Risk factors for compartment syndrome in traumatic brachial artery injuries: an institutional experience in 139 patients.

BACKGROUND: The brachial artery is the most common vascular injury encountered in upper extremity trauma. If not treated promptly, it can result in compartment syndrome (CS) and long-term disability. Here, we report an institutional experience of traumatic brachial artery injuries and establish risk factors for the development of upper extremity CS in this setting. METHODS: A retrospective review of 139 patients with traumatic brachial artery injury from 1985 to 2001 at a single institution. Patients were divided into two cohorts, those with evidence of CS and those without CS (NCS), for comparison. RESULTS: One hundred thirty-nine patients presented with traumatic brachial artery injuries (mean age, 28.4 years). Twenty-nine patients (20.9%) were diagnosed with upper extremity CS, and 28 of these patients underwent fasciotomy on recognition of their CS. Seven patients (6.4%) in the NCS cohort underwent fasciotomy as a result of absent distal pulses on initial examination. Mean follow-up was 51.6 days. Two patients required revision of their arterial repair, and one patient underwent amputation. The risk of CS was increased in the presence of combined arterial injuries (p = 0.03), combined nerve injuries (p = 0.04), motor deficits (p < 0.0001), fractures, and increased intraoperative blood loss (p = 0.001). Multivariate logistic regression performed on these variables revealed that elevated intraoperative blood loss, combined arterial injury, and open fracture were independent risk factors for the development of CS (OR 1.12, 5.79, and 2.68, respectively). CONCLUSION: Prompt evaluation and management of traumatic brachial artery injuries is important to prevent CS, which can lead to functional deficits. In the setting of combined arterial injury, open fracture, and significant intraoperative blood loss, prophylactic fasciotomy should be considered.

A prognostic model for the risk of development of upper extremity compartment syndrome in the setting of brachial artery injury.

A potentially devastating sequela of brachial artery injury in the setting of upper extremity trauma is the development of compartment syndrome (CS). We performed a retrospective review of 139 trauma patients with brachial artery injury from 1985-2001. Objective characteristics of each case were extracted and analyzed using multivariate logistic regression. Three variables were found to be significant in the final model: estimated intraoperative blood loss as a continuous variable, and presence of a multiple arterial injury and presence of an open fracture as categorical variables. Odds ratio were 1.12, 5.79, and 2.68, respectively. We used these variables to create a summative score for the development of CS with weights assigned proportional to the adjusted odds ratio. Odds of having CS for subjects in group 2 and group 3 are 5.3 and 15.1 times the odds for subjects in group 1, respectively. Applying multivariate regression analysis to the largest series of brachial artery injuries to date, we have developed a predictive scoring model of CS.

A case of spermatic cord teratoma in low-stage testicular cancer managed by surveillance.

BACKGROUND: A 25-year-old male presented to his local urologist with new-onset right testicular pain and swelling detected on self examination. A scrotal ultrasound scan showed a right testicular mass, suspicious for neoplasm. Serum levels of alpha-fetoprotein and human chorionic gonadotropin were found to be elevated at 920.2 microg/l and 637.4 U/l, respectively. The patient underwent right inguinal orchiectomy and was diagnosed with nonseminomatous germ cell tumor of the right testis, composed of yolk sac tumor, teratoma, and embryonal carcinoma with no evidence of metastatic disease. He opted to remain under surveillance rather than undergo primary chemotherapy or retroperitoneal lymph node dissection for his clinical stage I disease. Serologic relapse at 4 months after orchiectomy was successfully treated with bleomycin, etoposide and cisplatin (BEP) chemotherapy. INVESTIGATIONS: Surveillance comprised regular clinic visits, measurement of serum levels of alpha-fetoprotein, human chorionic gonadotropin and lactate dehydrogenase, chest X-ray and CT of the abdomen and pelvis. Pathology of the testicular mass was reviewed. DIAGNOSIS: A 1.7 cm nodule anterior to the right psoas muscle suspicious for metastatic disease that was seen on CT 16 months after orchiectomy was pathologically confirmed as recurrent mature teratoma in the spermatic cord. Additionally, one of eleven interaortocaval lymph nodes showed evidence of teratoma. MANAGEMENT: Bilateral nerve-sparing retroperitoneal lymph node dissection with complete excision of the right spermatic cord was performed. The patient has since remained disease-free, with normal levels of serum tumor markers and no evidence of metastasis on chest X-ray and abdominal CT.

Carcinosarcoma of the prostate with multiple metastases: case report and review of the literature.

A case of carcinosarcoma of the prostate in a previously healthy 65-year-old man is reported. The tumor was initially diagnosed as adenocarcinoma, but the prostatectomy specimen showed a 717-g prostate, with evidence of adenocarcinoma and carcinosarcoma without heterologous structures. By 3-month follow-up, local recurrence, and liver, lung, and bone metastases had developed in the patient. He died of disease 10 months postoperatively. Carcinosarcoma of the prostate is a very rare but highly aggressive cancer with limited therapeutic options that should be treated with surgery and managed symptomatically. We believe this article is the forty-second case reported in the literature.

