Genitourinary Trauma Bahaa S Malaeb, MD

Genitourinary Trauma Bahaa S Malaeb, MD
Assistant Professor, Genitourinary Trauma and Reconstructive Surgery University of Michigan, Ann Arbor Department of Urology

Outline Lower urinary tract External genitalia Injury severity score
Urethral Anterior Posterior Bladder External genitalia Penile Scrotal Injury severity score Upper urinary tract Kidney Ureter

Urologic Trauma Trauma leading cause of death among people aged 1-44 in the US Highest burden: young males 15-24 Isolated urologic injuries are uncommon GU injuries occur in 3-10% of abdominal trauma. Kidney most common GU organ injured, followed by bladder and urethra.

Part 1 Lower Tract

Urethral Injury Incidence
10 percent of pelvic fractures in males Rare in females Anterior urethra (fossa navicularis, pendulous/penile, bulbar) Blunt, penetrating, instrumentation Posterior urethra (membranous and prostatic) Pelvic fracture, penetrating, or iatrogenic.

Urethral Injury - Diagnosis
Classic signs Blood at the meatus High riding prostate Perineal or scrotal ecchymosis Imaging of choice Retrograde urethrogram Catheter should not be placed without RUG in the presence of above signs or suggestive mechanism of injury: penile penetrating trauma – AUA guideline, evidence grade C.

Grading of urethral injury
Grade 1 Contusion, normal RUG Grade 2 Stretch injury, no extravasation of contrast Grade 3 Partial disruption, contrast reaches bladder Grade 4 Complete disruption, urethral defect less than 2 cm Grade 5 Complete disruption, more than 2 cm or complex injury involving bladder neck, prostate, rectum or vagina.

Management Grade 1 and 2 injury Grade 3 with minor extravasation
Place catheter for days. Grade 3 with minor extravasation Attempt at placement of catheter. If resistance met, stop. Special cases: catheter placed without investigation: pericatheter RUG if blood is present

Major Extravasation or Complete Disruption
Anterior urethra Alignment and catheter drainage for 3-6 weeks Penetrating injury Anastomotic urethroplasty Posterior urethra Open primary alignment – discouraged. Endoscopic immediate realignment (within few days if injury) – cath for 3-6 weeks Initial SPT – 3 months prior to repair.

Question #1 3 months after removing realignment catheter following a urethral distraction injury, a 19 yo patient develops a 2 cm posterior obliterative stricture. Which of the following is TRUE about the repair?

Question #1 Orthopedic hardware in the pubic symphysis area is contraindication to open repair Incontinence is likely after posterior urethral reconstructive surgery Buckle mucosal graft urethroplasty is the recommended approach One-stage, open, perineal anastomotic urethroplasty is preferred. One-stage abdominal vesico-urethral anastomosis is the preferred approach

AUA Guideline statements
Establish prompt urinary drainage – Recommendation, Grade C Urethral catheter SPT SPT can be placed in setting of ORIF of pelvic fractures – expert opinion Clinicians may perform endoscopic realignments in stable patients with pelvic fracture associated injuries. Recommendation – Grade C Prolonged attempts should be avoided – clinical principle. (not in ER setting, timing within few days)

Monitor for complications – Recommendation, Grade C Stricture Erectile dysfunction Urinary incontinence Typically due to pelvic fracture rather than intervention. Prompt surgical repair for penetrating anterior urethral injury – expert opinion (only if surgeon has the experience, patient is stable, and no extensive tissue loss)

Bladder injury Occurs typically due to pelvic fractures (5% of all pelvic fractures) or blunt trauma in a setting of distended bladder (seat belt). 97% of patients with bladder injury have pelvic fractures Iatrogenic injuries (61/1000 OB/GYN procedures) Gross hematuria in over 90% Microscopic hematuria 0.6-5%

Imaging Diagnostic test of choice CT cystogram
Conventional cystogram (precontrast, AP, lateral, and post drainage films) Bladder needs to be filled to capacity ( ml by gravity in adults) Passive filling during delayed phase of CT urogram is not sufficient

Extraperitoneal rupture

Intraperitoneal Rupture

Management Extraperitoneal bladder injuries
Conservative management with foley drainage 10-14 days Cystogram prior to cath removal.

Question #2 Which of the following is an absolute indications for open repair of a blunt bladder rupture injury?

Question #2 Extraperitoneal rupture with contrast extravasation into the scrotum Extraperitoneal injury that has not healed after 2 weeks for foley catheter drainage Extraperitoneal rupture in the setting of a pelvic fracture managed by external fixation Intraperitoneal rupture Extraperitoneal rupture with gross hematuria

Extraperitoneal rupture
Contraindications for conservative management Bone fragments or foreign bodies Associated rectal, vaginal, bladder neck or prostatic injury Inadequate foley drainage due to clots internal fixation of pelvic fracture or patient is undergoing ex lap for associated injuries.

