Trauma genitourinario

Trauma genitourinario

1. Trauma&Genitourinario&
&
Dr.&Chris2an&Haussmann&
2015&
!

2. Guidelines on
Urological
Trauma
D.J. Summerton (Chair), N. Djakovic, N.D. Kitrey,
F.E. Kuehhas, N. Lumen, E. Serafetinidis, D.M. Sharma
© European Association of Urology 2015

3. Trauma&Genitourinario&
• Trauma!!!principal!causa!de!muerte!en!menores!40!años!
• Traumas!abdominales:!10715%!asociado!a!trauma!GU!
• Ambos!sexos,!más!común!en!hombres&
• En!todos!los!grupos!etáreos!
• Riñón!es!el!más!comúnmente!afectado!!
• Principal! problema! es! el! diagnósFco!!!politrauma,!
múlFples!lesiones,!pasa!desapercibido!
• Clasif.:! Alto! (Riñón! y! uréter)! y! bajo! (vejiga,! uretra! y!
genitales)!

4. Trauma&Genitourinario&
• Requiere&un&alto&índice&de&sospecha&&
– Trauma!Contuso:!caídas,!atropello,!acc.!AutomovilísFco,!
aceleración/desaceleración,!acc.! industrial,!
politraumaFzado,!deporte!de!contacto.!
– Trauma!Penetrante:!arma!de!fuego,!puñalada.!

5. Trauma&Genitourinario&
• Hallazgos!clínicos!sugieren!Trauma!GU:!Fx.!costales!
bajas,!hematoma!torácico!inferior/lumbar,!herida!
penetrante,!Fx.! de! pelvis,! globo! vesical,! trauma!
perineal,!próstata!ascendida.!
• Signos&capitales:!!
– Micro&o&macrohematuria**&
– Uretrorragia!
– Globo!vesical!
– Incapacidad!miccional!
– Próstata!ascendida!o!no!palpable!al!TR!
– Escape!vaginal!de!orina!
!

6. TRAUMA&RENAL&

7. Anatomía&
8 SECTION I ! Anatomy
vasculature via the pancreaticoduodenal artery. Overlying the 2nd
lumbar vertebrae, the paired renal arteries are the next branching
point of the aorta. To the urologist, renal artery anatomy is obvi-
ously of great importance and is discussed in detail in the kidney
section.
Moving distally on the aorta, the paired gonadal arteries are
encountered. In the male this artery is also called the testicular
artery and in the female it is the ovarian artery. The initial course
in both the male and female is similar, with the artery moving
caudally and laterally from the aorta, with the right gonadal
artery crossing anterior to the inferior vena cava. In
men, the gonadal artery then crosses over the ureter
and exits the retroperitoneum at the internal inguinal
ring. In women the course is different: Instead of exiting
the pelvis, the artery crosses medially back over the
external iliac vessels and enters the pelvis. It then pro-
ceeds via the suspensory ligament to the ovary. The destination
of the gonadal artery (the testis in the male and the ovary in the
female) has significant collateral sources of arterial blood, from
the deferential and cremasteric arteries in the male and the
uterine artery in the female. Thus the gonadal artery can gener-
ally be ligated during retroperitoneal surgery without detrimental
effect.
Great Vessels
The abdominal aorta and inferior vena cava are the great vessels
of the abdomen, providing vascular supply to the abdominal
organs and lower extremities (Figs. 1–10 and 1–11).
Abdominal Aorta
The aorta enters the abdomen via the aortic hiatus found between
the diaphragmatic crura in the posterior diaphragm at the level
of the 12th thoracic vertebrae (see Fig. 1–2). It continues caudally
to the 4th lumbar vertebrae, where it bifurcates into the common
iliac arteries. During its course through the abdomen the aorta
gives off a number of large branches (Table 1–2). The paired
inferior phrenic arteries are first. They supply the inferior
diaphragm and the superior portion of the adrenal gland (see Fig.
1–2). Next is the celiac trunk, which is the origin for the
common hepatic, left gastric, and splenic arteries that
supply the liver, stomach, and spleen, respectively. The
paired adrenal arteries follow with an artery going to
each adrenal gland. The superior mesenteric artery
leaves the aorta on the anterior side and supplies the
entire small intestine and majority of the large intestine.
Also of note, this artery communicates with the celiac trunk
Figure 1–5. Posterior abdominal wall musculature, deep dissection. The lumbodorsal fascia and costovertebral ligament are visualized,
arising from the transverse processes of the lumbar vertebrae. The relation of the kidney and pleura is also shown.
4 SECTION I ! Anatomy
B
A
Figure

1–1.

A
,

The

retroperitoneum

dissected.

The

anterior

perirenal

(Gerota)

fascia

has

been

removed.

B
,

1,

Diaphragm.

2,

Inferior

vena

cava.

3,

Right

adrenal

gland.

4,

Upper
pointer,

celiac

artery;

lower pointer,

celiac

autonomic

nervous

plexus.

5,

Right

kidney.

6,

Right

renal

vein.

7,

Gerota

fascia.

8,

Pararenal

retroperitoneal

fat.

9,

Perinephric

fat.

10,

Upper pointer,

right

gonadal

vein;

lower pointer,

right

gonadal

artery.

11,

Lumbar

lymph

nodes.

12,

Retroperitoneal

fat.

13,

Right

common

iliac

artery.

14,

Right

ureter.

15,

Sigmoid

colon

(cut).

16,

Esophagus

(cut).

17,

Right

crus

of

diaphragm.

18,

Left

inferior

phrenic

artery.

19,

Upper pointer
,

left

adrenal

gland;

lower pointer
,

left

adrenal

vein.

20,

Upper pointer,

superior

mesenteric

artery;

lower pointer,

left

renal

artery.

21,

Left

kidney.

22,

Upper pointer,

left

renal

vein;

lower pointer,

left

gonadal

vein.

23,

Aorta.

24,

Perinephric

fat.

25,

Aortic

autonomic

nervous

plexus.

26,

Upper pointer,

Gerota

fascia;

lower pointer,

inferior

mesenteric

ganglion.

27,

Inferior

mesenteric

artery.

28,

Aortic

bifurcation

into

common

iliac

arteries.

29,

Left

gonadal

artery

and

vein.

30,

Left

ureter.

31,

Psoas

major

muscle

covered

by

psoas

sheath.

32,

Cut

edge

of

peritoneum.

33,

Pelvic

cavity.

8. Trauma&renal&
• 175%!de!todos!los!traumas,!10%!de!los!traumas!abdominales!
• Trauma!más!común!de!la!vía!urinaria!
• Razón!hombre/mujer!de!!3/1!
!
• Mayoría!por!trauma&cerrado&de!alta!energía!
• Trauma!penetrante!se!asocia!a!lesiones!otros!órganos!
• Hematuria!a!menudo!presente!
• Alteraciones!renales!preexistentes!aumentan!riesgo!de!lesión!
renal!por!trauma!cerrado!(quistes,!tumores)!
• En!lesiones!severas!las!complicaciones&tardías&incluyen:!
hematoma,!hematuria,!urinoma,!infección,!dolor!HTA7RV!

