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644 ARTERIAL-URETERAL FISTULAS
Anatomic study of renal vessels (240 cases)
641
Lappas D.1, Lekas A.2, Gisakis I.1, Kyriopoulou E.1, Chrisofos M.2, Deliveliotis C.2, Scandalakis P.1 University of Athens, Dept. of Descriptive Anatomy, Athens, Greece, 2General Hospital Nikaia, Dept. of Urology, Piraeus, Greece 1
Introduction & Objectives: During a broad study on abdominal vessels (arteries, veins and lymph nodes) we studied and classified the variations of bilateral vessels (parietal or visceral ones). In the present study we refer to the renal arteries and veins. It is a useful knowledge for surgeons of this area and radiologists as well (angiography, invasive radiology). Material & Methods: The study was accomplished in the Dept. of Descriptive Anatomy (Medical School, University of Athens) and the Athens Coronary Laboratory. The observations were performed on 240 corpses of adult Greeks (139 males, 101 females) during the post mortem examinations. In this way, we were able to perform our observations in large anatomical incisions and study the origin of vessels. Results: A] Arteries: The study of renal blood supply showed that the classical knowledge that renal arteries are 2 branches originated from the abdominal aorta and finally can be 29 branches in the parenchyma, was valid for 136 cases (56.67%). We distinguished many variations that could be categorised as follows: 1. Polar arteries could originate from the renal artery: a) Superior polar artery (21 cases, 8.75%), b) Inferior polar artery (5 cases, 2.08%), c) Both superior and inferior polar artery (4 cases, 1.67%). 2. Two renal arteries on each side from the aorta: a) Two renal arteries (34 cases, 14.58%), b) Renal and superior polar artery (13 cases, 5.42%), c) Renal and inferior polar artery (12 cases, 5%). 3. Three or more arteries on each side: a) Three renal arteries (7 cases, 2.92%), b) Two renal and superior polar artery (3 cases, 1.25%), c) Two renal and inferior polar artery (4 cases, 1.67%). There were cases where the origin was not the same on both sides. B] Veins: The renal vessel system has obtained great interest recently because of vascular surgery and transplantations. Generally we knew that the variation of veins is greater than the respective arteries. 1) The left renal vein – in our study group- is a single vein. Of course, it is probable to bifurcated forming a loop around the abdominal aorta (7 cases, 2.92%). In the total of our cases the left renal vein received vein return from a suprarenal vein and from the internal spermatic vein. The junction of the above referred veins with the left renal one was done in an almost perpendicular way and this has a clinical significance, particularly in the second case. The existence of a second inferior vena cava (persistent inferior vena cava) leading to the left renal vein (4 cases, 1.67%) and the retro aortal route of the renal vein (5 cases, 2.08%) were remarkable cases. 2) The right renal vein does not show many differences referring its route. In 71 cases (29.58%) it was found to be double. Also, in 32 cases (13.33%) had 3 right renal veins. We did not observe any other vein to lead to the right renal vein. Our conclusion is that the right renal vein is multiple to a significant amount.
