Use of ureteral stents in the management of major renal trauma with urinary extravasation: is there a role?

Five patients with major (Grade IV) renal trauma required ureteral stent placement to facilitate urinary drainage. Three of these patients had stents placed for recurrent gross hematuria with flank pain. All three had obstructing blood clots present at the time of stent placement. The fourth patient had a stent placed because of persistent extravasation at 2 weeks postinjury. The last patient was considered at risk for persistent urinary extravasation because of a partial ureteropelvic junction obstruction and had a ureteral stent placed as part of the initial management. All patients were followed radiographically for resolution of extravasation. Long-term clinical follow-up consisted of serum creatinine evaluation and blood pressure monitoring. Urinary extravasation resolved in all five patients, as determined by radiologic evaluation, at a mean of 8 days after stent placement. Ureteral stents were left indwelling an average of 4 weeks. No patient developed hypertension, and all serum creatinine values were normal at a mean 26 months' follow-up. No patient developed urinoma or abscess, and none required open surgical exploration. Ureteral stents may be used safely and effectively to treat persistent or recurrent urinary extravasation resulting from major blunt renal trauma in appropriately selected patients. In addition, ureteral stents may avoid the need for surgical exploration in patients with Grade IV renal trauma who develop recurrent gross hematuria, flank pain, and persistent or recurrent extravasation secondary to clot obstruction.

Iatrogenic ureteral injuries: a 20-year experience in treating 165 injuries

PURPOSE

We reviewed the causes, treatment and morbidity associated with iatrogenic ureteral injuries.

MATERIALS AND METHODS

From 1972 to 1992 the charts of all patients with the diagnosis of iatrogenic ureteral injury were reviewed and 156 injuries were identified.

RESULTS

Urological, gynecological and general surgical procedures accounted for 70 (42%), 56 (34%) and 39 (24%) injuries, respectively. Of the injuries 91% occurred in the lower third, 7% in the middle third and 2% in the upper third of the ureter, respectively. Among the urological lesions 77% were identified at injury compared to only 33% of the nonurological cases. Nonurological and urological ureteral injuries detected postoperatively required 1.8 and 1.6 procedures, respectively, compared to only 1.2 procedures in both groups (p < 0.0006 and p < 0.013) when the injuries were detected immediately at operation.

CONCLUSIONS

Endourological procedures are the most common cause of iatrogenic ureteral injuries. When identified at injury and treated properly such injuries seldom lead to loss of renal function.

Outpatient nephrectomy for nonfunctioning kidneys

We describe a surgical approach that allows multicystic dysplastic and nonfunctioning hydronephrotic kidneys to be removed on an outpatient basis through a 2.5 to 3 cm. subcostal incision. In the last 5 years 40 children (age 4 months to 5 years, mean 8.2 months) were scheduled for outpatient nephrectomy in an ambulatory surgical unit in a hospital setting. Of the 40 patients 30 had a multicystic kidney. Renal size ranged from 3 x 2 to 9.5 x 7.2 cm. Operative time ranged from 20 to 70 minutes (mean 45.4). In 34 cases (85%) an intercostal block was also performed to provide analgesia for 18 to 24 hours. Nephrectomy was done on an outpatient basis in 39 of the 40 children (98%). Mean pain score (range 0 to 5) in the last 19 patients who underwent an intercostal block was 0.68 at discharge from the hospital, 0.85 at bedtime and 0.95, 24 hours later. We conclude that nephrectomy may be performed through a small incision on an outpatient basis with minimal morbidity, and that this approach offers an alternative to laparoscopic nephrectomy and nonsurgical management of these kidneys.

Renal histological changes secondary to ureteropelvic junction obstruction

The treatment of children with apparent ureteropelvic junction obstruction is controversial. In an asymptomatic infant or child the decision to recommend pyeloplasty usually is based on interpretation of the renal scan. We retrospectively analyzed the renal biopsy obtained during pyeloplasty in 55 children. Histological changes were compared to the differential renal function revealed on the preoperative renal scan. Histological changes were graded on a scale of I to V; I--normal, II--mild dilatation of the collecting tubules or Bowman's space and III to V--progressively severe changes of obstructive uropathy, including reduced glomerular number, glomerular hyalinization, cortical cysts and interstitial inflammation. Patient age ranged from 4 days to 19 years (mean 4.8 years). Mean differential function according to histological grade was I--49%, II--43%, III--42%, IV--30% and V--25%. Of 33 patients with a differential function of 40% or greater 26 (79%) had a grade I or II biopsy, while 21% had a more significant alteration in renal histology. In contrast when the differential function was less than 40% 6 of 18 patients (33%) had grade I or II disease on biopsy. In conclusion, in approximately 25% of children with ureteropelvic junction obstruction there is a disparity between preoperative differential renal function computed during diuretic renography and renal biopsy.

