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Ureteric Injuries: Diagnosis, Management, and Outcome
976
PENIS, URETHRA, TRAUMA AND FISTULAS
PENIS,URETHRA, TRAUMA AND FISTULAS Posttraumatic Renovascular Hypertension After Occult Renal Injury
R. C. MONTGOMERY, J. D. RICHARDSON AND J. I. ~ T Y Division , of General Surgery and Urology, University of Louisville School of Medicine, and Trauma Program i n Surgery, University of Louisville Hospital, Louisville, Kentucky J. Trauma, 4 5 106-110, 1998
Objective: Hypertension secondary to renal injury is a n unusual problem, but one that occurs with some frequency in a n active trauma unit. The incidence and management of posttraumatic renovascular hypertension at our Level I trauma center was reviewed. Methods: A retrospective review of a trauma database was performed on patients treated by our trauma service between 1977 and 1996. Seven patients were identified who developed arterial hypertension as a direct result of a renal injury. Results: All of the patients sustained multiple injuries, with five requiring celiotomy to control bleeding. Renal injuries were occult, and there was no compelling reason to suspect injury to the kidney. No patient had a history of hypertension or elevated arterial pressure on admission; however, sustained arterial hypertension was noted within 2 weeks to 8 months of injury. Arteriography was positive in all seven patients, with findings that included lacerations of the main renal artery, its major branches, or intrarenal constriction of the renal artery (presumably from scarring). Renal-vein renin assays localized to the injured kidney in six patients. Treatment included nephrectomy in four cases, revascularization in one case, and medical management in two cases. All of the patients treated operatively had prompt relief of their hypertension. The two patients treated solely by medical therapy had prompt, durable control of their arterial pressure with a single medication. However, medical treatment had failed before operation in several of the patients. Conclusions: Because of the serious complications associated with undiagnosed hypertension, new-onset or sustained hypertension after major trauma should be evaluated with attention to a possible renal cause.
Editorial Comment: This well documented report describes 7 patients in whom renovascular hypertension developed within 8 months of occult renal injury. In 6 cases renal injury was initially suspected because of hematuria and appropriate renal imaging studies were undertaken. However, results of all of these initial studies were normal, including computerized tomography in 3 cases, even when reviewed retrospectively after hypertension developed. Once hypertension was detected, arteriography demonstrated renal arterial injury in 6 patients and Page kidney in 1. Renal vein renins revealed a renovascular cause in each of these patients, and appropriate therapy corrected the problem. This series is perhaps the largest published of patients with proved renovascular hypertension secondary to renal trauma. Although the incidence of hypertension after renal injury is not addressed, this report is the first of a large number of patients in whom initial injury went undetected, even with appropriate evaluation. In our series of more than 2,500 renal injuries hypertension was detected in only 1 case but our long-term followup was poor. This report reminds us that undetectable renovascular injury occurs, and underscores the importance of careful blood pressure monitoring in patients with abdominal trauma. Jack W. McAninch, M.D. Ureteric Injuries: Diagnosis, Management, and Outcome A. M. A. GHALI,E. M. A. EL MALIK,A. I. A. IBMIM, G. ISMAIL AND M. RASHID, Asir Central Hospital and College of Medicine, King Saud University, Abha and King Fahad Armed Forces Hospital, Khamis Mushayt, Saudi Arabia J. Trauma, 4 6 150-158, 1999 Objectives: To define the current causes and the optimal methods of early diagnosis and management of ureteric injuries, both iatrogenic (excluding endourologic) and traumatic, and to determine the outcome of these injuries and which identifiable factors affect this outcome. Methods: A retrospective analysis was performed of all the 35 patients who sustained 40 ureteric injuries over a 5-year period (1991-1996). The methods used for diagnosis and management were reviewed. The outcome was assessed in terms of preservation of renal function. Results: The study group was composed of 28 patients with 32 iatrogenic injuries and 7 patients with 8 injuries caused by external trauma. Gynecologic procedures accounted for 63% (20 of 32) of the iatrogenic injuries, whereas motor vehicle crashes accounted for 75% of the external injuries (6 of 8 injuries). The successful diagnostic rate for direct inspection (intraoperatively), intravenous urogram, retrograde pyelogram, and anterograde pyelogram were 33% for the former two and 100% for the latter two. Treatment consisted of primary open repair in 26 cases, a staged procedure in 7 cases, and endoscopic stenting in Eicases. Of 36 cases with follow-up, complications developed in 9 cases (25%),7 cases of which were corrected surgically. Overall incidence of nephrectomy was 8%, and the factors that seemed to affect the outcome
BOOK REVIEW
adversely were pediatric age ( 5 1 2 years), injury to upper ureter, delay in recognition, the presence of a urinoma, and/or associated organ injury. Conclusion: Iatrogenic trauma is the leading cause of ureteric injuries. The single controllable factor adversely affecting the outcome of this rather uncommon injury seems to be delayed diagnosis. Wound inspection and intravenous urogram are not reliable for early and accurate diagnosis, and a retrograde pyelogram or an anterograde pyelogram may be needed. Uncontrollable factors adversely affecting the outcome include young age, injury to upper ureter, and associated injuries all seen in association with external trauma rather than iatrogenic injuries.
