Current epidemiology of genitourinary trauma

Legal Outcomes of Litigation After Iatrogenic Genitourinary Trauma

OBJECTIVE

To evaluate plaintiff and defendant characteristics associated with iatrogenic genitourinary (GU) trauma litigation and outcomes of closed claims.

METHODS

LexisNexis was queried in April 2023 using terms related to GU organs and injury, and manually reviewed for iatrogenic cases. Case details including defendant, organ involvement, and legal outcome were obtained. Multinomial regression analysis was performed to identify factors associated with outcome.

RESULTS

Four hundred ten cases involving 611 defendants were identified, with the ureter the most commonly affected organ (202/410, 49.3%). Most cases involved adult plaintiffs (380, 92.7%) and resulted in favor of the defense (227, 55.4%). Injuries resulted most frequently from gynecologic surgeries (179, 43.7%). Defendants were most commonly obstetricians/gynecologists (243/611, 39.8%) and urologists (168, 27.5%). Penile (OR 6.3 [95% CI 2.5-16.1]) and urethral (OR 4.8 [2.0-11.7]) injuries were associated with greater odds of a plaintiff verdict relative to ureter injury. A plaintiff verdict was also more likely when defendants were academic hospitals compared to individual practitioners (OR 4.3 [1.9-9.9]). In cases ruling in favor of the plaintiff, indemnity payments were larger when the defendants were comprised of individual practitioners compared to a hospital or medical group (median $549,613 vs $250,000, P <.001).

CONCLUSION

Urologists may be involved in medical malpractice lawsuits for iatrogenic injury even when they are uninvolved in the index procedure. Most cases that reach litigation result in defense verdicts regardless of the GU organ injured. Defendant characteristics associated with plaintiff verdicts are more nuanced, and providers should be aware of potential downstream effects of litigation.

An uncommon case of a bladder injury due to hip prosthesis migration: A case report

Bladder injuries, although rare, can occur as a complication of hip surgery, particularly when a hip prosthesis migrates into the bladder. We present the case of a 75-year-old woman with a bladder rupture secondary to prosthesis migration requiring repair via a transvesical approach. While total hip arthroplasty (THA) is common, intrapelvic complications such as bladder injury are less commonly reported. Early recognition and appropriate treatment are essential to avoid serious consequences. The management of prosthesis migration into the bladder is complex and requires detailed anatomical knowledge. Awareness of this potential complication is essential for both orthopaedic surgeons and urologists.

Gunshot wound injury to the genitourinary tract: a 4-year retrospective review at an academic level 1 trauma center

Background

Firearm injuries increased significantly during the coronavirus disease 2019 (COVID-19) pandemic. We aimed to describe our experience with patients admitted to a level 1 trauma center with gunshot-related trauma to the genitourinary (GU) tract before and during COVID-19 pandemic.

Methods

Patients sustaining gunshot-related trauma to the adrenals, kidneys, ureters, bladder, scrotum, testicles, penis, and urethra between January 1, 2018 and December 31, 2021 were identified from our institutional trauma database. Patient charts were queried to extract demographic information, management, and follow-up.

Results

A total of 117 patients met inclusion criteria with 39 (33%) of GU injuries occurring pre-COVID, and 78 (67%) occurring during or post-COVID. Seventy-two (62%) presented with kidney injury. Patients injured in the pre-COVID period were more likely to participate in a follow-up visit by 2.17 times at 60 days (P=0.017), 1.98 times at 90 days (P=0.030), and 2.04 times at 1-year (P=0.014) than during COVID. Pre-COVID, 46% of patients were injured in the city's northwestern region and 54% from other areas, during COVID 24% of patients came from the northwestern region compared to 76% from other areas (P=0.029).

Conclusions

Gunshot wounds (GSW) involving the GU tract increased during the COVID-19 pandemic, with renal injury most frequent. Follow-up visits declined by around half during the pandemic, primarily at 60 days, 90 days, and 1 year post-injury. The number of patients admitted with urologic injuries pre-COVID versus during COVID was significantly different depending on the patient's area of residence. More work is needed to evaluate the outcomes of traumatic GU injuries due to GSW pre- and post-pandemic.

An intricate vagina penetrating injury with a 22 cm cassava stick in situ for 6 months: a case report

BACKGROUND

Trauma remains one of the major causes of morbidity and mortality and a threat to attainment of sustainable development goal 11. Genital urinary trauma is reported in about 10% of patients presenting with trauma worldwide, and in about 6.6% of patients in Sub-Saharan Africa. If not careful enough, one may miss the foreign body in the vagina and this may be associated with morbidity, and although  rare, mortality.

CASE PRESENTATION

We report a case of a 7-year-old Black Ugandan that had suffered vagina trauma 6 months prior to presentation at our facility and presented with chronic vagina pus discharge for 6 months. Prior examinations had failed to recognize the foreign body and so did the two abdominal pelvic ultrasound scans. During examination under anesthesia, we were able to locate the cassava stick that had caused penetrating vagina injury and we were able to dislodge it. It was a blunt cassava stick with length of 22 cm and diameter of 2 cm. Although it had gone through the peritoneal cavity, we did not do a laparotomy.

CONCLUSION

This case emphasizes the need for a thorough vaginal exam including the need to do it under anesthesia with good lighting even when ultrasound scan findings are normal. It presents an opportunity for one to manage penetrating peritoneal injury without a laparotomy in highly selected cases. Gynecologists should be keen as well to rule out child molestation.

Penile Trauma Burden and Aetiology in the Paediatric and Adult Population: A Scoping Review and Critical Analysis of the Literature

Penile trauma is rare. It is associated with the impairment of physiological functions and deterioration in patients' quality of life. Currently, the relevance of age demographics in the occurrence of this debilitating injury has not been well discussed. The objective of this study was to provide a scoping review of penile trauma within the lens of the legal age of maturity. A search of the PubMed, Scopus and Web of Science databases was conducted, and then, the identified publications were used to conduct this scoping review focussing on the study aim. The results identified were categorised into five themes. This included publication information (author, year, country, study duration); demographic information (age of presentation, number of patients, relative burden); penile trauma clinical pattern (type, severity, associated injury), risk factors and clinical consequences. While mobile and active young adults were at risk of outdoor trauma, the report on penile trauma in the paediatric population is rare and usually focussed on sexual trauma. Penetrating trauma has been more extensively studied in comparison to blunt penile trauma despite the significance of the latter in the paediatric population. Injury severity classification is not available for most studies limiting their usefulness in the universal comparison of trauma severity and injury prognostication. There is a diversity in the burden and presentation of penile trauma. Available research studies are limited in the paediatric population, mostly focussed on penile fracture in adults and generally devoid of a standardised penile trauma severity description. Additional studies with a specific focus on penile trauma are required to characterise aetiological risks and injury severity across the legal age of maturity.

