STATE-OF-THE-ART CARE: TRAUMA/BLADDER CANCER
From the 61st Annual Meeting of the Canadian Urological Association
| UROLOGIC TRAUMA—Michael Coburn, MD, Associate Professor and Residency Program Director, Scott Department
of Urology, Baylor College of Medicine, and Chief of Urology, Ben Taub General Hospital, Houston, TX
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| Renal injury: when considering surgical exploration— determine whether (kidney adequately staged and imaged; patient
hemodynamically stable; hematoma minimal and nonpulsatile without active bleeding and expansion); assess
(“comfort zone” for performing difficult reconstructive surgery; available interventional radiologic capability); points—
computed tomography (CT) with contrast facilitates evaluation of injury; observation often sufficient for managing hemodynamically
stable lower-grade injuries
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| Higher-grade renal injuries: use appropriate techniques to—gain rapid access to pedicles and achieve renovascular
control; evacuate hematoma; achieve hemostasis; debride tissue; perform repair; provide drainage; renovascular
control—anterior approach has replaced flank approach; unless dealing with pedicle trauma, looping and dissection
of individual renal vessels unnecessary; use pedicle clamp access maneuver to gain vascular control prior to surgery;
basic concept of achieving preoperative vascular access to kidney remains sound; when managing polar injuries—
debride and close collecting system; repair parenchyma
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 | Penetrating injury: more lateral or deeper parenchymal injuries that do not involve pole—basic approach (remove
penetrating object; debride; close collecting system and vascular structures; use absorbable hemostatic agents to control
parenchymal bleeding, eg, thrombin-soaked Gelfoam; repair or patch capsule with peritoneum); when dealing with
adjacent visceral injury, separate renal and visceral injuries with viable omental flap tissue or by closing Gerota’s fascia;
through-and-through injuries—“opening and suturing” reasonable when patient has active bleeding from tract
and requires minimal radial nephrotomy; in most injuries without active bleeding, inject hemostatic agent, eg, Tisseal;
absorbable material, eg, Surgicel, works well when repairing major parenchymal laceration; point—surgery may be
used too often to manage penetrating trauma
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| Conclusions from consensus conference review of renal trauma: imaging—indicated for evaluating gross
hematuria and hypotension; CT preferred; “shock room” intravenous pyelography (IVP) not generally recommended;
penetrating trauma—more aggressive exploration of higher-grade renal trauma seems to produce higher nephrectomy
rate; exploration and repair remain standard management approaches; scheduled reimaging for high-risk injury—
important; patient at high risk who undergoes nonoperative management requires reimaging at ≈72 hr to detect urinoma
or enlarging hematoma before clinical problems develop
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| Ureteral injuries: blunt injuries rare; penetrating injuries—can be missed when management team has low index of
suspicion and difficulty visualizing area obscured by bleeding; surgical options include excision and primary anastomosis
for upper-third or middle-third of ureter, and reimplantation for lower-third
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| Conclusions from consensus conference: hematuria unreliable sign of ureteral injury; complete IVP relatively sensitive
for detecting extravasation; shock room IVP poor; if CT detects median extravasation pattern—suspect injury to extrarenal
collecting system or ureter; if necessary, perform retrograde pyelography; spiral CT—may miss injury; to
avoid problem, request evaluation of delayed excretory phase; observations—with penetrating trauma, early exploration
and repair achieve best outcome; nephrostomy tube and stenting reasonable when managing injury with delayed
presentation; some data suggest stenting significant ureteral contusions reduces leak rates; point—damage-control approaches
applicable for managing ureteral injuries
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| Bladder injuries: extraperitoneal rupture—nonoperative catheter drainage alone appropriate management; stress cystography
detects adequate bladder filling; intraperitoneal extravasation pattern—contrast pools in colic gutters and
true pelvis; sudden compression after injury usually causes blow-out in dome (surgical repair essential); points—
stress cystography key diagnostic tool (learning curve necessary to properly interpret data); operative repair appropriate
for penetrating injuries
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| Conclusions from consensus conference: gross hematuria reliable sign of bladder injury; stress cystography critical
diagnostic tool; operative repair necessary for penetrating and blunt intraperitoneal ruptures; catheter drainage—
applicable to managing blunt extraperitoneal rupture; inappropriate for extraperitoneal rupture with concomitant vaginal