643
Gunshot injuries of the ureter: one center 15-years experience Akay A.F. , Girgin S. , Akay H. , Sahin H. , Bircan K. 1
2
3
1
1
University of Dicle, Urology, Diyarbakir, Turkey, 2University of Dicle, General Surgery, Diyarbakir, Turkey, 3University of Dicle, Radiology, Diyarbakir, Turkey 1
Introduction & Objectives: Ureteral injuries is a rare condition, it is difficult to identify the best means of diagnostic methods and treatment. We report our experience with penetrating ureteral injuries secondary to gunshot wounds. The methods of diagnosis and treatment options of these cases are described and discussed. Material & Methods: A retrospective review of ureteral injuries due to penetrating trauma between January 1990 and December 2005, at Urology and General Surgery departments of our hospital. Ureteral injures were graded according to the AAST-OIS. We evaluated mechanism of injury, initial urinalysis, radiologic and operative procedure, associated injuries, and postoperative complication. Results: Totally twenty one (Sixteen male, five female) cases of gunshot ureteral injuries were evaluated retrospectively. The median patient age was 27.85 (16-48 years) years. All patients had signs and symptoms of an acute abdomen and only nine patients were evaluated radiologically. Hematuria was absent in 71.4 % of patients (15 of 21). All patients had associated injuries and were evaluated from grade I to V. Grade I had none, grade II had 1 (4.76 %), grade III had 3 (14.29 %), grade IV had 14 (66.6 %), grade V had 3 (14.29 %). Ureteral stent or nephrostomy tubes were used in all primarily repaired patients. Two patients developed urinary leakage and it resolved spontaneously. Conclusions: Ureteral injury is should always be in mind and in case of suspicion the surgeon should dissect and visualize the ureter during the exploration. Adequate debridment, and ureteral stenting or nephrostomy drainage are the good factors for succeed treatment.
Have renal trauma guidelines had any impact on urologists in the United Kingdom?
642
Sharma D., Butt N., Barrass B., Dawson C. Edith Cavell Hospital, Urology, Peterborough, United Kingdom Introduction & Objectives: In May of 2004, Evaluation and management of renal injuries: consensus statement of the renal trauma subcommittee was published in the BJU International. Guidelines from the European Association of Urology were made available online in 2003 and a shortened version published in January 2005. Urologists have been encouraged to follow guidelines based on the experience of trauma centers that are familiar with renal injury. Diagnostic Imaging plays an important role in suspected Renal Trauma so we utilised Imaging practices as a proxy to patterns of management. Objective: To investigate whether Urologists in the United Kingdom utilise renal trauma guidelines when requesting Diagnostic Imaging in suspected renal trauma. Material & Methods: A one-page anonymous questionnaire (Appendix) was developed by the authors following an extensive literature review. It was sent to 500 consultant Urologists in the United Kingdom. We asked a series of questions concerning guideline usage and Imaging preferences in different clinical scenarios. We also asked whether there were any local arrangements with radiological colleagues with regard to imaging in renal trauma. Results: 152 (30%) of 500 questionnaires were returned. 70% of respondents saw an estimated 5 or less cases of renal trauma per year. 71% of departments used guidelines but these differed. 52% of respondents believed that the published guidelines were appropriate for UK practice. 5% did not feel that they were appropriate and 32% were unsure. 20% used local guidelines. In stable patients with dipstick haematuria, 80% of the respondents requested imaging with ultrasound (50%) the most popular. In stable patients with gross haematuria, all respondents requested imaging with CT scanning (83%) the most popular. In stable children with suspected renal trauma, all respondents who managed paediatric cases would request imaging. Re-imaging following initial ultrasound was common. Imaging was described as easy or possible to obtain during regular working hours by 97% of respondents. This fell to 86% out of hours with 9% of respondents having difficulty obtaining imaging. Only 18% of respondents had interdepartmental protocols to facilitate the imaging process in suspected renal trauma. Conclusions: The majority of responding Urologists used guidelines in the management of renal trauma. However the guidelines chosen varied and adherence was not strict. Although the overall standard of care is probably acceptable, to facilitate best practice in the management of Renal Trauma, it would be ideal if Urologists were encouraged to adhere to established guidelines. Informed discussion with the local radiology department would probably facilitate this process. Expert guidelines are now readily available online (Uroweb).