Editorial Comment: The authors report 40 ureteral injuries (32iatrogenic and 8 from external trauma) during a 5-year period. Of the trauma cases 6 were caused by blunt trauma, which involved the upper ureter in 5. Diagnosis was delayed in a significant number of patients but excretory urography, retrograde ureterography and antegrade pyelography were diagnostic, and immediate intervention prevented nephrectomy in all but 2. This report indicates the successful outcome in most patients who sustain ureteral injury. Management by spatulated tension-free anastomosis of injuries to the mid and upper ureter, and by reimplantation into the bladder for lower ureteral injuries provides excellent results. I prefer to use internal Double-J*stents for all such injuries. Jack W. McAninch, M.D. Post-Traumatic Arterial Priapism: Colour Doppler Examination and Superselective Arterial Embolization
B. C. KANG,D. Y. LEE,J. Y. B m , S. Y. BAEK,S. W. LEEAND K. W. KIM,Department of Diagnostic Radiology, Mokdong Hospital, Ewha Women’s University College of Medicine, Severance Hospital, Yonsei University College of Medicine and Department of Diagnostic Radiology, Kangnam St. Mary’s Hospital, Catholic University College of Medicine, Seoul, Korea Clin. Rad., 5 3 830-834, 1998 Purpose: To evaluate selective embolization for management of post-traumatic priapism and colour Doppler sonography for the diagnosis of the causative lesion and for planning embolization. Materials and Methods: Six male patients with post-traumatic priapism underwent selective angiography and embolization. Colour Doppler sonography with grey-scale was performed in all six patients before angiography. Results: Selective angiography showed intracavernosal arteriovenous fistulas in all patients and pseudoaneurysm of the cavernosal artery (or common penile artery) in three patients. After successful embolization, detumescence was achieved in all patients. Colour Doppler sonography enabled localization and characterization of the lesion causing priapism in four patients. Grey-scale ultrasonography showed the dilated cavernosal sinuses in all patients. Conclusion: Angiography with selective embolization is safe and effective method to correct posttraumatic priapism. Colour Doppler sonography with grey scale is a useful preangiographic study, as it allows for characterization and localization of the causative lesion except lesions a t the proximal cavernosal or distal penile artery near the symphysis pubis.
Editorial Comment: In this report of 6 patients with posttraumatic priapism diagnosis was made on color Doppler sonography with gray scale. Selective arterial embolization was successful in all cases, and erectile function was preserved. Priapism consequent to penile or perineal trauma is usually of the high flow type. These patients typically have minimal or no pain and results of blood gas evaluation are normal. Injury to the cavernosal artery results in uncontrolled arterial flow into the corporeal body, and persistent erection ensues. Color Doppler with gray scale, as reported in this study, has also been successful in our experience to establish the diagnosis and localize the site of the lesion. Arterial embolization is effective, and potency should be maintained in most patients. Jack W. McAninch, M.D.
BOOK REVIEW Therapy in Nephrology and Hypertension: A Companion to Brenner and Rector‘s The Kidney
H. R. BRADY AND C. S. WILCOX, Philadelphia: W . B. Saunders Co., 693 pages, 1999 This book is a collection of state-of-the-art articles written by well-known clinical experts and investigators who have defined the discipline of nephrology for the last several decades, and is published as a clinical
* Medical Engineering Corp., New York, New York.
