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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