Topic Review Genitourinary Trauma Renal injury l GU

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Topic Review : Genitourinary Trauma

Topic Review : Genitourinary Trauma

Renal injury l GU tract - 10% of polytrauma patients l Renal injury –

Renal injury l GU tract - 10% of polytrauma patients l Renal injury – most common l blunt / penetrating trauma l Hematuria – best indicator but not always seen l Microscopic hematuria c shock – significant renal injury

Classification

Classification

Staging l Imaging modality contrast-enhanced CT spiral CT – rapid but disadvantaged US –

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

Flowsheet

Flowsheet

Management l Nonoperative -98%, even penetrating trauma; 55% of stab wound, 24% of gunshot

Management l Nonoperative -98%, even penetrating trauma; 55% of stab wound, 24% of gunshot wound Mc. Aninch et al, J Urol, 1991 -Hospitalization & Bed rest -Close F/U

Maagement l Operative: nephrectomy, renal exploration - Absolute indication persistent renal bleeding, expanding perirenal

Maagement l 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

Management l Operative Relative indication - Extravasation alone c GIV injuy: 87% conservatively -

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

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

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

Management l Renal reconstruction

Management l Renal reconstruction

Management Main renal artery trombosis Reovascular injury • < 8 hr • Replacemet graft

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

Ureteral injury l Etiology -External trauma: rare -Open Surgical Injury: hysterectomy (54%), colorectal surgery

Ureteral injury l Etiology -External trauma: rare -Open Surgical Injury: hysterectomy (54%), colorectal surgery (14%), pelvic surgery (8%), abdominal vascular surgery (6%) St. lezin, urology, 1991 vascular surgery: benign course hysterectomy&colorectal surgery: complicatable -Laparoscopic injury: mainly OBGY op -Ureteroscopic injury

Ureteral injury l Diagnosis - Hematuria - Intraop recognition - Excretory urogaphy - CT

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

Ureteral injury l Management -External trauma 1. contusion: minor -> ureteral stentin major &

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

Ureteral injury 3. Mid ureteral injury Ureteroureterostomy(Transureterosto my) 4. Lower ureteral injury ureteroneocystostomy, psoas

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

Ureteral injury

Ureteral injury

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

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

Ureteral injury Psoas hitch Boari flap

Ureteral injury Psoas hitch Boari flap

Ureteral injury - Sugical injury 1. Ligation: removal of ligation & ureteral stent or

Ureteral injury - Sugical injury 1. Ligation: removal of ligation & ureteral stent or ureterostomy(viability ) 2. Transection #Immediate recognition mainly same as external trauma in aortic surgery: controversial nephrectomy vs ureteoureterostomy

Ureteral injury # delayed recognition (post-op: 3 -30 d) Sign&Sx: fever, leukocytosis, generalized peritoneal

Ureteral injury # delayed recognition (post-op: 3 -30 d) Sign&Sx: fever, leukocytosis, generalized peritoneal signs Repair: controversial ureteral stenting -only 20 -50%, Max 73% ultimate success, at least 6 wks laparoscopic injury: less successful Open repair- immidiate vs delayed (several month) retrograde ureteral stenting fail-> nephrostomy and anterograde stenting Mc. Aninh et al

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

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

Bladder injury < 2% of abdominal injuries requiring op c urethral rupture (10 -29%)

Bladder 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 l Etiology -Blunt injury -Penetrating injury

Bladder injury l Diagnosis -Cystography extrapeitoneal intraperitoneal

Bladder injury l Diagnosis -Cystography extrapeitoneal intraperitoneal

Bladder injury - CT cystography

Bladder injury - CT cystography

Bladder injury l Management - Contusion: no specific therapy - Extraperitoneal injury. mainly catheter

Bladder injury l Management - Contusion: no specific therapy - Extraperitoneal injury. mainly catheter drainage only. bone fragment, open pelvic fx. , rectal perforation, catheter obstruction by clot -> open repair Cass et al, Urology, 1989 Kotkin et al, J Trauma, 199. laparotomy, orthopedic open reduction -> open repair

Bladder injury -Intraperitoneal injury 25% of all bladder injury, 12% combined with extraperitoneal injury

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

Bladder injury l Post injury management Antibiotics F/U cystography extraperitoneal rupture c conservative management:

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

Urethral injury 1. Posterior urethra Pelvic Fx. : 4 -14% / shear injury B:

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

Urethral injury l Diagnosis blood at urethral meatus, inability of voiding, palpably full bladder,

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

Urethral injury partial rupture complete rupture

Urethral injury partial rupture complete rupture

Urethral injury l Initial management -Primary realignment: partial/complete original: open -> indirect/endoscopic stenting Elliot,

Urethral injury l Initial management -Primary realignment: partial/complete original: open -> indirect/endoscopic stenting Elliot, J Urol, 1997 + suprapubic cystostomy for 3 -6 wks -Suprapubic cystostomy: if fails

Urethral injury l Delayed reconstruction 3 M: scar tissue -> stable, mature Imaging study:

Urethral injury l Delayed reconstruction 3 M: scar tissue -> stable, mature Imaging study: cystogram+RGU -Endoscopic reconstruction CIx: defect < 1 cm or significant dislocation -Surgical reconstruction perineal approach / pubotomy / staged: extensive stricture, previous failed urethroplasty(no available penile skin), infected

Urethral injury

Urethral injury

Urethral injury Complications - Impotence: 13 -30% - Incontinence: 2 -4% Corriere et al,

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 l after posterior reconstruction, 12 -15% -> first, endoscopic management

Urethral injury 2. Anterior urethra Straddle/penetrating injury -Initial management Catheter realignment/suprapubic cystostomy -Delayed reconstruction:

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

External genitalia injury 1. Penis -Amputation: replantation before 24 hr Revascularization of doral a.

External genitalia injury 1. Penis -Amputation: replantation before 24 hr 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

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

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

External genitalia injury 2. Testis -Imaging study US: must be adjunct to Pex Intratunical

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

External genitalia injury Ruptered tunica albuginea

External genitalia injury Ruptered tunica albuginea

External genitalia injury - Management. Surgical repair / exploration orchiectomy rate: delayed op 21%

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