gu trauma from top to bottom james cummings md division of urology university of missouri
TRANSCRIPT
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