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AL, Johnson MP, Smith C, et al. Long-term outcome in children after antenatal intervention for obstructive uropathies. Lancet. 1999;354:374-377.Gajewski JL, Johnson VV, Sandler SG, Sayegh A, Klumpp TR. A review of transfusion practice before, during, and after hematopoietic progenitor cell transplantation. Blood. 2008;112(8):3036-3047.Geiger S, Bobylev A, Schadelin S, Mayr J, Holland-Cunz S, Zimmermann P. Single-center, retrospective study of the outcome of laparoscopic inguinal herniorrhaphy in children. Medicine (Baltimore). 2007;96:e9486.Geisler DP, Jegathesan S, Parmley M, et al. Laparoscopic exploration for the clinically undetected hernia in infancy and childhood. Am J Surg. 2001;182:693-696.Geneviève D, de Pontual L, Amiel J, Sarnacki S, Lyonnet S. An overview of isolated and syndromic oesophageal atresia. Clin Genet. 2007;71:392-399.Georgeson K. Laparoscopic-assisted pull-through for Hirschsprung’s disease. Semin Pediatr Surg. 2002;11:205-210.Georgeson K. Results of
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Surgery_Schwartz. AL, Johnson MP, Smith C, et al. Long-term outcome in children after antenatal intervention for obstructive uropathies. Lancet. 1999;354:374-377.Gajewski JL, Johnson VV, Sandler SG, Sayegh A, Klumpp TR. A review of transfusion practice before, during, and after hematopoietic progenitor cell transplantation. Blood. 2008;112(8):3036-3047.Geiger S, Bobylev A, Schadelin S, Mayr J, Holland-Cunz S, Zimmermann P. Single-center, retrospective study of the outcome of laparoscopic inguinal herniorrhaphy in children. Medicine (Baltimore). 2007;96:e9486.Geisler DP, Jegathesan S, Parmley M, et al. Laparoscopic exploration for the clinically undetected hernia in infancy and childhood. Am J Surg. 2001;182:693-696.Geneviève D, de Pontual L, Amiel J, Sarnacki S, Lyonnet S. An overview of isolated and syndromic oesophageal atresia. Clin Genet. 2007;71:392-399.Georgeson K. Laparoscopic-assisted pull-through for Hirschsprung’s disease. Semin Pediatr Surg. 2002;11:205-210.Georgeson K. Results of
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and syndromic oesophageal atresia. Clin Genet. 2007;71:392-399.Georgeson K. Laparoscopic-assisted pull-through for Hirschsprung’s disease. Semin Pediatr Surg. 2002;11:205-210.Georgeson K. Results of laparoscopic antireflux procedures in neurologically normal infants and children. Semin Laparosc Surg, 2002;9(3):172-176.Georgoula C, Gardiner M. Pyloric stenosis a 100 years after Ramstedt. Arch Dis Child. 2012;97:741-745.Gollin GA, Abarbanell AA, Baerg J, et al. Peritoneal drainage as definitive management of intestinal perforation in extremely low-birth-weight infants. J Pediatr Surg. 2003;38:1814.Gorsler C, Schier F. Laparoscopic herniorrhaphy in children. Surg Endosc. 2003;17:571-573.Grant D, Abu-Elmagd K, Reyes J, et al. 2003 report of the intestine transplant registry: a new era has dawned. Ann Surg. 2005;241:607-613.Grikscheit TC, Ochoa ER, Ramsanahie A, et al. Tissueengineered large intestine resembles native colon with appropriate in vitro physiology and architecture. Ann
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Surgery_Schwartz. and syndromic oesophageal atresia. Clin Genet. 2007;71:392-399.Georgeson K. Laparoscopic-assisted pull-through for Hirschsprung’s disease. Semin Pediatr Surg. 2002;11:205-210.Georgeson K. Results of laparoscopic antireflux procedures in neurologically normal infants and children. Semin Laparosc Surg, 2002;9(3):172-176.Georgoula C, Gardiner M. Pyloric stenosis a 100 years after Ramstedt. Arch Dis Child. 2012;97:741-745.Gollin GA, Abarbanell AA, Baerg J, et al. Peritoneal drainage as definitive management of intestinal perforation in extremely low-birth-weight infants. J Pediatr Surg. 2003;38:1814.Gorsler C, Schier F. Laparoscopic herniorrhaphy in children. Surg Endosc. 2003;17:571-573.Grant D, Abu-Elmagd K, Reyes J, et al. 2003 report of the intestine transplant registry: a new era has dawned. Ann Surg. 2005;241:607-613.Grikscheit TC, Ochoa ER, Ramsanahie A, et al. Tissueengineered large intestine resembles native colon with appropriate in vitro physiology and architecture. Ann
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dawned. Ann Surg. 2005;241:607-613.Grikscheit TC, Ochoa ER, Ramsanahie A, et al. Tissueengineered large intestine resembles native colon with appropriate in vitro physiology and architecture. Ann Surg. 2003; 238:35-41.Gura KM, Lee S, Valim C, et al. Safety and efficacy of a fishoil-based fat emulsion in the treatment of parenteral nutritionassociated liver disease. Pediatrics. 2008;121:e678-e686.Guthrie S, Gordon P, Thomas V, et al. Necrotizing enterocolitis among neonates in the United States. J Perinatol. 2003;23:278.Hackam D, Caplan M. Necrotizing enterocolitis: pathophysiology from a historical context. Semin Pediatr Surg. 2018;27:11-18.Hackam DJ, Filler R, Pearl R. Enterocolitis after the surgical treatment of Hirschsprung’s disease: risk factors and financial impact. J Pediatr Surg. 1998;33:830-833.Hackam DJ, Potoka D, Meza M, et al. Utility of radiographic hepatic injury grade in predicting outcome for children after blunt abdominal trauma. J Pediatr Surg.
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Surgery_Schwartz. dawned. Ann Surg. 2005;241:607-613.Grikscheit TC, Ochoa ER, Ramsanahie A, et al. Tissueengineered large intestine resembles native colon with appropriate in vitro physiology and architecture. Ann Surg. 2003; 238:35-41.Gura KM, Lee S, Valim C, et al. Safety and efficacy of a fishoil-based fat emulsion in the treatment of parenteral nutritionassociated liver disease. Pediatrics. 2008;121:e678-e686.Guthrie S, Gordon P, Thomas V, et al. Necrotizing enterocolitis among neonates in the United States. J Perinatol. 2003;23:278.Hackam D, Caplan M. Necrotizing enterocolitis: pathophysiology from a historical context. Semin Pediatr Surg. 2018;27:11-18.Hackam DJ, Filler R, Pearl R. Enterocolitis after the surgical treatment of Hirschsprung’s disease: risk factors and financial impact. J Pediatr Surg. 1998;33:830-833.Hackam DJ, Potoka D, Meza M, et al. Utility of radiographic hepatic injury grade in predicting outcome for children after blunt abdominal trauma. J Pediatr Surg.
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J Pediatr Surg. 1998;33:830-833.Hackam DJ, Potoka D, Meza M, et al. Utility of radiographic hepatic injury grade in predicting outcome for children after blunt abdominal trauma. J Pediatr Surg. 2002;37:386-389.Hackam DJ, Reblock K, Barksdale E, et al. The influence of Down’s syndrome on the management and outcome of children with Hirschsprung’s disease. J Pediatr Surg. 2003;38:946-949.Hackam DJ, Superina R, Pearl R, et al. Single-stage repair of Hirschsprung’s disease: a comparison of 109 patients over 5 years. J Pediatr Surg. 1997;32:1028-1031.Hamner CE, Groner JI, Caniano DA, Hayes JR, Kenney BD. Blunt intraabdominal arterial injury in pediatric trauma patients: injury distribution and markers of outcome. J Pediatr Surg. 2008;43:916-923.Harnoss JC, Zelienka I, Probst P, et al. Antibiotics versus surgical therapy for uncomplicated appendicitis: systematic review and meta-analysis of controlled trials (PROSPERO 2015: CRD42015016882). Ann Surg. 2016;265:889-900.Harrison MR. Fetal
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Surgery_Schwartz. J Pediatr Surg. 1998;33:830-833.Hackam DJ, Potoka D, Meza M, et al. Utility of radiographic hepatic injury grade in predicting outcome for children after blunt abdominal trauma. J Pediatr Surg. 2002;37:386-389.Hackam DJ, Reblock K, Barksdale E, et al. The influence of Down’s syndrome on the management and outcome of children with Hirschsprung’s disease. J Pediatr Surg. 2003;38:946-949.Hackam DJ, Superina R, Pearl R, et al. Single-stage repair of Hirschsprung’s disease: a comparison of 109 patients over 5 years. J Pediatr Surg. 1997;32:1028-1031.Hamner CE, Groner JI, Caniano DA, Hayes JR, Kenney BD. Blunt intraabdominal arterial injury in pediatric trauma patients: injury distribution and markers of outcome. J Pediatr Surg. 2008;43:916-923.Harnoss JC, Zelienka I, Probst P, et al. Antibiotics versus surgical therapy for uncomplicated appendicitis: systematic review and meta-analysis of controlled trials (PROSPERO 2015: CRD42015016882). Ann Surg. 2016;265:889-900.Harrison MR. Fetal
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versus surgical therapy for uncomplicated appendicitis: systematic review and meta-analysis of controlled trials (PROSPERO 2015: CRD42015016882). Ann Surg. 2016;265:889-900.Harrison MR. Fetal surgery: trials, tribulations, and turf. J Pediatr Surg. 2003;38:275-282.Harrison MR, Keller RL, Hawgood S, et al. A randomized trial of fetal endoscopic tracheal occlusion for severe fetal congenital diaphragmatic hernia. N Engl J Med. 2003;349:1916-1924.Harrison MR, Sydorak RM, Farrell J, et al. Fetoscopic temporary tracheal occlusion for congenital diaphragmatic hernia: prelude to a randomized, controlled trial. J Pediatr Surg. 2003;38:1012-1020.Heath JK. Transcriptional networks and signaling pathways that govern vertebrate intestinal development. Curr Top Dev Biol. 2010;90:159-192.Hedrick H, Flake A, Crombleholme T, et al. History of fetal diagnosis and therapy: Children’s Hospital of Philadelphia experience. Fetal Diagn Ther. 2003;18:65-82.Hilton EN, Manson FD, Urquhart JE, et al.
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Surgery_Schwartz. versus surgical therapy for uncomplicated appendicitis: systematic review and meta-analysis of controlled trials (PROSPERO 2015: CRD42015016882). Ann Surg. 2016;265:889-900.Harrison MR. Fetal surgery: trials, tribulations, and turf. J Pediatr Surg. 2003;38:275-282.Harrison MR, Keller RL, Hawgood S, et al. A randomized trial of fetal endoscopic tracheal occlusion for severe fetal congenital diaphragmatic hernia. N Engl J Med. 2003;349:1916-1924.Harrison MR, Sydorak RM, Farrell J, et al. Fetoscopic temporary tracheal occlusion for congenital diaphragmatic hernia: prelude to a randomized, controlled trial. J Pediatr Surg. 2003;38:1012-1020.Heath JK. Transcriptional networks and signaling pathways that govern vertebrate intestinal development. Curr Top Dev Biol. 2010;90:159-192.Hedrick H, Flake A, Crombleholme T, et al. History of fetal diagnosis and therapy: Children’s Hospital of Philadelphia experience. Fetal Diagn Ther. 2003;18:65-82.Hilton EN, Manson FD, Urquhart JE, et al.
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H, Flake A, Crombleholme T, et al. History of fetal diagnosis and therapy: Children’s Hospital of Philadelphia experience. Fetal Diagn Ther. 2003;18:65-82.Hilton EN, Manson FD, Urquhart JE, et al. Left-sided embryonic expression of the BCL-6 corepressor, BCOR, is required for vertebrate laterality determination. Hum Mol Genet. 2007;16:1773-1782.Hirschl RB, Philip WF, Glick L, et al. A prospective, randomized pilot trial of perfluorocarbon-induced lung growth in newborns with congenital diaphragmatic hernia. J Pediatr Surg. 2003;38:283-289.Huh JW, Raghupathi R. New concepts in treatment of pediatric traumatic brain injury. Anesthesiol Clin. 2009;27(2):213-240.Hutchings L, Willett K. Cervical spine clearance in pediatric trauma: a review of current literature. J Trauma. 2009;67(4):687-691.Jani J, Nicolaides KH, Keller RL, et al. Observed to expected lung area to head circumference ratio in the prediction of survival in fetuses with isolated diaphragmatic hernia. Ultrasound Obstet
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Surgery_Schwartz. H, Flake A, Crombleholme T, et al. History of fetal diagnosis and therapy: Children’s Hospital of Philadelphia experience. Fetal Diagn Ther. 2003;18:65-82.Hilton EN, Manson FD, Urquhart JE, et al. Left-sided embryonic expression of the BCL-6 corepressor, BCOR, is required for vertebrate laterality determination. Hum Mol Genet. 2007;16:1773-1782.Hirschl RB, Philip WF, Glick L, et al. A prospective, randomized pilot trial of perfluorocarbon-induced lung growth in newborns with congenital diaphragmatic hernia. J Pediatr Surg. 2003;38:283-289.Huh JW, Raghupathi R. New concepts in treatment of pediatric traumatic brain injury. Anesthesiol Clin. 2009;27(2):213-240.Hutchings L, Willett K. Cervical spine clearance in pediatric trauma: a review of current literature. J Trauma. 2009;67(4):687-691.Jani J, Nicolaides KH, Keller RL, et al. Observed to expected lung area to head circumference ratio in the prediction of survival in fetuses with isolated diaphragmatic hernia. Ultrasound Obstet
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J, Nicolaides KH, Keller RL, et al. Observed to expected lung area to head circumference ratio in the prediction of survival in fetuses with isolated diaphragmatic hernia. Ultrasound Obstet Gynecol. 2007;30:67-71.Jani JC, Peralta CF, Nicolaides KH. Lung-to-head ratio: a need to unify the technique. Ultrasound Obstet Gynecol. 2012;39:2-6.Johnigan RH, Pereira KD, Poole MD. Community-acquired methicillin-resistant Staphylococcus aureus in children and adolescents: changing trends. Arch Otolaryngol Head Neck Surg. 2003;129(10):1049-1052.Johnson MP, Sutton LN, Rintoul N, et al. Fetal myelomeningocele repair: short-term clinical outcomes. Am J Obstet Gynecol. 2003;189:482-487.Kalapurakal J, Li S, Breslow N, et al. Influence of radiation therapy delay on abdominal tumor recurrence in patients with favorable histology Wilms’ tumor treated on NWTS-3 and NWTS-4: a report from the National Wilms’ Tumor Study Group. Int J Radiat Oncol Biol Phys. 2003;57:495-499.Kamata S, Ishikawa S, Usui N, et
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Surgery_Schwartz. J, Nicolaides KH, Keller RL, et al. Observed to expected lung area to head circumference ratio in the prediction of survival in fetuses with isolated diaphragmatic hernia. Ultrasound Obstet Gynecol. 2007;30:67-71.Jani JC, Peralta CF, Nicolaides KH. Lung-to-head ratio: a need to unify the technique. Ultrasound Obstet Gynecol. 2012;39:2-6.Johnigan RH, Pereira KD, Poole MD. Community-acquired methicillin-resistant Staphylococcus aureus in children and adolescents: changing trends. Arch Otolaryngol Head Neck Surg. 2003;129(10):1049-1052.Johnson MP, Sutton LN, Rintoul N, et al. Fetal myelomeningocele repair: short-term clinical outcomes. Am J Obstet Gynecol. 2003;189:482-487.Kalapurakal J, Li S, Breslow N, et al. Influence of radiation therapy delay on abdominal tumor recurrence in patients with favorable histology Wilms’ tumor treated on NWTS-3 and NWTS-4: a report from the National Wilms’ Tumor Study Group. Int J Radiat Oncol Biol Phys. 2003;57:495-499.Kamata S, Ishikawa S, Usui N, et
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favorable histology Wilms’ tumor treated on NWTS-3 and NWTS-4: a report from the National Wilms’ Tumor Study Group. Int J Radiat Oncol Biol Phys. 2003;57:495-499.Kamata S, Ishikawa S, Usui N, et al. Prenatal diagnosis of abdominal wall defects and their prognosis. J Pediatr Surg. 1996;31:267-271.Kantarci S, Al-Gazali L, Hill RS, et al. Mutations in LRP2, which encodes the multiligand receptor megalin, cause Donnai-Barrow and facio-oculo-acoustico-renal syndromes. Nat Genet. 2007;39:957-959.Katzenstein HM, Krailo MD, Malogolowkin M, et al. Hepatocellular carcinoma in children and adolescents: results from the Pediatric Oncology Group and the Children’s Cancer Group Intergroup Study. J Clin Oncol. 2002;20:2789-2797.Kim HB, Fauza D, Garza J, Oh JT, Nurko S, Jaksic T. Serial transverse enteroplasty (STEP): a novel bowel lengthening procedure. J Pediatr Surg. 2003;38:425-429.Kim HB, Lee PW, Garza J, et al. Serial transverse enteroplasty for short bowel syndrome: a case report. J Pediatr
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Surgery_Schwartz. favorable histology Wilms’ tumor treated on NWTS-3 and NWTS-4: a report from the National Wilms’ Tumor Study Group. Int J Radiat Oncol Biol Phys. 2003;57:495-499.Kamata S, Ishikawa S, Usui N, et al. Prenatal diagnosis of abdominal wall defects and their prognosis. J Pediatr Surg. 1996;31:267-271.Kantarci S, Al-Gazali L, Hill RS, et al. Mutations in LRP2, which encodes the multiligand receptor megalin, cause Donnai-Barrow and facio-oculo-acoustico-renal syndromes. Nat Genet. 2007;39:957-959.Katzenstein HM, Krailo MD, Malogolowkin M, et al. Hepatocellular carcinoma in children and adolescents: results from the Pediatric Oncology Group and the Children’s Cancer Group Intergroup Study. J Clin Oncol. 2002;20:2789-2797.Kim HB, Fauza D, Garza J, Oh JT, Nurko S, Jaksic T. Serial transverse enteroplasty (STEP): a novel bowel lengthening procedure. J Pediatr Surg. 2003;38:425-429.Kim HB, Lee PW, Garza J, et al. Serial transverse enteroplasty for short bowel syndrome: a case report. J Pediatr
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(STEP): a novel bowel lengthening procedure. J Pediatr Surg. 2003;38:425-429.Kim HB, Lee PW, Garza J, et al. Serial transverse enteroplasty for short bowel syndrome: a case report. J Pediatr Surg. 2003;38:881-885.Kim JR, Suh CH, Yoon HM, et al. Performance of MRI for suspected appendicitis in pediatric patients and negative appendectomy rate: a systematic review and meta-analysis. J Magn Reson Imaging. 2018;47(3):767-778.Brunicardi_Ch39_p1705-p1758.indd 175612/02/19 11:27 AM 1757PEDIATRIC SURGERYCHAPTER 39Kliegman RM. Models of the pathogenesis of necrotizing enterocolitis. J Pediatr. 1990;117:S2-S5.Kliegman RM, Fanaroff AA. Necrotizing enterocolitis. N Engl J Med. 1984;310:1093-1103.Koivusalo AI, Korpela R, Wirtavuori K, Piiparinen S, Rintala RJ, Pakarinen MP. A single-blinded, randomized comparison of laparoscopic versus open hernia repair in children. Pediatrics. 2009;123:332-337.Konkin D, O’hali W, Webber EM, Blair GK. Outcomes in esophageal atresia and tracheoesophageal
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Surgery_Schwartz. (STEP): a novel bowel lengthening procedure. J Pediatr Surg. 2003;38:425-429.Kim HB, Lee PW, Garza J, et al. Serial transverse enteroplasty for short bowel syndrome: a case report. J Pediatr Surg. 2003;38:881-885.Kim JR, Suh CH, Yoon HM, et al. Performance of MRI for suspected appendicitis in pediatric patients and negative appendectomy rate: a systematic review and meta-analysis. J Magn Reson Imaging. 2018;47(3):767-778.Brunicardi_Ch39_p1705-p1758.indd 175612/02/19 11:27 AM 1757PEDIATRIC SURGERYCHAPTER 39Kliegman RM. Models of the pathogenesis of necrotizing enterocolitis. J Pediatr. 1990;117:S2-S5.Kliegman RM, Fanaroff AA. Necrotizing enterocolitis. N Engl J Med. 1984;310:1093-1103.Koivusalo AI, Korpela R, Wirtavuori K, Piiparinen S, Rintala RJ, Pakarinen MP. A single-blinded, randomized comparison of laparoscopic versus open hernia repair in children. Pediatrics. 2009;123:332-337.Konkin D, O’hali W, Webber EM, Blair GK. Outcomes in esophageal atresia and tracheoesophageal