The role of point-of-care ultrasound in the assessment of pelvic urine leakage and diagnosis of urinoma

BACKGROUND

Urinoma, a rare condition resulting from urine leakage due to trauma to the kidney, bladder, or urethra, is typically diagnosed using enhanced computed tomography urogram with delayed imaging. This report presents two cases of urinoma likely caused by overdistention of the renal pelvis following excessive fluid intake and the presence of a ureteral stone.

CASE PRESENTATION

We present two cases of 36-year-old and 38-year-old patients who presented with flank pain. point-of-care ultrasound (POCUS) played a pivotal role in identifying perinephric fluid in Morrison's space and the splenorenal space, respectively. These ultrasound findings guided further investigations, leading to definitive diagnoses via abdominal pelvic CT scans. Treatment involved prophylactic antibiotics and the successful placement of a double J stent into the renal pelvis over the wire under fluoroscopic guidance, which resulted in significant clinical improvement for both patients.

CONCLUSIONS

This study demonstrates the rare occurrence of urinoma from urolithiasis, the use of POCUS in expediting diagnosis and treatment, and the importance of interpreting sonographic images in the correct clinical setting.

Summary Paper of the Updated 2023 European Association of Urology Guidelines on Urological Trauma

CONTEXT

The European Association of Urology (EAU) Guidelines Panel for Urological Trauma has produced guidelines in order to assist medical professionals in the management of urological trauma in adults for the past 20 yr. It must be emphasised that clinical guidelines present the best evidence available to the experts, but following guideline recommendations will not necessarily result in the best outcome. Guidelines can never replace clinical expertise when making treatment decisions for individual patients regarding other parameters such as experience and available facilities. Guidelines are not mandates and do not purport to be a legal standard of care.

OBJECTIVE

To present a summary of the 2023 version of the EAU guidelines on the management of urological trauma.

EVIDENCE ACQUISITION

A systematic literature search was conducted from 1966 to 2022, and articles with the highest certainty evidence were selected. It is important to note that due to its nature, genitourinary trauma literature still relies heavily on expert opinion and retrospective series.

EVIDENCE SYNTHESIS

Databases searched included Medline, EMBASE, and the Cochrane Libraries, covering a time frame between May 1, 2021 and April 29, 2022. A total of 1236 unique records were identified, retrieved, and screened for relevance.

CONCLUSIONS

The guidelines provide an evidence-based approach for the management of urological trauma.

PATIENT SUMMARY

Trauma is a serious public health problem with significant social and economic costs. Urological trauma is common; traffic accidents, falls, intrapersonal violence, and iatrogenic injuries are the main causes. Developments in technology, continuous training of medical professionals, and improved care of polytrauma patients reduce morbidity and maximise the opportunity for quick recovery.

The State of Urotrauma Education Among Residency Programs in the United States: A Systematic Review and Meta-Analysis

PURPOSE OF REVIEW

Management of urotrauma is a crucial part of a urologist's knowledge and training. We therefore sought to understand the state of urotrauma education in the United States.

RECENT FINDINGS

Using themes of "Urotrauma" and "Education," we performed a systematic review and meta-analysis by searching for studies in MEDLINE, all Cochrane libraries, EMBASE, BIOSIS, Scopus, and Web of Science through May 2023. The primary outcome was the pooled rate of urology trainee and program director attitudes toward urotrauma education. Secondary outcomes involved a descriptive summary of existing urotrauma curricula and an assessment of factors affecting urotrauma exposure. Of 12,230 unique records, 11 studies met the final eligibility criteria, and we included 2 in the meta-analysis. The majority of trainees and program directors reported having level 1 trauma center rotations (range 88-89%) and considered urotrauma exposure as an important aspect of residency education (83%, 95% CI 76-88%). Despite possible increases in trainee exposure to Society of Genitourinary Reconstructive Surgeons (GURS) faculty over the preceding decade, nearly a third of trainees and program directors currently felt there remained inadequate exposure to urotrauma during training (32%, 95% CI 19-46%). Factors affecting urotrauma education include the limited exposure to GURS-trained faculty and clinical factors such as case infrequency and non-operative trauma management. Urology resident exposure to urotrauma is inadequate in many training programs, underscoring the potential value of developing a standardized curriculum to improve urotrauma education for trainees. Further investigation is needed to characterize this issue and to understand how it impacts trainee practice readiness.

Urethral Injuries: Diagnostic and Management Strategies for Critical Care and Trauma Clinicians

Urologic trauma is a well-known cause of urethral injury with a range of management recommendations. Retrograde urethrogram remains the preferred initial diagnostic modality to evaluate a suspected urethral injury. The management thereafter varies based on mechanism of injury. Iatrogenic urethral injury is often caused by traumatic catheterization and is best managed by an attempted catheterization performed by an experienced clinician or suprapubic catheter to maximize urinary drainage. Penetrating trauma, most commonly associated with gunshot wounds, can cause either an anterior and/or posterior urethral injury and is best treated with early operative repair. Blunt trauma, most commonly associated with straddle injuries and pelvic fractures, can be treated with either early primary endoscopic realignment or delayed urethroplasty after suprapubic cystostomy. With any of the above injury patterns and treatment options, a well thought out and regimented follow-up with a urologist is of utmost importance for accurate assessment of outcomes and appropriate management of complications.

