Urological Emergency Research Articles

Scrotal exploration for suspected testicular torsion in adolescents and adults: analysis of a series of 135 cases

BackgroundTesticular torsion (TT) is the abnormal twisting of the spermatic cord leading to strangulation of the testis. Any non-traumatic acute scrotal pain in adolescents and young adults is considered TT until proven otherwise. It is a urological emergency. The diagnosis is clinically based on symptoms and signs that raise a high index of suspicions. Scrotal exploration is necessary, which will provide diagnostic certainty and allow treatment.MethodsThis study aimed to assess the clinical predictors of TT. This was a retrospective cross-sectional study of patients aged 15 years and older who underwent surgical exploration for suspected TT from January 2005 to December 2021 at Teaching Hospital Yalgado Ouedraogo (Burkina Faso). We compared the demographic data and clinical findings of patients according to the intraoperative diagnosis.ResultsIn total, 135 scrotal explorations were performed for suspected TT. The average age of the patients was 24.56 years. TT was found in 123 cases (91.11%), epididymo-orchitis in 8 cases (5.93%) and in 4 cases (2.96%) no abnormality was found. Scrotal swelling and elevation of the testicle were more common in TT than in other cases (p < 0.001 in both cases). Fever was more frequent when it was not a TT (p < 0.001). Scrotal Doppler ultrasound had a sensitivity of 91%. The orchiectomy rate was 60.16% (N = 74) in patients with TT.ConclusionThe clinical findings based on scrotal pain and swelling, elevation of the testicle and the absence of fever are sufficient to suggest TT and to perform surgical exploration.

Diagnostic algorithm and key differential diagnoses of hematuria

The different causes of hematuria depend largely on age, gender and clinical context. Macrohematuria should always be investigated using cystoscopy and advanced imaging (CT/MRI with urographic phase). The most common differential diagnoses of macrohematuria include urinary tract infection, stones and urothelial carcinoma. A urological emergency is defined as macrohematuria with blood clot, urinary retention and new vegetative symptoms.

Surgical Management of Ischemic Priapism: what are the New Options?

Ischemic priapism is a true urologic emergency. Prompt intervention is required to alleviate the compartment syndrome and restore perfusion to the corporal bodies; failure to do so results in irreversible damage, fibrosis, and profound erectile dysfunction. This paper's objective is to review current literature surrounding the management options for ischemic priapism, focusing on newer surgical techniques. A PubMed database search was performed in June 2024, encompassing the terms "priapism," and "surgical management." Articles were reviewed by two authors independently and included if they were deemed to pertain specifically to management of ischemic priapism. In the acute setting (certainly for priapism lasting <24 hours), management is often successful using bedside maneuvers such as aspiration, irrigation, and injection of sympathomimetic agents. For more prolonged priapism, more aggressive intervention is often warranted. Newer tunneling techniques-including penoscrotal decompression and the corporal snake maneuver-have shown promising preliminary results, not just in terms of priapism resolution but also perhaps sexual function recovery.

Seasonal Variations in Testicular Torsion: A Retrospective Study.

Testicular torsion (TT) is a urological emergency requiring prompt intervention to prevent irreversible damage to the testicle. This study aims to assess trends in men's TT referrals, diagnostic evaluation through Doppler sonography (DS) scan, symptoms before surgery, orchidectomy rates, and TT laterality in relation to age and seasons of the year. This observational retrospective cohort study included all patients treated for TT at King Abdullah University Hospital between 2009 and 2021. Patients underwent DS, scrotal exploration, orchidopexy, or orchidectomy. Data collected encompassed patient demographics, admission date, duration of symptoms, laterality, and surgical intervention. Our study consisted of 308 TT patients between the ages of 10 and 33. Approximately 194 (63%) patients who were taken to the hospital for an average of 47 hours got an orchidectomy. Although the majority of patients received orchidopexy within 72 hours of detorsion and orchidopexy, five patients (3.6%) required reperfusion following detorsion and orchidopexy. A total of 112 individuals (36.4%) underwent bilateral orchidopexy, which lasted anywhere from 9 to 26 hours, whereas 194 (63%) patients underwent orchidectomy, which lasted anything from 40 to 264 hours (p < 0.001). The prevalence of right-sided TT increases by 6% per year with age (p = 0.047). This study found a high association between the amount of recoverable testicular tissue and the duration of symptoms before surgery. Even after 72 hours, it is still possible to salvage the testicles, even though the success rate reduces from 75% within 24 hours to 3.6% beyond that. Additionally, elderly individuals are more likely to experience right-sided torsion.Seasonal variation was evident, with the highest incidence of TT occurring during winter months, suggesting potential environmental or physiological triggers.

