- •Preface and Acknowledgments
- •Contents
- •Contributors
- •1: Embryology for Urologists
- •Introduction
- •Renal Development
- •Pronephros
- •Mesonephros
- •Metanephros
- •Development of the Collecting System
- •Critical Steps in Further Development
- •Anomalies of the Kidney
- •Renal Agenesis
- •Renal Aplasia
- •Renal Hypoplasia
- •Renal Ectopia
- •Renal Fusion
- •Ureteral Development
- •Anomalies of Origin
- •Anomalies of Number
- •Incomplete Ureteral Duplication
- •Complete Ureteral Duplication
- •Ureteral Ectopia
- •Embryology of Ectopia
- •Clinical Correlation
- •Location of Ectopic Ureteral Orifices – Male (in Descending Order According to Incidence)
- •Symptoms
- •Ureteroceles
- •Congenital Ureteral Obstruction
- •Pipestem Ureter
- •Megaureter-Megacystis Syndrome
- •Prune Belly Syndrome
- •Vascular Ureteral Obstructions
- •Division of the Urogenital Sinus
- •Bladder Development
- •Urachal Anomalies
- •Cloacal Duct Anomalies
- •Other Bladder Anomalies
- •Bladder Diverticula
- •Bladder Extrophy
- •Gonadal Development
- •Testicular Differentiation
- •Ovarian Differentiation
- •Gonadal Anomalies
- •Genital Duct System
- •Disorders of Testicular Function
- •Female Ductal Development
- •Prostatic Urethral Valves
- •Gonadal Duct Anomalies
- •External Genital Development
- •Male External Genital Development
- •Female External Genital Development
- •Anomalies of the External Genitalia
- •References
- •2: Gross and Laparoscopic Anatomy of the Upper Urinary Tract and Retroperitoneum
- •Overview
- •The Kidneys
- •The Renal Vasculature
- •The Renal Collecting System
- •The Ureters
- •Retroperitoneal Lymphatics
- •Retroperitoneal Nerves
- •The Adrenal Glands
- •References
- •3: Gross and Laparoscopic Anatomy of the Lower Urinary Tract and Pelvis
- •Introduction
- •Female Pelvis
- •Male Pelvis
- •Pelvic Floor
- •Urinary Bladder
- •Urethra
- •Male Urethra
- •Female Urethra
- •Sphincter Mechanisms
- •The Bladder Neck Component
- •The Urethral Wall Component
- •The External Urethral Sphincter
- •Summary
- •References
- •4: Anatomy of the Male Reproductive System
- •Testis and Scrotum
- •Spermatogenesis
- •Hormonal Regulation of Spermatogenesis
- •Genetic Regulation of Spermatogenesis
- •Epididymis and Ductus Deferens
- •Accessory Sex Glands
- •Prostate
- •Seminal Vesicles
- •Bulbourethral Glands
- •Penis
- •Erection and Ejaculation
- •References
- •5: Imaging of the Upper Tracts
- •Anatomy of the Upper Tracts and Introduction to Imaging Modalities
- •Introduction
- •Renal Upper Tract Basic Anatomy
- •Modalities Used for Imaging the Upper Tracts
- •Ultrasound
- •Radiation Issues
- •Contrast Issues
- •Renal and Upper Tract Tumors
- •Benign Renal Tumors
- •Transitional Cell Carcinoma
- •Renal Mass Biopsy
- •Renal Stone Disease
- •Ultrasound
- •Plain Radiographs and IVU
- •Renal Cystic Disease
- •Benign Renal Cysts
- •Hereditary Renal Cystic Disease
- •Complex Renal Cysts
- •Renal Trauma
- •References
- •Introduction
- •Pathophysiology
- •Susceptibility and Resistance
- •Epidemiological Breakpoints
- •Clinical Breakpoints
- •Pharmacodynamic Parameters
- •Pharmacokinetic Parameters
- •Fosfomycin
- •Nitrofurantoin
- •Pivmecillinam
- •b-Lactam-Antibiotics
- •Penicillins
- •Cephalosporins
- •Carbapenems
- •Aminoglycosides
- •Fluoroquinolones
- •Trimethoprim, Cotrimoxazole
- •Glycopeptides
- •Linezolid
- •Conclusion
- •References
- •7: An Overview of Renal Physiology
- •Introduction
- •Body Fluid Compartments
- •Regulation of Potassium Balance
- •Regulation of Acid–Base Balance
- •Diuretics
- •Suggested Reading
