Emergencies in Urology - part 9 pptx

Deferred Emergency Surgery of Total Ruptureof the Posterior Urethra J.M.. Gil-Vernet Total rupture of the posterior urethra is a topic that in-terests all surgeons: general surgeons, ort

a b

Fig 21.4.1 a Iatrogenic damage resulting from endoscopic procedures, impaction of a stone in the right ureter Serious lesion of the iliac and pelvic ureter Cutaneous ureterostomy b Undiversion Contralateral renal autotransplantation and ureteroureteral

anastomosis after 10 years

would not have permitted a submucosal antireflux

tun-nel and its precarious vascularization would have led to

stenosis The poor locoregional state of the tissues

showed such procedures to be inadvisable

I decided on temporary nephroureterectomy,

con-tralateral autotransplantation, and ureteroureteral

der-ivation (Higgins operation) After the kidney had been

transferred to the bench it was perfused with Collins

solution at 4 °C, remaining submerged in a basin in

constant hypothermia There the ureter was resected to

within 2 cm of the pyelic junction The intraoperative

biopsy showed that there was no irrecuperable

degra-dation at this level

Meanwhile, the lumbotomy was closed and the

pa-tient repositioned Via a left paramedial, pararectal,

ex-traperitoneal incision, the primitive iliac vessels to

which the graft vessels were to be anastomosed were

dissected

The kidney was autotransplanted into the

contralat-eral iliac fossa While its vessels were being

anasto-mosed, the organ was maintained in hypothermia by

placing it between two compresses containing crushed

ice The clamps were removed and the kidney regainedits normal color Section of the sliding sleeve of the ure-ter of the contralateral kidney was followed by carefuldissection of the iliac segment of the ureter, avoidinginjury to Feitel’s artery which, as is frequently the case,originated from the trunk of the internal iliac artery,forming one of the most important lower pedicles ofthe ureter

Finally, using the surgical microscope at 4-6× andmicrosurgical instruments with 6-0 sutures, I per-formed the ureteroureteral anastomosis The first twosutures of the anastomosis were made in the proximaland distal extremes of the two anastomotic orifices andfrom there on the suture was continuous, avoiding theeversion of the mucosa The suture was watertight, be-cause no catheter was to be inserted

The postoperative phase was without complications.The undiversion restored the woman’s urinary appara-tus to normal – both anatomically and functionally –and, above all, she regained her mental stability Thepsychological benefit of the procedure has been enor-mous (Fig 21.4.1b)

The ureteroureteral derivation, or the Higgins

oper-ation, has been the subject of much discussion and has

even been considered reckless The risk of this

opera-tion lies in the technical imperfecopera-tion of the

anastomo-sis, but since the introduction of the surgical

micro-scope and the development of microsurgery, and

pro-vided that the operation is performed meticulously

us-ing microsurgical techniques within a perfectionist

mindset, it has every chance of success Without a

doubt, this operation must be included in the

) When exposing the receiving ureter, identify and

preserve its vascular and nerve pedicles

) In the iliac segment of the receiving ureter, make

the longitudinal incision on the lateroexternal side

) At the beginning, make the incision on the

receiv-ing ureter small so that it can be enlarged

after-ward as necessary

) Never make the perimeter of the longitudinal

inci-sion of the receiving ureter larger than the orifice

of the other ureter

) Choose resistant 6-0 suture material, above all with

good gliding capacity

) Make the two knots outside of the ureteral lumen

) Avoid eversion, tension, and kinking of the sa

muco-) The continuous suture from the two cardinal tures is preferable since it is tighter, is less likely tocause ischemia, and diminishes the risk of cuttingthe tissues

su-) When making the side-to-end anastomosis, thereare two main sutures: the upper-angle suture andthe lower-angle suture, which must be placed withrigorous precision and perfection so that they donot diminish the diameters of the proximal anddistal orifices of the receiving ureter, since they aredecisive for the permeability of the anastomosis Toachieve this, both in the distal extreme as well as inthe proximal extreme of the receiving ureter, thesuturing must be located at no more than 1 mmfrom the edge of the incision

) Remember that the result depends on the quality ofthe anastomosis

It will be precisely in this type of small-suture surgerythat the surgeon will have to aim to achieve maximumperfection and master the surgical technique, so as tomake a work of art out of every operation These are thesurgeon’s principal qualities and raison d’ˆetre

Iatrogenic Pathology, Undiversion, Contralateral Renal Autotransplantation 525

Deferred Emergency Surgery of Total Rupture

of the Posterior Urethra

J.M Gil-Vernet

Total rupture of the posterior urethra is a topic that

in-terests all surgeons: general surgeons, orthopedic

sur-geons, and urological sursur-geons, because it is a serious

trauma occurring with ever greater frequency and

pre-senting with severe pathology since the urinary and

sexual dysfunction of the patient, who is generally

young, interferes with his family and social

environ-ment

Its treatment is difficult and it is one of the most

con-troversial chapters in urology This emergency surgery,

whether of the urethra, the bladder, or the kidneys,

psupposes a change in our usual approach since it

re-quires that urologists involve themselves more in

emer-gency surgery, participate in the progression of the

trauma patient, and be familiar with the general lines of

management of the multiple-injury patient The course

of the serious lesion of the urethra essentially depends

on the immediate initial treatment, and therefore

emergency departments receiving accident victims

must have an integrated strategy for the treatment of

multiple-injury patients in which the emergency rooms

and the urology departments collaborate on the basis

of a protocol agreed upon with traumatologists and

or-thopedic surgeons

This protocol takes into account that, upon arrival in

the emergency room, a trauma patient with signs of

suspected fractured pelvis and consequently suspected

urological injury must, if the x-ray examination of the

skeleton confirms the fracture and if the patient’s

he-modynamic condition permits, be given an IVU, which

will permit elimination of a renal lesion or rupture of

the bladder, or will reveal the elevated position of the

bladder due to a substantial pelvic hematoma, this

lat-ter being a pathognomonic sign of total rupture of the

membranous urethra An overwhelming desire to

uri-nate, discrete urethrorrhagia, and retention of urine

are signs of suspected urethral rupture.

As soon as bladder distention starts, the minimal

cy-stotomy will be performed prior to checking the

loca-tion of the bladder by means of sonography

Toward the 4th or 5th day, the patient’s general

or-thopedic and urological condition will be evaluated

and, if the patient’s condition permits, the following

ex-plorations will be performed immediately before

surgi-cal repair of the urethra: (1) transrectal sonography, (2)cystography in optimal aseptic conditions and antibi-otic cover, (3) voiding cystourethrography attemptedthrough the suprapubic catheter, and (4) retrograde ur-ethrography with a small quantity of contrast mediumwith fluoroscopic monitoring

These explorations can confirm the clinical sis of complete rupture of the urethra, the degree of dia-stasis, and the prostatourethral dislocation marked bythe elevation of the bladder

diagno-From this point on, the urologist must meet with thetraumatologist in order to evaluate all the informationcompiled concerning the urethral rupture and the pel-vic fracture and to decide the time and type of urethraland pelvic repair

There can be two basic scenarios as regards pelvicfractures: the fracture can be stable or unstable In thecase of unstable fractures of the pelvic girdle, the cur-rent attitude of orthopedic surgeons is becoming moreand more interventionist, an attitude that is very posi-tive for reducing urethral shift

Orthopedic surgeons prefer osteosynthetic dures for stabilizing the pelvic ring, using the externalfixator for its reduction and fixation, or internal fixa-tion with nails or plates, which requires open surgery

proce-If the urethral rupture is accompanied by unstablepelvic fracture, the urologist and the orthopedic sur-geon must operate simultaneously, starting with ure-thral repair and continuing with osteosynthesis.For the urologist, the fracture of pubic branches ordiastasis facilitates urethral repair extraordinarily

In cases of stable fracture of the pelvis, the dic surgeon will advise rest, and will not intervene; itwill therefore be the urologist who must decide whattreatment to pursue

orthope-This is where an old controversy emerges When tooperate? Must one operate immediately or later?There are two possible therapeutic attitudes: one is

to perform end-to-end anastomosis of the urethraledges during deferred emergency surgery between the4th and the 8th day, and the other is to leave the drain-age of the cystostomy for 3 – 6 months and then treatthe existing complex stricture These are two differentconcepts The objective of the first is to repair the acute