977
PENIS, URETHRA, TRAUMA AND FISTULAS
PENIS,URETHRA, TRAUMA AND FISTULAS Posttraumatic Renovascular Hypertension After Occult Renal Injury
R. C. MONTGOMERY, J. D. RICHARDSON AND J. I. ~ T Y Division , of General Surgery and Urology, University of Louisville School of Medicine, and Trauma Program i n Surgery, University of Louisville Hospital, Louisville, Kentucky J. Trauma, 4 5 106-110, 1998
Objective: Hypertension secondary to renal injury is a n unusual problem, but one that occurs with some frequency in a n active trauma unit. The incidence and management of posttraumatic renovascular hypertension at our Level I trauma center was reviewed. Methods: A retrospective review of a trauma database was performed on patients treated by our trauma service between 1977 and 1996. Seven patients were identified who developed arterial hypertension as a direct result of a renal injury. Results: All of the patients sustained multiple injuries, with five requiring celiotomy to control bleeding. Renal injuries were occult, and there was no compelling reason to suspect injury to the kidney. No patient had a history of hypertension or elevated arterial pressure on admission; however, sustained arterial hypertension was noted within 2 weeks to 8 months of injury. Arteriography was positive in all seven patients, with findings that included lacerations of the main renal artery, its major branches, or intrarenal constriction of the renal artery (presumably from scarring). Renal-vein renin assays localized to the injured kidney in six patients. Treatment included nephrectomy in four cases, revascularization in one case, and medical management in two cases. All of the patients treated operatively had prompt relief of their hypertension. The two patients treated solely by medical therapy had prompt, durable control of their arterial pressure with a single medication. However, medical treatment had failed before operation in several of the patients. Conclusions: Because of the serious complications associated with undiagnosed hypertension, new-onset or sustained hypertension after major trauma should be evaluated with attention to a possible renal cause.
Editorial Comment: This well documented report describes 7 patients in whom renovascular hypertension developed within 8 months of occult renal injury. In 6 cases renal injury was initially suspected because of hematuria and appropriate renal imaging studies were undertaken. However, results of all of these initial studies were normal, including computerized tomography in 3 cases, even when reviewed retrospectively after hypertension developed. Once hypertension was detected, arteriography demonstrated renal arterial injury in 6 patients and Page kidney in 1. Renal vein renins revealed a renovascular cause in each of these patients, and appropriate therapy corrected the problem. This series is perhaps the largest published of patients with proved renovascular hypertension secondary to renal trauma. Although the incidence of hypertension after renal injury is not addressed, this report is the first of a large number of patients in whom initial injury went undetected, even with appropriate evaluation. In our series of more than 2,500 renal injuries hypertension was detected in only 1 case but our long-term followup was poor. This report reminds us that undetectable renovascular injury occurs, and underscores the importance of careful blood pressure monitoring in patients with abdominal trauma. Jack W. McAninch, M.D. Ureteric Injuries: Diagnosis, Management, and Outcome A. M. A. GHALI,E. M. A. EL MALIK,A. I. A. IBMIM, G. ISMAIL AND M. RASHID, Asir Central Hospital and College of Medicine, King Saud University, Abha and King Fahad Armed Forces Hospital, Khamis Mushayt, Saudi Arabia J. Trauma, 4 6 150-158, 1999 Objectives: To define the current causes and the optimal methods of early diagnosis and management of ureteric injuries, both iatrogenic (excluding endourologic) and traumatic, and to determine the outcome of these injuries and which identifiable factors affect this outcome. Methods: A retrospective analysis was performed of all the 35 patients who sustained 40 ureteric injuries over a 5-year period (1991-1996). The methods used for diagnosis and management were reviewed. The outcome was assessed in terms of preservation of renal function. Results: The study group was composed of 28 patients with 32 iatrogenic injuries and 7 patients with 8 injuries caused by external trauma. Gynecologic procedures accounted for 63% (20 of 32) of the iatrogenic injuries, whereas motor vehicle crashes accounted for 75% of the external injuries (6 of 8 injuries). The successful diagnostic rate for direct inspection (intraoperatively), intravenous urogram, retrograde pyelogram, and anterograde pyelogram were 33% for the former two and 100% for the latter two. Treatment consisted of primary open repair in 26 cases, a staged procedure in 7 cases, and endoscopic stenting in Eicases. Of 36 cases with follow-up, complications developed in 9 cases (25%),7 cases of which were corrected surgically. Overall incidence of nephrectomy was 8%, and the factors that seemed to affect the outcome
BOOK REVIEW
adversely were pediatric age ( 5 1 2 years), injury to upper ureter, delay in recognition, the presence of a urinoma, and/or associated organ injury. Conclusion: Iatrogenic trauma is the leading cause of ureteric injuries. The single controllable factor adversely affecting the outcome of this rather uncommon injury seems to be delayed diagnosis. Wound inspection and intravenous urogram are not reliable for early and accurate diagnosis, and a retrograde pyelogram or an anterograde pyelogram may be needed. Uncontrollable factors adversely affecting the outcome include young age, injury to upper ureter, and associated injuries all seen in association with external trauma rather than iatrogenic injuries.
