Emphysematous pyelonephritis: the impact of urolithiasis on disease severity.

BACKGROUND: Emphysematous pyelonephritis is a severe infection of the kidney associated with formation of gas in the renal parenchyma and/or collecting system. The purpose of this study was to evaluate outcomes of patients with emphysematous pyelonephritis in a contemporary cohort and to evaluate the impact of urolithiasis on disease severity. METHODS: A search of all imaging reports at University of California San Francisco (UCSF) for the term "emphysematous pyelonephritis" was undertaken from 2003-2014. Patients were included if there was clinical evidence of infection, no recent urologic instrumentation, and computerized tomography (CT) demonstrating gas in the renal parenchyma or collecting system. Clinical and laboratory variables were obtained from medical records. RESULTS: A total of 14 cases were identified. The majority of patients (57%) had gas confined to the collecting system. Three patients (21%) had gas in the renal parenchyma and 3 patients (21%) had gas extending into perirenal tissues. A total of 8 patients (57%) had concomitant urolithiasis. Seven patients (50%) were managed with antibiotic therapy alone while 6 patients (43%) required percutaneous drainage. No patients required immediate nephrectomy. There were no deaths. Patients with urolithiasis had less severe emphysematous pyelonephritis than patients without urolithiasis (P<0.05). CONCLUSIONS: The majority of patients in this study had gas contained within the collecting system and were treated successfully with antibiotics alone. Percutaneous drainage was successfully utilized in patients with more advanced disease. No patients required emergent nephrectomy. Emphysematous pyelonephritis in patients with urolithiasis was less severe than in patients without urolithiasis.

Trends in Renal Transplantation Rates in Patients with Congenital Urinary Tract Disorders.

PURPOSE: Improved bladder and renal management benefit patients with congenital uropathy and congenital pediatric kidney disease. This may translate to delayed initial renal transplantation in these patients, and improved graft and patient survival. Our primary study purpose was to determine whether patients with congenital uropathy and congenital pediatric kidney disease have demonstrated later time to first transplantation and/or graft survival. MATERIALS AND METHODS: SRTR (Scientific Registry of Transplant Recipients) was analyzed for first renal transplant and survival data in patients with congenital uropathy and congenital pediatric kidney disease from 1996 to 2012. Congenital uropathy included chronic pyelonephritis/reflux, prune belly syndrome and congenital obstructive uropathy. Congenital pediatric kidney disease included polycystic kidney disease, hypoplasia, dysplasia, dysgenesis, agenesis and familial nephropathy. RESULTS: A total of 7,088 patients with congenital uropathy and 24,315 with congenital pediatric kidney disease received a first renal transplant from 1996 to 2012. A significant shift was seen in both groups toward older age at initial renal transplantation in those 18 through 64 years old. In the congenital uropathy group this effect was most facilitated by decreased renal transplantion in patients between 18 and 35 years old (38% in 1996 vs 26% in 2012). The congenital pediatric kidney disease group showed a substantial decrease in patients who were 35 to 49 years old (from 39% to 29%). At 10-year followup the congenital uropathy group showed better graft and patient survival than the congenital pediatric kidney disease group. However, aged matched comparison revealed comparable survival rates in the 2 groups. CONCLUSIONS: Analysis of trends in the last 14 years demonstrated that patients with both lower and upper tract congenital anomalies experienced delayed time to the first renal transplant. Furthermore, patients had similar age matched graft and patient survival whether the primary source of renal demise was the congenital lower or upper tract. These findings may indicate that improved urological and nephrological care are promoting renal preservation in both groups.

The mechanism of continence after posterior urethroplasty.

The standard of care after a pelvic fracture urethral injury is a repair via a one-stage anastomotic posterior urethroplasty using a step-wise perineal approach. The initial injury, immediate postoperative management, and surgical repair can all affect urinary continence in these patients. Proximal continence mechanisms, particularly the bladder neck, are particularly important in maintaining urinary continence in these patients. Patients with bladder neck dysfunction should be counselled about the greater risk of urinary incontinence.