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randomized comparison of laparoscopic versus open hernia repair in children. Pediatrics. 2009;123:332-337.Konkin D, O’hali W, Webber EM, Blair GK. Outcomes in esophageal atresia and tracheoesophageal fistula. J Pediatr Surg. 2003;38:1726-1729.Kosloske AM. Operative techniques for the treatment of neonatal necrotizing enterocolitis. Surg Gynecol Obstet. 1979;149:740-744.Kosloske AM. Indications for operation in necrotizing enterocolitis revisited. J Pediatr Surg. 1994;29:663-666.Kosloske AM, Lilly JR. Paracentesis and lavage for diagnosis of intestinal gangrene in neonatal necrotizing enterocolitis. J Pediatr Surg. 1978;13:315-320.Lacroix J, Hebert PC, Hutchison JS, et al. Transfusion strategies for patients in pediatric intensive care units. N Engl J Med. 2007;356:1609-1619.Langer J, Durrant A, de la Torre L, et al. One-stage transanal Soave pullthrough for Hirschsprung disease: a multicenter experience with 141 children. Ann Surg. 2003;238:569-583.Levitt MA, Ferraraccio D, Arbesman
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Surgery_Schwartz. randomized comparison of laparoscopic versus open hernia repair in children. Pediatrics. 2009;123:332-337.Konkin D, O’hali W, Webber EM, Blair GK. Outcomes in esophageal atresia and tracheoesophageal fistula. J Pediatr Surg. 2003;38:1726-1729.Kosloske AM. Operative techniques for the treatment of neonatal necrotizing enterocolitis. Surg Gynecol Obstet. 1979;149:740-744.Kosloske AM. Indications for operation in necrotizing enterocolitis revisited. J Pediatr Surg. 1994;29:663-666.Kosloske AM, Lilly JR. Paracentesis and lavage for diagnosis of intestinal gangrene in neonatal necrotizing enterocolitis. J Pediatr Surg. 1978;13:315-320.Lacroix J, Hebert PC, Hutchison JS, et al. Transfusion strategies for patients in pediatric intensive care units. N Engl J Med. 2007;356:1609-1619.Langer J, Durrant A, de la Torre L, et al. One-stage transanal Soave pullthrough for Hirschsprung disease: a multicenter experience with 141 children. Ann Surg. 2003;238:569-583.Levitt MA, Ferraraccio D, Arbesman
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A, de la Torre L, et al. One-stage transanal Soave pullthrough for Hirschsprung disease: a multicenter experience with 141 children. Ann Surg. 2003;238:569-583.Levitt MA, Ferraraccio D, Arbesman M, et al. Variability of inguinal hernia surgical technique: a survey of North American pediatric surgeons. J Pediatr Surg. 2002;37:745-751.Lille ST, Rand RP, Tapper D, Gruss JS. The surgical management of giant cervicofacial lymphatic malformations. J Pediatr Surg. 1996;31:1648-1650.Limmer J, Gortner L, Kelsch G, Schutze F, Berger D. Diagnosis and treatment of necrotizing enterocolitis. A retrospective evaluation of abdominal paracentesis and continuous postoperative lavage. Acta Paediatr Suppl. 1994;396:65-69.Lintula H, Kokki H, Vanamo K. Single-blind randomized clinical trial of laparoscopic versus open appendicectomy in children. Br J Surg. 2001;88:510-514.Lipshutz G, Albanese C, Feldstein V, et al. Prospective analysis of lung-to-head ratio predicts survival for patients with prenatally
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Surgery_Schwartz. A, de la Torre L, et al. One-stage transanal Soave pullthrough for Hirschsprung disease: a multicenter experience with 141 children. Ann Surg. 2003;238:569-583.Levitt MA, Ferraraccio D, Arbesman M, et al. Variability of inguinal hernia surgical technique: a survey of North American pediatric surgeons. J Pediatr Surg. 2002;37:745-751.Lille ST, Rand RP, Tapper D, Gruss JS. The surgical management of giant cervicofacial lymphatic malformations. J Pediatr Surg. 1996;31:1648-1650.Limmer J, Gortner L, Kelsch G, Schutze F, Berger D. Diagnosis and treatment of necrotizing enterocolitis. A retrospective evaluation of abdominal paracentesis and continuous postoperative lavage. Acta Paediatr Suppl. 1994;396:65-69.Lintula H, Kokki H, Vanamo K. Single-blind randomized clinical trial of laparoscopic versus open appendicectomy in children. Br J Surg. 2001;88:510-514.Lipshutz G, Albanese C, Feldstein V, et al. Prospective analysis of lung-to-head ratio predicts survival for patients with prenatally
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open appendicectomy in children. Br J Surg. 2001;88:510-514.Lipshutz G, Albanese C, Feldstein V, et al. Prospective analysis of lung-to-head ratio predicts survival for patients with prenatally diagnosed congenital diaphragmatic hernia. J Pediatr Surg. 1997;32:1634-1636.Little D, Rescorla F, Grosfeld J, et al. Long-term analysis of children with esophageal atresia and tracheoesophageal fistula. J Pediatr Surg. 2003;38:852-856.Loeb DM, Thornton K, Shokek O. Pediatric soft tissue sarcomas. Surg Clin North Am. 2008;88:615-627.Luig M, Lui K. Epidemiology of necrotizing enterocolitis—part I: changing regional trends in extremely preterm infants over 14 years. J Paediatr Child Health. 2005;41:169-173.Lynch L, O’Donoghue D, Dean J, O’Sullivan J, O’Farrelly C, Golden-Mason L. Detection and characterization of hemopoietic stem cells in the adult human small intestine. J Immunol. 2006;176:5199-5204.Maheshwari A, Patel RM, Christensen RD. Anemia, red blood cell transfusions, and necrotizing
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Surgery_Schwartz. open appendicectomy in children. Br J Surg. 2001;88:510-514.Lipshutz G, Albanese C, Feldstein V, et al. Prospective analysis of lung-to-head ratio predicts survival for patients with prenatally diagnosed congenital diaphragmatic hernia. J Pediatr Surg. 1997;32:1634-1636.Little D, Rescorla F, Grosfeld J, et al. Long-term analysis of children with esophageal atresia and tracheoesophageal fistula. J Pediatr Surg. 2003;38:852-856.Loeb DM, Thornton K, Shokek O. Pediatric soft tissue sarcomas. Surg Clin North Am. 2008;88:615-627.Luig M, Lui K. Epidemiology of necrotizing enterocolitis—part I: changing regional trends in extremely preterm infants over 14 years. J Paediatr Child Health. 2005;41:169-173.Lynch L, O’Donoghue D, Dean J, O’Sullivan J, O’Farrelly C, Golden-Mason L. Detection and characterization of hemopoietic stem cells in the adult human small intestine. J Immunol. 2006;176:5199-5204.Maheshwari A, Patel RM, Christensen RD. Anemia, red blood cell transfusions, and necrotizing
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of hemopoietic stem cells in the adult human small intestine. J Immunol. 2006;176:5199-5204.Maheshwari A, Patel RM, Christensen RD. Anemia, red blood cell transfusions, and necrotizing enterocolitis. Semin Pediatr Surg. 2018;27:47-51.Mallick IH, Yang W, Winslet MC, Seifalian AM. Ischemia-reperfusion injury of the intestine and protective strategies against injury. Dig Dis Sci. 2004;49:1359-1377.Marianowski R, Ait Amer JL, Morisseau-Durand MP, et al. Risk factors for thyroglossal duct remnants after Sistrunk procedure in a pediatric population. Int J Pediatr Otorhinolaryngol. 2003;67:19-23.Maris JM, Weiss MJ, Guo C, et al. Loss of heterozygosity at 1p36 independently predicts for disease progression but not decreased overall survival probability in neuroblastoma patients: a Children’s Cancer Group Study. J Clin Oncol. 2000;18:1888-1899.Martinez-Tallo E, Claure N, Bancalari E. Necrotizing enterocolitis in full-term or near-term infants: risk factors. Biol Neonate.
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Surgery_Schwartz. of hemopoietic stem cells in the adult human small intestine. J Immunol. 2006;176:5199-5204.Maheshwari A, Patel RM, Christensen RD. Anemia, red blood cell transfusions, and necrotizing enterocolitis. Semin Pediatr Surg. 2018;27:47-51.Mallick IH, Yang W, Winslet MC, Seifalian AM. Ischemia-reperfusion injury of the intestine and protective strategies against injury. Dig Dis Sci. 2004;49:1359-1377.Marianowski R, Ait Amer JL, Morisseau-Durand MP, et al. Risk factors for thyroglossal duct remnants after Sistrunk procedure in a pediatric population. Int J Pediatr Otorhinolaryngol. 2003;67:19-23.Maris JM, Weiss MJ, Guo C, et al. Loss of heterozygosity at 1p36 independently predicts for disease progression but not decreased overall survival probability in neuroblastoma patients: a Children’s Cancer Group Study. J Clin Oncol. 2000;18:1888-1899.Martinez-Tallo E, Claure N, Bancalari E. Necrotizing enterocolitis in full-term or near-term infants: risk factors. Biol Neonate.
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Surgery_Schwartz. versus laparotomy for perforated necrotizing enterocolitis. J Pediatr Surg. 2001;36:1210-1213.Moss RL, Das JB, Raffensperger JG. Necrotizing enterocolitis and total parenteral nutrition-associated cholestasis. Nutrition. 1996;12:340-343.Moyer V, Moya F, Tibboel F, et al. Late versus early surgical correction for congenital diaphragmatic hernia in newborn infants. Cochrane Database Syst Rev. 2002;CD001695.Mullassery D, Ba’ath ME, Jesudason EC, Losty PD. Value of liver herniation in prediction of outcome in fetal congenital diaphragmatic hernia: a systematic review and meta-analysis. Ultrasound Obstet Gynecol. 2010;35:609-614.Nadler E, Stanford A, Zhang X, et al. Intestinal cytokine gene expression in infants with acute necrotizing enterocolitis: interleukin-11 mRNA expression inversely correlates with extent of disease. J Pediatr Surg. 2001;36:1122-1129.Neville HL, Andrassy RJ, Lally K, et al. Lymphatic mapping with sentinel node biopsy in pediatric patients. J Pediatr Surg.
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Surgery_Schwartz. correlates with extent of disease. J Pediatr Surg. 2001;36:1122-1129.Neville HL, Andrassy RJ, Lally K, et al. Lymphatic mapping with sentinel node biopsy in pediatric patients. J Pediatr Surg. 2000;35:961-964.Nino DF, Sodhi CP, Hackam DJ. Necrotizing enterocolitis: new insights into pathogenesis and mechanisms. Nat Rev Gastroenterol Hepatol. 2016;13:590-600.Nio M, Ohi R, Miyano T, et al. Fiveand 10-year survival rates after surgery for biliary atresia: a report from the Japanese Biliary Atresia Registry. J Pediatr Surg. 2003;38:997-1000.O’Donovan DJ, Baetiong A, Adams K, et al. Necrotizing enterocolitis and gastrointestinal complications after indomethacin therapy and surgical ligation in premature infants with patent ductus arteriosus. J Perinatol. 2003;23: 286-290.Olutoye OO, Coleman BG, Hubbard A, et al. Prenatal diagnosis and management of congenital lobar emphysema. J Pediatr Surg. 2000;35:792-795.Ortega JA, Douglass EC, Feusner J, et al. Randomized comparison of
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Surgery_Schwartz. J Pediatr Surg. 2003;38:886-891.Pritchard-Jones K. Controversies and advances in the management of Wilms’ tumour. Arch Dis Child. 2002;87:241-244.Puapong D, Kahng D, Ko A, et al. Ad libitum feeding: safely improving the cost-effectiveness of pyloromyotomy. J Pediatr Surg. 2002;37:1667-1668.Quinton AE, Smoleniec JS. Congenital lobar emphysema—the disappearing chest mass: antenatal ultrasound appearance. Ultrasound Obstet Gynecol. 2001;17:169-171.Rai SE, Sidhu AK, Krishnan RJ. Transfusion-associated necrotizing enterocolitis re-evaluated: a systematic review and meta-analysis. J Perinat Med. 2018;46(6):665-676.Reyes J, Bueno J, Kocoshis S, et al. Current status of intestinal transplantation in children. J Pediatr Surg. 1998;33:243-254.Rosen NG, Hong AR, Soffer S, et al. Rectovaginal fistula: a common diagnostic error with significant consequences in girls with anorectal malformations. J Pediatr Surg. 2002;37:961-965.Rothenberg S. Laparoscopic Nissen procedure in children. Semin Laparosc
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UrologyAhmad Shabsigh, Michael Sourial, Fara F. Bellows, Christopher McClung, Rama Jayanthi, Stephanie Kielb, Geoffrey N. Box, Bodo E. Knudsen, and Cheryl T. Lee 40chapterANATOMYThe anatomic structures that generally require urologic man-agement include the kidneys, adrenal glands, ureters, bladder, prostate, seminal vesicles, vas deferens, penis, urethra, scrotum, and testes. These organs are located in retroperitoneal or extra-peritoneal spaces. However, a transperitoneal approach may be utilized to access the kidney, ureters, bladder, or retroperitoneal lymph nodes during certain urologic operations.Kidney and Adrenal GlandThe kidneys are paired retroperitoneal organs that are invested in a fibro-fatty layer of tissue known as Gerota’s fascia. This natural barrier helps to tamponade bleeding and thus may provide renal and hemodynamic protection in cases of renal trauma or spontaneous renal hemorrhage. It also may assist in preventing tumor invasion into surrounding struc-tures in
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Surgery_Schwartz. UrologyAhmad Shabsigh, Michael Sourial, Fara F. Bellows, Christopher McClung, Rama Jayanthi, Stephanie Kielb, Geoffrey N. Box, Bodo E. Knudsen, and Cheryl T. Lee 40chapterANATOMYThe anatomic structures that generally require urologic man-agement include the kidneys, adrenal glands, ureters, bladder, prostate, seminal vesicles, vas deferens, penis, urethra, scrotum, and testes. These organs are located in retroperitoneal or extra-peritoneal spaces. However, a transperitoneal approach may be utilized to access the kidney, ureters, bladder, or retroperitoneal lymph nodes during certain urologic operations.Kidney and Adrenal GlandThe kidneys are paired retroperitoneal organs that are invested in a fibro-fatty layer of tissue known as Gerota’s fascia. This natural barrier helps to tamponade bleeding and thus may provide renal and hemodynamic protection in cases of renal trauma or spontaneous renal hemorrhage. It also may assist in preventing tumor invasion into surrounding struc-tures in
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and thus may provide renal and hemodynamic protection in cases of renal trauma or spontaneous renal hemorrhage. It also may assist in preventing tumor invasion into surrounding struc-tures in the case of large renal masses. The kidneys are bor-dered posterolaterally by the quadratus lumborum muscle and posteromedially by the psoas muscle. Additionally, the diaphragm drapes across the posterior aspect of the superior pole of each kidney.The left kidney is bordered anterolaterally by the spleen and descending colon. The pancreatic tail borders the antero-medial left kidney. The right kidney is bordered anterolaterally by the liver and the ascending colon. The second portion of the duodenum may be encountered near the right renal vessels and thus sometimes requires anteromedial reflection, known as the Kocher maneuver, to achieve intraoperative vascular control during right renal surgery.The kidneys are end organs, which are responsible for their vulnerability to infarction. The renal
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Surgery_Schwartz. and thus may provide renal and hemodynamic protection in cases of renal trauma or spontaneous renal hemorrhage. It also may assist in preventing tumor invasion into surrounding struc-tures in the case of large renal masses. The kidneys are bor-dered posterolaterally by the quadratus lumborum muscle and posteromedially by the psoas muscle. Additionally, the diaphragm drapes across the posterior aspect of the superior pole of each kidney.The left kidney is bordered anterolaterally by the spleen and descending colon. The pancreatic tail borders the antero-medial left kidney. The right kidney is bordered anterolaterally by the liver and the ascending colon. The second portion of the duodenum may be encountered near the right renal vessels and thus sometimes requires anteromedial reflection, known as the Kocher maneuver, to achieve intraoperative vascular control during right renal surgery.The kidneys are end organs, which are responsible for their vulnerability to infarction. The renal
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known as the Kocher maneuver, to achieve intraoperative vascular control during right renal surgery.The kidneys are end organs, which are responsible for their vulnerability to infarction. The renal arteries extend from the aorta and then branch into several segmental arteries and arterioles before becoming glomeruli. Each artery runs poste-rior to their respective renal vein. Occasionally, an accessory renal artery will arise, but in general, each kidney receives a single main renal artery. Each renal vein drains directly into the IVC and is located anteriorly to its respective renal artery when entering the kidney. The right renal vein is much shorter than the left and does not receive collateral venous drainage. The left renal vein passes anteriorly to the aorta and receives drainage from the left gonadal vein, the left inferior adrenal vein, and a lumbar vein.The collecting system of the kidney begins as minor caly-ces near the renal papillae and then coalesces into major calyces.
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Surgery_Schwartz. known as the Kocher maneuver, to achieve intraoperative vascular control during right renal surgery.The kidneys are end organs, which are responsible for their vulnerability to infarction. The renal arteries extend from the aorta and then branch into several segmental arteries and arterioles before becoming glomeruli. Each artery runs poste-rior to their respective renal vein. Occasionally, an accessory renal artery will arise, but in general, each kidney receives a single main renal artery. Each renal vein drains directly into the IVC and is located anteriorly to its respective renal artery when entering the kidney. The right renal vein is much shorter than the left and does not receive collateral venous drainage. The left renal vein passes anteriorly to the aorta and receives drainage from the left gonadal vein, the left inferior adrenal vein, and a lumbar vein.The collecting system of the kidney begins as minor caly-ces near the renal papillae and then coalesces into major calyces.
