- Email: [email protected]
Re: Evaluating the Role of Operative Repair of Extraperitoneal Bladder Rupture following Blunt Pelvic Trauma
LETTERS TO THE EDITOR/ERRATA
963
for reducing radiation exposure to patients and medical staff. Urologists should give special attention to these studies, and further research in this area is critical. The authors mention the importance of surgeon education regarding radiation safety and decreasing the standard default settings of fluoroscopy units. Considering the harmful effects of radiation, the endourologist should undertake measures to reduce staff and patient exposure as much as possible. These measures can be standard (time, distance and shielding) or alternative, as described in the literature.1e3 Furthermore, we can think critically and apply new measures. Sometimes fluoroscopy is used without an indication for imaging. One of these situations is when the location of the C-arm is changed during endourological operations, especially percutaneous nephrolithotomy (PNL). During nephroscopy the C-arm is adjusted several times by push-pull movements because of the conflict of the nephroscope and collimator. When imaging is required, the fluoroscopy device will need to be relocated on the patient. However, it often takes multiple images for the technician to relocate the fluoroscope successfully. The laser crosshairs of the C-arm collimators should be the guide for the surgeon and technician. Using laser crosshairs during PNL can be defined as follows. At the beginning of kidney puncture by access needle with the patient in the prone or supine position the laser crosshair lamp is opened, and the skin is marked at the center of the crosshair by a pen or clamp after locating the proper C-arm position. Following repositioning of the C-arm this point is used for locating without activating the beam. However, we know that not all C-arm units have laser crosshairs. As resourceful surgeons, urologists can develop their own laser crosshairs by using laser pointers by attaching them on the collimator of the C-arm. In conclusion, endourologists should be aware of radiation exposure as much as possible, and all measures that help reduce this exposure should be considered. Using laser crosshairs is a feasible and practical measure to avoid unnecessary fluoroscopy, which helps us follow the ALARA (as low as reasonably achievable) principle regarding radiation exposure during PNL. Respectfully, € ylemez Haluk So Department of Urology Hacettepe University Ankara
Kadir Yıldırım Department of Urology Silvan State Hospital Diyarbakır, Turkey e-mail: [email protected]
1. S€oylemez H, Sancaktutar AA, Altunoluk B et al: Re: Radiation protection in pediatric radiology. Urol Res 2012; 40: 621. 2. Yang RM, Morgan T and Bellman GC: Radiation protection during percutaneous nephrolithotomy: a new urologic surgery radiation shield. J Endourol 2002; 16: 727. 3. Alsyouf M, Arenas JL, Smith JC et al: Direct endoscopic visualization combined with ultrasound guided access during percutaneous nephrolithotomy: a feasibility study and comparison to a conventional cohort. J Urol 2016. http://dx.doi.org/10.1016/j.juro.2016.01.118.
Re: Evaluating the Role of Operative Repair of Extraperitoneal Bladder Rupture following Blunt Pelvic Trauma N. V. Johnsen, J. B. Young, W. S. Reynolds, M. R. Kaufman, D. F. Milam, O. D. Guillamondegui and R. R. Dmochowski J Urol 2016; 195: 661e665.
To the Editor: In this single center retrospective analysis the authors examined their experience managing simple extraperitoneal bladder injuries with catheter drainage alone or early
964
LETTERS TO THE EDITOR/ERRATA
cystorrhaphy as a secondary procedure during nonurological interventions. Extraperitoneal bladder injuries were classified as simple if there was no coexisting intraperitoneal bladder injury, bladder neck injury, urethral injury and/or bone fragment(s) in the bladder. A total of 80 patients were included in the final analysis, with 56 undergoing catheter drainage alone and 24 undergoing early cystorrhaphy as part of a nonurological procedure. We agree that conservative management of simple extraperitoneal bladder ruptures with catheter drainage alone is sufficient for definitive treatment. However, we disagree with the methodology and conclusions regarding operative repair of extraperitoneal bladder injuries. In our experience bladder fistulas resulting from extraperitoneal bladder injuries (whether managed operatively or nonoperatively) are rare, and the high number of fistulas in this data set raises the question of appropriate selection for operative management. Among the complications in the catheter drainage group there were 6 urinary tract fistulas. Four of these patients had a fistula in the thigh, while 2 had perineal fistulas in the setting of an open perineal wound requiring diverting colostomy. The authors provide little description of the severity of these extraperitoneal bladder injuries, or associated comorbidities or concomitant injuries. Lack of such detail precludes the ability to understand whether these complications could have been prevented with an alternative management strategy (ie early cystorrhaphy in the setting of an open perineal wound to avoid vesicocutaneous fistula instead of catheter drainage alone). Based on their findings, the authors conclude that patients undergoing operative repair for nonurological injuries have a decreased risk of complications and reduced intensive care unit (ICU)/hospital stay. We caution that the study results must be interpreted in the proper context. Patients who required operative intervention for nonurological injuries may have been categorically different from patients not requiring operative