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Trauma, and Genital and Urethral Reconstruction
TRAUMA, AND GENITAL AND URETHRAL RECONSTRUCTION
Methods: We described a series of 7 boys (mean age, 23.4 months) who underwent surgical repair of ASH. The diagnosis was made based on physical examination, which revealed a tense hydrocele in association with ipsilateral cystic abdominal mass, confirmed by ultrasonography. After exposing the hydrocele sac through a scrotal incision, tunica vaginalis was opened and marsupialization of the hydrocele along with undermined dartos muscle layer was performed. Follow-up ranged from 9-12 months (average, 10.7 months). Results: Overall, 10 ASH units (including 3 bilateral) were repaired. All of the affected testicles except one showed some degree of dysmorphism, according to ultrasonography or intraoperative findings, which resolved in all patients 3 months after surgery. There were no early postoperative complications except a mild scrotal edema. Neither recurrences of ASH nor testicular atrophy was observed. Conclusions: The diagnosis of ASH should be considered in a boy with hydrocele and concomitant abdominal mass, and can be established by ultrasonographic evaluation. Our experiment suggests that the modified trans-scrotal surgical method for management of ASH is reliable and effective with definite advantages. The high success rate, no extensive dissection of the inguinal canal, or complete excision of the sac, along with safety and simplicity of the procedure and short hospital stay, are important preconditions for the introduction of this method as a valid option for treatment of ASH. Editorial Comment: These authors add to a growing body of information suggesting that abdominal scrotal hydroceles should be corrected through a scrotal incision alone. We began to use this approach shortly after the report of Belman.1 We soon learned that the procedure is considerably easier than what we used to do, which included a difficult inguinal dissection through thickened and often inflamed tissue that jeopardized the spermatic vessels and vas deferens. I now believe that an initial inguinal incision for abdominal scrotal hydrocele is best avoided. Douglas A. Canning, M.D. 1. Belman AB: Abdominoscrotal hydrocele in infancy: a review and presentation of the scrotal approach for correction. J Urol 2001; 165: 225.
Trauma, and Genital and Urethral Reconstruction Nonoperative Management of Grade 5 Renal Injury in Children: Does it Have a Place? W. Eassa, M. A. El-Ghar, R. Jednak and M. El-Sherbiny Pediatric Urology Unit, Urology and Nephrology Center, Mansoura, Egypt Eur Urol 2010; 57: 154 –161.
Background: Nonoperative treatment of blunt renal trauma in children is progressively gaining acceptance; grade 5 renal trauma is associated with a significant rate of complications. Objective: To assess the feasibility and outcome of initial nonoperative management of grade 5 blunt renal trauma in children. Design, Setting, and Participants: This retrospective study included 18 children (12 boys and 6 girls; mean age: 8.4⫹/⫺3.4 yr) who presented to the authors’ institutes with grade 5 blunt renal trauma between 1990 and 2007. Measurements: An intravenous contrast-enhanced computed tomography (CT) scan demonstrated grade 5 renal trauma in all patients. Associated major vascular injuries were suspected in four patients. All were initially managed conservatively. Indications for intervention included hemodynamic instability, progressive urinoma, or persistent bleeding. Dimercaptosuccinic acid (DMSA) scans were performed at a mean time of 3.1 yr (range: 1–17) following the injury in nine patients. Results and Limitations: Four patients (22%) with suspected major vascular injuries required nephrectomy 1–21 d following the trauma. Two patients with continuing hemorrhage required selective lower-pole arterial embolization (11%). Three patients (17%) had their progressive urinoma drained percutaneously, and two of them required delayed reparative surgery for ureteropelvic junction (UPJ) avulsion. Nine patients (50%) were successfully managed nonopera-
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TRAUMA, AND GENITAL AND URETHRAL RECONSTRUCTION
tively. Kidneys were salvaged in 78% of patients. DMSA scanning showed a split function ⬎40% in 44% of evaluated kidneys. Two patients (22%) had split function ⬍30%. At last follow-up, none of the children were hypertensive or had any abnormality on urine analysis. Conclusions: Nonoperative management of grade 5 renal trauma is feasible. Prompt surgical intervention is required for those with major vascular injuries. Superselective arterial embolization can be an excellent option in patients with continuing hemorrhage and who have pseudoaneurysms. Patients with UPJ disruption can be salvaged by initial drainage of the urinoma followed by deferred correction. Editorial Comment: This retrospective study examined 18 children with major renal injuries during a 17-year period. Although I would not classify all of the injuries in this series as grade 5, the report adds to the growing body of literature supporting nonoperative and minimally invasive treatment of most major renal injuries. The authors used a variety of endourological and minimally invasive treatments in these children, including angioembolization and percutaneous drainage, reserving nephrectomy for only 4 patients. UPJ avulsion injuries were managed by initial percutaneous drainage, followed by successful delayed repair in 2 cases and immediate nephrectomy in 2. Hypertension was noted transiently in only 1 patient. The presence of a large medial hematoma with contrast enhancement during the CT arterial phase was associated with clinical instability, with renal pedicle injury confirmed during urgent nephrectomy. Allen F. Morey, M.D.