and rectal injuries; patients with 2 drainage failures—require surgery; problem occurs when catheter blocked by
clot; when dealing with pelvic fracture, approach patient in subacute setting when bleeding subsides; perform separation
procedures or surgical repair when necessary; point—delayed or damage-control approach applicable for complex
injuries or severe bleeding in pelvis
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| Urethral injuries (conclusions from consensus panel review)
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| Posterior urethral disruption: blood at meatus important sign (absent in some patients); place suprapubic tube percutaneously
or through open technique; catheter insertion and realignment—avoids urethroplasty in 30% to 50% of patients;
maintain catheterization 4 to 6 wk; points—retrograde urethrography critical; endoscopic procedures necessary because
most patients develop strictures (approach stabilizes ≈50% of patients without resorting to urethroplasty); if urethroplasty
necessary, place catheter across defect to prevent malalignment
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| Anterior urethral injuries: blunt trauma—typical straddle injury (if injury incomplete, place urethral catheter under direct
vision); complete transections of urethra from straddle injury (perform suprapubic diversion and delayed reconstruction
after stricture fully formed); penetrating trauma—once patient stabilized, and critical nature of injury
determined, implement selective repair and damage control
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| Damage-control surgery: system of strategies developed for managing critically ill trauma patients; to improve outcome
and survival among unstable patients—abbreviate initial laparotomy; control exsanguinating hemorrhage and
ongoing fecal contamination; use temporizing maneuvers at acute presentation to manage injuries that are not immediately
life-threatening; take patient to warm facility, eg, intensive care unit, for temporary or permanent abdominal closure
(depending on whether other injuries need surgical repair); optimize patient physically; return individual to
operating room for second look and definitive reconstruction; approach designed to—avoid lethal triad of physiologic
decline (ie, progressive hypothermia, acidosis, and coagulopathy) associated with profound blood loss and massive
blood and fluid replacement; also useful when managing injuries that are not necessarily life threatening;
measures used to implement strategy—packing solid abdominal viscera; using vascular stents to avoid complex reconstructions
when patients severely ill; ligating bowel first and performing bowel resection later
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| Temporizing strategies: renal injuries—if hematoma does not expand, do not explore (if possible, use delayed imaging
during resuscitation phase to select definitive nonoperative approach with appropriate staging); if patient too ill for
major reconstruction, achieve suture control of major bleeders, pack off area, and perform reconstruction later; ureteral
injuries—externalized stenting with plan for delayed reconstruction considered reasonable; perform ureteral ligation
and percutaneous diversion when necessary; bladder injuries—when patient too ill for complex repair,
externalized stenting and pelvic packing remain feasible option
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| Observations: definitive intervention after resuscitation—delayed exploration or selective nonoperative management
of kidney; primary reanastomosis or reimplantation of bladder (reconstruct later); despite increased injury severity—
mortality declined; resuscitation periods longer; damage control instituted earlier and before onset of physiologic compromise;
damage control strategies—can be included in algorithms for managing critically ill patients
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| Multidisciplinary trauma model: involves surgical specialists as well as general surgeons; urologists highly skilled
in—assessing risk of nonoperative management in elective setting; recognizing complications; performing reconstructive
surgery; urologists less skilled than general surgeons in—prioritizing injuries; making decisions based on critical
nature of injuries
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| HIGH-RISK SUPERFICIAL BLADDER CANCER: CONTEMPORARY MANAGEMENT—Colin P. N. Dinney, MD,
Professor and Chair, Department of Urology, University of Texas M.D. Anderson Cancer Center, Houston
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| Bladder cancer: common; usually superficial; not immediately life threatening; tends to recur and progress; options—
intravesical therapy to prevent recurrence and delay progression; cystectomy for tumors refractory to intravesical therapy;
goals—prevent recurrence; delay progression; reduce morbidity and cost; identify patients at high risk with refractory
progressive disease before development of metastases; prognostic indicators that help identify high-risk
patients—high-grade tumors (irrespective of stage); invasion into lamina propria; concomitant carcinoma in situ
(CIS); large tumors (often associated with microscopic focus of invasive disease)
