1. Injuries of the ureter, bladder, urethra,external genitalia
Lower GU Tract Trauma
Injuries of the ureter, bladder, urethra,external genitalia

2. Ureteral Injuries … Etiologies
External trauma..gunshot, stab, blunt
Open Surgery..hysterectomy, colectomy,AAA
Laparoscopic Surgery..pelvic endometriosis
Ureteroscopic..fibrosis, lack of luminal control
Instrumentation..retrograde pyelogram, ureteral dilation

3. Ureteral Injuries… External Force
Rare event, <4% penetrating and 1% blunt
Civilian and military rate 2-4%
Commonly associated other visceral injury: small-39-65%, large-28-33%, renal-10-28%, bladder-5%
2x2 rule- expect vascular damage 2cm above and 2cm below transected ureter
UPJ disruption rare..presents with hematuria and hypovolemic shock, dx best by CT
UPJ disruption presents with hematuria and nonresponsive hypovolemic, best diagnosed with CT or One shot IVU in OR, usually don’t have a perinephric hematoma

4. Ureteral Injury…Open Surgery
Operation assoc with Injury in Review of 13 series: hysterectomy-54%
colorectal-14%
pelvic(ovary,urethropexy*)-8%
abdominal vascular-6%
Urologic nonureteral procedures-21%
Gyn surgery rate of injury %
Abd-perineal colon resection %
*Retropubic approach

5. Ureteral Injury…Open Surgery
Open urological procedures associated with potential ureteral trauma…
Radical prostatectomy
Diverticulectomy
Seminal vesiculectomy
Pelvic Lymphadenctomy
Any open ureteral procedure

6. Ureteral Injury…Open Surgery
AAA & aortoiliac vascular procedures assoc with 12-20% risk of hydronephrosis 2º to manipulation, usually benign course
Injuries assoc with pelvic and colon surgery usually symptomatic and require intervention
Vascular procedure risk factors for Ureteral injury..reoperation, graft anterior to ureter, large AAA
1-2% develop stenosis due manipulation at vascular surgery,AAA or AortoIliac reconstruction
Symptoms include flank pain, fever, ileus, abdominal distention, urinary fistula

7. Ureteral Injury… Laparoscopic Surgery
Symptoms and signs of ureteral injury…fever, leukocytosis, peritonitis, hematuria, urinoma
Hemorrhage control difficulty in the ureterosacral ligament risk of ureteral injury
Gyn procedures… endometriosis, tubal ligation and hysterectomy common scene of injury
Rate of Gyn Laparoscopic ureteral injury ..1%
Fewer have hematuria and urinoma

8. Ureteral Injury... Laparoscopic Surgery
Avoidance of Ureteral Injury
Visualization
Hemorrhage control
Anatomic comprehension
Ureteral Lighted stent
Indigo carmine
Hydration

9. Ureteral Injury …Ureteroscopic Surgery
Injury rate 0-28% historically
Present acceptable rate average of  7%
Preventive measures:
Guide wire
small ureteroscopes  7fr
mucosal laceration- stop and stent
caution in fibrotic and edematous ureter

10. Ureteral Injury … Diagnosis
Hematuria % of stab & GSW.. 0-3rbc/hpf
History, wound or trauma source
Intraoperative recognition- >index of suspicion
IVU, 1 shot IVU-entire ureter must be seen
CT scan, Helical CT-delayed (20-25)min. image
Retrograde Pyelogram 1º or 2º imaging tool
Antegrade Ureterography –seldom used
Hematuria and hx and wound or trauma source are utmost importance in diagnosing ureteral trauma.When external violence is source of trauma,93% recognized promptly, 57% intraoperatively,Intraoperative recognition potentially enhanced by methylene blue
Medial extravasation or nonvisualization of ipsilateral ureter suggest ureteral injury

11. Ureteral Injury… Diagnosis with IVU

12. Ureteral Injury… Management
External Trauma
Contusion-observe…reconstruct
Partial transection- repair
Surgical Trauma
Ligation-viability ?- reconstruct, viable- stent
Transection- reconstruct, if vascular procedure
weigh risk of nephrectomy vs repair
Ureteroscopic Trauma
Laceration- stent
Avulsion- repair
Meticuous surgical technique and effective drainage internal and external are absolute necessity,
Vascular procedures are at higher risk for mortality with ureteral injury with urine leakage after attempted ureteral repair, thus nephrectomy must be weighed against the patients present and potential change in renal function. Delayed nephrectomy or repair are options to consider.

13. IVU-Scout

14. IVU-3 Min

15. IVU-20 Min
Ensnared ureter at pelvic reconstruction

17. Ureteral Injury …Management
Immediate Recognition
Vascular procedures-risk of failure with
repair –8-40%
- mortality of vascular
procedure 3-12% alone
Nonvascular procedures- treat as for external
violence
Ruptured AAA 12% of renal failure induced death which makes it difficult to perform nephrectomy in patient with injured ureter.