- •8: Ureteral Physiology and Pharmacology
- •Ureteral Anatomy
- •Modulation of Peristalsis
- •Ureteral Pharmacology
- •Conclusion
- •References
- •Introduction
- •Afferent Signaling Pathways
- •Efferent Signaling
- •Parasympathetic Nerves
- •Sympathetic Nerves
- •Vesico-Spinal-Vesical Micturition Reflex
- •Peripheral Targets
- •Afferent Signaling Mechanisms
- •Urothelium
- •Myocytes
- •Cholinergic Receptors
- •Muscarinic Receptors
- •Nicotinic Receptors
- •Adrenergic Receptors (ARs)
- •a-Adrenoceptors
- •b-Adrenoceptors
- •Transient Receptor Potential (TRP) Receptors
- •Phosphodiesterases (PDEs)
- •CNS Targets
- •Opioid Receptors
- •Serotonin (5-HT) Mechanisms
- •g-Amino Butyric Acid (GABA) Mechanisms
- •Gabapentin
- •Neurokinin and Neurokinin Receptors
- •Summary
- •References
- •10: Pharmacology of Sexual Function
- •Introduction
- •Sexual Desire/Arousal
- •Endocrinology
- •Steroids in the Male
- •Steroids in the Female
- •Neurohormones
- •Neurotransmitters
- •Dopamine
- •Serotonin
- •Pharmacological Strategies
- •CNS Drugs
- •Enzyme-inducing Antiepileptic Drugs
- •Erectile Function
- •Ejaculatory Function
- •Premature Ejaculation
- •Abnormal Ejaculation
- •Conclusions
- •References
- •Epidemiology
- •Calcium-Based Urolithiasis
- •Uric Acid Urolithiasis
- •Infectious Urolithiasis
- •Cystine-Based Urolithiasis
- •Aims
- •Who Deserves Metabolic Evaluation?
- •Metabolic Workup for Stone Producers
- •Medical History and Physical Examination
- •Stone Analysis
- •Serum Chemistry
- •Urine Evaluation
- •Urine Cultures
- •Urinalysis
- •Twenty-Four Hour Urine Collections
- •Radiologic Imaging
- •Medical Management
- •Conservative Management
- •Increased Fluid Intake
- •Citrus Juices
- •Dietary Restrictions
- •Restricted Oxalate Diet
- •Conservative Measures
- •Selective Medical Therapy
- •Absorptive Hypercalciuria
- •Thiazide
- •Orthophosphate
- •Renal Hypercalciuria
- •Primary Hyperparathyroidism
- •Hyperuricosuric Calcium Oxalate Nephrolithiasis
- •Enteric Hyperoxaluria
- •Hypocitraturic Calcium Oxalate Nephrolithiasis
- •Distal Renal Tubular Acidosis
- •Chronic Diarrheal States
- •Thiazide-Induced Hypocitraturia
- •Idiopathic Hypocitraturic Calcium Oxalate Nephrolithiasis
- •Hypomagnesiuric Calcium Nephrolithiasis
- •Gouty Diathesis
- •Cystinuria
- •Infection Lithiasis
- •Summary
- •References
- •12: Molecular Biology for Urologists
- •Introduction
- •Inherited Changes in Cancer Cells
- •VEGR and Cell Signaling
- •Targeting mTOR
- •Conclusion
- •References
- •13: Chemotherapeutic Agents for Urologic Oncology
- •Introduction
- •Bladder Cancer
- •Muscle Invasive Bladder Cancer
- •Metastatic Bladder Cancer
- •Conclusion
- •Prostate Cancer
- •Other Chemotherapeutic Drugs or Combinations for Treating HRPC
- •Conclusion
- •Renal Cell Carcinoma
- •Chemotherapy
- •Immunotherapy
- •Angiogenesis Inhibitor Drugs
- •Conclusion
- •Testicular Cancer
- •Stage I Seminoma
- •Stage I non-seminomatous Germ Cell Tumours (NSGCT)
- •Metastatic Germ Cell Tumours
- •Low-Volume Metastatic Disease (Stage II A/B)
- •Advanced Metastatic Disease
- •Salvage Chemotherapy for Relapsed or Refractory Disease
- •Conclusion
- •Penile Cancer
- •Side Effects of Chemotherapy
- •Conclusion
- •References
- •14: Tumor and Transplant Immunology
- •Antibodies
- •Cytotoxic and T-helper Cells
- •Immunosuppression
- •Induction Therapy
- •Maintenance Therapy
- •Rejection
- •Posttransplant Lymphoproliferative Disease
- •Summary
- •References
- •15: Pathophysiology of Renal Obstruction
- •Causes of Renal Obstruction
- •Effects on Prenatal Development