Ureteral Complications during Surgery

Historically, ureteral complications during surgery have been occurring since the earliest performances of major abdominal or pelvic surgery. In the early 1960s, few diagnostic techniques were available to diagnose ureteral injury and determine the subsequent timely treatment required. Illustrations from two different time periods of possible operative ureteral injury, ligation, or transection following major complicated surgical procedures are presented, along with the diagnostic and therapeutic approach currently followed. The first individual had apparently sustained a ureteral injury during a prior surgical procedure, which, with limited diagnostic options, was not recognized until she visited us years later—as was the case for many early ureteral injuries. Major abdominal or pelvic surgery may be extensive and complicated, especially when dense fibrosis, scarring, and benign or malignant mass formation are present. Unfortunately, surgical complications, including bleeding and ureteral concerns, may develop during these extensive procedures. A more recent patient underwent major, life-threatening retroperitoneal surgery due to a chronic aortoenteric fistula (17 months total preoperative hospitalization elsewhere), during which the left ureter was transected. In our second patient, recognition and correction of the ureteral transection during the aortic surgery, upon completion of the aortic repair, prevented a potential major renal complication. The timely diagnosis of the operative ureteral injury and the repair prior to wound closure prevented major postoperative complications. As some physicians believe that surgically induced ureteral injuries are increasing in frequency, we present this report to enhance awareness of the possibility of injury and the potential value of recognition prior to abdominal closure. In addition, current operative and postoperative strategies available to identify and reduce potential ureteral injury complications when they occur are discussed.

Positive Predictive Factors for Urogenital Injuries in Severely Injured Patients with Pelvic and Spinal Fractures: Introducing the UPPS Scoring System

Background and Objectives: Although urogenital injuries are common in severely injured patients, their diagnosis is often delayed. Predicting genitourinary injuries (GUI), especially in the immediate stages post injury, remains a challenge. This study aims to evaluate and determine positive predictive factors for the presence of GUI in polytrauma patients. Subsequently, these factors shall be used to develop an easy-to-use scoring system, deployable directly in the emergency setting. Materials and Methods: This study evaluates all severely injured patients with an Injury Severity Score (ISS) ≥ 16 admitted to the emergency departments of two German university hospitals between 2016 and 2020. These patients were retrospectively scanned for injuries of the thoracic and/or lumbar spine and/or the pelvic girdle. Demographic data was analyzed alongside trauma mechanism, type of injuries, mortality, length of hospital stays, surgeries, laboratory results, and urological treatment. Subgroup analysis was performed to compare patients with and without GUIs using t-tests. Conducting a binary logistic regression model, the significant factors were combined to create a scoring system, which was further analyzed for accuracy. Results: In total, 413 patients with an average ISS of 33.8 ± 15.0 were identified, and 47 patients (11.4%) sustained urogenital injuries with an average Abbreviated Injury Scale (AIS) score of 2.3 ± 1.1 (range: 1−5). The severity of the pelvic girdle injury correlated with the presence of urogenital injuries (p = 0.002), while there was no correlation with spinal injuries. Moreover, most GUIs resulted from motorcycle accidents (p < 0.001) and 87.2% of these patients were male. Patients with GUI were significantly more likely to show macrohematuria (p < 0.001) on admission and were more severely injured overall (ISS > 34). There was no significant difference in the length of intensive care unit (ICU) stay, the days until discharge, or death rates. Conclusions: Factors or circumstances which reliably predict the presence of GUI were found to include the male sex, a motorcycle accident, high severity of pelvic girdle fractures, macrohematuria on admission to the emergency department, and an ISS > 34. With these findings, we introduce the ‘Urotrauma in Polytrauma patients with Pelvic and/or Spinal injuries’ (UPPS) score for easier prediction of GUI in the emergency setting.

Nontraumatic Paraureteral Urinoma in a Cat with Urolithiasis

Urinoma is an encapsulated collection of urine due to a disruption in the collection system of the urinary tract. This condition is rarely reported in veterinary medicine. The aim of this study is to describe the clinical and diagnostic findings of a well-encapsulated paraureteral urinoma associated with urinary tract stones in a critical feline patient. The ultrasound examination of the abdomen revealed a well-defined collection of anechoic fluid containing the left kidney in the retroperitoneal space, while the radiographic examination revealed a loss of soft tissue contrast in the lumbar region. Both techniques confirmed the presence of stones in the bladder. Following the ultrasound-guided drainage of the lesion, the nature of the fluid was also confirmed to be urine. Due to the worsening of the cat’s health, to better define the extent and genesis of the lesion, a positive contrast radiographic study was performed by means of an ultrasound-guided percutaneous injection of a contrast medium into the lesion, which highlighted a wide and homogeneous radiopaque area in the left retroperitoneal space. These findings were confirmed with a postmortem examination, corroborating the diagnostic suspicion of urinoma. The percutaneous contrast inoculation performed in this critically ill patient plays a role in the diagnostic process to reach a final diagnosis in cases in which the patient’s clinical condition does not allow for performing an excretory positive contrast study.

Bioengineering solutions for Ureteric disorders: Clinical need, challenges and opportunities

Objectives

To summarise the causes of ureteric damage and the current standard of care, discussing the risks and benefits of available therapeutic options. We then focus on the current and future solutions that can be provided by ureteric bioengineering and provide a description of the ideal characteristics of a bioengineered product.

Methods

We performed a literature search in February 2021 in: Google Scholar, Medline, and Web of Science. Three searches were conducted, investigating: (a) the epidemiology of ureteric pathology, (b) the current standard of care, and (c) the state of the art in ureteric bioengineering.

Results

The most‐common causes of ureteric damage are iatrogenic injury and external trauma. Current approaches to treatment include stent placement or surgical reconstruction. Reconstruction can be done using either urological tissue or segments of the gastrointestinal tract. Limitations include scarring, strictures, and infections. Several bioengineered alternatives have been explored in animal studies, with variations in the choice of scaffold material, cellular seeding populations, and pre‐implantation processing. Natural grafts and hybrid material appear to be associated with superior outcomes. Furthermore, seeding of the scaffold material with stem cells or differentiated urothelial cells allows for better function compared to acellular scaffolds. Some studies have attempted to pre‐implant the graft in the omentum prior to reconstruction, but this has yet to prove any definitive benefits.

Conclusion

There is an unmet clinical need for safer and more effective treatment for ureteric injuries. Urological bioengineering is a promising solution in preclinical studies. However, substantial scientific, logistic, and economic challenges must be addressed to harness its transformative potential in improving outcomes.

[Do concomitant urological injuries in severely injured patients lead to poorer outcomes? : A multivariate risk analysis]

BACKGROUND

Severely injured patients with associated genitourinary (GU) injuries have only rarely been investigated in the current literature. If at all, analyses are commonly focussed on renal injuries, marginalising other GU traumas such as ureteral injuries. In this study, we would like to characterise patients with GU injuries and analyse the impact of such injuries on mortality and length of stay.

