Long-term follow-up of urethral reconstruction for blunt urethral injury at a young age: urinary and sexual quality of life outcomes.

INTRODUCTION: Little is known about long-term patient-reported outcomes following surgical repair for pediatric blunt urethral trauma. OBJECTIVE: The purpose was to evaluate long-term urinary outcomes, sexual function, and quality of life (QOL) of patients who undergo urethroplasty for blunt urethral trauma in childhood. STUDY DESIGN: After IRB approval, we retrospectively reviewed the records of patients who sustained blunt urethral injury at ≤18 years and underwent urethroplasty at our institution between 1978 and 2013. We then used a web-based survey to assess urinary/sexual/ejaculatory function and overall QOL using validated questionnaires. RESULTS: Of 68 eligible patients, 15 were able to be contacted (table). Median age of injury, age at urethroplasty, and age at follow-up were 17 (4-18), 17 (5-20), and 19 (13.5-21.5) years, respectively. The stricture was membranoprostatic in eight and bulbar in seven patients, with median length of 2 (1.6-2.6) cm. Excision/primary anastomosis was performed in all but three patients who required a buccal graft. Overall, 80% were 'very satisfied' and 20% were 'satisfied' with surgery. One patient reported a subsequent urethral intervention. On urethral stricture surgery patient-reported outcome measurement, the median bother (0 least, 24 worst) was 10 (8-12.5). The force of urine stream (1 strongest, 4 weakest) was 2 (1.5-2), with no report of urinary incontinence. The median Sexual Health Inventory for Men score (0 worst, 25 perfect) was 24 (22.5-24). The median ejaculatory function score (0 worst, 15 normal) was 14 (13-14.75). Six patients had fathered children and none reported infertility. Three patients reported <30° penile curvature not interfering with sex. Median QOL (0 worse, 10 best) was 8 (7.5-8). CONCLUSIONS: Urethroplasty after blunt urethral injury in young adult population is associated with a high long-term success rate with a low rate of long-term urinary and sexual consequences in adulthood.

Predictors of early treatment discontinuation in a cohort of patients treated with boceprevir-based therapy for hepatitis C infection.

In this real-world cohort, 49% of patients stopped boceprevir-based hepatitis C therapy early, with only 20% stopping due to treatment futility. Having more comorbidities was significantly associated with early discontinuation. Tolerability of boceprevir-based regimens may be substantially worse than reported in clinical trials, particularly for patients with comorbidities.

Fast neutrons measured in copper from the Hiroshima atomic bomb dome.

The first measurements of (63)Ni produced by A-bomb fast neutrons (above approximately 1 MeV) in copper samples from Hiroshima encompassed distances from approximately 380 to 5062 m from the hypocenter (the point on the ground directly under the bomb). They included the region of interest to survivor studies (approximately 900 to 1500 m) and provided the first direct validation of fast neutrons in that range. However, a significant measurement gap remained between the hypocenter and 380 m. Measurements close to the hypocenter are important as a high-value anchor for the slope of the curve for neutron activation as a function of distance. Here we report measurements of (63)Ni in copper samples from the historic Hiroshima Atomic Bomb Dome, which is located approximately 150 m from the hypocenter. These measurements extend the range of our previously published data for (63)Ni providing a more comprehensive and consistent A-bomb activation curve. The results are also in good agreement with calculations based on the current dosimetry system (DS02) and give further experimental support to the accuracy of this system that forms the basis for radiation risk estimates worldwide.

Neutron-induced 63Ni in copper samples from Hiroshima and Nagasaki: a comprehensive presentation of results obtained at the Munich Maier-Leibnitz Laboratory.