General surgical principles
Avoid disrupting pelvic hematoma If patient is undergoing ex-lap for associated abdominal injuries, repair bladder injuries (even extra-peritoneal) through a trans-vesical approach through the abdominal incision. Intra-peritoneal bladder injuries: repair in at least 2 layers

Retrograde cystography (CT or conventional) in patients with pelvic fracture and gross hematuria. Standard – absolute indication. Standard, Grade B Bladder injury is present in 29% of patients with gross hematuria and pelvic fractures Imaging in stable patient with gross hematuria and suggestive mechanism of injury OR pelvic ring fracture and clinical indicator. Recommendation – Grade C.

Perform surgical repair Intraperitoneal – Standard - Grade B Complicated extraperitoneal – recommendation, Grade C Urethral catheter drainage without SPT following repair of bladder injury – Standard, Grade B

Penile trauma Range in severity from contusion to amputation
penile fracture occur after blunt or bending injury to an erect penis. Penile fracture and penetrating penile injuries are managed the same way. Conservative management if Buck’s fascia is intact. Urethral injuries occur in 10 percent of penile fracture. Rule out urethral injury.

Penile Amputation

Penile Amputation Stabilize the patient Microvascular reimplantation
Attach corporal bodies to provide support No need to anastomose cavernosal arteries Microvascular anastomosis of the neurovascular bundle Urethral anastomosis. Debridement of distal shaft skin, close wound with proximal stump skin, can later perform skin grafting.

Question #3 A 31 yo urology resident presents with history of recent penile bending injury during sexual intercourse. In addition to a bruised ego, he suffers from penile swelling and bruising. What is the best way to evaluate suspected penile rupture?

Question #3 Ultrasonography of the penis Cavernosography
Exploration of the penile corpora through a midline scrotal incision Exploration of the penile corpora through a circumcision incision MRI of the penis

AUA Guidelines Suspect penile fracture in the presence of ecchymosis, swelling, cracking/snapping sound during intercourse or manipulation and immediate de-tumescence. Standard - Grade B (History can be vague and patients might not readily provide information) Perform surgical exploration and repair. Standard , Grade B. (ventral midline or circumcising incision – absorbable suture, improve long term outcomes)

AUA Guidelines US may be performed in patients with equivocal signs or symptoms. Expert opinion. (MRI, delayed presentation) Urethral evaluation if blood at meatus – Grade B RUG or cysto

Scrotal trauma Blunt or penetrating etiology
Cutaneous hematoma Hematocele (tunica albuginea and tunica vaginalis) Traumatic hematocele: suspect testicular injury Scrotal US: used primarily to evaluate integrity and blood flow of the testicle. Echogenicity and homogeneity of testicular tissue Integrity of tunica albuginea Scrotal examination +/- US in unconscious patient

Testicular injury Blunt (most common – athletic activity) or penetrating Intratesticular hematoma Imaging can not reliably rule out rupture Surgical exploration prompted. If no rupture noted, need to rule out tumor (follow up US) Surgical exploration warranted if mechanism suggestive and clinical suspicion present regardless of imaging findings.

Testicular Fracture Diagnosis mainly based on clinical suspicion.
80-90 % salvaged when managed within 72 hours. Fertility and endocrine considerations Debride extruding seminiferous tubules and close the tunica albuginea Leave drain Orchiectomy if minimal viable tissues

AUA Guidelines Surgical exploration when testicular injury suspected – CGrade B Surgeons should perform exploration and limited debridement of non viable tissue in patients with genital skin loss, Recommendation - Grade B Delayed grafting

Part 2 Upper Tract

Abbreviated Injury Scale (AIS)
Anatomically based, consensus-derived global severity scoring system Classifies each injury in every organ according to its relative severity on a six point scale: 1 Minor, 2 Moderate, 3 Serious, 4 Severe, 5 Critical, 6 Maximal (untreatable/not compatible with life) Used to calculate the Injury severity score

AIS score for kidney 1989 AAST Grade AIS 90
Grade 1, contusion or hematoma 2 Grade 2, hematoma or laceration Grade 3, laceration 3 Grade 4, laceration 4 Grade 4, vascular/main vessel injury 5 Grade 5, parenchymal or vascular Santucci RA, McAninch JW, Safir M et al. Validation of the American Association for the Surgery of Trauma organ injury severity scale for the kidney. J Trauma Feb;50(2):

Injury Severity Score (ISS)
Calculated using the AIS for the 3 most severely injured systems not organs Head and neck- including cervical spine Face - including the facial skeleton, nose, mouth, eyes and ears Chest - thoracic spine and diaphragm Abdomen or pelvic contents - abdominal organs and lumbar spine Extremities or pelvic girdle - pelvic skeleton External

