urogenital trauma (ureter,bladder urethra)

Progenitor trauma and management

1. URINARY BLADDER TRAUMA

2. Penetrating trauma Blunt trauma Pelvic # present in 85% In 10% of pelvic fractures Gross hematurea in 98% Iatrogenic Following cystoscopy , Laparoscopy, Intra-abdominal surgery Spontaneous Rupture Rare E tiology

3. Mechanism of vesical trauma Blow over full bladder -> increased intravesical pressure

4. Bladder contusion Extraperitoneal Rupture Intraperitoneal Rupture Combined Intra-and- Extraperitoneal Rupture (10%) Classification

5. Bladder Contusion Diagnosis of exclusion h/o blunt trauma lower abdomen with hematuria but radiology – WNL Hematuria after prolonged physical activity (cross country/ marathon)

6. Extraperitoneal Rupture 58% of all bladder injuries in adults and 14% in children Mostly associated with pelvic fracture (Bony spicule or shearing forces) Blood in rectum – associated rectal injury Distended palpable bladder excludes bladder injury

7. Patterns of extravasation Simple extraperitoneal rupture - Seen in 60% cases Extravasation in perivesical space Complex extraperitoneal rupture – Rupture of bladder base and neck -> Scrotum Injury to inferior fascia –> thigh (17%) and penis (11%) Extraperitoneal Rupture

8. Intraperitoneal Rupture 33% of all bladder injuries in adult and 77% in children Blunt trauma in full bladder Dome – weakest and least supported part Abdominal distension may present due to Intraperitoneal urine extravasation Associated ileus/ peritonitis.

9. Lower abdominal trauma Gross hematuria Inability to pass urine Other intra-abdominal injuries and pelvic fracture Patient who present late may have – peritonitis, septicemia, metabolic derangement. Intraperitoneal rupture -> unine absorption -> hyperchloremic metabolic acidosis, hypernatremia , hyperkalemia , azotemia Presentation

10. Urinalysis Almost all pt have gross hematuria 2%-5% - only microscopic hematuria Drain fluid creatinine level. If doubt persist – Cystogram: instill methylene blue mixed with 400ml saline via catheter – leakage of blue fluid confirm bladder injury Laboratory Investigations

11. Cystography Almost 100% diagnostic Bladder filled with contrast by gravity from a height of 75 cms In adults – at least 400 ml In children – 60 ml + 30 ml/yr of age, up to maximum of 400 ml Till bladder contraction occurs Get 4 Films Pre-contrast Scout KUB Post-contrast AP view – show most extravasation Post-contrast Oblique view – avoided in pt with pelvic # Post Drainage - show small extravasation Radiological Investigations

12. CT Urography Not as sensitive as cystography Preferred in polytrauma pt Radiological Investigations

13. USG Abdomen In extraperitoneal ruptures - retroperitonel fluid collection In intraperitoneal ruptures – fluid in pelvis Radiological Investigations

14. Isolated extraperitoneal ruptures Foley catheter drainage – heal 85% cases in 3 weeks Confirmatory cystogram before removing catheter Associated intraabdominal injuries If exploratory laparotomy required – bladder repair at the same time Repair – transvesically in single layer without disturbing perivesical hematoma SPC Treatment

15. If bladder neck involved or associated vaginal injury immediate reconstruction - to prevent later incontinence, bladder neck contracture and VVF If missed – corrected after 2-3 months Treatment

16. Intraperitoneal bladder ruptures Should be explored and repaired irrespective of mechanism of injury Lower midline incIsion -> Anterior, vertical cystotomy -> 2 layer, watertight closure + SPC In spontaneous rupture – edge should be excised -> HPE Iatrogenic bladder injuries during endoscopic surgery – usually small  catheter drainage and close observation T reatment

17. Catheter drainage – approx. 03 week. Cystogram prior to removal of urethral catheter Antibiotics at time of removal Post operative care

18. URETHRAL INJURY

19. Predominantly in males Present in 5% of pelvic fracture 90% associated with pelvic fracture 10 – 30% associated with bladder rupture Incidence