Urethral instrumentation in men with artificial urinary sphincter: a national survey among Brazilian urologists.

Urethral instrumentation (UI) in patients with an artificial urinary sphincter (AUS) demands technical considerations and poses a risk of urethral erosion, leading to serious clinical and legal consequences. We conducted a national survey to evaluate the knowledge and experience of Brazilian urologists with UI in these patients. This study used an electronic survey distributed to members of the Brazilian Society of Urology. The survey included 19 multiple-choice questions assessing sociodemographic characteristics, practice patterns, AUS training, knowledge of AUS components and functionality, experience with UI in AUS patients, and interest in further training. Urologists were classified as 'competent' in AUS manipulation if they had prior experience and confidence in performing UI. Among 536 participants (median age 47years [39-55]), 72.8% reported involvement in urological emergencies, with 89.9% indicating inadequate AUS training during residency. Only 29.7% had occasional or regular involvement with AUS surgeries. Of the participants, 53.4% had performed UI in men with an AUS. Prior UI had been attempted by healthcare staff in 36.2% of cases. Only 46.8% reported knowledge of AUS components and 45.1% felt competent in deactivating it. Regarding urethral catheterization, 47.2% knew the safe catheter diameter, and 20.9% identified safe catheterization duration. Overall, 45.1% self-declared competence in UI, yet many gave incorrect answers on catheter size and duration. Competence strongly correlated with knowledge of AUS components, regular implant involvement, and prior experience. Most (89.3%) expressed interest in additional training for UI. This study highlights significant gaps in training and knowledge among Brazilian urologists regarding UI in AUS patients. These deficiencies underscore the potential for enhanced education to improve patient outcomes and reduce AUS-associated complications in Brazil and possibly broader internationalcontexts.

The assessment and aetiology of drug-induced ischaemic priapism.

Ischaemic priapism is a urological emergency characterised by a prolonged, painful erection unrelated to sexual stimulation. While several aetiological factors contribute to this condition, the pharmacological causes have gained significant attention in recent years. This narrative review aims to comprehensively assess ischaemic priapism, specifically focusing on its pharmacological aetiology. We propose an approach and assessment strategy to the numerous factors associated with pharmacologically induced ischaemic priapism. By enhancing our understanding of the pharmacological causes of this condition, healthcare professionals can improve patient management and reduce the long-term complications associated with ischaemic priapism.

A comparative study of Silodosin vs. Tamsulosin in the management of Benign Prostatic Hyperplasia: Outcomes in a tertiary care setting in Karachi.

Background: Lower urinary tract symptoms (LUTS) caused by benign prostatic hyperplasia (BPH) are prevalent among aging males, with acute urinary retention (AUR) being a common urological emergency. Alpha-blockers, such as tamsulosin and silodosin, are widely used in managing BPH-related LUTS and improving outcomes in Trial Without Catheter (TWOC). However, the comparative efficacy of these two medications remains a topic of clinical interest. This study aims to compare the efficacy of tamsulosin versus silodosin in achieving successful TWOC and improving the International Prostate Symptom Score (IPSS) in patients with BPH at a tertiary care hospital in Karachi. Methodology: A randomized controlled trial was conducted involving 100 male patients with BPH, aged 45-85 years, who were randomly assigned to two groups: Group A (silodosin, 50 patients) and Group B (tamsulosin, 50 patients). The primary outcomes included successful TWOC (defined as a post-void residual volume of &lt;100 ml) and improvement in IPSS after one month. Statistical analyses were performed using the chi-square and Mann-Whitney U tests, with a significance level set at P ≤ 0.05. Results: In Group A, 70% of patients achieved a successful TWOC, compared to only 20% in Group B (P = 0.001). The mean IPSS score in Group A was significantly lower than in Group B (P = 0.001), indicating better symptom control with silodosin. Conclusion: Silodosin demonstrated superior efficacy in facilitating TWOC success and reducing LUTS compared to tamsulosin. These findings suggest that silodosin should be considered the preferred alpha-blocker for managing BPH, especially in patients with AUR, offering improved outcomes for both catheter removal and symptom relief.