9. CHAPTER 42 ! Upper Urinary Tract Trauma 1171
27 of 50 patients with penetrating renal trauma had microscopic
hematuria. Three of these patients had 0 to 3 RBCs/HPF, and one
of the three had a renal pedicle injury. The presence of shock,
degree of hematuria, location of the entry wound, and type of
injury do not permit reliable discrimination among categories.
Pediatric patients (younger than 18 years) sustaining blunt renal
trauma must be carefully evaluated. Children are known to be at
a greater risk for renal trauma than adults after blunt abdominal
injury (Brown and colleagues, 1998a). For pediatric patients,
liberal use of imaging studies should be considered, especially
in the setting of high-speed/high-energy deceleration injuries
and resuscitation; and (5) all pediatric patients with
greater than 5 red blood cells (RBCs)/HPF. Patients who
are hemodynamically unstable after initial resuscitation
require surgical intervention.
The best indicator of renal injury is hematuria, defined as
5 RBCs/HPF by most authors. Historically, when used as the sole
indication for renal imaging, IVP and other studies found a low
incidence of renal abnormalities. An extensive prospective study
based at San Francisco General Hospital evaluating indications for
radiographic imaging has been ongoing for more than 25 years.
The findings have been updated on three reports (Mee et al, 1989;
Miller and McAninch, 1995; Nicolaisen et al, 1985). Figure 42–2
provides the results of the study for adult blunt renal trauma. On
the basis of information from this study, all blunt trauma patients
with gross hematuria and patients with microscopic hematuria
and shock (systolic blood pressure <90 mm Hg any time during
evaluation and resuscitation) should undergo renal imaging,
usually with CT using intravenous contrast.
Patients with microscopic hematuria without shock
can be observed clinically without imaging studies. As
first noted by Miller and McAninch (1995), several studies confirm
the findings that these patients rarely have a significant injury
(<0.0016%). However, if possible renal injury is suspected on the
basis of history or examination, imaging should be performed. For
example, blunt rapid deceleration injuries such as high-speed
motor vehicle accidents or falls from great heights are at risk for
vascular injury. These can cause significant injury (usually ureteral
avulsion or vessel injury) in the absence of microscopic
hematuria.
Penetrating injuries with any degree of hematuria
should be imaged. In a report by Carroll and McAninch (1985),
Figure 42–1. Classification of renal injuries by grade (based on the organ injury scale of the American Association for the Surgery of
Trauma [based on Moore et al, 1989]).
Grade I Grade II Grade III
Grade IV Grade V
Figure 42–2. Algorithm demonstrating the results of the authors’
study on radiographic assessment of renal injuries. In adults with
blunt trauma, imaging studies may be performed selectively. SBP,
systolic blood pressure. (From Miller KS, McAninch JW.
Radiographic assessment of renal trauma. Our 15-year experience.
J Urol 1995;154:352–5.)
Microhematuria
and no shock
Imaged–
contusion
581
Imaged–
significant injury
3
No significant renal injuries missed
Without
imaging
1004
1 renal repair
Gross hematuria
or
microhematuria
and shock
(SBP <90 mm Hg)
all imaged–422
Significant
renal injuries
78
Renal repair
34
CHAPTER 42 ! Upper Urinary Tract Trauma 1171
27 of 50 patients with penetrating renal trauma had microscopic
hematuria. Three of these patients had 0 to 3 RBCs/HPF, and one
of the three had a renal pedicle injury. The presence of shock,
degree of hematuria, location of the entry wound, and type of
injury do not permit reliable discrimination among categories.
Pediatric patients (younger than 18 years) sustaining blunt renal
trauma must be carefully evaluated. Children are known to be at
a greater risk for renal trauma than adults after blunt abdominal
injury (Brown and colleagues, 1998a). For pediatric patients,
liberal use of imaging studies should be considered, especially
in the setting of high-speed/high-energy deceleration injuries
and resuscitation; and (5) all pediatric patients with
greater than 5 red blood cells (RBCs)/HPF. Patients who
are hemodynamically unstable after initial resuscitation
require surgical intervention.
The best indicator of renal injury is hematuria, defined as
5 RBCs/HPF by most authors. Historically, when used as the sole
indication for renal imaging, IVP and other studies found a low
incidence of renal abnormalities. An extensive prospective study
based at San Francisco General Hospital evaluating indications for
radiographic imaging has been ongoing for more than 25 years.
The findings have been updated on three reports (Mee et al, 1989;
Miller and McAninch, 1995; Nicolaisen et al, 1985). Figure 42–2
provides the results of the study for adult blunt renal trauma. On
the basis of information from this study, all blunt trauma patients
with gross hematuria and patients with microscopic hematuria
and shock (systolic blood pressure <90 mm Hg any time during
evaluation and resuscitation) should undergo renal imaging,
usually with CT using intravenous contrast.
Patients with microscopic hematuria without shock
can be observed clinically without imaging studies. As
first noted by Miller and McAninch (1995), several studies confirm
the findings that these patients rarely have a significant injury
(<0.0016%). However, if possible renal injury is suspected on the
basis of history or examination, imaging should be performed. For
example, blunt rapid deceleration injuries such as high-speed
motor vehicle accidents or falls from great heights are at risk for
vascular injury. These can cause significant injury (usually ureteral
avulsion or vessel injury) in the absence of microscopic
hematuria.
Penetrating injuries with any degree of hematuria
should be imaged. In a report by Carroll and McAninch (1985),
Figure 42–1. Classification of renal injuries by grade (based on the organ injury scale of the American Association for the Surgery of
Trauma [based on Moore et al, 1989]).
Grade I Grade II Grade III
Grade IV Grade V
Figure 42–2. Algorithm demonstrating the results of the authors’
study on radiographic assessment of renal injuries. In adults with
blunt trauma, imaging studies may be performed selectively. SBP,
systolic blood pressure. (From Miller KS, McAninch JW.
Radiographic assessment of renal trauma. Our 15-year experience.
J Urol 1995;154:352–5.)
Microhematuria
and no shock
Imaged–
contusion
581
Imaged–
significant injury
3
No significant renal injuries missed
Without
imaging
1004
1 renal repair
Gross hematuria
or
microhematuria
and shock
(SBP <90 mm Hg)
all imaged–422
Significant
renal injuries
78
Renal repair
34
Clasificación&

10. Evaluación&Diagnós2ca&
• Politrauma:!Estabilización/resucitación!(ABCDE)!
• Historia!y!examen!]sico!sugerentes!
• Lab:!!
– Hematuria!macro!o!micro!(uroManálisis)!
– Hematocrito!seriado!
– Crea2nina!basal!
• Imágenes:!!
– Indicaciones:!Penetrante,!contuso!con!hematuria!o!
hipotensión,!mec!des/aceleración!rápida,!lesión!de!otros!
órganos!
– GS:&TAC&Trifásico&con&fase&de&eliminación&tardía!(10715!min)!!
– Otros:!ECO,!PIV,!PIV7IO!

11. Manejo&
• ABC!del!Trauma!
• Grado!I!!!TTO!conservador*!
• Grado!II!!!
• Grado!III!!TTO!conservador!en!ausencia!de!lesiones!
Grado!IV!!!!!!!!intraperitoneales**!
!
• Grado!V!!!!!Exploración!renal!
*!Reposo!absoluto,!JJ!en!caso!de!sangrado,!control!imagen!
**!20%!sangrado!tardío,!mayoría!TTO!con!embolización!!

12. Manejo&
• Exploración!renal!
1. Hemorragia!renal!con!riesgo!
vital!/!Hemodinamia!inestable!
2. Exploración!por!lesiones!
asociadas!
3. Hematoma!retroperitoneal!
expansivo!o!pulsáFl!
4. Lesión!Grado!V!
• En!caso!de!cirugía!de!urgencia,!
priorizar!manejo!conservador!renal!si!
hemodinamia!lo!permite.!
• Exploración!renal!
1. Hemodinamia!inestable!
2. Exploración!por!lesiones!
asociadas!
3. Hematoma!peri7renal!expansivo!
o!pulsáFl!(laparotomía)!
4. Lesión!vascular!G!5!
• En!caso!de!cirugía!de!urgencia,!
priorizar!manejo!conservador!renal!si!
hemodinamia!lo!permite.!

