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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%) (p0.0001). 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.

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 ...

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.

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 complication...

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 onl...

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. Prostate 37:140–148, 1998. © 1998 Wiley-Liss, Inc.

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.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.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.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.

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.

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.

Purpose: We determine whether pediatric 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

Purpose: We determined whether nonoperative treatment of major renal lacerations with urinary extravasation adversely affects patient outcome.Materials and Methods: We reviewed all nonoperatively treated patients who presented between 1983 and 1994 with blunt renal trauma with major lacerations on initial staging computerized tomography. Patients with major lacerations associated with (31) and without (15) extravasation were compared for complications, blood transfusions and length of hospital stay.Results: Urinary extravasation spontaneously resolved in 27 of 31 patients (87.1%), while 4 (12.9%) required a ureteral stent for persistent extravasation. No complications occurred in patients without extravasation. Mean hospitalization was 8.3 and 7.7 days for patients with isolated renal injuries with and without extravasation, respectively. Blood transfusions were required in 4 patients with and none without extravasation.Conclusions: Nonoperative treatment of major renal lacerations with urinary ex...

Five patients with major (Grade IV) renal trauma required ureteral stent placement to facilitate urinary drainage. Three of these patients had stents placed for recurrent gross hematuria with flank pain. All three had obstructing blood clots present at the time of stent placement. The fourth patient had a stent placed because of persistent extravasation at 2 weeks postinjury. The last patient was considered at risk for persistent urinary extravasation because of a partial ureteropelvic junction obstruction and had a ureteral stent placed as part of the initial management. All patients were followed radiographically for resolution of extravasation. Long-term clinical follow-up consisted of serum creatinine evaluation and blood pressure monitoring. Urinary extravasation resolved in all five patients, as determined by radiologic evaluation, at a mean of 8 days after stent placement. Ureteral stents were left indwelling an average of 4 weeks. No patient developed hypertension, and all serum creatinine values were normal at a mean 26 months' follow-up. No patient developed urinoma or abscess, and none required open surgical exploration. Ureteral stents may be used safely and effectively to treat persistent or recurrent urinary extravasation resulting from major blunt renal trauma in appropriately selected patients. In addition, ureteral stents may avoid the need for surgical exploration in patients with Grade IV renal trauma who develop recurrent gross hematuria, flank pain, and persistent or recurrent extravasation secondary to clot obstruction.

A retrospective review of 20 ureterovaginal fistulas in 19 patients treated within the last 20 years was done. All fistulas developed after gynecological procedures. The ureterovaginal fistulas resolved in all 7 patients in whom a self-retaining internal stent was placed in either a retrograde (5) or antegrade (2) manner for a minimum of 4 to 8 weeks. In contrast to the literature, it is concluded that modern endourological treatment will result in resolution of a ureterovaginal fistula if passage of a suitable internal stent is feasible. Every effort should be made to treat a ureterovaginal fistula endourologically rather than resort to an open operation. Keu WORDS: ureter, wounds and injuries, fistula, endoscopy Ureterovaginal fistulas are a serious sequela of unrecognized ureteral injuries. Obstetrical and gynecological operations are responsible for producing the majority of ureterovaginal fistulas and the risk of a fistula is noted to be greater following radiation therapy. 1-5 Open repair of ureterovaginal fistulas has been advocated because of the development of stenosis and stricture formation in a large percentage of these injured ureter^.^.^ Traditionally, most ureterovaginal fistulas have been repaired by ureteroneo~ystostomy.~ However, with the development of newer endourological techniques, there is an increasing likelihood that these complicated ureteral injuries may be treated with less invasive endourological methods. Recently, we successfully treated a number of patients with ureterovaginal fistulas via endourological procedures. We reviewed our experience to determine the merits of endourology in the management of ureterovaginal fistula. MATERIALS AND METHODS From 1972 to 1992 we treated 20 ureterovaginal fistulas in 19 women at our hospitals. The records and radiographic studies of these women were retrospectively reviewed to determine if there is a role for endourology in the management of ureterovaginal fistula. Newer, more aggressive endourological techniques were introduced in the early 1980s. RESULTS

Five patients with complete posterior urethral obliteration (less than 3cm.) underwent endoscopic reconstitution of the urethra followed by planned direct vision internal urethrotomy and temporary self-dilation. Of these patients 3 complied with the treatment regimen and are currently free of voiding complaints (average followup 31 months), while 2 failed to perform self-dilation and required repeat internal urethrotomy. Of the latter 2 patients 1 then performed self-dilation and has a stable urethra (followup 2 years). The youngest patient refused to perform self-dilation and underwent successful perineal urethroplasty. Major complications did not occur. The treatment regimen as described is a suitable alternative to surgical urethroplasty in select patients with short urethral defects (less than 3cm.) who are willing to perform temporary urethral self-dilation.