Sports-related genitourinary injuries presenting to United States emergency departments.

OBJECTIVE: To describe epidemiologic features of sports-related genitourinary (GU) injuries and determine patient cohorts and particular sporting activities associated with increased GU injury risk. MATERIALS AND METHODS: The National Electronic Injury Surveillance System, a data set validated to provide a probability sample of injury-related US emergency department (ED) presentations, was analyzed to characterize GU injuries between 2002 and 2010. A total of 13,851 observations were analyzed to derive national estimates. RESULTS: Between 2002 and 2010, an estimated 137,525 individuals (95% confidence interval, 104,490-170,620) presented to US EDs with GU injuries sustained during sporting activities. Nearly three-quarters of injuries occurred in the pediatric population. The most common product involved was a bicycle, representing approximately one-third of injuries in both adult and pediatric populations. Injuries related to team sports such as football, baseball or softball, basketball, and soccer were also common, particularly among boys where they represented a combined third of all injuries. Eighty-nine percent of all patients were evaluated and treated in the ED without inpatient admission. The large majority of injuries involved the external genitalia (60%), and significant injuries of paired GU organs (kidneys and testicles) requiring inpatient admission were rare (8.5%). CONCLUSION: Sports-related GU injuries are most commonly sustained during the use of a bicycle. However, there are other associated activities with identifiable high-risk cohorts, products, and situations. Consumers, practitioners, and injury-prevention experts can use our epidemiologic data to prioritize and develop strategies aimed at the prevention and limitation of such injuries, particularly when counseling at-risk cohorts, such as those with solitary kidneys or testicles.

Bicycle-related genitourinary injuries in the USA from 2002-2010.

Among children, the incidence of bicycle-related genitourinary (GU) injuries was 448 per 100 000 (95% CI 383 to 514) and, among adults, was 53 per 100 000 (95% CI 36 to 71). Although children sustained more injuries, adults were more likely to being admitted to the hospital for the GU injury (OR 1.95, 95% CI 1.13 to 3.37). Children sustain nearly 10 times more GU injuries due to bicycles than adults, but adults have higher odds of sustaining injuries requiring admission.

Selective angioembolization for traumatic renal injuries: a survey on clinician practice.

PURPOSE: A variety of clinical and imaging findings are used by clinicians to determine utility of renal angioembolization (AE) in managing renal trauma. Our purpose was to investigate specific criteria that clinicians who manage high-grade renal trauma (HGRT) utilize in decision-making for primary or delayed AE. METHODS: A total of 413 urologists and interventional radiologists (IRs) who practice at level 1 or 2 trauma centers within the United States were provided an original survey via email on experience and opinions regarding the utility of AE for HGRT. We described overall practice patterns and assessed differences by clinician type, using the Fisher's exact test. RESULTS: A total of 79 (20 %) clinicians completed the survey. All clinicians had AE capability for HGRT management. A higher proportion of IRs reported using AE for grade I-II (33 vs. 3 %, p = 0.002), grade III (65 vs. 26 %, p = 0.001), and penetrating injuries (83 vs. 58 %, p = 0.02). A greater proportion of urologists reported using AE for grade V injuries (81 vs. 56 %, p = 0.03). Clinicians most commonly cited computed tomography evidence of active arterial bleeding (97 %), or arteriovenous fistula/pseudoaneurysm (94 %) as indications for primary AE, and 62 % identified concurrent visceral injury as factor that would necessitate surgical intervention. CONCLUSION: In a survey of clinicians, we report that IRs and urologists utilize AE differently when managing HGRT, as a higher proportion of IRs use AE to manage lower grade as well as penetrating injuries. Validation studies are needed to establish algorithms to identify patients with HGRT who would benefit from selective renal AE.

Intratesticular abscess in a solitary testicle: the case for testicle sparing management.

