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Lower Urinary Tract Trauma

Lower Urinary Tract Trauma. • bladder • posterior urethra. Bladder Trauma Blunt. • pelvic fracture • gross hematuria • abdominal pain • shock. Bladder and/or Urethral Injuries are Noted in 15% of Pelvic Fractures. Classification of Bladder Trauma. Minor • contusions Major

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Lower Urinary Tract Trauma

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  1. Lower Urinary Tract Trauma • bladder • posterior urethra

  2. Bladder Trauma Blunt • pelvic fracture • gross hematuria • abdominal pain • shock

  3. Bladder and/or Urethral Injuries are Noted in 15% of Pelvic Fractures

  4. Classification of Bladder Trauma Minor • contusions Major • extraperitoneal ruptures • intraperitoneal ruptures

  5. Bladder Trauma Cystography • 350 ml • full film • drainage film

  6. Bladder Rupture Extraperitoneal - 65% Intraperitoneal - 25% Combined - 10%

  7. Bladder Rupture Management • extraperitoneal cath drainage surgical repair • intraperitoneal surgical repair

  8. Posterior Urethral Rupture Distraction Injuries

  9. Pelvic Fracture • posterior urethral disruption - 5% • anterior ring disruption higher in bilateral • bleeding

  10. Urethral Trauma Signs • pelvic fracture - 98% • blood at meatus - 37-93% • scrotal hematoma • perineal hematoma • unable to void • unable to pass catheter • high riding prostate

  11. Diagnosis • retrograde urethrogram • unable to pass catheter retrograde urethrogram

  12. Posterior Urethral Rupture Options • primary realignment • delayed reconstruction perineal approach

  13. Posterior Urethral Injury Primary Realignment • limited associated injuries • optimum endoscopic equipment and fluoroscopy • hemodynamic stability

  14. Injury Delayed Reconstruction • suprapubic cystostomy repair bladder • reconstruction of urethral rupture defect 3 months OR after assoc. injuries heal

  15. Posterior Urethral Injuries Reconstruction Pre-op Studies • urethrogram • cystogram • penile duplex ultrasound • MRI

  16. Posterior Urethral Rupture Distraction Injuries Delayed Endoscopic Management • poor control • repeat procedures required • dilations necessary • fibrosis persists

  17. Posterior Urethral Rupture • do not use Urolume stents • fail • fibrosis - obstruction • calculi - obstruction

  18. Technical Points • high lithotomy • midline perineal incision • excise fibrosis - 28 F • spatulate • epithelium-epithelium anastomosis tension free split corpora partial pubectomy from below 5-0 (maxon, PDS, monocryl) • 16 F urethral catheter - 1 month

  19. Long Rupture Defects Methods of Gaining Length • mobilize bulbar urethra to penoscrotal junction • split corporal bodies • inferior pubectomy - perineal • total pubectomy • urethral rerouting

  20. Posterior Urethral Rupture Success • normal voiding • no dilations • no self dilations

  21. Posterior Urethral Rupture Summary (158 pts >1 yr follow-up) • Reconstruction Success 96% • Erectile Dysfunction 39% • Incontinence 12% • Total Incontinence 2% • Stress Incontinence 6% • Urge Incontinence 4%

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