MATERIALS AND METHODS

The inclusion criteria for this retrospective analysis of TraumaRegister DGU® data were: Injury Severity Score ≥ 16 within the period between 2009 and 2016 with available data on age and length of stay. A descriptive analysis was used to compare patients with and without GU injuries. The impact of GU injuries on mortality and length of hospital stay was evaluated by means of multivariate regression analyses.

RESULTS

In all, 90,962 patients met the inclusion criteria; 5.9% of them had suffered GU injuries (n = 5345). The prevalence in patients with pelvic fractures was up to 19%. On average, patients with GU trauma were 10 years younger (42.9 vs. 52.2 years) and more severely injured (ISS: 31.8 vs. 26.4). The multivariate analyses demonstrated that GU injuries in severely injured patients are no independent risk factor for mortality. However, particularly bladder and genital injuries result in longer hospitalisation.

CONCLUSION

GU injuries do not represent an additional risk factor for mortality. However, after adjusting for established prognosis factors, they can cause prolonged periods of hospitalisation of severely injured patients.

Hidden trauma: shedding light on the relationship between gun violence and infertility

Objective

To study the existing data on the relationship between penetrating abdominopelvic injuries and fertility guidance on managing fertility concerns of these patients using a case report and scoping review.

Design

Case report and scoping review.

Setting

Not applicable.

Patient(s)

People who have experienced abdominopelvic trauma from gun violence or in the course of combat.

Intervention(s)

None.

Main Outcome Measure(s)

We extracted case report data from electronic health records. We performed a scoping review using PubMed and Scopus. Search terms were related to penetrating abdominopelvic trauma, gunshot wounds (GSW), war, and fertility/infertility. We evaluated the study year, age and race, mechanism of injury, fertility outcomes, and how fertility concerns were addressed with patients who experienced penetrating abdominopelvic trauma.

Result(s)

In the case report, the couple had 10 years of infertility. The male partner experienced an abdominopelvic GSW before attempting to conceive. After evaluation, he was diagnosed with retrograde ejaculation. He recalled being advised that his GSW might affect his future fertility. The couple has discontinued care.

For the scoping review, 879 sources were identified and 25 studies were included in the review. Among the studies conducted in the United States, most patients included were African American.

Eighty-eight percent (n = 22) of the sources acknowledged the importance of fertility or used fertility-related outcome measures. One study commented on how to address fertility concerns with victims of abdominopelvic penetrating trauma.

Conclusion(s)

There is a paucity of data on the intersection of penetrating abdominopelvic injuries and fertility or guidance on how to discuss fertility issues with patients.

[Management of complications of upper urinary tract trauma (kidney and ureter)]

INTRODUCTION

Complications of kidney and ureter trauma are directly in the field of the urologist. If they have a second place in the vital prognosis, a good knowledge of these pathologies is essential.

METHODS

A systematic review of the literature was carried out using the Medline database in order to identify the most relevant articles in English and French.

RESULTS

Urinary extravasation in the context of blunt kidney trauma has a good functional prognosis. Impaired function of the traumatized kidney is linked to vascular damage associated with grade IV and V. Non operative management is the treatment of choice with deferred management in the event of septic or painful deterioration. The lesions of the ureter are predominantly iatrogenic. While incomplete lesions can be treated endoscopically, complete lesions (stenosis or wound) require surgery. The most frequent lesions, in the distal ureter are easily treated by ureterovesical reimplantation. Large losses of substance may require ileal replacement.

CONCLUSION

Blunt kidney trauma causing urinary extravasation, with an excellent prognosis, are treated conservatively. Conversely, lesions of the ureter require in the majority of cases an intervention to restore continuity.

Management of genitourinary trauma – current evaluation from the Sub-Saharan region: A systematic review

BACKGROUND

Trauma is a major cause of morbidity globally and the sixth leading cause of death, accounting for 10% of all mortalities. The genitourinary trauma is estimated for approximately 10% of all patients presenting with trauma, and the kidney is the most injured genitourinary organ globally. However, there is a paucity of data on genitourinary injury from the Sub-Saharan, and there may be variations from common genitourinary organs injured in developed nations.

AIM

To provide insight on the epidemiology and management of genitourinary trauma in Sub-Saharan Africa with recommendations based on international guidelines.

METHODS

A thorough literature search of genitourinary trauma was conducted using PubMed, Google Scholar and African Journal Online.

RESULTS

A total of 30 studies from the Sub-Saharan region were eligible for the study and reviewed for epidemiology, biodata, types of injury, mechanisms of injury, treatment and follow-up. After evaluating 21904 patients presenting with urological emergencies, approximately 6.6% of cases were due to genitourinary trauma. The commonest injury was urethral 42.9% (22.2-62.2%) followed by injury to the external genitalia (penis, scrotum, testes) 25.1% (8.8-67.7%).

CONCLUSION

Genitourinary injury in Sub-Saharan Africa is underreported, and the presence of more trauma registries, trained urologists and trauma facilities could improve the overall standard of care as well as providing data for research and development in the field.

Reconstructive surgery of the scrotum: a systematic review

The term scrotoplasty embraces several techniques which aim to restore a normal scrotal appearance and function. We provide here a quick reference tool to allow the urologist to select the appropriate surgical strategy among the several available options. A comprehensive research was carried out on MEDLINE/PubMed to identify relevant studies concerning this topic, including a range of key words, e.g., scrotoplasty, ventral phalloplasty, scrotal reconstruction, scrotomegaly, penoscrotal web, scrotal lifting, scrotal reduction, scrotectomy, scrotal lymphoedema. Scrotal skin defects may be related with Fournier's gangrene, traumatic events, and surgery for genital cancers or peno-scrotal lymphoedema. The reconstructive management of these conditions is relatively reproducible in the hands of experienced urologists, if aware of the basics of scrotal surgery. Primary tension-free wound closure and local pedicled flaps typically allow optimal surgical outcomes for repairing most of these scrotal defects, with split-thickness skin grafts (STSGs) and/or distant flaps being required only when dealing with extensive skin losses. The demand for genitals' aesthetic surgery among adults is on the increase recently. Although the scientific evidence regarding this topic is scarce, reduction scrotoplasty and peno-scrotal webbing correction techniques are easy, safe and effective solutions to improve genital cosmesis, being carried out in isolation or in combination with penile prosthesis implantation. More robust scientific evidence is needed to achieve a uniformed consensus regarding the optimal surgical management in this broad field, and surgical innovation should continue to refine current reconstructive techniques.

