Management of renal artery injuries from external trauma

We reviewed the records of 27 patients with main renal artery injury admitted to our hospitals from 1959 through June 1986. Before 1969, 7 patients were hospitalized of whom 4 had nonsurgical management with total loss of function of the affected kidney, 2 had immediate nephrectomy and 1 died before treatment. Despite the nonfunctioning kidney no hypertension developed in 3 of the 4 patients followed for an average of 72 months. After 1969 when immediate radiological assessment and surgical management of main renal artery injuries were instituted 20 patients were hospitalized. Of 4 patients treated nonoperatively loss of function of the affected kidney resulted and hypertension occurred in 1, necessitating delayed nephrectomy, after an average followup of 3.5 months. Immediate nephrectomy was performed in 10 patients and vascular repair in 3. In both survivors who underwent vascular repair followup at 24 and 36 months, respectively, showed no hypertension but loss of approximately half of the function of the affected kidney. The other 3 patients died before treatment. Aggressive management reduced markedly the time from injury to diagnosis from a median of 48 hours before 1969 to 5 hours after 1969 but only a small number of patients were suitable for vascular repair, and this procedure did not restore complete function to the kidney.     

Bladder rupture from external trauma: diagnosis and management

Rupture of the bladder from external trauma is usually due to a blow to the abdomen when the bladder is distended or associated with a fractured pelvis. The diagnosis is made by performance of a retrograde cystogram and observation of contrast extravasation. An intravenous contrast study is not acceptable. All patients with an intraperitoneal bladder rupture should have formal repair. Extraperitoneal bladder ruptures may be treated with catheter drainage if the urine clears of blood promptly, the catheter drains well, and the bladder neck is not involved in the injury. Otherwise, formal repair is mandatory.     

Ureteral injuries: external and iatrogenic

Both iatrogenic and traumatic ureteral injuries are rare. However, a high index of suspicion is warranted for ureteral injuries because ureteral injuries are associated with increased morbidity. The urologist should be familiar with several methods for identifying ureteral injuries and should make evaluations tailored to the clinical situation. Most ureteral injuries are short transections and can be repaired with debridement and ureteroureterostomy in the proximal and mid-ureter or ureteroneocystostomy in the distal ureter.     

Male genital injuries from external trauma

External trauma from a variety of causes, some unusual and bizarre, affect the male genitalia. Certain injuries are more common, have more severe consequences, or their management may be controversial. Seventy male genital injuries from external trauma are reported and include vacuum cleaner injuries, fracture of penis and the tourniquet syndrome.     

Immediate radiological evaluation and early surgical management of genitourinary injuries from external trauma

An immediate diagnostic evaluation of genitourinary trauma is mandatory for an early operation. A method of immediate radiological evaluation is presented and the accuracy rate in the diagnosis of the type and site of injury is detailed. The advantages of early surgical management are compared to the results with expectant management.     

The use of external fixation devices in the management of severe lower-extremity trauma and pelvic injuries in children

Between 1977 and 1982, 17 pediatric patients ranging in age from six to 14 years were treated for injuries that required the application of a total of 20 external fixation devices. The indications for the use of external fixation devices in children include: open fractures with soft-tissue injury, unstable fractures (diaphyseal, epiphyseal, and intra-articular), "polytrauma" patients, and unstable pelvic fractures. All fractures and soft-tissue injuries healed. The usual reported complications of external fixation devices, such as pin tract infections, delayed union, and refracture, were not encountered.     

Ureteral endometriosis: diagnosis and management

Ureteral endometriosis is a rare disease with only about 300 cases reported. The diagnosis is difficult. The symptoms are non-specific and the diagnosis is based on abdominal ultrasonography suspicion confirmed by intravenous pyelography. The management of ureteral endometriosis usually requires surgery. Hormone therapy should be offered to patients of childbearing age who desire to have children and have the disease in an early stage. Open or laparoscopic surgical treatment gives long-term favorable results.     