Those inhabitants of Hiroshima and Nagasaki who were affected by the A-bomb explosions, were exposed to a mixed neutron and gamma radiation field. Few years later about 120,000 survivors of both cities were selected, and since then radiation-induced late effects such as leukemia and solid tumors are being investigated in this cohort. When the present study was initiated, the fast neutron fluences that caused the neutron doses of these survivors had never been determined experimentally. In principle, this would have been possible if radioisotopes produced by fast neutrons from the A-bomb explosions had been detected in samples from Hiroshima and Nagasaki at distances where the inhabitants survived. However, no suitable radioisotope had so far been identified. As a contribution to a large international effort to re-evaluate the A-bomb dosimetry, the concentration of the radionuclide (63)Ni (half-life 100.1 years) has been measured in copper samples from Hiroshima and Nagasaki. These measurements were mainly performed at the Maier-Leibnitz-Laboratory in Munich, Germany, by means of accelerator mass spectrometry. Because the (63)Ni had been produced in these samples by fast A-bomb neutrons via the reaction (63)Cu(n,p)(63)Ni, these measurements allow direct experimental validation of calculated neutron doses to the members of the LSS cohort, for the first time. The results of these efforts have already been published in a compact form. A more detailed discussion of the methodical aspects of these measurements and their results are given in the present paper. Eight copper samples that had been significantly exposed to fast neutrons from the Hiroshima A-bomb explosion were investigated. In general, measured (63)Ni concentrations decreased in these samples with increasing distance to the hypocenter, from 4 x 10(6 ) (63)Ni nuclei per gram copper at 391 m, to about 1 x 10(5 ) (63)Ni nuclei per gram copper at about 1,400 m. Additional measurements performed on three large-distant copper samples from Hiroshima (distance to the hypocenter 1,880-7,500 m) and on three large-distant copper samples from Nagasaki (distance to the hypocenter 3,931-4,428 m) that were not exposed significantly to A-bomb neutrons, suggest a typical background concentration of about 8 x 10(4 ) (63)Ni nuclei per gram copper. If the observed background is accounted for, the results are consistent with state-of-the-art neutron transport calculations for Hiroshima, in particular for those distances where the victims survived and were included in the life span study cohort.

Evaluation and management of renal injuries: consensus statement of the renal trauma subcommittee.

OBJECTIVE: To determine the optimal evaluation and management of renal injuries by review of the world's English-language literature on the subject. METHODS: A consensus conference convened by the World Health Organization and the Societé Internationale d'Urologie met to critically review reports of the diagnosis and treatment of renal trauma. The English-language literature about renal trauma was identified using Medline, and additional cited works not detected in the initial search obtained. Evidence-based recommendations for the diagnosis and management of renal trauma were made with reference to a five-point scale. RESULTS: There were many Level 3 and 4 citations, few Level 2, and one Level 1 which supported clinical practice patterns. Findings of nearly 200 reviewed citations are summarized. CONCLUSIONS: Published reports on renal trauma still rely heavily on expert opinion and single-institution retrospective case series. Prospective trials of the most significant issues, when possible, might improve the quality of evidence that dictates the behaviour of practitioners.

Measuring fast neutrons in Hiroshima at distances relevant to atomic-bomb survivors.

Data from the survivors of the atomic bombs serve as the major basis for risk calculations of radiation-induced cancer in humans. A controversy has existed for almost two decades, however, concerning the possibility that neutron doses in Hiroshima may have been much larger than estimated. This controversy was based on measurements of radioisotopes activated by thermal neutrons that suggested much higher fluences at larger distances than expected. For fast neutrons, which contributed almost all the neutron dose, clear measurement validation has so far proved impossible at the large distances (900 to 1,500 m) most relevant to survivor locations. Here, the first results are reported for the detection of 63Ni produced predominantly by fast neutrons (above about 1 MeV) in copper samples from Hiroshima. This breakthrough was made possible by the development of chemical extraction methods and major improvements in the sensitivity of accelerator mass spectrometry for detection of 63Ni atoms (refs 8-11). When results are compared with 63Ni activation predicted by neutron doses for Hiroshima survivors, good agreement is observed at the distances most relevant to survivor data. These findings provide, for the first time, clear measurement validation of the neutron doses to survivors in Hiroshima.

Extramammary Paget's disease of the penis and scrotum: excision, reconstruction and evaluation of occult malignancy.