Penile fracture in a child presenting at teaching hospital in South-Western Uganda: a case report

Introduction and importancePenile fracture refers to the traumatic rupture of tunica albuginea in an erect penis. It is relatively uncommon and represents a urological emergency once it happens, necessitating immediate surgical intervention to prevent long-term complications. This condition presents a surgical challenge in both diagnosis and treatment due to the few urology specialists in our setting. We present a case of penile fracture surgically managed in a resource-limited setting with an excellent outcome.Case presentationWe present a 15-year-old male admitted to our teaching hospital with a 12-h history of onset of pain, progressive swelling, and an audible pop sound that preceded turning in bed on an erect penis. He, however, denied a history of masturbation. A penile ultrasound scan was done, which confirmed a tear of Tunica albuginea. Penile exploration was done, which revealed a tear in tunica albuginea that was repaired successfully. The patient recovered well with no complications.Clinical discussionA penile fracture is a rare surgical emergency. Successful outcomes hinge on timely diagnosis, proficient surgical repair, and comprehensive postoperative care. A penile fracture is a clinical diagnosis in the hands of an experienced surgeon.ConclusionsFindings of this case report highlight the importance of raising awareness among health workers and the general public about this rare condition, and the treatment options available in our less resourced setting.

Fournier's gangrene mortality: peri-umbilical cutaneous involvement as a crucial clinical indicator

BackgroundFournier's gangrene (FG) is a severe urological emergency characterized by high mortality and requiring intensive management. Our objective was to ascertain the clinical and biological determinants of mortality in cases of FG, assessed one month following the initial surgical intervention.MethodsWe conducted a retrospective study of male patients treated surgically for urologically-originating Fournier's gangrene, diagnosed through physical examination, from January 2002 to December 2022. We analyzed clinical predictors by dividing affected skin into nine zones: scrotal, penile, perineal, hypogastric, right inguinal, left inguinal, right flank, left flank, and peri-umbilical regions.ResultsOur study included 118 patients, average age 58.97 years (± 13.84). Among them, 60.2% had diabetes, 27.1% were hypertensive, and 51.7% had a performance status of ≥ 2. At admission, 70% had a quick SOFA score of 0. The one-month postoperative mortality rate was 12.7%. In univariate analysis, all predefined cutaneous areas were significant except the scrotal region, with higher odds ratios for upper abdominal involvement. Independent predictive factors for one-month postoperative mortality were a heart rate ≥ 89 bpm (p = 0.001; OR = 6.96; 95% CI 2.16–22.40), systolic blood pressure ≤ 115 mmHg (p = 0.009; OR = 4.24; 95% CI 1.34–13.41), and peri-umbilical involvement (p < 0.001; OR = 216.67; 95% CI 33.06–1420.20). Peri-umbilical involvement had a notably stronger predictive effect on one-month postoperative mortality.ConclusionFournier's gangrene prognosis worsens with more abdominal skin involvement. Key factors for one-month postoperative mortality are heart rate ≥ 89 bpm, systolic blood pressure ≤ 115 mmHg, and peri-umbilical involvement, which is notably linked to higher mortality.

Genitourethral foreign bodies: 20-year experience and outcomes from a single center.

The presentation of a foreign body in the lower urinary tract is a challenging urological emergency with highly variable management approaches. A retrospective cohort study was undertaken to identify the patients who presented with self-inserted genitourethral foreign body to adult tertiary centers within our local health network (Southern Adelaide Local Health Network, Adelaide, Australia) from October 2002 to October 2022. Patient demographics, type of foreign body, psychiatric comorbidities, retrieval techniques, complications, and readmission data were extracted. Twenty-seven cases were identified with a median age of 44 years. Twenty-three (85.2%) were male and 4 (14.8%) were female. Ten patients (37.0%) had a concurrent psychiatric illness. The most commonly inserted foreign bodies were plastic tubes/wires (29.6%). Twenty cases (74.1%) were retrieved endoscopically. Three patients (11.1%) required open cystotomy and one underwent a transperineal urethrotomy. Four patients (14.8%) represented after discharge. Two patients had repeat presentations for genitourinary foreign body insertion. A significant monotonic positive trend of foreign body presentations was identified (Mann-Kendall tau = 0.95, P = 0.043). Presentations of genitourethral foreign body insertions have trended upward over the past two decades. However, most cases were successfully managed endoscopically.

The Protective Effects of Citrulline on Testicular Injury Induced by Torsion and Detorsion in Adult Male Rats: An Experimental Study.