We present the case of a 24-year-old immunocompromised man with an intratesticular abscess. The patient presented with one week of left scrotal pain and swelling. Workup included scrotal ultrasonography which revealed a large fluid collection within the tunica albuginea of the left testis. Surgical exploration of the left testis evacuated a significant amount of purulent fluid. The residual viable testicular parenchyma was salvaged. Intraoperative cultures grew Morganella morganii. Follow-up ultrasonography showed resolution of the testicular fluid collection, and the patient was discharged home with oral antibiotics. Intratesticular abscesses are a rare clinical entity which often result in orchiectomy.

No small slam: increasing incidents of genitourinary injury from toilets and toilet seats.

OBJECTIVE: To describe the epidemiology of genitourinary (GU) injury from toilets that present to USA Emergency rooms (ERs). MATERIALS AND METHODS: The National Electronic Injury Surveillance System (NEISS) is a stratified probability sample of hospital ER visits for USA consumer product-related injuries. NEISS was used to estimate total toilet- and toilet seat-related GU injury for the years 2002-2010, as well as to describe demographics and injury characteristics. Analyses were performed using strata, primary sampling units and sample weights to accommodate the complex sample survey design. Data are reported as national estimates with 95% confidence intervals (CIs) provided. RESULTS: In all, 13 175 (95% CI 10 185-16 165) GU injuries related to toilets presented to ERs during 2002-2010. The most common mechanism involved crush from accidental fall of toilet seat, described in 9011 (68.4%, 95% CI 6907-11 115) cases. Most crush injuries were isolated to the penis (98.1%). Of crush injuries, 81.7% occurred in children aged 2-3 years and 99.3% occurred in the home. Crush injuries increased over the period 2002-2010 (P = 0.017) by ≈100 per year, ending with an estimated 1707 (95% CI 1011-2402) by 2010. Most patients who sustained toilet- and toilet seat-related GU injuries were treated in the ER and then discharged. CONCLUSION: While penile crush injury related to a toilet seat is an uncommon mechanism of urological injury in children, the number of incidents appears to be rising. These findings support educational efforts and interventions, such as exchange of heavy toilet seats with slow-close toilet seat technology.

Zip-related genital injury.

OBJECTIVE: To describe the epidemiology of genital injuries caused by trouser zips and to educate both consumers and the caregivers of patients who sustain such injuries. PATIENTS AND METHODS: The National Electronic Injury Surveillance System, a dataset validated to provide a probability sample of patients who present to emergency departments (EDs) in the USA with injuries, was analysed to characterize zip-related genital injuries occurring between 2002 and 2010. A total of 523 cases were analysed to obtain national estimates. RESULTS: Between 2002 and 2010, an estimated 17,616 patients presented to US EDs with trouser zip injuries to the genitals. The penis was almost always the only genital organ involved. Zip injuries represented nearly one-fifth of all penile injuries. Amongst adults, zips were the most frequent cause of penile injuries. Annual zip-related genital injury incidence remained stable over the study period. CONCLUSIONS: Zip-related genital injuries affect both paediatric and adult cohorts. Practitioners should be familiar with various zip-detachment strategies for these populations.

Gunshot wounds to the lower urinary tract: a single-institution experience.

