( Lecture ) Trauma in Urology

Renal injuries RI account for 1-5% of all traumas BLUNT – car, sport accidents –majority! PENETRATING –gunshots, stab wounds

AAST classification (American Associaton for the Surgery of Trauma) Contusion, non-expanding subcapsular haematoma, no laceration Non-expanding perirenal haematoma, cortical laceration < 1 cm deep, no urinary extravasation cortical laceration > 1cm, no u.extravasation Laceration: through corticomedullary junction into collecting system OR vascular: segm. renal artery or vein injury with contained haematoma Shattered kidney OR major vascular injury (renal pedicle injury or avulsion) 1,2 = minor injuries – 85-95% 3,4,5 = major injuries

Diagnosis ❏history: mechanism of injury, past renal injury, surgery or renal abnormalities ❏P/E: ABCs, renal vascular injury ––> shock • flank contusions, lower rib/vertebral #, upper abdominal/flank tenderness suggest blunt trauma Urinalysis, blood count, creatinine ❏U/A: hematuria, (> 5 RBC/HPF), degree of hematuria does not correlate with the degree of injury ❏imaging: Primary imaging -> USG Enhanced abdominal CT if patient stable ––> look for renal laceration, urinary extravasation, retroperitoneal hematoma, and associated intra-abdominal organ injury Intraoperative one/shot IVP , Second/line imaging – MRI,Scinti,Angiography

Treatment WW – grade I-III in stable patients Surgery • microscopic hematuria + isolated well-staged minor injuries do not need hospitalization • gross hematuria + contusion/minor lacerations: hospitalize, bedrest, repeat CT if bleeding persists Surgery • absolute indications: hemorrhage and hemodynamic instability • relative indications • nonviable tissue and major laceration • urinary extravasation • vascular injury • incomplete staging • laparotomy for associated injury

Complications ❏outcome • F/U with IVP or CT before discharge, and at 6 weeks Early: Haemorrhage, retroperitoneal urinoma, haematoma, abscess Late: Hypertension 5%, AV fistula, calculi, PNF, late bleeding

Ureteral injuries Pelvic surgery (uro, gyn, gen.s.) post RT Pelvic/abdomninal masses PID ureteroscope post RT Penetrating injury Severe blunt trauma, #spine

Clinical findings Flank pain, tenderness Sepsis Hydronephrosis!! Paralytic ileus VV / UV fistula / watery discharge via vagina/ Labs /CRP,Leu,urinalysis,creatinine/

Imaging USG IVU / enhanced CT ! APG Radionuclide scanning

Treatment First-line urinary diversion !!! (nephrostomy, ureteral stenting) Reconstructive surgery /reanast., reimpl., psas hitch, Boari flap, substitutions, crossed diversion, autoTPL…/

BLADDER TRAUMA ❏blunt (MVA, falls, and crush injury) vs BLADDER TRAUMA ❏blunt (MVA, falls, and crush injury) vs. penetrating trauma to lower abdomen, pelvis, or perineum ❏blunt is associated with pelvic # in 97% of cases History and Physical ❏abdominal tenderness and distension, and unable to void ❏may be few peritoneal signs or symptoms ❏associated injuries such as pelvic and long bone # are common ❏hemodynamic instability also common due to extensive blood loss in the pelvis

Investigations ❏U/A: gross hematuria in 95% of bladder ruptures Imaging Pelvic & Abdominal USG Cystography (300ml): extravasation CT cystography Classification ❏contusions: no urinary extravasation, damage to mucosa or muscularis ❏intraperitoneal ruptures: often involve the dome ❏extraperitoneal ruptures: involve anterior or lateral bladder wall

❏contusion: urethral catheter until hematuria completely resolves Management ❏depends on the type of bladder injury and the extent of associated injuries ❏contusion: urethral catheter until hematuria completely resolves ❏extraperitoneal bladder perforations can be managed non-operatively if associated injuries do not require a laparotomy and the urine is sterile at time of the injury • others will need surgical management ❏intraperitoneal injuries require drainage and a suprapubic catheter Complications ❏mortality is around 20%, and is usually due to associated injuries due to trauma rather than bladder rupture ❏complications of bladder injury itself are rare

