Trauma of Urinary Tract Trauma of Urinary Tract. Introduction Injury to the kidney is seen in approximately 8%–10% of patients with blunt or penetrating

TraumaTrauma of of Urinary Tract Urinary Tract

IntroductionIntroduction

Injury to the kidney is seen in Injury to the kidney is seen in approximately 8%–10% of approximately 8%–10% of patients with blunt or penetrating patients with blunt or penetrating abdominal injuries.abdominal injuries.

The vast majority (80%–90%) of The vast majority (80%–90%) of cases involve blunt rather than cases involve blunt rather than penetrating injury.penetrating injury.

RENAL TRAUMARENAL TRAUMA

IntroductionIntroduction

Serious renal injuries are frequently Serious renal injuries are frequently associated with injuries to other associated with injuries to other organs; multiorgan involvement organs; multiorgan involvement occurs in 80% of patients with occurs in 80% of patients with penetrating trauma and in 75% of penetrating trauma and in 75% of those with blunt trauma those with blunt trauma

The vast majority (98%) of isolated The vast majority (98%) of isolated renal injuries are classified as renal injuries are classified as minor injuriesminor injuries

Indications for Imaging Indications for Imaging Evaluation Evaluation Children with blunt trauma and Children with blunt trauma and

hematuria.hematuria. blunt trauma if associated with gross blunt trauma if associated with gross

hematuria hematuria microscopic hematuria and hypotensionmicroscopic hematuria and hypotension penetrating injury and hematuria .penetrating injury and hematuria . blunt trauma in patients with other blunt trauma in patients with other

injuries known to be associated with injuries known to be associated with renal injury.renal injury.

Imaging ModalitiesImaging Modalities

Computed Tomography.Computed Tomography. Intravenous Urography.Intravenous Urography. Angiography .Angiography . Retrograde Pyelography .Retrograde Pyelography . Ultrasonography .Ultrasonography . Radionuclide Renal Scintigraphy.Radionuclide Renal Scintigraphy. MR Imaging.MR Imaging.

CT SCANCT SCAN provide precise delineation of a provide precise delineation of a

renal laceration.renal laceration. determine the presence and determine the presence and

location of a renal hematoma.location of a renal hematoma. presence of active arterial presence of active arterial

extravasation.extravasation. presence of urinary presence of urinary

extravasation.extravasation. presence of devascularized presence of devascularized

segments of renal parenchyma.segments of renal parenchyma. differentiate trivial injuries from differentiate trivial injuries from

those requiring intervention.those requiring intervention.

Late cortical or early Late cortical or early nephrographic phase nephrographic phase ..

Excretory-phase :Excretory-phase :

Intravenous UrographyIntravenous Urography : :

no longer the primary modalityno longer the primary modality primary role: assessment of gross primary role: assessment of gross

functionfunction evaluation of the uninjured kidney evaluation of the uninjured kidney

in hemodynamically unstable in hemodynamically unstable patientspatients

unstable to undergo CTunstable to undergo CT already in the operating roomalready in the operating room

AngiographyAngiography

most vascular injuries can be assessed most vascular injuries can be assessed with CTwith CT

can provide more detailed information can provide more detailed information regarding the exact anatomic area of regarding the exact anatomic area of vascular injuryvascular injury

embolization may be used for nonsurgical embolization may be used for nonsurgical therapy in hemodynamically stable therapy in hemodynamically stable patientspatients

evaluation of suspected vascular evaluation of suspected vascular complications of injury complications of injury

Retrograde Pyelography Retrograde Pyelography

assessment of ureteral and renal assessment of ureteral and renal pelvic integrity when pelvic integrity when ureteropelvic junction injury is ureteropelvic junction injury is suspectedsuspected

not helpful in evaluating renal not helpful in evaluating renal parenchymal injuriesparenchymal injuries

UltrasonographyUltrasonography

detecting hemoperitoneum in detecting hemoperitoneum in patients with suspected patients with suspected intraperitoneal injuries following blunt intraperitoneal injuries following blunt traumatrauma

limited compared with CT in the limited compared with CT in the evaluation of the renal parenchyma evaluation of the renal parenchyma

comparing US with CT in this setting, comparing US with CT in this setting, several renal injuries were missed at several renal injuries were missed at trauma UStrauma US