Contralateral vesicoureteral reflux in children with a multicystic kidney

Multicystic kidneys are commonly diagnosed today due to the widespread use of prenatal ultrasound. Children with a multicystic kidney are at increased risk of contralateral renal abnormalities. We performed a voiding cystourethrogram on 65 children with a newly diagnosed multicystic kidney to determine the incidence of contralateral vesicoureteral reflux. Ten children (15%) with a multicystic kidney had contralateral vesicoureteral reflux, including 8 of 37 boys (22%) and 2 of 28 girls (7%). Contralateral reflux occurred in significantly more white (22%) than nonwhite (4%) patients (p < 0.001). Reflux was grade I in 2 children, II in 2, III in 2, IV in 1 and V in 3. All children were placed on antimicrobial prophylaxis. During a mean followup of 3.1 years grades I and II reflux resolved. Grade III reflux resolved in 1 child and remained stable in 1. Grade IV reflux was downgraded to III in 1 child on prophylaxis. One child with grade V reflux was stable on prophylaxis while the remaining 2 patients underwent ureteroneocystostomy. No child had a urinary tract infection. A significant proportion of white children with a multicystic kidney have contralateral vesicoureteral reflux and initial imaging should include a voiding cystourethrogram.

The changing management of ureterovaginal fistulas

A retrospective review of 20 ureterovaginal fistulas in 19 patients treated within the last 20 years was done. All fistulas developed after gynecological procedures. The ureterovaginal fistulas resolved in all 7 patients in whom a self-retaining internal stent was placed in either a retrograde (5) or antegrade (2) manner for a minimum of 4 to 8 weeks. In contrast to the literature, it is concluded that modern endourological treatment will result in resolution of a ureterovaginal fistula if passage of a suitable internal stent is feasible. Every effort should be made to treat a ureterovaginal fistula endourologically rather than resort to an open operation.

Evaluation and treatment of bladder rupture

The presence of urologic injury must be considered in patients who have sustained severe lower abdominal blunt trauma and in all patients with pelvic fracture. Physical findings that suggest the possibility of a bladder rupture include gross hematuria and an inability to urinate. A properly performed cystogram is diagnostic of bladder rupture and will define whether the rupture is intraperitoneal or extraperitoneal. Selected cases of extraperitoneal bladder rupture can be safely managed by catheter drainage, antibiotics, and close clinical observation. Intraperitoneal perforations require surgical exploration and bladder closure. Complications occurring as a result of bladder injury are minimized provided the injury is identified and repaired when indicated, and provided continuous unobstructive bladder drainage is achieved.

Use of transrectal ultrasound and biopsy in the detection of prostate cancer

Prostate cancer is the most common cancer diagnosed in U.S. men. In today's current urologic practice, there is considerable controversy regarding the appropriate treatment of prostate cancer. Transrectal ultrasound (TRUS) is the preferred modality for prostate imaging with established roles in the assessment of prostate size and guidance of accurate biopsies. This review will emphasize the history of TRUS and biopsy, patient preparation, technique of biopsy, interpretation of biopsies, and indications for repeat biopsies. The information gained by TRUS and biopsy is useful in counseling patients about potential treatment options.

Renal oncocytoma arising from a renal cyst: a case report and review of the literature

Renal oncocytoma accounts for approximately 3 to 4% of all solid renocortical tumors. An unusual case of renal oncocytoma arising from the wall of a simple renal cyst is reported and the literature is reviewed.

Urologic complications of spinal cord injury

Spinal cord injuries in the past were associated with a very high mortality, predominantly from urologic complications and sepsis. Improvements in the urologic and medical management of these patients have significantly decreased the morbidity and mortality. Many complications may still develop during the urologic management, however. Periodic follow-up is thus essential to recognize and treat urologic complications in order to preserve renal function.

Urologic consequences of myelodysplasia and other congenital abnormalities of the spinal cord

Spina bifida and other congenital abnormalities of the spinal cord are relatively common (1 per 1000 births). Early urologic evaluation to determine the extent of neurologic involvement of the lower urinary tract is essential. Urodynamic studies are important in determining voiding pressure and leak pressure and in classifying the type of detrusor and sphincter dysfunction. Therapy is directed toward preservation of the upper tracts. Many nonsurgical (clean intermittent catheterization and anticholinergic drugs) and surgical procedures allow the child to be continent and maintain a normal upper urinary tract. The importance of follow-up is stressed because neurourologic changes frequently occur, and prompt treatment or change of therapy is essential. Today, children with spina bifida are leading healthy, productive lives. A continued multidisciplinary approach to their care is important.