GU TRAUMA FROM TOP TO BOTTOM

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 fossanavicularis 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