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MP18-08 ADRENAL INJURIES: A NATIONAL TRAUMA DATA BANK ANALYSIS
THE JOURNAL OF UROLOGYâ
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MP18-07 CHANGING PATTERNS OF IATROGENIC URETERIC AND BLADDER INJURIES IN THE ERA OF LAPAROSCOPIC AND ROBOTIC SURGERY: A REVIEW OF 114 CONSECUTIVE INJURIES Sunu Philip*, Patrick Hurley, Southfield, MI INTRODUCTION AND OBJECTIVES: Iatrogenic ureter and bladder injuries are a rare complication of abdominal and pelvic surgery. Increasingly, complex abdomino-pelvic surgery is being performed with laparoscopic or robotic techniques. The aim of this study was to examine the patterns of bladder and ureteral injuries at a single institution with the increasing use of laparoscopic and robotic techniques. A secondary objective was to examine the manner in which these injuries sustained during laparoscopic and robotic surgery were managed METHODS: A review of all bladder and ureteral injuries sustained during abdominal and pelvic surgery from 2008 to 2013 was conducted. Medical records of all cases were reviewed. RESULTS: A total of 114 ureteral and bladder injuries were identified. The mean age of the patient group was 55 (range 21e96). Seven of the patients were male and 107(93%) were female. Gynecological surgery accounted for 95 of the 114 injuries (83%). The most common procedure associated with an injury was hysterectomy (75 percent) followed by colon resection (13%). Eleven procedures were performed laparoscopically (9.6%) and 7(6%) were performed robotically. Forty two (36%) patients sustained ureteral injuries and 72(63%) bladder injuries. Ten bladder injuries and 7 ureteral injuries were recognized postoperatively. All 11 patients in the laparoscopic group and 5 of the 7 patients in the robotic group required conversion to an open procedure for repair of the injury. The incidence of delayed injuries in the laparoscopic group was 27% (3 out of 11); 42% (3 out of 7) in the robotic group and 11% in the open group (11 out of 96). The majority of bladder injuries were repaired primarily. Twenty three of 42(54%) ureteral injuries required re-implantation of the ureter and construction of neocystoureterostomy. CONCLUSIONS: The incidence of missed or delayed injuries in this series was higher in the laparoscopic and robotic groups, although both these groups formed a small part of the total sample. Most bladder injuries were repaired primarily while at least half of the ureteral injuries required a reconstruction. Conversion was frequently required in both the laparoscopic and robotic groups to facilitate a repair. The estimated incidence ureteral and bladder injuries sustained during laparoscopic and robotic procedures did not differ significantly from open procedures in this series. This suggests that urologists consulted for these injuries intra-operatively be facile with laparoscopic and robotic techniques to facilitate a repair without conversion. Source of Funding: None
MP18-08 ADRENAL INJURIES: A NATIONAL TRAUMA DATA BANK ANALYSIS Jairam R. Eswara*, Boston, MA; Valary T. Raup, Julio Geminiani, Joel Vetter, Steven B. Brandes, St Louis, MO INTRODUCTION AND OBJECTIVES: Adrenal trauma is extremely rare and current literature is lacking in data from large case series. In this study, we analyze adrenal injuries using the National Trauma Data Bank (NTDB). METHODS: We performed a retrospective analysis of the NTDB from the years 2007e2011. Patient demographics, Injury Severity Score (ISS), mechanism of injury, blunt versus penetrating trauma, associated injuries and hypovolemic shock were assessed. Multivariable models were used to determine associations with outcomes such as need for surgery, type of surgery mean length of stay, need for ICU, and death. RESULTS: Of the 1,766,606 trauma cases in the data set, 8683 were identified as involving one or both adrenal glands. There were 7835 blunt and 663 penetrating injuries, and 184 of these injures were
Vol. 193, No. 4S, Supplement, Saturday, May 16, 2015