Scrotal self-inflicted gunshot injuries: report of two consecutive cases and literature review

Background

Isolated scrotal gunshot injuries are uncommon. Even more so when they are self-inflicted. The extent of the injury is determined by the caliber of the weapon. Established management protocols when followed yields excellent results.

Case presentations

We present two male patients, aged 41 and 51 years old, who sustained gunshot injuries to the scrotum following accidental discharges from hand guns stored in their trouser pockets. The first (41 years) sustained grade 5 American Association for Surgery of Trauma (AAST) left testicular injury and was managed by unilateral orchidectomy. The second (51 years old) sustained bilateral grade 4 AAST testicular injuries and had both testes salvaged by primary repair after meticulous debridement.

Conclusion

Isolated scrotal gunshot injuries can occur when low velocity guns are placed adjacent to the genitalia and accidentally discharged. The testes are endangered and can be devitalized requiring orchidectomy or salvaged by meticulous debridement and primary repair when viability is not compromised.

CT of Penetrating Abdominopelvic Trauma

Penetrating abdominopelvic trauma usually results from abdominal cavity violation from a firearm injury or a stab wound and is a leading cause of morbidity and mortality from traumatic injuries. Penetrating trauma can have subtle or complex imaging findings, posing a diagnostic challenge for radiologists. Contrast-enhanced CT is the modality of choice for evaluating penetrating injuries, with good sensitivity and specificity for solid-organ and hollow viscus injuries. Familiarity with the projectile kinetics of penetrating injuries is an important skill set for radiologists and aids in the diagnosis of both overt and subtle injuries. CT trajectography is a useful tool in CT interpretation that allows the identification of subtle injuries from the transfer of kinetic injury from the projectile to surrounding tissue. In CT trajectography, after the entry and exit wounds are delineated, the two points can be connected by placing cross-cursors and swiveling the cut planes obliquely in orthogonal planes to obtain a double-oblique orientation to visualize the wound track in profile. The path of the projectile and its ensuing damage is not always straight, and the imaging characteristics of free fluid of different attenuation in the abdomen (including hemoperitoneum) can support the diagnosis of visceral and vascular injuries. In addition, CT is increasingly used for evaluation of patients after damage control surgery and helps guide the management of injuries that were overlooked at surgery. An invited commentary by Paes and Munera is available online. Online supplemental material is available for this article. ©RSNA, 2021.

Gunshot wounds to the penis and scrotum: a narrative review of management in civilian and military settings

Gunshot wounds (GSW) to the penis and scrotum are present in two thirds of all genitourinary (GU) trauma, with a growing proportion of blast injuries in the military setting. Depending on the energy of the projectile, the injury patterns present differently for military and civilian GSWs. In this review, we sought to provide a detailed overview of GSWs to the external genitalia, from mechanisms to management. We examine how ballistic injury impacts tissues, as well as the types of injuries that occur, and how to assess these injuries to the external genitalia. If there is concern for injury to the deep structures of the penis or scrotum, operative exploration and repair is warranted. Relevant history and physical examination, role of imaging, and choice of conservative or surgical treatment options in the civilian and military setting are discussed, as well as guidelines for management set forth by the American Urological Association (AUA) and European Association of Urology (EAU).

Posteriorly Augmented Anastomotic Ureteroplasty with Lingual Mucosal Onlay Grafts for Long Proximal Ureteral Strictures: 10 Cases of Experience

Objective: To share the technique of posteriorly augmented anastomotic ureteroplasty with lingual mucosal onlay grafts for long proximal ureteral strictures as well as our initial experience with the technique. Methods: From October 2018 to September 2019, 10 cases of robotic and laparoscopic posteriorly augmented anastomotic ureteroplasty with lingual mucosal onlay grafts for long proximal ureteral strictures were recruited from our database of Reconstruction of Urinary Tract: Technology, Epidemiology and Result (RECUTTER). The perioperative and follow-up data were recorded. Complete success was defined as the absence of clinical symptoms, relieved stenosis on imaging, and a stable estimated glomerular filtration rate without serious complications. Results: All surgeries were completed without serious complications. There were eight laparoscopic surgeries and two robotic surgeries. The median length of defect after posteriorly augmented anastomosis was 3 cm (range, 3-5 cm). The median length of the lingual mucosa graft was 4 cm (range, 3-5 cm). The median operative time was 237 minutes (range, 189-310 minutes). The median estimated blood loss was 40 mL (range, 10-100 mL). The median postoperative length of stay was 7.5 days (range, 5-22 days). The Double-J stent was removed median 3.5 months (range, 2-7 months) after the surgery. At the median follow-up of 11 months (range, 7-20 months), all patients achieved the successful criteria of treatment. Conclusion: The posteriorly augmented anastomotic ureteroplasty with lingual mucosal onlay grafts for long proximal ureteral strictures is a feasible and safe technique, which may be an option especially for strictures marginally longer than those that can be safely repaired via end-to-end anastomosis.

Imaging of ureter: a primer for the emergency radiologist

In this review article, we will discuss the gamut of abnormalities involving the ureters. In the emergency department, ureterolithiasis is the most common indication for imaging abdomen and pelvis. However, spectrum of ureteral abnormalities including congenital, infectious and inflammatory, primary and secondary ureteral malignancies, retroperitoneal fibrosis rare described in this article may be encountered. Thus, we will describe acute subacute as well as chronic conditions that may affect ureter. Knowledge of common, as well as rare entities and their imaging features, is of utmost importance to enable appropriate management.

Blunt Trauma Resulting in Testicular Evisceration: A Case Report

Scrotal and testicular injuries are uncommon injuries, accounting for only a fraction of all trauma. Blunt scrotal trauma is accompanied by testicular rupture in up to 50% of cases. We present a rare case of scrotal rupture with evisceration of a viable, intact testicle after a motor vehicle accident. The patient’s presentation, associated injuries, operation, and post-operative course are described. In brief, this is a case of a 69-year-old male who sustained multiple rib, pelvic, and right femur fractures in addition to scrotal injury after a motor vehicle accident. He was taken quickly to the operating room for the scrotal rupture, and his testicle was successfully replaced and scrotal laceration repaired. He did well post-operatively. This case represents one of the few accounts of this particular injury in the literature.

