[Traumatic injuries of the kidney and the urinary tract in blunt abdominal trauma]. / Traumatische Verletzungen der Nieren und der ableitenden Harnwege bei stumpfen Bauchtraumata.

BACKGROUND: In the context of blunt abdominal trauma, injuries to the urinary tracts often occur, especially in polytrauma patients. Urotrauma is rarely immediately life-threatening but can lead to serious complications and chronic functional limitations during treatment. Therefore early urological involvement is crucial for adequate interdisciplinary treatment. METHODS: The most important facts for the clinical routine on the consultant urological management of urogenital injuries in blunt abdominal trauma are discussed according to the European "EAU guidelines on Urological Trauma" and the German "S3 guidelines on Polytrauma/Treatment of Severely Injured Patients" as well as the relevant literature. RESULTS: Urinary tract injuries can occur even with an initially inconspicuous status and always require explicit exclusion diagnostics by means of contrast medium tomography of the entire urinary tract and, if necessary, by means of urographic and endoscopic examinations. The most common urological intervention is catheterization of the urinary tract which is often required. Less common is urological surgery, which should be coordinated interdisciplinarily with visceral and trauma surgery. More than 90% of vitally threatening kidney injuries (usually up to the American Association for the Surgery of Trauma (AAST) grades 4-5) are now treated by interventional radiology. CONCLUSION: Due to possible complex injury patterns in blunt abdominal trauma, these patients should ideally be directed to (certified) trauma centers with subspecialized or maximum care from the departments of visceral and vascular surgery, trauma surgery, interventional radiology and urology.

Infecção do trato urinário por leveduras do gênero Candida ­ revisão de literatura / Urinary tract infection by yeast of the genus Candida - literature review / Infección del tracto urinario causada por levaduras del género Candida - revisión de la literatura

A ocorrência das infecções do trato urinário (ITU) causadas por leveduras do gênero Candida estão aumentando consideravelmente nas últimas décadas, sendo a Candida albicans a mais comumente diagnosticada como causadora deste tipo de infecções. Contudo, outras espécies, como exemplo da Candida tropicalis, estão emergindo como preocupantes causadores da doença. Neste sentido, o objetivo do presente trabalho é revisar os aspectos relacionados com as ITU causadas por leveduras do gênero Candida. Foi realizada uma pesquisa na base de dados PubMed, buscando artigos sobre a epidemiologia, patogenia e tratamento das ITU causadas por leveduras do gênero Candida. As espécies de Candida são os fungos patogênicos oportunistas mais relevantes causadores de infecções nosocomiais e podem causar infecção no trato urinário, tanto inferior (ureteres, bexiga e uretra) quanto superior (rins), principalmente em pacientes imunocomprometidos. Existem alguns fatores predisponentes, como gênero feminino, idade avançada, diabetes mellitus, hospitalização prolongada, imunossupressão, gravidez, hipertensão, neutropenia, cálculos renais, infecções nosocomiais, terapia antibiótica e procedimentos, como a cateterização, que atuam como facilitadores das ITU por Candida spp. A doença pode ocorrer de forma assintomática, porém, pode evoluir para casos mais graves com comprometimento sistêmico em situações de candidemia que pode causar a morte do paciente, principalmente se tratando de indivíduos imunocomprometidos. Sendo assim, devido ao risco existente, a doença não pode ser negligenciada e um diagnóstico preciso e um tratamento adequado devem ser estabelecidos.

The occurrence of urinary tract infections (UTI) caused by yeasts of the genus Candida has increased considerably in recent decades, with Candida albicans being the most commonly diagnosed as causing this type of infections. However, other species, such as Candida tropicalis, are emerging as worrisome causes of the disease. In this sense, the objective of the present paper is to review the aspects related to the UTI caused by yeasts of the genus Candida. A search was carried out in the PubMed database, searching for articles on the epidemiology, pathogenesis and treatment of UTI caused by yeasts of the genus Candida. Candida species are the most relevant opportunistic pathogenic fungi that cause nosocomial infections and can cause both lower (ureters, bladder and urethra) and upper (kidneys) urinary tract infections, especially in immunocompromised patients. There are some predisposing factors, such as female gender, advanced age, diabetes mellitus, prolonged hospitalization, immunosuppression, pregnancy, hypertension, neutropenia, kidney stones, nosocomial infections, antibiotic therapy and procedures, such as catheterization, that act as facilitators of UTI by Candida spp. The disease can occur asymptomatically, however, it can progress to more severe cases with systemic involvement in situations of candidemia that can cause the death of the patient, especially in immunocompromised individuals. Therefore, due to the existing risk, the disease cannot be neglected and an accurate diagnosis and adequate treatment must be established.

