The impracticality of MRI for the diagnosis of atypical penile fracture in the emergency setting.

We report the case of a patient who presented to the emergency department with a history suspicious for penile fracture without typical physical exam findings. A small penile fracture was present on MRI, but the diagnosis was missed, and surgery was withheld owing to this misinformation. Despite its technical accuracy, MRI may be impractical for the diagnosis of penile fracture in the emergency setting.

Symptomatic nephrolithiasis in prolonged survivors of Duchenne muscular dystrophy.

In this study, we describe the association between Duchenne muscular dystrophy (DMD) and symptomatic nephrolithiasis. The DMD patients were matched to non-ambulatory control patients with non-DMD neurological diagnoses via retrospective chart review. All patients with DMD and symptomatic nephrolithiasis were over 20 years old. We found that six of the 29 at-risk DMD patients had nephrolithiasis (20.7%) while only one of the 68 control patients had nephrolithiasis (1.5%) (p<0.0001). Controlling for duration of immobilization with stratified analysis, the risk ratio for nephrolithiasis among DMD patients compared with controls was 9.94. Using rate-based estimates of renal stone development per 10,000 patient-years, the ratio of stone development among DMD patients compared with controls was 18.5. On logistic regression analysis, the corrected odds ratio for nephrolithiasis comparing DMD patients to controls was 14.26. We conclude that, in our study group, DMD was an independent risk factor for symptomatic nephrolithiasis.

Removal of retained Foley catheter in bladder with novel use of ureteral catheter: lasso technique.

Numerous and varied foreign bodies have been described in the lower urinary tract. Techniques previously used to remove these objects have included open and endoscopic removal. We present a novel endoscopic technique using a ureteral catheter as a lasso to remove a retained foreign body, in this case a retained Foley catheter.

Nephrolithiasis in patients with duchenne muscular dystrophy.

OBJECTIVES: To present the first series of patients with Duchenne muscular dystrophy (DMD) and nephrolithiasis. METHODS: A retrospective chart review was done to identify patients with DMD who were referred for urologic consultation because of nephrolithiasis from June 2004 to April 2006. RESULTS: Four patients were identified with DMD and nephrolithiasis. Of the 4 patients, 2 underwent treatment, and their stones were obtained for analysis. The other 2 patients had stones diagnosed by computed tomography. Their stones were passed but not retrieved. Stone analysis for the available patients revealed a mixed calcareous composition. All 4 patients had had a relatively small stone burden. The patients ranged in age from 18 to 31 years. CONCLUSIONS: Stone disease appears to have many of the same characteristics in patients with DMD as it does in the general population. Risk factors, including immobilization and corticosteroid use, are present. Additional studies are needed before conclusions can be made regarding the associations between DMD and nephrolithiasis.

Current recommendations for imaging in the management of urologic traumas.

Three percent to 10% of trauma patients have genitourinary tract injuries. Radiologic imaging is essential for making the correct diagnosis and managing it appropriately. Which modality is appropriate is based on the mechanism of injury and patient presentation. Patients with pelvic injuries and gross hematuria should undergo either CT cystography or conventional cystography. Ultrasound is warranted in patients with scrotal trauma when physical exam is inconclusive. Patients with penetrating trauma to the external genitalia, who suffer blunt trauma to the penis, or who present with gross hematuria, blood at the meatus, inability to void, perineal/scrotal ecchymosis, or abnormal digital rectal exam should undergo retrograde urethrography. Using these criteria for imaging should lead to the proper diagnosis and minimize patient morbidity.

Sports participation and high grade renal injuries in children.