Arterial-Ureteral Fistulas
644
Van Den Bergh R.1, Moll F.2, De Vries J.P.3, Lock T.1 University Medical Center, Dept. of Urology, Utrecht, The Netherlands, 2University Medical Center, Dept. of Vascular Surgery, Utrecht, The Netherlands, 3Antonius Hospital, Dept. of Vascular Surgery, Nieuwegein, The Netherlands 1
Introduction & Objectives: Arterial-Ureteral Fistula (AUF) is a rare life-threatening condition which is increasingly described in the literature during the last decades. Although most urologists will never encounter this cause of hematuria, it is essential to be acquainted with the possibility of this diagnosis. Based on the experience in our clinic with multiple cases of AUF and all available relevant literature, a study has been performed which pays thorough attention to this subject. Material & Methods: The database of our clinic was extensively searched for cases of AUF. Furthermore a broad literature search in Pubmed and Embase has been performed in order to assemble all English articles dealing with arterial-ureteral fistulas. Results: Eight cases of AUF were retrieved from the patient records. We found 87 relevant articles in which exactly 100 separate cases were described. An AUF is the final result of an eroding process between an artery in poor condition and a fragile ureter resulting in necrosis. It presents with hematuria of which the extent and duration may vary greatly. Several mutual related factors are associated with the development of these fistulas. Two groups of patients which are particularly at risk can be distinguished. The incidence is rising, because risk factors are present more often. A swift and correct diagnosis before any intervention is taken is of vital importance to a low mortality rate, but remains challenging. Arteriography is the most sensitive investigation, but only when an active bleeding is present. Taking the possibility of the diagnosis AUF in consideration is the most important step in the diagnostic process. Based upon treatment options, cases can be divided into three periods. The classical choice is open surgery, vascular embolisation was introduced later and the most recent alternative is endovascular stent placement. A strongly decreasing mortality rate has been the result of the excellent results of these developments. The majority of risk factors for developing an i.e. also complicate open surgical treatment. The management of an AUF should be multidisciplinary from the first suspicion on. Urologist, vascular surgeon, and radiologist should all be involved. During pelvic surgery the formation of an AUF should be anticipated and preventive measures ought to be taken. Conclusions: In case of gross hematuria in a patient in which risk factors are present, the diagnosis AUF should always be considered. Obtaining diagnostic evidence of the diagnosis remains problematic. Clinical awareness of the possibility of the diagnosis is very important. Excellent treatment options are available.
Eur Urol Suppl 2007;6(2):183
641
Lappas D.1, Lekas A.2, Gisakis I.1, Kyriopoulou E.1, Chrisofos M.2, Deliveliotis C.2, Scandalakis P.1 University of Athens, Dept. of Descriptive Anatomy, Athens, Greece, 2General Hospital Nikaia, Dept. of Urology, Piraeus, Greece 1
Introduction & Objectives: During a broad study on abdominal vessels (arteries, veins and lymph nodes) we studied and classified the variations of bilateral vessels (parietal or visceral ones). In the present study we refer to the renal arteries and veins. It is a useful knowledge for surgeons of this area and radiologists as well (angiography, invasive radiology). Material & Methods: The study was accomplished in the Dept. of Descriptive Anatomy (Medical School, University of Athens) and the Athens Coronary Laboratory. The observations were performed on 240 corpses of adult Greeks (139 males, 101 females) during the post mortem examinations. In this way, we were able to perform our observations in large anatomical incisions and study the origin of vessels. Results: A] Arteries: The study of renal blood supply showed that the classical knowledge that renal arteries are 2 branches originated from the abdominal aorta and finally can be 29 branches in the parenchyma, was valid for 136 cases (56.67%). We distinguished many variations that could be categorised as follows: 1. Polar arteries could originate from the renal artery: a) Superior polar artery (21 cases, 8.75%), b) Inferior polar artery (5 cases, 2.08%), c) Both superior and inferior polar artery (4 cases, 1.67%). 2. Two renal arteries on each side from the aorta: a) Two renal arteries (34 cases, 14.58%), b) Renal and superior polar artery (13 cases, 5.42%), c) Renal and inferior polar artery (12 cases, 5%). 3. Three or more arteries on each side: a) Three renal arteries (7 cases, 2.92%), b) Two renal and superior polar artery (3 cases, 1.25%), c) Two renal and inferior polar artery (4 cases, 1.67%). There were cases where the origin was not the same on both sides. B] Veins: The renal vessel system has obtained great interest recently because of vascular surgery and transplantations. Generally we knew that the variation of veins is greater than the respective arteries. 1) The left renal vein – in our study group- is a single vein. Of course, it is probable to bifurcated forming a loop around the abdominal aorta (7 cases, 2.92%). In the total of our cases the left renal vein received vein return from a suprarenal vein and from the internal spermatic vein. The junction of the above referred veins with the left renal one was done in an almost perpendicular way and this has a clinical significance, particularly in the second case. The existence of a second inferior vena cava (persistent inferior vena cava) leading to the left renal vein (4 cases, 1.67%) and the retro aortal route of the renal vein (5 cases, 2.08%) were remarkable cases. 2) The right renal vein does not show many differences referring its route. In 71 cases (29.58%) it was found to be double. Also, in 32 cases (13.33%) had 3 right renal veins. We did not observe any other vein to lead to the right renal vein. Our conclusion is that the right renal vein is multiple to a significant amount.