Radionuclide Renal Radionuclide Renal Scintigraphy Scintigraphy

helpful in documenting the helpful in documenting the presence of a functioning kidneypresence of a functioning kidney

in patients with a contraindication in patients with a contraindication for iodinated contrast materialfor iodinated contrast material

in following up repair of in following up repair of renovascular traumarenovascular trauma

MR ImagingMR Imaging

to assess suspected renal injuryto assess suspected renal injury when there is a contraindication for when there is a contraindication for

iodinated contrast materialiodinated contrast material when CT is not availablewhen CT is not available Like contrast-enhanced CT, MR Like contrast-enhanced CT, MR

imaging with use of intravenous imaging with use of intravenous gadolinium-based contrast material gadolinium-based contrast material has proved helpful in the has proved helpful in the assessment of urinary extravasationassessment of urinary extravasation

Radiologic Classification Radiologic Classification of Renal Injuriesof Renal Injuries

Category ICategory I





Category ICategory I Category I renal injuries constitute 75%–Category I renal injuries constitute 75%–

85% of all renal injuries in most series and 85% of all renal injuries in most series and are generally managed conservatively.are generally managed conservatively.

The vast majority of minor injuries The vast majority of minor injuries represent small intrarenal hematomas represent small intrarenal hematomas (renal contusions).(renal contusions).

Subsegmental infarcts are increasingly Subsegmental infarcts are increasingly recognized at CT and usually they end recognized at CT and usually they end result in scar formationresult in scar formation..

Category IICategory II



Category IICategory II Comprise approximately 10% of renal injuriesComprise approximately 10% of renal injuries Urine leakage usually occurs into the lateral Urine leakage usually occurs into the lateral

perinephric spaceperinephric space Surgical exploration depending on Surgical exploration depending on

hemodynamic status and the evolution of the hemodynamic status and the evolution of the injuryinjury

Follow-up CT may be necessary to assess Follow-up CT may be necessary to assess interval change in the appearance of the interval change in the appearance of the injuryinjury

Category IIICategory III









account for approximately 5% of casesaccount for approximately 5% of cases generally require surgical exploration, generally require surgical exploration,

often nephrectomyoften nephrectomy Intraarterial embolization may be used Intraarterial embolization may be used

to salvage the kidneyto salvage the kidney The absence of a perinephric The absence of a perinephric

hematoma is characteristic of a renal hematoma is characteristic of a renal arterial occlusionarterial occlusion

Category IIICategory III A review of the literature showed that A review of the literature showed that

only five (14%) of 35 patients with only five (14%) of 35 patients with unilateral posttraumatic occlusion of the unilateral posttraumatic occlusion of the renal artery who underwent renal artery who underwent revascularization had return of normal revascularization had return of normal renal function; in all five patients, the renal function; in all five patients, the duration of the ischemia was less than 12 duration of the ischemia was less than 12 hours hours

revascularization may be attempted in revascularization may be attempted in patients with only one kidney or with patients with only one kidney or with bilateral renal arterial thrombosisbilateral renal arterial thrombosis

Category IVCategory IV

Category IVCategory IV Rare consequence of blunt trauma and are Rare consequence of blunt trauma and are

caused by sudden deceleration.caused by sudden deceleration. The diagnosis may be delayed because The diagnosis may be delayed because

hematuria is absent in one-third of patients.hematuria is absent in one-third of patients. Medial perinephric urinary extravasation.Medial perinephric urinary extravasation. A circumferential (circumrenal) urinoma may A circumferential (circumrenal) urinoma may

be seen around the affected kidney, but be seen around the affected kidney, but typically there is no perinephric hematoma.typically there is no perinephric hematoma.

Two groups: avulsion (complete transection) Two groups: avulsion (complete transection) and laceration (incomplete tear).and laceration (incomplete tear).




Penetrating InjuriesPenetrating Injuries

Penetrating InjuriesPenetrating Injuries

CT is not usually performed in CT is not usually performed in patients with an anterior stab patients with an anterior stab wound because these patients wound because these patients generally require exploratory generally require exploratory laparotomy due to the high laparotomy due to the high prevalence of bowel injury prevalence of bowel injury associated with this form of associated with this form of trauma. trauma.