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the left gonadal vein, the left inferior adrenal vein, and a lumbar vein.The collecting system of the kidney begins as minor caly-ces near the renal papillae and then coalesces into major calyces. Major calyces join to form the renal pelvis, which then tapers down to the ureteropelvic junction (UPJ), from which the ureter emanates. The pelvis is located posterior to its respective renal artery.The adrenal gland is superomedial to its respective kidney within Gerota’s fascia. Adrenal arterial supply arises from mul-tiple sources: the inferior phrenic artery, aortic branches, and renal arterial branches. Venous drainage mirrors arterial supply. On the right side, the adrenal gland drains directly into the IVC. The right adrenal vein can be quite short (<1 cm) and can be Anatomy 1759Kidney and Adrenal Gland / 1759Ureter / 1760Bladder and Prostate / 1760Penis / 1760Scrotum and Testes / 1760Infection 1761Cystitis / 1761Pyelonephritis / 1761Prostatitis / 1761Epididymo-Orchitis /
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Surgery_Schwartz. the left gonadal vein, the left inferior adrenal vein, and a lumbar vein.The collecting system of the kidney begins as minor caly-ces near the renal papillae and then coalesces into major calyces. Major calyces join to form the renal pelvis, which then tapers down to the ureteropelvic junction (UPJ), from which the ureter emanates. The pelvis is located posterior to its respective renal artery.The adrenal gland is superomedial to its respective kidney within Gerota’s fascia. Adrenal arterial supply arises from mul-tiple sources: the inferior phrenic artery, aortic branches, and renal arterial branches. Venous drainage mirrors arterial supply. On the right side, the adrenal gland drains directly into the IVC. The right adrenal vein can be quite short (<1 cm) and can be Anatomy 1759Kidney and Adrenal Gland / 1759Ureter / 1760Bladder and Prostate / 1760Penis / 1760Scrotum and Testes / 1760Infection 1761Cystitis / 1761Pyelonephritis / 1761Prostatitis / 1761Epididymo-Orchitis /
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and Adrenal Gland / 1759Ureter / 1760Bladder and Prostate / 1760Penis / 1760Scrotum and Testes / 1760Infection 1761Cystitis / 1761Pyelonephritis / 1761Prostatitis / 1761Epididymo-Orchitis / 1761Balanitis and Balanoposthitis / 1762Urinary Tract Obstruction 1762Urolithiasis / 1762Benign Prostatic Hyperplasia / 1763Urethral Stricture / 1764Other Causes of Obstruction / 1764Genitourinary Trauma 1764Kidneys / 1765Ureters / 1765Bladder / 1766Urethral Injuries / 1766External Genital Injuries / 1767Emergencies 1768Acute Urinary Retention / 1768Testicular Torsion / 1769Fournier’s Gangrene / 1769Priapism / 1769Paraphimosis / 1770Emphysematous Pyelonephritis / 1770Urologic Malignancies 1770Bladder Cancer / 1770Testicular Cancer / 1771Kidney Cancer / 1772Prostate Cancer / 1774Urethral Cancer / 1775Common Urologic Conditions 1775Urinary Incontinence and Voiding Dysfunction / 1775Erectile Dysfunction / 1775Pediatric Urology 1776Hypospadias / 1776Urinary Tract Infections in Children / 1777Prenatal
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Surgery_Schwartz. and Adrenal Gland / 1759Ureter / 1760Bladder and Prostate / 1760Penis / 1760Scrotum and Testes / 1760Infection 1761Cystitis / 1761Pyelonephritis / 1761Prostatitis / 1761Epididymo-Orchitis / 1761Balanitis and Balanoposthitis / 1762Urinary Tract Obstruction 1762Urolithiasis / 1762Benign Prostatic Hyperplasia / 1763Urethral Stricture / 1764Other Causes of Obstruction / 1764Genitourinary Trauma 1764Kidneys / 1765Ureters / 1765Bladder / 1766Urethral Injuries / 1766External Genital Injuries / 1767Emergencies 1768Acute Urinary Retention / 1768Testicular Torsion / 1769Fournier’s Gangrene / 1769Priapism / 1769Paraphimosis / 1770Emphysematous Pyelonephritis / 1770Urologic Malignancies 1770Bladder Cancer / 1770Testicular Cancer / 1771Kidney Cancer / 1772Prostate Cancer / 1774Urethral Cancer / 1775Common Urologic Conditions 1775Urinary Incontinence and Voiding Dysfunction / 1775Erectile Dysfunction / 1775Pediatric Urology 1776Hypospadias / 1776Urinary Tract Infections in Children / 1777Prenatal
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Urologic Conditions 1775Urinary Incontinence and Voiding Dysfunction / 1775Erectile Dysfunction / 1775Pediatric Urology 1776Hypospadias / 1776Urinary Tract Infections in Children / 1777Prenatal Hydronephrosis / 1777Cryptorchidism / 1777Brunicardi_Ch40_p1759-p1782.indd 175901/03/19 6:34 PM 1760Key Points1 Most small ureteral calculi will pass spontaneously or with the use of medical expulsive therapy, but larger stones (>6 mm) are better treated with ureteral stenting or lithotripsy.2 Benign prostatic hyperplasia can be managed effectively with medical therapy or minimally invasive endoscopic and robotic surgical techniques depending on the urinary symp-toms, patient bother, prostate size, and patient’s therapeutic choice. 3 Patients with recurrent urethral stricture after endoscopic treatment are unlikely to derive sustained benefit from future endoscopic therapies and should be referred for urethral reconstruction.4 The vast majority of renal trauma can be treated
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Surgery_Schwartz. Urologic Conditions 1775Urinary Incontinence and Voiding Dysfunction / 1775Erectile Dysfunction / 1775Pediatric Urology 1776Hypospadias / 1776Urinary Tract Infections in Children / 1777Prenatal Hydronephrosis / 1777Cryptorchidism / 1777Brunicardi_Ch40_p1759-p1782.indd 175901/03/19 6:34 PM 1760Key Points1 Most small ureteral calculi will pass spontaneously or with the use of medical expulsive therapy, but larger stones (>6 mm) are better treated with ureteral stenting or lithotripsy.2 Benign prostatic hyperplasia can be managed effectively with medical therapy or minimally invasive endoscopic and robotic surgical techniques depending on the urinary symp-toms, patient bother, prostate size, and patient’s therapeutic choice. 3 Patients with recurrent urethral stricture after endoscopic treatment are unlikely to derive sustained benefit from future endoscopic therapies and should be referred for urethral reconstruction.4 The vast majority of renal trauma can be treated
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endoscopic treatment are unlikely to derive sustained benefit from future endoscopic therapies and should be referred for urethral reconstruction.4 The vast majority of renal trauma can be treated conserva-tively, with early surgical intervention reserved for persistent bleeding, renal vascular, or ureteral injuries. 5 Extraperitoneal bladder ruptures can be treated conserva-tively, but intraperitoneal ruptures typically require surgical repair.6 Testicular torsion is an emergency where successful testicu-lar salvage is inversely related to the delay in repair, so cases with a high degree of clinical suspicion should not wait for a radiologic diagnosis.7 Fournier’s gangrene is a rapidly progressive and potentially lethal condition that requires aggressive débridement and close follow-up due to the frequent need for repeat débridement.8 The management of early stage prostate cancer has changed significantly, with a much greater emphasis on risk stratifi-cation. Low risk patients are
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Surgery_Schwartz. endoscopic treatment are unlikely to derive sustained benefit from future endoscopic therapies and should be referred for urethral reconstruction.4 The vast majority of renal trauma can be treated conserva-tively, with early surgical intervention reserved for persistent bleeding, renal vascular, or ureteral injuries. 5 Extraperitoneal bladder ruptures can be treated conserva-tively, but intraperitoneal ruptures typically require surgical repair.6 Testicular torsion is an emergency where successful testicu-lar salvage is inversely related to the delay in repair, so cases with a high degree of clinical suspicion should not wait for a radiologic diagnosis.7 Fournier’s gangrene is a rapidly progressive and potentially lethal condition that requires aggressive débridement and close follow-up due to the frequent need for repeat débridement.8 The management of early stage prostate cancer has changed significantly, with a much greater emphasis on risk stratifi-cation. Low risk patients are
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due to the frequent need for repeat débridement.8 The management of early stage prostate cancer has changed significantly, with a much greater emphasis on risk stratifi-cation. Low risk patients are largely treated with active surveillance. 9 Treatments for urinary incontinence and voiding dysfunction are varied depending on the etiology, severity, and bother of the symptom. Behavior modification, bladder retraining, and medical therapies can all be effective in improving symptoms without the need for surgery.a source of significant bleeding if inadvertently injured during renal or adrenal surgery.UreterThe ureters are smooth muscle–based tubular structures that connect the renal pelvis to the bladder. The blood supply arises from the surrounding vasculature. The proximal blood supply inserts on the medial aspect of the ureter and arises from the aorta and renal artery, and the distal blood supply inserts lat-erally and arises from the surrounding iliac vessels and their branches.
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Surgery_Schwartz. due to the frequent need for repeat débridement.8 The management of early stage prostate cancer has changed significantly, with a much greater emphasis on risk stratifi-cation. Low risk patients are largely treated with active surveillance. 9 Treatments for urinary incontinence and voiding dysfunction are varied depending on the etiology, severity, and bother of the symptom. Behavior modification, bladder retraining, and medical therapies can all be effective in improving symptoms without the need for surgery.a source of significant bleeding if inadvertently injured during renal or adrenal surgery.UreterThe ureters are smooth muscle–based tubular structures that connect the renal pelvis to the bladder. The blood supply arises from the surrounding vasculature. The proximal blood supply inserts on the medial aspect of the ureter and arises from the aorta and renal artery, and the distal blood supply inserts lat-erally and arises from the surrounding iliac vessels and their branches.
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inserts on the medial aspect of the ureter and arises from the aorta and renal artery, and the distal blood supply inserts lat-erally and arises from the surrounding iliac vessels and their branches. The arterial supply inserts via a fatty layer of tissue around the ureter, and thus surgical preservation of the periure-teral tissue is essential to maintain vascularization and achieve successful ureteral reconstruction.The ureters initially course along the psoas muscle and then run distally along the pelvic sidewall. They generally pass posterior to the uterine arteries, making them susceptible to injury during hysterectomy. The ureters enter the bladder lat-erally and pass through the bladder wall at an oblique angle, which helps prevent reflux of urine during bladder filling. The ureters propel urine into the bladder via the ureteral orifices.Bladder and ProstateThe bladder is located extraperitoneally in the pelvis and pos-terior to the pubis. A portion of the bladder dome is
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Surgery_Schwartz. inserts on the medial aspect of the ureter and arises from the aorta and renal artery, and the distal blood supply inserts lat-erally and arises from the surrounding iliac vessels and their branches. The arterial supply inserts via a fatty layer of tissue around the ureter, and thus surgical preservation of the periure-teral tissue is essential to maintain vascularization and achieve successful ureteral reconstruction.The ureters initially course along the psoas muscle and then run distally along the pelvic sidewall. They generally pass posterior to the uterine arteries, making them susceptible to injury during hysterectomy. The ureters enter the bladder lat-erally and pass through the bladder wall at an oblique angle, which helps prevent reflux of urine during bladder filling. The ureters propel urine into the bladder via the ureteral orifices.Bladder and ProstateThe bladder is located extraperitoneally in the pelvis and pos-terior to the pubis. A portion of the bladder dome is
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propel urine into the bladder via the ureteral orifices.Bladder and ProstateThe bladder is located extraperitoneally in the pelvis and pos-terior to the pubis. A portion of the bladder dome is draped by peritoneum, and rupture or injury at this location can result in intraperitoneal urine leakage and subsequent chemical peritoni-tis. The average adult bladder holds approximately 500 mL of urine; however, in rare cases, capacity can reach up to or greater than 1000 mL, in which case the bladder extends towards the umbilicus. The sigmoid colon lies adjacent to the bladder and can fistulize to the lateral wall or dome of the bladder in cases of diverticulitis or colon cancer. The rectum lies posteriorly to the bladder in men, and the uterus and vagina lie posteriorly to the bladder in women.The prostate is a walnut-shaped gland that encircles the urethra and is located in males immediately beneath the blad-der neck. Smooth muscle fibers distribute throughout the gland, which can contract
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Surgery_Schwartz. propel urine into the bladder via the ureteral orifices.Bladder and ProstateThe bladder is located extraperitoneally in the pelvis and pos-terior to the pubis. A portion of the bladder dome is draped by peritoneum, and rupture or injury at this location can result in intraperitoneal urine leakage and subsequent chemical peritoni-tis. The average adult bladder holds approximately 500 mL of urine; however, in rare cases, capacity can reach up to or greater than 1000 mL, in which case the bladder extends towards the umbilicus. The sigmoid colon lies adjacent to the bladder and can fistulize to the lateral wall or dome of the bladder in cases of diverticulitis or colon cancer. The rectum lies posteriorly to the bladder in men, and the uterus and vagina lie posteriorly to the bladder in women.The prostate is a walnut-shaped gland that encircles the urethra and is located in males immediately beneath the blad-der neck. Smooth muscle fibers distribute throughout the gland, which can contract
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Surgery_Schwartz_11636
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prostate is a walnut-shaped gland that encircles the urethra and is located in males immediately beneath the blad-der neck. Smooth muscle fibers distribute throughout the gland, which can contract and facilitate bladder outlet obstruction. The average prostate measures approximately 30 mL in volume. Puboprostatic ligaments suspend the prostate to the pubis, and in the instance of pelvic trauma, shearing forces can cause disrup-tion of the posterior urethra (known as pelvic fracture urethral injury). The external urethral sphincter houses the membranous urethra and sits just below the apex of the prostate. Vasculature to the bladder and prostate arises from the superior and inferior vesical arteries, which branch from the internal iliac arteries.PenisThe penis is comprised of three bodies: two corpora cavernosa, which are responsible for erection, and the corpus spongiosum, which surrounds the urethra and gives rise to the glans penis. These three structures are all encased by skin and
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Surgery_Schwartz. prostate is a walnut-shaped gland that encircles the urethra and is located in males immediately beneath the blad-der neck. Smooth muscle fibers distribute throughout the gland, which can contract and facilitate bladder outlet obstruction. The average prostate measures approximately 30 mL in volume. Puboprostatic ligaments suspend the prostate to the pubis, and in the instance of pelvic trauma, shearing forces can cause disrup-tion of the posterior urethra (known as pelvic fracture urethral injury). The external urethral sphincter houses the membranous urethra and sits just below the apex of the prostate. Vasculature to the bladder and prostate arises from the superior and inferior vesical arteries, which branch from the internal iliac arteries.PenisThe penis is comprised of three bodies: two corpora cavernosa, which are responsible for erection, and the corpus spongiosum, which surrounds the urethra and gives rise to the glans penis. These three structures are all encased by skin and
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two corpora cavernosa, which are responsible for erection, and the corpus spongiosum, which surrounds the urethra and gives rise to the glans penis. These three structures are all encased by skin and dartos fascia, as well as an inner investing layer of fascia called Buck’s fascia. The corpora cavernosa are spongy sinusoidal bodies that expand with parasympathetic neural stimulation to create an erection. Thick fascia, called tunica albuginea, assists in producing rigid-ity during erection. Each corpus cavernosum features a centrally located cavernosal artery, which arises from the penile artery. A porous septum separates the two corpora and allows for trans-corporal blood exchange. The corpus spongiosum is located on the ventrum of the penis. The corpus spongiosum lacks a tough fascia similar to tunica albuginea and thus does not exhibit the same rigidity during erection.Scrotum and TestesThe scrotum is a potential space that surrounds the testes, epididymis, and spermatic cords. The
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Surgery_Schwartz. two corpora cavernosa, which are responsible for erection, and the corpus spongiosum, which surrounds the urethra and gives rise to the glans penis. These three structures are all encased by skin and dartos fascia, as well as an inner investing layer of fascia called Buck’s fascia. The corpora cavernosa are spongy sinusoidal bodies that expand with parasympathetic neural stimulation to create an erection. Thick fascia, called tunica albuginea, assists in producing rigid-ity during erection. Each corpus cavernosum features a centrally located cavernosal artery, which arises from the penile artery. A porous septum separates the two corpora and allows for trans-corporal blood exchange. The corpus spongiosum is located on the ventrum of the penis. The corpus spongiosum lacks a tough fascia similar to tunica albuginea and thus does not exhibit the same rigidity during erection.Scrotum and TestesThe scrotum is a potential space that surrounds the testes, epididymis, and spermatic cords. The
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to tunica albuginea and thus does not exhibit the same rigidity during erection.Scrotum and TestesThe scrotum is a potential space that surrounds the testes, epididymis, and spermatic cords. The scrotum is comprised of many layers aside from skin and dartos fascia, and each derives from a particular layer of the anterior abdominal wall. The external spermatic fascia arises from the external oblique fascia, the cremasteric fascia arises from the internal oblique fascia, and the internal spermatic fascia arises from the transver-sus abdominis fascia. The testes are separated from the scrotal layers by the visceral and parietal layers of the tunica vaginalis, between which hydroceles form. The spermatic cord contains Brunicardi_Ch40_p1759-p1782.indd 176001/03/19 6:34 PM 1761UROLOGYCHAPTER 40the vas deferens, the venous pampiniform plexus, and arterial blood supply to the superior pole of the testis via three separate sources. The testicular artery arises directly from the aorta; the
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Surgery_Schwartz. to tunica albuginea and thus does not exhibit the same rigidity during erection.Scrotum and TestesThe scrotum is a potential space that surrounds the testes, epididymis, and spermatic cords. The scrotum is comprised of many layers aside from skin and dartos fascia, and each derives from a particular layer of the anterior abdominal wall. The external spermatic fascia arises from the external oblique fascia, the cremasteric fascia arises from the internal oblique fascia, and the internal spermatic fascia arises from the transver-sus abdominis fascia. The testes are separated from the scrotal layers by the visceral and parietal layers of the tunica vaginalis, between which hydroceles form. The spermatic cord contains Brunicardi_Ch40_p1759-p1782.indd 176001/03/19 6:34 PM 1761UROLOGYCHAPTER 40the vas deferens, the venous pampiniform plexus, and arterial blood supply to the superior pole of the testis via three separate sources. The testicular artery arises directly from the aorta; the
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40the vas deferens, the venous pampiniform plexus, and arterial blood supply to the superior pole of the testis via three separate sources. The testicular artery arises directly from the aorta; the deferential artery, which supplies the vas deferens, arises from the internal iliac artery; and the cremasteric artery, which sup-plies the cremaster musculature, arises from the external iliac artery. The presence of multiple arterial sources provides col-lateral flow and prevents ischemia in the event of injury to a particular vascular branch. The venous pampiniform plexus can dilate to form a palpable or visible varicocele, which can serve as an etiology of chronic testicular pain or infertility.INFECTIONCystitisUncomplicated cystitis usually presents as new onset urinary frequency, urgency, and dysuria. Patients may also report lower back pain, suprapubic pain, foul-smelling urine, or gross hema-turia. Urinalysis with microscopy assists with diagnosis by confirming the presence of
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Surgery_Schwartz. 40the vas deferens, the venous pampiniform plexus, and arterial blood supply to the superior pole of the testis via three separate sources. The testicular artery arises directly from the aorta; the deferential artery, which supplies the vas deferens, arises from the internal iliac artery; and the cremasteric artery, which sup-plies the cremaster musculature, arises from the external iliac artery. The presence of multiple arterial sources provides col-lateral flow and prevents ischemia in the event of injury to a particular vascular branch. The venous pampiniform plexus can dilate to form a palpable or visible varicocele, which can serve as an etiology of chronic testicular pain or infertility.INFECTIONCystitisUncomplicated cystitis usually presents as new onset urinary frequency, urgency, and dysuria. Patients may also report lower back pain, suprapubic pain, foul-smelling urine, or gross hema-turia. Urinalysis with microscopy assists with diagnosis by confirming the presence of
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and dysuria. Patients may also report lower back pain, suprapubic pain, foul-smelling urine, or gross hema-turia. Urinalysis with microscopy assists with diagnosis by confirming the presence of pyuria, hematuria, and bacteriuria. Office dipstick may be helpful, as the presence of nitrites reflects bacterial colonization and the presence of leukocyte esterase reflects pyuria. Risk factors for the development of uncompli-cated cystitis include female gender, sexual activity, and use of spermicides.1 Three days of antibiotics are generally sufficient for treatment of uncomplicated cystitis. Fluoroquinolones and trimethoprim-sulfamethoxazole are well tolerated and are eas-ily available. Nitrofurantoin, which is also commonly used for uncomplicated cystitis, requires 5 days of treatment. Men with uncomplicated cystitis should undergo 7 days of treatment.Complicated cystitis may arise in the setting of structural or functional urinary tract abnormalities, recent urinary tract
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Surgery_Schwartz. and dysuria. Patients may also report lower back pain, suprapubic pain, foul-smelling urine, or gross hema-turia. Urinalysis with microscopy assists with diagnosis by confirming the presence of pyuria, hematuria, and bacteriuria. Office dipstick may be helpful, as the presence of nitrites reflects bacterial colonization and the presence of leukocyte esterase reflects pyuria. Risk factors for the development of uncompli-cated cystitis include female gender, sexual activity, and use of spermicides.1 Three days of antibiotics are generally sufficient for treatment of uncomplicated cystitis. Fluoroquinolones and trimethoprim-sulfamethoxazole are well tolerated and are eas-ily available. Nitrofurantoin, which is also commonly used for uncomplicated cystitis, requires 5 days of treatment. Men with uncomplicated cystitis should undergo 7 days of treatment.Complicated cystitis may arise in the setting of structural or functional urinary tract abnormalities, recent urinary tract
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Men with uncomplicated cystitis should undergo 7 days of treatment.Complicated cystitis may arise in the setting of structural or functional urinary tract abnormalities, recent urinary tract instru-mentation, recent antimicrobial use, immunosuppressed states, pregnancy, or hospital-acquired infection. Symptoms may be simi-lar to uncomplicated cystitis but can progress to pyelonephritis if left untreated. Elderly or very young patients tend to exhibit leth-argy, change in mental status, or anorexia, which may confound the diagnosis of a urinary tract infection. Patients may require hos-pitalization if febrile or if symptoms are severe. Treatment consists of 10 to 14 days of antibiotics. Fluoroquinolones or trimethoprim-sulfamethoxazole are usually effective and should be administered based on culture results and/or regional bacteriograms. Asymp-tomatic bacteriuria does not require treatment unless detected dur-ing pregnancy or if urinary tract instrumentation is
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Surgery_Schwartz. Men with uncomplicated cystitis should undergo 7 days of treatment.Complicated cystitis may arise in the setting of structural or functional urinary tract abnormalities, recent urinary tract instru-mentation, recent antimicrobial use, immunosuppressed states, pregnancy, or hospital-acquired infection. Symptoms may be simi-lar to uncomplicated cystitis but can progress to pyelonephritis if left untreated. Elderly or very young patients tend to exhibit leth-argy, change in mental status, or anorexia, which may confound the diagnosis of a urinary tract infection. Patients may require hos-pitalization if febrile or if symptoms are severe. Treatment consists of 10 to 14 days of antibiotics. Fluoroquinolones or trimethoprim-sulfamethoxazole are usually effective and should be administered based on culture results and/or regional bacteriograms. Asymp-tomatic bacteriuria does not require treatment unless detected dur-ing pregnancy or if urinary tract instrumentation is
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be administered based on culture results and/or regional bacteriograms. Asymp-tomatic bacteriuria does not require treatment unless detected dur-ing pregnancy or if urinary tract instrumentation is planned.1PyelonephritisPyelonephritis arises when a bladder infection ascends proxi-mally along the ureters to the renal parenchyma. It may also result from hematogenous spread, such as in the case of intra-venous drug abuse or in patients with bacteremia from other sources. Patients with pyelonephritis may present with fevers, flank pain, nausea, vomiting, and lower urinary tract symptoms. Physical exam may reveal tenderness of the costovertebral angle. Patients may appear toxic, with poor oral intake. Labora-tory evaluation may reveal leukocytosis with elevated neutro-phils. Urinalysis usually demonstrates the presence of pyuria and bacteriuria, and urine culture should be sent prior to start-ing broad-spectrum antibiotics. Imaging should be considered to rule out obstruction, which could
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Surgery_Schwartz. be administered based on culture results and/or regional bacteriograms. Asymp-tomatic bacteriuria does not require treatment unless detected dur-ing pregnancy or if urinary tract instrumentation is planned.1PyelonephritisPyelonephritis arises when a bladder infection ascends proxi-mally along the ureters to the renal parenchyma. It may also result from hematogenous spread, such as in the case of intra-venous drug abuse or in patients with bacteremia from other sources. Patients with pyelonephritis may present with fevers, flank pain, nausea, vomiting, and lower urinary tract symptoms. Physical exam may reveal tenderness of the costovertebral angle. Patients may appear toxic, with poor oral intake. Labora-tory evaluation may reveal leukocytosis with elevated neutro-phils. Urinalysis usually demonstrates the presence of pyuria and bacteriuria, and urine culture should be sent prior to start-ing broad-spectrum antibiotics. Imaging should be considered to rule out obstruction, which could
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demonstrates the presence of pyuria and bacteriuria, and urine culture should be sent prior to start-ing broad-spectrum antibiotics. Imaging should be considered to rule out obstruction, which could prolong the recovery period despite appropriate antimicrobial treatment.Acute pyelonephritis requires 7 to 14 days of antibiotic therapy. Mild or moderate cases, even if febrile, can safely be treated as an outpatient with oral antibiotics. Fluoroquino-lones and trimethoprim-sulfamethoxazole are ideal for treating pyelonephritis. Nitrofurantoin should not be used as it does not penetrate renal parenchyma. Patients with concern for sepsis or inability to tolerate oral intake may require hospitalization with IV antibiotics while awaiting culture results. Fevers may persist for up to 72 hours despite appropriate treatment. The presence of persistent fevers or symptoms after this time period warrants cross-sectional imaging to rule out renal or perinephric abscess. Treatment for renal or
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Surgery_Schwartz. demonstrates the presence of pyuria and bacteriuria, and urine culture should be sent prior to start-ing broad-spectrum antibiotics. Imaging should be considered to rule out obstruction, which could prolong the recovery period despite appropriate antimicrobial treatment.Acute pyelonephritis requires 7 to 14 days of antibiotic therapy. Mild or moderate cases, even if febrile, can safely be treated as an outpatient with oral antibiotics. Fluoroquino-lones and trimethoprim-sulfamethoxazole are ideal for treating pyelonephritis. Nitrofurantoin should not be used as it does not penetrate renal parenchyma. Patients with concern for sepsis or inability to tolerate oral intake may require hospitalization with IV antibiotics while awaiting culture results. Fevers may persist for up to 72 hours despite appropriate treatment. The presence of persistent fevers or symptoms after this time period warrants cross-sectional imaging to rule out renal or perinephric abscess. Treatment for renal or
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despite appropriate treatment. The presence of persistent fevers or symptoms after this time period warrants cross-sectional imaging to rule out renal or perinephric abscess. Treatment for renal or perinephric abscess usually consists of percutaneous drainage and broad-spectrum IV antibiotics.ProstatitisAcute prostatitis is marked by fever, suprapubic or perineal pain, and new onset lower urinary tract symptoms, namely dys-uria, frequency, urgency, changes in stream caliber, or difficulty emptying the bladder. It is most often caused by urinary patho-gens. Digital rectal exam may reveal a tender and soft pros-tate. Bladder drainage with a Foley or suprapubic tube may be required if urinary retention is present. Treatment consists of a long-term course (4–6 weeks) of antibiotics. If not treated in a timely fashion, acute prostatitis can develop into severe sepsis or a prostatic abscess. Prostatic abscesses may require drainage via a transurethral approach or transrectal needle
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Surgery_Schwartz. despite appropriate treatment. The presence of persistent fevers or symptoms after this time period warrants cross-sectional imaging to rule out renal or perinephric abscess. Treatment for renal or perinephric abscess usually consists of percutaneous drainage and broad-spectrum IV antibiotics.ProstatitisAcute prostatitis is marked by fever, suprapubic or perineal pain, and new onset lower urinary tract symptoms, namely dys-uria, frequency, urgency, changes in stream caliber, or difficulty emptying the bladder. It is most often caused by urinary patho-gens. Digital rectal exam may reveal a tender and soft pros-tate. Bladder drainage with a Foley or suprapubic tube may be required if urinary retention is present. Treatment consists of a long-term course (4–6 weeks) of antibiotics. If not treated in a timely fashion, acute prostatitis can develop into severe sepsis or a prostatic abscess. Prostatic abscesses may require drainage via a transurethral approach or transrectal needle
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not treated in a timely fashion, acute prostatitis can develop into severe sepsis or a prostatic abscess. Prostatic abscesses may require drainage via a transurethral approach or transrectal needle aspiration.Chronic prostatitis may be bacterial or abacterial. Symptoms in both cases include perineal, suprapubic, or penile pain, along with urinary frequency, urgency, or change in stream caliber. Men may also report pain in the groin, lower back, or testes. Fever is not observed in chronic prostatitis, and onset may occur over many months. Patients with chronic bacterial prostatitis may also report recurrent UTIs, with cultures consistently exhibiting the same bacteria. Differentiation between the two etiologies requires culture of expressed prostatic secretion to confirm the presence or absence of bacteria. Treatment of chronic bacterial prostatitis includes long-term antibiotics and α-blockers.Chronic abacterial prostatitis is also known as chronic pel-vic pain syndrome (CPPS).
