Laparoscopic retroperitoneal lymph node dissection for low-stage testicular cancer.

BACKGROUND AND PURPOSE: Current management options for low-stage mixed malignant germ-cell testicular tumors (MMGCT) after radical orchiectomy include surveillance, chemotherapy, or retroperitoneal lymph node dissection (RPLND). The open RPLND is the surgical gold standard and has been duplicated laparoscopically with confirmed diagnostic effectiveness; however, its therapeutic oncologic value in MMGCT has never been proven. We present our laparoscopic RPLND (L-RPLND) data for low-stage MMGCT and paratesticular rhabdomyosarcoma. PATIENTS AND METHODS: Retrospective chart reviews were performed for patients who underwent L-RPLND at our institution for low clinical stage MMGCT and paratesticular rhabdomyosarcoma from May 2003 to December 2007. Patient data were compiled for surgical and clinical variables. RESULTS: A total of 26 L-RPLND procedures were completed, 3 for paratesticular rhabdomyosarcoma. Mean operative time was 250 minutes (range 176-369 min); estimated blood loss was 145 mL (range 50-500 mL); lymph node count was 23.8 (range 8-48); and hospital stay was 1.5 days (range 1-3 d). Four patients underwent postchemotherapy L-RPLND for residual nodes (1.1-2.9 cm). There were no conversions to an open procedure, blood transfusions, or operative complications. Chemotherapy was instituted in five of six patients with pathologic stage II disease. Mean follow-up was 23.7 months without retroperitoneal disease recurrence. CONCLUSION: L-RPLND as a diagnostic and therapeutic tool provides the benefits of a minimally invasive approach to MMGCT. It is the procedure of choice at our institution for low-stage MMGCT and paratesticular rhabdomyosarcoma.

Bladder rupture after blunt trauma: guidelines for diagnostic imaging.

PURPOSE: The purpose of this study was to establish guidelines for diagnostic imaging for bladder rupture in the blunt trauma victim with multiple injuries, in whom the delay caused by unnecessary testing can hamper the trauma surgeon and threaten outcome. METHODS: We undertook chart review (1995-1999) of patients with blunt trauma and bladder rupture at our four institutions and performed focused literature review of retrospective series. RESULTS: Of our 53 patients identified, all had gross hematuria and 85% had pelvic fracture. Literature review revealed similar rates. CONCLUSION: The classic combination of pelvic fracture and gross hematuria constitutes an absolute indication for immediate cystography in blunt trauma victims. Existing data do not support lower urinary tract imaging in all patients with either pelvic fracture or hematuria alone. Clinical indicators of bladder rupture may be used to identify atypical patients at higher risk. Patients with isolated hematuria and no physical signs of lower urinary tract injury may be spared the morbidity, time, and expense of immediate cystographic evaluation.

Renal cell carcinoma in patients with prior spinal cord injury.

INTRODUCTION: In patients with spinal cord injury (SCI), abdominal diseases such as renal carcinoma are often diagnosed and treated late in their course. METHODS: A population-based retrospective review of SCI patients receiving care for renal cell carcinoma (RCC) in all Department of Veterans Affairs (DVA) medical centers was conducted for fiscal years 1988 to 1998. RESULTS: Of 96 patients identified, 57 were evaluable and 27 met study criteria. The mean patient age was 59 (range, 41-79 years). The mean time between SCI and treatment for RCC was 25 years (range, 1-51 years). All patients were men; 22/27 (81%) had 1 or more comorbid conditions. RCC was an incidental finding on surveillance imaging studies in 81% (22/27) of the patients. All 27 patients were treated surgically, 74% (20/27) by radical nephrectomy and 26% (7/27) by partial nephrectomy. All tumors were renal cell adenocarcinomas. Pathological staging by the tumor, nodes, and metastasis system was possible in 25; 92% (23/25) of tumors were stage I and 8% (2/25) were stage II. Postoperative morbidity occurred in 56% (15/27), and death occurred in 7% (2/27). CONCLUSION: In SCI patients in the DVA system, diagnosis of RCC is usually the result of an incidental finding on surveillance imaging. Tumors are diagnosed at early stages and partial nephrectomy is often feasible. Many of the postoperative complications are related to the SCI, and may be preventable.

