Search

Purpose: We propose a simple, anatomically based classification of blunt urethral injury as a replacement for currently used classifications, which are not comprehensive, anatomically inconsistent or based on a mixed anatomical/mechanistic formula. The latter are difficult to learn and use, and have not been universally adopted., Materials and Methods: We reviewed most of the currently used general uroradiological, emergency radiological and urological textbooks to define the classification of urethral injuries that is most widely accepted. Most authors use the Colapinto and McCallum classification, modifications thereof or the older surgical classification of urethral injuries, which simply divides such injuries anatomically into anterior and posterior. However, there is little consensus about the best classification and none includes all of the blunt injuries of the urethra. To correct these difficulties we devised a comprehensive and anatomically consistent classification., Results: The proposed classification categorizes blunt urethral trauma as I-posterior urethra intact but stretched (Colapinto and McCallum type I), II-partial or complete pure posterior injury with tear of membranous urethra above the urogenital diaphragm (Colapinto and McCallum type II), III-partial or complete combined anterior/posterior urethral injury with disruption of the urogenital diaphragm (Colapinto and McCallum type III), IV-bladder neck injury with extension into the urethra, IVA-injury of the base of the bladder with periurethral extravasation simulating a true type IV urethral injury and V-partial or complete pure anterior urethral injury., Conclusions: The proposed classification is anatomically valid and includes all of the common types of blunt urethral injuries. Universal adoption of this system should permit comparison of various management/treatment modalities at various institutions.

We treated 27 patients with iatrogenic ureteral injuries during a 6-year period. Gynecological operations were the most common antecedent surgical procedures (52 per cent). The diagnosis of ureteral injury was made immediately in 4 patients and was delayed 1 to 34 days in 23. Three of the 4 injuries recognized during an operation were repaired successfully at the time of injury; the primary repair in the remaining patient leaked and ultimately resulted in a nephrectomy. In the delayed diagnosis group retrograde ureteral catheterization was successful in only 1 of 20 attempts. Of the 23 patients with injuries recognized in the postoperative period 11 were managed successfully with percutaneous nephrostomy (with or without stenting) alone, 3 required surgical repair after temporary percutaneous nephrostomy drainage, 4 were treated surgically without prior nephrostomy drainage and 1 had spontaneous resolution of hydronephrosis. The remaining 3 patients required nephrectomy: 1 because of a urinary fistula in a previously irradiated field, 1 because of a concomitant (ipsilateral) renal cell carcinoma and 1 because of renal hypertension. Percutaneous nephrostomy or ureteral stenting was successful as primary therapy in 73 per cent of the patients in whom it was used.

The use of percutaneous endourological techniques is demonstrated in recipients of renal allografts. Transplant complications that previously had required prompt surgical intervention may be approached safely by the judicious use of percutaneous manipulations. While examples of perirenal hematoma, renal abscess, urinary fistula and renal pelvic stone extraction are presented, close patient observation and a low threshold for surgical intervention are recommended to permit the continued, safe evaluation of this approach.

During the last 7 years we have managed more than 100 cases of bladder rupture, the majority owing to blunt trauma. Of these ruptures 62 were extraperitoneal, including 59 (95 per cent) with associated pelvic fractures. Twelve patients had an associated urethral injury and 5 had a concomitant intraperitoneal bladder rupture. Complex injuries with extravasation outside the confines of the perivesical space were noted in 42 per cent of the patients. Extravasation extended into the scrotum, thigh, anterior abdominal wall and penis, and through the obturator foramen. The 41 patients who were treated with catheter drainage alone did well.

During a 4-year 9-month interval 51 patients were seen with ruptured bladders. Of these patients 42 had suffered blunt trauma: 19 intraperitoneal, 22 extraperitoneal and 1 combined intraperitoneal and extraperitoneal injury. All patients with intraperitoneal injuries, 5 with extraperitoneal injuries and the 1 with combined injury were treated successfully by exploration, débridement, formal closure and catheter drainage. Of the patients with extraperitoneal injuries 16 were treated successfully by catheter drainage alone.

We report 3 cases of extraperitoneal bladder rupture in the absence of pelvic girdle disruption. The existence of this injury suggests that a mechanism other than that classically described for an extraperitoneal rupture is present. An etiology analogous to an intraperitoneal bladder rupture is proposed. It is suggested that in some patients this alternative mechanism is responsible for the bladder injury even in the presence of a coexisting pelvic fracture.

We report 4 cases of acute focal bacterial nephritis, a solid inflammatory lesion of the kidney. In each patient the findings on excretory urography, when combined with the clinical features, suggested the possibility of a renal abscess. Ultrasonography and computerized tomography aid in distinguishing this solid inflammatory process from that of frank abscess. The possible etiology of acute focal bacterial nephritis, its evolution to abscess formation and its distinguishing features are discussed.

Digital subtraction angiography was used in 10 renal allograft recipients with sustained hypertension after transplantation to detect transplant renal artery stenosis. Recipients with end-to-end vascular anastomoses were visualized adequately in the anteroposterior projection. Two cases of transplant renal artery stenosis were identified by digital subtraction angiography and then verified by catheter angiography. Patients with end-to-side vascular anastomoses may require additional oblique projections. Digital subtraction angiography is a safe, noninvasive and cost-effective screening procedure to diagnose transplant renal artery stenosis in most recipients. Catheter angiography can be applied more selectively to those recipients with stenosis observed by digital subtraction angiography or when more detailed imaging is required.