BACKGROUND: This study aimed to analyze characteristics and outcomes of gunshot wounds to the lower urinary tract at our Level I trauma center. Our hypothesis is that gunshot wounds to the lower urinary tract have characteristic bullet trajectories, injury patterns, and associated injuries. METHODS: Our prospective trauma database was composed of reviewed gunshot wounds to the lower urinary tract including the pelvic ureter, bladder, or urethra from 1989 through 2011. RESULTS: We identified 50 patients (median age, 25 years; range, 3-53 years) with lower urinary tract injury. There was a mean of 2.3 bullets per patient (range, 1-8), with 26 patients injured from a single bullet. Urologic injury involving only the bladder occurred in 72% (36 of 50) of the patients. Ureteral injury was diagnosed in 20% (10 of 50) of the patients. Bullet trajectory was known in the majority of multiple bullet injuries and all cases involving a single bullet.All patients but one were managed operatively. During exploration, 90% (34 of 38) with transmural bladder injury had recognized bladder entry and exit wounds. Overall, 80% (40 of 50) had concurrent gastrointestinal injury. In patients with a single gunshot wound to the lower urinary tract, 58% (15 of 26) sustained concomitant intestinal injury, and 23% (6 of 26) sustained rectal injury.Of 20 posteroanterior gunshot wounds, 80% had buttock entry. All 10 single-bullet buttock-entry gunshot wounds injured the bladder. Isolated ureteral injury was associated with lower abdominal entry and anteroposterior trajectory. Urethral injury occurred in 4, with 75% upper-thigh entry. CONCLUSION: Penetrating injuries to the lower urinary tract most commonly involve the bladder. During exploration for gunshot wounds to the bladder, two injury sites should be expected because failure to close may lead to complications. Gunshot wounds to the lower urinary tract often occur with concomitant bowel injury, with buttock entry. A multidisciplinary approach involving general surgery is imperative. LEVEL OF EVIDENCE: Epidemiologic study, level IV.

Product related adult genitourinary injuries treated at emergency departments in the United States from 2002 to 2010.

PURPOSE: We describe the epidemiological features of adult genitourinary injuries related to consumer products and determined the patient cohorts, products and situations associated with increased genitourinary injury risk. MATERIALS AND METHODS: The National Electronic Injury Surveillance System, a data set validated to provide a probability sample of injury related emergency department presentations in the United States, was analyzed to characterize genitourinary injuries from 2002 to 2010. We analyzed 3,545 observations to derive national estimates. RESULTS: An estimated 142,144 adults (95% CI 115,324-168,964) presented to American emergency departments with genitourinary injuries from 2002 to 2010. Of the injuries 69% occurred in men. A large majority of injuries involved the external genitalia. The most common categories of products involved were sporting items in 30.2% of cases, clothing articles in 9.4% and furniture in 9.2%. The highest prevalence of injury was at ages 18 to 28 years (37.5%), which was most often related to sports equipment, such as bicycles. Older cohorts (age greater than 65 years) more commonly sustained injuries during falls and often in the bathroom during use of a shower or tub. Of all patients 88% were evaluated and treated in the emergency department without inpatient admission, although the admission rate increased with increasing patient age. CONCLUSIONS: Acute genitourinary injury is often associated with common consumer items and with identifiable high risk cohorts, products and situations. Consumers, practitioners and safety champions can use our epidemiological data to prioritize and develop strategies aimed at the prevention, limitation and informed treatment of such injuries.

Pediatric genitourinary injuries in the United States from 2002 to 2010.

PURPOSE: We describe the epidemiological features of pediatric genitourinary injuries, and determine the products and events that may predict an increased risk of genitourinary injury during childhood. MATERIALS AND METHODS: The National Electronic Injury Surveillance System was queried to identify children 18 years or younger who sustained genitourinary injuries and presented to emergency departments in the United States between 2002 and 2010. Demographics and injury characteristics of these children were analyzed. Analyses were performed with adjustments for sample weighting and the stratified survey design. All data are reported as national estimates along with 95% confidence intervals. RESULTS: Based on 10,286 actual cases, an estimated 252,392 children (95% CI 205,579-299,194) sustained genitourinary injuries during the 9-year study period. Children 4 to 7 years old were most frequently injured (36.8% of all injuries), followed by those 8 to 11 years old (20.6%). Girls comprised 55% of the injured children. The yearly incidence of genitourinary injuries was stable across the period studied. The most commonly injured organs were female external genitalia (37.7%), penises (21.6%) and testicles (12%). Genitourinary injuries were most commonly associated with sporting and exercise equipment (35.7%), furniture (15.5%) and clothing items (11.9%). Of the patients 91% were treated at the emergency department and discharged home. CONCLUSIONS: Genitourinary injuries in children result in approximately 28,000 emergency department visits yearly. Efforts should be made to decrease the risk of genitourinary injuries in children by promoting the use of protective gear and safer product selection for those at greatest risk for injury.