La aparición de infecciones del tracto urinario (ITU) causadas por levaduras del género Candida ha aumentado considerablemente en las últimas décadas. Candida albicans es la infección por levaduras más comúnmente diagnosticada. Sin embargo, otras especies, como la Candida tropicalis, están surgiendo como causa preocupante de la enfermedad. En este sentido, el objetivo del presente trabajo es revisar los aspectos relacionados con la ITU causada por levaduras del género Candida. Se realizó una búsqueda en la base de datos PubMed, buscando artículos sobre la epidemiología, la patogénesis y el tratamiento de la ITU causada por levaduras del género Candida. Las especies de Candida son los hongos patógenos oportunistas más relevantes que causan infecciones nosocomiales y pueden provocar infecciones del tracto urinario inferior (uréteres, vejiga y uretra) y superior (riñones), especialmente en pacientes inmunodeprimidos. Existen algunos factores predisponentes, como el sexo femenino, la edad avanzada, la diabetes mellitus, la hospitalización prolongada, la inmunosupresión, el embarazo, la hipertensión, la neutropenia, los cálculos renales, las infecciones nosocomiales, la terapia con antibióticos y los procedimientos como el cateterismo, que actúan como facilitadores de la ITU por Candida spp. La enfermedad puede presentarse de forma asintomática, pero puede evolucionar a casos más graves con afectación sistémica en situaciones de candidemia que pueden causar la muerte del paciente, especialmente en individuos inmunodeprimidos. Por lo tanto, debido al riesgo existente, no se puede descuidar la enfermedad y se debe establecer un diagnóstico preciso y un tratamiento adecuado.

Judgment and Prevention of Urinary Tract Injury in Gynecological Surgery Based on Data Mining.

In this paper, a data mining-enabled model is developed to analyze the case-related data of 39 patients with urinary tract injury who underwent laparoscopic surgery in a certain hospital from 2012 to 2017. Statistics on the history and characteristics of the case data summarized and analyzed the causes of urinary tract injury and the urinary system. The relationship between the occurrence of injury and the type of surgery and the treatment and preventive measures taken for urinary tract injury during and after surgery are summarized. The statistical method with SPSS16.0 statistical software was used to analyze the data of this study, and the X 2 test was used to compare the rates. The differences of P ≤ 0.05 and P ≤ 0.01 were statistically significant. Laparoscopic surgery in gynecology is a minimally invasive technique, but it is still accompanied by the possibility of complications. During the experimental setup and implementation, we have observed that among 8742 cases of laparoscopic surgery complicated by urinary tract injury, there were 39 cases with a rate of 0.45%. In the past five years, the incidence of urinary tract injury in gynecological surgery in our country has increased year by year, and the number of cases of urinary tract injury has also increased year by year. Through analysis, it is found that the cause of the injury is related to the level of surgery, pelvic adhesion, and energy equipment. Based on the above problems, according to the clinical data of patients with urinary tract injury complicated by gynecological surgery in the hospital, the relevant factors of gynecological surgery complicated by urinary tract injury are analyzed to improve the awareness of urinary tract protection and prevention of injury during the operation and preventive measures are actively taken to avoid medical treatment.

Association between cystoscopy at the time of hysterectomy performed by a gynecologic oncologist and delayed urinary tract injury.

OBJECTIVE: Guidance regarding the use of cystoscopy at the time of hysterectomy is lacking in gynecologic oncology. We compare the rate of delayed urinary tract injury in women who underwent cystoscopy at the time of hysterectomy performed by a gynecologic oncologist for benign or malignant indication with those who did not. METHODS: This was a retrospective cohort study of patients who had a hysterectomy performed by a gynecologic oncologist recorded in the National Surgical Quality Improvement Program between January 2014 and December 2017. The primary outcome was delayed urinary tract injury in the 30-day post-operative period. Secondary outcomes were operative time and urinary tract infection rate. The exposure of interest was cystoscopy at the time of hysterectomy and bivariable tests were used to examine associations. RESULTS: We identified 33 355 women who underwent hysterectomy for benign (41%; n=13 621) or malignant (59%; n=19 734) indications performed by a gynecologic oncologist. Surgical approach was open (39%; n=12 974), laparoscopic or robotic-assisted laparoscopic (55%; n=18 272), and vaginal or vaginally-assisted (6%; n=2109). Overall, 12% of women (n=3873) underwent cystoscopy at the time of surgery; cystoscopy was more commonly performed in laparoscopic (15%; n=2829) and vaginal (12%; n=243) approaches than with open hysterectomy (6%; n=801) (p<0.001). There was no difference in the rate of delayed urinary tract injury in patients who underwent cystoscopy at the time of surgery compared with those who did not (0.4% vs 0.3%, p=0.32). However, patients who underwent cystoscopy were more likely to be diagnosed with a urinary tract infection (3% vs 2%, RR 1.3, 95% CI 1.1 to 1.6). In cases where cystoscopy was performed, median operative time was increased by 9 min (137 vs 128 min, p<0.001). CONCLUSION: Cystoscopy at the time of hysterectomy performed by a gynecologic oncologist does not result in a lower rate of delayed urinary tract injury compared with no cystoscopy.

