Successful surgical management of complete tracheal disruption due to penetrating injury

Successful management of penetrating injury to the trachea is rare, especially in Japan. A 32-year-old female attempted suicide by stabbing herself in the throat with a knife, and at operation the trachea was found to be completely disrupted. A median sternotomy made possible end-to-end anastomosis of the trachea. All other important organs including the great vessels, esophagus, and lungs were intact, but the pleura was open on the right side. The patient was managed under heavy sedation and with controlled ventilation for more than a week postoperatively, because of her suspected mental condition. She was extubated on postoperative day 13 and transferred to a mental hospital on day 16. We concluded that early diagnosis and surgical repair were important for the successful management of this patient with tracheal disruption.     

骨盆骨折后尿道损伤和阳萎

目的：探讨骨盆骨折后尿道并发阳萎的机制及如何避免阳萎的发生。方法：随访骨盆的后尿道损伤１８例与狭窄２５例的治疗效果。结果：后尿道损伤１８例,采用会师牵引复位术治疗,２例发生阳萎（１１．１％）;陈旧性后尿道狭窄２５例,经各种手术修复尿道后,５例发生阳萎（２０．０％）。结论：阳萎主要由骨盆骨折损伤勃起神经与血管及阴茎海绵体引起,伤后的手术操作及多次尿道复位或成形术,亦增加阳萎的发生率。     

Posterior urethral valves

Twenty cases of posterior urethral valves are reviewed with the presentation of several illustrative cases. Review of the current literature regarding management of patients is discussed.     

Posterior urethral reconstruction

Summary The posterior prostatomembranous urethral stricture or distraction defect has historically been the most formidable challenge of stricture surgery. This uncommon lesion occurs most often as the sequelae of pelvic fracture injuries, or straddle trauma, and is associated with serious urethral disruption and separation – an injury that is often complicted by inappropriate initial management using substitution skin flap techniques with the development of recurrent stenosis, irreversible impotence, and occasional incontinence. Management by endoscopic techniques may be possible in patients with short strictures or in those after prostatectomy, but they rarely play a role in resolving the complex obliterated urethra with a significant defect [1]. Resolution of post-traumatic posterior urethral distraction defects and other posterior urethral pathologic conditions has dramatically improved over the past two decades despite an inaccessible subpublic location involving exposed sphincter-active and erectile neurovascular anatomy. The contemporary, perineal, one-stage bulboprostatic anastomotic operation as popularized by Turner-Warwick [20] with selective scar excision is a versatile procedure with a high patent lumen success. Patients undergoing anastomotic urethroplasty have a substained patent urethral lumen success rate approaching 100 % versus those who have undergone urethral skin flap or patch repair, where the restricture rate in 5 and 10 years increases twofold to threefold [1, 20]. A patent urethra after an anastomotic urethroplasty at 6 months is free from further recurrent stricture and gives credence to Mr. Turner-Warwick's admonition that “urethra is the best substitute for urethra”.      

Anatomic considerations in penetrating gluteal wounds.

A retrospective study of 81 patients with penetrating gluteal wounds was performed to determine if the site of penetration was useful in predicting the likelihood of associated vascular or visceral injury. There were 53 gunshot wounds and 28 stab wounds, including one impalement. The gluteal region was divided into upper and lower zones by determining whether entry occurred above or below the greater trochanters. Sixty-six percent of all penetrating gluteal wounds entered the upper zone. Thirty-two percent of patients with upper zone penetration had associated vascular or visceral injury. Only one of 27 patients with lower zone penetration sustained major injury. The site of entry plays a critical role in determining the likelihood of serious injury associated with penetrating gluteal wounds. Wounds penetrating above the greater trochanters demand thorough evaluation, especially gunshot wounds.     

Foot deformities secondary to gluteal injection in infancy

We report six cases of foot deformities in children due to sciatic nerve dysfunction that appear to have been caused by gluteal intramuscular injection. Of four patients who developed cavovarus foot deformities, two also exhibited a component of ankle equinus. A fifth patient had a calcaneocavus foot deformity. In the sixth patient foot palsy resolved completely 1 year after injury, and no deformities developed. Identification of the muscle imbalance, as well as appropriate correction of the deformity before the implementation of muscle balancing procedures, led to the attainment of a satisfactory plantigrade gait in the first five patients with deformities. Bases on our experience with these six cases and reports in the literature, we recommend that the superolateral gluteal area between the crest of the ilium and the greater trochanter be properly defined as the preferred site for intramuscular injection.     

Penetrating injury to the gluteal region.