lesion in order to avoid stenosis, while the second

at-tempts to provoke stenosis

Operating at 3 – 6 months is a strategy whose

objec-tive is to avoid medicolegal problems as regards

impo-tence

Apart from great loss of time for the patient, a long

period of incapacity for work, expense, and prolonged

hospitalization, intervention between 3 and 6 months

makes the relatively simple treatment of the injury tract

– end-to-end anastomosis – the complicated treatment

– posttraumatic stenosis

The repair of these stenoses at 3 – 6 months is always

a difficult operation, since the membranous urethra

and the external striated sphincter are encased and

in-filtrated by hard scar tissue, and in these conditions,

ir-respective of the approach route and the type of

recon-struction that one uses, it is always a highly aggressive

operation, since one has to extirpate the scar tissue

en-closing the urethra and its sphincter and, even if the

re-construction of urinary continuity is successful, the

loss of the voluntary urinary control mechanism of

stress incontinence due to cervicourethral

insufficien-cy and alterations in ejaculation due to absence of the

energetic contractions of the external sphincter in

or-gasm It jeopardizes the patient’s future since, with

in-creasing age, hyperplasia or cancer of the prostate may

develop, and surgery will leave the patient completely

incontinent

The other position is that of reestablishing urinary

continuity in deferred emergency treatment within the

1st week after the accident, before pelvic fibrosis

rigidi-fies the anatomical structures

There are two treatment methods for this: one limits

itself to bringing the extremes of the urethral rupture

closer together, the other involves suturing the urethral

extremes edge to edge

The first involves the urethral splint, which aligns

the urethra by means of a permanent catheter placed

with open surgery or endoscopy

Others attempt to reduce the separation between the

edges by placing a Foley catheter and with permanent

traction, bringing the prostate closer to the urogenital

diaphragm, tying the prostatic apex with transfixion

sutures These methods result in a very high percentage

of stenosis

In the rare case of partial ruptures with little shift,

these procedures can achieve acceptable results, but not

in the case of total ruptures where the shift does not

permit the coalescence of the urethral segments

Other procedures such as urethrorrhaphy suture the

edges of the urethral extremes without tension This is

the ideal treatment Its objective is to ensure healing all

at once and to avoid stenosis It is the preferred method

since the results are better both from the urinary and

sexual point of view as well as with respect to the

pa-tient’s future

The main problem in urethrorrhaphy is finding theedges of the rupture, identifying them, and exposingthem in order to achieve a good anastomosis withouttension

There are three approach routes for this: the

perine-al, the transpubic or transsymphysiperine-al, and the bic route

retropu-The perineal route is often contraindicated in thecase of fractures of the ischiopubic rami, since the posi-tioning of the patient in the peritoneotomy position isnot advisable This route demands dissection of thebulbar urethra and ligation of the bulbar arteries,which supply most of the vascularization of the ure-thra; longitudinal section of the striated sphincter isobligatory The hematic infiltration makes identifica-tion of neurovascular structures located in the dia-phragm impossible

The transpubic route with resection of the sis is highly aggressive, jeopardizes the stability of thepelvic girdle, and must therefore be avoided

symphy-Pubic symphysiotomy using the cold knife nique is an excellent approach route, but it obliges thesurgeon to perform the longitudinal incision of the an-terior side of the striated sphincter in its middle line inorder to look for the distal extreme of the sectionedurethra and to perform the urethrorrhaphy The surgi-cal aggression causes injury to the walls, vessels, andnerves of the striated sphincter and the other struc-tures contained in the urogenital diaphragm, andtherefore the surgical iatrogenic damage is similar tothat of late repair of the stenosis

tech-The retropubic route is less aggressive It does notrequire changing the position of the patient, and it per-mits simultaneous treatment of the osseous and uri-nary lesions as well as evacuation of the hematoma.The disadvantage is the narrowness and depth of thesurgical field, which makes anatomical repair difficultsince the distal extreme of the urethra is retracted be-low the upper leaf of the middle perineal aponeurosis,which becomes difficult to find and clearly expose forgood anastomosis between the two urethral ends.Therefore, this route was abandoned in favor of thetranssymphysial and perineal route

This was the situation until 1988, when we describedthe urogenital diaphragm-raising maneuver, whichmarked a new surgical focus of the problem, making itless aggressive, easier, and providing better results byfacilitating suturing of the edges, which improved theprognosis of this serious trauma while preserving thesphincter mechanism In traumatic ruptures of theposterior urethra, the central perineal musculature andthe membranous urethra have greater mobility due tothe tearing of the middle perineal aponeurosis, thus fa-cilitating the maneuver

Raising the urogenital diaphragm pulls the distalmembranous urethra situated in a deep plane toward

Deferred Emergency Surgery of Total Rupture of the Posterior Urethra 527

b

c

Fig 21.5.1 a Pelvic hematoma

elevat-ing the prostate and bladder Retracted

distal urethral edge b Foley catheter

in the pelvic cavity, thread knotted at

its extreme c Foley balloon inflated

with 4.5 cc situated in the bulbar thra

Fig 21.5.2 a Upward traction of the catheter raising the urogenital diaphragm, raising of the distal end of the urethra b, c Good

exposure of the edges, easy placement of the four to five 5-0 Dexon sutures End-to-end anastomosis without tension

the surgeon, achieving greater superficial exposure,making an anastomosis of a high technical quality andthus preserving the vascularization of the urethra with-out the risk of injuring the external sphincter, thus ex-plaining the excellent anatomical and functional results

in reestablishing the urinary continuity (Figs 21.5.1 –21.5.3)

Case Report: A 44-year-old man was brought to theemergency room following a traffic accident presentingsigns of a pelvic fracture that was confirmed by x-ray as

a fracture of the left ischiopubic rami The patient sented signs of hypovolemic shock, thus impeding theIVU, an overwhelming desire to urinate, and discreteurethrorrhagia Fortunately, no urethral catheteriza-tion was attempted Bladder distention appeared andsonography revealed major pelvic hematoma, so mini-mum cystostomy was performed On rectal palpation,

pre-a b

Fig 21.5.3 a Cystography through a suprapubic catheter, prostatourethral dislocation, marked by elevation of the bladder taneous retrograde urethrography, pelviperineal extravasation of contrast medium b Voiding cystourethrography 1 year after

Simul-surgery No stenosis, good continence Excellent result

the prostate was not palpable, only bulging of the

ante-rior surface of the rectum and pain at the level of the

membranous urethra On the 4th day, the patient was

evaluated with the orthopedic surgeon who confirmed

that the pelvic ring was stable and only required bed

rest The urologist took charge of the case and

inter-vened on the 5th day after the accident Retrograde

ur-ethrography and cystography were performed in the

same operation A puboumbilical incision and

sym-physiotomy using the cold knife method achieved a

separation of 4-5 cm between the pubes The Retzius

cavity and iliac fossas contained large clots, which were

extracted from the same; thereafter careful hemostasis

was achieved A puboprostatic ligament and one of the

endopelvic fascias of the prostate were torn, the other

fascia and the puboprostatic ligament, which were

un-damaged, were cut, achieving mobilization of the

pros-tate and thus facilitating the realignment of the urethra

The prostatic apex maintained the proximal extreme

of the membranous urethra some 3 – 4 mm in length

The ischemic and torn edges were resected

The large hematic infiltration of the pelvic tissues

made it impossible to identify the retracted urethral

edge at the bottom of the pelvic excavation In theseconditions, it was considered impossible to completethe urethrorrhaphy However, it occurred to me to cath-eterize the urethra with a 14-F Foley catheter, and when

it emerged in the pelvic excavation, I tied a thread to itsend, pulling it back until it was situated in the bulbarurethra I inflated the balloon with 5 cc, pulled thethread in the cephalic direction, and when raising theurogenital diaphragm, which, as usual, was torn, theurethral edge appeared, allowing an easy and goodend-to-end anastomosis, yielding a perfect anatomicaland functional result

In cases with narrow and deep pelvises or in obesepatients, it is preferable to perform symphysiotomy us-ing the cold knife method and to finalize the operationreestablishing the pubic symphysis with two or threesutures

The total rupture of the posterior urethra is the cipal indication for this maneuver, which has shown it-self to be successful in the treatment of this serious ac-cident and in radical prostatectomy and intestinal blad-der replacement

prin-Deferred Emergency Surgery of Total Rupture of the Posterior Urethra 529

Surgery of Complicated Horseshoe Kidney

J.M Gil-Vernet

The horseshoe kidney must be regarded as a clinical

entity because of the importance of its pathology and

its incidence (1/200 pyelograms), even though it has no

pathognomonic signs or symptoms

The renal anomalies, be they of rotation, position,

but above all fusion, are very frequently associated with

urinary anomalies of the upper excretory tract and are

the cause of hydronephrosis, pyelonephritis, and

lithia-sis resulting from urinary obstruction

The multiple etiopathogenetic factors responsible

are high and ventral position of the pelvis, high

inser-tion and angulainser-tion of the pyeloureteral juncinser-tion, and

the ureter riding above the isthmus But the most

im-portant pathologies are the structural lesions of the

proximal ureter such as segmental aplasia or

hypopla-sia of the muscular stratum, or orientational anomaly

of its muscular fibers In a histological study conducted

with W Gregoir, the most frequent type of structural

alteration observed was collagenous hypertrophy,

which is the aspect frequently encountered in

congeni-tal hydronephrosis where the obstacle is essentially

functional, constituted by achalasia, and is not a true

stenosis, which in the case of the horseshoe kidney

(Fig 21.6.1) even reaches 3 – 5 cm below the

pyelourete-ral junction

The conventional techniques for the treatment of

these types of hydronephrosis in horseshoe kidney are

not suitable for correcting this anomaly since they are

not capable of eliminating the multiple

etiopathogene-tic factors responsible for this complication, thus

ex-plaining the poor results

However, the horseshoe kidney has a pathology of

its own, resulting from its topographic characteristics,

in which the pain caused by the pressure exerted by the

prevertebral isthmus on the solar plexus and its

viscer-al rami, on the aorta and the lymphatic circulation, is

the dominant clinical element It is the

nonpathologi-cal, but painful, horseshoe kidney, resulting in the

divi-sion of the symphysis followed by the displacement of

each kidney toward the corresponding lumbar fossa

and nephropexy by suturing the leaves of the renal

cap-sule to the adventitia of the lateral wall of the aorta, thus

liberating all these structures from the compression

caused by the isthmus

Fig 21.6.1 Diagram of a horseshoe kidney

The complicated anomalies, above all if they have ready undergone surgery, require a different surgicaltactic and technique They demand an operation thatcorrects the pathology of the actual renal anomalywhile correcting the pathology of its excretory tract,i.e., one must eliminate the isthmus in order to relievethe compression on nerves and vascular structures, re-sect the entire dysplastic segment of the ureter, givingthe kidney a normal anatomical orientation so that itsventral pelvis remains in the posterior or dorsal posi-tion, achieving downward drainage of the urine andpreserving all of the renal parenchyma