- •Prenatal Hydronephrosis
- •Spectrum of Renal Abnormalities
- •Renal Functional Changes
- •Renal Growth/Counterbalance
- •Vascular Changes
- •Inflammatory Mediators
- •Glomerular Development Changes
- •Mechanical Stretch of Renal Tubules
- •Unilateral Versus Bilateral
- •Limitations of Animal Models
- •Future Research
- •Issues in Patient Management
- •Diagnostic Imaging
- •Ultrasound
- •Intravenous Urography
- •Antegrade Urography and the Whitaker Test
- •Nuclear Renography
- •Computed Tomography
- •Magnetic Resonance Urography
- •Hypertension
- •Postobstructive Diuresis
- •References
- •Introduction
- •The Normal Lower Urinary Tract
- •Anatomy
- •Storage Function
- •Voiding Function
- •Neural Control
- •Symptoms
- •Flow Rate and Post-void Residual
- •Voiding Cystometry
- •Male
- •Female
- •Neurourology
- •Conclusions
- •References
- •17: Urologic Endocrinology
- •The Testis
- •Normal Androgen Metabolism
- •Epidemiological Aspects
- •Prostate
- •Brain
- •Muscle Mass and Adipose Tissue
- •Bones
- •Ematopoiesis
- •Metabolism
- •Cardiovascular System
- •Clinical Assessment
- •Biochemical Assessment
- •Treatment Modalities
- •Oral Preparations
- •Parenteral Preparations
- •Transdermal Preparations
- •Side Effects and Treatment Monitoring
- •Body Composition
- •Cognitive Decline
- •Bone Metabolism
- •The Kidneys
- •Endocrine Functions of the Kidney
- •Erythropoietin
- •Calcitriol
- •Renin
- •Paraneoplastic Syndromes
- •Hypercalcemia
- •Hypertension
- •Polycythemia
- •Other Endocrine Abnormalities
- •References
- •General Physiology
- •Prostate Innervation
- •Summary
- •References
- •Wound Healing
- •Inflammation
- •Proliferation
- •Remodeling
- •Principles of Plastic Surgery
- •Tissue Characteristics
- •Grafts
- •Flap
- •References
- •Lower Urinary Tract Symptoms
- •Storage Phase
- •Voiding Phase
- •Return to Storage Phase
- •Urodynamic Parameters
- •Urodynamic Techniques
- •Volume Voided Charts
- •Pad Testing
- •Typical Test Schedule
- •Uroflowmetry
- •Post Voiding Residual
- •Further Diagnostic Evaluation of Patients
- •Cystometry with or Without Video
- •Cystometry
- •Videocystometrography (Cystometry + Cystourethrography)
- •Cystometric Findings
- •Comment:
- •Measurements During the Storage Phase:
- •Measurements During the Voiding Phase:
- •Abnormal Function
- •Disorders of Sensation
- •Causes of Hypersensitive Bladder Sensation
- •Causes of Hyposensitive Bladder Sensation
- •Disorders of Detrusor Motor Function
- •Bladder Outflow Tract Dysfunction
- •Detrusor–Urethral Dyssynergia
- •Detrusor–Bladder Neck Dyssynergia
- •Detrusor–Sphincter Dyssynergia
- •Complex Urodynamic Investigation
- •Urethral Pressure Measurement
- •Technique
- •Neurophysiological Evaluation
- •Conclusion
- •References
- •Endoscopy
- •Cystourethroscopy
- •Ureteroscopy and Ureteropyeloscopy
- •Nephroscopy
- •Virtual Reality Simulators
- •Lasers
- •Clinical Application of Lasers
- •Condylomata Acuminata
- •Urolithiasis
- •Benign Prostatic Hyperplasia
- •Ureteral and Urethral Strictures
- •Conclusion
- •References
- •Introduction
- •The Prostatitis Syndromes
- •The Scope of the Problem
- •Category III CP/CPPS
- •The Goal of Treatment
- •Conservative Management
- •Drug Therapy
- •Antibiotics
- •Anti-inflammatories
- •Alpha blockers
- •Hormone Therapies
- •Phytotherapies
- •Analgesics, muscle relaxants and neuromodulators
- •Surgery
- •A Practical Management Plan
- •References
- •Orchitis
- •Definition and Etiology
- •Clinical Signs and Symptoms
- •Diagnostic Evaluation
- •Treatment of Infectious Orchitis
- •Epididymitis