PURPOSE: The risk of major renal injury resulting from various forms of sports participation is unknown. Urologists often recommend that children with a solitary kidney avoid contact sports. We reviewed our recent experience with pediatric renal trauma to determine if there is an association between different types of sports activity and high grade renal injury. MATERIALS AND METHODS: We retrospectively reviewed the medical records of 68 consecutive children with blunt renal injury who were treated at 2 level I trauma centers. Injuries were graded using the renal injury scale of the American Association for the Surgery of Trauma. Records were reviewed for mechanism of injury, associated injuries, management and injury severity score. Statistical analysis was performed using Fisher's exact test or Wilcoxon rank sum test. RESULTS: Of the 68 renal lesions 13 were grade I, 15 grade II, 15 grade III, 17 grade IV and 8 grade V. The most common cause of renal trauma was motor vehicle accidents, accounting for 21 injuries (30.1%). Accidents associated with nonmotorized sports activity accounted for 14 injuries (20.6%). Bicycle riding was the most common sports etiology, accounting for 8 of 14 cases (57.1%) at an age range of 5 to 15 years (mean 9.4). None of the bicycle injuries involved collision with a motor vehicle. Bicycling accounted for 1 grade I, 1 grade II, 1 grade III, 2 grade IV and 3 grade V injuries. Football, hockey and sledding were responsible for the remaining 6 sports related injuries. High grade renal injury (grade IV or V) was identified in 5 of 8 bicycle accidents (62.5%) and 1 of 6 nonbicycle sports related injuries (16.7%, p = 0.14). Injury severity scores ranged from 4 to 50 (mean 20.6) for bicycle renal injuries and 4 to 13 (mean 6.7) for nonbicycle sports related trauma (p <0.05). Parents indicated that blunt trauma from the handlebars was the major factor contributing to renal injury in 3 bicycle cases. Renal trauma from bicycle riding resulted in 1 nephrectomy. CONCLUSIONS: Bicycle riding is the most common sports related cause of renal injury in children and is associated with a significant risk of major renal injury. Families of children with a solitary kidney should be aware of this risk factor. Team contact sports are an uncommon cause of high grade renal injury. Current recommendations regarding sports participation by children with a solitary kidney need to be reevaluated.

Radioimmunoguided imaging of prostate cancer foci with histopathological correlation.

PURPOSE: We have previously presented a technique that fuses ProstaScint and pelvic CT images for the purpose of designing brachytherapy that targets areas at high risk for treatment failure. We now correlate areas of increased intensity seen on ProstaScint-CT fusion images to biopsy results in a series of 7 patients to evaluate the accuracy of this technique in localizing intraprostatic disease. METHODS AND MATERIALS: The 7 patients included in this study were evaluated between June 1998 and March 29, 1999 at Metrohealth Medical Center and University Hospitals of Cleveland in Cleveland, Ohio. ProstaScint and CT scans of each patient were obtained before transperineal biopsy and seed implantation. Each patient's prostate gland was biopsied at 12 separate sites determined independently of Prostascint-CT scan results. RESULTS: When correlated with biopsy results, our method yielded an overall accuracy of 80%: with a sensitivity of 79%, a specificity of 80%, a positive predictive value of 68%, and a negative predictive value of 88%. CONCLUSION: The image fusion of the pelvic CT scan and ProstaScint scan helped identify foci of adenocarcinoma within the prostate that correlated well with biopsy results. These data may be useful to escalate doses in regions containing tumor by either high-dose rate or low-dose rate brachytherapy, as well as by external beam techniques such as intensity modulated radiotherapy (IMRT).

Radiologic evaluation of pediatric blunt renal trauma in patients with microscopic hematuria.

As a result of the rapid increase in medical costs, the efficacy of diagnostic imaging is under examination, and efforts have been made to identify patients who may safely be spared radiographic imaging. We reviewed the records of children who presented to our institution with suspected blunt renal injuries to determine if radiographic evaluation is necessary in children with microscopic hematuria and blunt renal trauma. We retrospectively reviewed the medical records of 1200 children (ages less than 18 years) who sustained blunt abdominal trauma and who presented to our level I pediatric trauma center between 1995 and 1997. Urinalysis was performed in 299 patients (25%). Urinalysis results were correlated with findings on abdominal computed tomography (CT). All patients had more than three red blood cells per high power field (RBC/ hpf) or gross hematuria. Renal injuries were graded according to the injury scale defined by the American Association for the Surgery of Trauma. Sixty-five patients had microscopic hematuria. Thirty-five (54%) were evaluated with an abdominal CT scan. Three patients sustained significant renal injuries (grade II-V), and 32 patients had normal findings or renal contusions. Therefore only 3 of 65 patients (4.6%) sustained a significant renal injury. All three patients had other associated major organ injuries. Of the three patients with gross hematuria evaluated with abdominal CT, one (33%) sustained a significant renal injury and had no associated injuries. The degree of hematuria did not correlate with the grade of renal injury. Pediatric patients with blunt trauma, microscopic hematuria, and no associated injuries do not require radiologic evaluation, as significant renal injuries are unlikely. However, children who present with associated injuries and microscopic hematuria after blunt trauma may have significant renal injuries and should undergo radiologic evaluation.

Feasibility and acute toxicities of radioimmunoguided prostate brachytherapy.