al-This is achieved by means of uni- or bilateral transplantation and bench surgery This surgery is notparticularly complicated, but it solves the problem

auto-Case Report: A 10-year-old boy, with no relevant

family history and presenting at the age of 7 with

unde-fined abdominal pain with gastrointestinal upsets He

underwent appendectomy without benefit After that,

he presented with episodes of pain in the upper

abdo-men, particularly in the periumbilical region, radiating

toward the bilateral lumbar region Analysis revealed

slowly progressive albuminuria The diagnosis of

bilat-eral hydronephrosis was established by sonography,

but it was the IVP that defined the existence of a

horse-shoe kidney complicated by substantial dilation of the

pelvis, infundibula, and renal calyces on both sides

With this diagnosis, he was admitted at the age of 9 to

another hospital department where a left nephrostomy

was performed On the 30th day, a ureteropyeloplasty

of the left kidney was performed

In 1981, he was admitted to my urology department

with painful symptoms, urinary infection, and

recur-rence of the obstruction of the half of the kidney that

had undergone surgery It is well known that the renal

lesion associated with a malformation is all the more

serious the smaller the child is, requiring a rapid

solu-tion

In the surgical sessions of the 8th International

Course of Urology in Barcelona in 1981, I performed ex

Fig 21.6.2 IVP of a complicated horseshoe kidney Bilateral

vi-The kidney was extracted through a paramedial, rarectal, extraperitoneal incision, the ureter havingbeen cut below the parenchymatous edge, and placed

pa-in a vessel where the three arteries were cannulated andsimultaneously perfused with Collins 3 solution at 4 °C.The organ remained constantly immersed in controlledhypothermia and we proceeded to prepare the renalvessels Two veins were anastomosed to one another,the other very small one was ligated (sometimes it is al-

so possible to join two arteries), all using microsurgical

Fig 21.6.3 Selective arteriography of the isthmic artery

irrigat-ing the lower third of each kidney

Surgery of Complicated Horseshoe Kidney 531

Fig 21.6.4 The trunk and the two dividing branches of the

isth-mic artery in the inverted renal autotransplantation must be

conserved

Fig 21.6.5 Diagram of the transplanted kidney half

Fig 21.6.6 IVP of the right kidney after inverted renal

auto-transplantation into the iliac fossa

techniques The edge of the branch of the isthmic tery was exposed, the ureter and the pyeloureteral junc-tion resected, the pyelic sac reduced, and a place for im-plantation of the ureter prepared After completion ofthe bench surgery, the kidney was transferred to thepatient’s iliac fossa where it was placed in an invertedposition, that is to say, the superior pole was placed inthe inferior location, thus facilitating the vascular anas-tomoses (Fig 21.6.5) The iliac ureter was anastomosed

ar-to the inferior renal pelvis (Fig 21.6.6, 21.6.7) Duringthe course of the transplantation and in order to pre-vent the organ from warming up again during the longperiod of ischemia, the kidney was kept in hypother-mia between two cushions of cold compresses Thismethod of cooling does not obstruct the surgeon, itprotects the kidney effectively, and the surgeon has suf-ficient time to make the multiple vascular anastomoseswithout having to hurry, using the best technique Thekidney recovered its function immediately and nopostoperative problems occurred

Two months later, I performed the tion of the left kidney (Fig 21.6.7) following the samesurgical strategy Figure 21.6.8 shows the IVP 25 yearsafter the result

autotransplanta-Fig 21.6.7 Diagram of the transplant of the inverted horseshoe

kidney

It is the only surgical technique that can correct this

re-nal anomaly and the associated lesions

Fig 21.6.8 IVP 25 years after inverted renal

autotransplanta-tion of the horseshoe kidney Both kidneys have normal tion, and the pain, infection, and proteinuria have disap- peared.

func-Surgery of Complicated Horseshoe Kidney 533

Cold Fire

Ch.F Heyns

The word for gangrene in my home language,

Afri-kaans, is kouevuur, literally “cold fire”: to the patient a

gangrenous limb “burns like fire,” yet it feels cold

Un-like ordinary fire, which reveals itself by light, heat, and

smoke, “cold fire” is an insidious threat, which can be

more dangerous than searing flames

One

When I was a houseman (intern) doing medicine, I

worked with a registrar (resident) who had a rather

high opinion of his own medical knowledge and an

equal disdain for the ignorance displayed by “stupid”

surgeons who just “cut everything” and then referred

their patients to medicine because they lacked the

clini-cal acumen to diagnose or treat simple cardiac failure

The registrar always carried a hugely impressive

stethoscope around his neck, and never failed to

metic-ulously auscultate the chest of every patient we

encoun-tered on ward rounds (which consequently lasted all

day)

One day a known diabetic patient was admitted in a

state of confusion As usual, innumerable blood tests

and special investigations were requested, and the

reg-istrar wrote his usual meticulous orders for insulin to

be given according to a glucose sliding scale Every

morning on the ward round, he would carefully

exam-ine the patient’s chest with his stethoscope, pore

end-lessly over the results of blood tests, ECGs, and x-rays,

and berate the nursing staff for not adhering to his

in-sulin sliding scale

This continued for 2 or 3 days, but the patient’s

con-dition did not improve and the blood glucose remained

out of control Then one morning, the ward sister said

“Look at this, doctor” and pulled up the bed sheets,

showing us the extensive gangrene of the patient’s feet

I would have liked to conclude this anecdote by saying

that it had made the registrar a little more tolerant

to-ward “stupid” surgeons, but sadly this did not occur

Two

About 30 years ago, I was involved in the following dramathat occurred at a referral hospital about 1,500 km fromthe medical school where I had graduated Although Iprefer not to reveal which role I personally played duringthe drama, it will be clear that there were no heroes.The patient, a 50-year-old female with diabetes mel-litus on oral medication, was admitted to the surgeryward late on a Friday night with a referral letter simplystating “Ischio-rectal abscess, please see and treat.” Thepatient was somewhat confused and vaguely com-plained of pain “down below.”

The houseman did not really want to examine theobese and rather malodorous patient, so he simply didhis job, clerking (filling in forms) and sending bloodsamples away However, because the patient continuedmoaning as if in severe pain, he telephoned his imme-diate superior, the medical officer (MO) on call.The MO, in his second posthouseman year, had onlyworked in surgery for a few months and his clinical ex-perience was limited Despite being on call, he had gone

to a party, had drunk too much, and got to bed very late

At 3 a.m the phone rang and he was told about the tient He advised giving her an opiate i.m and said hewould come to see her in the morning Unfortunately,

pa-he overslept and did not see tpa-he patient before tpa-he wardround with the consultant surgeon at 8 o’clock.The surgeon was a very experienced and energeticman, but not very communicative The moment he sawthe patient, he ordered that she be taken to the operatingroom immediately, but did not bother to explain why Thehouseman reported that the laboratory results showednot only a very high glucose level, but also an elevatedurea and creatinine, low sodium and high potassium Theirate surgeon only repeated his command that the patientshould be taken to the operating room immediately.The anesthesiologist was very experienced and proud

of his reputation for being quick, but his knowledge wasrather outdated He set up a peripheral line and put thepatient “under” with a bolus of pentothal and mask an-esthesia on spontaneous breathing of nitrous oxide andhalothane, thinking that it would merely be an incisionand drainage of an ischiorectal abscess