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Surgery_Schwartz. not treated in a timely fashion, acute prostatitis can develop into severe sepsis or a prostatic abscess. Prostatic abscesses may require drainage via a transurethral approach or transrectal needle aspiration.Chronic prostatitis may be bacterial or abacterial. Symptoms in both cases include perineal, suprapubic, or penile pain, along with urinary frequency, urgency, or change in stream caliber. Men may also report pain in the groin, lower back, or testes. Fever is not observed in chronic prostatitis, and onset may occur over many months. Patients with chronic bacterial prostatitis may also report recurrent UTIs, with cultures consistently exhibiting the same bacteria. Differentiation between the two etiologies requires culture of expressed prostatic secretion to confirm the presence or absence of bacteria. Treatment of chronic bacterial prostatitis includes long-term antibiotics and α-blockers.Chronic abacterial prostatitis is also known as chronic pel-vic pain syndrome (CPPS).
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or absence of bacteria. Treatment of chronic bacterial prostatitis includes long-term antibiotics and α-blockers.Chronic abacterial prostatitis is also known as chronic pel-vic pain syndrome (CPPS). Symptoms are similar to chronic bacterial prostatitis, but generally do not respond well to long-term antibiotics for treatment. It is generally somewhat more difficult to achieve symptomatic relief when treating CPPS, and options include α-blockers, NSAIDs, neuromodulators, and/or pelvic floor physical therapy.2Epididymo-OrchitisEpididymitis refers to inflammation of the epididymis. In most cases of bacterial infection, the testis is also affected, thus is encompassed by the term “epididymo-orchitis.” Common eti-ologies include sexually transmitted infection, especially in younger males, or urinary tract infection, which is more com-monly seen in older males. Other possible etiologies include underlying congenital urologic abnormality or incomplete blad-der emptying. Symptoms include pain
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Surgery_Schwartz. or absence of bacteria. Treatment of chronic bacterial prostatitis includes long-term antibiotics and α-blockers.Chronic abacterial prostatitis is also known as chronic pel-vic pain syndrome (CPPS). Symptoms are similar to chronic bacterial prostatitis, but generally do not respond well to long-term antibiotics for treatment. It is generally somewhat more difficult to achieve symptomatic relief when treating CPPS, and options include α-blockers, NSAIDs, neuromodulators, and/or pelvic floor physical therapy.2Epididymo-OrchitisEpididymitis refers to inflammation of the epididymis. In most cases of bacterial infection, the testis is also affected, thus is encompassed by the term “epididymo-orchitis.” Common eti-ologies include sexually transmitted infection, especially in younger males, or urinary tract infection, which is more com-monly seen in older males. Other possible etiologies include underlying congenital urologic abnormality or incomplete blad-der emptying. Symptoms include pain
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tract infection, which is more com-monly seen in older males. Other possible etiologies include underlying congenital urologic abnormality or incomplete blad-der emptying. Symptoms include pain and swelling of the epi-didymis and testis. Some men may report nausea or vomiting, which arises as a result of irritation of the spermatic cord. Uri-nary symptoms may be present, but absence of symptoms does not rule out bacterial epididymo-orchitis. Physical exam gen-erally reveals a tender, swollen epididymis and testis. Scrotal skin erythema or reactive hydrocele may be present as well. A complete blood count should be performed to rule out leukocy-tosis, and urinalysis with urine culture should be collected prior to initiation of antibiotics. Urethral swab should be performed if sexually transmitted infection is a possible etiology. The clini-cal presentation of testicular torsion can be quite similar to that of Brunicardi_Ch40_p1759-p1782.indd 176101/03/19 6:34 PM 1762SPECIFIC
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Surgery_Schwartz. tract infection, which is more com-monly seen in older males. Other possible etiologies include underlying congenital urologic abnormality or incomplete blad-der emptying. Symptoms include pain and swelling of the epi-didymis and testis. Some men may report nausea or vomiting, which arises as a result of irritation of the spermatic cord. Uri-nary symptoms may be present, but absence of symptoms does not rule out bacterial epididymo-orchitis. Physical exam gen-erally reveals a tender, swollen epididymis and testis. Scrotal skin erythema or reactive hydrocele may be present as well. A complete blood count should be performed to rule out leukocy-tosis, and urinalysis with urine culture should be collected prior to initiation of antibiotics. Urethral swab should be performed if sexually transmitted infection is a possible etiology. The clini-cal presentation of testicular torsion can be quite similar to that of Brunicardi_Ch40_p1759-p1782.indd 176101/03/19 6:34 PM 1762SPECIFIC
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Surgery_Schwartz_11648
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transmitted infection is a possible etiology. The clini-cal presentation of testicular torsion can be quite similar to that of Brunicardi_Ch40_p1759-p1782.indd 176101/03/19 6:34 PM 1762SPECIFIC CONSIDERATIONSPART IIepididymo-orchitis. It may be quite difficult to clinically differenti-ate the two entities, but one should keep in mind that the onset of torsion tends to be slightly more acute (within 4–8 hours) than that of epididymo-orchitis (which generally arises over the course of 24–48 hours). Scrotal ultrasound can assist in diagnosis; how-ever, in cases of severe orchitis, testicular flow can be compro-mised, which may raise concern for torsion. Scrotal exploration should be considered in any equivocal case: a missed torsion can result in testicular loss secondary to necrosis.Treatment of epididymo-orchitis consists of single dose of ceftriaxone and azithromycin if there is concern for sexu-ally transmitted infection, as well as 14 days of oral antibiotic therapy, NSAIDs, and
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Surgery_Schwartz. transmitted infection is a possible etiology. The clini-cal presentation of testicular torsion can be quite similar to that of Brunicardi_Ch40_p1759-p1782.indd 176101/03/19 6:34 PM 1762SPECIFIC CONSIDERATIONSPART IIepididymo-orchitis. It may be quite difficult to clinically differenti-ate the two entities, but one should keep in mind that the onset of torsion tends to be slightly more acute (within 4–8 hours) than that of epididymo-orchitis (which generally arises over the course of 24–48 hours). Scrotal ultrasound can assist in diagnosis; how-ever, in cases of severe orchitis, testicular flow can be compro-mised, which may raise concern for torsion. Scrotal exploration should be considered in any equivocal case: a missed torsion can result in testicular loss secondary to necrosis.Treatment of epididymo-orchitis consists of single dose of ceftriaxone and azithromycin if there is concern for sexu-ally transmitted infection, as well as 14 days of oral antibiotic therapy, NSAIDs, and
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Surgery_Schwartz_11649
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of epididymo-orchitis consists of single dose of ceftriaxone and azithromycin if there is concern for sexu-ally transmitted infection, as well as 14 days of oral antibiotic therapy, NSAIDs, and scrotal support. If the patient exhibits fevers or toxic presentation, hospitalization with IV antibiotics may be required.Balanitis and BalanoposthitisBalanitis refers to inflammation of the glans penis. Balano-posthitis arises when the foreskin is also involved. Common etiologies include fungal infection, bacterial infection, contact dermatitis, or local trauma. Exam reveals a diffusely erythema-tous and warm glans penis, with inner preputial erythema as well if balanoposthitis is present. Treatment includes appropri-ate hygiene, topical antibiotics or antifungals, and occasionally topical steroids. If there is an inappropriate response to treat-ment, the differential diagnosis should include malignancy, pso-riasis, or infectious agents such as HPV.3URINARY TRACT OBSTRUCTIONUrolithiasisRenal
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Surgery_Schwartz. of epididymo-orchitis consists of single dose of ceftriaxone and azithromycin if there is concern for sexu-ally transmitted infection, as well as 14 days of oral antibiotic therapy, NSAIDs, and scrotal support. If the patient exhibits fevers or toxic presentation, hospitalization with IV antibiotics may be required.Balanitis and BalanoposthitisBalanitis refers to inflammation of the glans penis. Balano-posthitis arises when the foreskin is also involved. Common etiologies include fungal infection, bacterial infection, contact dermatitis, or local trauma. Exam reveals a diffusely erythema-tous and warm glans penis, with inner preputial erythema as well if balanoposthitis is present. Treatment includes appropri-ate hygiene, topical antibiotics or antifungals, and occasionally topical steroids. If there is an inappropriate response to treat-ment, the differential diagnosis should include malignancy, pso-riasis, or infectious agents such as HPV.3URINARY TRACT OBSTRUCTIONUrolithiasisRenal
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Surgery_Schwartz_11650
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If there is an inappropriate response to treat-ment, the differential diagnosis should include malignancy, pso-riasis, or infectious agents such as HPV.3URINARY TRACT OBSTRUCTIONUrolithiasisRenal stone disease is a common problem that is a major health care burden to society today. The prevalence of stone disease in the United States has increased over the past several decades as reported by the National Health and Nutrition Examination Survey (NHANES), and was estimated at 8.8% for the period between 2007 and 2010.4 This prevalence has increased with factors such as global warming, poor diet choices, and the obesity trend. Overall, the total estimated annual expenditure for individuals with claims for a diagnosis of urolithiasis was almost $2.1 billion in 2000, representing a 50% increase since 1994.5 Risk factors for stone formation include dietary habits, family history, white race, geographical location or occupa-tional exposure to heat/dehydration, intestinal disease, and male
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Surgery_Schwartz. If there is an inappropriate response to treat-ment, the differential diagnosis should include malignancy, pso-riasis, or infectious agents such as HPV.3URINARY TRACT OBSTRUCTIONUrolithiasisRenal stone disease is a common problem that is a major health care burden to society today. The prevalence of stone disease in the United States has increased over the past several decades as reported by the National Health and Nutrition Examination Survey (NHANES), and was estimated at 8.8% for the period between 2007 and 2010.4 This prevalence has increased with factors such as global warming, poor diet choices, and the obesity trend. Overall, the total estimated annual expenditure for individuals with claims for a diagnosis of urolithiasis was almost $2.1 billion in 2000, representing a 50% increase since 1994.5 Risk factors for stone formation include dietary habits, family history, white race, geographical location or occupa-tional exposure to heat/dehydration, intestinal disease, and male
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Surgery_Schwartz_11651
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since 1994.5 Risk factors for stone formation include dietary habits, family history, white race, geographical location or occupa-tional exposure to heat/dehydration, intestinal disease, and male gender, although the gender gap is decreasing.6 More recently, stone formation has also been associated with obesity, metabolic syndrome, and diabetes mellitus.7,8Stones are most commonly composed of calcium oxa-late. Other stone compositions include calcium phosphate, uric acid, cystine, medication-related, and infectious stones (stru-vite or carbonate apatite) or a mix thereof. Stone composition can vary based on a number of underlying pathophysiological processes. For example, hyperoxaluria may be seen in patients who have undergone small bowel resection, particularly the ter-minal ileum. This can result in an increase in unabsorbed fatty acids and bile salts which undergo saponification by binding with calcium in the bowel. The increase in unbound oxalate is absorbed by the large
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Surgery_Schwartz. since 1994.5 Risk factors for stone formation include dietary habits, family history, white race, geographical location or occupa-tional exposure to heat/dehydration, intestinal disease, and male gender, although the gender gap is decreasing.6 More recently, stone formation has also been associated with obesity, metabolic syndrome, and diabetes mellitus.7,8Stones are most commonly composed of calcium oxa-late. Other stone compositions include calcium phosphate, uric acid, cystine, medication-related, and infectious stones (stru-vite or carbonate apatite) or a mix thereof. Stone composition can vary based on a number of underlying pathophysiological processes. For example, hyperoxaluria may be seen in patients who have undergone small bowel resection, particularly the ter-minal ileum. This can result in an increase in unabsorbed fatty acids and bile salts which undergo saponification by binding with calcium in the bowel. The increase in unbound oxalate is absorbed by the large
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Surgery_Schwartz_11652
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Surgery_Schwartz
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This can result in an increase in unabsorbed fatty acids and bile salts which undergo saponification by binding with calcium in the bowel. The increase in unbound oxalate is absorbed by the large intestine and subsequently excreted in the urine, favoring the formation of calcium oxalate stones. Uric acid stones will form in a context of acidic urinary pH, low uri-nary volume, and high oral intake of purines. Countering these factors by alkalinizing the urine and increasing urine output Figure 40-1. Struvite (infectious) stones are evident on a plain radiograph of the abdomen. The red arrows highlight a left Stag-horn calculus filling the renal pelvis and calyces and several stones in the right lower pole of the kidney.may lead to dissolution of uric acid stones and reduced fur-ther formation.9 Proteus species, Klebsiella species, and other urease-producing bacteria metabolize urea into ammonium and bicarbonate. The alkaline milieu (pH >7) predisposes to infec-tious (struvite) stones
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Surgery_Schwartz. This can result in an increase in unabsorbed fatty acids and bile salts which undergo saponification by binding with calcium in the bowel. The increase in unbound oxalate is absorbed by the large intestine and subsequently excreted in the urine, favoring the formation of calcium oxalate stones. Uric acid stones will form in a context of acidic urinary pH, low uri-nary volume, and high oral intake of purines. Countering these factors by alkalinizing the urine and increasing urine output Figure 40-1. Struvite (infectious) stones are evident on a plain radiograph of the abdomen. The red arrows highlight a left Stag-horn calculus filling the renal pelvis and calyces and several stones in the right lower pole of the kidney.may lead to dissolution of uric acid stones and reduced fur-ther formation.9 Proteus species, Klebsiella species, and other urease-producing bacteria metabolize urea into ammonium and bicarbonate. The alkaline milieu (pH >7) predisposes to infec-tious (struvite) stones
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Surgery_Schwartz_11653
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Surgery_Schwartz
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Proteus species, Klebsiella species, and other urease-producing bacteria metabolize urea into ammonium and bicarbonate. The alkaline milieu (pH >7) predisposes to infec-tious (struvite) stones with the precipitation of magnesium, ammonium, and phosphate (Fig. 40-1).Evaluation for first-time stone formers should include a complete medical history and physical exam, basic metabolic panel, calcium, uric acid, urinalysis and culture, and radio-graphic imaging. A noncontrast computed tomography (CT) scan is the most sensitive (98%) and specific (97%) exam to detect urolithiasis10 and can provide additional anatomical infor-mation useful for surgical planning, although its use in recurrent stone formers should be balanced by cost and radiation expo-sure. Low-dose CT is currently the preferred imaging study for patients with a body mass index (BMI) <30. This imaging study uses less than one-third of the estimated effective ionizing radiation dose (3 mSv) compared to standard dose noncontrast
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Surgery_Schwartz. Proteus species, Klebsiella species, and other urease-producing bacteria metabolize urea into ammonium and bicarbonate. The alkaline milieu (pH >7) predisposes to infec-tious (struvite) stones with the precipitation of magnesium, ammonium, and phosphate (Fig. 40-1).Evaluation for first-time stone formers should include a complete medical history and physical exam, basic metabolic panel, calcium, uric acid, urinalysis and culture, and radio-graphic imaging. A noncontrast computed tomography (CT) scan is the most sensitive (98%) and specific (97%) exam to detect urolithiasis10 and can provide additional anatomical infor-mation useful for surgical planning, although its use in recurrent stone formers should be balanced by cost and radiation expo-sure. Low-dose CT is currently the preferred imaging study for patients with a body mass index (BMI) <30. This imaging study uses less than one-third of the estimated effective ionizing radiation dose (3 mSv) compared to standard dose noncontrast
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study for patients with a body mass index (BMI) <30. This imaging study uses less than one-third of the estimated effective ionizing radiation dose (3 mSv) compared to standard dose noncontrast CT (10 mSv),10 while maintaining excellent sensitivity (95%) and specificity (97%).11 Plain abdominal X-ray can be used to follow radiopaque stones such as calcium-containing stones or struvite stones, although at times struvite can be difficult to see on plain X-ray, especially when the fragments are small. Uric acid and triamterene stones are radiolucent on plain abdominal X-ray but will be visible on noncontrast CT. A full metabolic evaluation with a 24-hour urine collection is indicated in recur-rent stone formers, high-risk stone formers, or interested first-time stone formers.12The natural history of stones is variable and depends pri-marily on their size and location. Smaller and more distal stones are much more likely to pass spontaneously without the need for surgical
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Surgery_Schwartz. study for patients with a body mass index (BMI) <30. This imaging study uses less than one-third of the estimated effective ionizing radiation dose (3 mSv) compared to standard dose noncontrast CT (10 mSv),10 while maintaining excellent sensitivity (95%) and specificity (97%).11 Plain abdominal X-ray can be used to follow radiopaque stones such as calcium-containing stones or struvite stones, although at times struvite can be difficult to see on plain X-ray, especially when the fragments are small. Uric acid and triamterene stones are radiolucent on plain abdominal X-ray but will be visible on noncontrast CT. A full metabolic evaluation with a 24-hour urine collection is indicated in recur-rent stone formers, high-risk stone formers, or interested first-time stone formers.12The natural history of stones is variable and depends pri-marily on their size and location. Smaller and more distal stones are much more likely to pass spontaneously without the need for surgical
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Surgery_Schwartz_11655
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natural history of stones is variable and depends pri-marily on their size and location. Smaller and more distal stones are much more likely to pass spontaneously without the need for surgical intervention.13,14 Patients with ureteral stones ≤10 mm can be offered a period of observation if their pain is well controlled without signs of infection or renal insuf-ficiency. α-Blockers, which inhibit ureteral peristalsis, have been shown in meta-analyses to be particularly useful in patients with distal ureter stones ≤10 mm, improving the rate of stone passage from 54% to 77%,15,16 with shortened time to expulsion and fewer colic episodes.171Brunicardi_Ch40_p1759-p1782.indd 176201/03/19 6:34 PM 1763UROLOGYCHAPTER 40Patients who have not passed their stone after a 4to 6-week observation period, those with larger stones, or those who desire immediate intervention, may be offered one of three definitive surgical interventions: shockwave lithotripsy (SWL), ureteroscopy (URS), or
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Surgery_Schwartz. natural history of stones is variable and depends pri-marily on their size and location. Smaller and more distal stones are much more likely to pass spontaneously without the need for surgical intervention.13,14 Patients with ureteral stones ≤10 mm can be offered a period of observation if their pain is well controlled without signs of infection or renal insuf-ficiency. α-Blockers, which inhibit ureteral peristalsis, have been shown in meta-analyses to be particularly useful in patients with distal ureter stones ≤10 mm, improving the rate of stone passage from 54% to 77%,15,16 with shortened time to expulsion and fewer colic episodes.171Brunicardi_Ch40_p1759-p1782.indd 176201/03/19 6:34 PM 1763UROLOGYCHAPTER 40Patients who have not passed their stone after a 4to 6-week observation period, those with larger stones, or those who desire immediate intervention, may be offered one of three definitive surgical interventions: shockwave lithotripsy (SWL), ureteroscopy (URS), or
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period, those with larger stones, or those who desire immediate intervention, may be offered one of three definitive surgical interventions: shockwave lithotripsy (SWL), ureteroscopy (URS), or percutaneous nephrolithotomy (PCNL). Open surgical management of stones has been relegated to historic interest for the most part with less than 1% of stone surgery needing to be done open with access to modern endou-rologic equipment. The choice of the procedure will depend primarily on stone-related factors (e.g., stone size, location, and composition/density), and patient-related factors (e.g., comor-bidities, coagulopathy, obesity, renal anatomy, and surrounding structures).Shockwave lithotripsy is the procedure associated with the least morbidity and the lowest complication rate but is also associated with a lower success rate at treating stones as a single procedure and requires the patient to pass the stone fragments afterwards.15,16 The modality can be used for stones in the prox-imal
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Surgery_Schwartz. period, those with larger stones, or those who desire immediate intervention, may be offered one of three definitive surgical interventions: shockwave lithotripsy (SWL), ureteroscopy (URS), or percutaneous nephrolithotomy (PCNL). Open surgical management of stones has been relegated to historic interest for the most part with less than 1% of stone surgery needing to be done open with access to modern endou-rologic equipment. The choice of the procedure will depend primarily on stone-related factors (e.g., stone size, location, and composition/density), and patient-related factors (e.g., comor-bidities, coagulopathy, obesity, renal anatomy, and surrounding structures).Shockwave lithotripsy is the procedure associated with the least morbidity and the lowest complication rate but is also associated with a lower success rate at treating stones as a single procedure and requires the patient to pass the stone fragments afterwards.15,16 The modality can be used for stones in the prox-imal
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Surgery_Schwartz_11657
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with a lower success rate at treating stones as a single procedure and requires the patient to pass the stone fragments afterwards.15,16 The modality can be used for stones in the prox-imal ureter (particularly if <10 mm) or non–lower-pole renal stones <2 cm.15,16 The stone is located under fluoroscopic guid-ance, which is coupled to an extracorporeal lithotripter aimed at the stone. The stone is fragmented in a completely nonin-vasive manner. Complications associated with this procedure include subcapsular or perinephric renal hematoma and ureteral obstruction by stone fragments (“Steinstrausse”; Fig. 40-2). Ureteroscopy is the procedure of choice for patients with middle or distal ureteral stones. It also has a higher success rate than SWL in treating >10-mm proximal ureteral stones and renal stones.15,16 This procedure involves advancing a semi-rigid or flexible ureteroscope to the level of the stone and fragmenting it under direct visualization, often using a holmium:YAG laser.
