Urogenital dysfunction after abdominoperineal resection for carcinoma of the rectum

The long-term urogenital dysfunctions in 46 of 104 surviving patients submitted to abdominoperineal resection for rectal carcinoma between 1972 and 1986 were collected and assessed. Urinary retention was present in 41 percent of the men and 35 percent of women, while incontinence was present in 10 percent of men and 29 percent of women. Impotence was reported by 59 percent of the males, all sexually active before surgery. Dyspareunia was present in 50 percent of the women in the study. The possibility of treating prostatic hypertrophy concurrently with abdominoperineal resection in selected cases to avoid urinary retention is discussed. The limited number of responders to the survey may interfere with the global statistical significance.

Initial management of trauma. The next 60 minutes

If and when hemodynamic stability has been achieved in a trauma patient, a detailed physical examination and appropriate diagnostic studies are performed. The successful management of trauma demands that immediately life-threatening problems receive top priority and that patients be continuously reexamined and problems reprioritized as conditions change. Finally, it is imperative that appropriate surgical evaluation and treatment be undertaken as soon as possible. Trauma patients should not be allowed to languish or undergo extensive examination in a hospital lacking surgical or other specialists trained to treat the problems identified. Transfer to another facility, whether for specialized diagnostic tests or for evaluation and treatment by surgical specialists, should be accomplished as quickly as possible.

[Results of the West German multicenter study "Urological traumatology"]

The West German Multicenter Study on Urological Traumatology ran from April 1984 to December 1986. During this time, 19 departments of urology evenly scattered over the Federal Republic of Germany including Berlin (West) recorded and evaluated the data pertaining to a total of 385 patients (83% male, 17% female) with urogenital trauma. The distribution of the different mechanisms of injury demonstrates that 41% were due to traffic accidents; 13% each to accidents during sports and work; 8% to sexual activities; and 6% to violence. The trauma was slight in 40% of the cases, moderate in 21%, and severe in 39%. Of a total of 427 urogenital injuries, 27% were combined with intra-abdominal and 24% with pelvic injuries. Renal injuries were recorded in 51%, ruptures accounting for 49% of these and contusions for 48%. Hilar lesions were observed in 7%, with complete destruction of the organ occurred in 6% of these cases. In all, 76% of these traumas were treated conservatively, while 8% each required surgical reconstruction and nephrectomy. Traumatic lesions of the urinary bladder, urethra, penis, and scrotum including the testes and accessory organs were recorded in about 10% each. Macrohematuria was seen with 73% of renal, 83% of urinary bladder, and 73% or urethral injuries. Microhematuria occurred with 24%, 9%, and 13% of all cases, while no hematuria was ascertained in 3%, 5%, and 13% of renal, bladder and urethral traumas, respectively. The injury-related sensitivity of the different imaging methods was calculated at 95% for cystograms, 91% for retrograde urethrograms, and 83% for angiograms.(ABSTRACT TRUNCATED AT 250 WORDS)

[Late sequelae after urogenital trauma. Results of follow-up studies]

In the course of the Multicenter Study on Urological Traumatology ("UMCEST"), 61 patients who had been treated at the Departments of Urology of the Ludwig Maximilian University in Munich and the Heinrich Heine University in Düsseldorf were followed up. These included 39 patients with multiple trauma and 22 patients who had suffered isolated urological injuries. There were 45 patients with renal injuries, 7 with injuries to the bladder, and 11 who had presented with urethral injuries. Late complications were detected in 38% of the 45 patients with renal injuries. Of the 11 patients with urethral injuries, 6 suffered from urethral strictures, 9 from sexual dysfunction and 3 from incontinence. The 7 patients with bladder injuries had no late complications related to the bladder trauma.

[Injuries of the urogenital system]

Ultrasonography is accepted as a valuable screening method for the detection of renal trauma, although it does not make any functional contribution. Computerized tomography has replaced excretory urography for the evaluation of blunt renal trauma, because it makes more precise diagnosis possible. Arteriography is mandatory when injuries of the renal branch are suspected. The management of renal trauma should restore normal circulation and renal function and should preserve as much functioning renal tissue as possible. For renal contusion and minor cortical lacerations, even when there is a small extravasation of urine, conservative management is sufficient, while major cortical lacerations and injuries of the renal vessels require prompt operative methods. The classification of urethral ruptures is based on rectal palpation of the prostate, distribution and size of hematomas and urethrography. A primary catheter for diagnostic purposes is strictly contraindicated. Urinary diversion proximal to the urethral lesion is the primary therapeutic procedure, while the definite management of the ruptured urethra can be postponed. Injuries to the organs of the urogenital system are rarely life threatening, and in the case of multiple trauma their management can be adapted to fit in with the treatment of injuries to other vital organs. Nevertheless, diagnosis and adequate treatment of injured urogenital organs must not be neglected as long-lasting or permanent damage could result.