Urinary tract injuries during cesarean delivery: long-term outcome and management.

OBJECTIVE: Urinary tract injury during cesarean delivery is a rare but severe complication. Due to the high prevalence of cesarean delivery, this injury may pose a high burden of morbidity. We reviewed the cases of lower urinary tract injuries identified during cesarean delivery in a tertiary medical center and identified diagnosis and treatment methods, as well as short and long-term outcomes, to establish a protocol of care for such cases. METHODS: We included women with urinary tract injury during cesarean delivery between 2004 and 2018. The cases were identified according to ICD-9 codes, as well as free text in the medical report and discharge letter. Data were collected retrospectively. Telephone interviews were conducted to obtain additional data regarding long-term outcomes. RESULTS: In14 years, a total of 17,794 cesarean deliveries were performed at our institution (17.5% of all deliveries), 14 cases of bladder injury, and 11 cases of ureteral injury were identified featuring an incidence of 0.08 and 0.06%, respectively. All bladder injuries were diagnosed and repaired intra-operatively. Six (55%) cases of ureteral injury were diagnosed in the post-operative period, and 3 of these patients required further surgery for definitive treatment. None of the patients suffered long-term adverse effects. Most bladder injuries occurred in women with previous cesarean delivery in the presence of abdominal adhesions. In contrast, most ureteral injuries occurred in women with emergency cesarean delivery during the second stage of labor, and were accompanied by an extension of the uterine incision. All women had normal kidney function in follow up and did not suffer from long term sequelae. CONCLUSION: Urinary tract injury is an uncommon complication of cesarean delivery. A high index of suspicion is recommended to avoid late diagnosis and complications. We propose a comprehensive protocol for the management of these injuries.

Damage Control for renal trauma: the more conservative the surgeon, better for the kidney.

Urologic trauma is frequently reported in patients with penetrating trauma. Currently, the computerized tomography and vascular approach through angiography/embolization are the standard approaches for renal trauma. However, the management of renal or urinary tract trauma in a patient with hemodynamic instability and criteria for emergency laparotomy, is a topic of discussion. This article presents the consensus of the Trauma and Emergency Surgery Group (CTE) from Cali, for the management of penetrating renal and urinary tract trauma through damage control surgery. Intrasurgical perirenal hematoma characteristics, such as if it is expanding or actively bleeding, can be reference for deciding whether a conservative approach with subsequent radiological studies is possible. However, if there is evidence of severe kidney trauma, surgical exploration is mandatory and entails a high probability of requiring a nephrectomy. Urinary tract damage control should be conservative and deferred, because this type of trauma does not represent a risk in acute trauma management.

El trauma renal y de las vías urinarias se presenta con relativa frecuencia en pacientes con trauma penetrante. El estándar actual de manejo es realizar una evaluación imagenológica, por medio de tomografía computarizada y un abordaje vascular, a través de técnicas de angiografía/embolización. Sin embargo, el manejo de un paciente hemodinámicamente inestable con criterios de laparotomía de emergencia, con hallazgos de trauma renal o de vías urinarias es aún tema de discusión. El siguiente articulo presenta el consenso del grupo de Cirugía de Trauma y Emergencias (CTE) de Cali respecto al manejo del trauma penetrante renal y de vías urinarias mediante cirugía de control de daños. Las características intra quirúrgicas del hematoma perirrenal tales como si es expansivo o si tiene signos de sangrado activo, son puntos de referencia para decidir entre un abordaje conservador, por estudios imagenológicos posteriores. En cambio, si existe la sospecha de un trauma renal severo, se debe realizar exploración quirúrgica con alta probabilidad de una nefrectomía. El manejo de control de daños de las vías urinarias debe ser conservador y diferido, la lesión de estos órganos no representa un riesgo en el manejo agudo del trauma.