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Surgery_Schwartz. with a lower success rate at treating stones as a single procedure and requires the patient to pass the stone fragments afterwards.15,16 The modality can be used for stones in the prox-imal ureter (particularly if <10 mm) or non–lower-pole renal stones <2 cm.15,16 The stone is located under fluoroscopic guid-ance, which is coupled to an extracorporeal lithotripter aimed at the stone. The stone is fragmented in a completely nonin-vasive manner. Complications associated with this procedure include subcapsular or perinephric renal hematoma and ureteral obstruction by stone fragments (“Steinstrausse”; Fig. 40-2). Ureteroscopy is the procedure of choice for patients with middle or distal ureteral stones. It also has a higher success rate than SWL in treating >10-mm proximal ureteral stones and renal stones.15,16 This procedure involves advancing a semi-rigid or flexible ureteroscope to the level of the stone and fragmenting it under direct visualization, often using a holmium:YAG laser.
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renal stones.15,16 This procedure involves advancing a semi-rigid or flexible ureteroscope to the level of the stone and fragmenting it under direct visualization, often using a holmium:YAG laser. The surgeon is able to visualize the stone during fragmentation and thereby has some control over how small the fragments are. In addition, stone fragments may also be actively removed with a small nitinol stone basket. This is where the procedure may have an advantage over SWL. However, many patients have a ureteral stent placed after ureteroscopy, and, although tempo-rary, this remains a major source of morbidity for the patient. Specific complications of URS include ureteral injury or stric-ture. PCNL is reserved for patients with larger or more complex Figure 40-2. Ureteral obstruction in a patient with Steinstrausse. A plain abdominal radiograph (KUB) demonstrates Steinstrausse in the right distal ureter between the white arrows.stone burden, and requires a percutaneous tract into the
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Surgery_Schwartz. renal stones.15,16 This procedure involves advancing a semi-rigid or flexible ureteroscope to the level of the stone and fragmenting it under direct visualization, often using a holmium:YAG laser. The surgeon is able to visualize the stone during fragmentation and thereby has some control over how small the fragments are. In addition, stone fragments may also be actively removed with a small nitinol stone basket. This is where the procedure may have an advantage over SWL. However, many patients have a ureteral stent placed after ureteroscopy, and, although tempo-rary, this remains a major source of morbidity for the patient. Specific complications of URS include ureteral injury or stric-ture. PCNL is reserved for patients with larger or more complex Figure 40-2. Ureteral obstruction in a patient with Steinstrausse. A plain abdominal radiograph (KUB) demonstrates Steinstrausse in the right distal ureter between the white arrows.stone burden, and requires a percutaneous tract into the
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patient with Steinstrausse. A plain abdominal radiograph (KUB) demonstrates Steinstrausse in the right distal ureter between the white arrows.stone burden, and requires a percutaneous tract into the kidney. Most stones larger than 2 cm are treated with PCNL although there is a role for PCNL for smaller stones located in the lower pole of the collecting system.18,19 More powerful lithotripters (pneumatic, ultrasound) and larger instruments (stone graspers) can be used to fragment and remove these larger stones through the percutaneous tract. Complications include injury to adjacent organs, acute and delayed renal bleeding due to pseudoaneu-rysm or arteriovenous fistula formation, sepsis, or renal pelvis perforation.General preventative measures include correcting dietary habits, particularly increasing fluid intake to produce >2.5 liters of urine per day, limiting sodium, reducing animal protein intake, and monitoring foods high in oxalate. Medical therapy such as thiazide diuretics
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Surgery_Schwartz. patient with Steinstrausse. A plain abdominal radiograph (KUB) demonstrates Steinstrausse in the right distal ureter between the white arrows.stone burden, and requires a percutaneous tract into the kidney. Most stones larger than 2 cm are treated with PCNL although there is a role for PCNL for smaller stones located in the lower pole of the collecting system.18,19 More powerful lithotripters (pneumatic, ultrasound) and larger instruments (stone graspers) can be used to fragment and remove these larger stones through the percutaneous tract. Complications include injury to adjacent organs, acute and delayed renal bleeding due to pseudoaneu-rysm or arteriovenous fistula formation, sepsis, or renal pelvis perforation.General preventative measures include correcting dietary habits, particularly increasing fluid intake to produce >2.5 liters of urine per day, limiting sodium, reducing animal protein intake, and monitoring foods high in oxalate. Medical therapy such as thiazide diuretics
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Surgery_Schwartz_11660
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Surgery_Schwartz
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increasing fluid intake to produce >2.5 liters of urine per day, limiting sodium, reducing animal protein intake, and monitoring foods high in oxalate. Medical therapy such as thiazide diuretics (helpful for hypercalciuria), urinary alkalization with potassium citrate, or allopurinol may also be indicated depending on the clinical situation.12Benign Prostatic HyperplasiaBenign prostatic hyperplasia (BPH) refers to the histological findings of smooth muscle and fibroblast/epithelial cell pro-liferation in the transition zone of the prostate. Lower urinary tract symptoms (LUTS) may be secondary to benign prostatic enlargement (BPE) causing progressive bladder outlet obstruc-tion but may also be due to numerous other conditions (e.g., urethral stricture, infection, overactive or neurogenic bladder, malignancy). Although some male patients with LUTS may have BPE, not all patients with an enlarged prostate have LUTS. The prevalence of LUTS attributed to BPH in men over the age of 50 is
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Surgery_Schwartz. increasing fluid intake to produce >2.5 liters of urine per day, limiting sodium, reducing animal protein intake, and monitoring foods high in oxalate. Medical therapy such as thiazide diuretics (helpful for hypercalciuria), urinary alkalization with potassium citrate, or allopurinol may also be indicated depending on the clinical situation.12Benign Prostatic HyperplasiaBenign prostatic hyperplasia (BPH) refers to the histological findings of smooth muscle and fibroblast/epithelial cell pro-liferation in the transition zone of the prostate. Lower urinary tract symptoms (LUTS) may be secondary to benign prostatic enlargement (BPE) causing progressive bladder outlet obstruc-tion but may also be due to numerous other conditions (e.g., urethral stricture, infection, overactive or neurogenic bladder, malignancy). Although some male patients with LUTS may have BPE, not all patients with an enlarged prostate have LUTS. The prevalence of LUTS attributed to BPH in men over the age of 50 is
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Surgery_Schwartz_11661
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bladder, malignancy). Although some male patients with LUTS may have BPE, not all patients with an enlarged prostate have LUTS. The prevalence of LUTS attributed to BPH in men over the age of 50 is estimated at 50% to 75% and increases with age with a prevalence of 80% in men over the age of 70.20 The treatment modalities have dramatically evolved over the past decades, with medical management typically used for first-line therapy. Endoscopic and minimally invasive techniques are used for those failing or intolerant of medical therapy.Men with BPH/LUTS are evaluated with a complete his-tory and physical exam including digital rectal exam. LUTS should be clearly defined, in addition to their severity and degree of bother. Validated questionnaires to quantify the patient’s symptoms and degree of bother include the American Urologi-cal Association Symptom Index (AUA-SI) and the International Prostate Symptom Score (IPSS).21,22 Complications of BPH such as urinary retention, incontinence,
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Surgery_Schwartz. bladder, malignancy). Although some male patients with LUTS may have BPE, not all patients with an enlarged prostate have LUTS. The prevalence of LUTS attributed to BPH in men over the age of 50 is estimated at 50% to 75% and increases with age with a prevalence of 80% in men over the age of 70.20 The treatment modalities have dramatically evolved over the past decades, with medical management typically used for first-line therapy. Endoscopic and minimally invasive techniques are used for those failing or intolerant of medical therapy.Men with BPH/LUTS are evaluated with a complete his-tory and physical exam including digital rectal exam. LUTS should be clearly defined, in addition to their severity and degree of bother. Validated questionnaires to quantify the patient’s symptoms and degree of bother include the American Urologi-cal Association Symptom Index (AUA-SI) and the International Prostate Symptom Score (IPSS).21,22 Complications of BPH such as urinary retention, incontinence,
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of bother include the American Urologi-cal Association Symptom Index (AUA-SI) and the International Prostate Symptom Score (IPSS).21,22 Complications of BPH such as urinary retention, incontinence, renal failure, hema-turia, or recurrent infections should also be considered. Basic workup includes a urinalysis and culture to rule out infection. After an informative discussion about the risks and benefits of prostate cancer screening, a serum PSA is measured when life expectancy is >10 years and if the diagnosis of prostate can-cer will alter management.23 Other diagnostic testing such as cystoscopy, cytology, postvoid residual (PVR), urodynamics, and radiologic imaging of the prostate, although not done rou-tinely, may be required in patients with a definite indication (e.g., hematuria), uncertain diagnosis, poor response to therapy, or for surgical planning.24The first line of treatment is most commonly pharmaco-therapy for those men with bothersome symptoms. α-Blockers work by
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Surgery_Schwartz. of bother include the American Urologi-cal Association Symptom Index (AUA-SI) and the International Prostate Symptom Score (IPSS).21,22 Complications of BPH such as urinary retention, incontinence, renal failure, hema-turia, or recurrent infections should also be considered. Basic workup includes a urinalysis and culture to rule out infection. After an informative discussion about the risks and benefits of prostate cancer screening, a serum PSA is measured when life expectancy is >10 years and if the diagnosis of prostate can-cer will alter management.23 Other diagnostic testing such as cystoscopy, cytology, postvoid residual (PVR), urodynamics, and radiologic imaging of the prostate, although not done rou-tinely, may be required in patients with a definite indication (e.g., hematuria), uncertain diagnosis, poor response to therapy, or for surgical planning.24The first line of treatment is most commonly pharmaco-therapy for those men with bothersome symptoms. α-Blockers work by
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uncertain diagnosis, poor response to therapy, or for surgical planning.24The first line of treatment is most commonly pharmaco-therapy for those men with bothersome symptoms. α-Blockers work by relaxing the smooth muscle of the prostate and bladder neck. All α-blocker agents are equally effective,25 and their side effects may include orthostatic hypo-tension, dizziness, asthenia, headache, nasal congestion, and retrograde ejaculation. Their effect is usually seen within days. Five-α reductase inhibitors (5-ARIs) block the conversion of 2Brunicardi_Ch40_p1759-p1782.indd 176301/03/19 6:34 PM 1764SPECIFIC CONSIDERATIONSPART IItestosterone to dihydrotestosterone (DHT), the hormone primar-ily responsible for BPH progression. These reduce prostatic size by 20% to 25%,26 but their effects are seen only after 4 to 6 months. Side effects include erectile dysfunction, decreased libido, and, rarely, gynecomastia. 5-ARIs, but not α-blockers, can alter disease progression as demonstrated by
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Surgery_Schwartz. uncertain diagnosis, poor response to therapy, or for surgical planning.24The first line of treatment is most commonly pharmaco-therapy for those men with bothersome symptoms. α-Blockers work by relaxing the smooth muscle of the prostate and bladder neck. All α-blocker agents are equally effective,25 and their side effects may include orthostatic hypo-tension, dizziness, asthenia, headache, nasal congestion, and retrograde ejaculation. Their effect is usually seen within days. Five-α reductase inhibitors (5-ARIs) block the conversion of 2Brunicardi_Ch40_p1759-p1782.indd 176301/03/19 6:34 PM 1764SPECIFIC CONSIDERATIONSPART IItestosterone to dihydrotestosterone (DHT), the hormone primar-ily responsible for BPH progression. These reduce prostatic size by 20% to 25%,26 but their effects are seen only after 4 to 6 months. Side effects include erectile dysfunction, decreased libido, and, rarely, gynecomastia. 5-ARIs, but not α-blockers, can alter disease progression as demonstrated by
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are seen only after 4 to 6 months. Side effects include erectile dysfunction, decreased libido, and, rarely, gynecomastia. 5-ARIs, but not α-blockers, can alter disease progression as demonstrated by two landmark tri-als, the MTOPS27 and CombAT28 trials. These trials evaluated combination therapy using α-blockers and 5-ARIs. Patients on 5-ARIs, particularly those with larger prostates, had a reduced risk of both developing acute urinary retention and requiring surgical intervention. More recently, daily phosphodiesterase-5 inhibitors, which are most often used for erectile dysfunction (ED), have now been approved for treating patients with BPH. These can be particularly valuable in patients with concomitant ED.29,30Surgical modalities for BPH continue to evolve towards less invasive endoscopic procedures. Transurethral resection of the prostate (TURP) remains the mainstay of endoscopic pro-cedures, with low treatment failure and complication rates.31 TUR syndrome is associated with
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Surgery_Schwartz. are seen only after 4 to 6 months. Side effects include erectile dysfunction, decreased libido, and, rarely, gynecomastia. 5-ARIs, but not α-blockers, can alter disease progression as demonstrated by two landmark tri-als, the MTOPS27 and CombAT28 trials. These trials evaluated combination therapy using α-blockers and 5-ARIs. Patients on 5-ARIs, particularly those with larger prostates, had a reduced risk of both developing acute urinary retention and requiring surgical intervention. More recently, daily phosphodiesterase-5 inhibitors, which are most often used for erectile dysfunction (ED), have now been approved for treating patients with BPH. These can be particularly valuable in patients with concomitant ED.29,30Surgical modalities for BPH continue to evolve towards less invasive endoscopic procedures. Transurethral resection of the prostate (TURP) remains the mainstay of endoscopic pro-cedures, with low treatment failure and complication rates.31 TUR syndrome is associated with
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procedures. Transurethral resection of the prostate (TURP) remains the mainstay of endoscopic pro-cedures, with low treatment failure and complication rates.31 TUR syndrome is associated with prolonged use of hypotonic irrigation fluid, resulting in fluid overload and dilutional hypo-natremia. Symptoms include nausea/vomiting, bradycardia and hypertension, pulmonary edema, mental status changes, and rarely death. Other endoscopic modalities used today include bipolar TURP and various laser procedures (e.g., Ho:YAG laser enucleation of the prostate, Ho:YAG laser ablation of the prostate, and photoselective vaporization of the prostate) with the goal of enucleating or vaporizing prostatic tissue. Normal saline is used for irrigation with these modalities, which greatly reduces the risk of TUR syndrome. Generally, laser procedures have been associated with shorter catheterization time and length of stay with comparable improvements in LUTS to open prostatectomy or TURP.32-34 Open, and
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Surgery_Schwartz. procedures. Transurethral resection of the prostate (TURP) remains the mainstay of endoscopic pro-cedures, with low treatment failure and complication rates.31 TUR syndrome is associated with prolonged use of hypotonic irrigation fluid, resulting in fluid overload and dilutional hypo-natremia. Symptoms include nausea/vomiting, bradycardia and hypertension, pulmonary edema, mental status changes, and rarely death. Other endoscopic modalities used today include bipolar TURP and various laser procedures (e.g., Ho:YAG laser enucleation of the prostate, Ho:YAG laser ablation of the prostate, and photoselective vaporization of the prostate) with the goal of enucleating or vaporizing prostatic tissue. Normal saline is used for irrigation with these modalities, which greatly reduces the risk of TUR syndrome. Generally, laser procedures have been associated with shorter catheterization time and length of stay with comparable improvements in LUTS to open prostatectomy or TURP.32-34 Open, and
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TUR syndrome. Generally, laser procedures have been associated with shorter catheterization time and length of stay with comparable improvements in LUTS to open prostatectomy or TURP.32-34 Open, and more recently laparo-scopic and robotic simple prostatectomy can also be performed for patients with moderate-severe, bothersome LUTS due to BPH. These are usually reserved for patients with larger pros-tatic volumes (>100 cc), or patients requiring concomitant blad-der surgery (e.g., bladder diverticulectomy or stones).23Urethral StrictureA urethral stricture is an area of scarring or fibrosis that causes concentric narrowing of the urethra, impeding the flow of urine as it drains from the bladder. Strictures occur at a prevalence of 0.9% of the population in the United States.35 Causes of urethral stricture disease include trauma (19%), iatrogenic causes (33%), inflammatory causes (15%), and idiopathic causes (33%).36 Symptoms of urethral stricture disease include incomplete emptying,
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Surgery_Schwartz. TUR syndrome. Generally, laser procedures have been associated with shorter catheterization time and length of stay with comparable improvements in LUTS to open prostatectomy or TURP.32-34 Open, and more recently laparo-scopic and robotic simple prostatectomy can also be performed for patients with moderate-severe, bothersome LUTS due to BPH. These are usually reserved for patients with larger pros-tatic volumes (>100 cc), or patients requiring concomitant blad-der surgery (e.g., bladder diverticulectomy or stones).23Urethral StrictureA urethral stricture is an area of scarring or fibrosis that causes concentric narrowing of the urethra, impeding the flow of urine as it drains from the bladder. Strictures occur at a prevalence of 0.9% of the population in the United States.35 Causes of urethral stricture disease include trauma (19%), iatrogenic causes (33%), inflammatory causes (15%), and idiopathic causes (33%).36 Symptoms of urethral stricture disease include incomplete emptying,
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urethral stricture disease include trauma (19%), iatrogenic causes (33%), inflammatory causes (15%), and idiopathic causes (33%).36 Symptoms of urethral stricture disease include incomplete emptying, weak urinary stream, urinary urgency/frequency, and pain.37,38The anatomy of the urethra in men can be divided into the following segments proceeding from cephalad to caudad: prostatic, membranous, bulbous (the area between the pelvic floor and the penoscrotal junction), and penile. A stricture can occur in any segment of the urethra, but it is most common in the bulbar urethra.Options to treat urethral stricture disease can be divided into two general categories: endoscopic and surgical reconstruc-tion. Endoscopic treatments include a urethral dilation or stric-ture incision with a cystoscope. The latter is referred to as a direct vision internal urethrotomy. The success rate of one endo-scopic attempt to treat a urethral stricture is around 30%.39 The success of repeat endoscopic
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Surgery_Schwartz. urethral stricture disease include trauma (19%), iatrogenic causes (33%), inflammatory causes (15%), and idiopathic causes (33%).36 Symptoms of urethral stricture disease include incomplete emptying, weak urinary stream, urinary urgency/frequency, and pain.37,38The anatomy of the urethra in men can be divided into the following segments proceeding from cephalad to caudad: prostatic, membranous, bulbous (the area between the pelvic floor and the penoscrotal junction), and penile. A stricture can occur in any segment of the urethra, but it is most common in the bulbar urethra.Options to treat urethral stricture disease can be divided into two general categories: endoscopic and surgical reconstruc-tion. Endoscopic treatments include a urethral dilation or stric-ture incision with a cystoscope. The latter is referred to as a direct vision internal urethrotomy. The success rate of one endo-scopic attempt to treat a urethral stricture is around 30%.39 The success of repeat endoscopic
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The latter is referred to as a direct vision internal urethrotomy. The success rate of one endo-scopic attempt to treat a urethral stricture is around 30%.39 The success of repeat endoscopic treatments of a urethral stricture drops to 13%, and recurrent dilations have been associated with the need for more complex reconstructive surgeries for definitive management.39,40 For that reason, com-mon practice is to attempt one endoscopic intervention prior to referral for reconstructive surgery.Surgical reconstruction of the urethra, referred to as a ure-throplasty, can be divided into two general categories: excisional and tissue substitution. An excisional repair involves resection of the strictured segment of the urethra, and direct anastomo-sis of the two healthy urethral ends. This repair technique is generally reserved for membranous strictures and short bulbar strictures. Tissue substitution involves augmenting a narrowed urethral lumen with free tissue grafts. The most common tissue