Pubic hair grooming injuries presenting to U.S. emergency departments.

OBJECTIVE: To describe the demographics and mechanism of genitourinary (GU) injuries related to pubic hair grooming in patients who present to U.S. emergency departments (EDs). MATERIALS AND METHODS: The National Electronic Injury Surveillance System contains prospectively collected data from patients who present to EDs with consumer product-related injuries. The National Electronic Injury Surveillance System is a stratified probability sample, validated to provide national estimates of all patients who present to U.S. EDs with an injury. We reviewed the National Electronic Injury Surveillance System to identify incidents of GU injury related to pubic hair grooming for 2002-2010. The variables reviewed included age, race, gender, injury type, location (organ) of injury, hospital disposition, and grooming product. RESULTS: From 2002 to 2010, an observed 335 actual ED visits for GU injury related to grooming products provided an estimated 11,704 incidents (95% confidence interval 8430-15,004). The number of incidents increased fivefold during that period, amounting to an estimated increase of 247 incidents annually (95% confidence interval 110-384, P = .001). Of the cohort, 56.7% were women. The mean age was 30.8 years (95% confidence interval 28.8-32.9). Shaving razors were implicated in 83% of the injuries. Laceration was the most common type of injury (36.6%). The most common site of injury was the external female genitalia (36.0%). Most injuries (97.3%) were treated within the ED, with subsequent patient discharge. CONCLUSION: Most GU injuries that result from the use of grooming products are minor and involve the use of razors. The demographics of patients with GU injuries from grooming products largely paralleled observations about cultural grooming trends in the United States.

Prostate size is not associated with recovery of sexual function after minimally invasive radical prostatectomy.

OBJECTIVES: To investigate the association of prostate weight with recovery of sexual function after minimally invasive radical prostatectomy. METHODS: Between April 2001 and September 2007, two surgeons performed 856 consecutive laparoscopic radical prostatectomies for clinically localized prostate cancer. Patients were stratified into three groups by prostate weight: <35 g, 35-70 g, and >70 g. Sexual and urinary outcomes were assessed prospectively using the Expanded Prostate Cancer Index Composite (EPIC) questionnaire. Patients who underwent nerve sparing (unilateral or bilateral) with complete preoperative EPIC data, a minimum preoperative Sexual Health Inventory for Men score ≥21, and a minimum of 3 months of complete postoperative EPIC data were included in the analysis. RESULTS: Of the cohort of 856 men, 324 (38%) had complete, evaluable data and met the inclusion criteria for this study. Preoperatively, there were no significant differences by prostate weight in the EPIC sexual function or bother subscale scores or the proportion of patients participating in sexual intercourse. Postoperatively, we observed statistically similar returns to baseline EPIC sexual function and bother subscale scores and participation in sexual intercourse across all gland weight groups at all time points. EPIC sexual domain scores and the proportions of patients participating in sexual intercourse continued to increase up to 24 months postoperatively, but no group returned to preoperative function at any sampling point. CONCLUSIONS: Prostate size is not associated with postoperative recovery of sexual function in men undergoing minimally invasive radical prostatectomy.

Status of endoscopes and instruments used during NOTES.

Natural orifice translumenal endoscopic surgery (NOTES) requires an intentional perforation of a hollow lumen to pass an endoscope into an otherwise inaccessible body cavity with diagnostic or therapeutic intent. The limitations of current flexible instruments for this purpose are outlined, including the unsuitability for NOTES of current flexible needle knives, guidewires, balloons, overtubes, grasping forceps, and scissors. The development of novel suturing instruments, trocars, articulating instruments, flexible bipolar forceps, flexible clips, magnetic devices, and staplers as well as the advent of manual mechanical manipulators for flexible accessories is outlined. New instrument solutions for endosurgery are described, such as articulating flexible accessories for gastroscopes, novel "platforms" that can be rigidized, and unconventional scope arrangements. Debatably, the greatest current benefit of NOTES is that it may lead to further development of better instrumentation for endosurgery.

