Prepared by: Hashim Gulam , R2 Genitourinary trauma Prepared by: Hashim Gulam , R2

introduction Traumatic injury is a leading national and international health problem. In the United States, 1 of every 14 deaths—over 150,000 per year—results from trauma. trauma results in more deaths between ages 1 and 37 years than any other cause.

Gu trauma Renal Trauma Ureteric Trauma Bladder Trauma Urethral Trauma

RENAL TRAUMA Of all injuries to the genitourinary system, injuries to the kidney from external trauma are the most common (50% of all genitourinary trauma). Mechanism of injury: Blunt (motor vehicle accident, assault, falls) Penetrating ( gunshot wounds, stab wounds) Iatrogenic ( endourologic procedures,ESWL, renal biopsy, percutaneous renal procedures)

Clinical Diagnosis Mechanism of injury provides the framework for clinical assessment. Hematuria is the best indicator of traumatic urinary system injury. The degree of hematuria doesn’t correlate with the degree of injury. Flnk pain & tenderness,fractures of the lower ribs and upper lumbar and lower thoracic vertebrae are associated with renal injuries.

Indications for Renal Imaging Blunt trauma patients with gross hematuria Patients with microscopic hematuria and shock (systolic blood pressure of less than 90 mm Hg any time during evaluation and resuscitation) Penetrating injuries with any degree of hematuria Pediatric trauma patient with gross or significant microscopic hematuria (>50 RBC/HPF) Associated injuries suggesting underlying renal injury Major deceleration injury

Imaging Studies The preferred imaging study for renal trauma is contrast-enhanced CT. It is Highly sensitive and specific. provides the most definitive staging information: parenchymal lacerations, extravasation of can easily be detected & associated injuries to the abdominal organs can be identified.

the degree of retroperitoneal bleeding can be assessed by the size and dimensions of the retroperitoneal hematoma. Lack of uptake of contrast material in the parenchyma suggests arterial injury.

IVP: All patients who require immediate surgical exploration should undergo a one-shot high dose IVP (2 mls\kg of 60% contrast followed by a single KUB 10 minutes later). Angiography: to define arterial injuries suspected on CT or to localize arterial bleeding that can be controlled by embolization

Classifications of renal injury

Renal contusion of the left kidney

right renal stab wound (grade IV), demonstrating extensive urinary extravasation and large retroperitoneal hematoma

Injury to collecting system with extravasation Delayed imaging Injury to collecting system with extravasation

Renal pelvis injury with leak of urine Delayed imaging Renal pelvis injury with leak of urine

management Non operative: Majority of renal injuries can be managed conservatively. Admission to the hospital & bed rest till the urine become clear. Close monitoring of vitals & serial Hb, Hct. Close clinical follow up after discharge.

Indication for renal exploration Absolute: Persistent renal bleeding Pulsatile,expanding or uncontained hematoma Avulsion of the main renal artery or vein

Relative: Significant (25%-50%) non-viable tissue. Urinary extravasation . Arterial thrombosis. Penetrating trauma.

Renal exploration The goals of operative therapy are hemorrhage control and renal tissue preservation Surgical exploration of the acutely injured kidney is best done by a transabdominal approach, which allows complete inspection of intra-abdominal organs and bowel.

The surgical approach to the renal vessels and kidney: A, retroperitoneal incision over the aorta medial to the inferior mesenteric vein; B, anatomic relationships of the renal vessels;xs C, retroperitoneal incision lateral to the colon, exposing the kidney.

Renal exploration, débridement of nonviable tissue, hemostasis by individual suture ligation of bleeding vessels, watertight closure of the collecting system, and coverage or approximation of the parenchymal defect

When polar injuries cannot be reconstructed, a partial nephrectomy should be done and all nonviable tissue removed, hemostasis obtained, and the collecting system closed. The open parenchyma should then be covered when possible by a pedicle flap of omentum.

Indication for nephrectomy Total nephrectomy would be indicated immediately in extensive renal injuries when the patient's life would be threatened by attempted renal repair. Grade 5 injuries that deemed irreparable. Major vascular injury.