Acute kidney injury: novel biomarkers and potential utility for patient care in urology.

Urologists are integrally involved in the management of acute kidney injury (AKI), which is common after renal surgery or secondary to postrenal (obstructive) etiologies. The measurement of serum creatinine is a suboptimal indicator of AKI because it lags behind acute changes in renal function. Recent advances indicate that serum/urine biomarkers will prove useful for early detection of AKI, analogous to the use of cardiac enzymes for acute myocardial infarction. These serum/urine markers may guide future therapy, facilitate research efforts to reduce the severity of AKI, such as after partial nephrectomy, and allow for more accurate prognostication for patients with AKI.

Complications of open primary and post-chemotherapy retroperitoneal lymph node dissection for testicular cancer.

OBJECTIVE: Treatment decisions regarding the use of retroperitoneal lymph node dissection (RPLND) for low-stage and advanced testicular cancer may be influenced by the morbidity of the procedure. We sought to compare the complication profile of primary (P-) and post-chemotherapy (PC-) RPLND using a standardized complication grading scale. MATERIALS AND METHODS: A retrospective analysis was conducted of 112 and 96 patients who underwent P-RPLND and PC-RPLND, respectively, between 1982 and 2007 for perioperative outcomes and late complications. Postoperative complications were graded using a 5-tiered scale based on the severity and/or level of intervention required for resolution. RESULTS: P-RPLND patients had rates of 5%, 24%, and 7% for intraoperative, postoperative, and late complications, respectively. For PC-RPLND, these rates were 12%, 32%, and 7%, respectively (P = 0.11, 0.19, and 1, respectively). Major postoperative complications (grades III-V) were observed in 3 (3%) P-RPLND and 8 (8%) PC-RPLND patients (P = 0.15), including 1 fatal pulmonary embolus in a PC-RPLND patient. Ileus accounted for 63% and 45% of postoperative complications of P-RPLND and PC-RPLND, respectively. PC-RPLND was associated with significantly greater operative times, blood loss, and transfusion rates (P < 0.001). Compared with PC-RPLND after first-line chemotherapy for advanced NSGCT, there were no significant differences in perioperative outcomes for PC-RPLND performed in other settings. CONCLUSIONS: P-RPLND and PC-RPLND are associated with low rates of serious short- and long-term complications and negligible mortality, without significant differences between the 2 procedures. The safe morbidity profile of RPLND performed by fellowship-trained urologic oncologists should be considered during treatment decision-making for low-stage and advanced testicular cancer.

Utility of preoperative renal artery embolization for management of renal tumors with inferior vena caval thrombi.

OBJECTIVES: To review our experience with radical nephrectomy and inferior vena cava thrombectomy (RNIVCT) to determine the utility of preoperative embolization. Preoperative embolization has been used as an adjunctive procedure to facilitate surgical resection of complex renal tumors. METHODS: From 1990 to 2007, 225 patients with renal tumors and inferior vena cava thrombus underwent RNIVCT, including 135 patients who had undergone preoperative renal artery embolization and 90 patients who had not. The effect of embolization on perioperative morbidity and mortality, transfusion requirements, blood loss, and operative time was analyzed by comparing the 2 groups. RESULTS: The mean primary tumor size was similar in both groups; however, 67% of the RNIVCT embolization group vs 48% of the nonembolization group had retrohepatic (level III) or supradiaphragmatic (level IV) thrombus extension (P = .032). The RNIVCT embolization patients had a greater median number of perioperative units transfused (8 vs 4; P = .001), a longer operative time (390 vs 313 minutes; P < .001), more postoperative complications (43% vs 29%; P < .001), a longer intensive care unit stay (2 vs 0.5 days), and increased perioperative mortality (13% vs 3%; P = .017). No differences were found in intraoperative complications or length of hospitalization. Multivariate analysis showed a fivefold greater risk of perioperative death (adjusted odds ratio 5.5; P = .029) and a trend toward increased blood transfusion (regression coefficient 3.9; P = .08) with preoperative embolization. CONCLUSIONS: The results of our study have shown that routine preoperative renal artery embolization in patients undergoing RNIVCT does not provide any measurable benefit in reducing blood loss or complications and was associated with increased major perioperative complications and mortality.

Right-sided intrathoracic renal ectopia with Bochdalek's hernia.

A 23-year-old woman was evaluated for right flank pain of one year duration. Magnetic resonance imaging (MRI) revealed a 6 cm defect in the right hemidiaphragm with herniation of the right kidney, adrenal gland, and posterior right hepatic lobe consistent with a congenital right Bochdalek hernia. Computed tomography (CT) urogram confirmed lack of masses, hydronephrosis, and renal calculi and defined vascular and ureteral anatomy through the diaphragmatic hernia. Intrathoracic kidney is rare and is usually discovered incidentally. In the absence of other renal pathology it requires no surgical intervention.