Sum of the square of the three most severely injured systems For example Head and neck AIS = 4 Abdomen/Pelvis Bladder AIS = 2 Spleen AIS = 3 Kidney AIS = 4 Choose the highest = 4 Chest AIS = 3 ISS = = 41

Max of 75, ( ) or any single AIS with a score of 6 Correlates linearly with mortality, morbidity, organ-specific operative rate, hospital stay and other measures of severity ISS >15 indicates severe injury Baker SP et al, "The Injury Severity Score: a method for describing patients with multiple injuries and evaluating emergency care", J Trauma 14: ;1974

AIS score for kidney 1989 AAST Grade AIS 90
Grade 1, contusion or hematoma 2 Grade 2, hematoma or laceration Grade 3, laceration 3 Grade 4, laceration 4 Grade 4, vascular/main vessel injury 5 Grade 5, parenchymal or vascular Santucci RA, McAninch JW, Safir M et al. Validation of the American Association for the Surgery of Trauma organ injury severity scale for the kidney. J Trauma Feb;50(2):

Characteristics of Kidney Injury
Most commonly injured GU organ in trauma Incidence of renal injury 1.1 to 2.8% Disease of the young Median Age group Years 70-80% occur in patients under 44 years of age More common in males On average, 85% secondary to blunt trauma

Characteristics of Kidney Injury
Most injuries are minor Severe injuries: 27-68 % of penetrating 4-25% of blunt Associated injuries are common: 20-94% of renal trauma cases

Indications for Imaging
Diagnostic imaging in blunt trauma and gross hematuria OR microscopic hematuria and SBP less than 90 mmHG – Standard, Grade B Diagnostic imaging with IV contrast in stable trauma patient with mechanism of injury concerning for renal trauma. Recommendation, Grade C IV enhanced imaging with delayed when there is suspicion of renal injury – clinical principle.

Grading of Kidney Injury
1989 American Association for the Surgery of Trauma (AAST), Organ Injury Scale (OIS) Committee Based on expert opinion, published literature at the time and available imaging modalities then. Purpose was to create an objective organ injury scoring that reflects severity and outcome.

Grading of Kidney Injury, 1989 AAST*
Grade 1 Contusion, microscopic or gross hematuria, normal imaging subcapsular hematoma with no parenchymal injury *Advance one grade for multiple injuries

Grade 1 Grade 2 Non expanding perirenal hematoma confined to renal retroperitoneum Less than 1.0 cm parenchymal depth of renal cortex with no urinary extravasation *Advance one grade for multiple injuries

Grade 1 Grade 2 Grade 3 More than 1.0 cm deep laceration with no collecting system rupture or urinary extravasation *Advance one grade for multiple injuries

Grade 1 Grade 2 Grade 3 Grade 4 Laceration: parenchymal laceration extending through the renal cortex, medula and collecting system with urinary extravasation Vascular injury: main renal artery or vein injury with contained hemorrhage *Advance one grade for multiple injuries

Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Completely shattered kidney Avulsion of renal hilum *Advance one grade for multiple injuries

Shift in trend of management
Many studies have validated the 1989 AAST OIS of the kidney, but since 1989: Shift in trend of management Increased support for conservative management for most grade 4 and some grade 5 injuries. Better imaging to delineate exact injuries and identifications of injuries initially not included. Increased role of selective angioembolization

1998 AAST OIS

Revised Renal Injury Classification System

Management, hemodynamically stable
Grades 1, 2 and 3: observe No need for follow up imaging unless there is a drop in Hg/Hct Common practice: relative bed rest till hematuria clears Grade 4: observe initially. Repeat delayed in hours, stent if persistent extravasation. If Hct/Hg drop” angioembolization.

Management: indications for exploration
Unstable patient due to bleed Expanding pulsatile hematoma Grade 5 Risk if nephrectomy with exploration Grade 4: 10% (87% salvage rate) Grade 5: 74% (4% salvage rate)

AUA Guidelines The surgical team must perform immediate intervention (surgery or angioembolization in selected situations) in hemodynamically unstable patients with no or transient response to resuscitation. (Standard; Grade B) One shot IVP in patients not previously imaged to document presence of functional contralateral kidney (2ml/kg IVP contrast followed by KUB minutes.