- •Definition and Etiology
- •Clinical Signs and Symptoms
- •Diagnostic Evaluation of Epididymitis
- •Treatment of Acute Epididymitis
- •Treatment of Chronic Epididymitis
- •Treatment of Spermatic Cord Torsion
- •Fournier’s Gangrene
- •Definition and Etiology
- •Risk Factors
- •Clinical Signs and Symptoms
- •Diagnostic Evaluation
- •Treatment
- •References
- •Fungal Infections
- •Candidiasis
- •Aspergillosis
- •Cryptococcosis
- •Blastomycosis
- •Coccidioidomycosis
- •Histoplasmosis
- •Radiographic Findings
- •Treatment
- •Tuberculosis
- •Clinical Manifestations
- •Diagnosis
- •Treatment
- •Schistosomiasis
- •Clinical Manifestations
- •Diagnosis
- •Treatment
- •Filariasis
- •Clinical Manifestations
- •Diagnosis
- •Treatment
- •Onchocerciasis
- •References
- •25: Sexually Transmitted Infections
- •Introduction
- •STIs Associated with Genital Ulcers
- •Herpes Simplex Virus
- •Diagnosis
- •Treatment
- •Chancroid
- •Diagnosis
- •Treatment
- •Syphilis
- •Diagnosis
- •Treatment
- •Lymphogranuloma Venereum
- •Diagnosis
- •Treatment
- •Chlamydia
- •Diagnosis
- •Treatment
- •Gonorrhea
- •Diagnosis
- •Treatment
- •Trichomoniasis
- •Diagnosis
- •Treatment
- •Human Papilloma Virus
- •Diagnosis
- •Treatment
- •Scabies
- •Diagnosis
- •Treatment
- •References
- •26: Hematuria: Evaluation and Management
- •Introduction
- •Classification of Hematuria
- •Macroscopic Hematuria
- •Microscopic Hematuria
- •Dipstick Hematuria
- •Pseudohematuria
- •Factitious Hematuria
- •Menstruation
- •Aetiology
- •Malignancy
- •Urinary Calculi
- •Infection and Inflammation
- •Benign Prostatic Hyperplasia
- •Trauma
- •Drugs
- •Nephrological Causes
- •Assessment
- •History
- •Examination
- •Investigations
- •Dipstick Urinalysis
- •Cytology
- •Molecular Tests
- •Blood Tests
- •Flexible Cystoscopy
- •Upper Urinary Tract Evaluation
- •Renal USS
- •KUB Abdominal X-Ray
- •Intravenous Urography (IVU)
- •Computed Tomography (CT)
- •Retrograde Urogram Studies
- •Magnetic Resonance Imaging (MRI)
- •Additional Tests and Renal Biopsy
- •Intractable Hematuria
- •Loin Pain Hematuria Syndrome
- •References
- •27: Benign Prostatic Hyperplasia (BPH)
- •Historical Background
- •Pathophysiology
- •Patient Assessment
- •Treatment of BPH
- •Watchful Waiting
- •Drug Therapy
- •Interventional Therapies
- •Conclusions
- •References
- •28: Practical Guidelines for the Treatment of Erectile Dysfunction and Peyronie´s Disease
- •Erectile Dysfunction
- •Introduction
- •Diagnosis
- •Basic Evaluation
- •Cardiovascular System and Sexual Activity
- •Optional Tests
- •Treatment
- •Medical Treatment
- •Oral Agents
- •Phosphodiesterase Type 5 (PDE 5) Inhibitors
- •Nonresponders to PDE5 Inhibitors
- •Apomorphine SL
- •Yohimbine
- •Intracavernosal and Intraurethral Therapy
- •Intracavernosal Injection (ICI) Therapy
- •Intraurethral Therapy
- •Vacuum Constriction Devices
- •Surgical Therapy
- •Conclusion
- •Peyronie´s Disease (PD)
- •Introduction
- •Oral Drug Therapy
- •Intralesional Drug Therapy
- •Iontophoresis
- •Radiation Therapy
- •Surgical Therapy
- •References
- •29: Premature Ejaculation
- •Introduction
- •Epidemiology
- •Defining Premature Ejaculation
- •Voluntary Control
- •Sexual Satisfaction
- •Distress
- •Psychosexual Counseling
- •Pharmacological Treatment
- •On-Demand Treatment with Tramadol
- •Topical Anesthetics
- •Phosphodiesterase Inhibitors
- •Surgery
- •Conclusion
- •References
- •30: The Role of Interventional Management for Urinary Tract Calculi
- •Contraindications to ESWL
- •Complications of ESWL
- •PCNL Access
- •Instrumentation for PCNL