Placenta accreta spectrum: Management and outcomes in a tertiary centre in India: An observational cross-sectional study.

Our observational cross-sectional study looked at the risk factors, diagnosis, management and outcomes of placenta accrete spectrum at the Christian Medical College and Hospital, Vellore, India, between January 2013 and December 2018. A total of 21 cases of placenta accrete spectrum are described among whom a preop diagnosis was available in 14 cases. A previous history of Caesarean section and placenta previa was present in 90%. Caesarean hysterectomy was carried out in 80%, but none of those managed conservatively required interval hysterectomy. Urinary tract injury was the most common surgical complication, seen in over 50%. The mean blood loss was 3.5 l and 14 patients required intensive care unit admission, but no maternal mortality ensued. Thus, we conclude that the conservative management in carefully selected cases is feasible.

Trends, characteristics, and outcomes of placenta accreta spectrum: a national study in the United States.

BACKGROUND: Although an infrequent occurrence, the placenta can adhere abnormally to the gravid uterus leading to significantly high maternal morbidity and mortality during cesarean delivery. Contemporary national statistics related to a morbidly adherent placenta, referred to as placenta accreta spectrum, are needed. OBJECTIVE: This study aimed to examine national trends, characteristics, and perioperative outcomes of women who underwent cesarean delivery for placenta accreta spectrum in the United States. STUDY DESIGN: This is a population-based retrospective, observational study querying the National Inpatient Sample. The study cohort included women who underwent cesarean delivery from October 2015 to December 2017 and had a diagnosis of placenta accreta spectrum. The main outcome measures were patient characteristics and surgical outcomes related to placenta accreta spectrum assessed by the generalized estimating equation on multivariable analysis. The temporal trend of placenta accreta spectrum was also assessed by linear segmented regression with log transformation. RESULTS: Of 2,727,477 cases who underwent cesarean delivery during the study period, 8030 (0.29%) had the diagnosis of placenta accreta spectrum. Placenta accreta was the most common diagnosis (n=6205, 0.23%), followed by percreta (n=1060, 0.04%) and increta (n=765, 0.03%). The number of placenta accreta spectrum cases increased by 2.1% every quarter year from 0.27% to 0.32% (P=.004). On multivariable analysis, (1) patient demographics (older age, tobacco use, recent diagnosis, higher comorbidity, and use of assisted reproductive technology), (2) pregnancy characteristics (placenta previa, previous cesarean delivery, breech presentation, and grand multiparity), and (3) hospital factors (urban teaching center and large bed capacity hospital) represented the independent characteristics related to placenta accreta spectrum (all, P<.05). The median gestational age at cesarean delivery was 36 weeks for placenta accreta and 34 weeks for both placenta increta and percreta vs 39 weeks for non-placenta accreta spectrum cases (P<.001). On multivariable analysis, cesarean delivery complicated by placenta accreta spectrum was associated with increased risk of any surgical morbidities (78.3% vs 10.6%), Centers for Disease Control and Prevention-defined severe maternal morbidity (60.3% vs 3.1%), hemorrhage (54.1% vs 3.9%), coagulopathy (5.3% vs 0.3%), shock (5.0% vs 0.1%), urinary tract injury (8.3% vs 0.2%), and death (0.25% vs 0.01%) compared with cesarean delivery without placenta accreta spectrum. When further analyzed by subtype, cesarean delivery for placenta increta and percreta was associated with higher likelihood of hysterectomy (0.4% for non-placenta accreta spectrum, 45.8% for accreta, 82.4% for increta, 78.3% for percreta; P<.001) and urinary tract injury (0.2% for non-placenta accreta spectrum, 5.2% for accreta, 11.8% for increta, 24.5% for percreta; P<.001). Moreover, women in the placenta increta and percreta groups had markedly increased risks of surgical mortality compared with those without placenta accreta spectrum (increta, odds ratio, 19.9; and percreta, odds ratio, 32.1). CONCLUSION: Patient characteristics and outcomes differ across the placenta accreta spectrum subtypes, and women with placenta increta and percreta have considerably high surgical morbidity and mortality risks. Notably, 1 in 313 women undergoing cesarean delivery had a diagnosis of placenta accreta spectrum by the end of 2017, and the incidence seems to be higher than reported in previous studies.

Self-Induced Trauma to the Genitalia: a Review of the Literature and Management Schemes.