AUA Guidelines Clinicians may initially observe patients with renal parenchymal injury and urinary extravasation. Clinical principle

AUA Guidelines Clinicians should perform follow-up CT imaging for renal trauma patients having either (a) deep lacerations (AAST Grade IV-V) or (b) clinical signs of complications (e.g., fever, worsening flank pain, ongoing blood loss, abdominal distention). (Recommendation; Grade C)

AUA Guidelines Clinicians should perform urinary drainage in the presence of complications such as enlarging urinoma, fever, increasing pain, ileus, fistula or infection. (Recommendation; Evidence Strength: Grade C) Drainage should be achieved via ureteral stent and may be augmented by percutaneous urinoma drain, percutaneous nephrostomy or both. (Expert Opinion)

Question #4 Which statement is TRUE regarding management of kidney injury?

Question #4 Clinicians may initially observe patients with renal parenchymal injury and urinary extravasation. Follow up CT imaging in indicated in patients having either deep laceration (AAST IV-V) or clinical signs of complications (fevers, flank pain, abdominal distension…) The surgical team must perform immediate intervention in hemodynamically unstable patient. B and C All of the above

Long term Follow up Diuretic renogram in 6 weeks for injuries G3 or higher to evaluate for kidney function.

Ureteral trauma Iatrogenic injury is the most common
Endoscopic or open procedures Penetrating trauma accounts for most non iatrogenic injuries. Classified into Ureteropelvic junction Abdominal (iliac vessels) Pelvic Other classification: immediate and delayed

Grading of ureteral injury
Grade 1: Hematoma only Grade 2: Injury involving less than 50% of the circumference of the ureter Grade 3: Injury involving more than 50% of the circumference of the ureter Grade 4: Complete transsection with less than 2 cm of devascularization Grade 5: Complete transsection with more than 2 cm of devascularization

Question #5 In managing a suspected ureteral injury, which of the following statements are false?

Question #5 Direct inspection of the ureter should be performed during laparotomy in patients who have not been evaluated preoperatively. Surgeons should perform open ureteral repair when placement of a stent is not possible 3 weeks after ureteral injury sustained during lap hysterectomy. Incomplete ureteral injury during ureteroscopy should be managed with observation without stent placement. Surgeons should perform percutaneous nephrostomy placement and delayed repair when placement of a stent is not possible 3 weeks after ureteral injury sustained during lap hysterectomy. B and C

AUA Guidelines Clinicians should perform IV contrast enhanced abdominal/pelvic CT with delayed imaging (urogram) for stable trauma patients with suspected ureteral injuries. (Recommendation; Grade C) Consider RPG for inadequate evaluation.

AUA Guidelines Clinicians should directly inspect the ureters during laparotomy in patients with suspected ureteral injury who have not had preoperative imaging. (Clinical Principle) Dye test, direct inspection, RPG) Surgeons should repair traumatic ureteral lacerations at the time of laparotomy in stable patients. (Recommendation; Grade C)

AUA Guidelines Surgeons may manage ureteral injuries in unstable patients with temporary urinary drainage followed by delayed definitive management. (Clinical Principle) consider nephrostomy tube drainage for unstable or delayed presentation

AUA Guidelines Surgeons should manage traumatic ureteral contusions at the time of laparotomy with ureteral stenting or resection and primary repair depending on ureteral viability and clinical scenario. (Expert Opinion) Exception: high velocity injury – debridement of tissues and primary repair.

AUA Guidelines Surgeons should attempt ureteral stent placement in patients with incomplete ureteral injuries diagnosed postoperatively or in a delayed setting. (Recommendation; Grade C) Surgeons should perform percutaneous nephrostomy with delayed repair as needed in patients when stent placement is unsuccessful or not possible. (Recommendation; Evidence Strength: Grade C)

AUA Guidelines Surgeons should repair ureteral injuries located proximal to the iliac vessels with primary repair over a ureteral stent, when possible. (Recommendation; Grade C) Surgeons should repair ureteral injuries located distal to the iliac vessels with ureteral reimplantation or primary repair over a ureteral stent, when possible. (Recommendation; Grade C)

Surgical approaches Uretero-ureterostomy Trans UU Ureteroneocystostomy
Pyeloplasty Uretero calycostomy Ileal ureter Autotrasplantation Nephrectomy

Question #6 What is the treatment of choice for ureteral contusion sustained from a high velocity bullet to the mid ureter?

Question #6 Ureteral wrap with healthy periureteral tissue
Transureteroureterostomy Ureteral stent placement Observation Ureteroureterostomy

Thank you

Genitourinary Trauma Bahaa S Malaeb, MD

Similar presentations

Presentation on theme: "Genitourinary Trauma Bahaa S Malaeb, MD"— Presentation transcript:

Similar presentations

About project

Feedback

Log in

Auth with social network:

Genitourinary Trauma Bahaa S Malaeb, MD

Similar presentations

Presentation on theme: "Genitourinary Trauma Bahaa S Malaeb, MD"— Presentation transcript:

Similar presentations

About project

Feedback