- •Nephrostomy Drains Post PCNL
- •Contraindications to PCNL
- •Complications of PCNL
- •Semirigid Ureteroscopy
- •Flexible Ureteroscopy
- •Electrohydraulic Lithotripsy (EHL)
- •Ultrasound
- •Ballistic Lithotripsy
- •Laser Lithotripsy
- •Ureteric Stents
- •Staghorn Calculi
- •Lower Pole Stones
- •Horseshoe Kidneys and Stones
- •Calyceal Diverticula Stones
- •Stones and PUJ Obstruction
- •Treatment of Ureteric Colic
- •Medical Expulsive Therapy (MET)
- •Intervention for Ureteric Stones
- •Stones in Pregnancy
- •Morbid Obesity
- •References
- •Anatomy and Function
- •Pathophysiology
- •Management
- •Optical Urethrotomy/Dilatation
- •Urethral Stents
- •Preoperative Assessment
- •Urethroplasty
- •Anastomotic Urethroplasty
- •Substitution Urethroplasty
- •Grafts Versus Flaps
- •Oral Mucosal Grafts
- •Tissue Engineering
- •Graft Position
- •Conclusion
- •References
- •32: Urinary Incontinence
- •Epidemiology and Risk Factors
- •Pathophysiology
- •Urge Incontinence
- •Conservative Treatments
- •Pharmacotherapy
- •Invasive/ Surgical Therapies
- •Stress Urinary Incontinence
- •Male SUI Therapies
- •Female SUI Therapies
- •Mixed Urinary Incontinence
- •Conclusions
- •References
- •33: Neurogenic Bladder
- •Introduction
- •Examination and Diagnostic Tests
- •History and Physical Examination
- •Imaging
- •Urodynamics (UDS)
- •Evoked Potentials
- •Classifications
- •Somatic Pathways
- •Brain Lesions
- •Cerebrovascular Accident (CVA)
- •Parkinson’s Disease (PD)
- •Multiple Sclerosis
- •Huntington’s Disease
- •Dementias
- •Normal Pressure Hydrocephalus (NPH)
- •Tumors
- •Psychiatric Disorders
- •Spinal Lesions and Pathology
- •Intervertebral Disk Prolapse
- •Spinal Cord Injury (SCI)
- •Transverse Myelitis
- •Peripheral Neuropathies
- •Metabolic Neuropathies
- •Pelvic Surgery
- •Treatment
- •Summary
- •References
- •34: Pelvic Prolapse
- •Introduction
- •Epidemiology
- •Anatomy and Pathophysiology
- •Evaluation and Diagnosis
- •Outcome Measures
- •Imaging
- •Urodynamics
- •Indications for Management
- •Biosynthetics
- •Surgical Management
- •Anterior Compartment Repair
- •Uterine/Apical Prolapse
- •Enterocele Repair
- •Conclusion
- •References
- •35: Urinary Tract Fistula
- •Introduction
- •Urogynecologic Fistula
- •Vesicovaginal Fistula
- •Etiology and Risk Factors
- •Clinical Factors
- •Evaluation and Diagnosis
- •Pelvic Examination
- •Cystoscopy
- •Imaging
- •Treatment
- •Conservative Management
- •Surgical Management
- •Urethrovaginal Fistula
- •Etiology and Presentation
- •Diagnosis and Management
- •Ureterovaginal Fistula
- •Etiology and Presentation
- •Diagnosis and Management
- •Vesicouterine Fistula
- •Etiology and Presentation
- •Diagnosis and Management
- •Uro-Enteric Fistula
- •Vesicoenteric Fistula
- •Pyeloenteric Fistula
- •Urethrorectal Fistula
- •References
- •36: Urologic Trauma
- •Introduction
- •Kidney
- •Expectant Management
- •Endovascular Therapy
- •Operative Intervention
- •Operative Management: Follow-up
- •Reno-Vascular Injuries
- •Pediatric Renal Injuries
- •Adrenal
- •Ureter
- •Diagnosis
- •Treatment
- •Delayed Diagnosis
- •Bladder and Posterior Urethra
- •Bladder Injuries: Initial Management
- •Bladder Injuries: Formal Repair
- •Anterior Urethral Trauma
- •Fractured Penis
- •Penile Amputation
- •Scrotal and Testicular Trauma
- •Imaging
- •CT-IVP (CT with Delayed Images)
- •Technique
- •Cystogram
- •Technique
- •Retrograde Urethrogram (RUG)
- •Technique
- •Retrograde Pyelogram (RPG)
- •Technique
- •One-Shot IVP
- •Technique
- •References
- •37: Bladder Cancer
- •Who Should Be Investigated?