18. Ureteral Injury… Management
Delayed Recognition-66-76% of ureteral injuries
Sx’s-fever,leukocytosis, peritoneal signs
Stent placement-20-50% successful placement
with stent; 70% with 6wks stenting ..no other Rx
Attempt to Stent - drainage for 6-12wks
Failure to stent- PCN and drain for 3-6mos before delayed repair

19. Ureteral Injury Management
ureterocalcostomy
Autotransplantation
(Boari flap)

20. Ureteral Injury… Surgical Technique

21. Ureteral Injury…Complications
Dehisence
Prolonged urinary leakage
Fistula
Abscess
Stenosis/stricture
Hydronephrosis…... nephrectomy…renal failure

22. Bladder Injury…Etiology
Rare <2% of abdominal injuries requiring intervention
Result of high energy trauma
Mortality is high 12-22% (assoc. injuries)
Associated with urethral injury 10-29% of pts
Pelvic fracture commonly present

23. Bladder Injury…Etiology
Blunt Injury
pelvic fx %
usually pubic arch
Penetrating Injury
GSW-35% have major abd injury
22% are in shock 2º vascular insult
Iatrogenic Injury- Gyn 1-2%
35% have major abdominal wound, if vascular likely fatal, combat 15-20% baldder wounds

24. Bladder Injury… Diagnosis
History
acute: pelvic fracture, pelvic penetration
delayed: fever, peritoneal signs, BUN ,
scant or anuric
Physical exam
acute: pain,abd tenderness, ecchymosis
delayed: same

25. Bladder Injury… Diagnosis
Hematuria
Gross hematuria in % of blunt trauma
Gross hematuria occurs with severe injury
Microscopic hematuria 5% of blunt injuries*
GSW often manifest microhematuria
Any hematuria with lower abd GSW mandates full evaluation of bladder and ureters
The missed bladder disruptiive injury typically presents with less hematuria, fewer symptoms and signs of injury
* Contusion commonly produces microhematuria

26. Bladder Injury…Diagnosis Imaging
Cystography
Retrograde cystography+drainage film dx
100% of significant bladder injuries
Two step study:1.fill/film, 2.drain/film
13% of bladder ruptures seen on drainage view
Use cc contrast instilled by gravity

27. Bladder Injury…Extraperitoneal Rupture

28. Bladder Injury…Intraperitoneal Rupture

29. Bladder Injury… Computed Tomography
Optimal study retrograde placement of contrast via urethral catheter then CT pelvis
Use 350cc 30% contrast diluted 6:1 with saline(4% contrast)

30. Bladder Injury …CT Scan Extraperitoneal Extravasation

31. Bladder Injury…Management

32. Bladder Injury…Management
Contusion 67%-observe
Extraperitoneal 62% alone,12% combined with Intraperitoneal injury
Extraperitoneal -catheter drainage alone
open repair/suprapubic catheter
Intraperitoneal-25% alone,12% combined; open repair/suprapubic & urethral catheter, +/-abd exploration
Indications for open repair include: persistent bleeding, open orthopedic procedure to reduce and fix pelvic displaced pubic fracture. Open repair reduces risk of fistula, prolonged drainage(failure to heal), sepsis,and stricture without orhthopedic procedure.The orthopedic procedure adds a wound with hardware and large suction drains to the bladder injury and mandates closure of the bladder and/or other injuries with drainage and antibiotic coverage.

33. Bladder Injury…Management
Antibiotics- extraperitoneal: until 3 days after catheter removed
intraperitoneal: for 3 days postop
& post catheter
Catheter drainage-no repair days
repair 7-10 days
Cystography- always before catheter removal
76-87% heal at 10 days, all by 21st

34. Bladder Injury…Repair of Laceration

35. Urethral Injury…Etiology
Posterior Urethral: 1. pelvic fracture
2. shear injury
Common association: pelvic fracture 4-14%
Females- in pelvic fx, 2% incidence of urethral disruption
Bladder rupture association in 10-17% of pts with urethral injury
The disability of the urethral injury may long exceed that of any other injury.Rectal fistula occurrs in 8% of pelvic fracture and urethral disruption injuries.

36. Urethral Injury… Diagnosis
Blood at meatus(50%),urine retention,distended bladder
Blood at meatusretrograde urethrogram (RUG)
Catheter o passRUG
Prostate position- “high riding” prostate occurs in one third of pts
Urethrography-multiple techniques deliver:
1. 30% diatrizoate megluamine
2. 10 cc increments of contrast

37. Urethral Injury… Decision Tree

38. RUG Reveals.. Complete posterior urethral disruption

39. Urethral Injury… Classification
Type I: Urethral stretch injury
TypeII: Urethral disruption proximal to genitourinary diaphragm*
Type III: Urethral disruption both proximal and distal to the genitourinary diaphragm
* Injury may be partial or complete

40. Urethral Injury …Management
Initial.. Primary Realignment ie immediate indirect or endoscopically assisted urethral stenting with no pelvic dissection or sutures
Realign by Stent within 72 hrs, if feasible
Reduces stricture from 96% to 50-65%
Reduces risk of impotence, incontinence, stricture, operative blood loss

