Topic Review : Genitourinary Trauma

Renal injury GU tract - 10% of polytrauma patients Renal injury – most common blunt / penetrating trauma Hematuria – best indicator but not always seen Microscopic hematuria c shock – significant renal injury

Classification

Staging Imaging modality contrast-enhanced CT spiral CT – rapid but disadvantaged US – more developing IVP – replaced by CT

Flowsheet

Management Nonoperative -98%, even penetrating trauma; 55% of stab wound, 24% of gunshot wound McAninch et al, J Urol, 1991 -Hospitalization & Bed rest -Close F/U

Maagement - Absolute indication Operative: nephrectomy, renal exploration - Absolute indication persistent renal bleeding, expanding perirenal hematoma, pulsatile perirenal hematoma - Relative indication urinary extravasation, nonviable tissue, delayed diagnosis of arterial injury, segmental arterial injury, and incomplete staging

Management Operative Relative indication - Extravasation alone c GIV injuy: 87% conservatively - 20%> nonviable tissue: questionable - Segmental artery injury c laceration : operatively - Incomplete staging

Management Renal exploration early vascular control – before opening Gerota’s fascia

Management Renal reconstruction

Management Reovascular injury Main renal artery trombosis < 8hr Replacemet graft Enovascular stent- only 1 case Nephrectomy – critical, multiple injury Reovascular injury

Ureteral injury Etiology -External trauma: rare -Open Surgical Injury: hysterectomy (54%), colorectal surgery (14%), pelvic surgery (8%), abdominal vascular surgery (6%) vascular surgery: benign course hysterectomy&colorectal surgery: complicatable -Laparoscopic injury: mainly OBGY op -Ureteroscopic injury St.lezin, urology, 1991

Ureteral injury Diagnosis - Hematuria - Intraop recognition - Excretory urogaphy - CT - RGP/AGP

Ureteral injury Management -External trauma 1.contusion: minor -> ureteral stentin major & large -> ureteoureterostomy (ureteral vascular problem) 2.upper ureteral injury: ureteroueterostomy, ileal interposition

Ureteral injury 3. Mid ureteral injury Ureteroureterostomy(Transureteroureterostomy) 4. Lower ureteral injury ureteroneocystostomy, psoas hitch, Boari flap

Ureteral injury

Debridement of dead tissue Ureteral injury End-to-end Debridement of dead tissue Sparing adventitia Spatulation Watertight D-J stent

Ureteral injury Psoas hitch Boari flap

Ureteral injury - Sugical injury 1. Ligation: removal of ligation & ureteral stent or ureteroureterostomy(viability ) 2. Transection #Immediate recognition mainly same as external trauma in aortic surgery: controversial nephrectomy vs ureteoureterostomy NEPHRECTOMY: avoids the potential for postoperative urinary leakage around a prosthetic vascular graft, which can be fatal. ANTINEPHRECTOMY: post op renal insufficiency

Ureteral injury # delayed recognition (post-op: 3-30d) Sign&Sx: fever, leukocytosis, generalized peritoneal signs Repair: controversial ureteral stenting -only 20-50%, Max 73% ultimate success, at least 6wks laparoscopic injury: less successful Open repair- immidiate vs delayed (several month) retrograde ureteral stenting fail-> nephrostomy and anterograde stenting McAninh et al

Ureteral injury -Ureteroscopic Injury avulsion ; treat same as open/lapa injuy perforation; ureteral stenting

Bladder injury Etiology -Blunt injury -Penetrating injury < 2% of abdominal injuries requiring op c urethral rupture (10-29%) 6-10% of pelvic bone fx, 83-100% of bladde injury associated c pelvic bone fx. Cass et al, J Urol, 1984 Etiology -Blunt injury -Penetrating injury

Bladder injury Diagnosis -Cystography extrapeitoneal intraperitoneal

Bladder injury - CT cystography

Cass et al,Urology,1989 Kotkin et al, J Trauma, 1995 Bladder injury Management - Contusion: no specific therapy - Extraperitoneal injury .mainly catheter drainage only .bone fragment, open pelvic fx.,rectal perforation, catheter obstruction by clot -> open repair .laparotomy, orthopedic open reduction Cass et al,Urology,1989 Kotkin et al, J Trauma, 1995

Bladder injury -Intraperitoneal injury 25% of all bladder injury, 12% combined with extraperitoneal injury -> open repair c two-layer closure perivesical drainage, suprapubic&urethral catheter Reason) much larger than cystography persistent urinary leakage peritonitis

Bladder injury Post injury management Antibiotics F/U cystography extraperitoneal rupture c conservative management: 10-14d, if not healed 21d open repair: 7-10d

B:below prostatic apex Urethral injury 1.Posterior urethra Pelvic Fx.: 4-14% / shear injury B:below prostatic apex C:membranous/ bulbous

Urethral injury Diagnosis blood at urethral meatus, inability of voiding, palpably full bladder, peirneal hematoma - Urethrography

Urethral injury partial rupture complete rupture

Urethral injury Initial management -Primary realignment: partial/complete original: open -> indirect/endoscopic stenting Elliot, J Urol,1997 + suprapubic cystostomy for 3-6wks -Suprapubic cystostomy: if fails

Urethral injury Delayed reconstruction 3M: scar tissue -> stable, mature Imaging study: cystogram+RGU -Endoscopic reconstruction CIx: defect < 1cm or significant dislocation -Surgical reconstruction perineal approach / pubotomy / staged staged: extensive stricture, previous failed urethroplasty(no available penile skin), infected

Urethral injury

Urethral injury Complications - Impotence: 13-30% - Incontinence: 2-4% Corriere et al, J Trauma, 1994 open bladder neck > closed bladder neck (53%) Iselin at al, J Urol, 1999 - Stricture after posterior reconstruction, 12-15% -> first, endoscopic management

Urethral injury 2. Anterior urethra Straddle/penetrating injury -Initial management Catheter realignment/suprapubic cystostomy -Delayed reconstruction: anastomosis -Complication Impotence / stricture (<5% after anastomosis)

External genitalia injury 1.Penis -Amputation: replantation before 24hr Revascularization of doral a. is sufficient -Penile Fx.(rupture of corpus cavernosum) Pex:Penile swelling, ecchymosis Hx: popping sound, pain, immediate detumescense Cavernosography(sensitive), US, MRI

External genitalia injury Tx: Immediate repair / conservative management (prolonged adm, complication)

External genitalia injury 2. Testis -Imaging study US: must be adjunct to Pex Intratunical hematoma 1wks later

External genitalia injury Ruptered tunica albuginea

External genitalia injury Management .Surgical repair / exploration orchiectomy rate:delayed op 21% immidiate op 6% Cass et al, Urology, 1991 .Nonoperative Insignificant scrotal injury much pain, longer hospitalization intratesticular hematoma: 40% infection/necrosis