PURPOSE: We present a technique that fuses pelvic CT scans and ProstaScint images to localize areas of disease within the prostate gland to customize prostate implants. Additionally, the acute toxicity results from the first 43 patients treated with this technique are reviewed. METHODS AND MATERIALS: Between 2/97 and 8/98, 43 patients with clinical stage II prostate adenocarcinoma received ultrasound-guided transperineal implantation of I-125 or Pd-103 seeds. The median patient age was 70 years (range 49-79). Prior to treatment, the median Gleason score and prostate-specific antigen (PSA) were 6 (range 3-8) and 7.5 (range 1.8-16.6 ng/mL), respectively. The median follow-up was 10 months (range 2.9-20.4 months). RESULTS: The median PSA value at 10 months is 0.7 ng/mL. Significant acute complications within the first month following implantation included 13 Grade I urinary symptoms, 24 Grade II urinary symptoms, 6 Grade III symptoms, and no Grade IV complications. Beyond 4 months, complications included 12 Grade I urinary symptoms, 17 Grade II urinary symptoms, 1 Grade III, and 1 Grade IV complications. CONCLUSIONS: The image fusion of the pelvic CT scan and ProstaScint scans helped identify regions within the prostate at high risk of local failure, which were targeted with additional seeds during implantation.

Selective nonoperative management of blunt grade 5 renal injury.

PURPOSE: We determined the feasibility of a nonoperative approach to blunt grade 5 renal injury. MATERIALS AND METHODS: We retrospectively reviewed the records of all patients with grade 5 renal injury who presented to our level 1 trauma center from 1993 to 1998. Those treated nonoperatively and surgically were assigned to groups 1 and 2, respectively. Each group was compared with respect to the initial emergency department evaluation, computerized tomography findings, associated injuries, duration of hospital stay and intensive care unit stay, transfusion requirements, complications and followup imaging. RESULTS: Of 218 renal injuries evaluated 13 were grade 5. In group 1, 6 patients were treated nonoperatively and in group 2, 7 underwent exploration. Each group had similar average hospitalization (12.0 and 12.8 days, respectively). Patients in group 1 had fewer intensive care unit days (4.3 versus 9.0), significantly lower transfusion requirements (2.7 versus 25.2 units, p = 0.0124) and fewer complications during the hospital course. Followup computerized tomography of nonoperatively managed cases revealed functioning renal parenchyma with resolution of retroperitoneal hematoma. CONCLUSIONS: Conservative management of blunt grade 5 renal injury is feasible in patients who are hemodynamically stable at presentation.

Limitations of computerized tomography in staging invasive bladder cancer before radical cystectomy.

PURPOSE: Computerized tomography (CT) of the abdomen and pelvis is often routine in the preoperative staging assessment of invasive transitional cell carcinoma of the bladder. We determine the accuracy of staging CT findings, usefulness before planned extirpative surgery and impact on surgical management of this disease. MATERIALS AND METHODS: We retrospectively reviewed the medical records, including radiographic, operative and pathological reports, of 82 consecutive cases. All patients presented with muscle invasive bladder tumors, were considered candidates for radical cystectomy and underwent preoperative staging CT of the abdomen and pelvis between July 1994 and June 1998. The ability of CT to provide additional staging information in terms of depth of tumor invasion, local extent of tumor, pelvic lymph node involvement and distant metastases was examined. We determined whether CT findings altered surgical management for individual patients. RESULTS: CT was able to discriminate depth of invasion in only 1 patient (1.2%) and correctly identified extravesical tumor spread in 4 (4.9%). Lymph node and distant metastases were accurately determined in 4 (4.9%) and 2 (2.4%) cases, respectively. The overall accuracy of CT was 54. 9%, with an under staging and over staging rate of 39.0% and 6.1%, respectively. CT provided accurate, additional staging information in only 8 cases (9.8%). Surgical management was altered in 3 cases (3.7%) and only 1 (1.2%) avoided an unnecessary operation as a result of CT findings. CONCLUSIONS: Staging CT of the abdomen and pelvis in patients with invasive bladder carcinoma has limited accuracy, mainly because of its inability to detect microscopic or small volume extravesical tumor extension and lymph node metastases. CT tends to under stage advanced disease and failed to alter surgical management in nearly all of our cases.

Penile fracture and testicular rupture.

Traumatic injuries to the penis and testicles are uncommon, likely due to the well-protected location and degree of mobility of these organs. Because of this the management of these injuries has historically been controversial. However, current literature supports immediate evaluation and surgical repair of these traumatic injuries to prevent complications such as erectile dysfunction or testicular loss. Herein the diagnostic and therapeutic options for both traumatic penile fracture and testicular rupture are reviewed with emphasis on immediate evaluation and repair.

Limitations of routine spiral computerized tomography in the evaluation of bladder trauma.