A complex genitourinary injury following gunshot in a 12 Year old and systematic review

We highlight the case of a 12 year old male who presented after sustaining a gunshot injury to the scrotum resulting in testicular, prostatic, and urethral transection in addition to pelvic fracture, extra peritoneal bladder injury, and transmural injury to recto sigmoid and ileum. The patient underwent a left orchiectomy, primary repair of the bladder and urethra, placement of universal plate on superior pubic rami, and segmental rectosigmoid and ileum resection. These findings illustrate the collaborative efforts of trauma surgery and urology to treat complex lower genitourinary (GU) injuries and how the direct prioritization of surgical efforts provides acceptable outcomes.

Complete urethral disruption as a complication of urethral catheterization presenting as scrotal mass: A rare case

Complete urethral disruption due to urethral catheterization is rarely documented. Only seven cases of iatrogenic complete urethral disruption were reported from 1997 to 2003. We describe a case of complete urethral disruption due to urethral catheterization in an 80-year-old male who was referred because of a scrotal mass. Physical examination showed a palpable non-fluctuation mass in the scrotum and ultrasound examination revealed an intrascrotal balloon catheter. This was an obscure case of urethral catheterization complication presenting as a scrotal mass in an octogenarian patient with Fournier's gangrene.

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Iatrogenic urethral injuries can cause complete urethral disruption.

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Although rare, false passage to the scrotal area can be presented as a scrotal mass.

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Infection combined with aging are the risk factors that affecting urethral wall to become frail.

Fluorescence Imaging of the Ureter in Minimally Invasive Pelvic Surgery

STUDY OBJECTIVE

Determine near-optimal dose, safety, and efficacy of nerindocianine in pelvic ureter detection with near-infrared fluorescence imaging in women undergoing minimally invasive pelvic surgery with 3 Food and Drug Administration-cleared imaging systems.

DESIGN

Open label, phase 1/2a study.

SETTING

University of Alabama at Birmingham.

PATIENTS

Forty-one female subjects undergoing minimally invasive gynecologic surgery.

INTERVENTIONS

Subjects received a single dose of nerindocianine sodium, starting at 0.06-mg/kg body weight and increased/decreased until the near-optimal dose was determined (part A). Examine the degree of concordance between endoscopic and robotic devices (part B).

MEASUREMENTS AND MAIN RESULTS

In part A, composite scores were collected every 10 minutes for 30 minutes and then every 15 minutes through 90 minutes using a scale measuring the anatomy/laterality of ureter visualization. In part B (paired imaging system efficacy), 2 cohorts of 8 subjects each received the near-optimal dose. Composite scores for visualization of the ureter were collected at 10 and 30 minutes postinfusion with the Firefly Imaging System and either the PINPOINT or 1588 AIM endoscope. Composite scores were compared to examine the degree of concordance between devices. Part A comprised 25 total subjects enrolled in dosing groups 1, 2, and 3 (0.06-, 0.12-, and 0.045-mg/kg, respectively). Median time to first ureter visualization was 10 minutes (all groups). The nerindocianine 0.06-mg/kg and 0.12-mg/kg groups had longer length of time of visualization than the 0.045-mg/kg group, resulting in the selection of 0.06 mg/kg as the near-optimal dose. Part B enrolled 16 total subjects in 2 groups dosed at 0.06 mg/kg. Efficacy analysis showed no statistically significant difference in composite scores with Firefly versus PINPOINT or 1588 AIM.

CONCLUSION

Nerindocianine was well tolerated with visualization of the ureter demonstrated in 88.9% of the subjects through 90 minutes postdosing. No meaningful visualization differences were observed among the Food and Drug Administration-cleared surgical imaging systems used.

The Male Urethra: Imaging and Surgical Approach for Common Pathologies

Urethral pathology is common in clinical practice and important to recognize. It is essential to recognize urethral pathology on imaging and to understand how to best image the urethra. In this way, the radiologist can provide the urologist with the necessary information prior to intervention. Basic knowledge of commonly performed urethral surgeries can help the radiologist understand the expected appearance of the post-treatment urethra and common postoperative complications.

High Riding Prostate: Epidemiology of Genitourinary Injury in Motorcyclists from a UK Register of over 12,000 Victims

BACKGROUND

The mechanism of motorcycle accidents (high speeds, pelvis behind fuel tank) may predispose to genitourinary injury (GUI) but the epidemiology is poorly understood. Previous studies have assessed GUI patterns in cyclists, and road traffic accident victims in general, but no study has analyzed GUI patterns in a large cohort of motorcyclists.

OBJECTIVES

We aimed to better understand patterns of urological injuries among motorcyclists admitted to hospital. We aimed to determine any relationship between pelvic fracture and GUI patterns or severity.

METHODS

The Trauma Audit Research Network was reviewed to identify motorcyclists admitted between January 2012 and December 2016 (n = 12,374). Cases were divided into riders (n = 11,926) and pillion passengers (n = 448), and the data analyzed to identify urological injuries and their associations. The associations between pelvic fracture and other injury types were tested for significance by one- and two-way χ 2.

RESULTS

GUI was identified in 6%. Renal trauma was the most common GUI among riders (4%) and pillions (2%). There was no statistically significant relationship between grade of renal trauma and presence of pelvic fracture. Urethral injury occurred in 0.2% of riders and passengers, and bladder injury in 0.4% of riders and 0.7% of pillions. Urethral and bladder injuries were positively associated with pelvic fracture, which was present in 81 and 92%, respectively. Testicular trauma occurred in 0.4% of riders and 0.7% of pillions. Body armor was recorded in 3% of casualties with urological trauma, and 3% overall.

CONCLUSIONS

A significant proportion of motorcyclists brought to accident and emergency department have GUI, most commonly renal trauma. Pelvic fracture is more common in pillion passengers than riders, and associated with urethral and bladder injuries, but it does not predict severity of renal trauma. External genital injuries are rare, but we recommend examination in the tertiary survey, as consequences of missed injury are severe. Further research is needed to explore protective effects of motorcyclist clothing.

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.

