1. GU TRAUMA FROM TOP TO BOTTOM
James Cummings MD
Division of Urology
University of Missouri

2. HOW BIG A PROBLEM?
3-10% of multiple injured patients have GU component
10-15% of all abdominal trauma patients have GU involvement
27.7 million total ER visits in US per year for trauma so a lot of GU trauma is out there

3. SO WHY THE FEAR?
Hard to diagnose sometimes (kidneys and ureters in retroperitoneum)
It’s “down there” (bladder and urethra)
It’s not only “down there” but “gross” also (genitalia)

4. So a systematic approach to diagnosis and treatment is very helpful

5. RENAL TRAUMA Blunt most common – think deceleration
Penetrating – knife and gun club – entry, exit and pathway

7. TREATMENT
Observation common
Repair
Nephrectomy

8. URETER Blunt (rare – most often child at UPJ) Penetrating (rare)
Iatrogenic

9. Incidence of iatrogenic ureteral injury
Hysterectomy (Benign) 0.5%
Rectal surgery 0.7%
Ureteroscopy 0.4%
Aortic surgery < 1%
Lumbar laminectomy 6 cases

10. Diagnosis Requires high index of suspicion Often delayed
Radiographs sometimes helpful
In acute setting, direct inspection may be best

11. Ureteroureterostomy

12. Ureteroureterostomy

13. Ureteroureterostomy

14. Psoas Hitch

15. Boari Flap

16. Other Options Transureteroureterostomy Ileal ureter
Autotransplantation
Nephrectomy

17. BLADDER Blunt – bladder full, force applied to lower abdomen
Penetrating – knife and gun club
Iatrogenic – pelvic surgery in US, childbirth in sub-Saharan Africa

18. Presentation External injuries – gross hematuria
Iatrogenic – total incontinence from fistula

19. Treatment
If diagnosed at time of injury (either external or iatrogenic) can repair immediately
Absorbable sutures
Good drainage (urethral catheter vs suprapubic catheter vs both)

20. Operative technique
Perform repair when tissues are free of inflammation
Separate bladder and vagina
Close bladder and vagina
Tissue interposition
Vaginal vs. abdominal approach

21. Principles Adequate dissection and visualization
Tension-free closures with fine sutures
Adequate drainage

22. Other tissues for interposition
Peritoneum
Omentum
Gracilus

23. Tissue Interposition Aids in separating bladder and vagina
Brings in neovascularity

24. URETHRA
External force – primarily pelvic fracture (10% of all pelvic fractures have a urethral injury)
Iatrogenic

25. Presentation Blunt injury, pelvic fracture Unable to void
Blood at meatus
High riding prostate on exam

26. Urethrography
Small catheter in fossa navicularis with 1-2 cc in balloon
Gentle contrast injection
Oblique views if possible

27. Management Almost all get initial suprapubic catheter
Early endoscopic realignment
Delayed open repair

28. GENITALIA Multitude of etiologies Skin loss Penile tissue damage
Testis damage

29. Management Careful exam (sometimes best to do under anesthesia)
Identify what you have (genital skin and structures often do better in the long run even if they look awful)
Check the urethra
Try to put things back together

30. GU TRAUMA- TOP TO BOTTOM
High index of suspicion
Systematic approach
Compassion
Things can be put back together
Don’t be afraid