The first in this series of five papers concerns the evaluation and management of renal injuries. The authors of this paper come from four continents and seven countries, and they reviewed all papers ...on renal injury published between 1966 and April 2002. The results of the authors’ deliberations are present here as a consensus document.
OBJECTIVE
To determine the optimal evaluation and management of renal injuries by review of the world's English‐language literature on the subject.
METHODS
A consensus conference convened by the World Health Organization and the Societé Internationale d’Urologie met to critically review reports of the diagnosis and treatment of renal trauma. The English‐language literature about renal trauma was identified using Medline, and additional cited works not detected in the initial search obtained. Evidence‐based recommendations for the diagnosis and management of renal trauma were made with reference to a five‐point scale.
RESULTS
There were many Level 3 and 4 citations, few Level 2, and one Level 1 which supported clinical practice patterns. Findings of nearly 200 reviewed citations are summarized.
CONCLUSIONS
Published reports on renal trauma still rely heavily on expert opinion and single‐institution retrospective case series. Prospective trials of the most significant issues, when possible, might improve the quality of evidence that dictates the behaviour of practitioners.
In this continuation of the section on genitourinary trauma, the authors describe the consensus on urethral injury. This is an in‐depth statement, describing all aspects of the condition, from ...anatomy to general recommendations.
Little is known about long-term patient-reported outcomes following surgical repair for pediatric blunt urethral trauma.
The purpose was to evaluate long-term urinary outcomes, sexual function, and ...quality of life (QOL) of patients who undergo urethroplasty for blunt urethral trauma in childhood.
After IRB approval, we retrospectively reviewed the records of patients who sustained blunt urethral injury at ≤18 years and underwent urethroplasty at our institution between 1978 and 2013. We then used a web-based survey to assess urinary/sexual/ejaculatory function and overall QOL using validated questionnaires.
Of 68 eligible patients, 15 were able to be contacted (table). Median age of injury, age at urethroplasty, and age at follow-up were 17 (4–18), 17 (5–20), and 19 (13.5–21.5) years, respectively. The stricture was membranoprostatic in eight and bulbar in seven patients, with median length of 2 (1.6–2.6) cm. Excision/primary anastomosis was performed in all but three patients who required a buccal graft. Overall, 80% were ‘very satisfied’ and 20% were ‘satisfied’ with surgery. One patient reported a subsequent urethral intervention. On urethral stricture surgery patient-reported outcome measurement, the median bother (0 least, 24 worst) was 10 (8–12.5). The force of urine stream (1 strongest, 4 weakest) was 2 (1.5–2), with no report of urinary incontinence. The median Sexual Health Inventory for Men score (0 worst, 25 perfect) was 24 (22.5–24). The median ejaculatory function score (0 worst, 15 normal) was 14 (13–14.75). Six patients had fathered children and none reported infertility. Three patients reported <30° penile curvature not interfering with sex. Median QOL (0 worse, 10 best) was 8 (7.5–8).
Urethroplasty after blunt urethral injury in young adult population is associated with a high long-term success rate with a low rate of long-term urinary and sexual consequences in adulthood.Pt #Age at injury (years)Age at urethroplasty (years)Stx location/lengthTrauma mechanismPrior interventionAncillary maneuversUrethroplasty techniqueFollow-up (years)145PM – 2PFUD – MVCSPTPartial pubectomyEPA162716Bulbar – 1.5StraddleEPA831316Bulbar – 2.5StraddleVBMG – 4.5 cm1241314Bulbar – 2.6StraddleVBMG – 4 cm1451616PM – 2PFUD – MVCSPTPartial pubectomyEPA2361617Bulbar – 1.9StraddleEPA1371717Bulbar – 3StraddleDilationEPA2381718PM – 2.5PFUD – FallDVIU, dilationEPA1991717PM – 5PFUD – MVCSPTEPA20101818PMPFUDSPTEPA19111819PM – 1.2PFUD – FallSPTEPA13121818PM – 2PFUD –MVCRealignment, dilationEPA21131820Bulbar – 1StraddleDVIU, dilationEPA20141819PM – 1PFUD – MVCSPTEPA28151818Bulbar – 5.5StraddleDilationVBMG – 7 cm22
We provide guidelines of penile length and circumference to assist in counseling patients considering penile augmentation.
