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Biomedical subjects

Jack W McAninch

Publications and source records attributed to Jack W McAninch.

At least 19 recordsLinked to original sources
PubMed2006

Selective management of isolated and nonisolated grade IV renal injuries.

PURPOSE: We reviewed all grade IV renal injuries to report outcomes, and determined if operative and selective nonoperative management can lead to high salvage rates. We also determined if management and outcome differ significantly between cases of isolated grade IV renal injuries and those with associated multiorgan injuries. MATERIALS AND METHODS: We retrospectively reviewed the records of 153 grade IV renal injuries from a 25-year period. We divided these into isolated grade IV renal injuries (43) and those with associated nonrenal injuries (110), and analyzed both groups on the basis of type of renal injury, operative vs nonoperative management, operative nephrectomy rate and renal salvage rate. Salvage was defined as 25% or greater overall renal function (50% or greater function of the injured kidney). RESULTS: Of the 153 patients 103 were treated operatively and 50 nonoperatively with an overall salvage rate of 84%. Penetrating trauma accounted for 87 injuries and blunt trauma 66, while 52% (79 of 153) involved a renal vascular injury. The grade IV renal injuries with concurrent associated injuries requiring operative exploration were repaired at exploration with a 15% nephrectomy rate and an 83% salvage rate. Of the 43 patients with isolated injuries 18 (42%) underwent operative exploration with an average transfusion requirement of 8.5 units packed red blood cells. Two patients (11%) required nephrectomy, 1 kidney was nonfunctional postoperatively and 2 minor complications were identified. The remaining 25 (58%) isolated grade IV renal injuries were managed nonoperatively, with only 12 patients requiring transfusion (average 2.6 units) and a renal salvage rate of 88%. None of the 50 nonoperative cases (isolated or nonisolated renal injuries) required delayed nephrectomy. Six cases demonstrated nonfunctioning kidneys and 4 incurred minor complications. CONCLUSIONS: Management of grade IV renal injuries is complex and demanding if renal salvage is to be achieved. Selective operative vs nonoperative management is based on the presence of associated nonrenal injuries, the hemodynamic stability of the patient, the degree of renal staging and the skill of the surgeon. Isolated grade IV renal injuries represent a unique situation to treat the patient based solely on the extent of the renal injury, thus nonoperative management is used more frequently. Persistent bleeding represents the main indication for renal exploration and reconstruction. In all cases of severe renal injury nonoperative management should only occur after complete renal staging in hemodynamically stable patients.

Blood Transfusion↗
PubMed2006

Management of severe urethral complications of prostate cancer therapy.

PURPOSE: We present our management of urethral stenosis and rectourinary fistula resulting from prostate cancer therapy. We concentrated on cases refractory to minimally invasive treatment, such as dilation, urethrotomy, and urinary and/or fecal diversion. MATERIALS AND METHODS: In our prospectively collected urethral reconstruction database we identified patients who underwent reconstruction of urethral stenosis or rectourinary fistula who also received prior treatment for prostate cancer. We documented demographics, prostate cancer pretreatment characteristics, prostate cancer therapy type, urethral reconstruction type and success. RESULTS: A total of 48 patients met the inclusion criteria, including 16 with rectourinary fistula and 32 with urethral stenosis. Urethral complications followed prior radical prostatectomy, brachytherapy, external beam radiotherapy, cryotherapy, thermal ablation and any combination of these procedures. Stenosis repair was successful in 23 of 32 cases (73%) and it differed little between anterior and posterior urethral stenosis. Repair was accomplished by anastomotic urethroplasty in 19 cases, flap urethroplasty in 2, perineal urethrostomy in 2 and a urethral stent in 9. Prior external beam radiotherapy was a risk factor for urethral reconstruction failure. Fistula repair was successful in 14 of 15 patients (93%), excluding 1 who died postoperatively. The complexity of fistula management was dictated by fistula size and the presence or absence of coincident urethral stenosis. CONCLUSIONS: Urethral stenosis or rectourethral fistula following prostate cancer therapy can be managed by urethral reconstruction, such that normal voiding via the urethra is maintained, rather than abandoning the urethral outlet and performing heterotopic diversion. This can be accomplished with an acceptable rate of failure, given the complexity of the cases.