isolated to the adrenal glands. Of the 8683 adrenal injuries, 80 (0.9%) required surgery. However, none of the 184 isolated adrenal injures required surgery (p¼0.42). Factors associated with isolated adrenal injury include lower ISS (p<0.001), younger age (p<0.001), and penetrating injury (p<0.001). No isolated adrenal injuries were associated with death (12% vs. 0%, p<0.0001). The most common associated organ injuries were ribs (50.9%), thoracic (50.0%), liver (41.6%), vertebrae (30.9%), kidney (27.8%), and spleen (22.0%). Logistic regression showed that injures to the thorax (p¼0.0014) and multiple abdominal injuries (p<0.001) were associated with a lower rate of undergoing adrenal surgery. Higher ISS score (p¼0.007), penetrating injury (p<0.001), race (Black) (p¼0.029) and concurrent injuries to the spleen (p<0.001) and intestines (p¼0.016) were associated with a higher likelihood of requiring adrenal surgery. Older age (p<0.001), higher ISS score (p<0.001), race (Black, Other) (p¼0.03, p¼0.02), penetrating injuries (p<0.001) and injuries to the aorta/vena cava (p¼0.008), vessels (p¼0.001), thorax (p¼0.03), ribs (p¼0.005), stomach (p¼0.02), liver (p¼0.03), multiple abdominal injuries (p¼0.002), and brain/spinal cord (p<0.001) were associated with a higher mortality rate. CONCLUSIONS: Adrenal injuries are rare, comprising 0.49% of all traumatic injuries. In our database, isolated adrenal injuries were not fatal and did not require surgery. Younger age, race (Black), higher ISS score, penetrating injury, and concurrent injuries to the spleen/intestines were associated with a higher likelihood of requiring an adrenalectomy. Source of Funding: None
MP18-09 IATROGENIC GENITOURINARY INJURIES DURING COLORECTAL SURGERY: CHARACTERIZATION AND LONG-TERM OUTCOMES Valary T. Raup*, St Louis, MO; Jairam R. Eswara, Boston, MA; Steven B. Brandes, St Louis, MO INTRODUCTION AND OBJECTIVES: Little is known about the rates of iatrogenic genitourinary (GU) complications that occur during colorectal surgery, nor is there data regarding the long-term outcomes of these GU repairs. The purpose of this study is to quantify and categorize these injuries and analyze their long-term outcomes, with special attention to patients who have undergone pre-operative chemotherapy and or/pelvic radiation. METHODS: We performed a retrospective analysis of patients who developed iatrogenic GU injuries requiring surgical repair during colorectal surgery between 2003 and 2013. Repair failures were defined as development of urine leak/urinary fistula requiring repeat GU intervention. Possible risk factors associated with repair failures were examined, such as age, ASA score, comorbidities, type of colorectal surgery, and prior radiation or chemotherapy. RESULTS: There were 75 patients in this series, with a mean age of 57.5 years (22e91) at time of surgery and median follow up of 16.7 months (0e127). GU injuries occurred most frequently in lower abdominal resections (21), colectomies (16), colonic resections with concurrent total abdominal hysterectomies and bilateral salpingo-oophorectomies (13), and abdominoperineal resections (9). The most common initial GU repairs were cystorrhaphy (26), ureteroureterostomy (22), ureteroneocystotomy with psoas hitch (13), and ureteroneocystotomy without psoas hitch (11). Sixty-four patients had single GU repairs and 16 patients experienced failure of their initial repair with need for additional GU intervention. Of the patients who had undergone pre-operative pelvic radiation, 11/27 (41%) experienced failure of their GU repair, versus 5/48 (10%) that had not been previously irradiated (p¼0.003). Pre-operative chemotherapy as also shown to be associated with GU repair failure (12/35 vs. 4/40, p¼0.013). Fifty patients (67%) were alive at time of final follow-up, with a 30-day mortality rate of 4%. CONCLUSIONS: Pre-operative radiation and chemotherapy are associated with worse outcomes of GU repairs following GU injury during colorectal surgery. Further studies are required to assess potential benefit in postponing more complex GU repairs with interval
