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TITLE:

UROGENITAL  INJURIES, 51 pages (slides)

SLIDE TOPICS, SUBTOPICS and CONTENTS:

UROGENITAL  INJURIES
Trauma Refresher Course for Surgeons
Urogenital Injuries
Very brief overview of front-line management
Diagnosis and treatment
Structures:
    Kidneys
    Ureter
    Bladder
    Urethra/Penis
  Testicles
Renal: Initial Survey
Suspicion of a renal injury

1.  Mechanism of injury
Penetrating injury not necessarily a/w hematuria
High index of suspicion is required
Acceleration/Deceleration injury
 Renal: Initial Survey (cont)
2.  PE
Multiple rib fractures, transverse process fracture
Crushing injuries to chest and abdomen

3.  Hematuria  30-50/HPF
If microhematuria only, no radiologic w/u indicated
If a/w shock, radiologic w/u indicated
If gross hematuria only, radiologic w/u indicated
Renal: Radiographic Imaging
CT Scan with contrast is the gold standard.
Delayed images (if injury is confirmed)

Intravenous pyelogram (2 cc/kg)
    If CT unavailable   
    One shot in OR (@ 20 minutes), during exploration
Emergent exploration in unstable patient (i.e. vascular injury)
Other urgent condition (i.e. bowel injury)
Verifies normal contralateral kidney
If abnormal, exploration usually indicated
Renal -  Judging Severity
Graded I - V
I – III:      contusion to <1cm laceration
IV:      into the collecting system
V:     shattered kidney, vascular, or pedicle injury
Key issues
1. Is the contralateral kidney normal?
2.  Is the patient stable?  If not, due to renal injury?
3.  Is there a major segment of devascularised kidney?
4.  Is there extravasation of urine?
 Renal Injuries - Non-operative Management
Stable patient
No extravasation of urine
Stent placement if present:  no longer indication for surgery
Explore if not able to get stent in correct position
No major segment of devascularised tissue
Serial HCTs
Bedrest for several days, depending on extent
Followup CT scans
Surgery usually needed in penetrating trauma
Interventions - Angiography
Arteriography
           +/- stent placement
Raised flap
Short duration of injury (<4hrs)
Persistent hemorrhage in patient not amenable to surgical intervention or urologist/trauma surgeon not available
Indications for Exploration - Absolute
Expanding hematoma
Pulsatile hematoma
Bilateral main renal arterial injury (or solitary kidney)
Hemodynamic instability due to renal hemorrhage
Grade 5 renal injury
UPJ disruption (no visualization of ureter)

McAninch,J AUA Update 1991 VolX, 35
Indications for Exploration - Relative
Devitalized fragments (>20%)
Significant transfusion requirements
Persistent/increasing urinary leak after JJ stent
Signs of sepsis
Uncontrollable pain

McAninch,J AUA Update 1991 VolX, 35
Emergency Exploration
Vertical midline incision
Inspect, control bleeding
Posterior parietal peritoneum incised medial & parallel  to inferior mesenteric vein
Left renal vein mobilized
Control renal artery
Explore hematoma
Emergency Exploration
Intra-operative Renal Ischemia
Warm ischemia up to 30 minutes.
Ischemia damages proximal tubular cells.
Functional impairment is least when renal artery alone is occluded.
Intermittent re-perfusion is more damaging.
Cold Ischemia
Surface cooling 20 degrees C
10 -15 minutes
allows 3 hours of ischemia
Renal Repair - Partial Nephrectomy
Can be attempted if :
No vascular pedicle injury
Stable patient

Proximal vascular control prior to entering hematoma

Same techniques as spleen/liver repair

Renal Repair (cont)
Retroperitoneal drain essential
Leave in for 5 days

Unstable Patient with 2 kidneys
Low threshold for Nephrectomy

Urinary fistula
Usually temporary
Resolves spontaneously
Ureteral stent
Ureteral Injury
High index of suspicion
Especially in penetrating

Flank pain  not always present

Hematuria  not always present

CT/IVP
Extravasation (often not present)
Secondary signs of obstruction (hydro/stranding)
Ureteral Injury (cont)
Exploration if suspect injury during laparotomy
Indigo Carmine (1 amp) may be helpful
Retrograde pyelogram may be needed
Stent may be all that’s needed
Depends upon mechanism of injury

Percutaneous nephrostomy
Temporizing measure
Unstable
No urologist available
Ureteral Repair - Types
Depends upon location

Primary repair
Reimplant
Transureteroureterostomy
Psoas Hitch
Boari Flap
Renal mobilization/pelvis flap
Ileal ureter
Endoscopy
Autotransplant/Nephrectomy
Surgical Principles
Primary Ureteral Repair
Extravesical Reimplant
Intravesical reimplant
Psoas Hitch
Ureteral Repair - Types
 
Bladder Injuries
 
Bladder Injuries - Cystogram Technique
Fill to 300 cc or more
Get 3 Films
Scout KUB/Fill/Drainage
Almost 100% diagnostic if performed correctly

IVP and CT with IV CONTRAST are not accurate
Trauma CT cystogram with dilute contrast via urethral catheter is accurate
Bladder Injuries -  Surgical Repair
Extraperitoneal
Bladder drainage
Non-surgical treatment
Consider intravesical repair if exploring for other reasons

Intraperitoneal
Surgical repair
Bladder Injuries - Surgical Repair
Avoid hematoma
Low midline incision
Anterior, vertical cystotomy
Debridement
2 layer, watertight closure
Drain through urethra
?? SP tube
If repair is technically difficult
If patient is evacuating away from your care
More necessary in males
Bladder Injuries – Post-operative Care
Catheter drainage 7- 14 days

Cystogram prior to removal of urethral catheter

Antibiotics at time of removal
Urethral Injury
Present in 5% of pelvic fracture.
90% associated with pelvic fracture.
10 - 30% associated with bladder rupture

Diagnosis
Blood at  penile meatus
Prostate exam abnormal (high-riding)
Perineal hematoma
Retrograde urethrogram prior to attempted catheter placement




Urethra Injury – Urethrogram Technique
Oblique position

Small foley at meatus

35 cc slow injection

Contrast must reach bladder in order to call the study normal

Urethra -  Anatomic Divisions
Anterior
Anterior to the urogenital diaphragm
Penile urethra
Bulbar urethra
Most anterior urethral injuries are penetrating trauma or straddle.

Posterior
Posterior to the urogenital diaphragm
Prostatic urethra
Most posterior injuries are due to pelvic fractures.



Penile Injuries
Minimal debridement
Repair corpora if fractured
Be aware dorsal vessels and nerves
 

Penile Fracture
Penile Fracture
Penile Injuries - Amputation
Microsurgical repair, if have amputated portion

If not,
Cut corpora 1 cm shorter than urethra
Sew corpora closed vertically
Spatulate urethra, close to skin
Close skin over corpora

Testicular Trauma
Diagnosed primarily by mechanism  and PE
Palpable hematocele
Ultrasound may be  helpful.
May see tunical defect
Hematocele

Explore and close tunica when possible.
Testis salvage does not put sperm production at risk