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GU TRAUMA FROM TOP TO BOTTOM

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

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GU TRAUMA FROM TOP TO BOTTOM

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

  2. 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

  3. 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)

  4. So a systematic approach to diagnosis and treatment is very helpful

  5. RENAL TRAUMA • Blunt most common – think deceleration • Penetrating – knife and gun club – entry, exit and pathway

  6. TREATMENT • Observation common • Repair • Nephrectomy

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

  8. Incidence of iatrogenic ureteral injury • Hysterectomy (Benign) 0.5% • Rectal surgery 0.7% • Ureteroscopy 0.4% • Aortic surgery < 1% • Lumbar laminectomy 6 cases

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

  10. Ureteroureterostomy

  11. Ureteroureterostomy

  12. Ureteroureterostomy

  13. Psoas Hitch

  14. Boari Flap

  15. Other Options • Transureteroureterostomy • Ileal ureter • Autotransplantation • Nephrectomy

  16. BLADDER • Blunt – bladder full, force applied to lower abdomen • Penetrating – knife and gun club • Iatrogenic – pelvic surgery in US, childbirth in sub-Saharan Africa

  17. Presentation • External injuries – gross hematuria • Iatrogenic – total incontinence from fistula

  18. 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)

  19. Operative technique • Perform repair when tissues are free of inflammation • Separate bladder and vagina • Close bladder and vagina • Tissue interposition • Vaginal vs. abdominal approach

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

  21. Other tissues for interposition • Peritoneum • Omentum • Gracilus

  22. Tissue Interposition • Aids in separating bladder and vagina • Brings in neovascularity

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

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

  25. Urethrography • Small catheter in fossanavicularis with 1-2 cc in balloon • Gentle contrast injection • Oblique views if possible

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

  27. GENITALIA • Multitude of etiologies • Skin loss • Penile tissue damage • Testis damage

  28. 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

  29. GU TRAUMA- TOP TO BOTTOM • High index of suspicion • Systematic approach • Compassion • Things can be put back together • Don’t be afraid

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