Catálogo de publicaciones - libros

Failure of the lower urinary tract to drain adequately is one of the most common presenting emergencies seen by the practicing urologist. The wide variety of pathologies that can cause this problem needs to be taken into account when assessing the patient, as it is important not to subject the patient to undue risks.

Scrotal emergencies frequently result in a call to the urologist. It is important to remember that emergencies that involve the scrotum may be confined to scrotal structures or referred from other sources. There are a number of differential diagnoses to consider (Table 12.1), as the scrotum itself contains numerous structures: the testicles, epididymis, spermatic cord, and the scrotal tissue itself, comprised of several muscular and fascial layers. Without a thorough differential diagnosis of intrinsic and extrinsic causes of scrotal pain, a diagnosis may be missed. Careful history taking, directed physical exam, and urinalysis with the occasional use of Doppler ultrasound can discriminate between processes quite effectively (Table 12.2). In the hierarchy of concern when dealing with scrotal emergencies, the testicle assumes the position of importance, as loss of a testicle from torsion or failure to diagnose a testicular tumor carry disastrous consequences. Scrotal examination therefore absolutely must document the presence and characteristics of the testicles.

It has been estimated that genitourinary malignancies will account for 25% of new cancer diagnoses in the United States in 2005 ( Jemal et al. 2005 ). While the incidence of many of these malignancies has increased over the past two decades, the mortality rates appear to be decreasing. Early cancer detection combined with improvements in surgical and nonsurgical oncologic therapy account for these trends. Although not common, newly diagnosed cancer patients occasionally present in an emergent, life-threatening manner that warrants immediate medical or surgical intervention. As the prevalence of genitourinary malignancies continues to expand, additional patients can be expected to develop disease or treatment-related complications. This chapter will serve to review the diagnosis and management of oncologic emergencies as they pertain to the urologist.

Paraneoplastic syndromes represent a constellation of complex signs and symptoms that result from the release of various tumor-associated proteins rather than as a consequence of local or distant metastasis. Paraneoplastic syndromes have been estimated to occur in 15%–20% of all cancer patients. The syndromes may affect any of the systems of the body, may precede or follow the diagnosis of the underlying neoplasm, and may or may not parallel the course of the neoplasm in severity. The diagnosis and therapy for these syndromes can be challenging to a physician, but successful therapy may bring about worthwhile relief for the patient. These syndromes are important for many reasons. They occasionally aid in the early diagnosis of neoplasms, and they have aided in the discovery that many (and perhaps most) neoplasms produce hormones or other substances that can be used as tumor markers. These markers are of increasing use in early diagnosis, in following the course of neoplasm and targeting therapy. A better understanding of the precise mechanisms involved in neoplasm production of these remote effectsmay help to achieve a better understanding of the nature of the neoplastic process itself.

We have all been on either the giving or receiving end of a helpful intraoperative consult. It is always remarkable how a different point of view, a different incision, or a unique approach to the operative management of a problem can turn a sour occasion into a successful one. When one is the urologist called in to repair an iatrogenic injury to the genitourinary system, it is essential that we bring that fresh perspective to the situation. This is best accomplished via two principles: (1) do your best to duplicate the operative setting with which we are all more familiar - the elective case, and (2) be flexible and change your approach as demanded by the clinical situation at hand.

Terrorism has increasingly become an integral part of the reality in many regions of the world. In the past few decades, there has been a surge in the number and in the intensity of terrorist attacks all over the globe, and the treatment of terror-related mass casualty incidents presents a special challenge to the medical teams involved. According to the Worldwide Incidents Tracking System (WITS) of the American National Counterterrorism Center (National Counterterrorism Center 2006), there were 3, 204 terrorist incidents worldwide in the year 2004 with 6, 110 fatalities and 16, 257 wounded. Many of the casualties resulted from suicide bombings in Iraq, Chechnya, Uzbekistan, Israel, and Pakistan. Unfortunately, the numbers are expected to increase further and the world has realized that terrorist attacks are no longer confined to certain locations.

Contemporary history is unfortunately associated with pandemic civilian disasters that have made the concept of mass casualty events highly and painfully relevant for all medical and surgical specialties.

The kidneys are paired organs situated posteriorly behind the peritoneum on each side of the vertebral column and are surrounded by adipose connective tissue. Each kidney has a characteristic shape with a superior and inferior pole, a convex border placed laterally, and a concave medial border. Superiorly they are level with the upper border of the twelfth thoracic vertebra, inferiorly with the third lumbar. The right kidney is usually inferior due to the volume of the liver, while the left is a little longer and narrower and lies nearer the median plane. The long axis of each kidney is directed inferolaterally and the transverse posterolaterally.

The ureter is a thick-walled narrow tube measuring approximately 25–30 cm in length and varying in diameter from 1 to 10 mm, in cases of urinary obstruction even larger. It has three different layers (Fig. 15.5.1): The inner mucosal layer which is built of transitional epithelium, the middle layer which consists of circular and longitudinal muscular fibers, and the outer adventitial sheath where the vessels run which are responsible for the blood supply of the ureter. This supply comes from a network of vessels with different origins: the upper part of the ureter receives its blood mainly from the renal arteries, the midportion from the aorta and the iliac vessels, and the lower part from the superior vesical, vaginal, middle hemorrhoidal, and the uterine arteries. Since this vascular source can vary, it is mandatory to perform ureteral dissection cautiously.

Traumatic injury to the bladder is relatively uncommon in adults as well as children. However, the incidence of blunt trauma is rising as a result of modern transportation preferences and increasing reliance on motor vehicles that travel at higher speeds in parallel with advances in engine and mobile parts technology. Therefore, the incidence of intraabdominal and bladder injuries can be expected to rise as well ( Espinoza and Rodriguez 1997 ; Dobrowolski et al. 2002 ; McGahan et al. 2005 ). Also, domestic or professional accidents and violence of any sort, including terrorist activities, may contribute to the increasing frequency of intraabdominal and related bladder injury.