13. CHAPTER 42 ! Upper Urinary Tract Trauma 1175
vascular control before opening Gerota fascia can
decrease renal loss: in a comparative series, the total nephrec-
tomy rate was reduced from 56% to 18% (McAninch and Carroll,
1982). Carroll and coauthors (1989), evaluating the use of early
vascular control, reported the need to occlude the vessels in 12%
of renal explorations. In a series of 133 renal units in which early
vessel isolation and control before opening Gerota fascia was
achieved in all, McAninch and colleagues (1991) reported a renal
salvage rate of 88.7%.
The need for early vascular control has been questioned. Cor-
riere and colleagues (1991) reported a series of renal units in which
vascular control was obtained only if needed after opening Gerota
fascia. In this group, the total nephrectomy rate was 37.1%. Atala
and colleagues (1991) reported a similar group of patients with a
total nephrectomy rate of 36.2%. On the whole, the currently
available data support an improved renal salvage rate with early
vascular control because patients who require temporary vascular
occlusion cannot be reliably identified before renal inspection.
Renal Reconstruction
The principles of renal reconstruction after trauma
include complete renal exposure, measures for tempo -
rary vascular control, debridement of nonviable tissue,
hemostasis by individual suture ligation of bleeding
vessels, watertight closure of the collecting system if
possible, coverage or reapproximation of the parenchy -
mal defect, and judicious use of drains (Fig. 42–7).
Renorrhaphy is illustrated in Figure 42–8 and involves exposure
of the kidney, debridement of nonviable tissue, hemostasis
obtained with absorbable 4-0 chromic sutures on bleeding vessels
(the addition of hemostatic agents such as Floseal [Baxter; Deer-
field, IL] may also be helpful), closure of the collecting system,
and approximation of the margins of the laceration (3-0 absorb-
able suture) with the use of renal capsule and an absorbable hemo-
static agent bolster such as Gelfoam (Pfizer; New York, NY).
When polar injuries cannot be reconstructed, a partial nephrec-
tomy should be done and all nonviable tissue removed, hemo-
stasis obtained, and the collecting system closed. The open
parenchyma should then be covered when possible by a pedicle
flap of omentum (see Fig. 42–7). With its rich vascular and
In some reported series of penetrating injuries, associated organ
injury has been noted to be as high as 94% (McAninch et al,
1993). Injuries to the great vessels, liver, spleen, pancreas, and
bowel can be identified and stabilized if necessary before renal
exploration.
The surgical approach to renal exploration is shown in Figure
42–6 (McAninch and Carroll, 1989). The renal vessels are isolated
before exploration to provide the immediate capability to occlude
them if massive bleeding should ensue when Gerota’s fascia is
opened (Scott and Selzman, 1966). The transverse colon is lifted
superiorly onto the chest, and the small bowel is lifted superiorly
and to the right. This exposes the midretroperitoneum. An inci-
sion is made over the aorta in the retroperitoneum just superior
to the inferior mesenteric artery. The incision is extended superi-
orly to the ligament of Treitz. Exposure of the anterior surface of
the aorta is accomplished and followed superiorly to the left renal
vein, which crosses the aorta anteriorly. With a vessel loop con-
trolling the vein, the anatomic relationships of the right and left
renal arteries as they leave the aorta provide the ability to isolate
and secure these structures with vessel loops. The right renal vein
can be secured through this incision; if this proves difficult, reflect-
ing the second portion of the duodenum provides excellent expo-
sure to the vein.
Large hematomas may extend over the aorta and obscure the
landmarks for the planned initial retroperitoneal incision. In such
instances, the inferior mesenteric vein can be used as an anatomic
guide for an appropriate incision. By making the retroperitoneal
incision just medial to the inferior mesenteric vein and dissecting
through the hematoma, the anterior surface of the aorta can be
identified and followed superiorly to the crossing left renal vein.
The kidney is exposed by incising the peritoneum lateral to the
colon, followed by mobilization off Gerota fascia. This maneuver
often requires release of the splenic (left) or hepatic (right) attach-
ments of the colon. Gerota fascia is then opened and the kidney
with injury is completely dissected from the surrounding hema-
toma. Should troublesome bleeding develop, the previously iso-
lated vessels can be temporarily occluded with a vascular clamp
or a vessel loop tourniquet.
Is Early Vessel Isolation Necessary? Renal bleeding is a major
cause of nephrectomy in renal trauma. Obtaining early
Figure 42–6. The surgical approach to the renal vessels and kidney. A, Retroperitoneal incision over the aorta medial to the inferior
mesenteric vein. B, Anatomic relationships of the renal vessels. C, Retroperitoneal incision lateral to the colon, exposing the kidney.
Aorta
Inferior
mesenteric vein
Inferior
mesenteric vein
Left renal
vein
Right renal
vein
Left renal
artery
Right renal
artery
Gonadal
vein
A B C

14. 1176 SECTION IX ! Upper Urinary Tract Obstruction and Trauma
Figure 42–7. Technique for partial nephrectomy: A, total renal exposure; B, sharp removal of nonviable tissue; C, hemostasis obtained and
collecting system closed; D, defect covered.
B Partial polar
nephrectomy
A C Collecting system
closure
D Omental pedicle
flap
Figure 42–8. Technique for renorrhaphy: A, typical injury in midportion of kidney; B, debridement, hemostasis, and collecting system
closure; C, approximation of parenchymal margins; D, sutures tied over gelatin sponge bolster.
A Deep midrenal laceration into
pelvis
B Closure of pelvis
Ligation of vessels
C Defect closure D Absorbable gelatin
sponge (Gelfoam) bolster
lymphatic supply, omentum promotes wound healing and
decreases the risk of delayed bleeding and urinary extravasation.
Should it not be available, the use of absorbable mesh, peritoneal
graft, or retroperitoneal fat has been successful (Master and
McAninch, 2006).
Hemostatic agents such as Floseal are potent and have an
increasing role in the management of genitourinary trauma (Evans
and Morey, 2006). On the basis of experience from nephron-
sparing surgery, gelatin matrix was applied to a porcine model of
complex renal trauma and demonstrated less mean blood loss
than conventional suture treatment (Hick et al, 2005; Pursifull
et al, 2006).
In a high percentage of major renal injuries, intra-abdominal
structures are also injured, the liver and spleen being the most
common. Injuries to the colon, pancreas, and stomach also occur
frequently, and in previous years total nephrectomy was suggested
because of the high complication rate with attempted renal
salvage. However, renal repair in these injuries has been successful
with minimal complications (Rosen and McAninch, 1994; Wes-
sells and McAninch, 1996). Drains should be used liberally in
these repairs.
Renovascular Injuries. Renovascular injuries following trauma
are uncommon and often have associated injuries requiring
operative intervention. For major renovascular injuries, speedy
nephrectomy is advocated. In rare instances where repair is pos-
sible, renal salvage rates are low, exemplified by a 33% renal
salvage rate for main renal artery reconstruction even in the most
expert of hands (Elliott et al, 2007). Vascular repair requires occlu-
sion of the involved vessel with vascular clamps. The lacerated
main renal vessels injured by penetrating trauma can be repaired
with 5-0 nonabsorbable vascular suture (Fig. 42–9).
Main renal artery thrombosis from blunt trauma occurs second-
ary to deceleration injuries. The mobility of the kidney results in
stretch on the renal artery, which in turn causes the arterial intima,
low in elastic fibers, to disrupt. The consequent thrombus occludes
the vessel, rendering the kidney ischemic (Fig. 42–10). Prompt
diagnosis by CT or angiography may lead to immediate renal
exploration in the appropriate candidate in an attempt to salvage
the kidney, but outcomes for salvage remain dismally low and
nephrectomy is almost always required.
Case reports of successful renal revascularization through the
use of endovascular stents during angiography offer a new and
perhaps promising approach to the problem of blunt trauma renal
artery thrombosis caused by the intimal flap (Inoue et al, 2004).
The great disadvantage of this approach has been the inability to
effect anticoagulation in the polytrauma patient.
With delayed diagnosis ( >8 hours), the kidney typi -
cally cannot be salvaged (Cass, 1989). With a 15-year

15. TRAUMA&URETERAL&
&

16. Trauma&ureteral&
• Raras,!mayoría!iatrogénica!y!penetrantes!
• Desapercibidas!durante!cirugía!!
• >!uréter!inferior,!secuelas!graves!potenciales!
• FR:!Alteración!anatomía!(neo!avanzado,!Cx,!RT)!

