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Proteinuria as a predictor of renal injury
LETTERS TO THE EDITOR
PROTEINURIA RENAL INJURY
AS A PREDICTOR
OF
To the Editor: We have recently reviewed the medical records of 178 patients referred for intravenous urography (IVU) following blunt abdominal trauma sustained in motor vehicle accidents. The urine of 74 patients was examined for protein by dipstick (Labstick*) at the time of injury. Of the 37 patients with proteinuria, 14 (38 per cent) had evidence of renal injury on IVU. Of the 37 without proteinuria, only 2 (5.4 per cent) had a renal injury. The difference is highly significant (p < 0.005; Chi square). The absence of proteinuria had a negative predictive value (true negative/true negative + false negative) of 95 per cent. On the other hand, the severity of hematuria was, at best, a poor indicator of renal injury. We recognize that blood in the urine can result in false positive tests for proteinuria. However, all 74 patients demonstrated hematuria, the severity of which is poorly correlated with the existence of renal injury in other studies’” as well as ours. Because our study is retrospective, it is impossible to determine the exact nature of the protein and the quantities which are present. An animal model is currently being developed and prospective studies in humans are contemplated. In view of the increasingly conservative management of renal injury, the absence of proteinuria may allow selected patients to avoid intravenous urography in the emergency situation. Stanley P. Laucks, Jr., M.D.,
Ph.D. Department of Diagnostic Radiology University of Rochester Medical Center Rochester, New York 14642 Maurice S. F. McLachlan, M.D. Mount Sinai Medical Center 950 North 12th Street Milwaukee, Wisconsin 53201 References 1. McDonald EJ, et al: The role of emergency excretory urography in evaluation of blunt abdominal trauma, AJR 126: 734 (1976). 2. Bright TC, White K, and Peters PC: Significance of hematuria after trauma, J. Ural. 120: 455 (1978).
lished
in UROLOGY (vol. 16, page 664, December, various comments of a constructive nature since there are semantic errors, questionable anatomic assumptions, and contradictory suggestions on management. First, both cases should be classified as intrauterine torsion since both were properly diagnosed at birth. The neonatal period is immediately after birth. Dorland’s “Medical Dictionary” describes neonatal, “pertaining to the first four weeks after birth.” I compliment the authors for exploring and pexing the opposite testis in each case, although they did not describe their surgical technique. In their discussion the authors contradict themselves, stating “The suggested treatment of neonatal testicular torsion is unilateral scrotal exploration via an inguinal incision and orchiectomy.” Although the earlier literature and teaching suggest newborn torsion is extravaginal, in recent years several authors have reported the intravaginal variety of torsion in the newborn infant. ie3 In my opinion, simultaneous exploration of the opposite testis should include evagination of the parietal tunica (Bottle hydrocele technique) and orchidopexy with nonabsorbable sutures in at least two sites to allow agglutination and adhesion in the normal anatomic position, preventing the future exciting factors from causing rotation (twisting) by the cremaster muscle.4 The authors concluding remark that “torsion is not an emergency since testicular infarction is the rule” ignores the hope that some hormonal function may remain if detorsion is performed promptly and the testis replaced in the scrotum, particularly in bilateral simultaneous neonatal torsion. I believe immediate bilateral exploration can be done with nipple-sucking “anesthesia” (no anesthesia) using the infant circumcision board with restraints, through anterior crease after separate skin incisions. There is seldom reason to procrastinate and delay surgery; the infant may be discharged with the mother in a day or two. Lastly, I believe contralateral orchidopexy is mandatory to avoid losing the patient to follow-up but most importantly to negate the unfortunate 5 to lo-per cent incidence of metachronous torsion, rendering the infant eunuchoid, with no chance for procreation. 1980), deserves
R. H. Harrison, M.D. 2721 Osler Blvd. Bryan, Texas 77801
*Miles Laboratories, Elkhart, Indiana.
INTRAUTERINE
TESTICULAR
TORSION
To the Editor: The article, “Neonatal Torsion of Testicle,” by Gary E. Leach and Bimal K. Masih, pub-
120
1. Guiney M, and McGlinchey S: Torsion of the testis and the spermatic cord in the newborn, Surg. Gynecol. Obstet. 152: 273 (1981). 2. Bret A: Infarction and torsion of the testicle in the newborn, Rev. Franc Gynec. 63: 83 (1968).