- •Epidemiology
- •Risk Factors
- •Role of Screening
- •Signs and Symptoms
- •Imaging
- •Cystoscopy
- •Urine Tests
- •PDD-Assisted TUR
- •Pathology
- •NMIBC and Risk Groups
- •Intravesical Chemotherapy
- •Intravesical Immunotherapy
- •Immediate Cystectomy and CIS
- •Radical Cystectomy with Pelvic Lymph Node Dissection
- •sexual function-preserving techniques
- •Bladder-Preservation Treatments
- •Neoadjuvant Chemotherapy
- •Adjuvant Chemotherapy
- •Preoperative Radiotherapy
- •Follow-up After TUR in NMIBC
- •References
- •38: Prostate Cancer
- •Introduction
- •Epidemiology
- •Race
- •Geographic Variation
- •Risk Factors and Prevention
- •Family History
- •Diet and Lifestyle
- •Prevention
- •Screening and Diagnosis
- •Current Screening Recommendations
- •Biopsy
- •Pathology
- •Prognosis
- •Treatment of Prostate Cancer
- •Treatment for Localized Prostate Cancer (T1, T2)
- •Radical Prostatectomy
- •EBRT
- •IMRT
- •Brachytherapy
- •Treatment for Locally Advanced Prostate Cancer (T3, T4)
- •EBRT with ADT
- •Radical Prostatectomy
- •Androgen-Deprivation Therapy
- •Summary
- •References
- •39: The Management of Testis Cancer
- •Presentation and Diagnosis
- •Serum Tumor Markers
- •Primary Surgery
- •Testis Preserving Surgery
- •Risk Stratification
- •Surveillance Versus Primary RPLND
- •Primary RPLND
- •Adjuvant Treatment for High Risk
- •Clinical Stage 1 Seminoma
- •Risk-Stratified Adjuvant Treatment
- •Adjuvant Radiotherapy
- •Adjuvant Low Dose Chemotherapy
- •Primary Combination Chemotherapy
- •Late Toxicity
- •Salvage Strategies
- •Conclusion
- •References
- •Index
36
Urologic Trauma
Bradley D. Figler and Viraj A. Master
It is the urologist who will have to share the burden of the ultimate disability with the patient when the thoracic, and abdominal, and even orthopedic aspects are probably long forgotten.
—Richard Turner-Warwick, 19771
common injuries to the genitourinary tract resulting from external violence. Finally, a section on imaging highlights its importance in the management of GU trauma and serves as a quick-reference guide for some of the most commonly performed techniques in the trauma setting.
Introduction
Injury is a major cause of death and disability worldwide and the leading cause of death among young people in the USA. However, fatalities represent only a small fraction of those injured – of the 2.5 million patients who were hospitalized for injuries in 2003, only 148,000 died of their injuries.2,3 Urogenital injuries, though common, are often not life-threatening and are easily overlooked during the initial stabilization of the trauma patient, resulting in significant morbidity.
Great strides have been made over the last 2 decades in the diagnosis and management of genitourinary trauma. Injuries that were once managed surgically are now being observed,with predictable decreases in morbidity. Advances in imaging have improved detection and staging of injuries, and endovascular techniques have earned a definitive role in the management of renal trauma. Finally, endoscopic techniques, the hallmark of urology, have become routine in the management of certain injuries. Here, we review the essential components of the presentation, workup, and initial management of the most
Kidney
The kidneys are relatively well protected from external trauma by the spine and large musculature posteriorly and by abdominal viscera anteriorly. Nonetheless, the kidneys are the most commonly injured part of the genitourinary tract, with blunt trauma responsible for 80–90% of these injuries.4,5 A thorough history and physical are essential to the workup of a patient with suspected renal injury, but the most reliable sign of injury to the kidney is hematuria. Hematuria is usually classified as gross or microscopic (>5 RBC/HPF). Typically, the first voided specimen is analyzed because subsequent specimens may be diluted with resuscitative fluid.If the patient cannot void and suspicion for a urethral injury is low (absence of blood at the meatus and no pelvic fracture), a lubricated catheter can be gently placed in the bladder to obtain a specimen.