Only when the massively obese patient was put into

lithotomy did the area of perineal gangrene become

ap-parent The taciturn surgeon, a very slick operator,

ex-cised the gangrenous tissues in a flash and, to the

hor-ror of his assistants, rapidly extended the debridement

until the patient’s whole left buttock was denuded The

odor was intolerable, bleeding was profuse, the

assis-tants struggled to keep up with the surgeon’s flying

hands, the anesthesiologist eventually discovered that

the blood pressure was zero, and then it turned out that

no crossmatch had been ordered

While the houseman rushed off to get blood, the

sur-geon proceeded with his radical debridement, the

anes-thesiologist strapped the mask to the patient’s face and

started pumping in i.v fluids Halfway through the

de-bridement, the patient had a cardiac arrest and, despite

vigorous CPR, she died on the table

The most powerful diagnostic instrument in all of

medicine is the retrospectoscope Unfortunately it can

only be used when it is too late to be of real use to the

patient It has been said that doctors bury their

mis-takes However, the truth is that most of our mistakes

live on in memory to haunt us for the rest of our lives

Three

A 21-year-old man had undergone ritual circumcision

and was brought to hospital about 1 week later with

gangrene of his entire penis (Fig 21.7.1) The patient

also had bruises and abrasions on his arms and legs,

consistent with being beaten and tied up, but refused to

provide any information about his injuries

Among certain African tribes, circumcision has for

centuries formed part of an initiation ceremony led by

elders, lasting several days and constituting an essential

rite of passage from boyhood to manhood

Traditional-ly, circumcision was performed in early puberty, but

nowadays it is often performed on adults who are

al-Fig 21.7.1 Gangrene of the penile shaft as a complication of

rit-ual circumcision

ready sexually active and who may, in some cases, be willing to undergo the procedure Those who developcomplications are sometimes prohibited from seekingmedical help, which was probably the case in our patient.Traditionally, hemostasis was obtained using non-compressive dressings made from the leaves of certainplants, possibly with antiseptic properties, but these arenot available in urban areas, so materials such as paper

un-or even plastic are sometimes used The most dangerous

is when a string in the form of a small noose is placedaround the base of the penis to control bleeding Ische-mia and infection act synergistically to form a deadlycombination Circumcision subjects are not allowed toeat or drink during the period of initiation, thereforesepticemia is usually compounded with dehydration

The patient in question was admitted to hospital on

a weekend, given intravenous fluids and antibiotics, butnot taken to the operating room immediately, becausethe registrar thought that the gangrene had demarcatedand that the penis would slough spontaneously Whenthe patient was first seen by the urologist on Monday,

he appeared generally well and pain-free, and did nothave an elevated temperature However, the tell-talesign was that he had slight tachypnea and flaring nos-trils, indicating early respiratory distress

He was taken to the intensive care unit for intubationand aggressive resuscitation, then to the operatingroom for urgent penectomy (Fig 21.7.2) However, hedeveloped septicemia and multiorgan failure and, de-spite full ICU support, died a few days later

Clinical experience cannot be learned from books, itmust be learned in the school of life But without books

to impart the knowledge distilled from clinical ence, we would be forever condemned to learn onlyfrom our own mistakes – at our patients’ expense The simple lesson to be learned from these anec-

experi-dotes is clear: gangrene may be an insidious kouevuur

(cold fire), but it can consume the patient’s life just asrapidly as open flames

Fig 21.7.2 Amputation of the penile shaft for gangrene after

ritual circumcision

Cold Fire 535

Lost in the Kidney

M Hohenfellner

The general surgeons once presented a patient to us

who had had a hemicolectomy for large bowel cancer

more than 1 year before The patient’s immediate

prob-lem was that he had developed secondary bilateral

re-nal metastases

The therapeutic strategy was to remove the

metasta-ses in a single surgical metasta-session to allow adjuvant

chemo-therapy as soon as possible A median laparotomy was

performed First the right kidney was exposed

Howev-er, the metastases seen clearly in the MRI could not be

located, neither visually nor by palpation So the next

step was to employ intraoperative ultrasound, but even

this tool and a significant number of investigators,

in-cluding urologists and radiologists, could not clarify

the whereabouts of the metastasis

It was clear that any consideration to nephrectomize

the patient simply for not being able to find the tumor

was unacceptable As a last attempt, I incised the

fi-brous capsule and, very carefully, stripped the kidney

nearly completely of its capsule, leaving it just attached

at the lower pole After removing the capsule, repeatedpalpation immediately identified the exact location ofthe metastasis, which subsequently was easily removedwith free margins Surgical hemostasis included repo-sition of the kidney capsule

With this experience behind us, the removal of thecontralateral metastasis was a straightforward proce-dure The postoperative course was uneventful

Summary

1 The fibrous capsule of the kidney is a strong filterfor any haptic sensations Its removal allows eventhe smallest nodules to be detected by careful pal-pation

2 A relaxed overview in a complex situation can cilitate simple and effective solutions by preservingthe creativity of the surgeon in charge

fa-A Rare fa-Accident

R Hohenfellner

Background

In 1964, I moved from Vienna to Homburg/Saar to take

an Associate Professor position in one of the most

rec-ognized departments of urology headed by Prof C.E

Alken Still on duty at 4 p.m., I received a call from the

chief of the surgical department to join him

immediate-ly in the emergency room

History

At 3 p.m a 60-year-old gynecologist had a rather

excep-tional accident in his office in a small town nearby

When he tried to take a seat on his swivel chair in front

of his patient, the chair turned over and the metal

thread went through his anus high up into his rectum

The emergency team arrived immediately and

trans-ferred him, with the iron thread still in place, to the

sur-gical department of the university hospital

The Situation at Arrival

The patient was stable and fully conscious and was

placed in a Trendelenburg position on the operating

ta-ble; the anesthesiologist started with general anesthesia

Diagnosis and Therapy

The chief of the surgical department accompanied by

his senior resident looked at me:

“What is your diagnosis, Mr Hohenfellner?”

It was a critical question He was an experienced

ab-dominal surgeon, had served many years during the

Second World War in different army hospitals, and had

certainly encountered similar stab wound injuries

before He had already placed the patient on the

operat-ing table, makoperat-ing it impossible to take an x-ray

With the iron post still in his rectum, moving him

was highly risky

“Well,” I said, “the patient is stable, the emergency

lab will arrive soon, the length of the post is unknown,

an x-ray cannot be taken, but I want to insert a Foley,Sir.”

I inserted an 18-French Foley with no difficulty and

150 ml of hemorrhagic urine passed

“What does it tell you?”

“The thread went through the rectum and there issome sort of a bladder injury, maybe a penetrating one,but it is proximal of the prostate, Sir.”

“So what will be the first step?”

Again it was a difficult question for a urologist withalmost no experience in rectal and bladder stab woundinjuries However, from my residency in general sur-gery I remembered a case of severe bleeding during aso-called synchronous rectum resection from the peri-neal wound performed by two teams A Mikulicz tam-pon solved the problem in the end So, I thought, re-moving the post may cause severe bleeding

“The first step, Sir, should be a median laparotomyfrom the sternum down to the symphysis with inspec-tion of the abdomen At that time, the anesthesiologistwill have enough blood transfusion supplies to keephim stable, when a second team removes the post frombelow.”

“Let’s scrub!”

The Operation

He opened the abdomen and there was not much bloodinside The top of the post had perforated the rectumand the bladder above the trigone and then went outthrough the bladder dome in the rectus muscle Thesecond team was ready and removed the post The se-vere bleeding was immediately stopped by about 2 m ofthe transrectally inserted Mikulicz tampon

“It is your turn,” he said and moved to the other side

of the table I opened the back side of the bladder fromthe dome down to the perforation as in a vesicovaginalfistula Fortunately, the orifices could be identifiedwithin the hemorrhagic edematous bladder mucosaand intubated with ureter catheters He helped me closethe rectal wound with two layers of interrupted catgutand silk sutures I took a peritoneal graft from the leftabdominal wall and fixed it between the rectum and the

21.9 Selected Case Reports and Personal Experience

bladder to secure the overlying suture lines from the

rectum and the bladder Then three layers of a running

mucosa, interrupted detrusor suture line, and an extra

row of peritoneal sutures closed the bladder A

cystos-tomy tube was inserted

“Why this?” he asked

“Well, Sir, the running mucosa suture line is the

he-mostatic one Postoperatively, if the small bowel and

the peritoneal cavity become distended the peritoneum

overlying the bladder will also distend and the bladder

suture line will probably be disrupted if it was closed by

a single-layer suture line.”

“Have you seen this before?”

“Yes, Sir, in a young lady with a bladder rupture

fol-lowing a car accident On day 5, the abdomen distended

and suture insufficiency ensued, and she had to be

op-erated again.”

“And what is the next step?”

“Well, Sir, I have not much experience but a

right-side colostomy may protect the rectal suture line.”

Outcome

He performed the colostomy and the postoperativecourse was uneventful The Mikulicz tampon was re-moved with the patient under general anesthesia on the5th day and the bladder catheter 10 days later

The voiding cystourethrogram was normal, thecystostomy was removed and the patient went home for

3 months, when finally the colostomy was closed

Remarks

Today a CT would probably be the first diagnostic stepbut with the same therapeutic strategy

Still today the gynecologist’s present is on my desk:

a small silver dish with the engraving “Thank you”.But one question remains How does one cross theocean with no navigational equipment? With lots ofluck

R Hohenfellner

Introduction

Homburg/Saar 1965 I received the emergency call on

Saturday, 11 p.m during a birthday party and went in

the surgical department’s operating room The senior

resident said, “Thank you for coming and please have a

look inside.”

I climbed on a step behind him

History and Situation

“This is an 8-year-old girl, admitted by her mother, a

pediatrician, 2 hours ago with the symptoms of acute

appendicitis So we performed a standard

supraingui-nal incision and found a normal appendix However,

behind the appendix in the retroperitoneum – here you

can see it – there is a strange structure, maybe a tumor,

but we aren’t sure what it is Since it’s located in the

ret-roperitoneum, it may be arising from the urogenital

system, which is why I called you.”