Aged↗
PubMed2006

Nonoperative management outcomes of isolated urinary extravasation following renal lacerations due to external trauma.

PURPOSE: Urinary extravasation is a common finding in grade 4 and 5 renal injuries. To date there has been little written about the natural course of urinary extravasation following renal trauma. We reviewed data on the outcomes of urinary extravasation in the traumatized kidney when managed nonoperatively. MATERIALS AND METHODS: A retrospective review of the prospectively entered urological trauma database from San Francisco General Hospital was performed from 1979 to 2005. All patients with urinary extravasation after sustaining traumatic injury to the kidney as seen on computerized tomography were included in analysis. RESULTS: A total of 61 patients with urinary extravasation were identified. Of these patients 27 (44%) were treated operatively (26 of 27 underwent immediate and 1 of 27 underwent delayed open surgery). All (100%) operatively treated patients underwent renal exploration and repair at primary surgical management of associated abdominal and/or vascular injuries. Open surgical exploration resulted in nephrectomy in 5 of 27 (19%) patients. Of the 34 (56%) patients treated nonoperatively only 3 (9%) had persistent, nonprogressing urinary extravasation by computerized tomography 3 to 7 days after injury. All 3 (100%) of these patients underwent uncomplicated endoscopic ureteral stent placement followed by complete resolution of urinary extravasation. CONCLUSIONS: Nonoperative management of urinary extravasation in patients sustaining traumatic injury to the kidney without associated abdominal or vascular injury is safe and results in resolution in more than 90%. In patients with persistent urinary leakage endoscopic ureteral stent placement may be needed and is successful.

Adolescent↗
PubMed2006

The diagnosis, management, and outcomes of pediatric renal injuries.

Most pediatric renal trauma is minor and poses no significant danger to the child. A small percentage of children sustain a severe renal injury that demands immediate evaluation and decision of operative versus nonoperative management. Selective management of pediatric renal trauma based on mechanism of injury, hemodynamic stability,associated nonrenal injuries, and CT imaging has led to a renal exploration rate of 5%to 11% with renal salvage rates of more than 98%.

Child↗
PubMed2006

Diagnosis and management of testicular ruptures.

Testicular ruptures are a common occurrence in scrotal trauma that can go undetected ifa thorough examination or scrotal ultrasonography is not performed. Timely operative exploration and reconstruction is the standard of care and leads to high testicular salvage rates with hormonal, reproductive, and cosmetic benefits for the patient.

Diagnosis, Differential↗
PubMed2006

Ureteral injuries: external and iatrogenic.

Both iatrogenic and traumatic ureteral injuries are rare. However, a high index of suspicion is warranted for ureteral injuries because ureteral injuries are associated with increased morbidity. The urologist should be familiar with several methods for identifying ureteral injuries and should make evaluations tailored to the clinical situation. Most ureteral injuries are short transections and can be repaired with debridement and ureteroureterostomy in the proximal and mid-ureter or ureteroneocystostomy in the distal ureter.

Humans↗
PubMed2006

Operative management of renal injuries: parenchymal and vascular.

The decision to operate on a traumatized kidney should be made primarily on the basis of severity of injury to the kidney. Expanding or pulsatile retroperitoneal hematomas continue to be absolute indications for renal exploration. While parenchymal injuries, including severe parenchymal injuries, can usually be repaired, vascular injuries are generally less amenable to repair. Main renal arterial injuries should be repaired only if there is a solitary kidney injury or a bilateral main renal artery injury. Such tools as the American Association for the Surgery of Trauma renal organ injury scale can help the urologist in managing injuries and in salvaging kidneys that would otherwise be removed.

Humans↗
PubMed2006

Use of ultrasonography for the diagnosis of testicular injuries in blunt scrotal trauma.