Methods: We described a series of 7 boys (mean age, 23.4 months) who underwent surgical repair of ASH. The diagnosis was made based on physical examination, which revealed a tense hydrocele in association with ipsilateral cystic abdominal mass, confirmed by ultrasonography. After exposing the hydrocele sac through a scrotal incision, tunica vaginalis was opened and marsupialization of the hydrocele along with undermined dartos muscle layer was performed. Follow-up ranged from 9-12 months (average, 10.7 months). Results: Overall, 10 ASH units (including 3 bilateral) were repaired. All of the affected testicles except one showed some degree of dysmorphism, according to ultrasonography or intraoperative findings, which resolved in all patients 3 months after surgery. There were no early postoperative complications except a mild scrotal edema. Neither recurrences of ASH nor testicular atrophy was observed. Conclusions: The diagnosis of ASH should be considered in a boy with hydrocele and concomitant abdominal mass, and can be established by ultrasonographic evaluation. Our experiment suggests that the modified trans-scrotal surgical method for management of ASH is reliable and effective with definite advantages. The high success rate, no extensive dissection of the inguinal canal, or complete excision of the sac, along with safety and simplicity of the procedure and short hospital stay, are important preconditions for the introduction of this method as a valid option for treatment of ASH. Editorial Comment: These authors add to a growing body of information suggesting that abdominal scrotal hydroceles should be corrected through a scrotal incision alone. We began to use this approach shortly after the report of Belman.1 We soon learned that the procedure is considerably easier than what we used to do, which included a difficult inguinal dissection through thickened and often inflamed tissue that jeopardized the spermatic vessels and vas deferens. I now believe that an initial inguinal incision for abdominal scrotal hydrocele is best avoided. Douglas A. Canning, M.D. 1. Belman AB: Abdominoscrotal hydrocele in infancy: a review and presentation of the scrotal approach for correction. J Urol 2001; 165: 225.
Trauma, and Genital and Urethral Reconstruction Nonoperative Management of Grade 5 Renal Injury in Children: Does it Have a Place? W. Eassa, M. A. El-Ghar, R. Jednak and M. El-Sherbiny Pediatric Urology Unit, Urology and Nephrology Center, Mansoura, Egypt Eur Urol 2010; 57: 154 –161.
Background: Nonoperative treatment of blunt renal trauma in children is progressively gaining acceptance; grade 5 renal trauma is associated with a significant rate of complications. Objective: To assess the feasibility and outcome of initial nonoperative management of grade 5 blunt renal trauma in children. Design, Setting, and Participants: This retrospective study included 18 children (12 boys and 6 girls; mean age: 8.4⫹/⫺3.4 yr) who presented to the authors’ institutes with grade 5 blunt renal trauma between 1990 and 2007. Measurements: An intravenous contrast-enhanced computed tomography (CT) scan demonstrated grade 5 renal trauma in all patients. Associated major vascular injuries were suspected in four patients. All were initially managed conservatively. Indications for intervention included hemodynamic instability, progressive urinoma, or persistent bleeding. Dimercaptosuccinic acid (DMSA) scans were performed at a mean time of 3.1 yr (range: 1–17) following the injury in nine patients. Results and Limitations: Four patients (22%) with suspected major vascular injuries required nephrectomy 1–21 d following the trauma. Two patients with continuing hemorrhage required selective lower-pole arterial embolization (11%). Three patients (17%) had their progressive urinoma drained percutaneously, and two of them required delayed reparative surgery for ureteropelvic junction (UPJ) avulsion. Nine patients (50%) were successfully managed nonopera-
275
276
TRAUMA, AND GENITAL AND URETHRAL RECONSTRUCTION
tively. Kidneys were salvaged in 78% of patients. DMSA scanning showed a split function ⬎40% in 44% of evaluated kidneys. Two patients (22%) had split function ⬍30%. At last follow-up, none of the children were hypertensive or had any abnormality on urine analysis. Conclusions: Nonoperative management of grade 5 renal trauma is feasible. Prompt surgical intervention is required for those with major vascular injuries. Superselective arterial embolization can be an excellent option in patients with continuing hemorrhage and who have pseudoaneurysms. Patients with UPJ disruption can be salvaged by initial drainage of the urinoma followed by deferred correction. Editorial Comment: This retrospective study examined 18 children with major renal injuries during a 17-year period. Although I would not classify all of the injuries in this series as grade 5, the report adds to the growing body of literature supporting nonoperative and minimally invasive treatment of most major renal injuries. The authors used a variety of endourological and minimally invasive treatments in these children, including angioembolization and percutaneous drainage, reserving nephrectomy for only 4 patients. UPJ avulsion injuries were managed by initial percutaneous drainage, followed by successful delayed repair in 2 cases and immediate nephrectomy in 2. Hypertension was noted transiently in only 1 patient. The presence of a large medial hematoma with contrast enhancement during the CT arterial phase was associated with clinical instability, with renal pedicle injury confirmed during urgent nephrectomy. Allen F. Morey, M.D.