[Strategy of the interdisciplinary early intervention in unstable pelvic injuries and concomitant urogenital lesions]

Among our polytrauma patients, 36.3% suffered combination injuries of the pelvic ring and the urogenital tract, and 8 of the patients with this type of lesion underwent orthopedic and urological surgery in a single session on the day of the accident. One patient died of multiple organ failure, but otherwise we did not observe any complications; in particular, no infections occurred. By an average of 11 months after the operation, all patients were continent for urine and had normal urethrocystograms. In 3 cases the pelvic ring lesion was treated by plate fixation and in a further 3 cases by plate fixation with additional temporary external fixation. Definitive stabilization was achieved in all cases by an average of 2 weeks postoperatively.

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.

Diagnostic imaging of pelvic and chest wall trauma

Imaging of patients with pelvic trauma begins with a logical approach to plain radiographs. These films reveal the probable mechanism of injury and suggest a rationale for emergent reduction. Radiographs, along with the clinical impression, suggest the likelihood of associated soft tissue injury, possibly requiring further specific radiographic studies. Significant vascular injury most often accompanies disruption of the posterior pelvic ring. Bladder and urethral trauma may be suspected in any displaced type III pelvic fracture with suggestive clinical signs. Ideally, urethrography precedes bladder catheterization. Acetabular fractures must be recognized because of their implications for future hip joint function. CT is very helpful in definitive treatment planning of pelvic (especially acetabular) fractures but may be delayed until other life-threatening injuries have been addressed. Plain radiography is also well suited to evaluation of chest wall trauma. When multiple ribs are fractured in two places, the radiologist should suggest the possibility of flail chest. Sternal fractures and multiple rib fractures, including the first three ribs, may herald life-threatening vascular or cardiac damage. To summarize, the radiologist contributes most to the care of the trauma patient by recognizing roentgen patterns of injury, knowing which are commonly accompanied by damage to critical soft tissues, and performing the indicated radiographic studies efficiently.

Urologic complications associated with pelvic fractures

Patients with a history of lower abdominal trauma need to be assessed for concomitant urologic complications. Assessment of the genitourinary tract should be performed in an orderly progression to insure complete information. This article provides an overview of the evaluation, treatment, and complications associated with the bladder and male urethral injuries most commonly associated with pelvic fractures. Nursing considerations are presented for the immediate and long-term care of this patient grouping.

Genitourinary imaging and procedures by the emergency physician

Optimal imaging of the urinary tract in the Emergency Department does not require sophisticated or rare equipment. The supervising physician must review each ExU, cystogram, or RUG film as it becomes available and decide upon the proper course of action. Indications for contrast studies in injured patients continue to evolve, with a trend away from investigation of stable patients with microscopic hematuria on the first urine. Urethral catheterization and suprapubic cystostomy are complementary options for bladder drainage. Careful attention to details of anatomy and technique allow for success in the majority of patients. There are substantial pitfalls in the diagnosis and treatment of male genital emergencies. The acute treatment of priapism is rapidly changing as understanding of penile physiology becomes more complete. Acute scrotal pathology can be difficult to categorize without surgical exploration. Urologic consultation, therefore, is mandatory in these conditions.

[Mesorectal resection in oncologic surgery]

A surgical technique to "en bloc" resect the mesorectum while performing an anterior resection is here described. The procedure aims at preserving those nerves whose injury is responsible for a series of neurological sequalae, which affect the patient's quality of life. Fifteen dissections were carried out in order to demonstrate the possibility to perform an accurate mesorectal lymphadenectomy while preserving, in most cases, the nervi erigentes and, in some cases, the hypogastric plexus.

Displacements, malpositions, and miscellaneous injuries of the mare's urogenital tract

Although they are pivotal events in the continued production of new generations of horses, breeding and foaling are not without risk to the mare. This article reviews the accidents that can occur and result in injury, displacement, and malpositions of the urogenital tract of the mare.

Malpractice claims for urogenital injuries

Precise information regarding patient injuries, claims and compensation in medical malpractice cases is scarce. This dearth is especially evident among cases citing injury to the genitourinary system. In an effort to explore the topic of iatrogenic urogenital damage 3,454 malpractice claims were reviewed and an analysis of 122 cases involving urogenital injury is presented. The 2 types of claims that predominated were negligent surgery, and failure to diagnose and treat urogenital disease. Nonurological practitioners were the focus of allegations of negligence in two-thirds of each type of claim. Certain surgical procedures and clinical shortcomings in a wide range of specialties were identified as being prevalent causes of malpractice claims for urogenital injuries. The correlation between money paid to claimants and specific types of injury also was examined. Suggestions are offered regarding ways to reduce the risk of malpractice liability.