PURPOSE OF REVIEW: Self-induced genital trauma is rare, and prompt and evidence-based early intervention can improve the urinary and sexual function of these complex patients. This review has surveyed current literature and treatment trends to evaluate the clinical approach to managing genital trauma. RECENT FINDINGS: A literature review was performed regarding self-induced genitalia trauma and trauma management between 2000 and 2019 using MEDLINE® database, the Cochrane Library® Central Search, Web of Science, and Google Scholar. In total, 42 articles were considered relevant and included in this review. Self-induced trauma can be appropriately managed with a multidisciplinary approach. Treatment goals are to preserve urinary, sexual, and reproductive function. Specific evaluation includes mechanism of injury, imaging, and determining the extent of injury and surgical repair, if indicated. Due to the rarity of these injuries and their emergent nature, much of the management is based on retrospective data. Further research is needed to improve long-term functional outcomes in trauma patients.

Urinary System Iatrogenic Injuries: Problem Review.

INTRODUCTION: From May to December 2019, a literature review of the urinary system iatrogenic injury problem was performed. The most cited, representative articles in PubMed, Scopus, and WoS databases dedicated to this problem were selected. Urinary system iatrogenic injuries include ureter, bladder, urethra, and kidney traumas. It is widely thought that the main causes of such injuries are urological, obstetric, gynecological, and surgical operations on the retroperitoneal space, pelvis, or perineum. METHODS: The purpose of the study is to describe all aspects of the iatrogenic injure problem, under the established scheme and for each of the most damaged organs: the urethra, bladder, kidney, and ureter. The treatment of confirmed iatrogenic injuries largely depends on the period of its detection. Modern medical procedures provide conservative or minimally invasive treatment. An untimely diagnosis worsens the treatment prognosis. "Overlooked" urinary system trauma is a serious threat to society and a particular patient. Thus, incorrect or traumatic catheterization can lead to infection (RR 95%) and urethral stricture (RR ≥11-36%), and percutaneous puncture nephrostomy can cause the risk of functional renal parenchyma loss (median 5%), urinary congestion (7%), or sepsis (0.6-1.5%). RESULTS: Lost gain, profits, long-term and expensive, possibly multistage treatment, stress and depression, and the risks of suicide put a heavy financial, moral, and ethical burden on a person and society. Also, iatrogenic injury might have legal consequences. DISCUSSION/CONCLUSION: Thus, the significant problem of urinary tract iatrogenic injuries is still difficult to solve. There is a need to implement mandatory examining algorithms for patients at risk, as well as the multidisciplinary principle for all pelvic surgery.

Urethral Injury and Other Urologic Injuries During Transanal Total Mesorectal Excision: An International Collaborative Study.

OBJECTIVE: To identify risk factors for urethral and urologic injuries during transanal total mesorectal excision (taTME) and evaluate outcomes. BACKGROUND: Urethral injury is a rare complication of abdominoperineal resection (APR) that has not been reported during abdominal proctectomy. The Low Rectal Cancer Development Program international taTME registry recently reported a 0.8% incidence, but actual incidence and mechanisms of injury remain largely unknown. METHODS: A retrospective analysis of taTME cases complicated by urologic injury was conducted. Patient demographics, tumor characteristics, intraoperative details, and outcomes were analyzed, along with surgeons' experience and training in taTME. Surgeons' opinion of contributing factors and best approaches to avoid injuries were evaluated. RESULTS: Thirty-four urethral, 2 ureteral, and 3 bladder injuries were reported during taTME operations performed over 7 years by 32 surgical teams. Twenty injuries occurred during the teams' first 8 taTME cases ("early experience"), whereas the remainder occurred between the 12th to 101st case. Injuries resulted in a 22% conversion rate and 8% rate of unplanned APR or Hartmann procedure. At median follow-up of 27.6 months (range, 3-85), the urethral repair complication rate was 26% with a 9% rate of failed urethral repair requiring permanent urinary diversion. In patients with successful repair, 18% reported persistent urinary dysfunction. CONCLUSIONS: Urologic injuries result in substantial morbidity. Our survey indicated that those occurring in surgeons' early experience might best be reduced by implementation of structured taTME training and proctoring, whereas those occurring later relate to case complexity and may be avoided by more stringent case selection.

Needs Assessment for Lower Urinary Tract Injury Curriculum for FPMRS Fellowships.