20. Anterior - Anterior to urogenital diaphragm Penile urethra – b/w penoscrotal junction and meatus Bulbar urethra – b/w suspensory ligament of penis and penoscrotal junction Posterior - (3 cm) Posterior to urogenital diaphragm Membranous ( sphincteric ) urethra Prostatic urethra Most posterior injuries are due to pelvic fractures Anatomic Divisions

21. Etiology – Penetrating – uncommon Blunt – 90% Pelvic fracture (RTA/ Construction site/ industreal accidents) Present in 16% of cases with unilateral rami # and 41% with bilateral rami # Mechanisms – Upward displacement of hemipelvis and symphysis Diastasis of symphysis pubis – rupture of one puboprostatic ligament – stretching of membranous urethra in opposite direction – disruption Direct laceration by bony spicules P osterior urethral injuries

22. Diagnosis - Blood at penile meatus Inability to void Palpable bladder Perineal hematoma Prostate examination abnormal – displaced high up Retrograde Urethrography (RGU) Contrast extravasate into periurethral tissues without reaching bladder – Complete rupture Extravasate but also enters bladder – partial rupture No extravasation – intact/ contused Posterior urethral injuries

23. Indications – Treatment of choice in stable patients Associated bladder neck injury Associated Rectal injuries – contamination –> urethro -rectal fistulas Advantages – Low stricture rate than delayed repair (69% vs 100%) If scar formation occurs than simple dilatation may suffice Disadvantage – Higher chance of iatrogenic injury Neurovascular bundle – impotence External sphincter - Incontinence Primary Alignment

24. Techniques - Simple catheter placement across rupture Endoscopically assisted urethral alignment and cathater placement If pelvic hematoma : Never interfere it, Just SPC Interlocking sounds, in antegrade and retrograde fashion (Rail Roading) Primary Alignment

25. Indications – Treatment of choice in most patient Unstable patients Multiple injuries ( when other injuries take priority) Advantages – Easy No unnecessary disturbance of pelvic hematoma – no risk of blood loss/ infection No risk of iatrogenic impotence and incontinence In most cases stricture formed are <2cm – easily managed with delayed repair SPC with Delayed Repair

26. Techniques – Perineal approach with excision of scar and end-to-end anastomosis (PPU) Transpubic approach with Abdominoperineal repair – ‘Perineal Abdomino -Progressive Approach’ (PAPA) Choice of technique depends on length of stricture, amount of scar tissue requiring excision, presence of fractured displaced bony fragments SPC with Delayed Repair

27. Etiology – External trauma Blunt trauma Penetrating trauma Penile avulsion (rare) Penile fracture Iatrogenic Endoscopic procedure Urethral dilatation Catheterization Inadvertent pulling of Foleys Chronic indwelling catheter Anterior urethral injuries

28. Mechanism of injury – In straddle injury fixed bulbar urethra crushed b/w force causing injury and inferior surface of pubic symphysis In chronic indwelling catheter – infection -> inflammation -> Necrosis Anterior urethral injuries

29. Diagnosis - History of injury Blood at meatus Inability or difficulty in voiding Palpable bladder RGU Anterior urethral injuries

30. Extravasation of blood and urine Sleeve-fashion along penile shaft – confined to bucks fascia Extending to abdomen, chest, scrotum, perineum and mid thigh – confined by Colles fascia

31. Classification - Isolated Anterior urethral injuries – Goldmans Type V Types- Contusion – Normal RGU Incomplete Rupture – extravasation with some contrast in bladder Complete Rupture – extravasation and no contrast in bladder / proximal urethra Anterior urethral injuries

32. Management - In general : All injuries due to blunt trauma; penetrating injury with hemodynamic instability; associated other injuries; large urethral defects – best treated initially with SPC Contusion : gentle catheterization with small catheter for 2 – 3weeks Incomplete rupture : Initial – SPC – in 45% - 60% heal with epithelisation If explored – debridement of edges and closer with 6-0 absorbale suture Anterior urethral injuries

33. Anterior urethral injuries Management – Complete rupture : SPC – allow edema and inflammation to subside Primary repair may be undertaken in penetrating trauma – <2 cm defect – end to end anastomosis Longer defect – substitution urethroplasty Iatrogenic injuries : Mostly – contusion Mostly heal with small catheter for 1-2 weeks

34. Bibliography Smith’s General Urology 17 th edition Campbell – Walsh Urology 10 th edition