Urethral carcinosarcoma from bladder carcinosarcomatous lesions: analysis of clinicopathological features.

Carcinosarcoma (CS) of the bladder is a rare malignancy of the genitourinary tract that is highly aggressive with unfavorable prognoses. Data regarding the epidemiological and clinicopathological characteristics of CS of the urinary bladder have been limited due to the low reported incidence of the tumor. In particular, there is little evidence on recurrence patterns and surveillance after definitive surgical therapy. In this case report, we describe a urethral recurrence of CS after radical cystoprostatectomy for CS of the bladder. The goal of this case report is to review our current understanding of the pathological and recurrence patterns of patients with CS of the urinary bladder in order to better define postoperative care for patients with CS of the bladder.

The impact of prostate size on urinary quality of life indexes following laparoscopic radical prostatectomy.

PURPOSE: We assessed the effects of prostate size on long-term health related quality of life and functional outcomes after laparoscopic radical prostatectomy. MATERIALS AND METHODS: A total of 729 consecutive patients who underwent laparoscopic radical prostatectomy for localized prostate cancer were stratified by pathological prostate gland weight, including group 1--less than 35 gm, group 2--35 to 70 gm and group 3--greater than 70 gm. Urinary health related quality of life was assessed preoperatively and at regular intervals following laparoscopic radical prostatectomy using the validated Expanded Prostate Cancer Index Composite questionnaire. RESULTS: A total of 613 evaluable patients were studied with a mean age of 57.7 years, a preoperative prostate specific antigen of 6.0 ng/ml, a median preoperative and postoperative Gleason score of 6, and a mean pathological gland weight of 51.3 gm (range 13.4 to 145.7). Patients with the largest glands had significantly worse baseline urinary function, as demonstrated by Expanded Prostate Cancer Index Composite urinary domain summary (p <0.001) and subscale scores, including scores for urinary bother (p <0.001), urinary irritative/obstructive (p = 0.001) and urinary incontinence (p = 0.03). Patients in group 3 also had significantly older age, a higher body mass index, longer operative time and more blood loss (each p <0.05). Despite preoperative differences and possible confounders all groups approached similar urinary health related quality of life outcomes at all time points postoperatively. At 12 months patients with the largest glands had improved Expanded Prostate Cancer Index Composite urinary irritative/obstructive and urinary bother subscale scores compared to their baseline scores (p <0.05). CONCLUSIONS: In laparoscopic radical prostatectomy despite preoperative differences increasing prostatic size is not associated with delayed or worse postoperative urinary health related quality of life. Furthermore, in patients with large glands an improvement in urinary irritative/obstructive and bother symptoms from baseline may be seen 12 months postoperatively.

Laparoscopic treatment of simultaneous tumors in the liver and kidney.

BACKGROUND/AIMS: To report our experience with laparoscopic treatment of liver tumors during right-sided transperitoneal laparoscopic nephrectomy. METHODS: Two patients undergoing transperitoneal laparoscopic radical nephrectomy on the right side each had a concomitant tumor in the right lobe of the liver. The first patient was incidentally found to have a lesion suspicious for metastatic disease. The second had a known asymptomatic giant hemangioma of the liver. RESULTS: Total operative time was 130 and 101 min. Estimated blood loss was 400 and 300 ml. There were no complications. The first patient had bilateral papillary renal cell carcinoma and concomitant fibroadipose tissue within the liver. The second patient presented with clear cell carcinoma of the right kidney and a cavernous hemangioma of the liver. CONCLUSIONS: When indicated, simultaneous right-sided kidney and liver tumors may be treated by a combined laparoscopic transperitoneal approach. Laparoscopic expertise is advised.