Renal
Imaging Modailty for Stable Blunt Trauma with Gross Hematuria
CTAP with Contrast (~ 30 sec after contrast) and delayed (~ 10 minutes)
Hemodynamically unstable patients or large (> 4 cm) perirenal hematoma and/or contrast extravasation -> immediate surgical intervention or angioembolization
Most common site of ureteral injury during hysterectomy?
Ureter runs under the Broad ligament (contains uterine artery and vein) and the round ligament superiorly (round ligament is a homologue of the gubernaculum)
Also can occur a the vaginal cuff/bladder trigone
Diagnostic imaging?
CT cystogram (> 300 mL should be instilled or until patient uncomfortable)
Complete urethral disruption with contrast extravasation?
SPT and delayed repair
When to suspect penile fracture?
Triad of penile ecchymosis, cracking or snapping sounds during intercourse/masturbation, immediate detumescence
When/why to perform follow up CT imaging)?
1. Deep Laceration (Grade 4 or 5)
2. Clinical signs of complications (fevers, worsening flank pain, ongoing blood loss, abdominal distention)
High velocity?
Low velocity?
High velocity - risk of subsequent ureteral stenosis or necrosis from delayed injury therefore a stent is placed
Low velocity: can be repaired
Iatrogenic cystotomy, what else to look for?
Rule out concomitant ureteral injury (with retrogrades or direct inspection)
GSW: should rule out rectal injury
Management of Bladder Neck Injury?
Repair immediately. Delayed repair may impact continence
Equivocal signs/symptoms of penile fracture?
Penile US. If still uncertain, MRI
Predictors of Persistent bleeding?
Need at Least 2
1. Depth of parenchymal injury
2. Presence of arterial blush
3. Grade 3 (> 1 cm parenchymal laceration) or 4 (laceration through parenchyma into collecting system)
4. Medial hematoma
5. Hematoma > 3.5 cm thick
Ileal ureter, must be done with patient Cr < 2
Distal aspect of ileal ureter should be plugged into the bladder
Need Majority for Points
Intraperitoneal or complicated extraperitoneal
Complicated: bladder neck injury, bone fragment into bladder, rectal/vaginal injury, severe gross hematuria)
Uncomplicated penetrating trauma to anterior urethra vs. straddle injury?
Uncomplicated penetrating trauma prompt repair
If long debridement needed or shotgun injury, would marsupialize urethra onto ventral penile skin (to avoid chordee) and place SPT
Straddle injury - prompt drainage
Traumatic penile amputation?
Wrap in saline soaked gauze and place in plastic bag on ice.
Works up to 6 hours of warm ischemic time, 16 hours of cold ischemia
Reapproximating urethra and corporal bodies generally enough to preserve erectile function
Need at least 3
1. Significant deceleration or high velocity injury such as MVC or falling > 15 feet
2. Fractures to rib cage or spine
3. Gross hematuria
4. Microscopic hematuria with hypotension
L5 Transection of the ureter
Type of Repair
Proximal to iliac vessels, can perform UU over stent
Strictures distal to the iliacs can be repaired with psoas hitch +/- Boari flap
Persistent Leak after Cystorrhaphy for Bladder injury during Colon cancer resection?
Cystoscopy and biopsy to rule out persistent cancer prior to repeating cystorrhaphy
Concomitant pelvic injury with PFUI?
Diverting colostomy + urinary diversion (catheter or SPT)
Initial management is 24 hours of wet to dry dressings to assess for tissue viability
Non pulse RP hematoma found intraoperatively.
Next step?
Treatment Options for Retroperitoneal Fibrosis
Need majority
First line: steroids or tamoxifen
Second line: Immunomodulators (mycophenolate, azathioprine, cyclophosphamide) in conjunction with steroids can be primary or salvage treatment
Ureterolysis +/- omental wrapping if medical management unsuccessful
And blood supply?
Internal pudendal artery for Martius
Peritoneal flap for injuries high in vaginal fault
Distal VVF can be repair with Martius
Phases of Graft Take?
Need Times
Imbibition (0 - 48 hours) graft directly absorbs nutrients from its host bed
Inosculation (48 - 96 hours): fine capillaries between graft and host bed begin to align
Revascularization (96 hours to 7 days): graft survives due to completed vascular network
Butterfly hematoma confined by what layer?
And where do penile fractures most commonly occur?
Need specifics
Occur at 5 and 7 o'clock most commonly - where corporal bodies interact with corpus spongiosum (weakest point of corpora tunica)