Traumatic Injuries to Traumatic Injuries to Kidneys with Preexisting Kidneys with Preexisting AbnormalitiesAbnormalities disruption of the renal pelvis or disruption of the renal pelvis or

ureteropelvic junction in patients with ureteropelvic junction in patients with hydronephrosis or an extrarenal hydronephrosis or an extrarenal pelvis pelvis

intracystic hemorrhage or rupture of intracystic hemorrhage or rupture of a renal cyst with or without a renal cyst with or without communication with the collecting communication with the collecting systemsystem

rupture of a tumor.rupture of a tumor.

Traumatic Injuries to Traumatic Injuries to Kidneys with Preexisting Kidneys with Preexisting AbnormalitiesAbnormalities laceration of poorly protected laceration of poorly protected

ectopic or horseshoe kidneysectopic or horseshoe kidneys laceration of fragile, infected laceration of fragile, infected

kidneyskidneys CT provides more specific and CT provides more specific and

clinically useful information than clinically useful information than excretory urography in this excretory urography in this contextcontext

Traumatic Injuries to Traumatic Injuries to Kidneys with Preexisting Kidneys with Preexisting AbnormalitiesAbnormalities

Traumatic Injuries to Traumatic Injuries to Kidneys with Preexisting Kidneys with Preexisting AbnormalitiesAbnormalities

Urologic Complications in Urologic Complications in Renal InjuryRenal Injury

EarlyEarly: : include urinary extravasation include urinary extravasation and urinoma formation, delayed and urinoma formation, delayed bleeding, infected urinoma, bleeding, infected urinoma, perinephric abscess, sepsis, perinephric abscess, sepsis, arteriovenous fistula, pseudoaneurysm arteriovenous fistula, pseudoaneurysm and hypertensionand hypertension

LateLate:: include hydronephrosis, include hydronephrosis, hypertension, calculus formation, and hypertension, calculus formation, and chronic pyelonephritischronic pyelonephritis


delayed urologic complications occur delayed urologic complications occur more frequently in patients with a more frequently in patients with a devascularized fragment than in those devascularized fragment than in those with vascularized fragments.with vascularized fragments.

Infected urinomas and perinephric Infected urinomas and perinephric abscesses frequently occur in patients abscesses frequently occur in patients with an unrepaired, devitalized renal with an unrepaired, devitalized renal segment and concomitant injury to the segment and concomitant injury to the pancreas or bowel pancreas or bowel



Conclusions Conclusions

CT plays a major role in assessing CT plays a major role in assessing patients with renal injuriespatients with renal injuries

Understanding the radiologic Understanding the radiologic classification of traumatic renal injuries classification of traumatic renal injuries is helpful in patient triageis helpful in patient triage

The imaging findings in renal injury The imaging findings in renal injury should be integrated with clinical should be integrated with clinical information to assist in developing a information to assist in developing a treatment plantreatment plan

Introduction Introduction It is not life threatening per seIt is not life threatening per se, but their , but their

association with other potentially more association with other potentially more significant injuries necessitates an organized significant injuries necessitates an organized approach to diagnosis and managementapproach to diagnosis and management

Other injuries often take priority over injuries to Other injuries often take priority over injuries to the GU system and may initially interfere or the GU system and may initially interfere or postpone a complete urologic assessmentpostpone a complete urologic assessment

Initial evaluation should not differ from that of Initial evaluation should not differ from that of

other trauma patientsother trauma patients

Lower Genitourinary TraumaLower Genitourinary Trauma

Pathophysiology Pathophysiology The lower GU tract comprises the urinary bladder, The lower GU tract comprises the urinary bladder,

urethra, and external genitalia (penis and scrotum).urethra, and external genitalia (penis and scrotum). Blunt, penetrating and iatrogenic Blunt, penetrating and iatrogenic Bladder injury is rare owes to the bladder's Bladder injury is rare owes to the bladder's

protected position deep within the bony pelvis. protected position deep within the bony pelvis. Most bladder injuries occur in association with blunt Most bladder injuries occur in association with blunt

trauma. (extra-, intraperitoneal, or combined)trauma. (extra-, intraperitoneal, or combined) 85% of bladder injuries occur with pelvic fractures 85% of bladder injuries occur with pelvic fractures

especially pubic ramus fractures (95%).especially pubic ramus fractures (95%). Intraperitoneal rupture usually occur due to blow Intraperitoneal rupture usually occur due to blow

out of full bladderout of full bladder

Pathophysiology. . . Pathophysiology. . .