PURPOSE: We describe treatment and reconstruction in patients after surgery for extramammary Paget's disease of the penis and scrotum. We also investigated whether this disease causes an increased risk of undiagnosed visceral malignancy. MATERIALS AND METHODS: We reviewed the databases at our institution from 1996 to 2000 and identified 6 men 67 to 87 years old (mean age 76). In addition, we reviewed the literature on the clinical and pathological features of this disease. RESULTS: In our 6 patients scrotal involvement was present in 83% and penile extramammary Paget's disease was present in 33%. Each man underwent wide local excision and large skin defects were immediately reconstructed with split-thickness skin grafts. In 1 case extramammary Paget's disease had spread to the superficial inguinal nodes. At a mean followup of 29 months there has been no local recurrence and internal malignancy has not been diagnosed. Our literature review revealed 13 patients with penoscrotal extramammary Paget's disease and visceral malignancy, including 12 (92%) with malignancy of the genitourinary system. CONCLUSIONS: Extramammary Paget's disease of the penis and scrotum is a rare disease that can be managed by excision and immediate reconstruction with skin grafting or a local skin flap. Disease may spread to the regional lymph nodes. Although genitourinary cancer may accompany penoscrotal extramammary Paget's disease, an extensive search for cancer of the thorax or abdomen may be unnecessary because only 1 reported case of colon cancer has been associated with penile or scrotal extramammary Paget's disease.

Erectile function after anterior urethroplasty.

PURPOSE: We ascertained the impact of anterior urethroplasty on male sexual function. MATERIALS AND METHODS: A validated questionnaire was mailed to 200 men who underwent anterior urethroplasty to evaluate postoperative sexual function. Questions addressed the change in erect penile length and angle, patient satisfaction with erection, preoperative and postoperative coital frequency, and change in erection noted by the sexual partner. Results were stratified by the urethral reconstruction method, namely anastomosis, buccal mucosal graft, penile flap and all others, and compared with those in a similar group of men who underwent circumcision only. RESULTS: Of the 200 men who underwent urethroplasty 152 who were 17 to 83 years old (mean age 45.7) completed the questionnaire. Average followup was 36 months (range 3 to 149). Overall there was a similar incidence of sexual problems after urethroplasty and circumcision. Penile skin flap urethroplasty was associated with a slightly higher incidence of impaired sexual function than other procedures (p >0.05). Men with a longer stricture were most likely to report major changes in erectile function and penile length (p <0.05) but improvement was evident with time in 61.8%. CONCLUSIONS: Overall anterior urethral reconstruction appears no more likely to cause long-term postoperative sexual dysfunction than circumcision. Men with a long stricture may be at increased risk for transient erectile changes.

Validation of the American Association for the Surgery of Trauma organ injury severity scale for the kidney.

BACKGROUND: We queried an observational database of renal trauma patients to validate the organ injury severity scale (kidney) of the American Association for the Surgery of Trauma (AAST). METHODS: In a retrospective review of our renal trauma database (2,467 patients) with 58 clinical and radiographic patient variables, statistical "classification trees" were used to determine factors predicting need for surgical repair. RESULTS: Scales correlated with the need for surgery (grade I = 0%, grade II = 15%, grade III = 76%, grade IV = 78%, and grade V = 93%) and for nephrectomy (grade I = 0%, grade II = 0%, grade III = 3%, grade IV = 9%, and grade V = 86%). Classification tree analysis (confirmed in 83 additional patients) identified the AAST organ injury severity scale as the most important variable predicting the need for renal repair. CONCLUSION: In a retrospective review of more than 2,500 patients, we determined that the AAST organ injury severity scale correlates with the need for kidney repair or removal. Classification tree analysis confirmed the scale as the prime variable predicting need for surgical repair.

Grade IV renal injuries: evaluation, treatment, and outcome.

