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

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GU TRAUMA FROM TOP TO BOTTOM James Cummings MD Division of Urology University of Missouri

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Page 1: GU TRAUMA FROM TOP TO BOTTOM James Cummings MD Division of Urology University of Missouri

GU TRAUMA FROM TOP TO BOTTOM

James Cummings MDDivision of Urology

University of Missouri

Page 2: 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

• 27.7 million total ER visits in US per year for trauma so a lot of GU trauma is out there

Page 3: GU TRAUMA FROM TOP TO BOTTOM James Cummings MD Division of Urology University of Missouri

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)

Page 4: GU TRAUMA FROM TOP TO BOTTOM James Cummings MD Division of Urology University of Missouri

So a systematic approach to diagnosis and treatment is very

helpful

Page 5: GU TRAUMA FROM TOP TO BOTTOM James Cummings MD Division of Urology University of Missouri

RENAL TRAUMA

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

and pathway

Page 6: GU TRAUMA FROM TOP TO BOTTOM James Cummings MD Division of Urology University of Missouri
Page 7: GU TRAUMA FROM TOP TO BOTTOM James Cummings MD Division of Urology University of Missouri

TREATMENT

• Observation common• Repair• Nephrectomy

Page 8: GU TRAUMA FROM TOP TO BOTTOM James Cummings MD Division of Urology University of Missouri

URETER

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

Page 9: GU TRAUMA FROM TOP TO BOTTOM James Cummings MD Division of Urology University of Missouri

Incidence of iatrogenic ureteral injury

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

Page 10: GU TRAUMA FROM TOP TO BOTTOM James Cummings MD Division of Urology University of Missouri

Diagnosis

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

Page 11: GU TRAUMA FROM TOP TO BOTTOM James Cummings MD Division of Urology University of Missouri

Ureteroureterostomy

Page 12: GU TRAUMA FROM TOP TO BOTTOM James Cummings MD Division of Urology University of Missouri

Ureteroureterostomy

Page 13: GU TRAUMA FROM TOP TO BOTTOM James Cummings MD Division of Urology University of Missouri

Ureteroureterostomy

Page 14: GU TRAUMA FROM TOP TO BOTTOM James Cummings MD Division of Urology University of Missouri

Psoas Hitch

Page 15: GU TRAUMA FROM TOP TO BOTTOM James Cummings MD Division of Urology University of Missouri

Boari Flap

Page 16: GU TRAUMA FROM TOP TO BOTTOM James Cummings MD Division of Urology University of Missouri

Other Options

• Transureteroureterostomy• Ileal ureter• Autotransplantation• Nephrectomy

Page 17: GU TRAUMA FROM TOP TO BOTTOM James Cummings MD Division of Urology University of Missouri

BLADDER

• Blunt – bladder full, force applied to lower abdomen

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

sub-Saharan Africa

Page 18: GU TRAUMA FROM TOP TO BOTTOM James Cummings MD Division of Urology University of Missouri

Presentation

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

Page 19: GU TRAUMA FROM TOP TO BOTTOM James Cummings MD Division of Urology University of Missouri

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)

Page 20: GU TRAUMA FROM TOP TO BOTTOM James Cummings MD Division of Urology University of Missouri

Operative technique

• Perform repair when tissues are free of inflammation

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

Page 21: GU TRAUMA FROM TOP TO BOTTOM James Cummings MD Division of Urology University of Missouri

Principles

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

Page 22: GU TRAUMA FROM TOP TO BOTTOM James Cummings MD Division of Urology University of Missouri

Other tissues for interposition

• Peritoneum• Omentum• Gracilus

Page 23: GU TRAUMA FROM TOP TO BOTTOM James Cummings MD Division of Urology University of Missouri

Tissue Interposition

• Aids in separating bladder and vagina• Brings in neovascularity

Page 24: GU TRAUMA FROM TOP TO BOTTOM James Cummings MD Division of Urology University of Missouri

URETHRA

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

• Iatrogenic

Page 25: GU TRAUMA FROM TOP TO BOTTOM James Cummings MD Division of Urology University of Missouri

Presentation

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

Page 26: GU TRAUMA FROM TOP TO BOTTOM James Cummings MD Division of Urology University of Missouri

Urethrography

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

• Gentle contrast injection• Oblique views if possible

Page 27: GU TRAUMA FROM TOP TO BOTTOM James Cummings MD Division of Urology University of Missouri

Management

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

Page 28: GU TRAUMA FROM TOP TO BOTTOM James Cummings MD Division of Urology University of Missouri

GENITALIA

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

Page 29: GU TRAUMA FROM TOP TO BOTTOM James Cummings MD Division of Urology University of Missouri

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

Page 30: GU TRAUMA FROM TOP TO BOTTOM James Cummings MD Division of Urology University of Missouri

GU TRAUMA- TOP TO BOTTOM

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