Complications Urinoma: treated by systemic antibiotics if persist, internal ureteric stent often correct the problem. Delayed renal bleeding: occur several weeks after injury &The initial management is bed rest and hydration & if persist, angiography and embolization can often gain control. Perinephric abscess: treated by percutaneous drainage. HTN

Ureteral injury Ureteral injuries after external violence are rare, occurring in less than 4% of cases of penetrating trauma and less than 1% of cases of blunt trauma. Majority of ureteral injury are iatrogenic injuries. hysterectomy responsible for the majority of ureteral injury(54%), followed by colorectal surgery (14%), pelvic surgery such as ovarian tumor removal (8%), and abdominal vascular surgery (6%)

diagnosis Intra-operative recognition. 70-80% of iatrogenic injuries are diagnosed postoperatively. The presenting signs and symptoms may include flank pain (36-90%), fever and sepsis (10%), fistula, urinoma, prolonged ileus, and renal failure from bilateral obstruction (10%).

Imaging study IVP CT Retrograde pyelogram Antegrade pyelogram

management External trauma Contusion: if minor, stent placement. if large contusion, excision &U-U upper ureteral injury: direct u-u transureteroureterostomy autotransplantation ileal interposition segment: only for delayed repair

midureteral injury: direct u-u trans u-u lower ureteral injury: ureteric reimplantation psoas hitch. Boari flap.

Suggested management options for ureteral injuries at different levels.

Technique of ureteroureterostomy after traumatic disruption: A, injury site definition by ureteral mobilization; B, débridement of margins and spatulation; C, stent placement; D, approximation with 5-0 absorbable suture; E, final result

Transureteroureterostomy The donor ureter is brought to the contralateral side through a tunnel under the mesentery of the sigmoid colon superior to the inferior mesenteric artery. The anastomosis is performed in an end-to- side fashion.

Absolute contraindications to this procedure include a short donor ureter or a diseased recipient ureter Relative contraindications include a urothelial tumor, nephrolithiasis, pelvic or abdominal irradiation, retroperitoneal fibrosis, and in cases of a ureteral injury during aortoiliac bypass surgery

ureteroneocystostomy Ureteroneocystostomy is used to repair distal ureteral injuries that occur so close to the bladder that the bladder does not need to be brought up to the ureteral stump with a psoas hitch or Boari procedure.

psoas hitch Used if a tension-free anastomosis cannot be accomplished by a simple ureteroneocystostomy. Can be used to bridge a 6- to 10 cm defect . Involves mobilizing the bladder and pulling it superiorly and laterally by fixing it to the psoas tendon with absorbable suture. Care must be taken to avoid injuring the genitofemoral nerve

Boari bladder flap It involves creating a posterolateral bladder flap based on the superior vesical artery or one of its branches. Used in Injuries to the lower two thirds of the ureter with long ureteral defects. The procedure is time consuming & not commonly used

Surgical injury: Ligation: removal of the ligature and observation of the ureter for viability. If viability is in question, ureteroureterostomy or ureteral reimplantation should be performed. Stenting is advised.

Transection: Early recognition:nephrectomy vs U-U. Delayed recognition:stent placement for 6w-3m. If failed, place NT & attempt stenting after 2w wait several months and perform open repair in pts w/ persistent leaks or ureteral stricture

Ureteroscopy Injury: Avulsion: treated in the same manner as ureteral injuries after open or laparoscopic surgery. Perforation: treated by ureteral stenting, usually with no subsequent complications.

Bladder injury Etiology: Blunt: MVA, assault, falls. Penetrating: gunshot wound, stab wound. Iatrogenic: obstetric, gynecological, urological & orthopedic procedure. The most common associated injury is pelvic fracture, associated with 83% to 95% of bladder injuries.

classification Bladder contusion: trauma pt w/ hematuria w/ no evidence of urethral or renal injury and normal cystogram. Extraperitoneal bladder rupture: with pelvic # Intraperitoneal bladder rupture: with penetrating inj. Combination of intraperitoneal and extraperitoneal ruptures

Clinical presentation A triad of symptoms is often present (gross hematuria, suprapubic pain or tenderness, difficulty or inability to void) An abdominal examination may reveal distention, guarding, or rebound tenderness Absent bowel sounds and signs of peritoneal irritation indicate a possible intraperitoneal bladder rupture

Bilateral palpation of the bony pelvis may reveal abnormal motion indicating an open- book fracture or a disruption of the pelvic girdle. If blood is present at the urethral meatus, suspect a urethral injury.

Radiographic Imaging Cystography: 100% accurate in diagnosing significant bladder injury. Absolute indication: blunt external trauma is gross hematuria associated with pelvic fracture Penetrating trauma with any degree of hematuria. relative: gross hematuria without a pelvic fracture, microhematuria with pelvic fracture, isolated microscopic hematuria .

Extraperitoneal bladder rupture on cystography.

