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1. Genitourinary Trauma for the Rest of Us:How to pass the inservice or boards, survive nights on call and impress your friends Richard Santucci, MD
Chief of Urology, Detroit Receiving Hospital
Specialist-in-Chief, Urology, Detroit Medical Center
2. 2 Overview Renal
Ureter
External genitalia
Bladder
Urethra (not today, tomorrow)
3. 3 Where in the World?
4. 4 Detroit City of the Strait" (Ville d'Etroit)
1 million inhabitants
4.7 million in greater detroit
5. 5 Detroit Medical Center: 10 hospitals Trauma Hospital-Detroit Receiving Hospital
Childrens Hospital-Detroit Childrens Hospital
Veterans Hospital-VAMC Detroit
Womens Hospital-Hutzel Hospital
Rehabilitation Hospital-Rehab Institute of Michigan
Eye Hospital-Kresge Eye
University Hospital-Harper University Hospital
2 other general hospitals (distant)
Orthopedic hospital
6. 6 Detroit Receiving Hospital
7. 7 RENAL TRAUMA
8. 8 Renal Trauma Overview Most commonly injured GU organ
10% of all serious injuries have associated renal injury (closer to 1% actually?)
Variable etiology depending on the area
Rural: 80-95% blunt
Urban: as little as 15% blunt
9. 9 Hematuria and renal injury NOT related to the degree of injury
Gross Hematuria:
1/3rd of patients with renovascular injuries
24% of patients with renal artery occlusion
Only 63% of Grade IV injuries (4% have no hematuria whatsoever!)
10. 10 Physical exam: renal injury
11. 11 Whom to workup Penetrating trauma: EVERYONE
Blunt trauma: computed tomogram (CT) if
gross hematuria
microhematuria plus shock
microhematuria plus acceleration/deceleration
Mee et al. (1989)
Hardeman et al (1987)
12. 12 Imaging of hematuria CT preferred
With contrast
With delayed films (mandatory)
Why not get CT cystogram too?
Standard intravenous pyelogram (IVP): Forget it
One Shot intraoperative IVP
2 cc/kg intravenous contrast
Single film at 10 minutes
13. 13 Intraoperative One Shot IVP Allows safe avoidance of renal exploration in 32% (Morey et al, 1999)
Highly specific for urinary extravasation
Confirms existence of the other kidney
14. 14 Indications for renal trauma surgery Absolute
Grade V renal injury (debatable in blunt trauma): NEPHRECTOMY
Vascular injury in a single kidney: Vascular repair
Relative
Persistent bleeding > 2 units/day
Devitalized segment AND urinary extrav (80% complication rate?)
Renal pelvis injury
Ureter injury
Incomplete staging and ongoing laparotomy
Grade IV vein or artery (thrombosis): nephrectomy
2.5% of blunt renal injuries
Most penetrating renal injuries
15. 15 AAST Organ Injury Severity Scale for the Kidney
16. 16 Operative result by AAST Organ Injury Severity Scale
17. 17 Insignificant renal injuries Segmental artery
thrombosis
(wedge defect)
Urinary extravasation without renal pelvis or ureter injury
Observe
If persists, ureteral stent fixes the problem nearly 100%
18. 18 Watch out for active IV contrast extravasation
19. 19 Postinjury care: Renal trauma Expectant (nonoperative) therapy
Bed rest until gross hematuria resolves
Antibiotics if large hematoma or urine leak, especially if lots of road burn
Consider delayed scan
Check for hypertension for up to one year
Delayed bleed? Salvage angiography. (Operative exploration will result in nephrectomy).
20. 20 Surgical approach to renal injury
21. 21 Isolation of renal vessels
22. 22 To expose or not to expose Vascular control improved renal salvage from 56% to 18%. (n=375)
(McAninch and Carroll, J Trauma, 1982)
Vascular control had no effect (30% nephrectomy rate both groups, n=56).
(Gonzales et al, J Trauma, 1999)
Modern series: 9% nephrectomy rate of Grade IV renal injuries (with vascular control)
23. 23
24. 24 Renorrhaphy techniques
25. 25 Postoperative care: renorrhaphy Always leave a drain
NOT TO SUCTION
When output decreases day 2-3, check creatinine and if NOT urine, remove
Watch for hypertension, delayed bleeds
Frequent hematocrit checks
Warnings to patient about delayed bleed on discharge
26. 26 Complications: Renal injury Usually in first 2 weeks
Delayed bleed (angioembolize)
Abscess (open drainage)
Urinary fistula (divert urine)
Urinoma
Watch if small
Stent if not
Rarely require percutaneous nephrostomy
Did you miss a ureteral injury?
Delayed severe hematuria (AV fistula) (angioembolize)
Up to 1 year
hypertension
27. 27 Hypertension after renal injury Occur up to 15 years after injury
Occur even with normal CT or IVP
Subsequent arteriography unappreciated:
renal artery occlusion
artery stenosis
segmental artery injuries
extraparenchymal compression from scarring (Page kidney)
Exotic complaints it the young:
Headaches
chest pain
Nosebleeds
Severe fatigue
Stroke
Heart attack
28. 28 URETER
29. 29 Ureter injury Rare
4% penetrating trauma
1% blunt trauma (associated with large force injuries such as fractured lumbar process and spine dislocations)
Penetrating
Requires high degree of suspicion
Up to 45% have no hematuria
Examine the trajectory!
