Retroperitoneal/urinary tract injuries

Question 1

what is the weakest portion of the bladder?

Answer 1

The dome where the tracheal remnant fixes the bladder to the lower anterior abdominal wall

Question 2

what parts of the bladder are covered by the peritoneal reflection?

Answer 2

dome and posterior bladder (can have intraperitoneal injury here)

Question 3

which parts of the bladder are protected within the bony pelvis?

Answer 3

anterior wall, lateral wall, and base of the bladder (blow out injuries are less frequent, are typically from laceration by bony fragments from pelvic fx)

Question 4

where are extraperitoneal bladder perforations from?

Answer 4

anterior wall, lateral wall, base of the bladder (no true peritoneal lining)

Question 5

are a majority of bladder injuries blunt of sharp?

Answer 5

blunt

Question 6

is injury to the anterior urethra usually blunt or penetrating?

Answer 6

both

Question 7

is injury to the posterior urethra usually blunt of penetrating

Answer 7

blunt

Question 8

How do you dx bladder trauma?

Answer 8

retrograde cystography (CT)

Question 9

what does an extraperitoneal bladder rupture look like?

Answer 9

flame or sunburst contrast pattern

Question 10

what does an intraperitoneal bladder rupture look like

Answer 10

outlining loops or filling the cul-de-sac

Question 11

what is the treatment for intraperitoneal bladder perforations?

Answer 11

immediate repair

Question 12

what is the treatment for uncomplicated extraperitoneal bladder perforations?

Answer 12

foley drainage

Question 13

what is the treatment for complicated extraperitoneal bladder perforations?

Answer 13

repair at time of exploration for other injuries

Question 14

how do you repair the bladder?

Answer 14

two layer, water tight closure, with absorbable sutures, foley drainage

no need for suprapubic tube as long as foley can go in

Question 15

how should you treat urethral distraction injuries?

Answer 15

percutaneous suprapubic tube placement

once stable, can do primary realignment with cystoscopy and foley later

Question 16

how should you treat penetrating anterior urethral injuries?

Answer 16

exploration, primary closure at time of injury with tension-free, watertight closure w/absorbable sutures, foley

Question 17

how should you treat blunt anterior urethral injuries

Answer 17

prompt suprapubic tube placement or foley. Immediate operative repair or debridement is not recommended

Question 18

when should you get a retrograde cystography after foley placement?

Answer 18

10-14 days

Question 19

what is the MC long term complication of urethral injury?

Answer 19

stricture formation

Question 20

where does blood supply to the ureter come from?

Answer 20

the great vessels, medially in the abdominal ureter and laterally in the pelvic ureter

Question 21

what is the mc of injury to the ureter?

Answer 21

iatrogenic (ureteroscopy, hysteroscopy, colectomy)

Question 22

How do you dx a ureteral/renal injury?

Answer 22

IV enhanced CT (with delayed images for ureteral injury) with retrograde filling

Question 23

what is a grade I renal injury?

Answer 23

sub capsular hematoma without laceration or contusion

Question 24

what is a grade II renal injury?

Answer 24

non expanding perirenal hematoma, or lacerations <1 cm deep without urinary extravasation

Question 25

what is grade III renal injury?

Answer 25

parenchymal laceration >1 cm deep without collecting system injury

Question 26

what is a grade IV renal injury

Answer 26

laceration extending into the collecting system or vascular injury to the main hisar vessels with contained hemorrhage

Question 27

what is a grade V renal injury?

Answer 27

completely shattered parenchyma or avulsion of the renal hilum with devascularized kidney parenchyma

Question 28

Follow up CT for renal trauma should be done for?

Answer 28

grade IV-V injuries or w/clinical signs of complications such as fever, increased pain, distention

Question 29

medial hematoma suggests

Answer 29

vascular injury

Question 30

medial urinary extravasation suggests

Answer 30

ureteropelvic junction avulsion

Question 31

poor renal contrast enhancement suggests

Answer 31

artery laceration and or thrombus

Question 32

how do you repair a distal ureteral injury?

Answer 32

ureteroneocystostomy with or without posts hitch

Question 33

how do you repair a proximal ureteral injury (short segment)?

Answer 33

ureteroureterostomy

Question 34

how do you repair a proximal ureter injury (long segment)?

Answer 34

ureteroneocystostomy with posts hitch if possible, can also do Boari flap if ureter cannot be directly reimplanted into the bladder

Question 35

how should injuries at the ureteropelvic junction be managed?

Answer 35

dismembered pyeloplasty

Question 36

how to managed a ureteral injury in damage control surgery?

Answer 36

ureter can be ligated with post op nephrostomy tube or a ureteral stent can be inserted and externalized to drain urine outside the abdomen

Question 37

what is flank ecchymosis called?

Answer 37

Grey Turner sign

Question 38

what is umbilical ecchymosis called?

Answer 38

Cullen sign

Question 39

what is proximal thigh ecchymosis called?

Answer 39

Fox sign

Question 40

What is scrotal ecchymosis called?

Answer 40

Bryant sign

Question 41

How would you access the suprarenal inframesocolic aorta?

Answer 41

Left medial visceral rotation (Mattox maneuver)

Question 42

How would you access the infernal aorta?

Answer 42

reflect the mesocolon cephalic with evisceration of the small bowel to the right and incising through the retroperitoneum overlying the aorta

Question 43

how to get control of the infra hepatic and suprarenal IVC

Answer 43

kocher manuever

Question 44

How to control bleeding at the iliac vein bifurcation

Answer 44

division of the right common iliac artery (rare)

Question 45

how to treat an unstable patient with a renal artery transection with normal contralateral kidney?

Answer 45

nephrectomy

Question 46

can you do a renal vein ligation without nephrectomy on the left?

Answer 46

yes - collateral venous flow

Question 47

can you do a renal vein ligation without nephrectomy on the right?

Answer 47

no, must do nephrectomy either at index or second look surgery