Genitourinary Trauma Flashcards
What is the mechanism and presentation of penile fracture?
Mechanism * tunica albuginea thins out during erection * Blunt trauma shears tunica * Sudden increase in intracavernosal pressure Presentation * Popping sound * Acute penile pain and swelling * “Eggplant Deformity” * Rapid detumesence * +/- Hematuria (approx 10% associated urethral injury)
What is the management of penile trauma?
Prompt surgical exploration is indicated if penile fracture is suspected * Ultrasound or MRI is reserved only when the diagnosis of penile fracture is equivocal following history and physical exam * If a patient with a penile fracture has gross hematuria, inability to void, or blood at the meatus evaluation of the urethra with cystoscopy or retrograde urethrogram must be performed
When is penile reimplantation indicated?
* Prompt penile replantation is indicated in patients with traumatic penile amputation * A microscopic reanastomosis of the paired dorsal arteries, dorsal vein, and nerves prevents postoperative complications such as penile sensation loss, urethral stricture, and skin necrosis * Psychiatric consultation should be strongly considered in cases of self mutilation
What is the diagnostic procedure for renal trauma?
* Diagnostic imaging is indicated with gross hematuria or microscopic hematuria with transient hemodynamic instability * Intravenous contrast enhanced Ct scan of the abdomen and pelvis should be performed when there is a possible renal injury
What are the indications for radiologic assessment in the case of flank trauma?
* Flank/abdominal penetrating trauma * Blunt trauma with gross hematuria * Blunt trauma with microhematuria and shock * Deceleration injuries * Pediatric injuries with any hematuria
Describe the grading of renal trauma.
* Grade 1: contusion/subcapsular hematoma * Grade 2: < 1 cm parenchymal lesion * Grade 3: > 1 cm parenchymal lesion s urinary extravasation * Grade 4: deep laceration involving collecting system or injury to main renal vasc c contained hemorr * Grade 5: shattered kidney or renal hilar avulsion
What is the management of renal trauma?
* Non-invasive management should be implemented in patient with renal injury and hemodynamic stability * Immediate intervention is required in patients with renal injury who are hemodynamically unstable despite appropriate resuscitation * Urinary extravasation and renal injury can be observed in the hemodynamically stable patient with an intact collecting system (i.e. no UPJ disruption) * If fever, chills, ileus, increasing urinoma, fistula, or infection develop than urinary drainage via ureteral stent or percutaneous nephrostomy tube is indicated
What are the absolute indications for renal exploration following trauma?
* Non-viable tissue * Persistent renal bleeding * Life threatening bleeding * UPJ Rupture * Extracapsular urine extravasation * Incomplete staging * Renal pedicle avulsion * Expanding retroperitoneal hematoma
What is the diagnostic procedure for ureteral injury?
Intravenous contrast enhanced Ct scan of the abdomen and pelvis should be performed when there is a possible ureteral injury
What is the temporary management of ureteral injury?
Patient s with ureteral injury usually have other life- threatening injuries and temporary urinary drainage with percutaneous nephrostomy can be used with repair in delayed fashion.
What is the management of ureteral trauma?
* Endoscopic ureteral injuries (iatrogenic) should be managed with ureteral stent and/or percutaneous nephrostomy tube drainage Ureteral injuries proximal to the iliac vessels should be repaired primarily when possible * If long segment injury is apparent percutaneous nephrostomy tube drainage followed by delayed repair should be considered * Bowel interposition, transureteroureterostomy (TUU) or autotransplant can be considered Ureteral injuries distal to the level of the vessels should repaired with reimplant of the ureter * Psoas hitch can be used to gain length as can a bladder flap(boari) for extended distal ureteral injures
What are the contraindications to TUU?
Contraindications to TUU include a history of stone disease or previous ureteral malignancy
What is the etiology and mechanism of scrotal trauma?
Etiology * sports injuries * assault * motor vehicle accidents Mechanism testis entrapped against bony structure 50kg force to cause rupture
What is the surgical management of blunt scrotal trauma?
Surgical Management * Salvage rate highest with timely exploration * 25/30 (83%) salvaged * 4/5 not salvaged > 48 hours after injury (Buckley 2006) * < 72 hours 80 - 90% salvage rate * > 9 days salvage rate < 33% (Gross et al, Lupetin et al) Spermatic cord injuries * Vas deferens repair * Delayed if multiple injuries * Ligation of injured vessels Hematocele * > 5cm in size
What is the surgical management of penetrating scrotal trauma?
* Surgical exploration (debridement and tunical closure) should be performed in patients with suspected tunical rupture following blunt trauma * Scrotal ultrasound is reserved for cases where the diagnosis of tunical rupture is equivocal from the history and physical exam * Surgical exploration should be performed in all patients with penetrating scrotal trauma Gunshot wounds Stab wounds Exploration * Hematoma evacuation, debridement, primary closure of tunica albuginea * Corporal injuries * Spermatic cord evaluation * Higher rate of testis salvage for GSW as compared to stab wounds (75% to 23%)