Flank tenderness or ecchymosis as well as lower rib fractures are suggestive of underlying renal injury. In penetrating trauma, entry and exit wounds may be a helpful indicator that the
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kidney has been injured.Among the most impor- |
and nonexpanding without parenchymal lacer- |
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tant aspects of the history is the presence of a |
ation). Grade 2 injuries include hematoma (non- |
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rapid deceleration injury, as occurs in MVA or |
expanding and perirenal; confined to renal |
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fall from height, as these can lead to renal pedicle |
retroperitoneum) and laceration (<0.1 cm paren- |
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avulsion and may not result in hematuria.5 |
chymal depth with no urinary extravasation). |
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Guidelines for imaging patients with suspected |
Grade 3 injuries are lacerations >0.1 cm without |
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renal trauma are given in Fig. 36.1. Importantly, |
injury to the collecting system or urinary |
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though renal injury resulting from penetrating |
extravasation.Grade 4 includes lacerations exten- |
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trauma often presents with hematuria, there is |
ding through the renal cortex, medulla, and col- |
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no correlation between severity of injury and |
lecting system or vascular injury to the main |
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the degree of hematuria.6 Therefore, patients |
renal artery or vein with contained hemorrhage. |
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with penetrating trauma and any degree of |
Grade 5 injuries include shattered kidney (lac- |
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hematuria should undergo radiologic evalua- |
eration) or avulsion of the renal hilum (vascu- |
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tion. Following blunt trauma, imaging should be |
lar). Grade is advanced by one for bilateral |
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reserved for those with gross hematuria, micro- |
injuries up to grade 3. |
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scopic hematuria and a single SBP < 90 mmHg, |
Nonoperative management has traditionally |
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or rapid deceleration injuries; these criteria will |
been favored for those with minor (grade 1 and |
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detect greater than 99% of significant (grade 2 |
2) renal lacerations following blunt trauma, and |
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or greater) renal injuries.5 |
now a number of trauma centers have demon- |
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Renal injuries are graded according to a sys- |
strated that patients with major renal lacera- |
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tem developed by the American Association for |
tions from blunt8,10 and penetrating11,12 trauma, |
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the Surgery of Trauma Organ Injury Scaling |
with or without urinary extravasation, can be |
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Committee,7 represented graphically in Fig. 36.2. |
managed nonoperatively with no apparent increase |
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Grade 1 injuries include contusion (defined as |
in acute or long-term morbidity13. |
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microscopic or gross hematuria with normal |
Nonoperative management of grade 5 renal |
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urologic studies) and hematoma (subcapsular |
parenchymal injuries has been reported,14 but we |
O.R. for exploration with 1-shot IVP
Unstable
Expanding or pulsatile retroperitoneal hematoma Injury to renal pelvis or ureter
Yes
No
Gross hematuria
Microscopic hematuria + SBP < 90 mm Hg penetrating trauma, any hematuria
Rapid deceleration
Clinical signs of renal trauma
Microscopic hematuria in child ( > 50 RBC/hpf)
Stable
Explore with early vascular control
Observe
Post-op staging CT*
Optionally, if retroperitoneal hematoma is present and IVP demonstrates a normal contralateral kidney, can explore with early vascular control
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Grade V Injury |
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Grade IV vascular |
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Renal artery thrombosis in both |
Staging CT* |
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kidneys or solitary kidney |
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Renal pelvis or ureteral injury |
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Yes |
O.R. for exploration |
No |
Expectant management |
Figure 36.1. suggested algorithm for the conservative management of renal parenchymal injuries. SBP systolic blood pressure, O.R. operating room. *staging ct = ct of abdomen and pelvis with and without iV contrast and with delayed images.
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Urologic traUma
Figure 36.2. american association for the surgery of trauma organ injury severity scale for the kidney (a) grade 1 injury. (b) grade 2 injury. (c) grade 3 injury. (d) grade 4 parenchymal injury. (e) grade 4 vascular injury (note that the parenchyma subtended by the injured segmental artery is ischemic).(f) grade 5 vascular injury (renal artery thrombosis, which generally results from intimal disruption, is demonstrated in the close-up of the figure). (g) grade 5 parenchymal injury (“shattered kidney”). (h) grade 5 vascular injury (avulsion of the renal pedicle). (Used from mcaninch and master9. With permission).
strongly caution overinterpreting these results, as many reported grade 5 renal injuries simply represent multiple grade 3 or 4 renal lacerations to the same kidney. These injuries, which represent a very different injury pattern than a shatteredkidney,canoftenbemanagednonoperatively. However, renal pedicle avulsion or a shattered kidney typically results in massive bleeding and nephrectomy is usually required.15,16
Absolute indications for renal exploration are an expanding retroperitoneal hematoma, hemodynamic instability believed to be from the kidney, or injuries to the renal pelvis or ureter. Furthermore, a retroperitoneal hematoma in a patient that has not been properly staged should be explored (see below). Traditional indications for exploration, such as urinary extravasation or concomitant bowel or pancreas injury, may no longer apply.15
Expectant Management
Despite the clear benefits of non-operative management in terms of reducing complications and nephrectomies, complications requiring delayed intervention can be expected to occur. Aggressive monitoring during and after the hospitalization is essential to identifying the subset of patients who will require further intervention. Bed rest is recommended until the gross hematuria resolves. For grade 4 injuries with large amounts of urinary extravasation,follow-up imaging is recommended at 48–72 h to evaluate degree of ongoing extravasation. If there is no decrease in the extravasation after 72 h,a stent should be placed.When a stent is in place, a Foley catheter should – at least initially
– be used to maximize drainage. Serial hematocrits should be checked until the patient has been able to ambulate for at least 24 h.