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| Natural history of low-grade papillary disease, based on observations made at cystoscopy: good risk—solitary tumor at
diagnosis, and tumor-free on subsequent evaluation; patient has ≥80% chance of being tumor-free over next 12 mo (information
can be used to help modify surveillance); moderate risk—characterized by solitary tumor at diagnosis, recurrence
on first cystoscopic examination, or multiple tumors at presentation without recurrence on first follow-up
cystoscopy; risk for recurrence ≈50% over next 12 mo (information can be used in determining whether to initiate
treatment); high risk—multiple tumors at presentation; recurrence on first cystogram; patients fail over next 12 mo
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Intravesical Therapy
| Indications: absolute indications—high-grade disease; CIS; invasion into lamina propria (patients require re-resection
before embarking on therapy); large tumors; relative indications—recurrent low-grade papillary disease; multiple tumors
at presentation
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| Re-resection: key; incidence of residual disease after complete resection 40% to 75%; patients with residual T1 disease on
re-resection at increased risk for progression after bacillus Calmette-Guérin (BCG) therapy (change treatment approach);
≈30% of patients presumed to have nonmuscle-invasive >T2 disease actually harbor invasive disease (intravesical therapy
contraindicated)
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| Intravesical chemotherapy: patients who benefit most from approach have—low-grade disease; solitary tumor;
primary tumor at presentation; meta-analysis of patients receiving single perioperative dose of chemotherapy after
transurethral resection (TUR) for local disease showed—marked reduction in recurrence; thiotepa ineffective; treatment
most effective for patients with solitary tumors
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| BCG therapy: data show BCG—superior to TUR in reducing recurrence; achieved better recurrence-free survival
(with or without maintenance therapy) than intravesical chemotherapy; progression—meta-analysis showed BCG
alone superior to TUR (with or without chemotherapeutic instillation) in reducing progression among patients without
muscle-invasive disease; upper tract and prostatic urethral recurrence—seen in patients who have long history of
high-risk disease refractory to treatment; patients must be monitored, because occult sites provide reservoirs for development
of metastatic disease; data suggest BCG—does not reduce cancer-related mortality; maintenance seems to
benefit patients with CIS
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| Induction BCG: alternative to maintenance; patients can benefit from 2 courses of induction therapy or one course of
BCG plus mini-induction; those who fail 2 courses respond poorly to additional BCG therapy and face increased risk
for progression; caveat—no single agent effective in managing disease refractory to BCG
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| Stage T1, grade 3 (T1G3) superficial tumors: commonly managed by radical cystectomy; BCG therapy—does delay
progression in responders; potential responders cannot be separated from those patients who will fail therapy;
recommendation—administer intravesical BCG before resorting to radical cystectomy
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| Radical cystectomy for disease that resists BCG: treat patients relatively early; those patients who undergo cystectomy
<2 yr after diagnosis seem to have better outcome than patients who have surgery delayed
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| Based on summary of clinical data, intravesical BCG: most effective therapeutic agent; decreases recurrence; delays progression;
requires long-term follow-up to understand impact and to look for late recurrences in upper tract and prostate;
impact on survival less proven; optimal dose and dosing schedule continue to evolve (3-wk reinductions may be optimal);
toxicity acceptable; patients who fail 2 courses of BCG—generally do not respond to second-line therapy; face
increased risk for disease progression; face ≈30% risk of dying from superficial bladder cancer
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| Options under investigation for managing high-risk disease: fluorescent cystoscopy has potential to improve
disease detection and treatment efficacy; intravesical chemotherapy (gemcitabine alone ineffective; electromotive mitomycin
may enhance efficacy of BCG therapy); chemoprevention (combination of BCG and multivitamins [eg, Oncovite]
seemed to improve recurrence-free survival); BCG plus interferon (undergoing phase 3 studies); risk-based strategies—
assessment of BCG response based on polymorphisms in genes involved in inflammation (leads have developed in identifying
patients de novo who may respond to specific therapies); intravesical gene therapy (hindered by inability to transfer
genes to tumor cells; use of Syn 3 to enhance gene transfer under investigation)
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| Algorithm for treating noninvasive bladder cancer: patients with low risk (Ta, grade 1-2 disease)—require
