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

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Presentation on theme: "GU TRAUMA FROM TOP TO BOTTOM James Cummings MD Division of Urology University of Missouri."— Presentation transcript:

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

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7 TREATMENT Observation common Repair Nephrectomy

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

9 Incidence of iatrogenic ureteral injury Hysterectomy (Benign)0.5% Rectal surgery0.7% Ureteroscopy0.4% Aortic surgery< 1% Lumbar laminectomy6 cases

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

11 Ureteroureterostomy

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14 Psoas Hitch

15 Boari Flap

16 Other Options Transureteroureterostomy Ileal ureter Autotransplantation Nephrectomy

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

18 Presentation External injuries – gross hematuria Iatrogenic – total incontinence from fistula

19 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)

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

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

22 Other tissues for interposition Peritoneum Omentum Gracilus

23 Tissue Interposition Aids in separating bladder and vagina Brings in neovascularity

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

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

26 Urethrography Small catheter in fossa navicularis with 1-2 cc in balloon Gentle contrast injection Oblique views if possible

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

28 GENITALIA Multitude of etiologies Skin loss Penile tissue damage Testis damage

29 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

30 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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