Contemporary Management of Urogenital Injuries



Fig. 13.1
A 32-year-old young man who was a victim of a stab injury presented with grade IV injury of the left kidney; the patient was managed expectantly



A rigorous follow-up with CT imaging after renal injury is prudent for all patients because they are at increased risk of developing a wide variety of complications, for example, hemorrhage, urine leak , urinoma, AV fistula, and reno-cutaneous fistula [5].


Urinary Extravasation


Urinoma is observed in 1–7% after renal injury [6]. Patients usually are asymptomatic, in rare instance there are a nonspecific abdominal pain, fever, and a decline in the renal function. CT urography is the study of choice to delineate urine leak . The majority of the cases will resolve spontaneously. However, endoscopic placement of a stent and/or percutaneous drainage is indicated in cases of infection, persistent urine leak, and a large collection [7].


Delayed Hemorrhage


Delayed hemorrhage occurs most commonly in the first 2 weeks after the trauma. This may be attributed to the resorption of the necrotic tissue at the site of injury and recanalization between the intravascular space and extravascular space leading to pseudoaneurysm , which may erode into the pelvicalyceal system or perirenal space [8]. Clinically, the patient may develop hematuria, flank ecchymosis, new onset hypertension, or hemodynamic instability [9]. The incidence of delayed hemorrhage varies in the literature from 0 to 25%. The mainstay of the management is selective angioembolization ; rarely surgical exploration is performed which is associated with a high nephrectomy rate [1012].


Renal Insufficiency


Transient renal impairment is observed in these patients, and the outcome depends on multiple factors, such as the presence of hypovolemia , multiorgan failure , kidney parenchyma loss , preexisting renal impairment, age, and the use of nephrotoxic contrast [13]. The rate of dialysis according to the data from the National Trauma Data Bank (NTDB) is only 0.46% [14]. However, retrospective studies showed that 6% of the patients with high-grade injuries needed dialysis [15].


Urinary Fistulas


In rare instances, a urinary fistula can develop between a devitalized segment or missed segment after nephrectomy with the skin. Exploration with renorraphy/nephrectomy and resection of the fistulous tract is warranted [16].


Hypertension


Goldblatt’s kidney is still the plausible theory that explains hypertension after renal trauma [17]. The highest incidence of hypertension was as high as 40% [18]. Hypertension can be resolved spontaneously, controlled by medications, and in a rare instance, it may necessitate nephrectomy or partial nephrectomy of the devitalized segment [17, 19].


Follow-Up


A 3-month follow-up visit is mandatory after major renal injury. The follow-up should include a physical examination, urinalysis, hematocrit, basic metabolic workup, selective re-imaging, and serial blood pressure measurement [4]. The literature is inadequate on the subject of the long-term consequences of trauma on renal tissue. Long-term follow-up of renal trauma patients is the key to detecting insidious onset hypertension and prevent it from silent progression [17].



Ureteral Injury


Ureteral trauma accounts for less than 1% of all urologic traumas [20]. All ureteral segments are prone to injury; however, the proximal ureter is more often injured in 59.7% of the cases [21]. The intimate anatomy of the ureter with other structures has made isolated ureteral injuries implausible. Concomitant injuries to other organs are noted in 90.4% of the cases [21].

Hematuria is a poor indicator of ureteral injury. A recent meta-analysis showed that hematuria is present in 44% of patients with ureteral injury [21]. In combat injuries to the ureters , they may be affected by the blast effect, can become ischemic but are unlikely to cause of hematuria [22].

The most important step in diagnosing ureteral injury is high clinical suspicion based on the mechanism of injury, the trajectory of the missile, and intraoperative finding. Intravenous ureterogram can be falsely negative in 42.8% of cases. On the other hand, CT scan with delayed images and retrograde pyelogram can detect the injuries in 88.3% of the cases [21] (Fig. 13.2).

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Fig. 13.2
A 23-year-old young man sustained a stab injury to his abdomen. Delayed images demonstrate seepage of the contrast through the trajectory of the stab. At the time of exploration, the ureter was repaired by an end-to-end anastomosis

The most reliable way to detect ureteral injury is an intraoperative exploration of the ureter by a urologist [23]. Intravenous methylene blue/indigo carmine can aid in the localization of the ureteral injury; however in hypertensive patients the renal profusion is not sufficient; thus, there will be no excretion of methylene blue/indigo carmine in the urine [24]. If concomitant bladder injury is encountered, some authors are an advocate of insertion of bilateral, five French intraureteral pediatric feeding tube for frugal ureteral assessment [25].

Nevertheless, ureteral injuries can be missed in 38% of the patients [21]. Missed ureteral injuries have been associated with a high morbidity and mortality. One of the main contributions to this high figure of missed injuries is delayed necrosis phenomena after blast injuries [22]. The temporary cavity effect associated with the blast injuries may jeopardize the blood supply to the ureter ; this cannot be evident at the time of laparotomy or initial imaging.

