gu trauma from top to bottom
DESCRIPTION
GU TRAUMA FROM TOP TO BOTTOM. James Cummings MD Division 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 - PowerPoint PPT PresentationTRANSCRIPT
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GU TRAUMA FROM TOP TO BOTTOM
James Cummings MDDivision of Urology
University of Missouri
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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
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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)
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So a systematic approach to diagnosis and treatment is very
helpful
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RENAL TRAUMA
• Blunt most common – think deceleration• Penetrating – knife and gun club – entry, exit
and pathway
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TREATMENT
• Observation common• Repair• Nephrectomy
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URETER
• Blunt (rare – most often child at UPJ)• Penetrating (rare)• Iatrogenic
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Incidence of iatrogenic ureteral injury
• Hysterectomy (Benign) 0.5%• Rectal surgery 0.7%• Ureteroscopy 0.4%• Aortic surgery < 1%• Lumbar laminectomy 6 cases
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Diagnosis• Requires high index of suspicion• Often delayed• Radiographs sometimes helpful• In acute setting, direct inspection may be best
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Ureteroureterostomy
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Ureteroureterostomy
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Ureteroureterostomy
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Psoas Hitch
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Boari Flap
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Other Options
• Transureteroureterostomy• Ileal ureter• Autotransplantation• Nephrectomy
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BLADDER
• Blunt – bladder full, force applied to lower abdomen
• Penetrating – knife and gun club• Iatrogenic – pelvic surgery in US, childbirth in
sub-Saharan Africa
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Presentation
• External injuries – gross hematuria• Iatrogenic – total incontinence from fistula
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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)
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Operative technique• Perform repair when tissues are free of
inflammation• Separate bladder and vagina• Close bladder and vagina• Tissue interposition• Vaginal vs. abdominal approach
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Principles• Adequate dissection and visualization• Tension-free closures with fine sutures• Adequate drainage
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Other tissues for interposition
• Peritoneum• Omentum• Gracilus
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Tissue Interposition
• Aids in separating bladder and vagina• Brings in neovascularity
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URETHRA
• External force – primarily pelvic fracture (10% of all pelvic fractures have a urethral injury)
• Iatrogenic
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Presentation
• Blunt injury, pelvic fracture• Unable to void• Blood at meatus• High riding prostate on exam
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Urethrography
• Small catheter in fossa navicularis with 1-2 cc in balloon
• Gentle contrast injection• Oblique views if possible
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Management
• Almost all get initial suprapubic catheter• Early endoscopic realignment• Delayed open repair
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GENITALIA
• Multitude of etiologies• Skin loss• Penile tissue damage• Testis damage
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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
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GU TRAUMA- TOP TO BOTTOM
• High index of suspicion• Systematic approach• Compassion• Things can be put back together• Don’t be afraid