17. ANATOMÍA&URÉTERES&
4 SECTION I ! Anatomy
B
A
Figure

1–1.

A
,

The

retroperitoneum

dissected.

The

anterior

perirenal

(Gerota)

fascia

has

been

removed.

B
,

1,

Diaphragm.

2,

Inferior

vena

cava.

3,

Right

adrenal

gland.

4,

Upper
pointer,

celiac

artery;

lower pointer,

celiac

autonomic

nervous

plexus.

5,

Right

kidney.

6,

Right

renal

vein.

7,

Gerota

fascia.

8,

Pararenal

retroperitoneal

fat.

9,

Perinephric

fat.

10,

Upper pointer,

right

gonadal

vein;

lower pointer,

right

gonadal

artery.

11,

Lumbar

lymph

nodes.

12,

Retroperitoneal

fat.

13,

Right

common

iliac

artery.

14,

Right

ureter.

15,

Sigmoid

colon

(cut).

16,

Esophagus

(cut).

17,

Right

crus

of

diaphragm.

18,

Left

inferior

phrenic

artery.

19,

Upper pointer
,

left

adrenal

gland;

lower pointer
,

left

adrenal

vein.

20,

Upper pointer,

superior

mesenteric

artery;

lower pointer,

left

renal

artery.

21,

Left

kidney.

22,

Upper pointer,

left

renal

vein;

lower pointer,

left

gonadal

vein.

23,

Aorta.

24,

Perinephric

fat.

25,

Aortic

autonomic

nervous

plexus.

26,

Upper pointer,

Gerota

fascia;

lower pointer,

inferior

mesenteric

ganglion.

27,

Inferior

mesenteric

artery.

28,

Aortic

bifurcation

into

common

iliac

arteries.

29,

Left

gonadal

artery

and

vein.

30,

Left

ureter.

31,

Psoas

major

muscle

covered

by

psoas

sheath.

32,

Cut

edge

of

peritoneum.

33,

Pelvic

cavity.

18. Evaluación&Diagnós2ca&
• Mayoría!diagnosFcada!tarde!
• Requiere!alto!índice!de!sospecha:!Tipo!de!cirugía,!
uroperitoneo!con!elevación!de!creaFnina,!cólico!
renal,!drenajes!con!alto!débito.!
• Imágenes:!!
" TAC!muestra!extravasación!de!cte!en!caso!de!lesión!
penetrante!
" Hidronefrosis!

19. Manejo&
• Depende!de!Fpo!y!lugar!de!lesión.!Se!aconseja!la!reparación!inmediata!
• Ligadura,!lesión!parcial:!JJ!o!derivación!urinaria!con!nefrostomía!
• Lesión!completa:!!
– IO!reparación!primaria!o!reimplante!según!altura.!!
– Derivación!urinaria!en!caso!de!segmento&importante&con!reparación!diferida!
CHAPTER 42 ! Upper Urinary Tract Trauma 1183
2. Debride the ureter liberally until the edges bleed, especially
in high-velocity gunshot wounds.
3. Repair ureters with spatulated, tension-free, stented (Palmer
et al, 1983), watertight anastomosis; using fine absorbable
monofilament such as 5-0 polydioxanone; use optical mag-
nification and retroperitoneal drainage afterward.
4. Retroperitonealize the ureteral repair by closing peritoneum
over it.
5. With severely injured ureters, blast effect, concomitant vas-
cular surgery, and other complex cases, consider omental
interposition to isolate the repair when possible.
Ureteroureterostomy, or so-called end-to-end repair, is used in
injuries to the upper two thirds of the ureter. It is required com-
monly, up to 32% of the time in large series (Presti et al, 1989;
Elliott and McAninch, 2003), and has a reported success rate as
high as 90% (Carlton et al, 1971). Complications after ureteroure-
terostomy, usually urine leakage, occur 10% to 24% of the time
(Bright and Peters, 1977a; Pitts and Peterson, 1981; Presti et al,
1989; Campbell et al, 1992; Velmahos et al, 1996; Medina et al,
1998). Other acute complications include abscess and fistula.
Chronic complications, usually comprising ureteral stenosis, are
less common, involving approximately 5% (Palmer et al, 1999) to
12% (Velmahos et al, 1996) of patients. Interestingly, some authors
report prolonged leakage of urine from the drain in patients with
ureteral injury after external violence who underwent repair but
otherwise did well. Steers and colleagues (1985) reported that most
of their patients had persistent drainage (averaging 12 days) from
the retroperitoneal Penrose drain after repair. This has not been
our experience, but this observation might prompt watchful
waiting in such patients who leak persistently after repair. Routine
retroperitonealization of the repair may decrease the time or sever-
ity of postoperative urine leakage.
Management of dehiscence by percutaneous nephrostomy
placement and ureteral catheter placement for at least 6 weeks has
been reported in small studies, with a surprisingly good success
published data to assess its accuracy to date (Kenney et al, 1987;
Townsend and DeFalco, 1995). Reports of the utility of CT in
ureteral trauma are still limited to small numbers of cases.
Ureteral injuries can be difficult to diagnose on CT. If the
urinary extravasation from the ureteral injury is contained by
Gerota fascia, the extent of medial leakage can be small, obscuring
the diagnosis (Kenney et al, 1987). It is also known that ureteral
injuries often manifest with absence of contrast in the ureter on
delayed images. This underscores the absolute necessity of tracing
both ureters throughout their entire course on CT scans obtained
to evaluate urogenital injuries (Townsend and DeFalco, 1995). In
addition, because modern helical CT scanners can obtain images
before intravenous contrast dye is excreted in the urine, delayed
images must be obtained (5 to 20 minutes after contrast injection)
to allow contrast material to extravasate from the injured collect-
ing system, renal pelvis, or ureter (Brown et al, 1998; Mulligan
et al, 1998; Kawashima et al, 2001). Because ureteral injuries are
often detected late, periureteral urinoma seen on delayed CT scans
may be diagnostic (Gayer et al, 2002).
In reported series, all patients with significant ureteropelvic
laceration, for instance, had either medial extravasation of con-
trast material or nonopacification of the ipsilateral ureter on CT
(Kenney et al, 1987; Kawashima et al, 2001). Such findings should
always raise suspicion for ureteral injury.
Retrograde Ureterography. Retrograde ureterograms, the most
sensitive radiographic test for ureteral injury, are used in some
centers as a primary diagnostic technique to detect acute ureteral
injuries (Campbell et al, 1992); however, the authors tend to use
noninvasive methods such as one-shot IVP and CT scan or to
make the diagnosis intraoperatively when feasible. Retrograde ure-
terography is used, however, to delineate the extent of ureteral
injury seen on CT scan or IVP if further clinical information is
necessary. Retrograde ureterography is most commonly used to
diagnose missed ureteral injuries because it allows the simultane-
ous placement of a ureteral stent if possible.
Antegrade Ureterography. Anterograde ureterography is seldom
used in the authors’ practice. In cases in which ureteral injury is
discovered, we most often plan retrograde ureterography and stent
placement or open repair. If retrograde stent placement is not
possible (usually secondary to a large gap in the two ends of the
transected ureter), the authors use anterograde ureterography and
stent placement at the time of percutaneous nephrostomy place-
ment (Toporoff et al, 1992).
Management (Fig. 42–15)
External Trauma
Contusion
Ureteroureterostomy. Ureteral contusions, although the most
“minor” of ureteral injuries, can heal with stricture or breakdown
later if microvascular injury results in ureteral necrosis, with an
incidence that is not currently known. Severe or large areas of
contusion should be treated with excision of the damaged
area and ureteroureterostomy.
Following certain general principles of ureteral surgery increases
the success rate of this delicate surgery. Repair of the ureter must
be meticulous (Fig. 42–16). Ureteral blood supply is tenuous, and
a sequela of imperfect repair can be urine leakage that can result
in patient debility, nephrectomy, and in rare cases even death.
Principles of management of the injured ureter are as follows:
1. Mobilize the injured ureter carefully, sparing the adventitia
widely, so as not to devascularize the ureter.
Figure 42–15. Suggested management options for ureteral
injuries at different levels.
UPPER
Direct ureteroureterostomy
Transureteroureterostomy
MIDDLE
Direct ureteroureterostomy
Transureteroureterostomy
LOWER
Reimplantation
Psoas hitch
278Urological Trauma
function impairment.
¯ Haematuria is an unreliable indicator.
¯ Extravasation of contrast material in CT is the hallmark
sign of ureteral trauma, and in unclear cases, a retrograde
or antegrade urography is required for confirmation.
Management
¯ Partial injury can be managed with ureteral stenting or
urinary diversion by a nephrostomy.
¯ In complete injuries, ureteral reconstruction following
temporary urinary diversion is required.
¯ The type of repair procedure depends on the site of the
injury (Table 2), and it should follow the principles outlined
in Table 3.
¯ Proximal- and mid-ureteral injuries can often be managed
by primary uretero-ureterostomy, while a distal injury is
often treated with ureteral reimplantation.
Ta b l e 2 : U rete ra l re c o n st r u c t i o n o pt i o n s b y s i te of i n j u r y
Site of injuryReconstruction options
Upper ureterUretero-ureterostomy
Transuretero-ureterostomy
Uretero-calycostomy
Mid ureterUretero-ureterostomy
Transuretero-ureterostomy
Ureteral reimplantation and a Boari flap
Lower ureterUreteral reimplantation
Ureteral reimplantation with a psoas hitch
Complete Ileal interposition graft
Autotransplantation