Chitosan: effects on wound healing in urogenital tissue: preliminary report

We conducted a survey of the effect of chitosan on wounds of the genitourinary system in dogs. Wounds were made in the kidney, ureter and penile foreskin. Chitosan caused no adverse effects on urogenital wound healing. A decrease in fibrosis was seen in the wounds treated with chitosan in all tissues studied. These observations suggest that the morbidity of urogenital surgery may be decreased by treating the wounds with chitosan.

Emergency management of urologic trauma

Emergency management of urologic trauma can be expeditiously transected by reliance upon radiographic information and awareness of emergency priorities. Attention can be confidently focused on the area of maximal injury (upper versus lower urinary tract), and definitive or temporizing measures instituted according to circumstances. Although specialty management is ultimately required, diagnostic and therapeutic efforts initiated by emergency personnel are important to efficient appraisal and disposition.

Genitourinary emergencies: a prehospital perspective

Genitourinary emergencies present unique assessment and treatment challenges in the prehospital setting. Common chief complaints and patient presentations are listed in Table 3. Serious cases may involve hypovolemia, shock, severe pain, infection, or autonomic hyperreflexia. Prehospital management should focus on maintaining an adequate cardiovascular status, preventing excessive blood loss, relieving urinary retention, and alleviating pain. With these priorities in mind, prehospital treatment should have as its goals to treat pain, to reduce fear, and to minimize the complications of genitourinary emergencies.

Retroperitoneal injuries: pitfalls in diagnosis and management

Retroperitoneal injury caused by penetrating trauma or associated with progressive shock following blunt trauma is usually recognized promptly and managed appropriately. Isolated retroperitoneal injury from blunt trauma, unless accompanied by major hemorrhage or gross hematuria, is often difficult to diagnose and needed treatment may be delayed. Although clinical examination remains the cornerstone of diagnosis, the high incidence of ethanol abuse and/or concurrent head injury in trauma patients has led to increased use of computed tomography in the diagnosis of abdominal trauma. To determine the effect, if any, of CT examination on the diagnosis and management of retroperitoneal trauma, we reviewed our patient experience. During the 16-month period ending in April 1986, 135 patients sustained 177 retroperitoneal injuries (116 by blunt and 19 by penetrating trauma). There were 26 deaths (19% mortality). There were 90 pelvic fractures and 31 lumbar spine fractures, as well as 21 genitourinary, 12 gastrointestinal, five pancreatic, and eight major vascular injuries. Ten patients had isolated retroperitoneal hematomas. We conclude that (1) patients with retroperitoneal injuries and coexisting intraperitoneal injuries should have early operation; (2) isolated retroperitoneal trauma tends to lead to observation unless CT is used as part of the early assessment; and (3) routine use of CT in patients at risk accurately defines the extent of injury and enhances clinical management.

Initial management and evaluation of the multisystem injured patient, Part 2

Trauma is the fourth leading cause of death for all Americans, with a mortality rate of 61 deaths per 100,000 people. Although the definitive place for the management of major abdominal or thoracic hemorrhage, as well as neurologic or orthopedic problems, is the operating room in a tertiary care hospital, trauma is a time-related disease, and the more quickly hemorrhage is controlled and appropriate management initiated, the better the outcome.The author outlines a systematic approach to prehospital management of the trauma patient that includes a primary survey and a secondary survey. The primary survey (Part 1) focuses on life-threatening conditions that affect the airway and methods to clear the airway immediately. Once the airway is cleared, any anatomical or physiologic compromise that limits ventilation is identified and corrected, hemorrhage is controlled, and the cervical spine, if injury is suspected, is protected. The secondary survey (Part 2) is a comprehensive examination.

Deaths from urologic injury due to external trauma

The priority for treatment of a urologic injury in multiple injured patients from external trauma should be determined by the frequency of death from the urologic injury. The medical records of 2,058 patients with urologic injury from external trauma including 214 deaths were reviewed. Four deaths were attributed mainly to the urologic injury; one early in the postinjury period from continued severe hemorrhage from a ruptured kidney managed conservatively and three 6 to 8 weeks after injury from sepsis with a pelvic abscess from a ruptured urethra or bladder. The remaining 210 deaths were attributed to the associated injuries and occurred in the more severely injured older patients compared to the survivors. Death in multiple injured patients was rarely due to the urologic injury.