Genitourinary Trauma for the Rest of Us: How to pass the inservice or boards, survive nights on call and impress your fr

1. Genitourinary Trauma for the Rest of Us:How to pass the inservice or boards, survive nights on call and impress your friends Richard Santucci, MD Chief of Urology, Detroit Receiving Hospital Specialist-in-Chief, Urology, Detroit Medical Center

2. 2 Overview Renal Ureter External genitalia Bladder Urethra (not today, tomorrow)

3. 3 Where in the World?

4. 4 Detroit City of the Strait" (Ville d'Etroit) 1 million inhabitants 4.7 million in �greater detroit�

5. 5 Detroit Medical Center: 10 hospitals Trauma Hospital-Detroit Receiving Hospital Children�s Hospital-Detroit Children�s Hospital Veteran�s Hospital-VAMC Detroit Women�s Hospital-Hutzel Hospital Rehabilitation Hospital-Rehab Institute of Michigan Eye Hospital-Kresge Eye University Hospital-Harper University Hospital 2 other general hospitals (distant) Orthopedic hospital

6. 6 Detroit Receiving Hospital

7. 7 RENAL TRAUMA

8. 8 Renal Trauma Overview Most commonly injured GU organ 10% of all serious injuries have associated renal injury (closer to 1% actually?) Variable etiology depending on the area Rural: 80-95% blunt Urban: as little as 15% blunt

9. 9 Hematuria and renal injury NOT related to the degree of injury Gross Hematuria: 1/3rd of patients with renovascular injuries 24% of patients with renal artery occlusion Only 63% of Grade IV injuries (4% have no hematuria whatsoever!)

10. 10 Physical exam: renal injury

11. 11 Whom to workup Penetrating trauma: EVERYONE Blunt trauma: computed tomogram (CT) if gross hematuria microhematuria plus shock microhematuria plus acceleration/deceleration Mee et al. (1989) Hardeman et al (1987)

12. 12 Imaging of hematuria CT preferred With contrast With �delayed� films (mandatory) Why not get CT cystogram too? Standard intravenous pyelogram (IVP): Forget it �One Shot� intraoperative IVP 2 cc/kg intravenous contrast Single film at 10 minutes

13. 13 Intraoperative One Shot IVP Allows safe avoidance of renal exploration in 32% (Morey et al, 1999) Highly specific for urinary extravasation Confirms existence of the other kidney

14. 14 Indications for renal trauma surgery Absolute Grade V renal injury (debatable in blunt trauma): NEPHRECTOMY Vascular injury in a single kidney: Vascular repair Relative Persistent bleeding > 2 units/day Devitalized segment AND urinary extrav (80% complication rate?) Renal pelvis injury Ureter injury Incomplete staging and ongoing laparotomy Grade IV vein or artery (thrombosis): nephrectomy 2.5% of blunt renal injuries Most penetrating renal injuries

15. 15 AAST Organ Injury Severity Scale for the Kidney

16. 16 Operative result by AAST Organ Injury Severity Scale

17. 17 Insignificant renal injuries Segmental artery thrombosis (wedge defect) Urinary extravasation without renal pelvis or ureter injury Observe If persists, ureteral stent fixes the problem nearly 100%

18. 18 Watch out for active IV contrast extravasation

19. 19 Postinjury care: Renal trauma Expectant (nonoperative) therapy Bed rest until gross hematuria resolves Antibiotics if large hematoma or urine leak, especially if lots of road burn Consider delayed scan Check for hypertension for up to one year Delayed bleed? Salvage angiography. (Operative exploration will result in nephrectomy).

20. 20 Surgical approach to renal injury

21. 21 Isolation of renal vessels

22. 22 To expose or not to expose Vascular control improved renal salvage from 56% to 18%. (n=375) (McAninch and Carroll, J Trauma, 1982) Vascular control had no effect (30% nephrectomy rate both groups, n=56). (Gonzales et al, J Trauma, 1999) Modern series: 9% nephrectomy rate of Grade IV renal injuries (with vascular control)

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24. 24 Renorrhaphy techniques

25. 25 Postoperative care: renorrhaphy Always leave a drain NOT TO SUCTION When output decreases day 2-3, check creatinine and if NOT urine, remove Watch for hypertension, delayed bleeds Frequent hematocrit checks Warnings to patient about delayed bleed on discharge

26. 26 Complications: Renal injury Usually in first 2 weeks Delayed bleed (angioembolize) Abscess (open drainage) Urinary fistula (divert urine) Urinoma Watch if small Stent if not Rarely require percutaneous nephrostomy Did you miss a ureteral injury? Delayed severe hematuria (AV fistula) (angioembolize) Up to 1 year hypertension

27. 27 Hypertension after renal injury Occur up to 15 years after injury Occur even with �normal� CT or IVP Subsequent arteriography unappreciated: renal artery occlusion artery stenosis segmental artery injuries extraparenchymal compression from scarring (Page kidney) Exotic complaints it the young: Headaches chest pain Nosebleeds Severe fatigue Stroke Heart attack