643
Gunshot injuries of the ureter: one center 15-years experience Akay A.F. , Girgin S. , Akay H. , Sahin H. , Bircan K. 1
2
3
1
1
University of Dicle, Urology, Diyarbakir, Turkey, 2University of Dicle, General Surgery, Diyarbakir, Turkey, 3University of Dicle, Radiology, Diyarbakir, Turkey 1
Introduction & Objectives: Ureteral injuries is a rare condition, it is difficult to identify the best means of diagnostic methods and treatment. We report our experience with penetrating ureteral injuries secondary to gunshot wounds. The methods of diagnosis and treatment options of these cases are described and discussed. Material & Methods: A retrospective review of ureteral injuries due to penetrating trauma between January 1990 and December 2005, at Urology and General Surgery departments of our hospital. Ureteral injures were graded according to the AAST-OIS. We evaluated mechanism of injury, initial urinalysis, radiologic and operative procedure, associated injuries, and postoperative complication. Results: Totally twenty one (Sixteen male, five female) cases of gunshot ureteral injuries were evaluated retrospectively. The median patient age was 27.85 (16-48 years) years. All patients had signs and symptoms of an acute abdomen and only nine patients were evaluated radiologically. Hematuria was absent in 71.4 % of patients (15 of 21). All patients had associated injuries and were evaluated from grade I to V. Grade I had none, grade II had 1 (4.76 %), grade III had 3 (14.29 %), grade IV had 14 (66.6 %), grade V had 3 (14.29 %). Ureteral stent or nephrostomy tubes were used in all primarily repaired patients. Two patients developed urinary leakage and it resolved spontaneously. Conclusions: Ureteral injury is should always be in mind and in case of suspicion the surgeon should dissect and visualize the ureter during the exploration. Adequate debridment, and ureteral stenting or nephrostomy drainage are the good factors for succeed treatment.
Have renal trauma guidelines had any impact on urologists in the United Kingdom?
