Lower Urinary Tract
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Lower Urinary Tract Trauma. • bladder • posterior urethra. Bladder Trauma Blunt. • pelvic fracture • gross hematuria • abdominal pain • shock. Bladder and/or Urethral Injuries are Noted in 15% of Pelvic Fractures. Classification of Bladder Trauma. Minor • contusions Major

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Lower Urinary Tract

Trauma

• bladder

• posterior urethra


Bladder Trauma

Blunt

• pelvic fracture

• gross hematuria

• abdominal pain

• shock


Bladder and/or Urethral

Injuries are Noted in 15%

of Pelvic Fractures


Classification of Bladder Trauma

Minor

• contusions

Major

• extraperitoneal ruptures

• intraperitoneal ruptures


Bladder Trauma

Cystography

• 350 ml

• full film

• drainage film


Bladder Rupture

Extraperitoneal - 65%

Intraperitoneal - 25%

Combined - 10%


Bladder Rupture

Management

• extraperitoneal

cath drainage

surgical repair

• intraperitoneal

surgical repair


Posterior Urethral Rupture

Distraction Injuries


Pelvic Fracture

• posterior urethral

disruption - 5%

• anterior ring disruption

higher in bilateral

• bleeding


Urethral Trauma Signs

• pelvic fracture - 98%

• blood at meatus - 37-93%

• scrotal hematoma

• perineal hematoma

• unable to void

• unable to pass catheter

• high riding prostate


Diagnosis

• retrograde urethrogram

• unable to pass catheter

retrograde urethrogram


Posterior Urethral Rupture

Options

• primary realignment

• delayed reconstruction

perineal approach


Posterior Urethral Injury

Primary Realignment

• limited associated injuries

• optimum endoscopic equipment and fluoroscopy

• hemodynamic stability


Injury

Delayed Reconstruction

• suprapubic cystostomy

repair bladder

• reconstruction of urethral rupture defect

3 months OR

after assoc. injuries heal


Posterior Urethral Injuries

Reconstruction Pre-op Studies

• urethrogram

• cystogram

• penile duplex ultrasound

• MRI


Posterior Urethral Rupture

Distraction Injuries

Delayed

Endoscopic Management

• poor control

• repeat procedures required

• dilations necessary

• fibrosis persists


Posterior Urethral Rupture

• do not use Urolume stents

• fail

• fibrosis - obstruction

• calculi - obstruction


Technical Points

• high lithotomy

• midline perineal incision

• excise fibrosis - 28 F

• spatulate

• epithelium-epithelium anastomosis

tension free

split corpora

partial pubectomy from below

5-0 (maxon, PDS, monocryl)

• 16 F urethral catheter - 1 month


Long Rupture Defects

Methods of Gaining Length

• mobilize bulbar urethra to

penoscrotal junction

• split corporal bodies

• inferior pubectomy - perineal

• total pubectomy

• urethral rerouting


Posterior Urethral Rupture

Success

• normal voiding

• no dilations

• no self dilations


Posterior Urethral Rupture

Summary

(158 pts >1 yr follow-up)

• Reconstruction Success 96%

• Erectile Dysfunction 39%

• Incontinence 12%

• Total Incontinence 2%

• Stress Incontinence 6%

• Urge Incontinence 4%


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