OBJECTIVE: The aim of this study was to determine the level and types of training Accreditation Council for Graduate Medical Education-accredited programs use for female pelvic medicine and reconstructive surgery (FPMRS) fellows' education on lower urinary tract injuries (LUTIs). METHODS: Two surveys were developed to assess the need for LUTI curriculum from both program director (PD) and fellow vantages through a multistage process, including review by knowledgeable colleagues, cognitive interviews, and pilot testing. Surveys were distributed in an electronic link via e-mail to graduating fellows and program directors from each of the 58 Accreditation Council for Graduate Medical Education-accredited FPMRS programs. RESULTS: Thirty-four graduating FPMRS fellows (71%) and 39 FPMRS PDs (67%) completed the survey. Both PDs and fellows responded that both the evaluation and management of LUTI were necessary to FPMRS training. The majority of PDs use a combination of didactics and hands-on learning in the operating room (60% and 71%). Only 40% and 30% incorporate simulation into the curriculum to address LUTI. Graduating fellows report low numbers of procedures to evaluate and manage LUTI. Specifically, only 15% of fellows graduate with greater than 2 ureteral reimplantations and 44% graduate with no minimally invasive abdominal vesicovaginal fistula repairs. The majority of graduating fellows reported feeling prepared to evaluate for LUTI, but nearly one third do not feel ready to independently manage LUTI upon graduation. CONCLUSIONS: FPMRS PDs and fellows agree that the evaluation and management of LUTI are important; however, most programs use only didactics and hands-on learning in the operating room with extremely low case volumes, leading to decreased proficiency.

Experiencia en el manejo hospitalario del trauma renal de alto grado / Report on management of severe renal trauma

OBJETIVO: Caracterizar la condición clínica, el tipo de abordaje terapéutico y desenlaces de pacientes con trauma renal de alto grado (AAST: 4 y 5) atendidos en un hospital de tercer nivel. Cali, Colombia. MÉTODOS: Se realizó un estudio observacional descriptivo con pacientes mayores de 15 años atendidos entre el 1 de enero de 2015 y el 1 enero de 2019, con diagnóstico de traumatismo renal y traumatismo de vasos renales. Se recolectaron variables demográficas, clínicas y de severidad del trauma. Se realizó un análisis univariado con tablas de frecuencia, medidas de tendencia central, dependiendo de tipo de intervención, lesiones asociadas, uso de hemoderivados e índices de severidad. RESULTADOS: Se analizaron 71 historias clínicas, 82% de sexo masculino, el promedio de edad fue 25 años (rango: 15-55). Respecto al grado trauma renal, el 69%de los pacientes fueron grado IV y el 31% grado V. Las lesiones penetrantes se vieron en un 87% vs 13% delesiones por mecanismo contuso (no penetrante). El 54% de los pacientes fueron puntuados con un Índice de Severidadde Trauma >= 25 y el 51% de los pacientes presentó un Índice de Trauma Abdominal <= 24. Se observó manejo quirúrgico en 67% vs 32% para manejo no quirúrgico. El tiempo de estancia hospitalaria fue de 17 días en promedio y el 16,9% tuvo complicaciones. CONCLUSIONES: El traumatismo renal de alto grado es una condición clínica frecuente en pacientes masculinos entre la segunda y tercera década de vida, en nuestro medio la mayoría corresponden a traumas penetrantes. La mayoría de casos fueron manejados con algún procedimiento quirúrgico, sin embargo, con un importante porcentaje de manejo conservador con tasas de complicaciones menores del 30 %, que cambia el paradigma del tratamiento del trauma renal de alto grado

OBJECTIVE: To characterize the clinical condition, the type of therapeutic approach and outcome of patients with severe renal trauma (AAST: 4 and 5) treated in a tertiary hospital. Cali, Colombia. METHODS: A descriptive observational study was conducted with patients older than 15 years treated between January 1, 2015 and January 1, 2019, with a diagnosis of renal trauma and renal vessel trauma. Demographic, clinical and trauma severity variables were collected. A univariate analysis was carried out with frequency tables, measures of central tendency, depending on type of intervention, associated lesions, use of blood products and severity indices. RESULTS: 71 medical records were analyzed, 82% male, the average age was 25 years (range: 15-55). Regarding renal traumatic grade, 69% of the patients were grade IV and 31% grade V. Penetrating injuries were seen in 87% versus 13% of injuries due to blunt (non-penetrating) mechanism. 54% of the patients were scored with a trauma severity index >= 25 and 51% of the patients had an abdominal trauma index <= 24. Surgical management was managed in 67% vs. 32% for non-trauma management. surgical. The hospital stay was 17 days on average and 16.9% had complications. CONCLUSIONS: Severe renal trauma is a frequent clinical condition in male patients between the second and third decade of life, in our environment the majority corresponds to penetrating traumas. Most cases were managed with some surgical procedure, however, with a significant percentage of conservative management with complication rates of less than 30%, which changes the paradigm of treatment of high-grade renal trauma

Lesión de vía urinaria superior tras traumatismo cerrado, a propósito de un caso / Upper urinary tract injury by blunt trauma, about a case

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Blunt trauma pelvic fracture-associated genitourinary and concomitant lower gastrointestinal injury: incidence, morbidity, and mortality.