intervention. The authors do not report the number or extent of nonurological injuries or the indications for ICU stay. Typically an extraperitoneal bladder injury would not be a reason for keeping patients in the ICU or prolonging their hospital stay, so using ICU/hospital length of stay is an improper means to assess outcome. Finally, while patients who underwent cystorrhaphy had a shorter median time to negative cystography, this result is also subject to bias. Urologists may decide to wait longer before obtaining a cystogram in nonoperative patients, and patients with certain concomitant injuries may not be able to undergo cystography as soon as patients who undergo operative repair (ie those with multisystem trauma and continued complex ICU care). As a result, it is difficult to conclude that operative management of extraperitoneal bladder injuries decreases length of catheterization. Research on management of traumatic bladder injuries is sparse, and we believe it is important to continue to advance the literature and understanding of management of genitourinary trauma. The authors state that cystorrhaphy reduces the length of ICU stay and decreases hospital stay. Their analysis does not allow such conclusions. To truly assess differences in outcomes, we recommend randomization of patients to surgical vs nonsurgical treatment, regardless of whether they are scheduled to undergo surgery with another service, and performing cystography at a set time in both groups of patients to determine whether catheter drainage is actually required for a longer period in one group compared to the other. In addition, future studies would benefit from appropriate delineation of nonurological injuries and improved description regarding the impact of bladder injury on prolonged ICU and/or hospital stay. Respectfully, Lindsay Hampson, Judith Hagedorn and Bryan B. Voelzke Department of Urology Harborview Medical Center University of Washington Seattle, Washington
Reply by Authors: We agree that this series has limitations related to the retrospective nature of the review as well as to variations in practice patterns during the study period. The emphasis on registry formation and maintenance is gathering steam in urology, and this study is an example of a single institution registry that was accessed for purposes of critically evaluating patients with these injuries in an attempt to optimize treatment and patient outcomes.
LETTERS TO THE EDITOR/ERRATA
Hampson et al correctly state that there were variations in strategies behind the decision to perform catheter drainage only or early cystorrhaphy as part of nonurological procedures. They also underscore the rare complication of bladder fistulas. It is noteworthy that increasingly patients at large trauma centers are stabilized and often treated without urological input, sometimes initially and sometimes entirely. In some cases the delay in urological input may be several days, and the relatively high number of fistulas in our cohort likely underscores the potential risk that this delay represents. Urinary fistula formation clearly is related to delayed recognition of complicated presentations and is an outcome that could often be prevented with appropriate risk factor identification. Therefore, the interaction of trauma surgeons and their urological counterparts is critical to ensure adequate assessment, strategic management and appropriate subsequent followup care for associated urological injuries in individuals with major trauma. This subgroup that manifested fistulas is the topic of another submission from our group related to the potential complications of conservative management in this population, as we agree that optimization of care in these cases with risk factors for fistula formation may prevent overall occurrence. Linked to the concerns of Hampson et al related to fistula formation is the decision regarding the timing of operative intervention. It should be stressed that in many cases the delay in intervention is related to the underlying global morbidity of the individual, as well as to delays in urological consultation, as stated previously. It is noteworthy that no patient in this study was kept in the ICU or the hospital specifically due to urological injuries, with all individuals having comorbidities and associated injuries that accounted for the prolonged stay. However, there was a significant difference in length of stay between those who did and did not undergo repair during nonurological intervention. Although this likely was not a causal relationship, it highlights a potentially modifiable risk factor for long-term complications. Hampson et al also make a salient point related to timing of cystography. Even in tightly managed circumstances radiographic tests may be delayed for a variety of reasons. Therefore, the frame of reference for time to performing cystography is representative of not only the underlying injury and treatment, but also ongoing factors related to individual global injury circumstances. We are currently working to implement a prospective standardized protocol for posttraumatic bladder rupture cases to standardize care, and to provide objective data on the optimal timing of cystography in operative and nonoperative cases. The authors implore major referral institutions to continue to optimize multidisciplinary care of the traumatized patient inclusive of early and appropriate consultation with surgical subspecialists. Most importantly, strategic decision making related to patient care and intervention should be a combined decision between the trauma/acute care surgery group and the surgical specialty consultants involved in the care of these often gravely injured individuals.