Testicular torsion is a critical urological emergency that can lead to testicular ischemia and significant tissue damage. Citrulline, a supplement known for enhancing cellular metabolism and mitigating oxidative stress and inflammation, has been explored for its protective effects against testicular injury resulting from torsion and detorsion in rat models. This study involved 42 Wistar rats, divided into six groups: Sham, torsion/detorsion (T/D), and four groups receiving varying doses of Citrulline (300, 600, 900 mg/kg) and vitamin E (20 mg/kg). A surgical procedure was performed to induce torsion by rotating the left testicle for 4 hr, followed by reperfusion. Daily oral administration of the supplements continued for one week post-surgery. Assessments included oxidative stress markers, apoptosis, inflammation, pathology, and sperm parameters. Statistical analysis was conducted using GraphPad Prism. Citrulline administration at doses of 600 and 900 mg/kg significantly reduced malondialdehyde (MDA) and reactive oxygen species (ROS) levels. Additionally, it increased glutathione (GSH) levels and decreased protein carbonyl levels at the 900 mg/kg dose. The expression of interleukin-6 (IL-6) decreased at 900 mg/kg, tumor necrosis factor-alpha (TNF-α) levels dropped at 600 and 900 mg/kg, and the pro-apoptotic factor Bax was reduced at all doses. Sperm analysis showed improved sperm count and motility at the 900 mg/kg dose. Histological examination revealed significant positive effects of Citrulline on testicular tissue. Citrulline effectively lowers oxidative stress, inflammation, while enhancing sperm quality and pathological outcomes. These results indicate that Citrulline has potential as a therapeutic agent for testicular torsion.

To the 60th anniversary of Igor Vitalievich Poddubny

Prof. Igor V. Poddubny, a member of the Editorial Board of the Russian Journal of Pediatric Surgery, Dr. Sci. (med), celebrated his 60th anniversary on September 25, 2024. The basic area of his interest and research is mini-invasive endoscopic surgeries in children and adolescents. He has developed and implemented into clinical practice modern surgical techniques for treating children with various emergency and elective surgeries in urology, coloproctology and gynecology. He was the first in Russia to perform endoscopic surgical interventions for varicocele, abdominal cryptorchidism, cysts of parenchymal organs of the abdominal cavity and retroperitoneal space, as well as laparoscopic nephrectomy, heminephroterectomy, adrenalectomy. He also operated patients with Hirschsprung's disease, ulcerative colitis, Crohn's disease, colon polyposis, complex malformations of the uterus and vagina, etc.

Thirty-five years of the French Association of Urologists in Training (AFUF) a scoping review and bibliometric analysis of scientific literature conducted by urologists in training.

The objective of this scoping review was to identify the topics of research and the types of studies published by the French Association of Urologists in Training (AFUF) since it was created, 35 years ago and to perform a bibliometric analysis. A scoping review on PubMed, Google scholar, Excerpta Medica database (EMBASE) was conducted from 1989 until the 31st of December 2023. The PRISMA extended guidelines for scoping reviews were followed. Articles were independently screened and analyzed by two reviewers. The theme type, primary results, language of publication, number of male and female authors and number of citations from each included article were extracted. A total of 32 articles were included among which 17 surveys and 11 cohort studies. There was a median percentage of 20% women among authors. Fifteen articles (47%) were published in French and 17 articles in English. The median number of citations was 4.5. The topics covered were urologist in training's surgical education, well-being, professional practice, and urologic emergencies: renal trauma and spermatic cord torsion. The creation of large national databases enabled the generation of multiple studies focusing on previously under-represented topics. Over the 35 years since it was created, The AFUF has had an interesting and prolific scientific output. It has shown its concerns for urologists in training.

Preparing the future combat surgeon: a survey of the military general surgery trainee GME experience

IntroductionGraduate medical education (GME) lacks a standardized military training program for general surgery residents, and concern exists that they may not be prepared to serve as combat surgeons on training...

Late Phase Testicular Torsion in Pre-Geriatic Age: A Case Report

Background: Testicular torsion is a urological emergency caused by a twist of spermatic cord, which result in testicular tissue ischemia and requiring immediate surgery. The incidence occurred generally in children and adolescents, rarely found in adults. Severe Scrotal pain is the most common manifestation of testicular torsion. The definitive treatment for testicular torsion is surgery, either one of orchidopexy or orchidectomy. The prognosis of testicular torsion depends on the onset of symptoms and the decision time for surgery. Case Report: A 52-year-old man presented to emergency department with a history of gradual severe right-sided scrotal pain (visual analogue scale 8) radiated to the right groin in the last 3 day before admission. Previously, the patient's genitals were hit by the table. On physical examination, the testicles were found to be asymmetrical, swollen, redness, tenderness, and the testicle felt hard and immobilized, either the cremaster reflex or the Phren sign test were negative. The TWIST score was 6 (high risk for testicular torsion). Orchidopexy and orchidectomy were performed immediately without Scrotal Doppler Ultrasonography due to operational problems. Histopathology examination of the orchidectomy specimen impression showed an inflammation sign with exudative fluid presentation. Conclusion: Gradual Severe scrotal pain manifestations should be suspected as testicular torsion as soon as possible before it evolves into later phase. One of the causes of late phase testicular torsion is late admission to Hospital. Surgical emergency action should be taken considering theemergency state without waiting for ideal sonography

Phosphodiesterase inhibitors and testicular torsion: A systematic review and meta-analysis of animal studies.