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MP18-07 CHANGING PATTERNS OF IATROGENIC URETERIC AND BLADDER INJURIES IN THE ERA OF LAPAROSCOPIC AND ROBOTIC SURGERY: A REVIEW OF 114 CONSECUTIVE INJURIES Sunu Philip*, Patrick Hurley, Southfield, MI INTRODUCTION AND OBJECTIVES: Iatrogenic ureter and bladder injuries are a rare complication of abdominal and pelvic surgery. Increasingly, complex abdomino-pelvic surgery is being performed with laparoscopic or robotic techniques. The aim of this study was to examine the patterns of bladder and ureteral injuries at a single institution with the increasing use of laparoscopic and robotic techniques. A secondary objective was to examine the manner in which these injuries sustained during laparoscopic and robotic surgery were managed METHODS: A review of all bladder and ureteral injuries sustained during abdominal and pelvic surgery from 2008 to 2013 was conducted. Medical records of all cases were reviewed. RESULTS: A total of 114 ureteral and bladder injuries were identified. The mean age of the patient group was 55 (range 21e96). Seven of the patients were male and 107(93%) were female. Gynecological surgery accounted for 95 of the 114 injuries (83%). The most common procedure associated with an injury was hysterectomy (75 percent) followed by colon resection (13%). Eleven procedures were performed laparoscopically (9.6%) and 7(6%) were performed robotically. Forty two (36%) patients sustained ureteral injuries and 72(63%) bladder injuries. Ten bladder injuries and 7 ureteral injuries were recognized postoperatively. All 11 patients in the laparoscopic group and 5 of the 7 patients in the robotic group required conversion to an open procedure for repair of the injury. The incidence of delayed injuries in the laparoscopic group was 27% (3 out of 11); 42% (3 out of 7) in the robotic group and 11% in the open group (11 out of 96). The majority of bladder injuries were repaired primarily. Twenty three of 42(54%) ureteral injuries required re-implantation of the ureter and construction of neocystoureterostomy. CONCLUSIONS: The incidence of missed or delayed injuries in this series was higher in the laparoscopic and robotic groups, although both these groups formed a small part of the total sample. Most bladder injuries were repaired primarily while at least half of the ureteral injuries required a reconstruction. Conversion was frequently required in both the laparoscopic and robotic groups to facilitate a repair. The estimated incidence ureteral and bladder injuries sustained during laparoscopic and robotic procedures did not differ significantly from open procedures in this series. This suggests that urologists consulted for these injuries intra-operatively be facile with laparoscopic and robotic techniques to facilitate a repair without conversion. Source of Funding: None
MP18-08 ADRENAL INJURIES: A NATIONAL TRAUMA DATA BANK ANALYSIS Jairam R. Eswara*, Boston, MA; Valary T. Raup, Julio Geminiani, Joel Vetter, Steven B. Brandes, St Louis, MO INTRODUCTION AND OBJECTIVES: Adrenal trauma is extremely rare and current literature is lacking in data from large case series. In this study, we analyze adrenal injuries using the National Trauma Data Bank (NTDB). METHODS: We performed a retrospective analysis of the NTDB from the years 2007e2011. Patient demographics, Injury Severity Score (ISS), mechanism of injury, blunt versus penetrating trauma, associated injuries and hypovolemic shock were assessed. Multivariable models were used to determine associations with outcomes such as need for surgery, type of surgery mean length of stay, need for ICU, and death. RESULTS: Of the 1,766,606 trauma cases in the data set, 8683 were identified as involving one or both adrenal glands. There were 7835 blunt and 663 penetrating injuries, and 184 of these injures were
Vol. 193, No. 4S, Supplement, Saturday, May 16, 2015