PURPOSE: We evaluate the accuracy of spiral computerized tomography (CT) in diagnosing traumatic bladder rupture. MATERIALS AND METHODS: Medical records of 24 consecutive patients diagnosed with traumatic bladder rupture at our level 1 trauma center from 1993 to 1998 were retrospectively reviewed. Of the patients 15 underwent retrograde cystography and spiral CT of the abdomen and pelvis. The results of these imaging studies were compared. RESULTS: Retrograde cystography successfully diagnosed all cases of bladder rupture and correctly classified injuries confirmed surgically. Spiral CT successfully diagnosed 9 of 15 bladder ruptures (60%), and correctly classified 4 of 5 intraperitoneal (80%) and 6 of 11 extraperitoneal (55%) ruptures. CONCLUSIONS: Spiral CT is less accurate than retrograde cystography in diagnosing traumatic bladder rupture.

Limitations of routine spiral computerized tomography in the evaluation of blunt renal trauma.

PURPOSE: We have observed that injury to the renal collecting system may be missed during routine abdominal spiral computerized tomography (CT) for trauma. A definitive protocol for spiral CT has been established to identify all cases of renal collecting system injury. MATERIALS AND METHODS: A retrospective review of 35 consecutive cases of blunt renal trauma evaluated with spiral CT between 1994 and 1997 at our Level I trauma center was performed. Each patient received 100 cc intravenous contrast at 2 cc per second. There was a 60-second delay after the start of contrast infusion before scanning was initiated. RESULTS: Of the 35 cases 3 (8.6%) injuries to the renal collecting system were detected on delayed scans obtained after the initial CT failed to demonstrate contrast extravasation. Therefore, at our institution we have modified the protocol for spiral CT for abdominal trauma by repeating scans of the kidneys after the initial scans are completed. CONCLUSIONS: Injury to the renal collecting system may be missed during routine spiral CT, thereby incorrectly under staging renal trauma. In all cases of suspected blunt renal trauma evaluated with spiral CT repeat scans of the kidneys should be performed.

Prostate cancer and prostate bed SPECT imaging with ProstaScint: semiquantitative correlation with prostatic biopsy results.

BACKGROUND: ProstaScint (Cytogen Corporation, Princeton, NJ) murine monoclonal antibody imaging is FDA-approved for imaging of prostate cancer patients at high risk for metastatic disease and patients postprostatectomy with a rising serum prostate-specific antigen (PSA) level. ProstaScint is a murine monoclonal antibody which targets prostate-specific membrane antigen (PSMA). PSMA expression is upregulated in primary and metastatic prostate cancer. FDA Cytogen (Princeton, NJ) protocol studies using 111indium-labeled ProstaScint revealed correlation between areas of increased concentration in the prostate and biopsy-proven tumors in patients imaged pretherapy. METHODS: In our study, four transverse, single-photon emission tomography (SPECT) images were isolated and regions of interest were selected and correlated with pretherapy prostate biopsy results. Prostate cancer and normal tissue prostate/muscle background (P/M) ratios were derived, so that postprostatectomy/radiation therapy patients could be evaluated for the presence of residual prostate cancer. Twenty-three pretherapy prostate cancer patients with quadrant/sextant biopsies had SPECT 96-hr 111indium ProstaScint pelvic images. The four transverse 1-cm slices above the midline penile blood pool were chosen, and four to six 27-30-pixel regions of interest were placed over the prostate bed. The background muscle region of interest was placed over the external obturator muscle region. The P/M ratio was calculated and compared to the quadrant/sextant prostatic biopsy result. The same procedure was applied to 17 posttherapy prostate cancer patients with rising PSA. RESULTS: In the 23 pretherapy prostate cancer patients, there was a correlation between the P/M ratio of at least 3.0 in 32 of 35 prostatic cancer biopsy regions, and there was correlation with P/M ratios less than 3.0 in 82 of 89 negative biopsy regions. Seventeen posttherapy patients underwent ProstaScint studies. Six underwent biopsy, with typically one biopsy site per patient. All 6 had P/M ratios greater than 3.0 in the biopsied region. Five out of six biopsies revealed residual prostate cancer. CONCLUSIONS: A prostate/muscle ratio was developed from 111indium ProstaScint regions of interest obtained on 1-cm SPECT transverse slices through the prostate bed in 23 patients preprostatic cancer therapy. A P/M ratio above 3.0 correlated in the majority of positive cases, and a P/M ratio below 3.0 was demonstrated in negative prostatic biopsy cases. The P/M ratio of above 3.0 or below 3.0 also separated those posttherapy prostate cancer patients with rising PSA who had residual prostate carcinoma in the prostate bed.