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 sys...

Traumatic urethrocavernous communications may develop as an acute or late complication after blunt penile trauma, usually associated with penile fracture.l.2 In approximately a third of penile fractures an associated urethral injury results in urethrocorporeal communication. Urethrocavernous fistula as a late sequela of penile or perineal trauma without penile fracture has rarely been reported. Successful treatment depends on fistula size. Small fistulas appear to resolve with conservative management, while larger fistulas may require surgical repair. We report a case in which a urethrocavernous fistula secondary to blunt penile trauma with no associated penile fracture was successfully treated with oral digoxin therapy. CASE REPORT A 17-year-old man received a direct blow to the penis and pelvis with a soccer ball. Several days after the injury he noticed bleeding from the urethra only during erections. He was not sexually active and spontaneous erections were normal before the injury. The fistula did not heal spontaneously. Hematuria persisted despite oral antibiotic therapy given anecdotally due to the possibility of lower urinary tract infection and oral phenylpropanolamine given with the intention of suppressing nocturnal erections. Retrograde urethrography and cystoscopy were performed 6 weeks after the injury with the patient under general anesthesia. Urethrography showed no abnormalities and cystoscopy demonstrated a small area thought to be the source of bleeding in the bulbous urethra along the right side. This site was fulgurated with the Bugbee electrode but bleeding with erections persisted. Penile color duplex ultrasonography after injection of 20 pg. prostaglandin El revealed normal arterial flow and no fistulous process. Dynamic infusion cavernosography showed a small fistula between the corpus cavernosum and spongiosum (see figure). Digoxin therapy (0.25 mg. daily) was begun orally based on recent evidence that this drug may be associated with impotence by inhibiting va~orelaxation.~ Digoxin and serum electrolyte levels were monitored weekly. Bleeding resolved after digoxin levels became therapeutic (0.77 pg./l., therapeutic range 0.5 to 2.0). After 8 weeks of therapy bleeding ceased and repeat dynamic infusion cavernosography revealed a healed fistula. Digoxin was discontinued and there have been no further episodes of bleeding. The patient reports normal spontaneous erections. DISCUSSION Our case and that of Motiwalaz involved a urethrocavernous fistula of the penile urethra secondary to blunt penile trauma without a concomitant penile fracture. This finding is unusual. Urethrocavernous fistula as a late sequela of penile or perineal trauma without penile fracture has rarely been reported. Such fistulas are usually associated with a penile fracture. The hallmark diagnostic sign is gross hematuria with erection and diagnosis is made on retrograde urethrog

The presence of a urologic injury must be considered in all patients with pelvic fracture. Uroradiographic evaluation starting with retrograde urethrography is indicated in all male patients with concomitant gross hematuria, bloody urethral discharge, scrotal or perineal ecchymosis, a nonpalpable prostate on rectal examination, or an inability to urinate. If the urethra is normal, a catheter may be passed, and in the presence of gross hematuria, a cystogram must be performed. Female patients rarely suffer urethral lacerations. The urethra is examined, and a Foley catheter may be passed without a urethrogram. The immediate management of associated urologic injuries continues to evolve and evoke controversy. Selected cases of extraperitoneal bladder perforation may be safely managed solely by catheter drainage. Intraperitoneal perforations require surgical exploration and repair. Urethral disruption (partial or complete) may be safely managed by primary cystostomy drainage with management of potential complications (stricture, impotence, incontinence) in 4 to 6 months.

Synergistic necrotizing fasciitis of the penis and scrotum was described first by Fournier and remains a rare but life-threatening disease. In Fournier's initial description the process was believed to be idiopathic. During the last 10 years we have treated 20 patients with Fournier's gangrene and a definite urologic or colorectal cause could be identified as the source of the infection in 19 (95 per cent). Despite the use of broad-spectrum antibiotics and aggressive surgical débridement the mortality rate was 45 per cent.

Cutaneous pancreatic fistula is a rare but potential complication of left renal surgery. Two cases form the basis of this report.

A total of 5 traumatic quadriplegic patients underwent 10 extracorporeal shock wave lithotripsy treatments with either a local (bupivacaine 0.25 per cent) field block or no anesthesia. Significant intraoperative hypertension as determined by the anesthesiologist occurred in 2 patients and responded to intravenous hydralazine. The complete clinical syndrome of autonomic dysreflexia did not occur. Three patients are free of stones and 2 have insignificant residual caliceal fragments. Extracorporeal shock wave lithotripsy may be performed safely in traumatic quadriplegic patients without the added risk of general or regional anesthesia. It is recommended that during therapy these patients should be monitored closely by an anesthesiologist for the signs and symptoms of autonomic dysreflexia.