We prospectively measured flaccid and erect penile dimensions in 80 ...physically normal men before and after pharmacological erection.
Mean flaccid length was 8.8 cm., stretched length 12.4 cm. and erect length 12.9 cm. Neither patient age nor size of the flaccid penis accurately predicted erectile length. Stretched length most closely correlated with erect length.
Only men with a flaccid length of less than 4 cm., or a stretched or erect length of less than 7.5 cm. should be considered candidates for penile lengthening.
We ascertained the impact of anterior urethroplasty on male sexual function.
A validated questionnaire was mailed to 200 men who underwent anterior urethroplasty to evaluate postoperative sexual ...function. Questions addressed the change in erect penile length and angle, patient satisfaction with erection, preoperative and postoperative coital frequency, and change in erection noted by the sexual partner. Results were stratified by the urethral reconstruction method, namely anastomosis, buccal mucosal graft, penile flap and all others, and compared with those in a similar group of men who underwent circumcision only.
Of the 200 men who underwent urethroplasty 152 who were 17 to 83 years old (mean age 45.7) completed the questionnaire. Average followup was 36 months (range 3 to 149). Overall there was a similar incidence of sexual problems after urethroplasty and circumcision. Penile skin flap urethroplasty was associated with a slightly higher incidence of impaired sexual function than other procedures (p >0.05). Men with a longer stricture were most likely to report major changes in erectile function and penile length (p <0.05) but improvement was evident with time in 61.8%.
Overall anterior urethral reconstruction appears no more likely to cause long-term postoperative sexual dysfunction than circumcision. Men with a long stricture may be at increased risk for transient erectile changes.
We determined the use of scrotal ultrasonography in the initial diagnosis and management of testicular injuries due to blunt scrotal trauma.
We performed a retrospective review of 65 patients ...presenting to our Emergency Department with blunt scrotal trauma in the last 25 years. In 47 patients an inconclusive clinical examination prompted scrotal ultrasonography. A heterogeneous echo pattern of the testicular parenchyma with loss of contour definition was the basis for diagnosis of testicular rupture. The sensitivity and specificity of scrotal ultrasonography were determined by comparing this radiographic criterion with definitive intraoperative findings and the need for delayed orchiectomy due to undiagnosed testicular rupture.
Of the 65 patients sustaining blunt scrotal trauma 44 (68%) underwent scrotal exploration, and 30 (46%) of these injuries involved rupture of the tunica albuginea. Among the 47 scrotal ultrasounds performed to supplement a nondiagnostic clinic examination, there were 32 suspected testicular ruptures. Thus, the 2 false-positives resulted in a specificity of 93.5% in those patients explored. No delayed orchiectomies were performed for missed testicular ruptures, resulting in 100% sensitivity. The majority of testicular ruptures were salvaged (83%), with only 5 of the 30 (17%) requiring orchiectomy (4 of these patients had delayed presentation greater than 48 hours).
Scrotal ultrasonography, with the single radiographic finding of a heterogeneous echo pattern of the testicular parenchyma with loss of contour definition, is highly sensitive and specific in the diagnosis of testicular rupture in an otherwise equivocal scrotal examination. Accurate diagnosis and prompt repair led to a salvage rate for testicular rupture specifically of 83% and overall of 92%, with preservation of the testicular parenchyma and hormonal function, and avoidance of the delayed complications of chronic pain, atrophy and orchiectomy associated with missed testicular rupture.
Both iatrogenic and traumatic ureteral injuries are rare. However, a high index of suspicion is warranted for ureteral injuries because ureteral injuries are associated with increased morbidity. The ...urologist should be familiar with several methods for identifying ureteral injuries and should make evaluations tailored to the clinical situation. Most ureteral injuries are short transections and can be repaired with debridement and ureteroureterostomy in the proximal and mid-ureter or ureteroneocystostomy in the distal ureter.