Diagnosis

The cylinder-like bulging structure, 2 – 3 cm in size,

was located behind the cecum reaching down into the

pelvis and I had absolutely no idea what it could be I

washed my hands longer than necessary

The skin incision along the Langer line was rather

short and the exposure was limited By palpation I had

the impression of elasticity, possibly with fluid inside.

In the early 1960s, pediatric urology was still a

young discipline The diagnosis concerning the upper

tract was made exclusively based on an IVP Quite often

reflux studies performed preoperatively were

com-pared with postoperative IVPs to demonstrate the

ex-cellent results in grade 4 antireflux surgery The same

was true for so-called tailoring in obstructive

megaure-ters Extensive tailoring of the upper and lower ureter

was done in a single session with still unknown late

re-sults

“Maybe it is a megaureter,” I murmured “Have you

done a urine analysis?”

“I don’t know if this was done She was admitted by hermother with an acute abdomen, high temperature, and14,000 white cells, a clear indication to operate on herimmediately.”

Treatment

“So let’s do a puncture.” With a rather thin needle, Ipunctured the structure and aspirated roughly 80 ml ofputrid fluid, obviously infected urine The structurecollapsed and a second normal ureter could be identi-fied lying close to the wall of the dilated one

“It’s a double system,” I said, “and one is obstructedand infected The problem is we don’t know if the dilat-

ed ureter is only obstructive and drains the better part

of the kidney or if it is dilated and infected because it isobstructed and refluxing Furthermore, we have no in-formation on the contralateral side Is there a healthykidney or almost none at all?”

“So you have to reimplant the obstructed and dilatedorifice, and also the refluxing one in the bladder.”

“But she has a severe infection!”

“So what would you like to do?”

“First of all, the nurse can insert a bladder catheterbecause it’s easier to prepare the ureter if the bladder isempty.”

I started to separate the normal ureter from the lated one, anxious not to disturb the common bloodsupply By chance I found a cleavage plane between thedense fibrous tissue with the longitudinally runningvessels and the adventitia of the normal ureter It took

di-a long time, but findi-ally the megdi-aureter wdi-as sepdi-ardi-ateddown to the bladder, so I clamped and dissected it I leftthe distal stump open due to the risk of ureteral stumpempyema It became easier to prepare in the proximaldirection and we inserted a hook The normal uretershowed good peristalsis, and when the separation wasfinished the dilated megaureter was long enough toperform a ureterocutaneostomy

21.10 Selected Case Reports and Personal Experience

Postoperative Course

The patient’s temperature dropped immediately and

the postoperative course was uneventful There was

on-ly a small amount of urine in the cutaneostomy bag

Ten days later, the IVP showed a normal kidney on

the left side and a normal lower system on the right side

with a small nonfunctioning upper pole Fortunately,

there was no reflux in the right lower system

Dr Oberhausen from the Institute for Radioisotopes

took an interest in the case Later recognized

world-wide for the Oberhausen Clearance Curve, he

per-formed one of the first split renal function tests with

re-gions of interest on the right side The right upper pole

region showed less then 10 % but the total right

func-tion was still 40 % of the total renal funcfunc-tion

The girl went home and was readmitted 2 months

later She was asymptomatic and the stoma looked

per-fect The cystoscopy showed a normal left orifice and

two on the right side with a small ureterocele on the

lower one A right supracostal incision was made and

3 – 4 cm of the upper pole, showing severe

pyelone-phritic scars, was resected The lower part of the kidney

looked normal and the ureter was carefully dissected

free from the dilated one A Foley catheter was inserted

in the stoma and fixed with sutures at the upper pole

The “pull through and out maneuver” was performed

easily and thereafter the stoma was excised and closed

Remarks

The discussion concerning the nomenclature and

clas-sification of the dilated ureter continued for many years

until the Philadelphia Consensus was reached in 1974

Until that time, primary obstructed megaureter hadbeen classified as a reflux or nonreflux megaureter Par-kulainen’s Reflux Grading was accepted at the sametime, as was Emmet’s Grading for dilatation

However, the discussion concerning the treatment

of megaureters and double systems persisted

In the early 1980s, looking at the long-term follow-up

in adults with obstructive megaureters, we found thatthe majority of gross dilated ureters in childhood ended

up as asymptomatic, low segmental dilated ureters.For duplex systems, Woodard’s Strategy, developed

in 1996, was accepted worldwide In symptomatic ble systems:

dou-1 Start from below, resect the ureterocele, and plant both ureters with an antireflux method

im-2 Wait and see and approach the upper tract only if itbecomes necessary

In children with a pyelocutaneostomy and neostomy, stomal obstruction is an extremely rarefinding If the greater omentum is wrapped around theureter (Roth 1967; Lodde 2004), stomal obstruction al-

ureterocuta-so significantly reduced in adults later on

References

Roth A (1967) Transabdominal transperitoneal bilateral omento-ureterostomy Annual meeting of North Central section, AUA, Cleveland Ohio Sept 27 – 30:196

Winter CC (1972) Cutaneous ureterostomy: clinical tion J Urol 1o7:233 – 239

applica-Winter CC (1976) Long term results of cutaneous terostomy J Urol 116:311 – 315

omento-ure-Lodde M et al (2004) Uretero-ureterocutaneostomy wrapped

by Omentum BJU International 953:371 – 373

Posterior Sagittal Approach in Pediatric Urology

F Ikoma

What is the best route to surgically treat an iatrogenic

high-grade female hypospadias in a 2-year-old girl

with subsequent, almost total urinary incontinence? Is

the posterior sagittal approach the best to treat such a

difficult emergency? Or are other treatments more

ap-propriate?

Some years ago, a small 2-year-old girl had received

a surgical treatment by a pediatric surgeon for her

con-genital urethral diverticulum The pediatric surgeon

had cut with scissors both the anterior wall of vagina

and the posterior wall of urethra from the urethral

me-atus to the bladder neck After the procedure for the

urethral diverticulum, it was impossible for the

sur-geon to make sutures to close the opened urethra, even

with large bilateral perineal incisions, and her urethra

remained with high-grade female hypospadias after

surgery This pediatric surgeon soon afterward

intro-duced me to this unfortunate child who had subtotal

urinary incontinence after surgery

At this time, I tried to redo the interrupted sutures

with absorbable sutures to close the posterior urethral

wall and the anterior vaginal wall separately in layers

However, because of very small field of view and very

difficult manipulation of instruments in the small

vagi-na, my surgical repair disappointingly failed and her

urinary incontinence continued I thought it was better

to wait until puberty for the next radical treatment

Per-haps a sufficient field of view would be possible at that

time, via the vaginal approach, but a good or poor

re-sult after surgery could not be guaranteed I chose not

to reconstruct the bladder neck

(Young-Dees-Leadbet-ter) because the child was too young

Ureterosigmoido-stomy was, I thought, only the last-resort treatment

Now she has a cystostomy and is awaiting future

sur-gery at puberty

However, I am afraid that I will no longer be able do

such detailed and difficult surgery when she reaches

puberty, because I have already retired The surgical

solutions she needs should come in the near future

Now I would like to emphasize the importance of the

posterior approach (Kraske 1885) in pediatric and

adult urology If I had been able to use the posterior

ap-proach at that time, we could have celebrated a

success-ful surgical result for this child

The posterior approach consists of three mainroutes: pararectal routes, transanorectal routes, andperianorectal routes (Fig 21.11.1)

Pararectal routes (posterior pararectal routes) volve lateral displacement of rectum and are suitable forreaching the bladder neck and prostate Pararectalroutes (Fig 21.11.2) are classified into several routes de-pending on the site of incision: the ischiorectal route(Voelcker 1919) through the fossa ischiorectalis; the coc-cygoperineal route (Couvelaire 1951); the sacral route(Thiermann 1952); and the sagittal route (deVries andPe˜na 1982) Since 1993, I have used this posterior sagittalpararectal route for minimization (plication) and/or de-nudation of enlarged Müllerian duct cysts (prostaticutricle), which are handled easily in this manner Semi-nal vesicles and seminal ducts are also easily viewed.Transanorectal routes (posterior sagittal transano-rectal routes) (Fig 21.11.3) involve a longitudinal inci-sion of the anorectal wall and reach not only the blad-der neck and prostate, but also the posterior urethraand caudal vagina Transanorectal routes are also clas-sified into several routes depending on the site of theanorectal wall incision: the posterior and anteriortransrectal route (Kraske 1885); the posterior and ante-rior transanorectal route (York Mason 1969; Pe˜na anddeVries 1982), involving a longitudinal incision of boththe posterior and anterior anorectal wall; the anteriortransanorectal route (Young 1913), with a longitudinalincision of only the anterior anorectal wall; the anteriortransrectal route (Saposhkoff 1922), with a transverseincision of anterior rectal wall; and the anterior perine-

in-al transanorectin-al route (Cukier1985), entailing a neal incision and longitudinal incision of the anterioranorectal wall These transanorectal routes require atemporal colostomy

peri-Another route, the posterior sagittal perianorectalroute (Boeckel 1908; Pint´er 1996) (Fig 21.11.4) entailstemporal mobilization and cranial displacement of theentire rectum and anus and does not require temporalcolostomy