PURPOSE: Limited data exist on the characteristics, risk factors, and management of blunt trauma pelvic fractures causing genitourinary (GU) and lower gastrointestinal (GI) injury. We sought to determine these parameters and elucidate independent risk factors. METHODS: The National Trauma Data Bank for years 2010-2014 was queried for pelvic fractures by ICD-9-CM codes. Exclusion criteria included age ≤ 17 years, penetrating injury, or incomplete records. Patients were divided into three cohorts: pelvic fracture, pelvic fracture with GU injury, and pelvic fracture with GU and GI injury. Between-group comparisons were made using stratified analysis. Multivariable logistic regression was used to determine independent risk factors for concomitant GI injury. RESULTS: In total, 180,931 pelvic fractures were found, 3.3% had GU, and 0.15% had GU and GI injury. Most common mechanism was vehicular collision. Injury severity score, pelvic AIS, and mortality were higher with combined injury (p < 0.001), leading to longer hospital and ICU stays and ventilator days (p < 0.001) with more frequent discharges to acute rehabilitation (p < 0.01). Surgical management of concomitant injuries involved both urinary (62%) and rectal repairs (81%) or diversions (29% and 46%, respectively). Male gender (OR = 2.42), disruption of the pelvic circle (OR = 6.04), pubis fracture (OR = 2.07), innominate fracture (OR = 1.84), and SBP < 90 mmgh (OR = 1.59) were the strongest independent predictors of combined injury (p < 0.01). CONCLUSION: Pelvic fractures with lower GU and GI injury represent < 1% of pelvic fractures. They are associated with more severe injuries and increased hospital resource utilization. Strongest independent predictors are disruption of the pelvic circle, male gender, innominate fracture, and SBP < 90mm Hg.

Outcomes following a clinical algorithm allowing for delayed hysterectomy in the management of severe placenta accreta spectrum.

BACKGROUND: The incidence of placenta accreta spectrum is rising. Management is most commonly with cesarean hysterectomy. These deliveries often are complicated by massive hemorrhage, urinary tract injury, and admission to the intensive care unit. Up to 60% of patients require transfusion of ≥4 units of packed red blood cells. There is also a significant risk of death of up to 7%. OBJECTIVE: The purpose of this study was to assess the outcomes of patients with antenatal diagnosis of placenta percreta that was managed with delayed hysterectomy as compared with those patients who underwent immediate cesarean hysterectomy. STUDY DESIGN: We performed a retrospective study of all patients with an antepartum diagnosis of placenta percreta at our large academic institution from January 1, 2012, to May 30, 2018. Patients were treated according to standard clinical practice that included scheduled cesarean delivery at 34-35 weeks gestation and intraoperative multidisciplinary decision-making regarding immediate vs delayed hysterectomy. In cases of delayed hysterectomy, the hysterotomy for cesarean birth used a fetal surgery technique to minimize blood loss, with a plan for hysterectomy 4-6 weeks after delivery. We collected data regarding demographics, maternal comorbidities, time to interval hysterectomy, blood loss, need for transfusion, occurrence of urinary tract injury and other maternal complications, and maternal and fetal mortality rates. Descriptive statistics were performed, and Wilcoxon rank-sum and chi-square tests were used as appropriate. RESULTS: We identified 49 patients with an antepartum diagnosis of placenta percreta who were treated at Vanderbilt University Medical Center during the specified period. Of these patients, 34 were confirmed to have severe placenta accreta spectrum, defined as increta or percreta at the time of delivery. Delayed hysterectomy was performed in 14 patients: 9 as scheduled and 5 before the scheduled date. Immediate cesarean hysterectomy was completed in 20 patients: 16 because of intraoperative assessment of resectability and 4 because of preoperative or intraoperative bleeding. The median (interquartile range) estimated blood loss at delayed hysterectomy of 750 mL (650-1450 mL) and the sum total for delivery and delayed hysterectomy of 1300 mL (70 -2150 mL) were significantly lower than the estimated blood loss at immediate hysterectomy of 3000 mL (2375-4250 mL; P<.01 and P=.037, respectively). The median (interquartile range) units of packed red blood cells that were transfused at delayed hysterectomy was 0 (0-2 units), which was significantly lower than units transfused at immediate cesarean hysterectomy (4 units [2-8.25 units]; P<.01). Nine of 20 patients (45%) required transfusion of ≥4 units of red blood cells at immediate cesarean hysterectomy, whereas only 2 of 14 patients (14.2%) required transfusion of ≥4 units of red blood cells at the time of delayed hysterectomy (P=.016). There was 1 maternal death in each group, which were incidences of 7% and 5% in the delayed and immediate hysterectomy patients, respectively. CONCLUSION: Delayed hysterectomy may represent a strategy for minimizing the degree of hemorrhage and need for massive blood transfusion in patients with an antenatal diagnosis of placenta percreta by allowing time for uterine blood flow to decrease and for the placenta to regress from surrounding structures.