642
Sharma D., Butt N., Barrass B., Dawson C. Edith Cavell Hospital, Urology, Peterborough, United Kingdom Introduction & Objectives: In May of 2004, Evaluation and management of renal injuries: consensus statement of the renal trauma subcommittee was published in the BJU International. Guidelines from the European Association of Urology were made available online in 2003 and a shortened version published in January 2005. Urologists have been encouraged to follow guidelines based on the experience of trauma centers that are familiar with renal injury. Diagnostic Imaging plays an important role in suspected Renal Trauma so we utilised Imaging practices as a proxy to patterns of management. Objective: To investigate whether Urologists in the United Kingdom utilise renal trauma guidelines when requesting Diagnostic Imaging in suspected renal trauma. Material & Methods: A one-page anonymous questionnaire (Appendix) was developed by the authors following an extensive literature review. It was sent to 500 consultant Urologists in the United Kingdom. We asked a series of questions concerning guideline usage and Imaging preferences in different clinical scenarios. We also asked whether there were any local arrangements with radiological colleagues with regard to imaging in renal trauma. Results: 152 (30%) of 500 questionnaires were returned. 70% of respondents saw an estimated 5 or less cases of renal trauma per year. 71% of departments used guidelines but these differed. 52% of respondents believed that the published guidelines were appropriate for UK practice. 5% did not feel that they were appropriate and 32% were unsure. 20% used local guidelines. In stable patients with dipstick haematuria, 80% of the respondents requested imaging with ultrasound (50%) the most popular. In stable patients with gross haematuria, all respondents requested imaging with CT scanning (83%) the most popular. In stable children with suspected renal trauma, all respondents who managed paediatric cases would request imaging. Re-imaging following initial ultrasound was common. Imaging was described as easy or possible to obtain during regular working hours by 97% of respondents. This fell to 86% out of hours with 9% of respondents having difficulty obtaining imaging. Only 18% of respondents had interdepartmental protocols to facilitate the imaging process in suspected renal trauma. Conclusions: The majority of responding Urologists used guidelines in the management of renal trauma. However the guidelines chosen varied and adherence was not strict. Although the overall standard of care is probably acceptable, to facilitate best practice in the management of Renal Trauma, it would be ideal if Urologists were encouraged to adhere to established guidelines. Informed discussion with the local radiology department would probably facilitate this process. Expert guidelines are now readily available online (Uroweb).
Arterial-Ureteral Fistulas
644
Van Den Bergh R.1, Moll F.2, De Vries J.P.3, Lock T.1 University Medical Center, Dept. of Urology, Utrecht, The Netherlands, 2University Medical Center, Dept. of Vascular Surgery, Utrecht, The Netherlands, 3Antonius Hospital, Dept. of Vascular Surgery, Nieuwegein, The Netherlands 1
Introduction & Objectives: Arterial-Ureteral Fistula (AUF) is a rare life-threatening condition which is increasingly described in the literature during the last decades. Although most urologists will never encounter this cause of hematuria, it is essential to be acquainted with the possibility of this diagnosis. Based on the experience in our clinic with multiple cases of AUF and all available relevant literature, a study has been performed which pays thorough attention to this subject. Material & Methods: The database of our clinic was extensively searched for cases of AUF. Furthermore a broad literature search in Pubmed and Embase has been performed in order to assemble all English articles dealing with arterial-ureteral fistulas. Results: Eight cases of AUF were retrieved from the patient records. We found 87 relevant articles in which exactly 100 separate cases were described. An AUF is the final result of an eroding process between an artery in poor condition and a fragile ureter resulting in necrosis. It presents with hematuria of which the extent and duration may vary greatly. Several mutual related factors are associated with the development of these fistulas. Two groups of patients which are particularly at risk can be distinguished. The incidence is rising, because risk factors are present more often. A swift and correct diagnosis before any intervention is taken is of vital importance to a low mortality rate, but remains challenging. Arteriography is the most sensitive investigation, but only when an active bleeding is present. Taking the possibility of the diagnosis AUF in consideration is the most important step in the diagnostic process. Based upon treatment options, cases can be divided into three periods. The classical choice is open surgery, vascular embolisation was introduced later and the most recent alternative is endovascular stent placement. A strongly decreasing mortality rate has been the result of the excellent results of these developments. The majority of risk factors for developing an i.e. also complicate open surgical treatment. The management of an AUF should be multidisciplinary from the first suspicion on. Urologist, vascular surgeon, and radiologist should all be involved. During pelvic surgery the formation of an AUF should be anticipated and preventive measures ought to be taken. Conclusions: In case of gross hematuria in a patient in which risk factors are present, the diagnosis AUF should always be considered. Obtaining diagnostic evidence of the diagnosis remains problematic. Clinical awareness of the possibility of the diagnosis is very important. Excellent treatment options are available.
Eur Urol Suppl 2007;6(2):183