isolated to the adrenal glands. Of the 8683 adrenal injuries, 80 (0.9%) required surgery. However, none of the 184 isolated adrenal injures required surgery (p¼0.42). Factors associated with isolated adrenal injury include lower ISS (p<0.001), younger age (p<0.001), and penetrating injury (p<0.001). No isolated adrenal injuries were associated with death (12% vs. 0%, p<0.0001). The most common associated organ injuries were ribs (50.9%), thoracic (50.0%), liver (41.6%), vertebrae (30.9%), kidney (27.8%), and spleen (22.0%). Logistic regression showed that injures to the thorax (p¼0.0014) and multiple abdominal injuries (p<0.001) were associated with a lower rate of undergoing adrenal surgery. Higher ISS score (p¼0.007), penetrating injury (p<0.001), race (Black) (p¼0.029) and concurrent injuries to the spleen (p<0.001) and intestines (p¼0.016) were associated with a higher likelihood of requiring adrenal surgery. Older age (p<0.001), higher ISS score (p<0.001), race (Black, Other) (p¼0.03, p¼0.02), penetrating injuries (p<0.001) and injuries to the aorta/vena cava (p¼0.008), vessels (p¼0.001), thorax (p¼0.03), ribs (p¼0.005), stomach (p¼0.02), liver (p¼0.03), multiple abdominal injuries (p¼0.002), and brain/spinal cord (p<0.001) were associated with a higher mortality rate. CONCLUSIONS: Adrenal injuries are rare, comprising 0.49% of all traumatic injuries. In our database, isolated adrenal injuries were not fatal and did not require surgery. Younger age, race (Black), higher ISS score, penetrating injury, and concurrent injuries to the spleen/intestines were associated with a higher likelihood of requiring an adrenalectomy. Source of Funding: None
MP18-09 IATROGENIC GENITOURINARY INJURIES DURING COLORECTAL SURGERY: CHARACTERIZATION AND LONG-TERM OUTCOMES Valary T. Raup*, St Louis, MO; Jairam R. Eswara, Boston, MA; Steven B. Brandes, St Louis, MO INTRODUCTION AND OBJECTIVES: Little is known about the rates of iatrogenic genitourinary (GU) complications that occur during colorectal surgery, nor is there data regarding the long-term outcomes of these GU repairs. The purpose of this study is to quantify and categorize these injuries and analyze their long-term outcomes, with special attention to patients who have undergone pre-operative chemotherapy and or/pelvic radiation. METHODS: We performed a retrospective analysis of patients who developed iatrogenic GU injuries requiring surgical repair during colorectal surgery between 2003 and 2013. Repair failures were defined as development of urine leak/urinary fistula requiring repeat GU intervention. Possible risk factors associated with repair failures were examined, such as age, ASA score, comorbidities, type of colorectal surgery, and prior radiation or chemotherapy. RESULTS: There were 75 patients in this series, with a mean age of 57.5 years (22e91) at time of surgery and median follow up of 16.7 months (0e127). GU injuries occurred most frequently in lower abdominal resections (21), colectomies (16), colonic resections with concurrent total abdominal hysterectomies and bilateral salpingo-oophorectomies (13), and abdominoperineal resections (9). The most common initial GU repairs were cystorrhaphy (26), ureteroureterostomy (22), ureteroneocystotomy with psoas hitch (13), and ureteroneocystotomy without psoas hitch (11). Sixty-four patients had single GU repairs and 16 patients experienced failure of their initial repair with need for additional GU intervention. Of the patients who had undergone pre-operative pelvic radiation, 11/27 (41%) experienced failure of their GU repair, versus 5/48 (10%) that had not been previously irradiated (p¼0.003). Pre-operative chemotherapy as also shown to be associated with GU repair failure (12/35 vs. 4/40, p¼0.013). Fifty patients (67%) were alive at time of final follow-up, with a 30-day mortality rate of 4%. CONCLUSIONS: Pre-operative radiation and chemotherapy are associated with worse outcomes of GU repairs following GU injury during colorectal surgery. Further studies are required to assess potential benefit in postponing more complex GU repairs with interval