965
963
for reducing radiation exposure to patients and medical staff. Urologists should give special attention to these studies, and further research in this area is critical. The authors mention the importance of surgeon education regarding radiation safety and decreasing the standard default settings of fluoroscopy units. Considering the harmful effects of radiation, the endourologist should undertake measures to reduce staff and patient exposure as much as possible. These measures can be standard (time, distance and shielding) or alternative, as described in the literature.1e3 Furthermore, we can think critically and apply new measures. Sometimes fluoroscopy is used without an indication for imaging. One of these situations is when the location of the C-arm is changed during endourological operations, especially percutaneous nephrolithotomy (PNL). During nephroscopy the C-arm is adjusted several times by push-pull movements because of the conflict of the nephroscope and collimator. When imaging is required, the fluoroscopy device will need to be relocated on the patient. However, it often takes multiple images for the technician to relocate the fluoroscope successfully. The laser crosshairs of the C-arm collimators should be the guide for the surgeon and technician. Using laser crosshairs during PNL can be defined as follows. At the beginning of kidney puncture by access needle with the patient in the prone or supine position the laser crosshair lamp is opened, and the skin is marked at the center of the crosshair by a pen or clamp after locating the proper C-arm position. Following repositioning of the C-arm this point is used for locating without activating the beam. However, we know that not all C-arm units have laser crosshairs. As resourceful surgeons, urologists can develop their own laser crosshairs by using laser pointers by attaching them on the collimator of the C-arm. In conclusion, endourologists should be aware of radiation exposure as much as possible, and all measures that help reduce this exposure should be considered. Using laser crosshairs is a feasible and practical measure to avoid unnecessary fluoroscopy, which helps us follow the ALARA (as low as reasonably achievable) principle regarding radiation exposure during PNL. Respectfully, € ylemez Haluk So Department of Urology Hacettepe University Ankara
Kadir Yıldırım Department of Urology Silvan State Hospital Diyarbakır, Turkey e-mail: [email protected]
1. S€oylemez H, Sancaktutar AA, Altunoluk B et al: Re: Radiation protection in pediatric radiology. Urol Res 2012; 40: 621. 2. Yang RM, Morgan T and Bellman GC: Radiation protection during percutaneous nephrolithotomy: a new urologic surgery radiation shield. J Endourol 2002; 16: 727. 3. Alsyouf M, Arenas JL, Smith JC et al: Direct endoscopic visualization combined with ultrasound guided access during percutaneous nephrolithotomy: a feasibility study and comparison to a conventional cohort. J Urol 2016. http://dx.doi.org/10.1016/j.juro.2016.01.118.
Re: Evaluating the Role of Operative Repair of Extraperitoneal Bladder Rupture following Blunt Pelvic Trauma N. V. Johnsen, J. B. Young, W. S. Reynolds, M. R. Kaufman, D. F. Milam, O. D. Guillamondegui and R. R. Dmochowski J Urol 2016; 195: 661e665.
To the Editor: In this single center retrospective analysis the authors examined their experience managing simple extraperitoneal bladder injuries with catheter drainage alone or early
964
LETTERS TO THE EDITOR/ERRATA
cystorrhaphy as a secondary procedure during nonurological interventions. Extraperitoneal bladder injuries were classified as simple if there was no coexisting intraperitoneal bladder injury, bladder neck injury, urethral injury and/or bone fragment(s) in the bladder. A total of 80 patients were included in the final analysis, with 56 undergoing catheter drainage alone and 24 undergoing early cystorrhaphy as part of a nonurological procedure. We agree that conservative management of simple extraperitoneal bladder ruptures with catheter drainage alone is sufficient for definitive treatment. However, we disagree with the methodology and conclusions regarding operative repair of extraperitoneal bladder injuries. In our experience bladder fistulas resulting from extraperitoneal bladder injuries (whether managed operatively or nonoperatively) are rare, and the high number of fistulas in this data set raises the question of appropriate selection for operative management. Among the complications in the catheter drainage group there were 6 urinary tract fistulas. Four of these patients had a fistula in the thigh, while 2 had perineal fistulas in the setting of an open perineal wound requiring diverting colostomy. The authors provide little description of the severity of these extraperitoneal bladder injuries, or associated comorbidities or concomitant injuries. Lack of such detail precludes the ability to understand whether these complications could have been prevented with an alternative management strategy (ie early cystorrhaphy in the setting of an open perineal wound to avoid vesicocutaneous fistula instead of catheter drainage alone). Based on their findings, the authors conclude that patients undergoing operative repair for nonurological injuries have a decreased risk of complications and reduced intensive care unit (ICU)/hospital stay. We caution that the study results must be interpreted in the proper context. Patients who required operative intervention for nonurological injuries may have been categorically different from patients not requiring operative intervention. The authors do not report the number or extent of nonurological injuries