41. Urethral Injury… Management
Incomplete urethral tear best Rx by stenting with urethral catheter. 16 Fr silicone Foley for 6 wks
Technique for realignment.. Mutiple
If realignment cannot be achieved, use S/P cystotomy with no traction, no dissection, no sutures.
If urethtral and S/P catheter placed, after 6wks RUG, dc urethral tube, S/P 7-14 days later

42. Urethral Injury… Management
Initial con’t.. S/P cystotomy may be used to stabilize pt with pelvic fx operated by ortho for fx reduction
Catheter should be placed well above operated site
Use subq tunnel to shift catheter away from the plated pubic site

43. Urethral Injury… Management
Delayed Recontruction
Timing..maintain S/P dranage 3-6 months
Preoperative evaluation.. Combined urethro cystogram
Endoscopic Reconstruction..avoid if defect>1cm
Surgical Reconstruction..perineal or pubectomy, abdominal-perineal

44. Urethral Injury… Preop Evaluation

45. Delayed Perineal Urethroplasty

46. Delayed Reconstruction… Staged Urethroplasty
Indications for Staged Procedure
Extensive Stricture withour available penile skin for fasciocutaneous flap
Previous failed anastomotic urethroplasty without available penile skin for f/c flap
Severe perineal infection/inflammation

47. Urethral Injury…Management Complications
Impotence-13-30% of pts with pelvic fx and urethral distraction Rx with 1º realignment
Incontinence-2-4%, open bladder neck before urethroplasty  to 50%
Stricture % after posterior urethral reconstruction*
* 97% stricture free after IOU

48. Urethral Injury… Anterior Urethra
Anterior Urethral injury..rare,5-10% of large series
Etiology.. Straddle, Penetrating(knife, gun)
Diagnosis..Index of Suspicion, RUG
Management:GSW-Realignment, S/P Cystotomy
Straddle-S/P Cystotomy, Delayed
reconsruction
Complications..Impotence(6%),stricture(5-12%)
Use caution in debridement of corpus spongiosum. Delayed recinstruction for straddle injury should be done with stricture excision and urethral realignment.Low velocity- GSW primary repair, High velocity- delayed repair

49. External Genitalia Injury
Penile amputation..37% complete, 87% are psychotic, all hx of psych illness, 17% have suicidal ideationinvolve Psychiatry early
Reimplantation..indications-all with penis available unless patient is transsexual
Reimplantation..6 hrs warm ischemia and 24 hrs cold ischemia tolerated

50. External Genitalia Injury
Reimplantation technique*..
1.wrap penis in sterile gauze in saline in bag & ice bath
2. Urethral closure.. Two layer over catheter
3. Tunica albigunea..4-o absorbable suture
4. Minimal neurovascular dissection
5. Microanastomosis of dorsal artery,vein, nerve
6. Suprapubic cystotomy in most cases
Artery anastomosis use 11-o nylon, dorsal vein use 9-o nylon, dorsal nerve use 10-o nylon
*Outcome is generally good.

51. External Genitalia Injury
Gunshot and Penetrating Wounds
RUG in all, 50% have urethral injury
Explore and repair Low-velocity injuries
High velocity-control blood loss, minimize debridement of corporeal tissue,delay repair
Manage associated injuries, divert to S/P cystotomy when appropriate
Shotgun injury..debride, divert, delay repair
Remove wadding from wound it is nidus for infection.Usually recover erection in 6 weeks

52. Penile Fracture
Occurs during tumesence due force and tunica albuginea thinning 2.4mm to mm
Diagnosis..History force to penis,popping sound, detumesence, delay in presentation
Physical Exam..angulation, ecchymosis, corporeal defect may be present(rolling sign),eggplant sign, butterfly sign

53. Penile Fracture Urethral injury found in 38% of cases
Urethrogram when indicated..blood at meatus, retention, gross hematuria
Imaging..UTZ, MRI, Cavernosography(obtain delayed film)-use small ga. Needle, 30% diatrizoate meglumine
Management.. Immediate repair, use absorbable suture

54. Penile Fracture
Management..nonoperative not recommended due to high complication rate
Outcomes..Impotence occurs though low rate
Curvature 5%, more common with delayed presentation

55. Penile Soft Tissue Injury
Rare.. include human and dog bites
Soft tissue injury from intentional modification
Management..Debridement, RUG if indicated
1º or 2º closure
Antibiotics, dog-cefazolin
human-amp/sulbactam
Massive injury- principles noted above

56. Testes Injury Blunt..50% risk of rupture
Penetrating..civilian, 2% of all GSW
Associated injury..common,83%(thigh,penis, perineum, urethra) with GSW, and bilateral 31%
Vas deferens injury 10% with blunt trauma

57. Testes Injury…Imaging
Sonography useful but should always default to physical exam findings suggesting exploration
Radionuclide scanning not indicated

58. Testes Injury…Management
Hematocele..explore all significant hematocele, intratesticular hematoma, and tunica albiguinea rupture regardless of sonogram
Penetrating wound..explore all
Nonoperative for significant hematocele usually results loss of testis tissue
Surgical principle is debride avascular tissue and reconstruct where possible* .

59. Testes Injury…Outcomes
Generally good
Complication risk..1.wound infection,2. loss of testis tissue,3. loss of spermatogenesis and/or 4. transportation of spermatoza