Patients may present with an infected urinoma and uremia days or weeks after the injury; other presentations include prolonged ileus, sepsis, wound dehiscence, and persistent drainage from the incision [21].

The aim of ureteral repair is to preserve the renal function and prevent the formation of urinoma [25]. The principles successful repair are adequate ureteric debridement and careful mobilization, spatulated, tension-free, water-tight anastomosis, adequate drainage of the retroperitoneum, and quarantining the anastomosis from other organs by omental wrap [2528].

In the acute phase , the decision to proceed with the primary repair of the injured ureter depends on the stability of the patient, presence of other organ injuries, fecal contamination of the field, and the extent of the ureteral injury. Also, the involvement of the upper and mid ureter in injury may require a complex repair [2629].

There are conflicting opinions about the use of ureteral stents in the setting of the trauma. In one hand, some authors believe stents should be abandoned in trauma setting because it is associated with obstruction, stricture formation, and inflammation from the foreign body, stent migration, and patient discomfort. On the other hand, other authors are an advocate of stent insertion, especially in the setting of high-velocity gunshots wounds [21, 30].

When the primary repair of the injured ureter is not feasible, the ureter should be ligated and marked with a radio-opaque surgical clip , which can help in the planning of surgical repair [31]. The drainage of the kidney can be achieved by inserting percutaneous nephrostomy after stabilization of the patient. Open nephrostomy tube placement is not advisable because it is time-consuming and challenging [5].

Delayed ureteral repair should be performed when the patient has recovered from other injuries. There are several factors that should be considered before proceeding with ureteral repair in this scenario, such as resolving of any inflammatory process in the retroperitoneum and pelvis. Adding to that, adequacy of kidney function which can be assessed by nuclear scintigraphy, reassessing the length and the location of the ureteral injury using antegrade and retrograde imaging, and evaluation of the bladder capacity before using it in any reconstructive procedure for the ureter [31].

Table 13.1 Summarizes the reconstruction options for each segment of the ureter .


Table 13.1
Reconstruction options for each segment of the ureter
































Uretero-pelvic junction
 
Reanastamosis

Proximal and mid ureter

Short defect

End-to-end anastamosis

Long defect

Vesico psoas hitch

Boari flap

Transureterureterostomy

Distal ureter

Short defect

Reimplantation

Long defect

Vesico psoas hitch

Boari flap


Bladder Injury


Serkin et al. reviewed The Joint Theater Trauma Registry of all US military between October 2001 and January 2008. He found that 21% of the patients had bladder injury and 29% of them had concomitant pelvic fractures [3].

In the context of pelvic fracture , signs of bladder injuries may be overlooked. The incidence of missed urological injuries in the presence of pelvic fracture at the initial assessment was 23%. Two third of these missed injuries were bladder injuries. The frequency of intraperitoneal bladder injury was equal to the extra-peritoneal injury. The lag time between the initial assessment and the diagnosis of missed injury in the extra-peritoneal injury compared to intraperitoneal injury was 6.7 days and 19 h, respectively [32].

In every case of pelvic fracture , a workup should be directed to rule out an associated bladder injury. However, the presence of widening of the SI joint, symphysis pubis, and fractures of the sacrum are correlated more frequently with bladder injuries [33].

Traditionally in stable patients the workup includes cystogram with AP and lateral films; however, the cystogram can miss bladder injuries and in few occasions it cannot differentiate between intraperitoneal and extraperitoneal injuries [32]. In our institution, we obtain CT-cystogram to rule out bladder injury in every case of multiple injuries, gunshot for the pelvis, penetrating injuries below the umbilicus, and presence of gross hematuria. We believe that CT-cystogram is more accurate than conventional cystogram and associated with better delineation of the location, extent of the injury, and easiness in imaging interpretation (Figs. 13.3 and 13.4).

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Fig. 13.3
CT cystogram demonstrates contrast material surrounding loops of bowel consistent with intraperitoneal bladder rupture


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Fig. 13.4
Plain film cystogram reveals extraperitoneal bladder rupture with extravasation into the scrotum. Surgical exploration revealed anterior bladder neck and prostatic urethral laceration

Intra-operative identification of bladder injury can be achieved by inflating the bladder with 300–400 cm3 saline with methylene blue. In this case, primary repair of the injury is encouraged and the decision to leave suprapubic catheter is based on surgeon discernment.

The presence of simultaneous rectal injury and bladder injury makes patients more prone for rectovesical fistula and urinoma. The experience of the Vietnam War stressed on the role of fecal diversion, rectal wound repair, distal rectal washout (DRWO) , and presacral drainage to decrease the rate of infectious complications [34]. On the other hand, the notion of the modern experience in civilian causalities has linked the distal rectal washout and presacral drainage with a higher rate of infections. Some authors recommend omental flap interposition between the rectum and posterior bladder to decrease the incidence of fistulas [35].

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Nov 17, 2017 | Posted by in MUSCULOSKELETAL MEDICINE | Comments Off on Contemporary Management of Urogenital Injuries
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