TUR and perioperative chemotherapy (unless bladder perforated); if progressing to multifocal or recurrent disease,
may be candidates for intravesical chemotherapy rather than BCG
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| Patients at intermediate or high risk: patients with CIS or high-grade Ta disease—receive TUR and perioperative chemotherapy
within 2 to 3 hr of surgery, followed by BCG maintenance therapy; if disease does not progress after first
cystoscopy, wait 6 mo to determine whether treatment failed; if problem noted at 6 mo, consider administering BCG
plus interferon, investigational agents, or cystectomy (ie, these individuals make excellent candidates for investigational
therapy); patients with T1 disease—high risk; require re-resection; cystectomy recommended if patient has residual
T1 or T2 disease; BCG with or without interferon considered alternative to surgery (if disease persists at 3 mo,
perform cystectomy)
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| Conclusions: optimal therapy undefined; consider—risk-stratification for surveillance; perioperative chemotherapy for
low-risk tumors; patients—at high risk can receive BCG or BCG plus interferon; with T1 disease require repeat resection;
with refractory disease, require cystectomy (new management strategies necessary for these patients)
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Suggested Reading
Best CD et al: Traumatic ureteral injuries: a single institution experience validating the American Association for
the Surgery of Trauma-Organ Injury Scale grading system. J Urol 173:1202, 2005; Brewer ME et al: Prospective
comparison of microscopic and gross hematuria as predictors of bladder injury in blunt trauma. Urology 69:1086,
2007; Coburn M: Damage control for urologic injury. Surg Clin North Am 77:821, 1997; Dinney CP et al: Efficacy
of a single intravesical treatment with Ad-IFN/Syn 3 is dependent on dose and urine IFN concentration obtained:
implications for clinical investigation. Cancer Gene Ther 13:125, 2006; Dinney CP et al: Genetic
polymorphism in bladder cancer. Front Biosci 12:192, 2007; Dobrowolski ZF et al: Treatment of posterior and
anterior urethral trauma. BJU 89:752, 2002; Fraga GP et al: Penetrating ureteral trauma. Int Braz J Urol 33:142,
2007; Gontero P, Frea B: Actual experience and future development of gemcitabine in superficial bladder cancer.
Ann Oncol 17 (Suppl 5):v23, 2006; Jordan GH et al: Reconstruction and management of posterior urethral
and straddle injuries of the urethra. Urol Clin North Am 33:97, 2006; Kamat AM, Dinney CP: A combination of
BCG and electromotive mitomycin for high-risk superficial bladder cancer. Nat Clin Pract Urol 3:472, 2006; Kuan
JK et al: American Association for the Surgery of Trauma Organ Injury Scale for kidney injuries predicts nephrectomy,
dialysis, and death in patients with blunt injury and nephrectomy for penetrating injury. J Trauma 60:351,
2006; Lamm DL et al: Bladder cancer: current optimal intravesical treatment. Urol Nurs 25:323, 2005; Lee YJ
et al: Renal trauma. Radiol Clin North Am 45:581, 2007; O’Donnell MA: Advances in the management of superficial
bladder cancer. Semin Oncol 34:85, 2007; Raj GV et al: Treatment paradigm shift may improve survival of
patients with high risk superficial bladder cancer. J Urol 177:1283, 2007; Santucci RA et al: Evaluation and
management of renal injuries: consensus statement of the renal trauma subcommittee. BJU International 93:937,
2004.
Educational Objectives
| The goal of this program is to improve the management of ureteral trauma and high-risk superficial bladder cancer. After
hearing and assimilating this program, the clinician will be better able to:
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| Assess current guidelines for managing traumatic ureteral injuries.
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| Select appropriate techniques for managing renal, ureteral, bladder, and urethral injuries.
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| Implement damage-control strategies designed to improve outcomes and survival among unstable patients.
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| Define the role of intravesical therapy in the management of high-risk superficial bladder cancer.
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| Determine the clinical benefits associated with intravesical bacillus Calmette-Guérin (BCG) therapy for superficial
bladder cancer.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty members to disclose relevant
financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified
conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business
or commercial interest. For this program, the following has been disclosed: Dr. Coburn is affiliated with Canji/
Schering-Plough.
Acknowledgements
Drs. Coburn and Dinney gave their scientific presentations at the 61st Annual Meeting of the Canadian Urological
Association held June 25 to 28, 2006, in Halifax, NS. The Audio-Digest Foundation thanks the speakers and the Canadian
Urological Association for their cooperation in the production of this program.
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