Urban free falls and patterns of renal injury: a 20-year experience with 396 cases.

OBJECTIVE: To determine the distribution and stage of renal injuries from free falls and to determine the appropriate methods for their evaluation and management. MATERIALS AND METHODS: We reviewed the records of 423 patients with renal injuries after a fall from height. Twenty-seven patients did not survive their injuries and were removed from the study. RESULTS: Based on the American Association for the Surgery of Trauma grading scale, 372 of the renal injuries (94%) were grade 1, whereas 24 injuries (6%) were grade 2 to 4. None of the injuries was grade 5. Of the patients with grade 2 to 4 renal injuries, nine patients had grade 2, three patients had grade 3, nine patients had grade 4, and one patients had a forniceal rupture, as well as two patients with ureteropelvic junction disruptions (one bilateral), four with segmental vascular injuries, and two with hilar vessel injuries. Mean height of free fall was 23.1 feet (range, 10-60 feet) and mean Injury Severity Score was 20.6. Neither the degree of renal injury nor the Injury Severity Score statistically correlated to the height of the free fall. Patients with grade 2 to 4 were more likely than patients with grade 1 renal injuries to be in shock and to have intra-abdominal injuries, gross hematuria, and higher Injury Severity Score(33%, 34%, 62%, 24.6 vs. 6%, 9%, 14%, 20.1, respectively). The degree of hematuria and the grade of renal injury, however, did not correlate. Grade 2 to 4 renal injuries had microscopic hematuria and no shock in 8.3% (2 of 24 patients) and no hematuria in 20.8% (5 of 24 patients). Thus, standard selection criteria for renal imaging of blunt trauma, namely gross hematuria or microhematuria and shock would have missed 7 or 29% of our grade 2 to 4 renal injuries, or 1.8% of all grade 1 to 4. Half of the patients with grade 2 to 4 renal injuries had associated multiple-system injuries, and half had flank ecchymosis or tenderness. Of the patients with grade 2 to 4 injuries, 9 patients (37%) underwent surgical exploration and repair of injury. All renal units were preserved and underwent successful reconstruction. Six of the nine patients initially were explored because of associated intra-abdominal injuries. No major urological sequelae were noted postoperatively or in follow-up of all renal injuries. CONCLUSION: The height of the free fall cannot reliably predict the degree of the resulting renal injury. Despite the absence of hematuria or shock, vertical deceleration injuries, in particular those associated with multiple-system injuries and/or physical signs of potential renal injury (e.g., flank ecchymosis), demand renal imaging. After a fall from height, the ureteropelvic junction and renal vasculature should also be imaged for potential injury.

The effect of pregnancy and contractile activity on bladder muscarinic receptor subtypes.

In the rabbit bladder, pregnancy and prolonged bladder contractions decrease both muscarinic receptor density and contractile response, whereas newborns show enhanced muscarinic contractile response. Although the M(2) receptor predominates in rabbit bladder, we and others have shown that the affinity of a series of subtype selective muscarinic antagonists for inhibition of muscarinic agonist-induced contractions is most consistent with the pharmacologically defined M(3) receptor directly mediating smooth muscle contraction. Bladders from fetal rabbits, gravid rabbits, and male rabbits exposed to 4 hr of induced spontaneous contractions were used to determine whether changes in receptor density and contractility are due to a selective decrease in either the M(2) or M(3) muscarinic receptor subtype. To determine organ specificity, the heart and uterus were also studied. Gravid rabbits of 3 weeks' gestation and their fetal rabbits were studied. In male rabbits, bladder contractions were induced for 4 hr by ligating the catheterized penis at its base. Muscarinic receptor density and subtype distribution were determined by radioligand binding and immunoprecipitation. Receptor density was 24% lower in gravid bladder body, unchanged in gravid bladder base, 54% lower in gravid uterus, 115% higher in fetal bladders, and 34% lower after induced bladder contractions. Immunoprecipitation showed greater M(2) receptors than M(3) in all tissues studied, whereas M(l) and M(4) receptors were undetectable. There was no difference from control in the ratio of M(2) to M(3) receptor in any tissues except that a greater proportion of M(3) receptors was found in male vs. female bladders. Changes in contractile response to cholinergic stimulation in the gravid, fetal, and experimental detrusor instability model are associated with changes in total receptor density and not solely with changes in the M(3) receptor subtype that mediates bladder smooth muscle contraction. Neurourol. Urodynam. 18:511-520, 1999.

