Urosurgery 18 - Trauma

• I
• Contusion -  Microscopic or gross hematuria, urologic studies normal
• Hematoma - Subcapsular, nonexpanding hematoma without parenchymal laceration

• II
• Hematoma - Nonexpanding perirenal hematoma confined to renal retroperitoneum
• Laceration - Laceration <1 cm of renal cortex without urinary extravasation

• III
• Laceration -  Laceration >1 cm depth of renal cortex without collecting system rupture or urinary extravasation

• IV
• Laceration - Parenchymal laceration extending through renal cortex, medulla, and collecting system
• Vascular -  Main renal artery or vein injury with contained hemorrhage

• V
• Laceration - Completely shattered kidney
• Vascular -  Avulsion of renal hilum, devascularizing the kidney

• If there is no loss of length - Spatulation and end-to-end anastomosis without tension
• If there is little loss of length - Mobilise kidney, Psoas hitch of bladder (hitch on Psoas minor muscle), Boari operation
• If there is marked loss of length - Transureteroureterostomy, Interposition of isolated bowel loop or mobilised appendix, Nephrectomy

Ureteroneocystostomy (UNC) refers to reimplantation of the ureter into the bladder. In the adult population, ureteroneocystostomy is primarily used for disease or trauma involving the lower third portion of the ureter that results in obstruction or fistula. In children, ureteroneocystostomy it is commonly used for surgical treatment of vesicoureteral reflux (VUR)

• Indication - Injury, stricture, or obstruction of the distal 3-4 cm of the ureter.
• Distal injuries differ from more proximal injuries in that they are frequently associated with disruption of the blood supply from the iliac vessels and are thus best repaired with a ureteroneocystostomy.

• The surgical approach for ureteroneocystostomy
• - Modified Politano-Leadbetter procedure
• - Lich-Gregoir and modified Lich-Gregoir (involving detrusorrhaphy) procedures. he modified Lich-Gregoir (involving detrusorrhaphy) is a common procedure performed for VUR in the pediatric population
• Modifications, such as a psoas hitch (tacking the posterior bladder wall to the psoas muscle) and a Boari flap (tubularization of a flap of bladder to extend from the bladder to the ureteral orifice), allow for correction of ureteral defects that are longer than 5 cm.

• 
• Psoas muscle -
• Origin - T12, L1-5, Insertion - Lesser trochanter

• Psoas minor - 
• Origin - T12. L1, Insertion - Iliopectneal arch 

• Iliacus 
• Origin - Iliac fossa, Insertion - Lesser trochanter of femur

• 1. Intraperitoneal (20 per cent) - is usually secondary to a blow or fall on a distended bladder,
• 2. Extraperitoneal (80 per cent) - caused by blunt trauma or surgical damage. When the pelvis is fractured by blunt trauma, fragments from the fracture site may perforate the bladder.

• Symptoms - There is usually a history of lower abdominal trauma. Blunt injury is the usual cause. Patients ordinarily are unable to urinate, but when spontaneous voiding occurs, gross hematuria is usually present.
• Signs - hemorrhagic shock secondary to excessive pelvic bleeding, marked suprapubic and lower abdomen tenderness.

A. Emergency measures - treat shock and hemorrhage

B. Management of bladder injury - Catheterization usually is required in patients with pelvic trauma but not if bloody urethral discharge is noted. Bloody urethral discharge indicates urethral injury, and a urethrogram is necessary before catheterization. 

• 1. Extraperitoneal injury
• – Catheter drainage for 10 days.
• - Large blood clots in the bladder or injuries involving the bladder neck should be managed surgically. A lower midline abdominal incision should be made. As the bladder is approached in the midline, a pelvic hematoma, which is usually lateral, should be avoided. Entering the pelvic hematoma can result in increased bleeding from release of tamponade and in infection of the hematoma, with subsequent pelvic abscess. The bladder should be opened in the midline and carefully inspected. After repair, a suprapubic cystostomy tube is usually left in place to ensure complete urinary drainage and control of bleeding.

• 2. Intraperitoneal injury
• – lower midline laparotomy
• - The peritoneum must be closed carefully over the area of injury. The bladder is then closed in separate layers by absorbable suture.
• - At the time of closure, care should be taken that the suprapubic cystostomy is in the extraperitoneal position.

C. Treatment of pelvic fracture

D. Treatment of pelvic hematoma

• Pelvic abscess may develop from extraperitoneal bladder rupture; if the urine becomes infected.
• Peritonitis may develop in intraperitoneal rupture.

The length of male urethra is around 20cm. The urethra can be separated into two broad anatomic divisions:

• 1. Posterior urethra 
• - prostatic
• - membranous - 2 to 2.5 cm

• 2. Anterior urethra
• - bulbous
• - pendulous portions.

1, prostatic urethra; 2, verumontanum, into which enter the ejaculatory ducts; 3, membranous urethra, note physiologic narrowing of urethral luminal diameter due to external striated sphincter; 4, bulbar urethra; 5, pendulous urethra.

• When pelvic fractures occur from blunt trauma, the membranous urethra is sheared from the prostatic apex at the prostatomembranous junction.
• It may be associated with an extraperitoneal rupture of the bladder.