The perianorectal route followed by the transvaginalroute or anterior perineal transanorectal route fol-lowed by the transvaginal route is, I believe, an optimalroute to treat the iatrogenic expansive high-grade fe-

21.11 Selected Case Reports and Personal Experience

ment of rectum (© Hohenfellner 2007)

Posterior Sagittal Approach in Pediatric Urology 543

trans-transanorectal route (York Mason, 1969; Pe˜na and deVries,

1982), d Anterior transanorectal route supine position (Young,

1913) (© Hohenfellner 2007)

Fig 21.11.3 e, f Anterior transrectal route (transverse incision

of anterior rectal wall between bilateral tuber ischii)

(Saposh-koff, 1922), g, h, i Anterior perineal transanorectal route

(Cu-kier, 1985)

Posterior Sagittal Approach in Pediatric Urology 545

b

c

Fig 21.11.4 a–c Peri-anorectal route a–c Dissection and

mobi-lisation of anus and rectum after dividing of both distal and

proximal sphincter mechanisms (Pint´er, 1996)

d

e

f

Fig 21.11.4 d–f Dissection and mobilisation of anus and

rec-tum together with all sphincter mechanisms (Boeckel, 1908) (© Hohenfellner 2007)

male hypospadias of my young female patient But until

now I have had no experience with these routes

The posterior sagittal approaches have recently been

used in pediatric surgery (Pe˜na and deVries 1982) for

anorectal anomalies, but in urology, especially in

pedi-atric urology, they are very seldom used

For the radical surgery of high-grade adrenogenital

syndrome, hydrometrocolpos, cloacal anomaly,

en-larged Müllerian duct cyst, vesico- and/or

urethrorec-tal fistula, trauma and stenosis of posterior urethra,

and iatrogenic female urethral trauma, as in the case

presented herein, these posterior sagittal approaches

are very useful I would like to see a young urologist

now learn to use these routes routinely so that they can

be available for emergency treatment in pediatric and

adult urology

References

Boeckel J (1908) Nouveau proc´ed´e de prostatectomie par bilisation temporaire du segment ano-rectal Rev Chirurg 3:386

mo-Couvelaire R, Bouffard J-R (1951) L’ad´enomectomie que par voie coccyp´erin´eale droite J Urol 57:362

prostati-DeVries PA, Pe˜na A (1982) Posterior sagittal anorectoplasty J Ped Surg 17:638

Kilpatrick FR, Mason AY (1969) Post-operative recto-urethral fistula J Urol 41:649

Kraske P (1885) Zur Exstirpation hochsitzender krebse Verhand Deutsch Gesell Chir 14:464

Mastdarm-Pe˜na A, deVries PA (1982) Posterior sagittal anorectoplasty: important technical considerations and new applications J Ped Surg 17:796

Pint´er AB, Hock A, V´asty´an A, Farkas A (1996) Does the rior sagittal approach with the perirectal dissection impair fecal continence in a normal rectum? J Ped Surg 31:1349 Saposhkoff KJ (1922) Über den Zutritt zur Prostata und Sa- menblasen Verhand d XV Kongr Russ Chir St Petersburg Sept br.

poste-Thiermann E (1952) Sakrale Prostatektomie bei Hypertrophie der Vorsteherdrüse Z Urol 45:742

Voelcker F (1919) Die Prostatektomie als gut übersichtliche Operation Z Urol Chir 4:253

Young HH, Stone HB (1913) An operation for urethro-rectal fistula report of three cases Trans Am Assoc Genito Urin Surg 8:270

Zimmern PE, Cukier J (1985) Prostatic and membranous ethrorectal fistulas: a new technique of surgical closure J Ur-

ur-ol 134:355

Posterior Sagittal Approach in Pediatric Urology 547

Postoperative Urinary Retention After Hypospadias Repair

F Ikoma

If complete urinary retention occurs just after

remov-ing an indwellremov-ing catheter for hypospadias repair, what

is the best course of action?

Some young boys can experience urinary retention

after removing an indwelling catheter placed for

hypo-spadias repair on the 2nd or 3rd postoperative day

be-cause of edema, pain, or simply fear Manipulating the

formed urethra and inserting catheters are strongly

discouraged If this is done, the urethra will form a

fis-tula It is better to make a temporary cystostomy

imme-diately and to await diminishing of local edema for a

few days so that the boy can urinate independently

Fig 21.12.1 a–g The use of a fishing lead sinker for the double stop suture

a–d The second stage of hypospadias repairs (© Hohenfellner 2007)

a

skin incision

around fistula

Hairs in the Urethra of a Hypospadias Patient

F Ikoma

When at puberty hairs are found in the skin–urethra

formed in a hypospadias patient who has received

ur-ethroplasty using penoscrotal skin as a child, what is

the best course to follow?

Occasionally, urethroscopy shows hair growth in the

formed skin–urethra in high-grade hypospadias

pa-tients Optic electric coagulation of hair roots is

some-times possible, but most often it is difficult and

incom-plete I believe that it is better to surgically open the

skin–urethra at the site where hairs are found from the

ventral side with careful, complete electric coagulation

of every hair root directly in situ This procedure is

fol-lowed by placing an indwelling catheter through the

entire urethra into the bladder, closing the window of

skin–urethra using interrupted sutures with

absorb-able threads such Vicryl 6-0, covering the closed

win-dow with bilateral penile skin by three layers of

subcu-taneous continuous sutures with nonabsorbable

threads such as nylon or Prolene(6-0) (the first layer,

deep dartos; the second layer, superficial subcutaneous

dartos; the third layer, edge of penile skin for

adapta-tion), and fixing these three threads with double stops

Fig 21.12.1 e–f Closure of urethral fistula (© Hohenfellner 2007)

at both ends using sponge fragments and small leadsinkers (Fig 21.12.1) (see Ikoma 1994) If these threecovering layers of subcutaneous continuous suturescan be made securely, we can leave the skin-urethralwindow open Postoperative fistula formation is veryrare A few days after the surgery, the indwelling cathe-ter is removed and the patient can urinate by himself

At the 10th postoperative day, the three layers of suturesare removed

If we are afraid of too much scarring of the thra at the site of hairs after electric coagulation, the Jo-hannson procedure is better After 6 months, we canclose the urethral Johannson window using the samemethod as mentioned above

skin–ure-References

Ikoma F (1994) Hypospadiekorrektur nach Denis Browne In: Hohenfellner R (ed) Ausgewählte urologische OP-Techni- ken Georg Thieme Verlag, p 477

Prolene (6-0)

21.13 Selected Case Reports and Personal Experience

A Tale of Two Brothers

W Månsson

Reconstruction of the urinary tract using intestinal

segments is associated with the risk of numerous side

effects, most of which develop gradually after surgery

This case report of two brothers, now 36 and 34 years of

age, illustrates an acute emergency situation that

re-quires immediate evaluation and treatment Both

brothers suffered from the same type of

life-threaten-ing complication, and different treatment options were

applied

The Elder Brother

This man suffered from urge incontinence, refractory

to conservative treatment Cystometry showed

detru-sor instability He had no abnormal neurological

find-ings He underwent urinary diversion in October of

1997 Based on previous psychiatric history, we initially

recommended an ileal conduit, but testing the

appli-ances available caused allergic skin problems, hence

the dermatologist advised against conduit diversion

Continent diversion with construction of a

Lundia-na pouch (Davidsson et al 1996; Månsson et al 2003)

was performed Briefly, in this procedure the distal

10 cm of the ileum and the right colonic segment are

isolated The colonic segment is opened along the

ante-rior taenia down to the level of the ileocecal valve, and

from there a transverse incision is made to the base of

the valve The ileal segment is tapered snugly over a

10-F catheter with a GIA stapler The first cartridge is

placed obliquely to preserve as much as possible of the

diameter of the ileal opening, as this will create the

sto-ma The edges of the cecal wall incision are then

grasped with two Babcock clamps and a third Babcock

clamp is used to grasp the ileocecal valve, which is

pulled out between the previous two clamps A TA

55-stapler with 4.8-mm staples is placed to incorporate the

edges of the cecal wall and part of the valve The fired

staple line closes the cecum, tapers the valve, and

teth-ers the narrowed ileocecal valve to the cecal wall A

uni-formly narrowed diameter is thus achieved along the

entire length of the outlet and a small flap valve created

at the junction with the pouch The ileocecal segment is

rotated 180° counter-clockwise, the ureters are

im-planted with the LeDuc technique, and the pouch is tubularized and closed The stoma is in the right lowerquadrant or in the umbilicus Catheterization is usuallydone with a 16-F Foley catheter

de-After the continent diversion, the patient had a functioning reservoir and was continent with conve-nient catheterization intervals Nonetheless, over thefollowing 4 years, he presented at the emergency roomseveral times with epididymitis and symptoms of py-elonephritis and abdominal pain, but the symptomsdisappeared and several workups were uneventful Healso developed epilepsy

well-He was admitted to our department in October 2001with a history of a fall and trauma to the abdomen