Of our last 2483 renal trauma patients, 113 had grade IV injuries. In most the mechanism was a penetrating injury (60%: 30% gunshot, 30% stab wounds). Associated injuries were common (80%) and hospital stays prolonged, averaging 16 days. Most of the patients (70%) required transfusion, some massively (average volume 4.4 liters, range 0-30 liters). Surprisingly, not all patients with grade IV renal injuries had gross hematuria: 25% had microhematuria, and 4% had neither microscopic nor gross hematuria. Computed tomography (CT) diagnosed the injury correctly in 100% of the patients in whom it was performed; when CT was not available, "one-shot" intraoperative intravenous pyelography (IVP) demonstrated grossly abnormal findings in 90%. Renal exploration was performed in 78%, resulting in 69% renorrhaphy and 9% nephrectomy rates in our 113 patients. Almost all those with penetrating trauma required exploration (97%), whereas only 50% of those with blunt trauma did so. The overall complication rate and kidney-specific complication rate did not differ significantly between patients who were observed and those who underwent surgery. Complications rates were similar in grade IV renal laceration patients and grade III patients. Delayed complications after hospital discharge were not seen, although follow-up was rare in this inner-city trauma population. Among the 21% of patients in whom postoperative nucleotide renal function scans were available, function was generally good (average 36%). Only patients who underwent concomitant vascular repair had poor function (below 20%).

Outcome after major renovascular injuries: a Western trauma association multicenter report.

BACKGROUND: Major renal vascular injuries are uncommon and are frequently associated with a poor outcome. In addition to renal dysfunction, posttraumatic renovascular hypertension may result, although the true incidence of this complication is unknown. The objective of this study was to describe the factors contributing to outcome after major renovascular trauma. We hypothesized that the highest percentage of renal salvage would be achieved by minimizing the time from injury to repair. METHODS: This was a retrospective chart review over a 16-year period conducted at six university trauma centers of patients with American Association for the Surgery of Trauma grade IV/V renal injuries surviving longer than 24 hours. Postinjury renal function with poor outcome was defined as renal failure requiring dialysis, serum creatinine greater than or equal to 2 mg/dL, renal scan showing less than 25% function of the injured kidney, postinjury hypertension requiring treatment, or delayed nephrectomy. Data collected for analysis included demographics, mechanism of injury, presence of shock, presence of hematuria, associated injuries, type of renal injury (major artery, renal vein, segmental artery), type of repair (primary vascular repair, revascularization, observation, nephrectomy), time from injury to definitive renal surgery, and type of surgeon performing the operation (urologist, vascular surgeon, trauma surgeon). RESULTS: Eighty-nine patients met inclusion criteria; 49% were injured from blunt mechanisms. Patients with blunt injuries were 2.29 times more likely to have a poor outcome compared with those with penetrating injuries. Similarly, the odds ratio of having a poor outcome with a grade V injury (n = 32) versus grade IV (n = 57) was 2.2 (p = 0.085). Arterial repairs had significantly worse outcomes than vein repairs (p = 0.005). Neither the time to definitive surgery nor the operating surgeon's specialty significantly affected outcome. Ten percent (nine patients) developed hypertension or renal failure postoperatively: three had immediate nephrectomies, four had arterial repairs with one intraoperative failure requiring nephrectomy, and two were observed. Of the 20 good outcomes for grade V injuries, 15 had immediate nephrectomy, 1 had a renal artery repair, 1 had a bypass graft, 1 underwent a partial nephrectomy, and 2 were observed. CONCLUSION: Factors associated with a poor outcome following renovascular injuries include blunt trauma, the presence of a grade V injury, and an attempted arterial repair. Patients with blunt major vascular injuries (grade V) are likely to have associated major parenchymal disruption, which contributes to the poor function of the revascularized kidney. These patients may be best served by immediate nephrectomy, provided that there is a functioning contralateral kidney.

Accelerator mass spectrometry of 63Ni at the Munich Tandem Laboratory for estimating fast neutron fluences from the Hiroshima atomic bomb.