Renal trauma: indications and techniques for surgical exploration.

Injury secondary to trauma has become increasingly common in modern society. In the United States, in excess of 55 million trauma patients are evaluated each year, and trauma is the leading cause of mortality in people under the age of 40 years. Of the patients with abdominal trauma, approximately 10% have an injury to the urinary tract. Renal injury, occurring in 1-5% of all traumas, is due primarily to blunt trauma. Advances in the imaging and staging of renal trauma as well as in treatment strategies have decreased the need for surgical intervention and increased renal preservation. Nevertheless, no consensus exists regarding indications and techniques for renal exploration. The goals of treatment include accurate staging, maximal preservation of renal function, and minimal complications. We discuss our current approach in the management of renal trauma.

Reconstructive surgery for trauma of the upper urinary tract.

In general, the authors surgically reconstruct kidneys with major parenchymal lacerations or vascular injuries, particularly when intra-abdominal injuries are present. Regardless of the mechanism of injury, roughly 90% of explored kidneys can be successfully reconstructed. Adherence to the principles of early proximal vascular control, debridement of devitalized tissue, hemostasis, closure of the collecting system, and coverage of the defect maximizes the salvage of renal function while minimizing potential complications. As to ureteral injuries, a high index of suspicion is crucial, especially because urinalysis and imaging studies can be unreliable. The majority of ureteral injuries can be successfully reconstructed by primary repair, ureteroureterostomy, or ureteral reimplantations, with or without a psoas bladder hitch.

Adenocarcinoma in a duplicated bladder.

We report a rare case of duplication of the bladder, urethra, uterus, vagina, and associated anomalies in a woman. As an infant, she initially underwent successful surgical reconstruction. As an adult, she developed adenocarcinoma within the defunctionalized bladder moiety. The surgical management and pathology of this cancer are detailed and the pertinent literature reviewed.

Leiomyosarcoma of the renal vein.

The preoperative diagnosis for primary leiomyosarcoma of the renal vein, an extremely rare tumor, is difficult. The tumor predominantly occurs in women and on the left side. Its natural history is toward distant metastases and a poor 5-year survival rate. Nephrectomy and en-bloc surgical resection remain the mainstay of therapy. We present three such cases and review the world literature.

External genitalia gunshot wounds: a ten-year experience with fifty-six cases.

OBJECTIVE: To determine the appropriate methods for the diagnosis and management of gunshot injuries to the external genitalia. DESIGN: Retrospective analysis. MATERIALS AND METHODS: Fifty-six patients with gunshot wounds (GSWs) to the external genitalia were seen over the last 10 years. All patients underwent physical examination, radiographic staging, and surgical exploration, according to protocol. RESULTS: There were 25 testicular, 19 scrotal soft tissue, 14 penile, 4 epididymal, 4 urethral, 4 vasal, and 3 superficial scrotal skin injuries. When possible, all injuries, except for the vasal and 1 urethral injury, were primarily repaired with excellent long-term results. Orchiectomy was required in half of testes struck by gunshots. Associated injuries with single GSWs were mostly to the proximity soft tissue and were amenable to conservative management. Major associated injuries were present in patients with multiple GSWs. In the absence of a suspected major associated injury, genital GSWs required only two diagnostic studies, a retrograde urethrogram for suspected urethral injury and a routine abdominal radiograph. Gunshot injuries to the penis or perineum, blood at the penile meatus, or gross hematuria were highly suggestive of urethral injury. CONCLUSIONS: Successful management of genital GSWs is dependent upon prompt surgical exploration, conservative debridement, and primary repair.

