An in-house coordinator program to increase organ donation in public trauma hospitals.

A 4-year retrospective study was conducted regarding the donor potential, consent rates, and organ recovery at a large 500-bed public trauma hospital. An independent organ procurement organization hired two in-house coordinators, one white and one black, to work exclusively in the hospital. The duties of the in-house coordinators included the following: working with nurses, physicians, and residents to identify donors; closely managing and coordinating the consent process; and assisting organ procurement coordinators in donor management. Following the program's implementation and the use of race-specific requesters, a 64% increase in consent rate resulted along with an overall increase of 94% in the number of organ donors. The consent rate of blacks increase 115%, whereas the number of black organ donors increased 154%. The Hispanic consent rate increased 48% with a corresponding increase of 83% in the number of Hispanic organ donors. In addition, the white consent rate increased from 55% (the 3-year average from 1993 to 1995) to 75% in 1996, resulting in a 36% increase following the implementation of the program. The investment of dedicated race-sensitive personnel in large urban county trauma facilities can result in a significant increase in donor conversion rates.

The Baylor College of Medicine experience with gold seed implantation.

Advances in imaging technology and implant technique have led to the resurgent interest and practice of brachytherapy for the treatment of prostate cancer. Brachytherapy is a form of radiation treatment in which radioactive sources are placed directly into the tumor; it offers the advantage of maximizing the radiation dose delivered to the tumor while sparing the adjacent normal tissue. Permanent implants have become an important component of radiation delivery. Interstitial gold radioisotope (Au-198) implants for prostate cancer were introduced at Baylor College of Medicine in 1965. The rationale for using Au-198, instead of the two most commonly used radioisotopes, Palladium-103 (Pd-103) and Iodine-125 (I-125), is discussed, and the Baylor implant technique is compared to that used in other centers. Retrospective review divides the patient population into pre-ultrasound versus post-ultrasound eras. Dosimetric calculation and disease control with the Au-198 seed implant for prostatic cancer are reviewed for the two different eras; toxicity is evaluated in the post-ultrasound era only. In the pre-ultrasound era, 510 patients were treated with pelvic lymph node sampling and gold seed insertion of the prostate followed by external beam radiation. In the post-ultrasound era, 54 patients were treated definitively with ultrasound-guided transperineal Au-198 implant followed by external beam irradiation. A small group of 30 patients in the post-ultrasound era were evaluated for the efficacy of Au-198 re-implantation for locally recurrent disease.

Concurrence of de novo membranous glomerulonephritis and recurrent IgA nephropathy in a renal allograft.

Recurrent IgA nephropathy is commonly reported in renal transplant. De novo membranous glomerulonephritis is the most frequent type of glomerulonephritis seen in renal transplant. Nevertheless, to the best of our knowledge, the association of these two conditions in a single patient has never been documented. We wish to report one such case.

Genitourinary emergencies.

An awareness of pitfalls and perils in diagnosis of traumatic injuries to the genitourinary tract, and indications and contraindications for studies and instrumentation, will help diagnose these sometimes underdiagnosed injuries and help minimize morbidity. Suspicion of testicular torsion should lead to prompt urologic consultation, and priapism also should be promptly treated to preserve function. The treatment of acute urinary retention consists of prompt bladder drainage with attention to etiology and methods.

Ureteral injury.

The management of ureteral injuries resulting from external violence or surgery is usually straightforward and is primarily a problem of recognition and development of a treatment plan that allows either repair of the injury away from the site of pathology or conservative drainage and diversion. However, decisions as to the proper therapy can be complicated by legal, economic, and emotional considerations, which make management of these patients difficult. In the last 5 years, endoscopic manipulation of the ureter for the treatment of stones and stricture has become commonplace. Perforation of the ureter occurs in as many as 20 per cent of cases. Sequelae from these inadvertent injuries are rare, particularly if the injury is managed by proximal diversion with percutaneous nephrostomy and placement of a ureteral stent. Three to ten days of drainage is usually all that is required to heal these injuries. The ureter, of course, may also be avulsed during the course of basket extraction of stone, and open operative correction would then be required. The ureter is a delicate structure. To paraphrase a famous patriot, force in the cause of ureteral stone extraction or ureteral catheterization is a vice!

Etiology, classification, and management of renal trauma.

Management of blunt renal trauma demands an aggressive effort to define the extent and severity of the renal injury with imaging studies. In general, a conservative approach to treatment is recommended that may include an early surgical exploration when the risk of late hemorrhage is great and the kidney or a portion of the kidney has obviously already been lost. To treat all patients with surgery or with expectant treatment is illogical. If expectant treatment is elected and the patient has a significant renal injury, every effort should be made to follow the patient adequately with ultrasound or CT scans in order to identify at the earliest opportunity an expanding hematoma and prevent needless nephrectomy and shock. Of most importance is to avoid inadequate studies that fail to define the source of injury and lead in the long run to inadequate surgical management. A tongue-in-cheek representation of such a scheme of treatment is illustrated in Figure 5.

Operative injury to the lower urinary tract.

Operative injury to the lower urinary tract is extremely common. Most of these injuries occur during the course of gynecologic surgery and involve the bladder. Urethral injury is most commonly found following urethral diverticulectomy or with urologic endoscopic procedures. Correction of specific injuries to the bladder and urethra are discussed.

Intrarenal abscess. Report of 14 cases.

Six of 14 patients with renal abscess had prior history of urinary tract infection; initial symptoms included fever and flank pain in 12. A drip-infusion intravenous pyelogram was the most sensitive radiologic test, but selective renal arteriography was most specific. Urine cultures were positive in all 14 patients; blood cultures were positive in nine. Six patients were treated with antibiotics alone and eight required surgery. Of the eight, five had pus-filled cavities, one had multiple stones, one had a renal infarct, and one had a resolving abscess. Of six treated with antibiotics alone, one died of unrelated complications and five have demonstrated no pathological renal condition after three to six years.

The use of microfibrillar collagen hemostat for control of renal bleeding.

Microfibrillar collagen hemostat was used in 23 patients with renal injuries owing to multiple causes in an attempt to control small vessel bleeding from raw renal surface areas. Minimal complications have occurred with the use of this substance. Control of bleeding has been prompt and no late bleeding has occurred.

Penetrating renal injuries and the management of renal pedicle injury.

Injury to the upper urinary tract from penetrating trauma frequently is associated with injury to other abdominal organs. Management of the renal injury requires knowledge of the effect of injury of these other organs on the renal repair. Frequently the associated injury may dictate a need for nephrectomy when a complicated procedure would be necessary for repair of the kidney, but one should always keep in mind the high incidence of acute renal failure found in penetrating abdominal injuries and make a maximum effort to converse renal parenchyma in these patients. If renal repair is attempted, watertight repair of the renal collecting system, adequate debridement of injured renal tissue, accurate assessment of the presence or absence of blast effect, meticulous hemostasis, and adequate drainage are imperative.

Radiotherapy in the management of stage C carcinoma of the prostate.

A small number of patients with limited stage C carcinoma of the prostate have been treated with combined interstitial and external beam radiotherapy with gratifying results. Whereas more patients will have to be followed for at least 10 to 15 years to completely evaluate this modality of treatment, the results continue to encourage us in its use.

Radiotherapy in the management of stage C carcinoma of the prostate.

A small number of patients with limited stage C carcinoma of the prostate have been treated with combined interstitial and external beam radiotherapy with gratifying results. Whereas more patients will have to be followed for at least 10 to 15 years to completely evaluate this modality of treatment, the results continue to encourage us in its use.