Eight cases of life-threatening sequelae of relatively minor penetrating injuries of the gluteal region, involving the gluteal or internal pudendal arteries, are reported. The modes of presentation included exsanguinating external hemorrhage (two), acute false aneurysm (one), and chronic false aneurysm (five). Failure to appreciate the nature of the lesion led to inappropriate initial management in seven instances. This series emphasizes the danger of direct incision of lesions in this region which are suspected of being abscesses that are in fact false aneurysms ("pulsatile abscesses") and demonstrates the need for a high index of suspicion for problems related to these vessels following penetrating trauma to the gluteal region, even if seemingly minor, and the need for adequate investigation and planning before surgery.     

Reconstruction of posterior urethral disruption

Posterior urethral disruption may be a devastating complication of pelvic trauma. The acute management of these injuries is reviewed as well as the controversy surrounding early versus delayed repair. The various approaches to delayed repair of pelvic fracture urethral distraction defects are presented and the technique of perineal repair is discussed in detail.     

损伤严重程度评分在骨盆骨折并后尿道断裂治疗中的应用

目的：探讨损伤严重程序评分（ISS）在骨盆骨折并后尿道断裂治疗中应用的意义。方法以AIS－90版为基础,采用ISS评分对293例男性闭合性骨盆骨折并后尿道断裂病人进行评估分析。结果ISS值随损伤部位数增加而增高,ISS值高,死亡率亦高,Ⅰ期尿道吻合组ISS＜16分,尿道会师术组ISS16－39分,膀胱造瘘组ISS平均≥40分。结论骨盆骨折并后尿道断裂为多发损伤,尿道断裂急症处理方法的选择应根据病人伤情程度及局部情况等决定,ISS评分在骨盆骨折并后尿道断裂的治疗选择中有重要的指导意义。     

Posterior urethral polyp: a recurrent case]

A 38-year-old man was admitted to our hospital complaining of difficult, frequent urination to our hospital. Transrectal echography and digital examination showed chronic prostatitis. He was treated with medication for chronic prostatitis but his condition did not improve. Retrograde urethrography revealed an obstructive change in the prostatic urethra and urethroscopic findings showed a urethral tumor in the posterior urethra. Transurethral resection of the tumor was performed. Pathological diagnosis of the urethral tumor indicated a urethral caruncle. After one year, the patient was readmitted to our hospital with the same complaints as before. Urethroscopic findings revealed the recurrence of a urethral polyp in the posterior urethra. Transurethral resection of the polyp was performed. Pathological findings revealed that the inner structure of the polyp showed a prostatic glandular pattern that after staining with anti-prostatic acid phosphatase antibody. The final diagnosis was that the polyp had a prostatic-type epithelium in the prostatic urethra.     

Posterior urethral stricture repair.

Experience with 54 operations for the membranous-prostatic urethral stricture is presented. There were 7 operations performed through pubectomy exposure, 6 Badenoch operations, 31 exteriorization 2-stage operations using a perineal-scrotal flap for the first stage and 10, 1-stage transperineal end-to-end anastomoses after scar tissue had been excised. The technique for the transperineal approach is presented. Presently, a 1-stage end-to-end anastomosis of the bu.ferred. Exteriorization urethroplasty using the perineal-scrotal flap is recommended when an end-to-end anastomosis is not feasible, either because of a long stricture or severe scar secondary to previous operative failures. The pubectomy approach is seldom needed but the Waterhouse pubectomy procedure is recommended as a possibility in patients who cannot be placed in the exaggerated lithotomy position.     

Posterior urethral valves in siblings

The etiology and incidence of posterior urethral valves is unknown. We report on a pair of non-twin siblings with identical pathology stemming from type I posterior urethral valves as well as discordance in a pair of monozygotic twins. Familial posterior urethral valves have been reported before in both twin and non-twin siblings. The occurrence of identical pathology in non-twin siblings suggests the possibility of an inherited trait as does its occurrence in identical twins. However, non-identical clinical manifestation is as common as is identical presentation in both groups. There are also instances of discordance in monozygotic twins suggesting the possibility of a random mutation. As such, we recommend urologic evaluation of the male siblings of affected patients with posterior urethral valves. Further prospective and retrospective analyses are needed to define the genetic etiology of valves.     

Posterior urethral trauma and strictures: an attempt to solve a controversy

Three cases of traumatic partial or complete posterior urethral rupture and subsequent stricture are reported. Treatment consisted of early suprapubic cystostomy, with/or without concomitant primary realignment of the urethra over a catheter, followed by urethral dilations and internal urethrotomy when indicated. Followup of 4 or more years showed excellent results.