We sought to identify the long-term success rate of perineal anastomotic reconstruction for posterior urethral disruption.
We reviewed the records of 82 patients with traumatic prostatomembranous ...urethral strictures who underwent perineal anastomotic urethroplasty by 1 surgeon.
Excision of fibrosis with simple perineal anastomosis was performed in 52 patients (63%), while pubectomy was required in 30 (37%) to obtain a tension-free anastomosis. Median followup was longer than 1 year. Potency improved from 46% before reconstruction to 62% postoperatively. Nine patients (11%) required 1 endoscopic urethrotomy after urethroplasty to improve flow rate and this procedure was successful in 8 (88%). In 3 patients (3%) urethroplasty ultimately failed and they remained untreated because of insurmountable co-morbidity. Overall, long-term success was observed in 79 patients (97%).
Excellent long-term results can be expected from anastomotic urethroplasty in patients with traumatic posterior urethral strictures. Subsequent urethrotomy, when required, has a high likelihood of success. A significant number of patients regain potency after urethral reconstruction. Persistent impotence probably reflects the severity of pelvic trauma.
To evaluate the efficacy of buccal mucosa in the repair of adult urethral stricture disease, we report our experience with its use as a nontubularized onlay graft during bulbar urethral ...reconstruction.
From June 1993 to January 1996, 75 men underwent anterior urethral reconstruction for stricture disease. Single-stage urethroplasty with an onlay patch graft of buccal mucosa was performed in 13 patients with complex, refractory strictures of the bulbar urethra. In all cases, a two-team approach was used in which one team harvested the graft from the mouth while the perineal team simultaneously exposed and calibrated the stricture.
The length of buccal mucosa ranged from 3.5 to 17 cm (average length 6.2). In 8 patients, other reconstructive techniques were used concomitantly, including fasciocutaneous penile flap or stricture excision and primary anastomosis, depending on the length and severity of the scarred area. Median follow-up time was 18 months. Excellent results were obtained in all 13 patients and none has required urethral dilation or instrumentation subsequently. Operative time was significantly less than with other forms of substitution urethroplasty.
Excellent results can be expected when buccal mucosa is used for urethral substitution in men with refractory bulbar strictures. For patients with long or dense strictures, buccal mucosal grafts may easily be combined with other reconstructive techniques. In patients with less complex stricture disease, the reduced operative time of this two-team approach may be beneficial.
We describe our experience with blunt straddle injuries to the anterior urethra and identify factors that may affect patient outcome.
We reviewed the San Francisco General Hospital Urologic Trauma ...data base to identify men with blunt straddle injury. We analyzed presentation and initial management, location and length of urethral stricture, surgical options, and long-term outcome after reconstruction.
Of 78 patients, 40% presented to the emergency department acutely and 60% presented 6 months to 10 years after injury complaining of obstructive symptoms, of whom 30% reported at least 1 episode of urinary retention. Initial acute management was suprapubic cystostomy in 81% of cases and primary realignment in 19%. Urethral strictures were predominantly located in the proximal bulb. Mean stricture length was significantly longer in men with delayed presentation (2.7 vs 1.8 cm, p <0.05). No relationship was found between stricture length and the mechanism of injury or initial management technique. However, patients who had undergone primary realignment required complex flap or graft urethroplasty at a greater rate compared with men who had undergone suprapubic diversion (p = 0.054). Transperineal urethroplasty was required in 92% of patients with the majority undergoing end-to-end anastomosis. The success rate was 95% at a mean followup of 25 months (range 10 to 180). Recurrent stricture occurred in 4 men with prior urethral manipulation and it was managed successfully by direct vision internal urethrotomy alone.
After blunt straddle injury to the perineum the primary morbidity is anterior urethral stricture, for which suprapubic cystostomy is appropriate initial management. The majority of patients require surgery but with careful preoperative planning and adequate resection of fibrotic tissue the long-term success rate can approach 95%. If it arises, recurrent stricture responds well to direct vision internal urethrotomy alone.
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