PURPOSE: We determined the use of scrotal ultrasonography in the initial diagnosis and management of testicular injuries due to blunt scrotal trauma. MATERIALS AND METHODS: We performed a retrospective review of 65 patients presenting to our Emergency Department with blunt scrotal trauma in the last 25 years. In 47 patients an inconclusive clinical examination prompted scrotal ultrasonography. A heterogeneous echo pattern of the testicular parenchyma with loss of contour definition was the basis for diagnosis of testicular rupture. The sensitivity and specificity of scrotal ultrasonography were determined by comparing this radiographic criterion with definitive intraoperative findings and the need for delayed orchiectomy due to undiagnosed testicular rupture. RESULTS: Of the 65 patients sustaining blunt scrotal trauma 44 (68%) underwent scrotal exploration, and 30 (46%) of these injuries involved rupture of the tunica albuginea. Among the 47 scrotal ultrasounds performed to supplement a nondiagnostic clinic examination, there were 32 suspected testicular ruptures. Thus, the 2 false-positives resulted in a specificity of 93.5% in those patients explored. No delayed orchiectomies were performed for missed testicular ruptures, resulting in 100% sensitivity. The majority of testicular ruptures were salvaged (83%), with only 5 of the 30 (17%) requiring orchiectomy (4 of these patients had delayed presentation greater than 48 hours). CONCLUSIONS: Scrotal ultrasonography, with the single radiographic finding of a heterogeneous echo pattern of the testicular parenchyma with loss of contour definition, is highly sensitive and specific in the diagnosis of testicular rupture in an otherwise equivocal scrotal examination. Accurate diagnosis and prompt repair led to a salvage rate for testicular rupture specifically of 83% and overall of 92%, with preservation of the testicular parenchyma and hormonal function, and avoidance of the delayed complications of chronic pain, atrophy and orchiectomy associated with missed testicular rupture.

Humans↗
PubMed2005

Urethral injuries in the Civil War.

PURPOSE: We compiled all cases of urethral injury received in battle during the Civil War to detail their management and determine the outcome of treatment. MATERIALS AND METHODS: Surgeon medical reports of individual cases of urethral injury listed in the Medical and Surgical History of the Civil War, and pension records available in the National Archives and Records Administration were reviewed. RESULTS: A total of 105 cases of urethral injury from gunshot wounds, comprising 7% of all urogenital casualties, were reported during the Civil War between 1861 and 1865. Of them 22 (21%) were fatal and 83 patients (79%) cases survived. Debridement and catheter drainage of urinary extravasation or perineal urethrotomy was initial treatment. The majority of urethral injuries were complicated by troublesome strictures, fistulas, urinary incontinence and erectile impotence. Only 19 patients (23%) recovered fully. CONCLUSIONS: Civil War urethral injuries had devastating long-term consequences.

American Civil War↗
PubMed2004

Urologic emergencies.

Genitourinary emergencies are commonly seen in the emergency room, and the primary care physician plays a vital role in the initial evaluation and treatment of each. Although genitourinary trauma is rarely life threatening, it may be the cause of significant long-term morbidity. Key clinical indicators outlined in this article (eg, inability to urinate, gross hematuria) combined with judicious use of imaging help stage the injury and allow a safe and rational approach to treatment. The acute scrotum frequently presents a challenging problem to both the emergentologist and urologist. Although epididymitis may be managed nonoperatively, there should be no delay in exploring suspected testis torsion. The conditions of the penis outlined require urgent treatment to preserve potency (priapism) and restore normal function (eg, penile amputation). Acute urinary retention has a myriad of underlying etiologies, and treatment must be individualized. Urgent bladder decompression by urethral or suprapubic catheterization provides initial relief until urologic consultation is available.

Acute Disease↗
PubMed2004

Straddle injuries to the bulbar urethra: management and outcomes in 78 patients.