or the indications for ICU stay. Typically an extraperitoneal bladder injury would not be a reason for keeping patients in the ICU or prolonging their hospital stay, so using ICU/hospital length of stay is an improper means to assess outcome. Finally, while patients who underwent cystorrhaphy had a shorter median time to negative cystography, this result is also subject to bias. Urologists may decide to wait longer before obtaining a cystogram in nonoperative patients, and patients with certain concomitant injuries may not be able to undergo cystography as soon as patients who undergo operative repair (ie those with multisystem trauma and continued complex ICU care). As a result, it is difficult to conclude that operative management of extraperitoneal bladder injuries decreases length of catheterization. Research on management of traumatic bladder injuries is sparse, and we believe it is important to continue to advance the literature and understanding of management of genitourinary trauma. The authors state that cystorrhaphy reduces the length of ICU stay and decreases hospital stay. Their analysis does not allow such conclusions. To truly assess differences in outcomes, we recommend randomization of patients to surgical vs nonsurgical treatment, regardless of whether they are scheduled to undergo surgery with another service, and performing cystography at a set time in both groups of patients to determine whether catheter drainage is actually required for a longer period in one group compared to the other. In addition, future studies would benefit from appropriate delineation of nonurological injuries and improved description regarding the impact of bladder injury on prolonged ICU and/or hospital stay. Respectfully, Lindsay Hampson, Judith Hagedorn and Bryan B. Voelzke Department of Urology Harborview Medical Center University of Washington Seattle, Washington
Reply by Authors: We agree that this series has limitations related to the retrospective nature of the review as well as to variations in practice patterns during the study period. The emphasis on registry formation and maintenance is gathering steam in urology, and this study is an example of a single institution registry that was accessed for purposes of critically evaluating patients with these injuries in an attempt to optimize treatment and patient outcomes.
LETTERS TO THE EDITOR/ERRATA
Hampson et al correctly state that there were variations in strategies behind the decision to perform catheter drainage only or early cystorrhaphy as part of nonurological procedures. They also underscore the rare complication of bladder fistulas. It is noteworthy that increasingly patients at large trauma centers are stabilized and often treated without urological input, sometimes initially and sometimes entirely. In some cases the delay in urological input may be several days, and the relatively high number of fistulas in our cohort likely underscores the potential risk that this delay represents. Urinary fistula formation clearly is related to delayed recognition of complicated presentations and is an outcome that could often be prevented with appropriate risk factor identification. Therefore, the interaction of trauma surgeons and their urological counterparts is critical to ensure adequate assessment, strategic management and appropriate subsequent followup care for associated urological injuries in individuals with major trauma. This subgroup that manifested fistulas is the topic of another submission from our group related to the potential complications of conservative management in this population, as we agree that optimization of care in these cases with risk factors for fistula formation may prevent overall occurrence. Linked to the concerns of Hampson et al related to fistula formation is the decision regarding the timing of operative intervention. It should be stressed that in many cases the delay in intervention is related to the underlying global morbidity of the individual, as well as to delays in urological consultation, as stated previously. It is noteworthy that no patient in this study was kept in the ICU or the hospital specifically due to urological injuries, with all individuals having comorbidities and associated injuries that accounted for the prolonged stay. However, there was a significant difference in length of stay between those who did and did not undergo repair during nonurological intervention. Although this likely was not a causal relationship, it highlights a potentially modifiable risk factor for long-term complications. Hampson et al also make a salient point related to timing of cystography. Even in tightly managed circumstances radiographic tests may be delayed for a variety of reasons. Therefore, the frame of reference for time to performing cystography is representative of not only the underlying injury and treatment, but also ongoing factors related to individual global injury circumstances. We are currently working to implement a prospective standardized protocol for posttraumatic bladder rupture cases to standardize care, and to provide objective data on the optimal timing of cystography in operative and nonoperative cases. The authors implore major referral institutions to continue to optimize multidisciplinary care of the traumatized patient inclusive of early and appropriate consultation with surgical subspecialists. Most importantly, strategic decision making related to patient care and intervention should be a combined decision between the trauma/acute care surgery group and the surgical specialty consultants involved in the care of these often gravely injured individuals.
965