Editorial Comment: The authors report 40 ureteral injuries (32iatrogenic and 8 from external trauma) during a 5-year period. Of the trauma cases 6 were caused by blunt trauma, which involved the upper ureter in 5. Diagnosis was delayed in a significant number of patients but excretory urography, retrograde ureterography and antegrade pyelography were diagnostic, and immediate intervention prevented nephrectomy in all but 2. This report indicates the successful outcome in most patients who sustain ureteral injury. Management by spatulated tension-free anastomosis of injuries to the mid and upper ureter, and by reimplantation into the bladder for lower ureteral injuries provides excellent results. I prefer to use internal Double-J*stents for all such injuries. Jack W. McAninch, M.D. Post-Traumatic Arterial Priapism: Colour Doppler Examination and Superselective Arterial Embolization
B. C. KANG,D. Y. LEE,J. Y. B m , S. Y. BAEK,S. W. LEEAND K. W. KIM,Department of Diagnostic Radiology, Mokdong Hospital, Ewha Women’s University College of Medicine, Severance Hospital, Yonsei University College of Medicine and Department of Diagnostic Radiology, Kangnam St. Mary’s Hospital, Catholic University College of Medicine, Seoul, Korea Clin. Rad., 5 3 830-834, 1998 Purpose: To evaluate selective embolization for management of post-traumatic priapism and colour Doppler sonography for the diagnosis of the causative lesion and for planning embolization. Materials and Methods: Six male patients with post-traumatic priapism underwent selective angiography and embolization. Colour Doppler sonography with grey-scale was performed in all six patients before angiography. Results: Selective angiography showed intracavernosal arteriovenous fistulas in all patients and pseudoaneurysm of the cavernosal artery (or common penile artery) in three patients. After successful embolization, detumescence was achieved in all patients. Colour Doppler sonography enabled localization and characterization of the lesion causing priapism in four patients. Grey-scale ultrasonography showed the dilated cavernosal sinuses in all patients. Conclusion: Angiography with selective embolization is safe and effective method to correct posttraumatic priapism. Colour Doppler sonography with grey scale is a useful preangiographic study, as it allows for characterization and localization of the causative lesion except lesions a t the proximal cavernosal or distal penile artery near the symphysis pubis.
Editorial Comment: In this report of 6 patients with posttraumatic priapism diagnosis was made on color Doppler sonography with gray scale. Selective arterial embolization was successful in all cases, and erectile function was preserved. Priapism consequent to penile or perineal trauma is usually of the high flow type. These patients typically have minimal or no pain and results of blood gas evaluation are normal. Injury to the cavernosal artery results in uncontrolled arterial flow into the corporeal body, and persistent erection ensues. Color Doppler with gray scale, as reported in this study, has also been successful in our experience to establish the diagnosis and localize the site of the lesion. Arterial embolization is effective, and potency should be maintained in most patients. Jack W. McAninch, M.D.
BOOK REVIEW Therapy in Nephrology and Hypertension: A Companion to Brenner and Rector‘s The Kidney
H. R. BRADY AND C. S. WILCOX, Philadelphia: W . B. Saunders Co., 693 pages, 1999 This book is a collection of state-of-the-art articles written by well-known clinical experts and investigators who have defined the discipline of nephrology for the last several decades, and is published as a clinical
* Medical Engineering Corp., New York, New York.
977