Urethral injury is predominantly a male Urethral injury is predominantly a male problem.problem.

60% blunt, 40% iatrogenic and 60% blunt, 40% iatrogenic and penetratingpenetrating

In males, the urethra is divided into the In males, the urethra is divided into the proximal (posterior) segment and the proximal (posterior) segment and the distal (anterior) segment by the distal (anterior) segment by the urogenital diaphragm.urogenital diaphragm.

The posterior urethra extends from the The posterior urethra extends from the bladder to the urogenital diaphragm.bladder to the urogenital diaphragm.

- prostatic- prostatic

- membranous (sphenctiric)- membranous (sphenctiric)

Pathophysiology. . .Pathophysiology. . .

Posterior urethra injuries: mostly secondary Posterior urethra injuries: mostly secondary to pelvic fractures.to pelvic fractures.

Anterior urethral injuries (bulbous & Anterior urethral injuries (bulbous & pendulous)pendulous)– straddle-type (e.g. bicycles, skateboards)straddle-type (e.g. bicycles, skateboards)– penetrating (often self-inflicted) injuries.penetrating (often self-inflicted) injuries.

Anterior urethral injuries are most often Anterior urethral injuries are most often isolatedisolated

Pathophysiology. . .Pathophysiology. . .

External genitalia injuries are usually External genitalia injuries are usually secondary to injuries caused by: secondary to injuries caused by:

- Gun-shots or penetration - Gun-shots or penetration

- Blunt trauma- Blunt trauma

- Vigorous sexual activity- Vigorous sexual activity

- Suction device cleaners- Suction device cleaners

- Mutilation (self-inflicted or - Mutilation (self-inflicted or otherwise). otherwise).

Main causes of bladder Main causes of bladder injuries injuries

– Motor Vehicle AccidentsMotor Vehicle Accidents– Bicycle accidentsBicycle accidents– StabbingsStabbings– ImpalementsImpalements– GunfireGunfire– IatrogenicIatrogenic

Main causes of Main causes of urethral injuries urethral injuries

– Straddle-type mechanism (e.g. Straddle-type mechanism (e.g. bicycles, skateboards, falls onto bicycles, skateboards, falls onto the perineum)the perineum)

– Mutilation (self-inflicted or Mutilation (self-inflicted or otherwise)otherwise)

– GunfireGunfire– StabbingsStabbings– IatrogenicIatrogenic

History. . . History. . . Bladder trauma:Bladder trauma: SP painSP pain HematuriaHematuria - in blunt trauma 95%-100% have gross - in blunt trauma 95%-100% have gross

hematuria hematuria - in penetrating trauma often microscopic- in penetrating trauma often microscopic Inability to void after the injury.Inability to void after the injury. If the patient can not provide such information and If the patient can not provide such information and

gross hematuria is present, suspect bladder injury. gross hematuria is present, suspect bladder injury.

i.e. Patients with any degree of hematuria i.e. Patients with any degree of hematuria after lower abdominal penetrating injury after lower abdominal penetrating injury should undergo complete diagnostic should undergo complete diagnostic evaluation for bladder and ureteral injury.evaluation for bladder and ureteral injury.

History. . .History. . .Urethral traumaUrethral trauma

– Knowledge of associated injuries that can Knowledge of associated injuries that can cause urethral injury is required for diagnosis.cause urethral injury is required for diagnosis.

– Bleeding per urethra (urethrarhagia)Bleeding per urethra (urethrarhagia)– A history of inability to void indicates the A history of inability to void indicates the

possibility of urethral trauma.possibility of urethral trauma.