UROLOGY
/
JANUARY 1982
/
VOLUME XIX, NUMBER 1
PROTEINURIA RENAL INJURY
AS A PREDICTOR
OF
To the Editor: We have recently reviewed the medical records of 178 patients referred for intravenous urography (IVU) following blunt abdominal trauma sustained in motor vehicle accidents. The urine of 74 patients was examined for protein by dipstick (Labstick*) at the time of injury. Of the 37 patients with proteinuria, 14 (38 per cent) had evidence of renal injury on IVU. Of the 37 without proteinuria, only 2 (5.4 per cent) had a renal injury. The difference is highly significant (p < 0.005; Chi square). The absence of proteinuria had a negative predictive value (true negative/true negative + false negative) of 95 per cent. On the other hand, the severity of hematuria was, at best, a poor indicator of renal injury. We recognize that blood in the urine can result in false positive tests for proteinuria. However, all 74 patients demonstrated hematuria, the severity of which is poorly correlated with the existence of renal injury in other studies’” as well as ours. Because our study is retrospective, it is impossible to determine the exact nature of the protein and the quantities which are present. An animal model is currently being developed and prospective studies in humans are contemplated. In view of the increasingly conservative management of renal injury, the absence of proteinuria may allow selected patients to avoid intravenous urography in the emergency situation. Stanley P. Laucks, Jr., M.D.,
Ph.D. Department of Diagnostic Radiology University of Rochester Medical Center Rochester, New York 14642 Maurice S. F. McLachlan, M.D. Mount Sinai Medical Center 950 North 12th Street Milwaukee, Wisconsin 53201 References 1. McDonald EJ, et al: The role of emergency excretory urography in evaluation of blunt abdominal trauma, AJR 126: 734 (1976). 2. Bright TC, White K, and Peters PC: Significance of hematuria after trauma, J. Ural. 120: 455 (1978).
lished
in UROLOGY (vol. 16, page 664, December, various comments of a constructive nature since there are semantic errors, questionable anatomic assumptions, and contradictory suggestions on management. First, both cases should be classified as intrauterine torsion since both were properly diagnosed at birth. The neonatal period is immediately after birth. Dorland’s “Medical Dictionary” describes neonatal, “pertaining to the first four weeks after birth.” I compliment the authors for exploring and pexing the opposite testis in each case, although they did not describe their surgical technique. In their discussion the authors contradict themselves, stating “The suggested treatment of neonatal testicular torsion is unilateral scrotal exploration via an inguinal incision and orchiectomy.” Although the earlier literature and teaching suggest newborn torsion is extravaginal, in recent years several authors have reported the intravaginal variety of torsion in the newborn infant. ie3 In my opinion, simultaneous exploration of the opposite testis should include evagination of the parietal tunica (Bottle hydrocele technique) and orchidopexy with nonabsorbable sutures in at least two sites to allow agglutination and adhesion in the normal anatomic position, preventing the future exciting factors from causing rotation (twisting) by the cremaster muscle.4 The authors concluding remark that “torsion is not an emergency since testicular infarction is the rule” ignores the hope that some hormonal function may remain if detorsion is performed promptly and the testis replaced in the scrotum, particularly in bilateral simultaneous neonatal torsion. I believe immediate bilateral exploration can be done with nipple-sucking “anesthesia” (no anesthesia) using the infant circumcision board with restraints, through anterior crease after separate skin incisions. There is seldom reason to procrastinate and delay surgery; the infant may be discharged with the mother in a day or two. Lastly, I believe contralateral orchidopexy is mandatory to avoid losing the patient to follow-up but most importantly to negate the unfortunate 5 to lo-per cent incidence of metachronous torsion, rendering the infant eunuchoid, with no chance for procreation. 1980), deserves
R. H. Harrison, M.D. 2721 Osler Blvd. Bryan, Texas 77801
*Miles Laboratories, Elkhart, Indiana.
INTRAUTERINE
TESTICULAR
TORSION
To the Editor: The article, “Neonatal Torsion of Testicle,” by Gary E. Leach and Bimal K. Masih, pub-
120
1. Guiney M, and McGlinchey S: Torsion of the testis and the spermatic cord in the newborn, Surg. Gynecol. Obstet. 152: 273 (1981). 2. Bret A: Infarction and torsion of the testicle in the newborn, Rev. Franc Gynec. 63: 83 (1968).
UROLOGY
/
JANUARY 1982
/
VOLUME XIX, NUMBER 1