2 days previously, possibly in conjunction with an leptic fit He initially felt no pain, but great discomfortgradually developed He was febrile with a temperature

epi-of 39 °C and had an increase in WBC, and his abdomenwas tender with clinical signs of peritonitis A CT scanshowed fluid around the reservoir

The patient was taken to the OR with a tentative agnosis of perforation/rupture of the pouch There wasfoul-smelling fluid in the pelvic cavity A 1×1-cm hole

di-in the reservoir wall was observed, di-initially covered bysmall bowel loops Inflammatory reactions were noted

on the reservoir wall and the small bowel loops The fect in the reservoir wall was revised and closed in twolayers, and the abdominal cavity was irrigated anddrained, as was the pouch The postoperative coursewas uneventful, and the patient was able to resume in-termittent self-catheterization after 4 weeks In August

de-2005, IVP was normal, as was endoscopic control of thereservoir and the native bladder

The Younger Brother

This man also had a psychiatric history In 1995, he tained a spinal cord injury after a fall, and becameparaplegic and developed a neurogenic bladder withurine leakage due to severe hyperreflexia Conservativetreatment measures were unsuccessful In November

sus-1999, he underwent continent urinary diversion withconstruction of a Lundiana pouch, as described above

Except for a few episodes of pyocystitis, the course at

follow-up was uneventful with a well-functioning,

easi-ly catheterized pouch However, he eventualeasi-ly

devel-oped fecal incontinence and a colostomy was

per-formed in 2001 The following year, he underwent acute

laparotomy due to small-bowel obstruction caused by

adhesions, and he later developed a large incisional

hernia that was repaired with a preperitoneal synthetic

net His psychiatric problems recurred, and he was

placed on lithium medication There was a suspicion of

renal tubular damage, probably due to the lithium

medication Nevertheless, he was able to care for his

two stomas

In August 2005, he sustained trauma to his right leg

when it was jammed in a closing bus door A week later,

he was admitted to the emergency room of the

orthope-dic department due to swelling of the leg, and he was

diagnosed with a deep venous thrombosis up to the

lev-el of the inguinal ligament He was referred to the

de-partment of internal medicine, and full-dose

heparini-zation was instituted along with warfarin therapy

On the 2nd day, the patient started to complain of

abdominal pain He had no trouble emptying his

reser-voir In the evening, he took himself by wheelchair to

the designated smoking area to have a cigarette The

following day he had a temperature of 39 °C The

gener-al surgeon found his abdomen distended and tense and

believed that the problem was constipation When it

was noted that serum creatinine had risen to 190 µmol/l,

a catheter was reintroduced in the pouch but yielded only

220 ml of urine, after which a bladder scan revealed a

re-maining volume of 850 ml At that point, the urologist on

call was notified, and he found the patient febrile and

mentally confused The abdominal findings were

diffi-cult to interpret, but due to suspected perforation, a

wide-bore catheter was introduced into the pouch, which

yielded 1,500 ml of urine The patient was taken to the

x-ray department, contrast medium was introduced into

the pouch, and a CT was performed, which showed large

amounts of fluid with contrast medium in the abdominal

cavity By that time, the patient was septic with disturbed

electrolytes and circulation, and he was tachypneic He

was intubated and ventilated with a respirator

In this case we chose a conservative approach,

be-cause the patient was fully heparinized and in poor

cir-culatory and respiratory condition He was placed on

broad-spectrum antibiotics, and he was ventilated for

3 days He had an indwelling catheter, and a drainage

tube was inserted to drain abdominal fluid Over the

course of time, two more tubes had to be inserted under

guidance of ultrasound due to recurring fever and

raised C-reactive protein caused by the remaining

in-fected urine The course was protracted, and it was not

until 6 weeks after admission that all drainage tubes

could be removed and the patient could resume mittent self-catheterization

inter-Two weeks after this patient was discharged, his der brother underwent emergency laparotomy at an-other hospital due to a second perforation of the pouch!

el-A small hole was closed

Perforation or Rupture of Continent Urinary Pouch

The urological histories of these two brothers illustratethe most serious acute complication after continent re-construction of the urinary tract The etiology of theperforation or rupture may differ, although overdisten-sion, blunt trauma, and trauma from catheterizationhave been suggested (Månsson et al 1997; Singh andChoong 2004) The complication seems to be morecommon after continent cutaneous diversion than afterneobladder construction, because in the latter the ex-ternal sphincter can yield to high pressure in the pouchand function as a pop-off valve to allow the escape ofurine This might not happen in a reservoir that has anoutlet with a competent closure mechanism Treatmentmay be achieved through laparotomy with closure ofthe hole, which is usually rather small, or simply bydrainage of the pouch, the latter of which requires care-ful observation of the patient

Lessons Learned

) Continent urinary tract reconstruction should not

be performed in patients with a psychiatric history

) Acute abdominal pain in a patient with continentcutaneous diversion or an orthotopic neobladdershould be regarded as a perforation or rupture ofthe pouch until proven otherwise

) Symptoms and signs of this complication may beobscured in patients with a spinal cord injury

re-B, Nurmi M, Pedersen J, Schultz A, Sörensen re-B, Urnes T, Wolf

H (1997) Perforation of continent urinary reservoirs dinavian experience Scand J Urol Nephrol 31:529

Scan-Månsson W, Davidsson T, Könyves J, Liedberg F, Scan-Månsson Å, Wullt B (2003) Continent urinary tract reconstruction – the Lund experience BJU Int 92:271

Singh S, Choong S (2004) Rupture and perforation of urinary reservoirs made from bowel World J Urol 22:222

A Tale of Two Brothers 551

Unfortunate Honeymoon Under the Palm Trees

J.A Mart´ınez-Pi ˜neiro

In February 1989, a 31-year-old Spanish man and his

young wife went to Santo Domingo on honeymoon to

enjoy the balmy climate and beaches of the Caribbean

island, while Europe was freezing

One windy day, when the couple was lying on the

sand, a nearly palm tree fell, killing the wife instantly

and crushing the man’s pelvis As a result of the pelvic

fracture, the membranous urethra, bladder neck, and

rectum were severely ruptured In the local hospital, a

suprapubic catheter was placed, but no surgery was

un-dertaken A few days later, Fournier’s gangrene

devel-oped, which prompted the evacuation of the patient to

a Florida hospital, where a life-saving, wide excision of

the necrotic scrotal skin and a colostomy were

per-formed

Two months later, the patient was flown to Avil´es,

Spain, his home city At the local hospital,

posttransfu-sional hepatitis was detected and the colostomy closed,

leaving the cystostomy in place

Six months after the trauma, the patient was sent to

the urological department of La Paz University

Hospi-tal of Madrid He still bore the cystostomy catheter, the

right testis was palpable underneath the skin of the

in-ner face of the thigh, and the left one remained in a

small scrotal remnant He complained of impotence,

the hepatic enzymes were elevated, and x-rays showed

Fig 21.15.1 X-ray of the pelvis, showing severe deformity

a severe pelvic deformity and large bony callus in bothischiopubic rami (Fig 21.15.1); the antegrade cystou-rethrogram revealed a gaping and distorted bladderneck as well as obstruction of the prostatic urethra atthe level of the verumontanum and faint contrast im-ages, suggesting the existence of several fistulous tracts(Fig 21.15.2); the retrograde urethrogram confirmedthe occlusion of the bulbar urethra and faint fistuloustracts within the perineum (Fig 21.15.3)

With diagnosis of a complex posterior urethral traction defect, a bulboprostatic end-to-end anastomo-sis was undertaken via a perineal route The operationsucceeded in restoring urethral continuity (Fig 21.15.4),

dis-Fig 21.15.2 Cystourethrogram through the cystostomy

cathe-ter Open and distorted bladder neck Urethral disruption at the level of verumontanum and faintly contrasted tracts in the perineum

Fig 21.15.3 Retrograde urethrogram showing an occluded

bulbar urethra and fistulous tracts in the perineum

Fig 21.15.4 Cystourethrogram after end-to-end anastomotic

urethroplasty Urethral continuity restored, but bladder neck

wide open

but total urinary incontinence was a disturbing sequel

for the patient, although it was foreseen by us in view of

the cystogram image, suggestive of bladder neck injury

and adhesions to the pubic rami Usually, this condition

moves the urologist to perform a bladder neck plasty in

the same stage as the urethroplasty in order to spare the

patient another operation In this case, we left the

blad-der neck surgery for a second stage, which was

per-formed 1 month later Then the bladder neck was

liber-ated from firm adherences to the pubic bone and

tubu-larized; an omental flap was also interposed between

the neck and bones

Despite a good anatomic result (Fig 21.15.5), the

pa-tient still complained of stress incontinence and

noc-turnal enuresis, suggestive of a lesion of the external

sphincter Because the patient also suffered from a loss

Fig 21.15.5 Cystourethrogram after bladder neck

tubularizati-on Morphology restored

Fig 21.15.6 Plain film showing the AMS urinary artificial

sphincter components

of erection, we proposed the simultaneous tion of two prosthetic devices, a Scott-AMS artificialsphincter and a Dynaflex impotence intracavernousprosthesis The latter model was chosen in view of thesmall size of the scrotum, which would not admit twointrascrotal pumps The implantation took place inJanuary 1991 and the success was impressive, with highpatient satisfaction for 4 years (Fig 21.15.6) Then re-current incontinence due to malfunction of the cuff oc-curred, requiring replacement of the 4.5-cm cuff with aclose-fitting 4-cm cuff

implanta-Seven years and eight operations after the moon casualty, the young man was enjoying a dry andpotent life, but at what price!

