ACCURACY OF ULTRASONOGRAPHY IN DIAGNOSIS OF TESTICULAR RUPTURE AFTER TESTICULAR TRAUMA

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WHEN TO PERFORM SURGICAL EXPLORATION IN PATIENTS WITH “PRESUMED PENILE FRACTURE”?

ACCURACY OF ULTRASONOGRAPHY IN DIAGNOSIS OF TESTICULAR RUPTURE AFTER TESTICULAR TRAUMA

Cavalcanti A., Koifman L., Favorito L., Manes C., Rachid Filho D., Carvalho J., Rabelo P.

El Ammari J., Guichard G., Wallerand H., Chabannes E., Bernardini S., Bittard H., Kleinclauss F.

Hospital Municipal Souza Aguiar, Urology, Rio de Janeiro, Brazil

Chu Saint Jacques, Urology and Renal Transplantation, Besançon, France

INTRODUCTION & OBJECTIVES: Penile fracture is defined as a rupture of the tunica

INTRODUCTION & OBJECTIVES: Because of the acute pain, clinical examination of the traumatized scrotum is difficult and yields limited information. Interest of ultrasonography and colour doppler is controversial. Ultrasonography (US) can help the surgeon to evaluate the lesions and can influence the management of the scrotal trauma. However its sensitivity and specificity for the diagnosis of rupture of testicle are low. The aim of this study is to determine the value of ultrasonography for the diagnosis of traumatic testis rupture.

albuginea of one or both corpora cavernosa in the erect penis. Is an uncommon trauma with a reported incidence of 1/175000 patients admitted at the emergency room and is probably an unreported condition in many cases. In front of a patient with a suspicion of penile fracture, different degrees of trauma must be considerate, range from a superficial haematoma to a bilateral tunica albuginea rupture associated with urethral injury. The aim of this study is to analyse the indications for surgical exploration in patients with “presumed penile fracture”. MATERIAL & METHODS: Charts of 102 patients admitted at our emergency department were reviewed. Surgical indications, surgical finds and outcomes were analysed. RESULTS: The indication of surgical exploration was based on clinical history and physical examination and the most important point was the chance of tunica albuginea rupture. Image methods were used only in few cases, to confirm the absence of tunica rupture in patients with low suspicion for that. 86 (84.3%) patients were submitted to surgical exploration and the most common indications were: a presence of a typical history (pain, haematoma, click sound and detumescense) and the presence of a moderate or significant haematoma (abnormal palpation or unpapable corpora cavernosa). In the group submitted to surgical exploration significant injuries (rupture of tunica albuginea or urethra) were observed in 79 (91.8%) case. In 7 (8.2%) cases a haematoma associated to venous injury were found. A selected group of 16 (15.7%) patients were submitted to a conservative approach. In this group two points were remarkable for the therapeutic decision: An untypical history (specially the absence of penile detumescense or the possibility of erections after the trauma) and the presence of a small haematoma with normal corpora cavernosa palpation. The follow-up in those patents (12/16) have demonstrated excellent outcomes. CONCLUSIONS: The therapeutic indications for patients with a “presumed penile fracture” must be based on clinical history and physical examination. Immediate surgical repair is the therapy of choice in high suspicion of tunica albuginea rupture. Conservative therapy is restricted to presumed penile fracture with low suspicion of tunica albuginea rupture.

MATERIAL & METHODS: From 1994 to 2005, 30 patients 14 to 86 years old (mean age 30.7) with scrotal trauma were operated in our institution. All patients had an emergency scrotal ultrasonography using a 7or 10 MHz transducer before surgical exploration. Ultrasounds findings (tunica albuginea rupture, intratesticular haematoma, extruded testicular parenchyma, haematocoele, epididymis lesions) were compared to surgical results to evaluate the accuracy of ultrasound diagnosis. RESULTS: Physical examination founded enlarged scrotum in 26/30 (86.7%) and haematocoele in only 7/30 (23.3%). Ultrasound diagnosis of haematocoele was made in 20 of 30 patients (66.7%). Haematocoele was confirmed by surgical exploration in 18 patients. Sensitivity (Sen) of US for haematocoele is 85.7% and specificty (Spe) is 75%. The positive (PPV) and negative predictive value (NPV) were 72% and 95% respectively. Tunica albuginea rupture was suspected by US in 12 patients and was confirmed in only 8 (Sen : 57%, Spe : 75%, PPV : 67%, NPV : 67%). Intratesticular haematoma was founded in 9 patients and confirmed in 5 (Sen : 71.4%, Spe : 83%, PPV : 55%, VPN : 90%). Epididimis lesions were suspected in 7 patients and confirmed by surgery in 4 (Sen : 57%, Spe : 87%, PPV : 57%, NPV : 87%). Considering all ultrasound findings (haematocoele, tunica albuginea disruption, extruded tesicular parenchyma, hypoechogenic testis parenchyma) testis rupture was suspected by US in 17 patients. Twelve of 17 patients presented a testis rupture at the time of surgery and there were 5 false positive patients. In 13 cases, US didn’t suspect testicular rupture but 3 patients presented a tunica albuginea rupture surgically confirmed. The global sensitivity and specificity of US were 80% and 67% respectively. PPV and NPV were 70% and 77% respectively. CONCLUSIONS: Testicular rupture is one of the most severe injuries after scrotal trauma that needs early surgical treatment to improve conservative treatment of the testis. Clinically, testis rupture is often impossible to diagnose. Scrotal ultrasonography examination can distinguish severe injuries of the scrotum such as haematocele, tunica albuginea rupture, hypoechogenic parenchyma, that suggest testicular rupture. However its sensitivity for the diagnosis of testicular rupture is moderate (80%) with a risk of false negative. Ultrasonography is not accurate enough to determine whether surgery is necessary but can be interesting to complete physical examination.