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500 |
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Practical Urology: EssEntial PrinciPlEs and PracticE |
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Endovascular Therapy |
preserve as much renal function as reasonably |
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possible. Though principles of damage control |
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Angio-embolization is an effective therapy for |
and preservation of renal function may initially |
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select patients with renal hemorrhage.17 The fol- |
be at odds, it is clear that early control of the |
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lowing criteria have been proposed for angio- |
renal hilum is rapid, easily accomplished, and |
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embolization: Persistent bleeding from a renal |
reduces the need for nephrectomy.20,21 Thus, we |
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segmental artery; unstable condition with grade |
believe that renal exploration should only be |
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3–4 injury; arteriovenous fistula or pseudoan- |
approached with early control of the renal |
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eurysm; persistent gross hematuria and/or rap- |
pedicle. |
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idly decreasing hematocrit requiring 2 U blood.18 |
In select patients who may not tolerate repair, |
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Patients with shattered kidney or injury to the |
it is reasonable to pack the retroperitoneum and |
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main renal artery or vein should be surgically |
return 24 h later for exploration and repair. |
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treated, as embolization does not seem to be |
Renal exploration should be approached |
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effective in these patients and can delay appro- |
transperitoneally through a midline incision, |
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priate treatment in an unstable patient, leading |
which should be carried up to the xiphoid pro- |
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to significant morbidity or even mortality. |
cess in order to permit adequate exposure of the |
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Endovascular stenting is not generally useful in |
upper retroperitoneum. The peritoneum is |
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the trauma patient, as it requires anticoagula- |
incised over the aorta from the level of the IMA |
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tion, which is typically contraindicated in the |
to the level of the left renal vein. If the aorta is |
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patient with multiple organ-system injury. |
obscured by a retroperitoneal hematoma, the |
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incision can be made medial to the IMV, which |
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Operative Intervention |
is usually readily identified. The left renal vein is |
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secured with a vessel loop and then the left renal |
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The patient who requires operative intervention |
artery, right renal vein, and right renal artery are |
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secured in that order. If there is uncontrolled |
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following renal trauma is usually unstable and |
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bleeding, the vessel loops can be used to occlude |
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rushed to the operating room without adequate |
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the artery, though often manual compression of |
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imaging. However, it remains essential to radio- |
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the kidney is sufficient. |
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graphically stage the injury. Though IVP is much |
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Principles of renal reconstruction in the |
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less reliable than CT – especially for parenchymal |
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trauma setting include exposure of the entire |
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injuries11 – a one-shot IVP is simple to perform |
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(for technique, see “Imaging” section), does not |
kidney, early vascular control, debridement of |
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nonviable tissue, meticulous hemostasis, water- |
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typically prolong the procedure, and may identify |
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tight closure of the collecting system, careful |
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an injury that would otherwise be missed, leading |
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reapproximation of the parenchymal edges or |
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to potentially life-threatening complications post- |
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coverage of the parenchymal defect, and drain |
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operatively. Most importantly, the IVP will iden- |
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placement.22 Individual vessels should be suture- |
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tify the presence or absence of a contralateral |
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ligated with 4-0 chromic suture, and collecting |
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kidney, which cannot be accurately determined |
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system tears should be oversewn with running |
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by palpation.19 When there is a high index of sus- |
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picion,especially in the case of penetrating trauma |
4-0 chromic suture. Typically, large parenchy- |
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mal defects are approximated in a tension-free |
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where the trajectory is suggestive of injury to the |
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manner over a bolster made of thrombin-soaked |
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collecting system or ureter, it is reasonable to |
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Gelfoam that is tied at 1 cm intervals with an |
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inject 1–2 cc of dilute methylene blue into the |
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absorbable suture. In the setting of contamina- |
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renal pelvis. One or more laparotomy pads can be |
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tion from bowel or pancreatic injuries, pledgets |
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placed into the retroperitoneum to identify the |
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should be made from absorbable material, such |
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source, and the ureter can be occluded to further |
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as vicryl mesh or peritoneum. |
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help identify an occult leak from the kidney. |
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Technique: Renal Exploration
and Repair
The goals of operative intervention for renal trauma are to control hemorrhage, adequately repair defects to the collecting system, and
Operative Management: Follow-up
If the drain output is minimal, it should be removed after 48–72 h. If output is high, the drain fluid creatinine should be checked. If consistent with serum, it can be removed, but if consistent with urine then a more prolonged period