Testicular torsion is a common urological emergency in children and teenagers that, in most cases, requires surgical exploration and detorsion. However, even after a successful intervention, a high number of patients still develop irreversible damage. To investigate whether the administration of phosphodiesterase inhibitors (PDE) in animal models of testicular torsion can reduce damages caused by the ischemia-reperfusion syndrome. A systematic search of the Medline, Web of Science, Embase, and Ovid databases for studies up to December 2023 was performed using PRISMA guidelines. A detailed search was conducted using the following key terms: "testicles," "ischemia," "reperfusion," and "phosphodiesterase inhibitors." There was no restriction regarding language or year of publication. We investigated spermatogenesis by the Johnsen's biopsy score (JTBS) and histological damage by the Cosentino's biopsy score (CBS). Malondialdehyde (MDA), nitric oxide (NO), superoxide dismutase (SOD), and glutathione peroxidase (GPx) testicular levels were also analyzed. Initially, 296 articles were identified. However, only 20 studies met the inclusion criteria. PDE inhibitors improved JTBS (MD=2.53, CI=1.94 to 3.13), CBS (MD=-1.11, CI=-1.25 to -0.97) and SOD (SMD=3.27, CI=1.59 to 4.95) outcomes. PDE did not improve MDA (SMD=-0.93, CI=-2.19 to 0.34), NO (SMD=-0.54, CI=-1.56 to 0.48), and GPx (SMD=0.77, CI=-0.38 to 1.92) outcomes. A higher dose of PDE inhibitors only improved CBS outcome. This review indicates that the administration of PDE inhibitors in rats ameliorated the outcomes, representing a promising complementary strategy for spermatogenesis recovery following testicular torsion. Our review suggests that JTBS and CBS could be translated into future human studies, validating and extending these findings within the context of human physiopathology, while providing applicability of interventions in real clinical practice.

Penile and Testicular Incarceration with a Metal Foreign Body - Full Recovery of Erectile Function after 4 Days of Entrapment.

Penile incarceration with a foreign body is a rare urological emergency necessitating prompt intervention. We present a 59-year-old patient who entrapped penis and right testicle with metal thread reducer for sexual arousal four days prior to admission to Emergency room. Ultrasound revealed significantly reduced Color Doppler signal in right testicle and completely absent signal in penile artery. After admission metal reducer was removed using a hacksaw in analgosedation. Magnetic resonance imaging showed penile ishemic changes. Patient had reduction of penile swelling and parts of the skin highly suspected of necrosis recovered fully with preserved sensations. Despite penile ischemia on magnetic resonance imaging patient had full recovery obtaining normal erections. Patient was discharged six days after admission, presenting with normal International Index Erectile Function on follow up exam.

Replantation following complete penile amputation: Summary of perioperative experience and treatment strategies.

To date, there are only case reports of penile amputation, a rare urological emergency with a low-treatment successful rate, and there are still no advanced, detailed surgical or perioperative treatment plans. Effective treatments for these rare diseases are urgently needed. The researchers summarized the perioperative experience of 20 patients who underwent replantation after complete penile amputation at several hospitals over the past 5 years and shared experience in detail. Only 1 of the 20 surgeries failed, and both urinary and erectile functions were successfully restored in other cases, indicating that the surgical methods and perioperative treatments summarized by researchers are feasible and highly successful for replantation following complete penile amputation. Researchers have summarized the method and perioperative plan for replantation following penile amputation based on a summary of 20 cases, thereby providing guidance for urologists and andrologists.

73-year-old patient with urological emergency

73-year-old patient with urological emergency

Editorial Comment on “Learning by Clinical Reasoning Versus Interactive Lecture: An Analytical and Experimental Study of Teaching Urological Emergencies”

Editorial Comment on “Learning by Clinical Reasoning Versus Interactive Lecture: An Analytical and Experimental Study of Teaching Urological Emergencies”