899 GENITAL BURNS IN PEDIATRIC PATIENTS Cavalcanti A.1, Reis R.1, Beatriz A.2, Neurauper M.L.2, Afcer I.2, Favorito L.2 1

Hospital Municipal Souza Aguiar, Urology, Rio de Janeiro, Brazil, 2Hospital

Municipal Souza Aguiar, Pediatric, Rio de Janeiro, Brazil INTRODUCTION & OBJECTIVES: The aim of this report is to review the experience in the management of genital burns at a major burn centre MATERIAL & METHODS: Seventy-seven children who sustained genital burns admitted at our institution during five years are discussed. RESULTS: Genital and perineal burns occurred in the context of major burns (average corporal area: 21.9%) and were rarely isolated. The age range from 1 month to 13 years (average: 56.8 months). The majority was boys: 60 (77.9%). A total of 68.9% were caused by hot liquids (scalds), 24, and 7% were flame or contact burns, and 6, 4% electrical burns. The majority of the cases could be treated conservatively with loose debridement, topical, and parenteral antibiotics with satisfactory outcomes. An aggressive treatment with extensive debridement and reconstruction with grafts and flaps were necessary in only 7 cases (9.1%). CONCLUSIONS: Most perineal and genital burns in children are superficial and can be treated successfully with a conservative approach. Child abuse should be vigorously investigated in those cases.

900 MANAGEMENT OF PENILE URETHRAL LESION IN PENILE BLUNT TRAUMA Favorito L., Cavalcante A., Krambeck R., Alexandre A. Souza Aguiar Municipal Hospital, Urology, Rio de Janeiro, Brazil INTRODUCTION & OBJECTIVES: Traumatic lesions to the penis may extend into the corpus spongiosum, causing laceration or complete transection of the urethra. Blunt Penile trauma is usually related to sexual intercourse or manipulation. The aim of this paper is to report the authors experience with the management of urethral injuries in patients with penile blunt trauma. MATERIAL & METHODS: In the period between January 1982 and October 2004, 77 patients admitted at our emergency department with diagnosis of penile blunt trauma were retrospectively reviewed, and the cases with associated urethral injury selected. Medical history, diagnostic management, surgical finds and outcomes were analysed. Sexual trauma was the most common cause of injury corresponding to 72 (93.5%) cases, followed by lesion due to penis manipulation in 4 (5.2%) and directly trauma through the flaccid penis in 1 case (1.3%). Patient’s age ranged from 18 and 63 years (mean 33 years). RESULTS: From 77 cases assessed, 11 (14.2%) patients had urethral injury; 62 (80.5%) had injury of the corpora cavernosa and 4 (5.2%) had injury of the dorsal vein. The aetiology of urethral injuries was sexual intercourse in 10 cases (91%) and directly trauma through the flaccid penis in 1 case (9%). A partial urethral disruption was presented in 8 patients (72.8%) and a total disruption in 3 cases (27.2%). Pre-op urethrogram was done in 7 patients with a suspicion of urethral trauma. When a partial injury was present the urethra was closed over the catheter and in the presence of a total injury an end-to-end anastomosis was done. CONCLUSIONS: The presented data supports: 1) incidence of urethral injury associated with blunt penile trauma and 2) no clinically apparent urethral structures were appreciated with primary urethral repair after a follow-up superior to 6 months. Eur Urol Suppl 2006;5(2):247