20. 1184 SECTION IX ! Upper Urinary Tract Obstruction and Trauma
Upper Ureteral Injuries
Ureteroureterostomy. Ureteral avulsion from the renal pelvis, or
very proximal ureteral injury, can be managed by reimplantation
of the ureter directly into the renal pelvis. The principles of repair
include spatulation, lack of tension, stenting, postoperative drain-
age, and a watertight anastomosis with fine nonreactive absorb-
able suture. Although the majority of these injuries are treated by
open surgery (especially when not discovered immediately), lapa-
roscopic repair of ureteral injuries is increasingly common in the
literature (Tulikangas et al, 2001; Ou et al, 2005). Laparoscopic
pyeloplasty in the absence of trauma is now quite common
(Eden et al, 2004; Yanke et al, 2008), and this procedure might
mature into laparoscopic repair of traumatic UPJ avulsion in the
future. Rarely, ureterocalycostomy, in which the ureteral stump is
sewn end to side into an exposed renal calyx, can also be used
where there is profound damage to the renal pelvis and UPJ
(Matlaga et al, 2005). With technologic advances, robotics can
also be successfully and safely used for a wide variety of delayed
upper urinary tract reconstructions including dismembered pyelo-
plasty, ureteroureterostomy, and ureterocalicostomy (Mufarrij
et al, 2007).
rate (83% [Toporoff et al, 1992] to 88% [Lang, 1984]). Other
authors have recommended stenting for a longer period, up to 8
weeks (Steers et al, 1985).
Rarely, acute nephrectomy is required to treat ureteral injury
after external violence. Reasons for nephrectomy include associ-
ated severe visceral injuries (although damage control without
nephrectomy is probably preferable) or severe associated injury to
the ipsilateral kidney when renal repair is not possible (McGinty
and Mendez, 1977; Gill and McRoberts, 1992). Delayed nephrec-
tomy may be required because of poor renal function (which can
sometimes be seen after delayed recognition of an obstructing
ureteral injury), severe panureteral injury when ileal ureter or
other reconstruction is impossible, or persistent ureteral fistula
(especially vascular fistula) despite previous intervention (Ghali
et al, 1999).
Internal Stenting. Minor ureteral contusions can be treated with
stent placement. Caution must be exercised, however, because
minor-appearing ureteral contusions may stricture later or break
down secondary to unappreciated microvascular damage to the
ureter. When in doubt, the injured portion of the ureter should
be debrided and ureteroureterostomy used to repair the injury.
Figure 42–16. Technique of ureteroureterostomy after traumatic disruption: A, injury site definition by ureteral mobilization;
B, debridement of margins and spatulation; C, stent placement; D, approximation with 5-0 absorbable suture; E, final result.
A
B
E
D
C
279Urological Trauma
Ta b l e 3 : P r i n c i p l e s of s u rg i ca l re pa i r of u rete ra l i n j u r y
Debridement of necrotic tissue
Spatulation of ureteral ends
Watertight mucosa-to-mucosa anastomosis with absorbable
sutures
Internal stenting
External drain
Isolation of injury with peritoneum or omentum
Bladder Trauma
Bladder injuries can be due to external (blunt or penetrating)
or iatrogenic trauma. Iatrogenic trauma is caused by external
laceration or internal perforation (mainly during TURB). Blunt
bladder injuries are strongly associated with pelvic fractures.
Bladder injuries are classified as extraperitoneal, intraperito-
neal or combined.
Diagnostic evaluation
Clinical signs and symptoms
External trauma
¯ Cardinal sign: visible haematuria.
¯ Others: abdominal tenderness, inability to void, bruises
over the suprapubic region, and abdominal distension (in
case of urinary ascites).
¯ Penetrating bladder injury: entrance- and exit wounds in
lower abdomen or perineum.
¯ Bloody urethrorrhagia: suspect concomitant urethral injury.
Iatrogenic trauma
¯ External perforation: extravasation of urine, visible lacera-
tion, clear fluid in the surgical field, appearance of the blad-
der catheter, and blood and/or gas (in case of laparoscopy)
in the urine bag.

21. TRAUMA&VESICAL&

22. Trauma&vesical&
• Penetrante!vs!Contuso!
– Contuso:!con!vejiga!llena!
• TraumáFco!vs!Iatrogénico!
• Clasificación:!!
– Extra7peritoneales!
– Intra7peritoneales!
– Combinadas.!

23. Anatomía&&

25. Evaluación&Diagnós2ca&
• Traumá2co:!!
– Hematuria!macros,!dolor!abdom,!dificultad!miccional,!contusión!
suprapúbica,!distensión!(asciFs!urinaria)!
– Penetrante:!heridas!de!entrada!y!salida!
• Iatrogénico:!
– Extravasación!orina,!visión!directa,!aparición!Foley,!sangre/aire!en!
la!bolsa!de!Foley.!
– Sx!post7op:!hematuria!,!dolor,!distensión,!íleo,!peritoniFs,!sepsis!,!
orina!por!la!herida!,!disminución!gasto!urinario!y!aumento!
creaFnina,!débitos!altos!por!drenaje!
• Imágenes:!!
– Cistogra]a!convencional/TAC!!(Cistoscopía)!