External genitalia traumaExternal genitalia trauma a history of psychiatric problemsa history of psychiatric problems use of penile ringsuse of penile rings excessive sexual activity excessive sexual activity A history of popping sound, sudden pain, loss of A history of popping sound, sudden pain, loss of

erection, and swelling after trauma to the erect erection, and swelling after trauma to the erect penis is important (penile) penis is important (penile)

Penile traumaPenile trauma– Loss of skinLoss of skin– Swelling and ecchymosisSwelling and ecchymosis– AngulationAngulation– Palpable corporal defectPalpable corporal defect– "rolling sign," in which clot lying near the "rolling sign," in which clot lying near the

fracture site is palpable as a firm, immobile, fracture site is palpable as a firm, immobile, discrete swelling over which the penile skin can discrete swelling over which the penile skin can be rolled. be rolled.

– hugely deformed ecchymotic penis ("eggplant hugely deformed ecchymotic penis ("eggplant deformity"), a sign that is highly diagnostic of #deformity"), a sign that is highly diagnostic of #

– Level of mutilationLevel of mutilation– Viability of mutilated segmentViability of mutilated segment

Scrotal traumaScrotal trauma

– EdemaEdema

– Loss of skinLoss of skin

– DiscolorationDiscoloration

– TendernessTenderness

– Condition of testesCondition of testes

Anterior Urethral Anterior Urethral RuptureRupture Urine filling penis and scrotum and Urine filling penis and scrotum and

extending into abdomen beneath extending into abdomen beneath Scarpa’s fascia. No extension into Scarpa’s fascia. No extension into thigh.thigh.

Butterfly HematomaButterfly Hematoma

Anterior urethral rupture through Buck’s Anterior urethral rupture through Buck’s fascia confined by Colles’ fasciafascia confined by Colles’ fascia

Lab Studies:Lab Studies: CBC to obtain a hematocrit and a CBC to obtain a hematocrit and a

platelet countplatelet count

PT and a PTT to check for coagulopathyPT and a PTT to check for coagulopathy

Blood type and cross matchingBlood type and cross matching

Urinalysis to assess for hematuria.Urinalysis to assess for hematuria.

Imaging Studies:Imaging Studies: Plain radiographPlain radiograph of the pelvis to assess of the pelvis to assess

presence and extent of bony injurypresence and extent of bony injury

Retrograde urethrogramRetrograde urethrogram– Indicated prior to the insertion of a Foley Indicated prior to the insertion of a Foley

catheter when urethral injury is suspected and in catheter when urethral injury is suspected and in all patient with penetrating penile injury (involve all patient with penetrating penile injury (involve the urethra in 50%)the urethra in 50%)

– Urethrography is performed with water-soluble Urethrography is performed with water-soluble contrast material and preferably under contrast material and preferably under fluoroscopy fluoroscopy

– If fluoroscopy is unavailable, multiple plain films If fluoroscopy is unavailable, multiple plain films are obtained with 10-mL injections of contrast are obtained with 10-mL injections of contrast material into the distal urethramaterial into the distal urethra

– Perivesical hematomas may be seen on Perivesical hematomas may be seen on cystograms as compression or displacement cystograms as compression or displacement of the bladder. (Tear drop appearance)of the bladder. (Tear drop appearance)

– Gross hematuria without extravasation Gross hematuria without extravasation indicates bladder contusion. indicates bladder contusion.

– Extravasation of contrast material into the Extravasation of contrast material into the bowel lumen or into the vagina is possible in bowel lumen or into the vagina is possible in penetrating trauma.penetrating trauma.

Imaging Studies. . .Imaging Studies. . .UltrasonographyUltrasonography– Used as a screening tool to indicate bladder wall Used as a screening tool to indicate bladder wall

abnormalities or presence of fluid in the abdomen but abnormalities or presence of fluid in the abdomen but suffers from low sensitivity in excluding bladder injury.suffers from low sensitivity in excluding bladder injury.

– It is also used in assessing the condition of the testes. It is also used in assessing the condition of the testes. (contraversial) (contraversial)

– May be useful in the acute setting of abdominal May be useful in the acute setting of abdominal trauma as part of the focused abdominal sonography trauma as part of the focused abdominal sonography in trauma (FAST) examination of the injured patient.in trauma (FAST) examination of the injured patient.