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Surgery_Schwartz. The latter is referred to as a direct vision internal urethrotomy. The success rate of one endo-scopic attempt to treat a urethral stricture is around 30%.39 The success of repeat endoscopic treatments of a urethral stricture drops to 13%, and recurrent dilations have been associated with the need for more complex reconstructive surgeries for definitive management.39,40 For that reason, com-mon practice is to attempt one endoscopic intervention prior to referral for reconstructive surgery.Surgical reconstruction of the urethra, referred to as a ure-throplasty, can be divided into two general categories: excisional and tissue substitution. An excisional repair involves resection of the strictured segment of the urethra, and direct anastomo-sis of the two healthy urethral ends. This repair technique is generally reserved for membranous strictures and short bulbar strictures. Tissue substitution involves augmenting a narrowed urethral lumen with free tissue grafts. The most common tissue
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is generally reserved for membranous strictures and short bulbar strictures. Tissue substitution involves augmenting a narrowed urethral lumen with free tissue grafts. The most common tissue substitute is buccal (oral) mucosal graft.Other Causes of ObstructionRetroperitoneal fibrosis (RPF) is a rare cause of ureteric obstruction secondary to an inflammatory and fibrotic pro-cess of the retroperitoneal structures. Most cases (>70%) are idiopathic. Identifiable causes in the remaining cases include periaortic inflammation due to aneurysms, medications (e.g., methysergide, ergot derivatives, β-blockers, phenacetin), infec-tions (e.g., tuberculosis, schistosomiasis), and malignancy (e.g., lymphoma, multiple myeloma, sarcoma). Symptoms are non-specific and may include general abdominal discomfort or back pain, flank pain due to ureteral obstruction, or lower extremity edema due to vena caval compression. Laboratory abnormali-ties such as normocytic anemia, an elevated C-reactive protein,
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Surgery_Schwartz. is generally reserved for membranous strictures and short bulbar strictures. Tissue substitution involves augmenting a narrowed urethral lumen with free tissue grafts. The most common tissue substitute is buccal (oral) mucosal graft.Other Causes of ObstructionRetroperitoneal fibrosis (RPF) is a rare cause of ureteric obstruction secondary to an inflammatory and fibrotic pro-cess of the retroperitoneal structures. Most cases (>70%) are idiopathic. Identifiable causes in the remaining cases include periaortic inflammation due to aneurysms, medications (e.g., methysergide, ergot derivatives, β-blockers, phenacetin), infec-tions (e.g., tuberculosis, schistosomiasis), and malignancy (e.g., lymphoma, multiple myeloma, sarcoma). Symptoms are non-specific and may include general abdominal discomfort or back pain, flank pain due to ureteral obstruction, or lower extremity edema due to vena caval compression. Laboratory abnormali-ties such as normocytic anemia, an elevated C-reactive protein,
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or back pain, flank pain due to ureteral obstruction, or lower extremity edema due to vena caval compression. Laboratory abnormali-ties such as normocytic anemia, an elevated C-reactive protein, or ESR are identified in about two-thirds of cases.41 The classic radiological findings consist of a well-defined retroperitoneal soft tissue mass encasing the great vessels with medialization of the ureters. Contrast enhancement on CT scan, magnetic reso-nance imaging (MRI), and positron emission tomography (PET) scan can also be used to monitor disease activity and assess response to treatment.42Patients with symptomatic renal obstruction, renal insuf-ficiency, or signs of infection should be decompressed with either ureteral stents or nephrostomy and monitored for postob-structive diuresis. Biopsy of the retroperitoneal mass to exclude malignancy should be considered prior to commencing treat-ment. Steroid therapy remains the mainstay of medical treat-ment, although other immunosuppressive
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Surgery_Schwartz. or back pain, flank pain due to ureteral obstruction, or lower extremity edema due to vena caval compression. Laboratory abnormali-ties such as normocytic anemia, an elevated C-reactive protein, or ESR are identified in about two-thirds of cases.41 The classic radiological findings consist of a well-defined retroperitoneal soft tissue mass encasing the great vessels with medialization of the ureters. Contrast enhancement on CT scan, magnetic reso-nance imaging (MRI), and positron emission tomography (PET) scan can also be used to monitor disease activity and assess response to treatment.42Patients with symptomatic renal obstruction, renal insuf-ficiency, or signs of infection should be decompressed with either ureteral stents or nephrostomy and monitored for postob-structive diuresis. Biopsy of the retroperitoneal mass to exclude malignancy should be considered prior to commencing treat-ment. Steroid therapy remains the mainstay of medical treat-ment, although other immunosuppressive
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of the retroperitoneal mass to exclude malignancy should be considered prior to commencing treat-ment. Steroid therapy remains the mainstay of medical treat-ment, although other immunosuppressive agents have been described.43 If medical treatment fails, open or minimally inva-sive bilateral ureterolysis with intraperitonealization or omental wrapping of the ureters is indicated.Ureteral obstruction secondary to tumor (benign or malig-nant) is commonly encountered. Ureteral stenting can be tried initially, but it fails in approximately one-half of cases.44 Other strategies such as percutaneous nephrostomy, ureteral stenting in tandem, metallic, and metal-mesh stents have been described. Metallic stents may be more cost-effective due to less frequent stent exchanges,45-47 although cost savings may be offset by the limited life expectancy in this patient population.44GENITOURINARY TRAUMAGenitourinary (GU) trauma is rare. Approximately 10% of vic-tims of abdominal trauma will have a
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Surgery_Schwartz. of the retroperitoneal mass to exclude malignancy should be considered prior to commencing treat-ment. Steroid therapy remains the mainstay of medical treat-ment, although other immunosuppressive agents have been described.43 If medical treatment fails, open or minimally inva-sive bilateral ureterolysis with intraperitonealization or omental wrapping of the ureters is indicated.Ureteral obstruction secondary to tumor (benign or malig-nant) is commonly encountered. Ureteral stenting can be tried initially, but it fails in approximately one-half of cases.44 Other strategies such as percutaneous nephrostomy, ureteral stenting in tandem, metallic, and metal-mesh stents have been described. Metallic stents may be more cost-effective due to less frequent stent exchanges,45-47 although cost savings may be offset by the limited life expectancy in this patient population.44GENITOURINARY TRAUMAGenitourinary (GU) trauma is rare. Approximately 10% of vic-tims of abdominal trauma will have a
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savings may be offset by the limited life expectancy in this patient population.44GENITOURINARY TRAUMAGenitourinary (GU) trauma is rare. Approximately 10% of vic-tims of abdominal trauma will have a urologic injury.48 Any portion of the GU tract can be injured including the follow-ing: kidneys, ureters, bladder, urethra, and the external genita-lia including the testicles. Mechanisms of trauma parallel other injury mechanisms, the majority of which include blunt and penetrating injuries. This section will be divided into the man-agement of each organ involved in the GU system.3Brunicardi_Ch40_p1759-p1782.indd 176401/03/19 6:34 PM 1765UROLOGYCHAPTER 40Table 40-1The American Association for the Surgery of Trauma (AAST) renal trauma grading systemGRADEDESCRIPTIONMANAGEMENT1Contusion or nonenlarging subcapsular perirenal hematomaGenerally managed conservatively.2Perinephric hematoma without obvious parenchymal laceration on CT, or a <1 cm laceration into the cortex of the
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Surgery_Schwartz. savings may be offset by the limited life expectancy in this patient population.44GENITOURINARY TRAUMAGenitourinary (GU) trauma is rare. Approximately 10% of vic-tims of abdominal trauma will have a urologic injury.48 Any portion of the GU tract can be injured including the follow-ing: kidneys, ureters, bladder, urethra, and the external genita-lia including the testicles. Mechanisms of trauma parallel other injury mechanisms, the majority of which include blunt and penetrating injuries. This section will be divided into the man-agement of each organ involved in the GU system.3Brunicardi_Ch40_p1759-p1782.indd 176401/03/19 6:34 PM 1765UROLOGYCHAPTER 40Table 40-1The American Association for the Surgery of Trauma (AAST) renal trauma grading systemGRADEDESCRIPTIONMANAGEMENT1Contusion or nonenlarging subcapsular perirenal hematomaGenerally managed conservatively.2Perinephric hematoma without obvious parenchymal laceration on CT, or a <1 cm laceration into the cortex of the
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or nonenlarging subcapsular perirenal hematomaGenerally managed conservatively.2Perinephric hematoma without obvious parenchymal laceration on CT, or a <1 cm laceration into the cortex of the kidneyGenerally managed conservatively in a stable patient.3>1 cm laceration into the cortex without involvement of the collecting systemGenerally managed conservatively in a stable patient.4A deep laceration into the collecting system with evidence of urinary extravasation on CT, or a segmental renal artery or vein injury with contained hematoma, or partial vessel laceration, or vessel thrombosisCan be observed expectantly in the stable patient, but may require subsequent urgent or delayed repair. Renal artery embolization may be an option for those who fail conservative therapy.5Renal pedicle injury or multiple deep renal lacerations (“shattered kidney”)Patients often require surgical exploration, but stable patients with only parenchymal injury may be safely treated conservatively.CT =
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Surgery_Schwartz. or nonenlarging subcapsular perirenal hematomaGenerally managed conservatively.2Perinephric hematoma without obvious parenchymal laceration on CT, or a <1 cm laceration into the cortex of the kidneyGenerally managed conservatively in a stable patient.3>1 cm laceration into the cortex without involvement of the collecting systemGenerally managed conservatively in a stable patient.4A deep laceration into the collecting system with evidence of urinary extravasation on CT, or a segmental renal artery or vein injury with contained hematoma, or partial vessel laceration, or vessel thrombosisCan be observed expectantly in the stable patient, but may require subsequent urgent or delayed repair. Renal artery embolization may be an option for those who fail conservative therapy.5Renal pedicle injury or multiple deep renal lacerations (“shattered kidney”)Patients often require surgical exploration, but stable patients with only parenchymal injury may be safely treated conservatively.CT =
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injury or multiple deep renal lacerations (“shattered kidney”)Patients often require surgical exploration, but stable patients with only parenchymal injury may be safely treated conservatively.CT = computed tomography.KidneysThe prime goal of renal trauma management is preservation of renal function. Renal trauma has become largely nonop-erative in modern times, especially in the setting of lowto intermediate-grade renal injuries from a blunt mechanism of action. The role of angioembolization through vascular and interventional radiology has further increased this nonopera-tive management.49,50The first goal of renal trauma is to accurately grade the renal injury. The gold standard test to diagnose and stage a renal injury includes a CT scan with IV contrast, with delayed images. In most centers, this is referred to as a “CT urogram,” in which delayed contrast imaging delineates the upper urinary tract collecting system. Criteria that would mandate renal imaging include the presence
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Surgery_Schwartz. injury or multiple deep renal lacerations (“shattered kidney”)Patients often require surgical exploration, but stable patients with only parenchymal injury may be safely treated conservatively.CT = computed tomography.KidneysThe prime goal of renal trauma management is preservation of renal function. Renal trauma has become largely nonop-erative in modern times, especially in the setting of lowto intermediate-grade renal injuries from a blunt mechanism of action. The role of angioembolization through vascular and interventional radiology has further increased this nonopera-tive management.49,50The first goal of renal trauma is to accurately grade the renal injury. The gold standard test to diagnose and stage a renal injury includes a CT scan with IV contrast, with delayed images. In most centers, this is referred to as a “CT urogram,” in which delayed contrast imaging delineates the upper urinary tract collecting system. Criteria that would mandate renal imaging include the presence
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centers, this is referred to as a “CT urogram,” in which delayed contrast imaging delineates the upper urinary tract collecting system. Criteria that would mandate renal imaging include the presence of gross hematuria, microscopic hematuria with hypotension, and mechanisms increasing the prevalence of renal injury (sudden deceleration injuries, flank contusion, etc). The American Association for the Surgery of Trauma (AAST) renal trauma grading system is described in Table 40-1.51,52The management of renal injuries depends not only on the grade but also on the injury mechanism and clinical symptoms. Absolute indications for surgical or radiological intervention on renal trauma include life-threatening hemorrhage, renal pedicle avulsion, or pulsatile/expanding retroperitoneal hematoma. Moreover, those suffering penetrating renal trauma with a ret-roperitoneal hematoma should undergo exploration when hemo-dynamic instability exists.In a hemodynamically stable patient with a renal
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Surgery_Schwartz. centers, this is referred to as a “CT urogram,” in which delayed contrast imaging delineates the upper urinary tract collecting system. Criteria that would mandate renal imaging include the presence of gross hematuria, microscopic hematuria with hypotension, and mechanisms increasing the prevalence of renal injury (sudden deceleration injuries, flank contusion, etc). The American Association for the Surgery of Trauma (AAST) renal trauma grading system is described in Table 40-1.51,52The management of renal injuries depends not only on the grade but also on the injury mechanism and clinical symptoms. Absolute indications for surgical or radiological intervention on renal trauma include life-threatening hemorrhage, renal pedicle avulsion, or pulsatile/expanding retroperitoneal hematoma. Moreover, those suffering penetrating renal trauma with a ret-roperitoneal hematoma should undergo exploration when hemo-dynamic instability exists.In a hemodynamically stable patient with a renal
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Moreover, those suffering penetrating renal trauma with a ret-roperitoneal hematoma should undergo exploration when hemo-dynamic instability exists.In a hemodynamically stable patient with a renal injury, renal trauma should be initially observed. Data suggests that this approach may even be feasible in the setting of isolated, penetrating renal injuries.53 Conservative management entails bed rest and hemodynamic monitoring. Patients with a grade 4 renal injury (Fig. 40-3A to D) should be treated in the same manner, and a repeat CT scan should be done to make certain that the urinary extravasation has resolved.54 Otherwise, urinoma and subsequent abscess formation may occur. If uri-nary extravasation is persistent, placement of a ureteral stent or nephrostomy tube should be considered.Across the board, the most common surgery for renal sur-gery in modern times is unfortunately a nephrectomy.55 Early renal vascular control may minimize nephrectomy rates.56 This is accomplished by
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Surgery_Schwartz. Moreover, those suffering penetrating renal trauma with a ret-roperitoneal hematoma should undergo exploration when hemo-dynamic instability exists.In a hemodynamically stable patient with a renal injury, renal trauma should be initially observed. Data suggests that this approach may even be feasible in the setting of isolated, penetrating renal injuries.53 Conservative management entails bed rest and hemodynamic monitoring. Patients with a grade 4 renal injury (Fig. 40-3A to D) should be treated in the same manner, and a repeat CT scan should be done to make certain that the urinary extravasation has resolved.54 Otherwise, urinoma and subsequent abscess formation may occur. If uri-nary extravasation is persistent, placement of a ureteral stent or nephrostomy tube should be considered.Across the board, the most common surgery for renal sur-gery in modern times is unfortunately a nephrectomy.55 Early renal vascular control may minimize nephrectomy rates.56 This is accomplished by
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the board, the most common surgery for renal sur-gery in modern times is unfortunately a nephrectomy.55 Early renal vascular control may minimize nephrectomy rates.56 This is accomplished by isolating the renal vascular medially prior to opening the perinephric hematoma. If uncontrolled bleeding is encountered once the hematoma is opened, occlusion of the renal vasculature can be performed. At that time, a renorrhaphy can be safely done as can a nephrectomy in the setting of a grade 5 renal injury.UretersThere is no association between the magnitude of ureteral injury and the degree of hematuria that is present.57 A high index of suspicion is required. Diagnosis requires either a CT urogram, IVP, or a cystoscopy with a retrograde pyelogram. Unlike renal injury, the ureters more commonly are injured through iatro-genic mechanisms. Common surgical procedures in which the ureters are injured include gynecological, colorectal, and uro-logical surgeries. The repair of ureteric injuries
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Surgery_Schwartz. the board, the most common surgery for renal sur-gery in modern times is unfortunately a nephrectomy.55 Early renal vascular control may minimize nephrectomy rates.56 This is accomplished by isolating the renal vascular medially prior to opening the perinephric hematoma. If uncontrolled bleeding is encountered once the hematoma is opened, occlusion of the renal vasculature can be performed. At that time, a renorrhaphy can be safely done as can a nephrectomy in the setting of a grade 5 renal injury.UretersThere is no association between the magnitude of ureteral injury and the degree of hematuria that is present.57 A high index of suspicion is required. Diagnosis requires either a CT urogram, IVP, or a cystoscopy with a retrograde pyelogram. Unlike renal injury, the ureters more commonly are injured through iatro-genic mechanisms. Common surgical procedures in which the ureters are injured include gynecological, colorectal, and uro-logical surgeries. The repair of ureteric injuries
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are injured through iatro-genic mechanisms. Common surgical procedures in which the ureters are injured include gynecological, colorectal, and uro-logical surgeries. The repair of ureteric injuries depends on the time of identification from initial injury, location, and length of the injured ureteral segment involved.Iatrogenic ureteral injuries should be initially managed with ureteral stent placement when possible. When stenting is not fea-sible, open repair may be attempted when the patient presents shortly after injury. When stent placement is not feasible or when presentation is delayed, nephrostomy tube placement should be considered until formal repair can be safely done.Ureteral injuries of traumatic origin (penetrating injuries, multiple intra-abdominal traumas) should be repaired during the index admission when possible. Hemodynamically stable patients undergoing laparotomy for other reasons in which a high index of suspicion of a ureteral injury is present should have
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Surgery_Schwartz. are injured through iatro-genic mechanisms. Common surgical procedures in which the ureters are injured include gynecological, colorectal, and uro-logical surgeries. The repair of ureteric injuries depends on the time of identification from initial injury, location, and length of the injured ureteral segment involved.Iatrogenic ureteral injuries should be initially managed with ureteral stent placement when possible. When stenting is not fea-sible, open repair may be attempted when the patient presents shortly after injury. When stent placement is not feasible or when presentation is delayed, nephrostomy tube placement should be considered until formal repair can be safely done.Ureteral injuries of traumatic origin (penetrating injuries, multiple intra-abdominal traumas) should be repaired during the index admission when possible. Hemodynamically stable patients undergoing laparotomy for other reasons in which a high index of suspicion of a ureteral injury is present should have
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during the index admission when possible. Hemodynamically stable patients undergoing laparotomy for other reasons in which a high index of suspicion of a ureteral injury is present should have ureteral exploration. Stable patients in this same situation that are identified to have a ureteral injury should have primary repair at the time of exploration. If a patient is hemodynamically unstable, the ureter can be ligated with subsequent nephrostomy tube placement. Ureteral repair can then be delayed until the patient is stable for surgery.4Brunicardi_Ch40_p1759-p1782.indd 176501/03/19 6:34 PM 1766SPECIFIC CONSIDERATIONSPART IIABCDFigure 40-3. Grade 4 renal injury as demonstrated on abdominal computed tomography imaging with intravenous contrast. A. The yellow arrow points to extravasated contrast in the right perirenal fat. B and C. The right kidney has been fractured, as seen at the yellow arrow. Hematoma and extravasated contrast are seen in the mid-anterior pole of the kidney. D.