26. CHAPTER 88 ! Genital and Lower Urinary Tract Trauma 2515
drainage, after which radiographic confirmation of healing is
essential. Bone spicules within the bladder wall (Fig. 88–12 on the
Expert Consult website) may compromise healing. Antimicrobial
agents are instituted on the day of injury and continued for at
least 1 week to prevent infection of the pelvic hematoma.
Several authors (Cass, 1989; Kotkin and Koch, 1995) have
reported fewer complications, such as fistula, failure to heal, clot
retention, and sepsis, with open repair (5% overall) versus conser-
vative management (12% overall). For this reason, blunt
extraperitoneal injuries warrant immediate open repair
to prevent complications such as fistula, abscess, and
prolonged leak in the presence of any complicating fea -
tures. If a patient whose condition is stable is undergo -
ing exploratory laparotomy for other associated injuries
or internal fixation of pelvic fracture, it is prudent to
surgically repair the extraperitoneal rupture at the same
setting. The anterior bladder wall is entered, and the tear is closed
intravesically with absorbable suture. The perivesical pelvic hema-
toma should not be disturbed. When internal fixation of pelvic
fractures is performed, concomitant bladder repair is recom-
mended because urine leakage from the injured bladder onto the
orthopedic fixative hardware is prevented, thereby reducing the
risk of hardware infection. Drainage of the repaired bladder can
be safely accomplished with a large-bore Foley catheter alone, and
cystography performed 1 week after repair should verify bladder
healing.
All penetrating or intraperitoneal injuries resulting
from external trauma should be managed by immediate
operative repair. These injuries are often larger than suggested
on cystography and are unlikely to heal spontaneously, and con-
tinued leak of urine causes a chemical peritonitis. Although most
injuries are repaired with open surgery, select patients may undergo
laparoscopic repair (Kim et al, 2008)—primarily those whose
bladder may have been injured during laparoscopic surgical pro-
cedures. When bladder injuries are explored after penetrating
trauma without preliminary imaging, the ureteral orifices should
be inspected for clear efflux; ureteral integrity may also be ensured
by intravenous administration of indigo carmine or methylene
blue or retrograde passage of a ureteral catheter. Any penetrating
Figure 88–10. CT cystogram demonstrates contrast material
surrounding loops of bowel consistent with intraperitoneal
bladder rupture.
Figure 88–11. A, Dense flame-shaped pattern of contrast extravasation in pelvis due to extraperitoneal bladder rupture. B, Repeated
cystogram in same patient after 2 weeks of catheter drainage shows completely healed bladder.
A B
medium is inadequate for diagnosis of bladder rupture—
retrograde filling is required. Conventional abdominal CT of
the trauma patient may show findings suggestive of bladder injury
but is not considered to be adequate for bladder evaluation without
retrograde contrast distention (Mee et al, 1987; Udekwu et al,
1996; Hsieh et al, 2002).
Management. The usual treatment of uncomplicated
extraperitoneal bladder ruptures, when conditions are
ideal, is conservative management with urethral cathe -
ter drainage alone (Fig. 88–11). A large-bore (22 Fr) Foley cath-
eter should be used to promote adequate drainage—if output is
poor, fluoroscopic cystography should be considered to ensure
proper catheter placement. Cystography is necessary to verify
complete healing before catheter removal 14 days after injury;
occasionally, extravasation may persist for several additional
weeks but will resolve with continuation of urethral catheter
CHAPTER 88 ! Genital and Lower Urinary Tract Trauma 2515
drainage, after which radiographic confirmation of healing is
essential. Bone spicules within the bladder wall (Fig. 88–12 on the
Expert Consult website) may compromise healing. Antimicrobial
agents are instituted on the day of injury and continued for at
least 1 week to prevent infection of the pelvic hematoma.
Several authors (Cass, 1989; Kotkin and Koch, 1995) have
reported fewer complications, such as fistula, failure to heal, clot
retention, and sepsis, with open repair (5% overall) versus conser-
vative management (12% overall). For this reason, blunt
extraperitoneal injuries warrant immediate open repair
to prevent complications such as fistula, abscess, and
prolonged leak in the presence of any complicating fea -
tures. If a patient whose condition is stable is undergo -
ing exploratory laparotomy for other associated injuries
or internal fixation of pelvic fracture, it is prudent to
surgically repair the extraperitoneal rupture at the same
setting. The anterior bladder wall is entered, and the tear is closed
intravesically with absorbable suture. The perivesical pelvic hema-
toma should not be disturbed. When internal fixation of pelvic
fractures is performed, concomitant bladder repair is recom-
mended because urine leakage from the injured bladder onto the
orthopedic fixative hardware is prevented, thereby reducing the
risk of hardware infection. Drainage of the repaired bladder can
be safely accomplished with a large-bore Foley catheter alone, and
cystography performed 1 week after repair should verify bladder
healing.
All penetrating or intraperitoneal injuries resulting
from external trauma should be managed by immediate
operative repair. These injuries are often larger than suggested
on cystography and are unlikely to heal spontaneously, and con-
tinued leak of urine causes a chemical peritonitis. Although most
injuries are repaired with open surgery, select patients may undergo
laparoscopic repair (Kim et al, 2008)—primarily those whose
bladder may have been injured during laparoscopic surgical pro-
cedures. When bladder injuries are explored after penetrating
trauma without preliminary imaging, the ureteral orifices should
be inspected for clear efflux; ureteral integrity may also be ensured
by intravenous administration of indigo carmine or methylene
blue or retrograde passage of a ureteral catheter. Any penetrating
Figure 88–10. CT cystogram demonstrates contrast material
surrounding loops of bowel consistent with intraperitoneal
bladder rupture.
Figure 88–11. A, Dense flame-shaped pattern of contrast extravasation in pelvis due to extraperitoneal bladder rupture. B, Repeated
cystogram in same patient after 2 weeks of catheter drainage shows completely healed bladder.
A B
medium is inadequate for diagnosis of bladder rupture—
retrograde filling is required. Conventional abdominal CT of
the trauma patient may show findings suggestive of bladder injury
but is not considered to be adequate for bladder evaluation without
retrograde contrast distention (Mee et al, 1987; Udekwu et al,
1996; Hsieh et al, 2002).
Management. The usual treatment of uncomplicated
extraperitoneal bladder ruptures, when conditions are
ideal, is conservative management with urethral cathe -
ter drainage alone (Fig. 88–11). A large-bore (22 Fr) Foley cath-
eter should be used to promote adequate drainage—if output is
poor, fluoroscopic cystography should be considered to ensure
proper catheter placement. Cystography is necessary to verify
complete healing before catheter removal 14 days after injury;
occasionally, extravasation may persist for several additional
weeks but will resolve with continuation of urethral catheter

27. Manejo&
• Intraperitoneales&
• Reparación!quirúrgica!(vesicorrafia)!en!2!planos!+!S.!
Foley:!
– Compromiso!cuello,!fragmentos!óseos,!lesión!rectal!
concomitante,!atrapamiento!pared!vesical.!
• Extraperitoneales&&
– Conservador:!S.!Foley!3!lúmenes!con!irrigación!vesical!
conFnua!

28. TRAUMA&URETRAL&
&

29. Anatomía&

30. Trauma&ureteral&
• Espectro:!!
– Contusión!o!esFramiento!
– Desgarro!parcial!
– Desgarro/Transección!completa!
• !Diferenciar!entre!UA!y!UP!

31. Trauma&ureteral&anterior&
• Uretra&anterior/distal&(UA):!anterior!a!porción!membranosa!
– Primera!causa!Iatrogénica!(Sonda),!<!frec.!Fx!pene,!trauma!penetrante!
• Diagnós2co&UA:!!
– Historia!sondeo!frustro,!uretrorragia!post!coital!
– Sangre!en!MUE!lo!mas!común!!!CanFdad!=!severidad!
– Otros:!hematoma!genital,!dolor,!fractura!de!pene!
• Imágenes:&&
– Uretrogra]a!retrograda!!GS!para!evaluar!lesión!a!TODOS&
– En!lesión!UA!SÍ!se!podría!poner!S.!Foley!
• Manejo:&
– Derivación!urinaria!SP!o!CU!!+!reparación!diferida!
– Reparación!inmediata:!Fx!pene,!penetrante,!!proyecFles!