honey-Unfortunate Honeymoon Under the Palm Trees 553

Intravenous Uroperitoneogram

J.A Mart´ınez-Pi ˜neiro

In April 1979, a 68-year-old woman underwent a

hyster-ectomy for a huge myoma Anuria ensued immediately,

which proved resistant to diuretics and aggressive

hydra-tion Three days later, a urologic consultation was

re-quested by the gynecologists and she was referred to the

urological department of La Paz University Hospital in

Madrid The exam revealed an obese patient with

severe-ly distended abdomen, signs of ascites, arterial

hyper-tension (190/100 mm Hg), moderate acidosis (pH 7.25),

blood creatinine 2.80 mg/dl, K 5.5 nmol/l, Na 130 nmol/l,

and mild hypocalcemia (7.9 mg/dl) Ultrasound revealed

a left dilated upper urinary tract and intraperitoneal

flu-id An IVU showed bilateral nephrogram in early films,

but very poor concentration of the contrast medium in

the excretory phase prevented an accurate diagnosis In

delayed films, the entire peritoneal cavity appeared to be

filled with contrast, which outlined a distended stomach

and some intestinal loops, but hindered the visualization

of the urinary tract (Fig 21.16.1) A section of one of the

ureters, with intraperitoneal urine leakage, was

suspect-ed, and to confirm the suspicion a bilateral retrograde

ureteral catheterization was undertaken The right

cath-eter did not pass beyond the 10-cm mark, the left

cathe-ter passed only 5 cm; contrast injection revealed

com-plete obstruction on both sides

Given the left upper tract dilatation, together with

radiopaque ascites (uroperitoneogram), a tentative

di-agnosis of left ureteric ligation and right ureteric

sec-tion with ligasec-tion of the distal stump was made An

ur-gent laparotomy was undertaken, in which more than

6 l of peritoneal fluid were aspirated before damage was

assessed The right pelvic ureter appeared completely

severed with the proximal stump draining urine freely,

while the distal stump was ligated The left juxtavesical

ureter appeared only ligated (with silk) A right

spatu-lated end-to-end anastomosis was performed and the

left ureter simply deligated

The patient’s recovery was uneventful, but 7 months

afterward she complained of pain in the left lumbar

fos-sa and a left obstructive uropathy was detected on

ul-trasound scan and IVU The right urinary tract was

normal A left ureteroneocystostomy with psoas hitch

was performed; the last 5 cm of the ureter were

sur-rounded by severe fibrosis, and the ureter itself showed

Fig 21.16.1 Delayed IVU shows right kidney nephrogram and

contrast medium filling the entire peritoneal cavity and ing a gas-distended stomach and some intestinal loops

outla 5-mm-long stricture The poutlathologist reported tense fibrosis of the wall, unspecific inflammation, andgranulomatous reaction to a foreign body One year lat-

in-er, both upper tracts looked normal on IVU

The intravenous urogram is usually diagnostic when

an intraoperative ureteral trauma is suspected In thisparticular case, the curious and as yet undescribed peri-toneal uroperitoneogram aroused the suspicion of a ure-teral section with intraperitoneal urine leakage Anotherlesson is that the removal of a ureteral nonabsorbable su-ture standing for 3 days may entail the risk of stricture,even when the assessment of ureteral viability seemspositive, contradicting the general feeling that simpledeligation gives satisfactory restoration of the ureter,particularly if the interval of ligation is less than 1 week

Coitus Interruptus

J.A Mart´ınez-Pi ˜neiro

In the evening of February 26, 1991, a 25-year-old man

presented at the emergency unit of La Paz University

Hospital of Madrid with swelling and subcutaneous

ec-chymoses of the penis and scrotum (Fig 21.17.1) He

said that in the heat of sexual intercourse he had hit the

mons pubis of his partner with his erect penis, then

heard an audible crack and experienced pain and

im-mediate detumescence

Ultrasound revealed a lateral tear in the right corpus

cavernosum, near the penoscrotal junction Surgical

exploration made it possible to evacuate a hematoma

and close the tunica albuginea tear with a running

su-ture of an absorbable 3-0 monofilament A pressure

dressing was applied and cyproterone acetate

pre-scribed for 3 weeks to avoid erections

The patient regained spontaneous erections

1 month later and full sexual activity shortly afterward

Fracture of the penis is a relatively uncommon

trau-ma that occurs during erection, usually caused by a

sudden bending during intercourse More uncommon

is the association with partial or total urethral

disrup-tion, that when left unrepaired leads to stricture

Fig 21.17.1 Sight of the genitalia with swelling and

ecchymo-ses.

Early surgical repair of the corpora (and urethra if volved) offers the best chance for healing and preserva-tion of erectile function

in-21.17 Selected Case Reports and Personal Experience

Exploding Bladder

J Motsch, Ch Schramm

A 64-year-old Jehovah’s Witness with initially no

coag-ulation defect and no anemia suffered from severe

he-maturia from a bladder tumor, so that a transurethral

monopolar electrocoagulation and insertion of an

irri-gation Foley catheter was performed under general

an-esthesia After the procedure, the irrigational solution

showed no further bleeding

A few hours later, a drop of the hemoglobin

concen-tration to 6 g % and unstable vital signs were

encoun-tered and the patient was transferred to the ICU The

ir-rigation of the bladder via infusion suddenly stopped

and manual irrigation was impossible The patient was

immediately transferred to the operating room with a

suspected tamponade of the bladder During the 4 h of

transurethral coagulation and extraction of blood

clots, a noise like a dog’s bark was heard

Upon returning to the ICU, a drop in the oxygen uration occurred Breathing sounds were attenuated.The chest x-ray showed a bilateral (double-sided)pneumothorax and retroperitoneal air bubbles Fortreatment, chest tubes were inserted in both pleuralcavities

sat-Two main reasons may explain this dramatic event.First, during the long electrocoagulation of the bladder,

a significant amount of hydrolysis with a consecutiveproduction of a small amount of detonating gas (oxy-hydrogen) occurred This mini-explosion caused theintroduction of air retroperitoneally up to the inter-pleural space and the double-sided pneumothorax.Second, the shock-wave caused by the explosion in thebladder induced a barotrauma by direct rupture of al-veoli on the surface of the lungs

Education by Humiliation

By Far the Best Way of Learning!

A.R Mundy

Roughly 10 years ago, I was invited to operate in Iran to

treat a number of urological problems relating to war

wounds during the Iran–Iraq war On the first day, I was

taken on a ward round and the first patient I saw was

standing smartly to the side of his bed holding a urine

drainage bag on the end of a suprapubic catheter I was

told that he had a prostatorectal fistula as a result of a

gunshot wound and was shown an x-ray with a bullet

perfectly in place between his rectum and bladder

Contrast studies confirmed that the bullet was in a

cavi-ty that communicated with the rectum and the

pros-tate I was told that everything else was normal He told

me he had feces in his urine and he was very glad that I

had come over from England to fix it, as he had had

three failed operations over the previous 4 years

We went to the operating room that afternoon and I

did a transperineal excision of the cavity and closure of

the fistula, removing the bullet and interposing a

graci-lis flap between the two closure lines The following

day, I went to see him to see how he was and he said he

was very well indeed and that he was very grateful to

me for doing his operation but why was he still passing

feces in his urine We obtained another contrast study

and I was told that there was another fistula slightly

higher up, this one into the bladder, presumably from

one of the previous attempts to close his fistula; and so

we took him back to the operating room later that same

day and closed that fistula, transperineally as before

The following day, I went back to see him again andwas again pleased to see him standing by his bed, al-though not quite as robust as the previous day “Thankyou so much,” he said, “I am very grateful to you for do-ing the operation but why am I still passing feces in myurine?” A further contrast study showed a second vesi-cocolic fistula higher up than the other We went back

to the operating room and this time did a nal closure of that fistula The following morning I wentback to see him This time he was unable to stand by hisbed, not surprisingly, and when he said “Thank youvery much for doing the operation,” I was terrified hewas going to tell me about feces in his urine again, but

transabdomi-on that third occasitransabdomi-on we had finally dealt with theproblem – at last

I learned two lessons from that experience Firstly, ifsomebody has had an injury and has one problem as aconsequence of it he may well have a second or thirdproblem as well: I have come across this situation sever-

al times The second lesson I learned was never to trustother people’s results or reports of x-ray studies with-out the images I have experienced this type of problemmany times An investigator, when he is a surgeon, andparticularly when he is not, never has quite the same at-titude toward an investigation and its interpretation, if

he himself is not going to be doing the surgery Get yourown investigations and review them carefully yourself

21.19 Selected Case Reports and Personal Experience