Computed tomography (CT) in the evaluation of bladder and ureteral trauma: indications, technique, and diagnosis

INTRODUCTION

Trauma to the genitourinary system includes blunt and penetrating injuries to bladder and ureters. These are rare injuries and are overlooked as other abdominal and pelvic injuries often take priority. Delayed diagnosis can lead to significant morbidity and mortality. Computed tomography has taken a central role in the imaging of the ureters and bladder.

METHODS

This article reviews the anatomic relationships, mechanisms of injury, and clinical presentation to help physicians determine when bladder and ureteral injuries should be suspected and further imaging should be pursued. Radiologic evaluation of bladder and ureteral injury with CT cystography and CT urography, respectively, will be reviewed.

CONCLUSION

CT cystography and CT urography are effective tools in identifying potentially serious injuries to the genitourinary system. Timely recognition of these injuries can be crucial for the overall management and prognosis.

Migrated bullet in the bladder presenting 18 years after a gunshot wound

Gunshot wounds to the genitourinary system are relatively rare, and it is even rarer a retained bullet migrates into the urinary tract. We describe a case where the bullet migrated into the bladder and formed a bladder stone eighteen years after the injury. This presentation is unique as it is one of the longest times from gunshot wound to presentation in the current literature.

Characteristics of Traumatic Urogenital Injuries in Emergency Department; a 10-year Cross-sectional Study

INTRODUCTION

Urogenital system injuries (UGIs) are seen in 10% of adult cases with multiple trauma. Although UGIs are rarely life threatening, they can cause major long-term morbidities. This study aimed to evaluate the characteristics of traumatic UGIs in patients who were referred to emergency department following multiple traumas.

METHODS

This retrospective cross-sectional study was conducted on multiple trauma patients who were presented to emergency department during a 10-year period (2008-2017). All patients with kidney, ureter, bladder, urethra, or external genitalia injuries were studied. The patients' data were extracted from their clinical profiles.

RESULTS

Out of the 13598 admitted patients in our trauma center, UGIs were seen in 267 (1.9%) cases. The mean age of patients with UGIs was 27.3 ± 6.1 years (74.15% male). The highest incidence of UGI was seen in those aged between 21 and 30 years (39.7%) and motorcycle accidents (49%) was the most frequent cause of trauma. 221 patients had an unstable situation and were emergently transferred to operation room (13.57% with traumatic kidney injury). The most common injured sites of urogenital system were kidney with 155 (58%) cases, followed by external genitalia with 91 (34.1%) cases. 77.5% of cases were managed conservatively and the rest (22.5%) underwent surgical procedures.

CONCLUSION

UGIs comprise a low percentage (2%) of traumatic injuries, which are mostly caused by blunt trauma due to road traffic accidents. Kidney is the most common injured organ and UGIs mostly happen in young ages.

Experience of a Tertiary-Level Urology Center in the Clinical Urological Events of Rare and Very Rare Incidence. II. Urological Self-Inflicted Harms: 1. Unintentional Patient's Side-Inflictor Urological Injuries

INTRODUCTION

Unintentional self-inflicted injuries mainly refer to those injuries which are inflicted by the patient himself with benign intentions. In urology, they may vary and result in significant morbidities.

PATIENTS AND METHODS

A retrospective search of our patients' data records for the reported cases of patient's side-inflictor urological injuries during the period July 2006 - June 2016 was made. Each case was studied for age, gender, primary diagnosis, injury inflictor, involved organ, motivating factor, mechanism, diagnosis, management, and final outcome.

RESULTS

Of more than 55,000 urological procedures, 26 patients (0.047%) were involved in unintentional patient's side-inflictor urological injuries. The age range was 8-76 years and included 23 males and 3 females. Fifteen patients (57.7%) had urological disorders before the injury. They could be differentiated into direct organ involvement injuries (53.8%) and catheter involvement injuries (46.2%). External male urogenital organs were involved in 69.3% of cases which were diagnosed on physical examination. The inflictor of the injury was the patient himself, a relative, and another patient in 73.1, 19.2, and 7.7% of cases, respectively. Motivating factors were relief of painful conditions (34.6%), psychiatric disorders (38.5%), and sexual purposes (27%). Final outcomes were short-term harm, long-term harm, and permanent disability in 50, 11.5, and 38.5% of cases, respectively.

CONCLUSION

Unintentional patient's side-inflictor urological injuries are very rare events and mainly involve the external male urogenital organs under different motivating stressors. They could be differen-tiated into direct organ and catheter manipulation injuries with variable final outcomes from mild short-term harms to permanent disabilities.

Urinoma: Prompt Diagnosis and Treatment Can Prevent Abscess Formation, Hydronephrosis, and a Progressive Loss of Renal Function

This case describes a 70-year-old female who presented with right flank pain around the site where a stent had been placed in her right kidney at an outside hospital several months earlier. The patient arrived tachycardic with a leukocytosis and a lactic acidosis. Further imaging revealed a very hydronephrotic right kidney and an extremely large fluid collection in the right retroperitoneum extending into the right flank consistent with leakage of urine from the obstructed right kidney. Prompt treatment of this rare phenomenon is crucial for delay in medical care can lead to abscess, hydronephrosis, electrolyte instability, and a progressive loss of renal function. Treatment for small urinomas is usually conservative as the collection will most often be reabsorbed. Larger urinomas even without systemic signs often necessitate more aggressive medical treatment. A drainage catheter can be placed with ultrasound or CT guidance. Percutaneous nephrostomy tubes are often used as well for additional drainage and decompression. Fluid culture is recommended to guide antibiotic treatment.

Injury severity score associated with concurrent bladder injury in patients with blunt urethral injury

BACKGROUND

Delayed diagnosis of concurrent bladder damage in a patient with blunt urethral trauma can lead to a high rate of morbidity. In patients with a high index of suspicion, genitourinary workup is recommended. In complicated patients with multi-trauma, this workup has a risk of being delayed. A proven prognostic indicator to evaluate the likelihood of bladder injury in this population has not been established. The aim of this study was to determine if there was a clinical association between the Injury Severity Score (ISS) and bladder injury involvement among these patients.

METHODS

Retrospective analysis was performed on a cohort of 98 patients who presented with blunt urethral trauma to R. Adams Cowley Shock Trauma Center between 2002 and 2014. Univariate analysis was performed to determine if there was an association between concurrent bladder injuries and ISS among other factors. A receiver operating characteristic curve plot was performed to analyze the association between ISS and bladder involvement.