• Patients usually complain of lower abdominal pain and inability to urinate.
• Blood at the urethral meatus is the single most important sign of urethral injury. The presence of blood at the external urethral meatus indicates that immediate urethrography is necessary to establish the diagnosis. Catheterization should not be done. Incomplete prostatomembranous disruption is seen as minor extravasation, with a portion of contrast material passing into the prostatic urethra and bladder.
• Suprapubic tenderness and the presence of pelvic fracture.
• Rectal examination may reveal a large pelvic hematoma with the prostate displaced superiorly (high riding prostate). Superior displacement of the prostate does not occur if the puboprostatic ligaments remain intact.

• 1. Immediate management -
• - Lower midline incision, evacuation of hematoma
• - Suprapubic cystostomy to provide urinary drainage.
• - The suprapubic cystostomy is maintained in place for about 3 months, in case of incomplete lacerations, SPC can be removed within 2-3 weeks.
• - The cystostomy tube should not be removed before voiding cystourethrography shows that no extravasation persists.

2. Delayed urethral reconstruction - Reconstruction of the urethra after prostatic disruption can be undertaken within 3 months, assuming there is no pelvic abscess or other evidence of persistent pelvic infection. The preferred approach is a single-stage reconstruction of the urethral rupture defect with direct excision of the strictured area and anastomosis of the bulbous urethra directly to the apex of the prostate. A 16F silicone urethral catheter should be left in place along with a suprapubic cystostomy. Catheters are removed within a month, and the patient is then able to void.

• 1. Stricturer
• - Primary repair and anastomosis - 50% cases.
• - Delayed repair - 5%.
• 2. Impotence
• 3. Incontinence.

• The anterior urethra is the portion distal to the urogenital diaphragm.
• Cycling accidents, loose manhole covers and gymnasium accidents astride the beam
• Self-instrumentation or iatrogenic instrumentation may cause partial disruption

Extravasated urine is confined in front of the midperineal point by the attachment of Colles’ fascia to the triangular ligament and by the attachment of Scarpa’s fascia just below the inguinal ligament. The external spermatic fascia stops it getting into the inguinal canals. Extravasated urine collects in the scrotum and penis and beneath the deep layer of superficial fascia in the abdominal wall.

• A. Symptoms -
• There is local pain into the perineum and sometimes massive perineal hematoma.
• If voiding has occurred and extravasation is noted, sudden swelling in the area will be present.
• If diagnosis has been delayed, sepsis and severe infection may be present.

• B. Signs
• The perineum is very tender; a mass may be found, as may blood at the urethral meatus.
• Perineal bruising and haematoma, typically with a butterfly distribution.
• Rectal examination reveals a normal prostate.
• The patient usually has a desire to void, but voiding should not be allowed until assessment of the urethra is complete.
• No attempt should be made to pass a urethral catheter

• When presentation of such injuries is delayed, there is massive urinary extravasation and infection in the perineum and the scrotum.
• Heavy bleeding from the corpus spongiosum injury may occur in the perineum as well as through the urethral meatus.
• The complications of urinary extravasation are chiefly sepsis and infection.
• Stricture at the site of injury is a common complication, but surgical reconstruction may not be required unless the stricture significantly reduces urinary flow rates.

A. Immediate management - Major blood loss usually does not occur from straddle injury. If heavy bleeding does occur, local pressure for control, followed by resuscitation, is required.

• B. Specific Measures
• 1. The patient with urethral contusion shows no evidence of extravasation, and the urethra remains intact. After urethrography, the patient is allowed to void; and if the voiding occurs normally, without pain or bleeding, no additional treatment is necessary. If bleeding persists, urethral catheter drainage can be done.
• 2. Urethral lacerations - SPC and complete urinary diversion, voiding study in 2-3 weeks, remove SPC if no extravasation is documented. Infection and abscess formation are common after extensive urinary extravasation and require antibiotic therapy.

• Indications -
• 1. In the patients where urethral access is not possible such as
• - complete urethral stenosis
• - bladder neck contracture
• - traumatic urethral disruption.
• 2. Need for a chronic indwelling catheter (i.e., neurogenic bladder, poor patient or cooperation/support for clean intermittent catheterization) because some evidence suggests that an SC may be associated with less discomfort than a urethral catheter.
• 3. Relative indications for SC placement also include patients who decline urethral catheterization for sexual or self-image purposes.

• Techniques of SPC insertion
• Percutaneous blind technique
• Open Technique

Technique of blind technique - The distended bladder should be palpated or percussed to delineate its borders. Failure to palpate the bladder is a relative contraindication to blind percutaneous access techniques. A 5- to 10-mm incision is 3 to 4 cm above the symphysis pubis in the midline of the abdomen. Access can then be obtained using a trocar technique, in which a sharp stylet or trocar is used to penetrate the layers of the abdominal wall and bladder. An alternative approach employs the Seldinger technique. 

• Complications -
• Related to initial insertion - hematuria, perivesical fluid collections, surrounding organ injury
• Long-term use - catheter blockage/ encrustation, dislodgement, skin site infections, symptomatic UTI, urothelial neoplasms, and stone formation

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