28. 28 URETER

29. 29 Ureter injury Rare 4% penetrating trauma 1% blunt trauma (associated with large force injuries such as fractured lumbar process and spine dislocations) Penetrating Requires high degree of suspicion Up to 45% have no hematuria Examine the trajectory! Often missed at first

30. 30 Ureter injury: detection techniques Inject 1-2 cc methylene blue with 27g needle into collecting system Use intraoperative �one shot� IVP (0-67% sensitive) CT Follow the ureter through its entire course

31. 31 Principles of ureter repair Debride back to bleeding edge (especially in high velocity gunshot). Spatulate Stent Watertight closure Preserve periureteral blood supply Drain

32. 32 MID: Uretero-ureterostomy

33. 33 Psoas Hitch Boari Flap

34. 34 Transuretero-ureterostomy

35. 35 Often not picked up

36. 36 External genital trauma

37. 37 Testes Trauma Rare in general But, in significant scrotal blunt trauma, rupture can be as high as 50% Bilateral 1.5% Assaults and sports injuries predominate Local anesthetic block may improve exam

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39. 39 Testes Trauma: Penetrating 2% of all civilian GSW Bilaterally, as much as 15X more common than blunt injury Explore equivocal cases 92-97% require exploration Salvage in 35-65% Debride as much as 50% of ruined parenchyma and close capsule

40. 40 Repair Repair Repair Repair

41. 41 Testes Trauma: Penetrating Associated injuries common Thigh (75%)�femoral vessels? Penis (37%) Perineum (25%) Urethra (18%) Transection of the vas in 10%

42. 42 Imaging hard to interpret

43. 43 Penile Trauma Amputation Self mutilation most common 87% are acutely psychotic Reimplant if possible, formalize the amputation if not Keep amputated penis in wet sterile gauze, in sterile baggy, put baggy on ice Many do well (18-25% strictures/fistulae)

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45. 45 Reimplant

46. 46 Not always a happy ending

47. 47 Penile Trauma Gunshot Rare Get a urethrogram (50% involvement) Treat associated injuries (80% of the time, 5% unstable) Repair primarily, unless massive tissue destruction (as from shotgun) Reasonably low complications

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49. 49 BLADDER

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56. 56 Bladder: Diagnosis: CT Cystography

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61. 61 POSTERIOR URETHRA

62. 62 Main Points

63. 63 Main points : Kidney Get a CT in everyone with Gross hematuria Microhematuria + deceleration or shock Treat most kidneys nonoperatively Indications for operation: Grade V renal injury Persistent bleeding Suspected ureter or collecting system injury Incomplete staging and ALREADY having lap Isolate the vessels first

64. 64 Main Points: Bladder Get a CT cystogram if pelvic fracture Consider treating extraperitoneal bladder ruptures OPEN, especially if undergoing lap and DEFINITELY if undergoing pelvic ORIF Microhematuria usually means no significant injury to bladder

65. 65 Main Points: Ureter Suspect ureter injuries and you�ll miss them less

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67. 67 Bladder Question A 43-year old woman sustains a single gunshot wound to the abdomen. You are consulted at the time of emergency laparotomy for an obvious bullet hole in the dome of the bladder. You should: � a. open the bladder anteriorly and inspect the inside of the bladder b. perform an intraoperative cystogram c. debride the bullet hole and close it in two layers d. perform an intraoperative IVP e. place a ureteral stent � Answer: a.

68. 68 Bladder Question A 24-year-old man is struck by a car and sustains multiple injuries including a pelvic fracture. He has blood at the meatus and a retrograde urethrogram is normal. A catheter is passed and the bladder is filled with 200 cc of contrast. A full and post-drainage film are normal. The next step should be: � a. evaluation of the upper tracts by CT scan b. repeat the cystogram c. leave catheter and irrigate as needed to clear clots d. flexible cystoscopy to exclude a urethral or bladder injury e. intravenous urogram with tomograms � Answer: b.

69. 69 Urethra Question A 25-year old pedestrian is struck by an automobile. On arrival in the emergency room, a plain film of the pelvis reveals a left superior and inferior pubic ramus fracture as well as a fracture of the sacroiliac joint. Examination of the patient reveals a suprapubic mass. No blood is noted at the meatus and the prostate is in the normal position on digital examination. The most appropriate initial diagnostic test is: � a. IVP b. retrograde urethrogram c. cystogram d. pelvic CT scan e. peritoneal lavage � Answer: b

70. 70 Genital Trauma Question A three-year-old boy is seen because his foreskin is caught in his zipper. The best treatment is: � a. circumcision b. manipulation of the zipper under general anesthesia c. manipulation of the zipper under local anesthesia d. divide the median bar of the zipper with a bone cutter e. excision of the piece of penile skin caught � Answer: d

71. 71 Genital Trauma Question A 22 year old man sustains a severe burn of his genitalia. There is marked bullous edema and eschar formation of the entire penis and much of the scrotum. He has had a Foley catheter in his urethra to monitor urine output. The most appropriate initial management is: a. radical eschar debridement b. split thickness skin grafts as soon as possible c. antibiotic therapy and topical cleansing with water d. remove the Foley and insert a suprapubic tube e. observe until the wound begins to granulate � Answer: b