– Unclear rule in penile fractureUnclear rule in penile fracture

CT scan of abdomen and pelvisCT scan of abdomen and pelvis– CT cystography is Specific in aiding in the diagnosis of CT cystography is Specific in aiding in the diagnosis of

bladder injuries but carries low sensitivity.bladder injuries but carries low sensitivity.– Because most of these patients already require CT to Because most of these patients already require CT to

evaluate pelvic fracture or intra-abdominal injury, CT evaluate pelvic fracture or intra-abdominal injury, CT cystography saves time. cystography saves time.

penile fracture penile fracture

US of penile fracture US of penile fracture

Management of Bladder Management of Bladder TraumaTrauma

Bladder contusionBladder contusion – Adequate drainage of the bladder should result in Adequate drainage of the bladder should result in

resolution within a few days. resolution within a few days. – Follow-up cystography is recommended to assess Follow-up cystography is recommended to assess

integrity of the bladder wall. integrity of the bladder wall.

Extraperitoneal ruptureExtraperitoneal rupture Can most commonly be managed with adequate Can most commonly be managed with adequate

bladder drainage and broad-spectrum antibiotics.bladder drainage and broad-spectrum antibiotics. Cystogram should be performed after 10-14 days Cystogram should be performed after 10-14 days The catheter should be removed if extravasation has The catheter should be removed if extravasation has

resolved (76% to 87%) , but if the extravasation is resolved (76% to 87%) , but if the extravasation is persistent, cystography is repeated at 21 days (all heal persistent, cystography is repeated at 21 days (all heal by 3 weeks . surgical intervention is required if persist. by 3 weeks . surgical intervention is required if persist.

Persistent severe hematuria and infection of the pelvic Persistent severe hematuria and infection of the pelvic hematoma are contraindications to conservative hematoma are contraindications to conservative therapy.therapy.

Management of Bladder Management of Bladder TraumaTraumaExtraperitoneal ruptureExtraperitoneal rupture Another relative indication for repair of Another relative indication for repair of

extraperitoneal rupture is found in patients extraperitoneal rupture is found in patients undergoing laparotomy for other reasons undergoing laparotomy for other reasons

Surgical repair is performed by opening the Surgical repair is performed by opening the dome of the bladder and repairing the dome of the bladder and repairing the laceration from the inside in one layer. laceration from the inside in one layer.

At open repair, careful inspection for associated At open repair, careful inspection for associated lower urinary tract injuries is mandatory so as lower urinary tract injuries is mandatory so as not to miss urethral disruption, prostate injury, not to miss urethral disruption, prostate injury, bladder neck injury, or unexpected bladder neck injury, or unexpected intraperitoneal injuries. intraperitoneal injuries.

If the bladder has been repaired, a cystogram is If the bladder has been repaired, a cystogram is obtained 7 to 10 days after surgery obtained 7 to 10 days after surgery

some authors have supported open repair of some authors have supported open repair of extraperitoneal bladder rupture.extraperitoneal bladder rupture.

Management of Bladder Management of Bladder TraumaTraumaIntraperitoneal rupture Intraperitoneal rupture Surgically repaired with a watertight two-layer closure Surgically repaired with a watertight two-layer closure

with absorbable suture and perivesical drain with absorbable suture and perivesical drain placement. placement.

Adequate drainage with a urethral catheter and Adequate drainage with a urethral catheter and suprapubic cystostomy catheter for 10 days. suprapubic cystostomy catheter for 10 days.

A cystogram should be performed to assess the A cystogram should be performed to assess the integrity of the repair before removing catheters. integrity of the repair before removing catheters.

The urethral catheter should be removed and the The urethral catheter should be removed and the postvoid residuals should be checked for to ensure postvoid residuals should be checked for to ensure adequate bladder evacuation before removing the adequate bladder evacuation before removing the suprapubic cystostomy catheter the following day.suprapubic cystostomy catheter the following day.

There are several reasons for this There are several reasons for this approach:approach:

1.1. Intraperitoneal ruptures are often Intraperitoneal ruptures are often much larger than suggested on much larger than suggested on cystography and are unlikely to heal cystography and are unlikely to heal spontaneously.spontaneously.

2.2. They cause urinary leakage into the They cause urinary leakage into the abdominal cavity with resultant abdominal cavity with resultant peritonitis, which can be fatal.peritonitis, which can be fatal.