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Surgery_Schwartz. during the index admission when possible. Hemodynamically stable patients undergoing laparotomy for other reasons in which a high index of suspicion of a ureteral injury is present should have ureteral exploration. Stable patients in this same situation that are identified to have a ureteral injury should have primary repair at the time of exploration. If a patient is hemodynamically unstable, the ureter can be ligated with subsequent nephrostomy tube placement. Ureteral repair can then be delayed until the patient is stable for surgery.4Brunicardi_Ch40_p1759-p1782.indd 176501/03/19 6:34 PM 1766SPECIFIC CONSIDERATIONSPART IIABCDFigure 40-3. Grade 4 renal injury as demonstrated on abdominal computed tomography imaging with intravenous contrast. A. The yellow arrow points to extravasated contrast in the right perirenal fat. B and C. The right kidney has been fractured, as seen at the yellow arrow. Hematoma and extravasated contrast are seen in the mid-anterior pole of the kidney. D.
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contrast in the right perirenal fat. B and C. The right kidney has been fractured, as seen at the yellow arrow. Hematoma and extravasated contrast are seen in the mid-anterior pole of the kidney. D. Coronal view. The yellow arrow reveals the upper pole renal fracture with disruption of the collecting system.The definitive operative management of a ureteral injury depends on the location and the extent of devitalization. It is important to debride devitalized ends of the ureter, whether it is from a contusion via a gunshot wound or an iatrogenic ther-mal injury. Upper ureteral injuries that are short can generally be resected and anastomosed primarily.58 Ureteral mobilization with preservation of ureteral adventitia to maintain vascular supply can aid in bridging short defects. In modern times, more aggressive maneuvers to directly anastomose more proximal ureteral injuries to the bladder are possible. Maneuvers used to bridge the defect of ureteral length for direct anastomosis to the
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Surgery_Schwartz. contrast in the right perirenal fat. B and C. The right kidney has been fractured, as seen at the yellow arrow. Hematoma and extravasated contrast are seen in the mid-anterior pole of the kidney. D. Coronal view. The yellow arrow reveals the upper pole renal fracture with disruption of the collecting system.The definitive operative management of a ureteral injury depends on the location and the extent of devitalization. It is important to debride devitalized ends of the ureter, whether it is from a contusion via a gunshot wound or an iatrogenic ther-mal injury. Upper ureteral injuries that are short can generally be resected and anastomosed primarily.58 Ureteral mobilization with preservation of ureteral adventitia to maintain vascular supply can aid in bridging short defects. In modern times, more aggressive maneuvers to directly anastomose more proximal ureteral injuries to the bladder are possible. Maneuvers used to bridge the defect of ureteral length for direct anastomosis to the
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more aggressive maneuvers to directly anastomose more proximal ureteral injuries to the bladder are possible. Maneuvers used to bridge the defect of ureteral length for direct anastomosis to the bladder include the following: bladder mobilization with liga-tion of the contralateral bladder pedicles, psoas hitch (tacking the bladder down to the ipsilateral psoas tendon), and the Boari flap with downward nephropexy. Creation of a Boari flap uti-lizes a tubularized flap of anterior bladder wall to bridge long defects. Bridging defects as high as the proximal ureter have been reported in association with this technique.59 When blad-der-to-ureter anastomosis is not possible with these maneuvers, the remaining options include trans-ureteroureterostomy (anas-tomosing the injured ureter to the contralateral ureter), creation of an ileal ureter, or renal auto transplantation to the pelvis.BladderThe bladder can be injured through iatrogenic and classic trau-matic mechanisms. Indications for
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Surgery_Schwartz. more aggressive maneuvers to directly anastomose more proximal ureteral injuries to the bladder are possible. Maneuvers used to bridge the defect of ureteral length for direct anastomosis to the bladder include the following: bladder mobilization with liga-tion of the contralateral bladder pedicles, psoas hitch (tacking the bladder down to the ipsilateral psoas tendon), and the Boari flap with downward nephropexy. Creation of a Boari flap uti-lizes a tubularized flap of anterior bladder wall to bridge long defects. Bridging defects as high as the proximal ureter have been reported in association with this technique.59 When blad-der-to-ureter anastomosis is not possible with these maneuvers, the remaining options include trans-ureteroureterostomy (anas-tomosing the injured ureter to the contralateral ureter), creation of an ileal ureter, or renal auto transplantation to the pelvis.BladderThe bladder can be injured through iatrogenic and classic trau-matic mechanisms. Indications for
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contralateral ureter), creation of an ileal ureter, or renal auto transplantation to the pelvis.BladderThe bladder can be injured through iatrogenic and classic trau-matic mechanisms. Indications for bladder imaging include gross hematuria in the setting of injuries with a correlation for bladder injury. The most common clinical scenario is gross hematuria associated with a pelvic fracture, which is associated with a 29% chance of bladder laceration.60 Diagnosis of bladder injuries requires either a CT cystogram or a fluoroscopic cysto-gram. The sensitivities and specificities of these two modalities are similar.61,62 The bladder should be filled with approximately 300 cc of contrast for either of these imaging modalities. Contrast may be visible at the sight of injury, within the perito-neal space (Fig. 40-4A), or in the perivesical space (Fig. 40-4B). Simply capping the Foley catheter alone on a delayed excretory phase of abdominal CT imaging is insufficient to diagnose a bladder
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Surgery_Schwartz. contralateral ureter), creation of an ileal ureter, or renal auto transplantation to the pelvis.BladderThe bladder can be injured through iatrogenic and classic trau-matic mechanisms. Indications for bladder imaging include gross hematuria in the setting of injuries with a correlation for bladder injury. The most common clinical scenario is gross hematuria associated with a pelvic fracture, which is associated with a 29% chance of bladder laceration.60 Diagnosis of bladder injuries requires either a CT cystogram or a fluoroscopic cysto-gram. The sensitivities and specificities of these two modalities are similar.61,62 The bladder should be filled with approximately 300 cc of contrast for either of these imaging modalities. Contrast may be visible at the sight of injury, within the perito-neal space (Fig. 40-4A), or in the perivesical space (Fig. 40-4B). Simply capping the Foley catheter alone on a delayed excretory phase of abdominal CT imaging is insufficient to diagnose a bladder
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space (Fig. 40-4A), or in the perivesical space (Fig. 40-4B). Simply capping the Foley catheter alone on a delayed excretory phase of abdominal CT imaging is insufficient to diagnose a bladder injury.61Two general categories of bladder injuries are extraperito-neal and intraperitoneal injuries. An intraperitoneal injury requires repair during the index admission after the patient has been resuscitated. Delayed repairs are associated with abdominal sepsis. Conversely, extra peritoneal injuries can gen-erally be managed with Foley catheter drainage alone. Situa-tions in which extraperitoneal bladder injuries should be treated with operative repair include complex injuries involving bone spicules from a pelvic fracture within the laceration and concur-rent rectal or bladder lacerations, which increase the possibility of fistula formation. Bladder neck injuries should also be treated operatively during the index admission as these injuries occa-sionally do no heal with Foley catheter
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Surgery_Schwartz. space (Fig. 40-4A), or in the perivesical space (Fig. 40-4B). Simply capping the Foley catheter alone on a delayed excretory phase of abdominal CT imaging is insufficient to diagnose a bladder injury.61Two general categories of bladder injuries are extraperito-neal and intraperitoneal injuries. An intraperitoneal injury requires repair during the index admission after the patient has been resuscitated. Delayed repairs are associated with abdominal sepsis. Conversely, extra peritoneal injuries can gen-erally be managed with Foley catheter drainage alone. Situa-tions in which extraperitoneal bladder injuries should be treated with operative repair include complex injuries involving bone spicules from a pelvic fracture within the laceration and concur-rent rectal or bladder lacerations, which increase the possibility of fistula formation. Bladder neck injuries should also be treated operatively during the index admission as these injuries occa-sionally do no heal with Foley catheter
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which increase the possibility of fistula formation. Bladder neck injuries should also be treated operatively during the index admission as these injuries occa-sionally do no heal with Foley catheter drainage alone. Repeat cystography should be done 7 to 14 days later prior to Foley removal to ensure that the laceration, or operative repair, has healed.63Urethral InjuriesCommon mechanisms of trauma of the urethra include pelvic fracture associated injuries and straddle injuries. Pelvic fracture associated injuries occur at the level of the membranous urethra, whereas straddle injuries occur at the level of the bulbar urethra. The clinical hallmark of a urethral injury is blood at the meatus. A retrograde urethrogram should be done when this clinical sign is present to diagnose an injury, prior to attempted Foley cath-eter placement (Fig. 40-5A).64,65The initial step in management of a urethral injury is bladder drainage to prevent urinoma formation and subsequent abscess formation. In
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Surgery_Schwartz. which increase the possibility of fistula formation. Bladder neck injuries should also be treated operatively during the index admission as these injuries occa-sionally do no heal with Foley catheter drainage alone. Repeat cystography should be done 7 to 14 days later prior to Foley removal to ensure that the laceration, or operative repair, has healed.63Urethral InjuriesCommon mechanisms of trauma of the urethra include pelvic fracture associated injuries and straddle injuries. Pelvic fracture associated injuries occur at the level of the membranous urethra, whereas straddle injuries occur at the level of the bulbar urethra. The clinical hallmark of a urethral injury is blood at the meatus. A retrograde urethrogram should be done when this clinical sign is present to diagnose an injury, prior to attempted Foley cath-eter placement (Fig. 40-5A).64,65The initial step in management of a urethral injury is bladder drainage to prevent urinoma formation and subsequent abscess formation. In
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to attempted Foley cath-eter placement (Fig. 40-5A).64,65The initial step in management of a urethral injury is bladder drainage to prevent urinoma formation and subsequent abscess formation. In general, this is accomplished through 5Brunicardi_Ch40_p1759-p1782.indd 176601/03/19 6:35 PM 1767UROLOGYCHAPTER 40Figure 40-4. Intraperitoneal and extraperitoneal bladder injuries. A. During a computed tomography (CT) cystogram, intraperitoneal contrast is seen within the peritoneal space at the red arrow. B. During a CT cystogram, extravesical contrast is seen contained within the extraperitoneal space at the red arrow.ABFigure 40-5. A. Retrograde urethrogram showing an area of nar-rowing at the double white arrow. This indicates a bulbar urethral stricture. B. After urethroplasty, a retrograde urethrogram demon-strates a normal-appearing and patent bulbar urethra at the arrow.ABplacement of an SP tube. After stabilization, some centers per-form “primary urethral alignment.” This is a
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Surgery_Schwartz. to attempted Foley cath-eter placement (Fig. 40-5A).64,65The initial step in management of a urethral injury is bladder drainage to prevent urinoma formation and subsequent abscess formation. In general, this is accomplished through 5Brunicardi_Ch40_p1759-p1782.indd 176601/03/19 6:35 PM 1767UROLOGYCHAPTER 40Figure 40-4. Intraperitoneal and extraperitoneal bladder injuries. A. During a computed tomography (CT) cystogram, intraperitoneal contrast is seen within the peritoneal space at the red arrow. B. During a CT cystogram, extravesical contrast is seen contained within the extraperitoneal space at the red arrow.ABFigure 40-5. A. Retrograde urethrogram showing an area of nar-rowing at the double white arrow. This indicates a bulbar urethral stricture. B. After urethroplasty, a retrograde urethrogram demon-strates a normal-appearing and patent bulbar urethra at the arrow.ABplacement of an SP tube. After stabilization, some centers per-form “primary urethral alignment.” This is a
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urethrogram demon-strates a normal-appearing and patent bulbar urethra at the arrow.ABplacement of an SP tube. After stabilization, some centers per-form “primary urethral alignment.” This is a dual antegrade and retrograde endoscopic procedure utilizing fluoroscopy to bridge the urethral defect and to place a Foley catheter across the injury. Subsequent restructure rates are high, but the severity of stricture formation may be less when primary alignment is performed.66 If patients are managed with an SP tube alone, the site of disruption leaves the patient with a urethral stricture and subsequent restructure. This requires a treatment with a urethro-plasty after the patient’s period of convalescence has resolved (Fig. 40-5B).Penetrating injuries to the anterior urethra are rare. In a hemodynamically stable patient with an uncomplicated injury, it is expert opinion to perform exploration with primary repair during index admission. Complicated injuries with extensive tissue
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Surgery_Schwartz. urethrogram demon-strates a normal-appearing and patent bulbar urethra at the arrow.ABplacement of an SP tube. After stabilization, some centers per-form “primary urethral alignment.” This is a dual antegrade and retrograde endoscopic procedure utilizing fluoroscopy to bridge the urethral defect and to place a Foley catheter across the injury. Subsequent restructure rates are high, but the severity of stricture formation may be less when primary alignment is performed.66 If patients are managed with an SP tube alone, the site of disruption leaves the patient with a urethral stricture and subsequent restructure. This requires a treatment with a urethro-plasty after the patient’s period of convalescence has resolved (Fig. 40-5B).Penetrating injuries to the anterior urethra are rare. In a hemodynamically stable patient with an uncomplicated injury, it is expert opinion to perform exploration with primary repair during index admission. Complicated injuries with extensive tissue
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In a hemodynamically stable patient with an uncomplicated injury, it is expert opinion to perform exploration with primary repair during index admission. Complicated injuries with extensive tissue devitalization should be managed with SP tube urinary diversion and delayed reconstruction.67External Genital InjuriesPenile fractures classically occur with excessive torqueing of the erect penis. This excessive torqueing results in rupture of the tunica albuginea, the fascial coating of the erectile bodies. Common symptoms include immediate detumescence with subsequent development of a hematoma. Clinical history and examination alone are sufficient to warrant surgical exploration with primary suture repair of the corporal body laceration. For equivocal cases, ultrasonography or an MRI may be done.68,69 Up to 10% of penile fractures are associated with urethral inju-ries. Blood at the meatus signifies the possibility of a coexisting urethral injury. This should be evaluated with either a
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Surgery_Schwartz. In a hemodynamically stable patient with an uncomplicated injury, it is expert opinion to perform exploration with primary repair during index admission. Complicated injuries with extensive tissue devitalization should be managed with SP tube urinary diversion and delayed reconstruction.67External Genital InjuriesPenile fractures classically occur with excessive torqueing of the erect penis. This excessive torqueing results in rupture of the tunica albuginea, the fascial coating of the erectile bodies. Common symptoms include immediate detumescence with subsequent development of a hematoma. Clinical history and examination alone are sufficient to warrant surgical exploration with primary suture repair of the corporal body laceration. For equivocal cases, ultrasonography or an MRI may be done.68,69 Up to 10% of penile fractures are associated with urethral inju-ries. Blood at the meatus signifies the possibility of a coexisting urethral injury. This should be evaluated with either a
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done.68,69 Up to 10% of penile fractures are associated with urethral inju-ries. Blood at the meatus signifies the possibility of a coexisting urethral injury. This should be evaluated with either a retrograde urethrogram or cystoscopy at the time of repair.Scrotal trauma generally occurs from a blunt mechanism. Injuries to the testis, epididymis, and spermatic cord may occur. Hematomas with subsequent ecchymosis are common with such injuries. Testicular rupture occurs with fracture of the fascial coating of the testicle, called the tunica albuginea. This may occur with blunt or penetrating mechanisms. The most spe-cific findings on ultrasonography are loss of testicular contour and heterogeneous echotexture of parenchyma. The highest reported sensitivity for testicular rupture on ultrasound is 93%.70 With diagnosis of a testicular rupture or when a high index of Brunicardi_Ch40_p1759-p1782.indd 176701/03/19 6:35 PM 1768SPECIFIC CONSIDERATIONSPART IIBladderUrethraPosterior
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Surgery_Schwartz. done.68,69 Up to 10% of penile fractures are associated with urethral inju-ries. Blood at the meatus signifies the possibility of a coexisting urethral injury. This should be evaluated with either a retrograde urethrogram or cystoscopy at the time of repair.Scrotal trauma generally occurs from a blunt mechanism. Injuries to the testis, epididymis, and spermatic cord may occur. Hematomas with subsequent ecchymosis are common with such injuries. Testicular rupture occurs with fracture of the fascial coating of the testicle, called the tunica albuginea. This may occur with blunt or penetrating mechanisms. The most spe-cific findings on ultrasonography are loss of testicular contour and heterogeneous echotexture of parenchyma. The highest reported sensitivity for testicular rupture on ultrasound is 93%.70 With diagnosis of a testicular rupture or when a high index of Brunicardi_Ch40_p1759-p1782.indd 176701/03/19 6:35 PM 1768SPECIFIC CONSIDERATIONSPART IIBladderUrethraPosterior
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ultrasound is 93%.70 With diagnosis of a testicular rupture or when a high index of Brunicardi_Ch40_p1759-p1782.indd 176701/03/19 6:35 PM 1768SPECIFIC CONSIDERATIONSPART IIBladderUrethraPosterior prostateAnterior prostateABFigure 40-6. Coudé catheter. A. A schematic drawing of a lat-eral view of the prostatic urethra showing the upward angulation at the bladder neck, which a coudé catheter is helpful in negotiating. B. The tip of a coudé catheter. Note the curved tip, which should always point to 12 o’clock when inserted.suspicion is present (especially with penetrating trauma), explo-ration should be performed. Testicular salvage rates are high in modern times and involve suture repair of the site of rupture.70 When primary repair is not possible, a simple orchiectomy should be performed.EMERGENCIESAcute Urinary RetentionAcute urinary retention (AUR) can happen in men or women and results from a variety of causes, although it most commonly occurs in men with benign prostatic
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Surgery_Schwartz. ultrasound is 93%.70 With diagnosis of a testicular rupture or when a high index of Brunicardi_Ch40_p1759-p1782.indd 176701/03/19 6:35 PM 1768SPECIFIC CONSIDERATIONSPART IIBladderUrethraPosterior prostateAnterior prostateABFigure 40-6. Coudé catheter. A. A schematic drawing of a lat-eral view of the prostatic urethra showing the upward angulation at the bladder neck, which a coudé catheter is helpful in negotiating. B. The tip of a coudé catheter. Note the curved tip, which should always point to 12 o’clock when inserted.suspicion is present (especially with penetrating trauma), explo-ration should be performed. Testicular salvage rates are high in modern times and involve suture repair of the site of rupture.70 When primary repair is not possible, a simple orchiectomy should be performed.EMERGENCIESAcute Urinary RetentionAcute urinary retention (AUR) can happen in men or women and results from a variety of causes, although it most commonly occurs in men with benign prostatic
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Urinary RetentionAcute urinary retention (AUR) can happen in men or women and results from a variety of causes, although it most commonly occurs in men with benign prostatic hyperplasia (BPH).71,72 Other chronic causes of poor bladder emptying, such as diabetic neuropathy, urethral stricture, multiple sclerosis, or Parkinson’s disease, can result in episodes of complete urinary retention, often when the bladder becomes overdistended. This frequently occurs in the hospital setting when patients have limited mobil-ity and are receiving medications that decrease bladder con-tractility, including opiates or anticholinergics. Constipation, a common side effect of those medications, can itself worsen uri-nary retention. Significant hematuria can result in the formation of blood clots, which may block the urethra and cause retention.Although some patients receiving large doses of narcot-ics or those with chronically decompensated bladders may not experience discomfort, most patients with AUR
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Surgery_Schwartz. Urinary RetentionAcute urinary retention (AUR) can happen in men or women and results from a variety of causes, although it most commonly occurs in men with benign prostatic hyperplasia (BPH).71,72 Other chronic causes of poor bladder emptying, such as diabetic neuropathy, urethral stricture, multiple sclerosis, or Parkinson’s disease, can result in episodes of complete urinary retention, often when the bladder becomes overdistended. This frequently occurs in the hospital setting when patients have limited mobil-ity and are receiving medications that decrease bladder con-tractility, including opiates or anticholinergics. Constipation, a common side effect of those medications, can itself worsen uri-nary retention. Significant hematuria can result in the formation of blood clots, which may block the urethra and cause retention.Although some patients receiving large doses of narcot-ics or those with chronically decompensated bladders may not experience discomfort, most patients with AUR