Often missed at first
30. 30 Ureter injury: detection techniques Inject 1-2 cc methylene blue with 27g needle into collecting system
Use intraoperative one shot IVP (0-67% sensitive)
CT
Follow the ureter through its entire course
31. 31 Principles of ureter repair Debride back to bleeding edge (especially in high velocity gunshot).
Spatulate
Stent
Watertight closure
Preserve periureteral blood supply
Drain
32. 32 MID: Uretero-ureterostomy
33. 33 Psoas Hitch Boari Flap
34. 34 Transuretero-ureterostomy
35. 35 Often not picked up
36. 36 External genital trauma
37. 37 Testes Trauma Rare in general
But, in significant scrotal blunt trauma, rupture can be as high as 50%
Bilateral 1.5%
Assaults and sports injuries predominate
Local anesthetic block may improve exam
38. 38
39. 39 Testes Trauma: Penetrating 2% of all civilian GSW
Bilaterally, as much as 15X more common than blunt injury
Explore equivocal cases
92-97% require exploration
Salvage in 35-65%
Debride as much as 50% of ruined parenchyma and close capsule
40. 40 Repair Repair Repair Repair
41. 41 Testes Trauma: Penetrating Associated injuries common
Thigh (75%)femoral vessels?
Penis (37%)
Perineum (25%)
Urethra (18%)
Transection of the vas in 10%
42. 42 Imaging hard to interpret
43. 43 Penile Trauma Amputation
Self mutilation most common
87% are acutely psychotic
Reimplant if possible, formalize the amputation if not
Keep amputated penis in wet sterile gauze, in sterile baggy, put baggy on ice
Many do well (18-25% strictures/fistulae)
44. 44
45. 45 Reimplant
46. 46 Not always a happy ending
47. 47 Penile Trauma Gunshot
Rare
Get a urethrogram (50% involvement)
Treat associated injuries (80% of the time, 5% unstable)
Repair primarily, unless massive tissue destruction (as from shotgun)
Reasonably low complications
48. 48
49. 49 BLADDER
50. 50
51. 51
52. 52
53. 53
54. 54
55. 55
56. 56 Bladder: Diagnosis: CT Cystography
57. 57
58. 58
59. 59
60. 60
61. 61 POSTERIOR URETHRA
62. 62 Main Points
63. 63 Main points : Kidney Get a CT in everyone with
Gross hematuria
Microhematuria + deceleration or shock
Treat most kidneys nonoperatively
Indications for operation:
Grade V renal injury
Persistent bleeding
Suspected ureter or collecting system injury
Incomplete staging and ALREADY having lap
Isolate the vessels first
64. 64 Main Points: Bladder Get a CT cystogram if pelvic fracture
Consider treating extraperitoneal bladder ruptures OPEN, especially if undergoing lap and DEFINITELY if undergoing pelvic ORIF
Microhematuria usually means no significant injury to bladder
65. 65 Main Points: Ureter Suspect ureter injuries and youll miss them less
66. 66
67. 67 Bladder Question A 43-year old woman sustains a single gunshot wound to the abdomen. You are consulted at the time of emergency laparotomy for an obvious bullet hole in the dome of the bladder. You should:
a. open the bladder anteriorly and inspect the inside of the bladder
b. perform an intraoperative cystogram
c. debride the bullet hole and close it in two layers
d. perform an intraoperative IVP
e. place a ureteral stent
Answer: a.
68. 68 Bladder Question A 24-year-old man is struck by a car and sustains multiple injuries including a pelvic fracture. He has blood at the meatus and a retrograde urethrogram is normal. A catheter is passed and the bladder is filled with 200 cc of contrast. A full and post-drainage film are normal. The next step should be:
a. evaluation of the upper tracts by CT scan
b. repeat the cystogram
c. leave catheter and irrigate as needed to clear clots
d. flexible cystoscopy to exclude a urethral or bladder injury
e. intravenous urogram with tomograms
Answer: b.
69. 69 Urethra Question A 25-year old pedestrian is struck by an automobile. On arrival in the emergency room, a plain film of the pelvis reveals a left superior and inferior pubic ramus fracture as well as a fracture of the sacroiliac joint. Examination of the patient reveals a suprapubic mass. No blood is noted at the meatus and the prostate is in the normal position on digital examination. The most appropriate initial diagnostic test is:
a. IVP
b. retrograde urethrogram
c. cystogram
d. pelvic CT scan
e. peritoneal lavage
Answer: b
70. 70 Genital Trauma Question A three-year-old boy is seen because his foreskin is caught in his zipper. The best treatment is:
a. circumcision
b. manipulation of the zipper under general anesthesia
c. manipulation of the zipper under local anesthesia
d. divide the median bar of the zipper with a bone cutter
e. excision of the piece of penile skin caught
Answer: d
71. 71 Genital Trauma Question A 22 year old man sustains a severe burn of his genitalia. There is marked bullous edema and eschar formation of the entire penis and much of the scrotum. He has had a Foley catheter in his urethra to monitor urine output. The most appropriate initial management is:
a. radical eschar debridement
b. split thickness skin grafts as soon as possible
c. antibiotic therapy and topical cleansing with water
d. remove the Foley and insert a suprapubic tube
e. observe until the wound begins to granulate
Answer: b