Evaluation and management of renal injuries: consensus statement of the renal trauma subcommittee

OBJECTIVE: To determine the optimal evaluation and management of renal injuries by review of the world's English-language literature on the subject. METHODS: A consensus conference convened by the World Health Organization and the Societé Internationale d'Urologie met to critically review reports of the diagnosis and treatment of renal trauma. The English-language literature about renal trauma was identified using Medline, and additional cited works not detected in the initial search obtained. Evidence-based recommendations for the diagnosis and management of renal trauma were made with reference to a five-point scale. RESULTS: There were many Level 3 and 4 citations, few Level 2, and one Level 1 which supported clinical practice patterns. Findings of nearly 200 reviewed citations are summarized. CONCLUSIONS: Published reports on renal trauma still rely heavily on expert opinion and single-institution retrospective case series. Prospective trials of the most significant issues, when possible, might improve the quality of evidence that dictates the behaviour of practitioners.     

An international survey of pelvic trauma surgeons on the management of pelvic ring injuries

IntroductionThere exists substantial variability in the management of pelvic ring injuries among pelvic trauma surgeons. The objective of this study was to perform a comprehensive survey on the management of pelvic ring injuries among an international group of pelvic trauma surgeons to determine areas of agreement and disagreement.MethodsA 45-item questionnaire was developed using an online survey platform and distributed to 30 international pelvic trauma surgeons. The survey consisted of general questions on the acute management of pelvic ring injuries and questions regarding 5 cases: Lateral compression (LC) type 1 injury, LC-3, Anterior-posterior compression (APC) type 3 injury, a combined vertical shear (VS) injury through the sacrum, and VS injury through sacroiliac joint. Respondents were shown blinded anteroposterior pelvis radiographs and axial computed tomography (CT) images for each case and asked if the injury needed fixation, the type of fixation, the order of fixation, and postoperative weight-bearing status. The Kappa statistic was calculated to assess agreement between respondents for each question.ResultsNineteen out of 30 pelvic trauma surgeons completed the survey. Respondents practiced in Brazil (n = 1), Germany (n = 1), India (n = 1), Italy (n = 1) United Kingdom (n = 1), and the United States (n = 14). Of the 45 questions in this survey, 38 (84%) had minimal to no agreement among the respondents. There was moderate agreement, for performing lumbopelvic fixation when indicated, for anterior and posterior fixation of the LC-3 injury, and on forgoing EUA or stress X-rays for the APC-3 injury. There was strong agreement for open reduction and internal fixation of the anterior pelvic ring in the APC-3 injury and the VS injury through the SI joint. In contrast, LC-1 injury and combined VS pelvic ring injury through the sacrum had no areas of moderate to strong agreement.DiscussionThis study identified specific areas of pelvic ring injury management with minimal to no agreement among pelvic trauma surgeons. Future research should target these areas with a lack of agreement to decrease practice variability and improve patient outcomes.     

Ureteral stenting in the management of urinoma after severe blunt renal trauma in children

Posttraumatic urinomas are well-described complications associated with the nonoperative management of major blunt renal injuries. Urinoma drainage using a percutaneously placed catheter has been the traditional method used to alleviate symptoms and promote resolution without the need for open intervention. The authors describe 2 pediatric cases in which urinomas associated with grade IV renal lacerations were treated successfully utilizing internal ureteral stents.     

Nonoperative management of bladder rupture from external trauma

Nonoperative (catheter) management was used in 18 patients with extraperitoneal rupture of the bladder with limited extravasation of dye found by retrograde cystogram. Complications occurred in 4 of the 18 patients. A review of the literature shows a 20 to 25-per cent complication rate with nonoperative management of bladder rupture. However, with a small extraperitoneal rupture with limited extravasation, especially in a female, the nonoperative (catheter) management will give a satisfactory result.     

Renovascular injuries from external trauma. Diagnosis, treatment, and outcome

Blunt trauma of the deceleration or acceleration type is the most common cause of renal pedicle injuries comprising thrombosis or rupture of the main renal artery, branch renal artery, or the renal vein. There are no symptoms or signs specific to this injury, and hematuria is absent in one third of the cases. Severe multiple associated injuries are present in almost all cases, with a mortality rate of 44 per cent. Radiologic evaluation with intravenous urography shows nonappearance of the involved kidney. CT reveals nonenhancement of the kidney except for the periphery of the cortex from collateral circulation (rim sign), and renal arteriography shows occlusion of the renal artery or its branches. Despite immediate radiologic evaluation resulting in a short time from injury to diagnosis, most of the patients are not candidates for vascular repair owing to the high incidence of severe associated injuries, especially a second injury to the same kidney. Even with vascular repair, the function of the kidney is not restored to normal. Late hypertension is found in 50 per cent of patients with main renal artery thrombosis managed conservatively.