Prophylactic Antimicrobial AgentsProphylactic Antimicrobial Agents

Management of Bladder Management of Bladder TraumaTrauma

Penetrating injuries Penetrating injuries The preferred method is surgical The preferred method is surgical

intervention; open the dome of the intervention; open the dome of the bladder and perform a full inspection. bladder and perform a full inspection.

Indigo carmine IV injection is used to Indigo carmine IV injection is used to help identify distal ureters. help identify distal ureters.

Management of posterior Management of posterior Urethral InjuryUrethral InjuryI.I. Primary Realignment (stenting)Primary Realignment (stenting)

II.II. Suprapubic Cystostomy (p/c or open)Suprapubic Cystostomy (p/c or open)1.1. Failed primary realignmentFailed primary realignment

2.2. Unstable patient Unstable patient

3.3. Always (96%) develop a urethral stricture Always (96%) develop a urethral stricture requiring posterior urethroplastyrequiring posterior urethroplasty

III.III. Delayed Reconstruction (3-12 M)Delayed Reconstruction (3-12 M)1.1. At 3 months, scar tissue at the urethral At 3 months, scar tissue at the urethral

disruption site is stable and mature disruption site is stable and mature

2.2. After the associated injuries are stabilized and After the associated injuries are stabilized and the patient is ambulatory.the patient is ambulatory.

Management of anterior Management of anterior Urethral InjuryUrethral Injury Initial S.P.C. is the treatment of choice for Initial S.P.C. is the treatment of choice for

straddle injuries or blunt crushing injuries to the straddle injuries or blunt crushing injuries to the anterior urethra and secondary repair is planned anterior urethra and secondary repair is planned 3 months post injury 3 months post injury

most experts have recommended primary most experts have recommended primary surgical repair of urethral gunshot injuries (low-surgical repair of urethral gunshot injuries (low-velocity)velocity)

Initial suprapubic urinary diversion is Initial suprapubic urinary diversion is recommended after high-velocity gunshot recommended after high-velocity gunshot wounds to the urethra, followed by delayed wounds to the urethra, followed by delayed reconstructionreconstruction

Management of penile injuryManagement of penile injury(amputation)(amputation) every attempt should be made to do replantation, even every attempt should be made to do replantation, even

against the patient's wishes at the timeagainst the patient's wishes at the time

The amputated penis should be wrapped in sterile gauze The amputated penis should be wrapped in sterile gauze wetted with sterile saline and placed within a sterile plastic wetted with sterile saline and placed within a sterile plastic bag in a second container of ice and water. (This bag in a second container of ice and water. (This combination solution prevents contact cold ischemic combination solution prevents contact cold ischemic injury.) injury.)

Success has been reported after 16 hours of cold ischemia, Success has been reported after 16 hours of cold ischemia, and after 6 hours of warm ischemiaand after 6 hours of warm ischemia

If the amputated segment is not available for replantation, If the amputated segment is not available for replantation, then penile resection, with closure of the corpora and then penile resection, with closure of the corpora and formation of a spatulated urethral neomeatus, is performedformation of a spatulated urethral neomeatus, is performed

Management of penile Management of penile injuryinjury(amputation)(amputation) Later, if the patient desires reconstruction, Later, if the patient desires reconstruction,

several options exist to lengthen the remaining several options exist to lengthen the remaining penile stump: penile stump:

(1) releasing the suspensory ligament(1) releasing the suspensory ligament (2) defatting the pubis(2) defatting the pubis (3) placing a rigid penile prosthesis after (3) placing a rigid penile prosthesis after

multiple relaxing incisions in the corpora multiple relaxing incisions in the corpora cavernosacavernosa

(4) Total free flap penile reconstruction may (4) Total free flap penile reconstruction may also be requiredalso be required

Repairing of the penisRepairing of the penis

Penile fracturePenile fracture

Management of penile Management of penile injury (injury (Penile FracturePenile Fracture ) )

Due to rupture of the corpus cavernosum Due to rupture of the corpus cavernosum from trauma to the erect penisfrom trauma to the erect penis