PURPOSE: We describe our experience with blunt straddle injuries to the anterior urethra and identify factors that may affect patient outcome. MATERIALS AND METHODS: We reviewed the San Francisco General Hospital Urologic Trauma data base to identify men with blunt straddle injury. We analyzed presentation and initial management, location and length of urethral stricture, surgical options, and long-term outcome after reconstruction. RESULTS: Of 78 patients, 40% presented to the emergency department acutely and 60% presented 6 months to 10 years after injury complaining of obstructive symptoms, of whom 30% reported at least 1 episode of urinary retention. Initial acute management was suprapubic cystostomy in 81% of cases and primary realignment in 19%. Urethral strictures were predominantly located in the proximal bulb. Mean stricture length was significantly longer in men with delayed presentation (2.7 vs 1.8 cm, p <0.05). No relationship was found between stricture length and the mechanism of injury or initial management technique. However, patients who had undergone primary realignment required complex flap or graft urethroplasty at a greater rate compared with men who had undergone suprapubic diversion (p = 0.054). Transperineal urethroplasty was required in 92% of patients with the majority undergoing end-to-end anastomosis. The success rate was 95% at a mean followup of 25 months (range 10 to 180). Recurrent stricture occurred in 4 men with prior urethral manipulation and it was managed successfully by direct vision internal urethrotomy alone. CONCLUSIONS: After blunt straddle injury to the perineum the primary morbidity is anterior urethral stricture, for which suprapubic cystostomy is appropriate initial management. The majority of patients require surgery but with careful preoperative planning and adequate resection of fibrotic tissue the long-term success rate can approach 95%. If it arises, recurrent stricture responds well to direct vision internal urethrotomy alone.

Adolescent↗
PubMed2004

The distribution of neuronal and inducible nitric oxide synthase in urethral stricture formation.

PURPOSE: The distribution of neuronal (n) and inducible (i) nitric oxide synthase (NOS) may have a role in the maintenance of normal urethral spongiosum and during the development of spongiofibrosis in urethral stricture disease. MATERIALS AND METHODS: Eight normal and 33 strictured human bulbar urethras were studied by histological and immunohistochemical techniques for the neuronal markers S-100, nNOS and iNOS. The smooth muscle-to-collagen ratio was calculated by morphometric analysis of Masson's trichrome sections. Immunohistochemical staining patterns of the neuronal markers in normal urethral tissue was compared to that in urethral stricture tissue with spongiofibrosis. RESULTS: The smooth muscle-to-collagen ratio was significantly lower in the strictured urethra compared to that in the control group (p = 0.001). In the strictured bulbar urethra nNOS immunoreactivity was decreased compared to that in normal urethral tissue. The severity of spongiofibrosis corresponded to the loss of nNOS immunoreactivity. iNOS immunoreactivity was found in strictured urethral epithelium and spongiosal tissue, whereas the control group was nonimmunoreactive to iNOS. CONCLUSIONS: Urethral stricture formation is a fibrotic process associated with significant changes in NOS metabolism. Abnormal collagen synthesis following urethral trauma may be stimulated by inappropriate iNOS activity. A functional nerve supply to the urethral spongiosum seems to be crucial in the maintenance of the unique ultrastructure of the urethral spongiosum.

Adult↗
PubMed2004

Urethroplasty in patients older than 65 years: indications, results, outcomes and suggested treatment modifications.

PURPOSE: Despite an aging population, the results of urethroplasty in elderly patients have not been extensively reported. We performed a multi-institutional review of urethroplasty results in 70 elderly males to determine outcomes. MATERIALS AND METHODS: We reviewed all urethroplasties performed on males older than 64 years with at least 6 months of followup at 4 medical centers. Stricture type varied and included anastomotic urethroplasty (44%), penile fasciocutaneous onlay flap (31%), Johanson urethroplasty (stage 1, 6%, stages 1 and 2, 4%), buccal mucosa grafts (7%), foreskin grafts (6%) and meatoplasty (1%). RESULTS: Stricture recurred in 11 (16%) patients, but was managed with a single direct visual internal urethrotomy or dilation in 5 of 11 patients, yielding a final success rate of 91%. Recurrent strictures were more common after fasciocutaneous flaps (7 of 22 cases, 32%) than end-to-end urethroplasty (2 of 31 cases, 6%, p <0.05). Compared to patients younger than 65 years there were more treatment failures, but this was not statistically significant. Perioperative complications were uncommon. Moderate bladder outlet obstructive symptoms developed in 3 patients due to benign prostatic hyperplasia. Notably 6 patients treated previously for post-radiation strictures did well without complications. CONCLUSIONS: Older men tolerate urethroplasty and these data indicate that therapy should not be withheld solely on the basis of age. The potential for impaired flap blood supply in this population is suggested but has not been proven. Benign prostatic hyperplasia must be considered in those patients who have decreased stream after stricture repair.

Age Factors↗