Traumatic renal artery occlusion: a 15-year review.

BACKGROUND: To better define what constitutes appropriate treatment for traumatic renal artery occlusion, we report our 15-year experience in managing this injury. METHODS: A retrospective chart review was performed to evaluate treatment outcomes and complications of 12 patients (13 injuries) who presented to our trauma centers with renal artery occlusion secondary to blunt injury. RESULTS: Five of 12 patients underwent attempted surgical revascularization with a median warm ischemia time of 5 hours (range, 4.5-36 hours). Of these five patients, one required nephrectomy for inability to establish arterial flow, three demonstrated no function, and one had return to 9% differential function on postoperative renal scan. Seven patients did not have attempted revascularization, and none of them experienced immediate complications. Hypertension developed in three patients (43%) who required nephrectomy to control blood pressure at a mean of 5 months after injury (range, 3-7 months). Four patients remained asymptomatic and normotensive at a mean follow-up of 11 months (range, 4 weeks to 2.6 years). CONCLUSION: Surgical revascularization for traumatic renal artery occlusion seldom results in a successful outcome. Patients who are observed must have close follow-up for hypertension.

Current indications for open stone surgery in the treatment of renal and ureteral calculi.

PURPOSE: The development and advances in extracorporeal shock wave lithotripsy and endourological procedures have greatly diminished the need for open surgery in the treatment of renal and ureteral stones. We reviewed our experience with open stone surgery to determine the current indications and efficacy of this treatment modality. MATERIALS AND METHODS: Hospital and office charts, operative notes and records, and pertinent radiographic studies of all patients undergoing open stone surgery from January 1991 through December 1995 at 3 university affiliated hospitals were reviewed. Patient characteristics, stone burden, indications, surgical factors and outcomes were reviewed for each patient. RESULTS: Of 780 procedures performed for stone removal, 42 were open surgical procedures (5.4%) including pyelolithotomy in 15 (extended pyelolithotomy or pyelonephrolithotomy in 7), anatrophic nephrolithotomy in 14, ureterolithotomy in 7 and radial nephrolithotomy in 6. There were 24 men and 18 women ranging in age from 1 to 90 years (mean age 51.5). The most common indications for open surgery were complex stone burden (55%); failure of extracorporeal shock wave lithotripsy or endourological treatment (29%); anatomic abnormalities such as ureteropelvic junction obstruction, infundibular stenosis and/or renal caliceal diverticulum (24%); morbid obesity (10%) and co-morbid medical disease (7%). Mean estimated blood loss was 428 cc. Average hospital stay was 6.4 days. The stone-free rate after surgery was 93%. Five patients had minor postoperative complications that resolved with appropriate therapy. CONCLUSIONS: While most patients with renal and ureteral stones can be treated with less invasive techniques, open stone surgery continues to represent a reasonable alternative for a small segment of the urinary stone population.

Are pediatric patients more susceptible to major renal injury from blunt trauma? A comparative study.

PURPOSE: We determine whether pediatric patients are more susceptible to major renal injury than adults. MATERIALS AND METHODS: We retrospectively reviewed the medical records of 34 consecutive children 2 to 17 years old (mean age 10) and 35 consecutive adults 19 to 59 years old (mean age 32) with blunt renal trauma who presented to our 2 level I trauma centers between 1990 and 1996. Patients with incomplete charts were excluded from study. According to the organ injury scaling committee of the American Association for the Surgery of Trauma renal injuries were graded based on computerized tomography results or laparotomy findings (4 adults) with major injuries classified as grade IV or V. Vascular injuries were excluded from study. Injury severity scores were calculated using the abbreviated injury scale. RESULTS: Injury severity scores ranged from 4 to 75 (mean 16) in the pediatric and 5 to 50 (mean 22) in the adult populations (p <0.01). Overall 16 of the 34 children (47%) and 8 of the 35 adults (23%) sustained major renal injuries (p <0.04). In 4 children who required surgical exploration for hemodynamic instability injury severity score ranged from 17 to 42 (mean 26) and all had major renal injuries. In 7 of the 35 adults (20%) who underwent surgical exploration because of hemodynamic instability and/or positive diagnostic peritoneal lavage injury severity score ranged from 22 to 50 (mean 34). Three of these 7 adults (42%) had major renal injuries and all had other visceral injuries at exploration. CONCLUSIONS: Children are more likely than adults to sustain renal injury from blunt abdominal trauma.