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block the urethra and cause retention.Although some patients receiving large doses of narcot-ics or those with chronically decompensated bladders may not experience discomfort, most patients with AUR have significant pain. Untreated severe urinary retention (often accompanied by overflow incontinence) may result in acute renal failure. Treat-ment should include placement of a urethral catheter as quickly as possible. However, BPH or urethral strictures often make the placement of a catheter difficult. For men with BPH, a coude (French for curved) catheter is helpful in negotiating past the angulation in the prostatic urethra (Fig. 40-6A). The curved por-tion (which is angled in line with the balloon port) is maintained at the 12 o’clock position as it is passed through the urethra (Fig. 40-6B). A common mistake is to use a smaller catheter to bypass the enlarged prostate. However, a larger (18F to 20F) catheter is less flexible and is more likely to push into the blad-der rather than
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Surgery_Schwartz. block the urethra and cause retention.Although some patients receiving large doses of narcot-ics or those with chronically decompensated bladders may not experience discomfort, most patients with AUR have significant pain. Untreated severe urinary retention (often accompanied by overflow incontinence) may result in acute renal failure. Treat-ment should include placement of a urethral catheter as quickly as possible. However, BPH or urethral strictures often make the placement of a catheter difficult. For men with BPH, a coude (French for curved) catheter is helpful in negotiating past the angulation in the prostatic urethra (Fig. 40-6A). The curved por-tion (which is angled in line with the balloon port) is maintained at the 12 o’clock position as it is passed through the urethra (Fig. 40-6B). A common mistake is to use a smaller catheter to bypass the enlarged prostate. However, a larger (18F to 20F) catheter is less flexible and is more likely to push into the blad-der rather than
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A common mistake is to use a smaller catheter to bypass the enlarged prostate. However, a larger (18F to 20F) catheter is less flexible and is more likely to push into the blad-der rather than curl in the prostatic urethra.Smaller catheters, however, are quite useful for bypass-ing a urethral stricture. A urethral stricture should be suspected when the catheter meets resistance closer to the meatus, as many strictures occur in the distal urethra, which is narrower than the proximal portion. Using a 12F or 14F catheter often will allow the passage of the catheter into the bladder. If cath-eter placement is not successful, a urologic consultation should be requested. The urologist can either choose to (a) use a cys-toscope, guidewire, and urethral dilators to dilate the stricture and place a Council-tip catheter via Seldinger technique; or (b) place a suprapubic tube approximately two fingerbreadths above the pubic symphysis. With regard to the suprapubic tube, ultrasound-guidance or
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Surgery_Schwartz. A common mistake is to use a smaller catheter to bypass the enlarged prostate. However, a larger (18F to 20F) catheter is less flexible and is more likely to push into the blad-der rather than curl in the prostatic urethra.Smaller catheters, however, are quite useful for bypass-ing a urethral stricture. A urethral stricture should be suspected when the catheter meets resistance closer to the meatus, as many strictures occur in the distal urethra, which is narrower than the proximal portion. Using a 12F or 14F catheter often will allow the passage of the catheter into the bladder. If cath-eter placement is not successful, a urologic consultation should be requested. The urologist can either choose to (a) use a cys-toscope, guidewire, and urethral dilators to dilate the stricture and place a Council-tip catheter via Seldinger technique; or (b) place a suprapubic tube approximately two fingerbreadths above the pubic symphysis. With regard to the suprapubic tube, ultrasound-guidance or
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a Council-tip catheter via Seldinger technique; or (b) place a suprapubic tube approximately two fingerbreadths above the pubic symphysis. With regard to the suprapubic tube, ultrasound-guidance or aspiration with a finder needle should be used first to localize the bladder and avoid intra-abdominal contents, although bowel injury is unlikely with a distended bladder filling the pelvis. If hematuria is the cause of retention, continuous bladder irrigation often is necessary to prevent clot formation. This is done through a large three-way catheter that has an additional port for fluid inflow. Fluid is infused by grav-ity only because the use of higher pressure may result in bladder rupture if outflow is occluded.Once the bladder is adequately drained, the cause of AUR should be addressed. For men with suspected BPH, an α-blocker such as tamsulosin should be started, and these have been shown to increase the likelihood of a successful trial without a catheter.73 Although finasteride
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Surgery_Schwartz. a Council-tip catheter via Seldinger technique; or (b) place a suprapubic tube approximately two fingerbreadths above the pubic symphysis. With regard to the suprapubic tube, ultrasound-guidance or aspiration with a finder needle should be used first to localize the bladder and avoid intra-abdominal contents, although bowel injury is unlikely with a distended bladder filling the pelvis. If hematuria is the cause of retention, continuous bladder irrigation often is necessary to prevent clot formation. This is done through a large three-way catheter that has an additional port for fluid inflow. Fluid is infused by grav-ity only because the use of higher pressure may result in bladder rupture if outflow is occluded.Once the bladder is adequately drained, the cause of AUR should be addressed. For men with suspected BPH, an α-blocker such as tamsulosin should be started, and these have been shown to increase the likelihood of a successful trial without a catheter.73 Although finasteride
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For men with suspected BPH, an α-blocker such as tamsulosin should be started, and these have been shown to increase the likelihood of a successful trial without a catheter.73 Although finasteride and dutasteride (5α-reductase inhibitors) have been shown to reduce the incidence of urinary retention by 50%, they require several months to take effect and are most beneficial in large prostates; therefore, they will not provide significant benefit in the short term. Narcotics should be tapered as tolerated, and constipation should be treated.Acute spinal cord compression, which is accompanied by saddle paresthesias, is a neurologic emergency that requires neurosurgical or orthopedic consultation. In most cases, except severe neurologic injuries, patients will be able to resume void-ing, and the catheter can be removed after 1 to 2 days. Postvoid residuals should be checked with a portable ultrasound device (bladder scanner) or by “straight” catheterization to determine the residual amount
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Surgery_Schwartz. For men with suspected BPH, an α-blocker such as tamsulosin should be started, and these have been shown to increase the likelihood of a successful trial without a catheter.73 Although finasteride and dutasteride (5α-reductase inhibitors) have been shown to reduce the incidence of urinary retention by 50%, they require several months to take effect and are most beneficial in large prostates; therefore, they will not provide significant benefit in the short term. Narcotics should be tapered as tolerated, and constipation should be treated.Acute spinal cord compression, which is accompanied by saddle paresthesias, is a neurologic emergency that requires neurosurgical or orthopedic consultation. In most cases, except severe neurologic injuries, patients will be able to resume void-ing, and the catheter can be removed after 1 to 2 days. Postvoid residuals should be checked with a portable ultrasound device (bladder scanner) or by “straight” catheterization to determine the residual amount
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Surgery_Schwartz
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catheter can be removed after 1 to 2 days. Postvoid residuals should be checked with a portable ultrasound device (bladder scanner) or by “straight” catheterization to determine the residual amount of urine left after the patient tries to empty his or her bladder. In patients with severe liver dysfunction, the bladder scanner may inadvertently misinterpret ascites for urine. The inability to void or the presence of a postvoid residual over 200 mL is concerning for development of another episode of AUR. Patients may be given the option of an indwelling cath-eter for another few days with a subsequent voiding trial or to perform clean intermittent catheterization (CIC), whereby, after Brunicardi_Ch40_p1759-p1782.indd 176801/03/19 6:35 PM 1769UROLOGYCHAPTER 40Figure 40-7. Fournier’s gangrene. A. Necrotic scrotal skin from Fournier’s gangrene. B. Debridement of gangrenous tissue. Note the extensive debridement, which is commonly required. The right testicle required removal in this
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Surgery_Schwartz. catheter can be removed after 1 to 2 days. Postvoid residuals should be checked with a portable ultrasound device (bladder scanner) or by “straight” catheterization to determine the residual amount of urine left after the patient tries to empty his or her bladder. In patients with severe liver dysfunction, the bladder scanner may inadvertently misinterpret ascites for urine. The inability to void or the presence of a postvoid residual over 200 mL is concerning for development of another episode of AUR. Patients may be given the option of an indwelling cath-eter for another few days with a subsequent voiding trial or to perform clean intermittent catheterization (CIC), whereby, after Brunicardi_Ch40_p1759-p1782.indd 176801/03/19 6:35 PM 1769UROLOGYCHAPTER 40Figure 40-7. Fournier’s gangrene. A. Necrotic scrotal skin from Fournier’s gangrene. B. Debridement of gangrenous tissue. Note the extensive debridement, which is commonly required. The right testicle required removal in this
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Surgery_Schwartz_11696
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Surgery_Schwartz
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A. Necrotic scrotal skin from Fournier’s gangrene. B. Debridement of gangrenous tissue. Note the extensive debridement, which is commonly required. The right testicle required removal in this case (the left is wrapped in gauze), but typically, the testes are not involved with the necrotic process.predetermined intervals (4–6 hours) or after voiding attempts, the patient passes a catheter into the bladder and empties it. This is the preferred method because it reduces the likelihood of infections from indwelling catheters and may improve blad-der functionality. However, most patients are resistant to this approach.Testicular TorsionThe differential diagnosis of acute scrotal pain includes testicu-lar torsion.74 This usually occurs in neonates or adolescent boys but may be observed in other age groups. The blood supply to the testicle is compromised due to twisting of the spermatic cord within the tunica vaginalis, resulting in ischemia to the epididy-mis and the testis. In newborns, an
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Surgery_Schwartz. A. Necrotic scrotal skin from Fournier’s gangrene. B. Debridement of gangrenous tissue. Note the extensive debridement, which is commonly required. The right testicle required removal in this case (the left is wrapped in gauze), but typically, the testes are not involved with the necrotic process.predetermined intervals (4–6 hours) or after voiding attempts, the patient passes a catheter into the bladder and empties it. This is the preferred method because it reduces the likelihood of infections from indwelling catheters and may improve blad-der functionality. However, most patients are resistant to this approach.Testicular TorsionThe differential diagnosis of acute scrotal pain includes testicu-lar torsion.74 This usually occurs in neonates or adolescent boys but may be observed in other age groups. The blood supply to the testicle is compromised due to twisting of the spermatic cord within the tunica vaginalis, resulting in ischemia to the epididy-mis and the testis. In newborns, an
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Surgery_Schwartz_11697
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Surgery_Schwartz
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age groups. The blood supply to the testicle is compromised due to twisting of the spermatic cord within the tunica vaginalis, resulting in ischemia to the epididy-mis and the testis. In newborns, an extravaginal torsion also can occur with twisting of the tunica vaginalis and spermatic cord together. Risk factors for torsion include undescended testis, testicular tumor, and a “bell-clapper” deformity—poor guber-nacular fixation of the testicles to the scrotal wall.Clinical history is vital for diagnosis.75 Patients describe a sudden onset of pain at a distinct point in time, with subsequent swelling. Physical examination may demonstrate a swollen, asymmetric scrotum with a tender, high-riding testicle. Children normally have a brisk cremasteric reflex that usually is lost in the setting of torsion. The diagnosis is made by clinical history and examination but can be supported by a Doppler ultrasound, which typically shows decreased intratesticular blood flow rela-tive to the
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Surgery_Schwartz. age groups. The blood supply to the testicle is compromised due to twisting of the spermatic cord within the tunica vaginalis, resulting in ischemia to the epididy-mis and the testis. In newborns, an extravaginal torsion also can occur with twisting of the tunica vaginalis and spermatic cord together. Risk factors for torsion include undescended testis, testicular tumor, and a “bell-clapper” deformity—poor guber-nacular fixation of the testicles to the scrotal wall.Clinical history is vital for diagnosis.75 Patients describe a sudden onset of pain at a distinct point in time, with subsequent swelling. Physical examination may demonstrate a swollen, asymmetric scrotum with a tender, high-riding testicle. Children normally have a brisk cremasteric reflex that usually is lost in the setting of torsion. The diagnosis is made by clinical history and examination but can be supported by a Doppler ultrasound, which typically shows decreased intratesticular blood flow rela-tive to the
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Surgery_Schwartz_11698
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Surgery_Schwartz
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setting of torsion. The diagnosis is made by clinical history and examination but can be supported by a Doppler ultrasound, which typically shows decreased intratesticular blood flow rela-tive to the contralateral testis. If an ultrasound is not promptly available, timely surgical exploration should be performed.Immediate surgical exploration can salvage an ischemic testis.76 At the time of surgery, the contralateral testes also must be explored and fixed to the dartos fascia due to the pos-sibility that the same anatomic defect allowing torsion exists on the contralateral side. Midline (along the median raphe) or bilateral transverse scrotal incisions are made. Once the testis is detorsed, it should be assessed for viability after being given time for normal blood flow to resume. One can assess the blood flow using intraoperative Doppler or by incis-ing the tunica vaginalis and observing tissue viability. The testes are fixed to the dartos fascia with a small, nonabsorbable suture on
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Surgery_Schwartz. setting of torsion. The diagnosis is made by clinical history and examination but can be supported by a Doppler ultrasound, which typically shows decreased intratesticular blood flow rela-tive to the contralateral testis. If an ultrasound is not promptly available, timely surgical exploration should be performed.Immediate surgical exploration can salvage an ischemic testis.76 At the time of surgery, the contralateral testes also must be explored and fixed to the dartos fascia due to the pos-sibility that the same anatomic defect allowing torsion exists on the contralateral side. Midline (along the median raphe) or bilateral transverse scrotal incisions are made. Once the testis is detorsed, it should be assessed for viability after being given time for normal blood flow to resume. One can assess the blood flow using intraoperative Doppler or by incis-ing the tunica vaginalis and observing tissue viability. The testes are fixed to the dartos fascia with a small, nonabsorbable suture on
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Surgery_Schwartz_11699
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Surgery_Schwartz
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assess the blood flow using intraoperative Doppler or by incis-ing the tunica vaginalis and observing tissue viability. The testes are fixed to the dartos fascia with a small, nonabsorbable suture on their medial, lateral, and dependent aspects, taking care to ensure that the spermatic cord is not twisted before doing so. An orchiectomy should be performed to avoid later risk of abscess formation only if the testis is clearly necrotic.Fournier’s GangreneFournier’s gangrene is a necrotizing fasciitis of the male geni-talia and perineum that can be rapidly progressive and fatal if not treated promptly (Fig. 40-7). The mortality rate has been reported to be as high as 67%.77 Risk factors for Fournier’s gangrene include perirectal abscesses, diabetes, obesity, and chronic alcoholism.78 The often polymicrobial infection spreads along dartos, Scarpa’s, and Colles’ fascia. Clinical signs include perineal and scrotal pain, inflammation, necrosis, and crepitus.78 The diagnosis is largely made
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Surgery_Schwartz. assess the blood flow using intraoperative Doppler or by incis-ing the tunica vaginalis and observing tissue viability. The testes are fixed to the dartos fascia with a small, nonabsorbable suture on their medial, lateral, and dependent aspects, taking care to ensure that the spermatic cord is not twisted before doing so. An orchiectomy should be performed to avoid later risk of abscess formation only if the testis is clearly necrotic.Fournier’s GangreneFournier’s gangrene is a necrotizing fasciitis of the male geni-talia and perineum that can be rapidly progressive and fatal if not treated promptly (Fig. 40-7). The mortality rate has been reported to be as high as 67%.77 Risk factors for Fournier’s gangrene include perirectal abscesses, diabetes, obesity, and chronic alcoholism.78 The often polymicrobial infection spreads along dartos, Scarpa’s, and Colles’ fascia. Clinical signs include perineal and scrotal pain, inflammation, necrosis, and crepitus.78 The diagnosis is largely made
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Surgery_Schwartz_11700
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Surgery_Schwartz
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polymicrobial infection spreads along dartos, Scarpa’s, and Colles’ fascia. Clinical signs include perineal and scrotal pain, inflammation, necrosis, and crepitus.78 The diagnosis is largely made on clinical suspicion; however, radiographic findings on CT imaging often assist with the diag-nosis, including soft tissue air associated with fluid collections within the deep fascia.79Prompt and aggressive surgical debridement of nonvia-ble tissue and broad spectrum antibiotics are necessary to prevent further spread (Fig. 40-7A). Fecal diversion with endorectal tubes serve as an option for conservative fecal diversion.80 If there is damage to the external anal sphincter, 67patients may require a colostomy. Patients frequently require return trips to the operating room for further debridement. Negative pressure wound therapy systems have been shown to reduce hospitalization time by aiding in wound healing.81 Reconstructive strategies involving skin grafting are needed when large tissue
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Surgery_Schwartz. polymicrobial infection spreads along dartos, Scarpa’s, and Colles’ fascia. Clinical signs include perineal and scrotal pain, inflammation, necrosis, and crepitus.78 The diagnosis is largely made on clinical suspicion; however, radiographic findings on CT imaging often assist with the diag-nosis, including soft tissue air associated with fluid collections within the deep fascia.79Prompt and aggressive surgical debridement of nonvia-ble tissue and broad spectrum antibiotics are necessary to prevent further spread (Fig. 40-7A). Fecal diversion with endorectal tubes serve as an option for conservative fecal diversion.80 If there is damage to the external anal sphincter, 67patients may require a colostomy. Patients frequently require return trips to the operating room for further debridement. Negative pressure wound therapy systems have been shown to reduce hospitalization time by aiding in wound healing.81 Reconstructive strategies involving skin grafting are needed when large tissue
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Surgery_Schwartz_11701
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Surgery_Schwartz
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Negative pressure wound therapy systems have been shown to reduce hospitalization time by aiding in wound healing.81 Reconstructive strategies involving skin grafting are needed when large tissue defects result from extensive tissue damage.PriapismPriapism is a persistent erection for greater than 4 hours unre-lated to sexual stimulation.82 Priapism is divided into two types, based on the underlying pathophysiology. The most common type—low-flow/ischemic priapism—is a medical emergency. On examination, the penis is very tender, and both cavernosal bodies will be rigid while the glans will be flaccid. Decreased venous outflow with persistent inflow results in increased intracorporal pressure and tumescence, which is the normal process of erection. Diminished arterial inflow due to elevated Brunicardi_Ch40_p1759-p1782.indd 176901/03/19 6:35 PM 1770SPECIFIC CONSIDERATIONSPART IIintrapenile pressure usually is brief under normal circumstances. Priapism is essentially a compartment
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Surgery_Schwartz. Negative pressure wound therapy systems have been shown to reduce hospitalization time by aiding in wound healing.81 Reconstructive strategies involving skin grafting are needed when large tissue defects result from extensive tissue damage.PriapismPriapism is a persistent erection for greater than 4 hours unre-lated to sexual stimulation.82 Priapism is divided into two types, based on the underlying pathophysiology. The most common type—low-flow/ischemic priapism—is a medical emergency. On examination, the penis is very tender, and both cavernosal bodies will be rigid while the glans will be flaccid. Decreased venous outflow with persistent inflow results in increased intracorporal pressure and tumescence, which is the normal process of erection. Diminished arterial inflow due to elevated Brunicardi_Ch40_p1759-p1782.indd 176901/03/19 6:35 PM 1770SPECIFIC CONSIDERATIONSPART IIintrapenile pressure usually is brief under normal circumstances. Priapism is essentially a compartment
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