gu trauma from top to bottom

GU TRAUMA FROM TOP TO BOTTOM

James Cummings MDDivision of Urology

University of Missouri

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

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)

So a systematic approach to diagnosis and treatment is very

helpful

RENAL TRAUMA

• Blunt most common – think deceleration• Penetrating – knife and gun club – entry, exit

and pathway

TREATMENT

• Observation common• Repair• Nephrectomy

URETER

• Blunt (rare – most often child at UPJ)• Penetrating (rare)• Iatrogenic

Incidence of iatrogenic ureteral injury

• Hysterectomy (Benign) 0.5%• Rectal surgery 0.7%• Ureteroscopy 0.4%• Aortic surgery < 1%• Lumbar laminectomy 6 cases

Diagnosis• Requires high index of suspicion• Often delayed• Radiographs sometimes helpful• In acute setting, direct inspection may be best

Ureteroureterostomy

Ureteroureterostomy

Ureteroureterostomy

Psoas Hitch

Boari Flap

Other Options

• Transureteroureterostomy• Ileal ureter• Autotransplantation• Nephrectomy

BLADDER

• Blunt – bladder full, force applied to lower abdomen

• Penetrating – knife and gun club• Iatrogenic – pelvic surgery in US, childbirth in

sub-Saharan Africa

Presentation

• External injuries – gross hematuria• Iatrogenic – total incontinence from fistula

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)

Operative technique• Perform repair when tissues are free of

inflammation• Separate bladder and vagina• Close bladder and vagina• Tissue interposition• Vaginal vs. abdominal approach

Principles• Adequate dissection and visualization• Tension-free closures with fine sutures• Adequate drainage

Other tissues for interposition

• Peritoneum• Omentum• Gracilus

Tissue Interposition

• Aids in separating bladder and vagina• Brings in neovascularity

URETHRA

• External force – primarily pelvic fracture (10% of all pelvic fractures have a urethral injury)

• Iatrogenic

Presentation

• Blunt injury, pelvic fracture• Unable to void• Blood at meatus• High riding prostate on exam

Urethrography

• Small catheter in fossa navicularis with 1-2 cc in balloon

• Gentle contrast injection• Oblique views if possible

Management

• Almost all get initial suprapubic catheter• Early endoscopic realignment• Delayed open repair

GENITALIA

• Multitude of etiologies• Skin loss• Penile tissue damage• Testis damage

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

GU TRAUMA- TOP TO BOTTOM

• High index of suspicion• Systematic approach• Compassion• Things can be put back together• Don’t be afraid