Intraoperative Evaluation of Urinary Tract Injuries at the Time of Pelvic Surgery: A Systematic Review.

OBJECTIVE: The aim of this study was to determine the safety and efficacy of methods for intraoperative evaluation of urinary tract injury during pelvic surgery. METHODS: PubMed, EMBASE, CINAHL, Web of Science, Scopus, ProQuest, the Cochrane Library, and Clinicaltrials.gov were searched from 1947 to February 2018. Articles or abstracts describing the routine evaluation of urinary tract injuries during pelvic surgery in adults were included, surgical indications of urinary tract anomaly, stones, or malignancy were excluded. There were no restrictions on study design or language. Outcomes included injuries diagnosed intraoperatively, delayed diagnoses, adverse effects, subjective assessments, time to use, and cost. Data were extracted in duplicate at an individual-participant level. Prevalence of injuries, sensitivity, specificity, and predictive values of each diagnostic method were calculated. A combination of generalized linear models and a Bayesian approach were used to separately pool diagnostic accuracy measures. RESULTS: There were 5303 titles, 527 abstracts, and 164 full-text articles assessed for eligibility; 69 articles were analyzed. Diagnostic methods retrieved were cystoscopy using saline, dextrose or unspecified distention media, oral phenazopyridine and vitamin B, intravenous (IV) methylene blue, IV sodium fluorescein, IV indigo carmine, prophylactic retrograde ureteral stents, and transabdominal Doppler ultrasound. Prevalence of urinary tract injury ranged from 0.3% to 2.8%. Sensitivity ranged 63% to 91%, and specificity, 99.7% to 100%, with no significant differences suggested between methods. CONCLUSIONS: All evaluable methods of intraoperative urinary tract assessment during pelvic surgery are safe and effective with specificity of greater than 99% and low rates of complications. Larger, more rigorous studies are required to evaluate the diagnostic accuracy of some newer methods.

Kidney and uro-trauma: WSES-AAST guidelines.

Renal and urogenital injuries occur in approximately 10-20% of abdominal trauma in adults and children. Optimal management should take into consideration the anatomic injury, the hemodynamic status, and the associated injuries. The management of urogenital trauma aims to restore homeostasis and normal physiology especially in pediatric patients where non-operative management is considered the gold standard. As with all traumatic conditions, the management of urogenital trauma should be multidisciplinary including urologists, interventional radiologists, and trauma surgeons, as well as emergency and ICU physicians. The aim of this paper is to present the World Society of Emergency Surgery (WSES) and the American Association for the Surgery of Trauma (AAST) kidney and urogenital trauma management guidelines.

ACR Appropriateness Criteria® Penetrating Trauma-Lower Abdomen and Pelvis.

Lower urinary tract injury is most commonly the result of blunt trauma but can also result from penetrating or iatrogenic trauma. Clinical findings in patients with a mechanism of penetrating trauma to the lower urinary tract include lacerations or puncture wounds of the pelvis, perineum, buttocks, or genitalia, as well as gross hematuria or inability to void. CT cystography or fluoroscopy retrograde cystography are usually the most appropriate initial imaging procedures in patients with a mechanism of penetrating trauma to the lower urinary tract. CT of the pelvis with intravenous contrast, pelvic radiography, fluoroscopic retrograde urethrography, and CT of the pelvis without intravenous contrast may be appropriate in some cases. Arteriography, radiographic intravenous urography, CT of the pelvis without and with intravenous contrast, ultrasound, MRI, and nuclear scintigraphy are usually not appropriate. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.