Intraperitoneal bladder rupture on cystography Intraperitoneal bladder rupture on cystography. Bowel loops are commonly outlined by contrast in the abdominal cavity. Figure 105–15. Intraperitoneal bladder rupture on cystography. Bowel loops are commonly outlined by contrast in the abdominal cavity.

CT cystogram Retrograde urethrogram: if blood at urethral meatus present.

computed tomography cystogram demonstrating extraperitoneal extravasation

management Contusion: No specific treatment. Extraperitoneal bladder injury: can be managed safely with simple catheter drainage and Abx Leave the catheter in for 7-10 days, then obtain a cystogram. Approximately 85% of the time, the laceration is sealed and the catheter is removed for a voiding trial.

Indication for immediate open repair: bone fragment projecting into bladder. open pelvic fracture. rectal perforation. pts undergoing laparotomy for other reasons.

Technique of closure of extraperitoneal bladder rupture Technique of closure of extraperitoneal bladder rupture. The transvesical approach provides optimal exposure to close the rupture with interrupted absorbable suture

Intraperitoneal bladder injury: Surgical exploration with two-layer closure with absorbable suture,Place SP tube and perivesical drain. Maintain patient on prophylactic Abx. Cystogram is obtained 7 to 10 days after surgery .

Urethral injury Classified into 2 broad categories based on the anatomical site of the trauma posterior urethral injury & anterior urethral injury. Etiology: Blunt trauma such as MVA or falls, penetrating injuries. Iatrogenic injury like traumatic catheter placement, transurethral procedures, or dilation. Posterior urethral injuries commonly associated with pelvic fractures Anterior urethral injuries come from blunt trauma to the perineum (straddle injuries)

Prostatic urethra Posterior urethra Membranous urethra Bulbous urethra Anterior urethra penile urethra

diagnosis Urethral injury should be suspected in the setting of pelvic fracture, traumatic catheterization, straddle injuries, or any penetrating injury near the urethra. Symptoms include hematuria or inability to void.

Physical examination may reveal blood at the meatus or a high-riding prostate gland upon rectal examination. Extravasation of blood along the fascial planes of the perineum is another indication of injury to the urethra. The diagnosis is made by performance of a retrograde urethrogram.

Technique Small bore (14F) urethral catheter Place 1-2cm into urethra ( fossa navicularis) Inflate the balloon with 1-2cc water. Gently inject contrast in 10ml increments Lateral decubitus films (static or fluoro)

Anteroposterior film of the pubis shows a straddle fracture involving all four pubic rami.

Retrograde urethrogram in pelvic fracture patient shows complete disruption of posterior urethra.

Classification of posterior urethral injuries Type I: Urethral stretch injury  Type II: Urethral disruption proximal to the genitourinary diaphragm  Type III: Urethral disruption both proximal and distal to the genitourinary diaphragm

Management The traditional intervention for men with posterior urethral injury secondary to pelvic fracture is placement of a suprapubic catheter for bladder drainage and subsequent delayed repair The suprapubic catheter can be safely placed either percutaneously or via an open approach with a small incision. Ultimate repair can be performed 6-12 weeks after the event, after the pelvic hematoma has resolved and the patient's orthopedic injuries have stabilized.

An attempt at primary realignment of the distraction with a urethral catheter is reasonable in stable patients either acutely or within several days of injury (ie, 5-7 d post injury). When the urethral catheter is removed after 4 to 6 weeks, it is imperative to retain a suprapubic catheter because most patients will, despite realignment, develop posterior urethral stenosis. If the patient voids satisfactorily through the urethra, the suprapubic catheter can be removed 7 to 14 days later.

Incomplete urethral tears are best treated by stenting with a urethral catheter. There is no evidence that a gentle attempt to place a urethral catheter can convert an incomplete into a complete transection

Penetrating anterior urethral injuries should be explored. The area of injury should be examined, and devitalized tissue should be debrided carefully to minimize tissue loss. Defects of up to 2 cm in the bulbar urethra and up to 1.5 cm in the penile urethra can be repaired primarily via a direct anastomosis over a catheter with fine absorbable suture. Longer defects should never be repaired emergently;Urinary diversion with a suprapubic catheter is performed till time of delayed reconstruction .

In cases of female urethral disruption related to pelvic fracture, most authorities suggest immediate primary repair, or at least urethral realignment over a catheter, to avoid subsequent urethrovaginal fistulas or urethral obliteration.

Concomitant vaginal lacerations must also be closed acutely to prevent vaginal stenosis. Delayed reconstruction is problematic because the female urethra is too short (about 4 cm) to be amenable to anastomotic repair when it becomes embedded in scar.