling and decision making processes. This underscores the importance of attention to continued postoperative care and interactions. The role of S-CAHPS in urology requires further exploration in this era of quality improvement.

Should blunt segmental vascular renal injuries be considered an American Association for the Surgery of Trauma Grade 4 renal injury?

BACKGROUND: Renal segmental vascular injury (SVI) following blunt abdominal trauma is not part of the original American Association for the Surgery of Trauma (AAST) renal injury grading system. Recent recommendations support classifying SVI as an AAST Grade 4 (G4) injury. Our primary aim was to compare outcomes following blunt renal SVI and blunt renal collecting system lacerations (CSLs). We hypothesize that renal SVI fare well with conservative management alone and should be relegated a less severe renal AAST grade. METHODS: We retrospectively identified patients with SVI and G4 CSL admitted to a Level 1 trauma center between 2003 and 2010. Penetrating trauma was excluded. Need for surgical intervention, length of stay, kidney salvage (>25% renal preservation on renography 6-12 weeks after injury), and delayed complication rates were compared between the SVI and CSL injuries. Statistical analysis used χ, Fisher's exact, and t tests. RESULTS: A total of 56 patients with SVI and 88 patients with G4 CSL sustained blunt trauma. Age, Injury Severity Score (ISS), and length of stay were similar for the two groups. Five patients in each group died of concomitant, nonrenal injuries. In the G4 CSL group, 15 patients underwent major interventions, and 32 patients underwent minor interventions. Only one patient in the SVI group underwent a major intervention. The renal salvage rate was 85.7% following SVI versus 62.5% following CSL (p = 0.107). CONCLUSION: Overall, surgical interventions are significantly lower among the SVI cohort than the G4 CSL cohort. Further analysis using a larger cohort of patients is recommended before revising the current renal grading system. Adding SVI as a G4 injury could potentially increase the heterogeneity of G4 injuries and decrease the ability of the AAST renal injury grading system to predict outcomes, such as nephrectomy rate. LEVEL OF EVIDENCE: Epidemiologic study, level IV.