Urethral injuries Posterior/ Anterior urethra Laceration, transection, contusion Iatrogenic (catheter, uro ) most common site is membranous urethra due to blunt trauma, MVAs: • associated with pelvic fractures (10% of such fractures) External forces (falls astride an object, perineal blow, …bulbar urethral injury other causes: iatrogenic instrumentation, prosthesis insertion, penile fracture, masturbation with urethral manipulation

Posterior urethra assoc. w/ pelvic fractures - > prostate avulsion from the membranous u. -> apical displacement of the prostate - > Pelvic urinoma, haematoma sensation of voiding without urine output DR Exam.: high riding prostate blood at the urethral meatus !

X- Ray (pelvic fracture) Urethrography !!

Treatment drainage (suprapubic cystostomy) immediate surgery (suspected bladder lacerations, disruptions, massive pelvic bleeding, etc.) delayed surgery (>3 months after the injury)

Complications after delayed surg.repair Incontinence 5% Stricture 5%

Anterior urethra straddle injury iatrogenic instrumentations self-instrumentations

Clinical findings perineal, penile, scrotal haematoma…butterfly urethral bleeding normal DRE

Diagnosis Urethrography: demonstrates extravasation and location of injury do not perform cystoscopy or catheterization before retrograde urethrography if urethral trauma suspected

Treatment ❏simple contusions - no treatment ❏partial urethral disruption • with no resistance to catheterization - Foley x 2-3 weeks • with resistance to catheterization • suprapubic cystostomy • periodic flow rates/urethrograms to evaluate for stricture formation ❏complete disruption • immediate repair if patient stable, delayed repair if unstable suprapubic cystostomy

URETHRAL STRICTURE ❏refers only to anterior urethral scarring (posterior strictures not included) ❏involves scar in corpus spongiosum ❏contraction of this scar will decrease size of urethral lumen ❏more common in males

Etiology ❏congenital ❏trauma ❏infection • may cause hydronephrosis • treat at time of endoscopy with dilatation, internal urethrotomy ❏trauma • instrumentation (most common, at fossa navicularis) • external trauma • urethral trauma with stricture formation ❏infection • common with gonorrhea in the past (not common now) • long-term indwelling catheter • balanitis xerotica obliterans • causes meatal stenosis

Diagnosis and Evaluation ❏signs and symptoms • decreased force/amount of urinary stream • spraying • double stream • post-void dribbling • other UTIs (prostatitis, epididymitis) ❏laboratory findings • flow rates < 10 mL/s (normal = 20 mL/s) • UA and culture usually negative, but may show pyuria, bacteria ❏radiologic findings • urethrogram, VCUG, or ultrasound will demonstrate location ❏urethroscopy

❏internal urethrotomy Treatment ❏dilatation • temporarily increases lumen size by breaking up scar tissue • healing will reform scar tissue and recreate stricture • not usually curative ❏internal urethrotomy • endoscopically incise stricture without skin incision • cure rate 70-80% with single treatment, 90% with repeated courses ❏open surgical reconstruction • completely excise strictures < 2 cm, extending 1 cm beyond each end • patch graft urethroplasty if > 2 cm • full-thickness skin graft obtained from penis to replace urethra

Scrotal injuries Scrotal injury: hematocele, testicular disruption, torsion, skin avulsion, traumatic amputations HEMATOCELE ❏trauma with bleed into tunica vaginalis ❏ultrasound helpful to exclude fracture of testis which requires surgical repair ❏treatment • ice packs, analgesics, surgical repair Rupture Testis Result of testicular compression against the pubis bone, from direct blow, or straddle injuries Extent depends on location of rupture Tunica albuginea ruptures (inner layer of tuncia vaginalis) allows intratesticular hematoma to rupture into hematocele Rupture of tunica vaginalis allow blood to collect under scrotal wall causing scrotal hematoma Doppler often sufficient to assess extent Surgery for uncertain dx, tunica albuginea rupture, compromised doppler flow

Blood as a filling defect in testis

Penile injuries Penile fracture (sex. intercourse -> disruption of the tunica albuginea -> haematoma, CAVE: urethral injury) Penile constriction – rings Penile amputation