32. Trauma&ureteral&posterior&
• Uretra&posterior&(UP):!uretra!membranosa!a!vejiga!
– Por!Fx!pelvis!en!AAM!(4719%!UP!masculina!y!076%!uretra!femenina).!
• Diagnós2co&UP:!!
– Historia!de!Fx!pelvis,!uretrorragia!
– Imposibilidad!de!orinar,!globo!vesical,!TR!próstata!ascendida!
• Imágenes:&&
– Uretrogra]a!retrograda!!GS!para!evaluar!lesión!a!TODOS&
– Evitar&Sonda&uretral,&hasta!obtener!imagen!uretral!
!!!!!**(paciente!inestable)!
!
• Manejo:!
– Derivación!urinaria!SP!o!CU*!+!reparación!diferido!+/7!uretroplaska!
– Reparación!inmediata:!Con!lesión!rectal!o!cuello!vesical!asociado!
!

33. TRAUMA&GENITAL&

34. Trauma&genital&
• Traumas!GU!!33766%!genitales!externos!
• Mucho!más!frecuente!en!hombres,!15740!años!(anatomía,!
AAM,!deportes,!guerra,!violencia)!
• Causado!!
– 80%!trauma!contuso!
– 20%!trauma!penetrante!
!

35. TRAUMA&&
GENITAL&MASCULINO&
&

36. Anatomía&genital&masculina&

37. Fractura&de&pene&
• Desgarro!de!la!túnica&albugínea&
del!cuerpo!cavernoso!
• Usualmente!durante!coito!al!salir!
de!vagina!y!golpear!contra!sínfisis!
del!pubis!o!periné!femenino,!
masturbación.!
• Lesión!uretral!en!10720%!a!nivel!
• Riesgo:!disfunción!erécFl!y!
enfermedad!de!Peyronie!

38. Diagnos2co&
!
– Sonido!de!crujido/estallido,!dolor!
y!detumescencia!inmediata!
– Luego!hematoma!cuerpo!pene!
(“eggplant!deformity!/!
berenjena”),!incluso!hasta!pared!
abdominal,!periné!y!escroto!(si!
lesión!en!fascia!de!Buck)!
– Rotura!de!túnica!puede!ser!
palpable!
!
Imágenes&
• !ECO!(negaFva!no!descarta)!o!
RNM!podrían!ser!úFles!
– Considerar!uretrogra]a!
retrograda!(Si!uretrorragia!

39. Manejo&
• EMERGENCIA!!!&!!intervención!quirúrgica!inmediata!
– Incisión,! denudación! inspección! de! CC! y! CE,!
idenFficación!de!lesión!y!reparación&de&T.&Albugínea&
con&sutura&absorbible&(vicril&2M0)&
– Sutura!lesión!uretral!
– Hematoma!sin!rotura!de!albugínea!cavernosa:!!
• AINEs!+!Hielo!
– No!se!recomienda!tratamiento!conservador!

40. 2508 SECTION XV ! Benign and Malignant Bladder Disorders
fashion over a catheter. Therapy with broad-spectrum antibiotics
and 1 month of sexual abstinence are recommended. In uncircum-
cised patients, strong consideration should be given to performing
limited circumcision at the conclusion of the repair because wide
mobilization of the foreskin may place the distal prepuce at risk
for ischemia.
Outcome and Complications. Immediate surgical reconstruction
results in faster recovery, decreased morbidity, lower complication
rates, and lower incidence of long-term penile curvature
(Nicolaisen et al, 1983; Orvis and McAninch, 1989; Hinev, 2002;
El-Taher et al, 2004; Muentener et al, 2004). Although immediate
repair results in penile curvature in less than 5% of patients (El
Atat et al, 2008), conservative management of penile fracture has
been associated with penile curvature in more than 10% of
patients, abscess or debilitating plaques in 25% to 30%, and sig-
nificantly longer hospitalization times and recovery (Meares,
1971; Nicolaisen et al, 1983; Kalash and Young, 1984; Orvis and
McAninch, 1989). Zargooshi (2002) reported in a personal surgical
series of 170 patients that surgical management of penile fractures
resulted in erectile function comparable to that of a control popu-
lation. Timing of surgery may also influence long-term success—
those undergoing repair within 8 hours of injury had significantly
better long-term results than did those having surgery delayed 36
hours after the fracture occurred (Asgari et al, 1996; Karadeniz
et al, 1996).
Gunshot and Penetrating Injuries
Gunshot Wounds. The majority of penetrating wounds to the
genitalia are due to gunshots (Mohr et al, 2003), and most require
surgical exploration. Treatment principles include immedi -
ate exploration, copious irrigation, excision of foreign
matter, antibiotic prophylaxis, and surgical closure.
Gunshot injuries to the phallus are rarely isolated wounds—nearly
all victims have significant associated injuries, including abdomi-
nal, pelvic, lower extremity, vascular, or additional genitourinary
injuries (Bandi and Santucci, 2004; Kunkle et al, 2008). Excellent
cosmetic and functional outcomes can be expected with immedi-
ate reconstruction (Gomez et al, 1993; Cavalcanti et al, 2006). An
artificial erection may be induced to ensure penile straightness,
suspected penile fracture because it is time consuming
and unfamiliar to most urologists and radiologists (Morey
et al, 2004). Ultrasonography, although noninvasive and easy to
perform, has also been associated with significant false-negative
studies (Koga et al, 1993; Fedel et al, 1996).
Magnetic resonance imaging (MRI) is a noninvasive
and accurate means of demonstrating disruption of the
tunica albuginea (Fedel et al, 1996; Uder et al, 2002). Argu-
ments against the routine use of MRI are the expense, limited
availability, and time requirements involved with the study. MRI
is reasonable in the evaluation of patients without the
typical presentation and physical findings of penile
fracture.
False fracture has been reported in patients who present with
penile swelling and ecchymosis, and some even describe the
classic “snap-pop” or rapid detumescence typically associated with
fracture (Feki et al, 2007). Physical examination may not be ade-
quate for definitive diagnosis of a corporeal tear in these circum-
stances (Shah et al, 2003). Surgical exploration (Fig. 88–3 on the
Expert Consult website) or evaluation with MRI should be consid-
ered. Another condition that may mimic penile fracture is rupture
of the dorsal penile artery or vein during sexual intercourse
(Armenakas et al, 2001; Bar-Yosef et al, 2007).
Management. Multiple contemporary publications indi -
cate that suspected penile fractures should be promptly
explored and surgically repaired. Although small lateral
incisions may be used for localized hematomas or pal -
pable tunical defects (El Bahnasawy and Gomha, 2000; Nasser
and Mostafa, 2008), a distal circumcising incision is appro-
priate in most cases, thus providing exposure to all three
penile compartments. Closure of the tunical defect with
interrupted 2-0 or 3-0 absorbable sutures is recom -
mended; deep corporeal vascular ligation or excessive
debridement of the delicate underlying erectile tissue
must be avoided. Induction of an artificial erection with saline
or colored dye may aid in locating the corporeal laceration (Shaeer,
2006). Partial urethral injuries should be oversewn with fine
absorbable suture over a urethral catheter. Complete urethral inju-
ries should be debrided, mobilized, and repaired in a tension-free
Figure 88–2. A, Large arrow indicates pronounced ecchymosis and swelling in this patient with a penile fracture sustained during
intercourse. Small arrow indicates blood at urethral meatus. B, During surgical exploration and repair, urethral laceration with exposed
Foley catheter is noted (large arrow). Small arrow indicates laceration of corpus cavernosum.
A B

41. TRAUMA&&
ESCROTAL/TESTICULAR&
&

42. Anatomía&

43. Hematoma&
1. Escrotales&cutáneos&(ExtraMescrotal):&piel!del!escroto!por!
trauma!directo,!trauma!uretral!o!desplazamiento!sangre!
subcutánea!
2. Hematocele&(IntraMescrotal):&espacio!entre!túnica!albugínea!
y!túnica!vaginal!por!trama,!cirugía!escrotal!o!sangre!desde!
cavidad!peritoneal.!
7 Diagnós2co:!Historia,!Ex.!
]sico,!ECO!(Doppler)!