Muscarinic receptor subtypes in normal, fetal, and gravid rabbit bladder, heart and uterus.

In the rabbit bladder, pregnancy has been shown to induce a significant decrease in both muscarinic receptor density and response to muscarinic stimulation. Neonatal rabbit bladders have a high muscarinic receptor density and contractile response to bethanechol stimulation. The bladders from 7 gravid rabbits, 7 age-matched virgin controls, and 32 fetal rabbits of 3 week gestation were studied. Compared to control tissue, filtration binding demonstrated receptor density to be 24.3% lower in gravid bladder dome, 41.2% lower in gravid bladder base, and 114.8% higher in fetal bladders. While total receptor density was not different from control in gravid heart, fetal hearts showed a 2.5 fold increased receptor density. There was also a 61% reduction in muscarinic receptor density in the gravid uterus. Immunoprecipitation assays using muscarinic receptor subtype specific antisera were used to measure the relative levels of m1, m2, m3 and m4 receptors. The m2 receptor was the predominant subtype in the bladder and uterus, and the only subtype detected in rabbit heart. The m3 receptor protein was also present, but in lower levels in the bladder and uterus. The m1 and m4 receptors were not detected in any of the tissues studied. Furthermore, the relative percent of each receptor did not statistically change for the gravid or fetal rabbit bladder, uterus, or heart, when compared to its control. Differences in the contractile response to cholinergic stimulation of the gravid bladder and uterus, and of the fetal bladder then, can be attributed to changes in muscarinic receptor density and not to changes in receptor subtype.

Adult acute idiopathic scrotal edema.

We report here a rare case of adult acute idiopathic scrotal edema (AISE). Its characteristics and management are the same for adults as for prepubertal boys. AISE typically affects prepubertal boys, with an acute onset of a relatively painless scrotal erythema and subcutaneous edema, which resolves spontaneously, without sequela, in 1 to 3 days. The erythema and swelling can also extend to the perineum, abdomen, or penis. Its diagnosis is primarily made by exclusion. Vital signs, urinalysis, urine and tissue culture, and white blood cell count are normal. Palpably normal scrotal contents on physical examination and thickened scrotal wall and normal testis arterial flow on scrotal ultrasound with color flow Doppler further confirm the diagnosis. Differentiating AISE from a scrotal surgical emergency is essential in order to avoid unnecessary exploration.

Ureteral injuries from penetrating trauma.

Twelve patients with ureteral injuries from stab or gunshot wounds were evaluated. All 12 underwent surgical exploration on admission. None of the injuries were diagnosed preoperatively. Eleven of 12 injuries were diagnosed during surgical exploration. Diagnosis was delayed in one patient, until 2 weeks after injury, when a CT scan revealed a urinoma. High-dose intravenous urograms (IVUs) were nondiagnostic in nine of nine patients. Hematuria was absent in 45% of patients (5 of 11). Repair of ureteral injury was successfully performed on the proximal and middle portions of the ureter (nine patients) with stented ureteroureterostomy. Three patients sustained distal ureteral injuries. Two underwent ureteroneocystostomy and psoas hitch, and one a primary repair. Mean follow-up time after repair was 4 months in nine patients, and only two minor complications were noted. Currently available preoperative methods, including urinalysis and high-dose IVU, are not reliable for detecting penetrating ureteral injury. In addition, 1 of 12 ureteral injuries was not initially identified, despite routine surgical exploration, urinalysis, and high-dose IVU. A high index of suspicion is required to diagnose ureteral injury.