1. Topic Review : Genitourinary Trauma

2. 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

3. Classification

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

5. Flowsheet

6. 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

7. 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

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

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

10. Management
Renal reconstruction

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

12. 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

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

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

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

16. Ureteral injury

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

18. Ureteral injury
Psoas hitch
Boari flap

19. 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

20. 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

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

22. 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

23. Bladder injury
Diagnosis
-Cystography
extrapeitoneal
intraperitoneal

24. Bladder injury
- CT cystography

25. 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, Kotkin et al, J Trauma, 1995

26. 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

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

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

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

30. Urethral injury
partial rupture
complete rupture

31. 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

32. 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

33. Urethral injury

34. 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

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

36. 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

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

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

39. External genitalia injury
Ruptered tunica albuginea

40. 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