RESULTS

Of the 98 patients with blunt urethral trauma, 28 had concurrent bladder injury. ISS was shown to have a significant correlation with concurrent bladder injury (OR = 2.2 per 10 unit change in ISS, p = 0.0001). ROC curve analysis showed an area under the curve for the prediction of bladder injury. Patients with ISS ≥ 34 had a 54% chance of bladder injury, while patients with ISS < 34 had a 13% chance.

CONCLUSION

ISS ≥ 34, a score in the range of severe multi-trauma, may be a clinical indicator of bladder injury in patients presenting with blunt urethral trauma.

FUNDING

This research was supported in part by the Proposed Research Initiated by Students and Mentors (PRISM) Program, University of Maryland School of Medicine Office of Student Research.

Haematuria in Sport: A Review

CONTEXT

Haematuria is a common urological presentation associated with patient anxiety and clinically relevant underlying pathology. However, the prevalence and pathophysiology of haematuria following sporting exercise is less well documented.

OBJECTIVES

This review paper seeks to clarify the prevalence of microscopic and macroscopic haematuria in association with sporting exercise reported in the literature, and the pathophysiology behind it. We review the relation of haematuria to injury to the urinary tract in sport, as well as the incidence of underlying disease, urological and incidental, following investigation for exercise-induced haematuria.

EVIDENCE ACQUISITION

A non-systematic literature review was conducted of articles and studies using the Pubmed database. Articles were selected with preference for the highest level of evidence available, with relevant data extracted, analysed, and summarised. Supplementary information was collected by cross-referencing the reference lists.

EVIDENCE SYNTHESIS

Multiple studies have shown that clinically significant haematuria is common after exercise. Physiological changes occurring during exercise result in increased glomerular permeability and microscopic haematuria in up to 95% of cases. The degree of haematuria is related to the intensity of the exercise. However, participating in contact sports increases the risk of macroscopic haematuria. Red cell haemolysis and rhabdomyolysis also play a role in urine discolouration following exercise and can be present in 30%. Haematuria following exercise-related trauma is regarded an important indication for further urological investigation. Haematuria may be absent in 44% of cases of urological injury. Renal trauma accounts for 80% of urological trauma, with 30% of these being due to sporting activity. Incidental findings on computed tomography for haematuria are common, with 50% showing positive extraurinary findings. Incidental malignancy, however, is rare.

CONCLUSIONS

Haematuria is common following exercise and results from physiological changes and contact-related trauma to the urinary tract. All cases of haematuria should be investigated as underlying trauma and extraurinary disease are common incidental findings on investigation.

PATIENT SUMMARY

Blood in the urine following exercise is a common phenomenon and occurs due to vascular responses to sports and trauma as well as blood and muscle cell breakdown. Although it may not be present in all cases of trauma, blood in the urine should be investigated due to the risk of discovering underlying injury to the urinary tract and other incidental findings.

Scrotal reconstruction and testicular prosthetics

Scrotal surgery encompasses a wide-variety of surgical techniques for an even wider variety of indications. In this manuscript, we review our indications, techniques, and pit-falls for various reconstructive scrotal surgeries as-well-as surgical tips for placement of testicular prostheses. Penoscrotal webbing (PSW) is an abnormal, often-problematic distal insertion of scrotal skin onto the ventral penile shaft. There are several effective and straightforward techniques used to revise this condition, which include simple scrotoplasty, single- or double-Z-plasty, or the VY-flap scrotoplasty. Reconstruction is also commonly indicated following scrotal skin loss caused by infection, trauma, lymphedema, hidradenitis, and cancer. Although initial management of these conditions often involves scrotal skin removal, repair of expansive scrotal skin loss can be technically difficult and can be accomplished by using one of several skin flaps or skin grafting. Split-thickness skin grafting of scrotal defects can be accomplished easily, and provides durable results.

Expanding Applications of Renal Mobilization and Downward Nephropexy in Ureteral Reconstruction

OBJECTIVE

To evaluate renal mobilization with downward nephropexy as an adjunct maneuver to facilitate various methods of reconstruction of the upper urinary tract with limited ureteral length.

MATERIALS AND METHODS

We retrospectively reviewed all upper urinary tract reconstructive procedures performed from 2007 to 2015 to identify those requiring downward renal mobilization with nephropexy. Data including concomitant maneuvers, stricture location, prior surgeries, and intraoperative details were analyzed. Success rates, defined by resolution of symptoms and avoidance of further intervention, and complications were evaluated.

RESULTS

Of 92 patients undergoing ureteral reconstruction during the study period, 18 (19.6%) involved renal mobilization with downward nephropexy to gain additional ureteral length (5/7 [71.4%] of ureterocalycostomies, 8/26 [30.1%] of Boari flap bladder reconfigurations, 4/12 [33.3%] of ureteroureterostomies, and 1/12 [8.3%] of ileal ureters). Two-thirds of patients (12/18, 66.7%) had undergone unsuccessful prior open, laparoscopic, or endoscopic reconstruction attempts. Renal mobilization was performed open in 15/18 (83.3%) cases and laparoscopically in 3/18 (16.7%). After renal mobilization, the average distance of downward movement achieved was 3.3 cm (range 3-5 cm). With a mean follow-up of 50.4 months (range 3-87 months), overall success rate defined as ureteral patency was 88.9%, with 2/18 patients (11.1%) requiring a subsequent nephrectomy for failed upper tract reconstruction and persistent symptomatic hydronephrosis.

CONCLUSION

Downward renal mobilization and nephropexy is a safe and versatile technique that can be effectively combined with many other reconstructive maneuvers.

Treatment of complex perineal trauma. A review of the literature

Perineal injuries are uncommon, but not rare. They may present a wide variety of injury patterns which demand an accurate diagnostic assessment and treatment. Perineal injuries may occur as isolated injuries to the soft tissues or may be associated with pelvic organ, abdominal or even lower extremity injury. Hence the importance to know in depth not only the anatomy of the perineum and its organs, but also the implications of the patient's hemodynamic stability on the decision making process when treating these injuries using established trauma guidelines. The purpose of this review is to describe the current epidemiology and clinical presentation of perineal injuries in order to provide specific guidelines for the diagnosis and treatment of both stable and unstable patients.