44. Manejo&
• Tratar!la!causa!asociada:!lesión!uretral,!rotura!tesFcular,!
lesión!intra7abdominal!
• Hematoma!Escrotales!cutáneos:!!
– Conservador:!suspensión/elevación!escrotal!+!Ice!packs!
• Hematoceles:!
– Mayoría!según!criterio!clínico,!laboratorio!y!evolución!
– Hematocele!traumáFco!(>!por!Rotura&tes2cular):!
cirugía&precoz&

45. Rotura/Fractura&Tes2cular&
– Desgarro! de! la! túnica! albugínea! más!
extrusión!de!Tub.!Seminiferos!y!hematocele!
– En!50%!de!los!traumas!contuso,!con!fuerza!
de!al!menos!50kg!
– DiagnósFco!principalmente!clínico:!dolor,!nauseas,!vómitos,!
sincope,!historia!sugerente.!
– Imágenes:&ECO:!ecotextura!heterogénea!con!visión!de!la!
fractura!en!un!20%!y!posible!visualización!de!extrusión!de!TS.!
– EMERGENCIA!!!!!!Reparación&quirúrgica&precoz&

46. ROTURA/FRACTURA&
TESTICULAR&

47. Rotura/Fractura&Tes2cular&
• Reconstrucción&primaria&tes2cular&y&escroto&
1. Abordaje!escrotal!
2. Evacuar!de!Hematocele!y!coágulos!
3. Debridar!túbulos!seminíferos!y!tejido!necróFco!
4. Cerrar!túnica!albugínea!con!sutura!conFnua!
reabsorbible!470!
!!**!Colgajo!libre!túnica!vaginal!para!cierre!de!teste!
1. Reparar!lesiones!de!epidídimo!
2. Drenaje!Penrose!peritesFcular!por!incisión!separada!36!
hr!
3. ATB!amplio!espectro!x!7!días,!vacuna!anFtetánica!
4. Cierre!primario!de!piel!o!diferido!con!injerto!

48. CHAPTER 88 ! Genital and Lower Urinary Tract Trauma 2511
scrotal trauma (Elsaharty et al, 1984; Manson, 1989; Lrhorfi
et al, 2002).
Management. Early exploration and repair of testicular
injury is associated with increased testicular salvage,
reduced convalescence and disability, faster return to
normal activities, and preservation of fertility and hor -
monal function (Kukadia et al, 1996). Minor scrotal injuries
without testicular damage can be managed with ice, elevation,
analgesics, and irrigation and closure in some circumstances.
The objectives of surgical exploration and repair are testicular
salvage, prevention of infection, control of bleeding, and reduced
convalescence. Transverse scrotal incision is preferable in most
cases. The tunica albuginea should be closed with small
absorbable sutures after removal of necrotic and
extruded seminiferous tubules. Even small defects in the
tunica albuginea should be closed, because progressive swelling
and intratesticular pressure can continue to extrude seminiferous
tubules. Every attempt to salvage the testis should be performed;
loss of capsule tissue may require removal of additional paren-
chyma to allow closure of the remaining tunica albuginea. A flap
or graft of tunica vaginalis may be used to cover a large defect in
the tunica albuginea in an otherwise salvageable testis (Fig. 88–5);
synthetic grafts are not recommended for this purpose (Ferguson
and Brandes, 2007). Significant intratesticular hematomas should
be explored and drained even in the absence of testicular rupture
to prevent progressive pressure necrosis and atrophy, delayed
exploration (40%), and orchiectomy (15%) (Cass and Luxenberg,
1988). Significant hematoceles should also be explored, regardless
of imaging studies, because up to 80% are caused by testicular
rupture (Vaccaro et al, 1986).
Penetrating scrotal injuries should be surgically
explored to inspect for vascular and vasal injury; as in
blunt trauma the same principles of salvage, hemostasis, and
reconstruction apply. The vas deferens is injured in 7% to 9% of
scrotal gunshot wounds (Gomez et al, 1993; Brandes et al, 1995).
The injured vas should be ligated with nonabsorbable suture and
delayed reconstruction performed if necessary. Approximately
Figure 88–4. Ultrasound examination demonstrates hypoechoic
intratesticular areas (arrow) consistent with testicular rupture
sustained by blunt trauma. Scrotal exploration revealed large
hematocele and exposed seminiferous tubules.
Figure 88–5. A, Testicular rupture after blunt trauma. B, Reconstructed testis after debridement and closure. Arrow indicates placement of
tunica vaginalis graft.
A B
Differential diagnosis of testicular fracture includes hematocele
without rupture, torsion of the testis or an appendage, reactive
hydrocele, hematoma of the epididymis or spermatic cord, and
intratesticular hematoma. A nonpalpable testis in a trauma patient
should raise the possibility of dislocation outside the scrotum.
This entity usually occurs after motorcycle crashes when extreme
forces on the scrotum expel the testis into surrounding tissues
such as the superficial inguinal pouch (50%) or to a pubic, penile,
pelvic, abdominal, or perineal location (Schwartz and Faerber,
1994; Bromberg, 2003). Bilateral dislocation after trauma has been
reported (Bromberg et al, 2003; O’Brien et al, 2004). Manual or
surgical reduction of the displaced testis is indicated. Finally,
approximately 5% of spermatic cord torsions are believed to be
precipitated by trauma; torsion should be considered in all cases
of significant scrotal pain without signs or symptoms of major
Rotura/Fractura&Tes2cular&

49. Dislocación&tes2cular&
• Desplazamiento!del!teskculo!a!posiciones!extra7escrotales!
• Accidentes!en!moto!a!alta!velocidad,!infrecuente.!
• Uni!o!bilateral!
• Puede!dislocarse!a!abdomen,!pubis,!canal!inguinal,!canal!
femoral,!pene!o!periné!
• Puede!acompañarse!de!torsión!o!rotura!tesFcular!
• Diagnos2co:!dolor!y!bolsa!escrotal!vacía.!Si!no!puede!ser!
encontrado,!ECO/ECO!Doppler!o!TAC!son!de!ayuda!
• Manejo:!exploración!quirúrgica!precoz!y!orquidopexia!con!
incisión!inguinal!para!mejor!manejo!de!cordón.!

50. Dislocación&tes2cular&
• Dislocación&Tes2cular&

52. Trauma&penetrante&tes2cular&
• Exploración!quirúrgica!y!reconstrucción!tesFcular!
• Lesiones!penetrantes!escrotales!son!bilaterales!en!30%!(vs!1!%!
contusa)!
• Herida&penetrante&de&tescculo&
– Manejo!similar!a!Rotura!
TesFcular!
• Sangrado&de&vasos&del&cordón&
espermá2co&
– Ligadura!
• Disrupción&completa&Cordón&
– Orquidectomía!
• No&logra&reconstrucción/&tejido&
mínimo&viable&
– Orquidectomía!
• Lesiones&por&explosivos:&&
– Reconstrucciones!complejas!

53. !
!
!
FIN!