After the release of the present dosimetry system DS86 in 1987, measurements have shown that DS86 may substantially underestimate thermal neutron fluences at large distances (>1,000 m) from the hypocenter in Hiroshima. This discrepancy casts doubts on the DS86 neutron source term and, consequently, the survivors' estimated neutron doses. However, the doses were caused mainly by fast neutrons. To determine retrospectively fast neutron fluences in Hiroshima, the reaction 63Cu(n, p)63Ni can be used, if adequate copper samples can be found. Measuring 63Ni (half life 100 y) in Hiroshima samples requires a very sensitive technique, such as accelerator mass spectrometry (AMS), because of the relatively small amounts of 63Ni expected (approximately 10(5)-10(6) atoms per gram of copper). Experiments performed at Lawrence Livermore National Laboratory have demonstrated in 1996 that AMS can be used to measure 63Ni in Hiroshima copper samples. Subsequently, a collaboration was established with the Technical University of Munich in view of its potential to perform more sensitive measurements of 63Ni than the Livermore facility and in the interest of interlaboratory validation. This paper presents the progress made at the Munich facility in the measurement of 63Ni by AMS. The Munich accelerator mass spectrometry facility is a combination of a high energy tandem accelerator and a detection system featuring a gas-filled magnet. It is designed for high sensitivity measurements of long-lived radioisotopes. Optimization of the ion source setup has further improved the sensitivity for 63Ni by reducing the background level of the 63Cu isobar interference by about two orders of magnitude. Current background levels correspond to a ratio of 63Ni/Ni<2x10(-14) and suggest that, with adequate copper samples, the assessment of fast neutron fluences in Hiroshima and Nagasaki is possible for ground distances of up to 1500 m, and--under favorable conditions--even beyond. To demonstrate this capability, we have measured successfully 6Ni/Ni ratios as low as (3.5 +/- 0.6) x 10(-13). The latter are, based on DS86, representative of a ratio expected from a typical Hiroshima copper sample at about 1,300-m ground range.

Complications related to the high lithotomy position during urethral reconstruction.

PURPOSE: We identified risk factors for complications of the lower extremities related to high lithotomy positioning during specific urethral reconstruction procedures in male patients. MATERIALS AND METHODS: Records from 185 open urethroplasties were evaluated for position related complications of the lower extremities (the compartmental syndrome, rhabdomyolysis, neurapraxia). Morphometric data (patient height, weight) and surgical details (duration of surgery and lithotomy positioning, types of repair and stirrups, stricture length and location) were assessed. RESULTS: In the 185 patients 18 position related complications (10%) were identified, 4 of which were severe. Univariate analysis showed length of stricture, and duration of surgery and lithotomy positioning to be statistically significant risk factors (p <0.05). Height, weight, body mass index and type of stirrups did not increase risk. Anterior end-to-end anastomosis and straightforward buccal mucosa patch grafts entailed negligible risk. Longer procedures (prostatomembranous and penile skin flap repairs) had higher complication rates (12% and 22%, respectively). Beginning penile skin flap procedures with patients in the supine position during flap harvesting followed by repositioning into high lithotomy for perineal flap transfer virtually eliminated the risk of severe complications. CONCLUSIONS: The risk of position related complications during urethral reconstruction is directly proportional to the duration of high lithotomy positioning. Procedures of less than 5 hours in duration had minimal risk. For complex flap procedures, we perform penile flap dissection with the patient supine and reposition for perineal flap transfer.

Sonographic staging of anterior urethral strictures.

PURPOSE: Although radiographic retrograde urethrography has traditionally been the gold standard for imaging the anterior urethra, sonourethrography has proved to be precise and effective for evaluating urethral strictures. We review the evolution of sonourethrography and demonstrate its practical contemporary applications. MATERIALS AND METHODS: We performed literature reviews on MEDLINE and chart reviews of our patient records from 1988 to 1998. RESULTS: Sonourethrography measures stricture length in the bulbar urethra more accurately than conventional retrograde urethrography. Spongiofibrosis is manifested sonographically by a lack of urethral distensibility during retrograde instillation of saline solution. Posterior shadowing is noted in severe posttraumatic cases. Sonographic staging before treatment of complex or reoperative anterior strictures elucidates complicating features, such as calculi, urethral hair, false passage and stent encrustation. CONCLUSIONS: Sonographic staging of anterior urethral strictures offers clinically important information that may be useful in guiding reconstructive therapy.

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.