Conservative treatment involving sedatives, Conservative treatment involving sedatives, ice packs, and pressure bandages is ice packs, and pressure bandages is condemned because of:condemned because of:– prolonged hospitalization (4 to 71 days), prolonged hospitalization (4 to 71 days), – healing with deformity in as many as 10%, healing with deformity in as many as 10%, – prolonged penile pain, sometimes for monthsprolonged penile pain, sometimes for months– penile pulsatile hematoma, penile pulsatile hematoma, – huge penile residual mass, huge penile residual mass, – pulsatile cavernosal diverticulum, and pulsatile cavernosal diverticulum, and – expanding penile hematomaexpanding penile hematoma

Dangerous posturesDangerous postures»»

Curvature after Curvature after fracturefracture

Management of penile Management of penile injury (Pinjury (Penile Fractureenile Fracture))

Because of the unacceptable complication rate Because of the unacceptable complication rate associated with non-operative treatment, we advocate associated with non-operative treatment, we advocate immediate repair of penile fractureimmediate repair of penile fracture

faster recovery, shorter hospitalization, less morbidity, faster recovery, shorter hospitalization, less morbidity, and less penile deformityand less penile deformity

Sub-coronal approach is recommended because it allows Sub-coronal approach is recommended because it allows excellent exposure of the entire penis, as required in excellent exposure of the entire penis, as required in large or bilateral ruptures or associated urethral injurylarge or bilateral ruptures or associated urethral injury

A high suspicion for associated urethral injury must be A high suspicion for associated urethral injury must be maintained during open inspection of the injurymaintained during open inspection of the injury

blood clot at the site of blood clot at the site of discontinuitydiscontinuity

suturingsuturing of rapture tunica of rapture tunica albuginea and urethra albuginea and urethra

Management of testicular Management of testicular injuryinjury Explore and repair all cases of significant Explore and repair all cases of significant

hematocele, intratesticular hematoma, or frank hematocele, intratesticular hematoma, or frank rupture of the tunica albuginea.rupture of the tunica albuginea.

Lack of evidence for tunical rupture on ultrasound is Lack of evidence for tunical rupture on ultrasound is not a sufficient reason to delay exploration because not a sufficient reason to delay exploration because it results in increased orchidectomy rates it results in increased orchidectomy rates

When gunshot wounds involve the testicle or When gunshot wounds involve the testicle or spermatic cord, the testicle can be salvaged in only spermatic cord, the testicle can be salvaged in only 35% to 65% 35% to 65%

In blunt injury, significant intratesticular hematoma In blunt injury, significant intratesticular hematoma should be drained because increased intratesticular should be drained because increased intratesticular pressure from these collections can result in pressure from these collections can result in testicular atrophy and appearance of ASATtesticular atrophy and appearance of ASAT

Management of testicular Management of testicular injuryinjury Significant, mutilating injuries of the Significant, mutilating injuries of the

scrotum, such as those that occur after scrotum, such as those that occur after close-range shotgun blast, should be close-range shotgun blast, should be treated in a staged fashiontreated in a staged fashion

Conservative therapy results in higher Conservative therapy results in higher orchiectomy rates when the patient's orchiectomy rates when the patient's condition ultimately forces delayed condition ultimately forces delayed scrotal explorationscrotal exploration

Complications Complications Bladder injuriesBladder injuries

– UrinomasUrinomas– Fistulization (rectum, vagina, bowel, Fistulization (rectum, vagina, bowel,

cutaneous)cutaneous)– Pelvic hematoma infectionPelvic hematoma infection– Difficulties voidingDifficulties voiding– Distal ureteral obstructionDistal ureteral obstruction

Complications Complications Urethral Urethral

injuriesinjuries– Strictures Strictures – Incontinence Incontinence – ImpotenceImpotence

Penile injuryPenile injury– AngulationAngulation– Painful Painful

erectionerection– ImpotenceImpotence

Complications Complications Scrotal injuriesScrotal injuries

– Infection Infection – Loss of testes Loss of testes – Skin necrosis Skin necrosis – Testicular atrophyTesticular atrophy– InfertilityInfertility

Prognosis for patients with lower GU tract Prognosis for patients with lower GU tract injuries is related to their associated injuries is related to their associated injuriesinjuries

Documents

Trauma of Urinary Tract Trauma of Urinary Tract. Introduction Injury to the kidney is seen in approximately 8%–10% of patients with blunt or penetrating