Diagnosis and classification of injuries of the pancreas

Based on experience of treatment of pancreatic injuries in 150 patients, all the variants of this organ trauma are classified. Anatomic study on topography of main pancreatic duct was carried out. Proposed classification and method help to decide on adequate scope of surgery regarding not only injury of the pancreas but also of other organs, and to decrease number of complications and lethality.     

Cervical spine injuries. Diagnosis and classification.

Roentogenographic techniques in the evaluation of the patient with a cervical spine injury entail several considerations that should be respected in defining and classifying the lesion according to the mechanism of injury. Unilateral or bilateral facet dislocation with separation of posterior elements usually implies disruptive flexion injury. Anterior wedging of a vertebral body indicates flexion with some degree of compression. Comminution of the vertebral body indicates a predominant compressive element to the injury. An anterior-inferior marginal fracture indicates extension injury. Impaction of the inferior articulating processes or fracture of the pedicle producing a more horizontal appearance of the facet indicates disruption of interspinous ligaments and the probability that significant instability exists. Studies should not be terminated until complete visualization of all cervical segments has been obtained, including the cervico-thoracic junction.     

Anterior urethral injuries.

Seventeen patients are reviewed who presented at the Birmingham Accident Hospital over a 20-year period with injuries to the anterior urethra. Fourteen of the injuries resulted from isolated direct blows to the perineum, while 3 were associated with multiple injuries. The clinical features and management of these patients are discussed in conjunction with a review of the relevant literature. A protocol for the management of this type of injury is outlined.     

Initial management of acute urethral injuries

A study was made of 30 cases of acute urethral trauma treated over a 7-year period. There were 10 anterior and 20 posterior urethral injuries, the majority of these being partial ruptures. Posterior urethral injuries were caused by road traffic accidents in 75% of cases while 80% of the anterior urethral injuries were of the "straddle" type. There was only 1 case of iatrogenic injury to the anterior urethra. During follow-up, all patients required periodic dilatations for stricture except for the single case of iatrogenic injury. An average of 5 dilatations controlled all of the strictures except for 2 that required urethroplasties.     

Initial management of anterior and posterior urethral injuries

The key to the initial management of a urethral injury is prompt diagnosis, accurate staging of the injury, and properly selecting an intervention that minimizes the overall chances for the debilitating complications of incontinence, impotence, and urethral stricture. Although somewhat controversial, blunt traumatic posterior injuries generally are managed best by primary realignment (when feasible), straddle injuries of the bulbar urethra by suprapubic urinary diversion, and penetrating urethral injuries by primary repair and urinary diversion.     

Pelvic fracture urethral injuries in girls

PURPOSE: Injuries to the female urethra associated with pelvic fracture are uncommon. They may vary from urethral contusion to partial or circumferential rupture. When disruption has occurred at the level of the proximal urethra, it is usually complete and often associated with vaginal laceration. We retrospectively reviewed the records of a series of girls with pelvic fracture urethral stricture and present surgical treatment to restore urethral continuity and the outcome. MATERIALS AND METHODS: Between 1984 and 1997, 8 girls 4 to 16 years old (median age 9.6) with urethral injuries associated with pelvic fracture were treated at our institutions. Immediate therapy involved suprapubic cystostomy in 4 cases, urethral catheter alignment and simultaneous suprapubic cystostomy in 3, and primary suturing of the urethra, bladder neck and vagina in 1. Delayed 1-stage anastomotic repair was performed in 1 patient with urethral avulsion at the level of the bladder neck and in 5 with a proximal urethral distraction defect, while a neourethra was constructed from the anterior vaginal wall in a 2-stage procedure in 1 with mid urethral avulsion. Concomitant vaginal rupture in 7 cases was treated at delayed urethral reconstruction in 5 and by primary repair in 2. The surgical approach was retropubic in 3 cases, vaginal-retropubic in 1 and vaginal-transpubic in 4. Associated injuries included rectal injury in 3 girls and bladder neck laceration in 4. Overall postoperative followup was 6 months to 6.3 years (median 3 years). RESULTS: Urethral obliteration developed in all patients treated with suprapubic cystostomy and simultaneous urethral realignment. The stricture-free rate for 1-stage anastomotic repair and substitution urethroplasty was 100%. In 1 girl complete urinary incontinence developed, while another has mild stress incontinence. Retrospectively the 2 incontinent girls had had an associated bladder neck injury at the initial trauma. Two recurrent vaginal strictures were treated successfully with additional transpositions of lateral labial flaps. CONCLUSIONS: This study emphasizes that combined vaginal-partial transpubic access is a reliable approach for resolving complex obliterative urethral strictures and associated urethrovaginal fistulas or severe bladder neck damage after traumatic pelvic fracture injury in female pediatric patients. Although our experience with the initial management of these injuries is limited, we advocate early cystostomy drainage and deferred surgical reconstruction when life threatening clinical conditions are present or extensive traumatized tissue in the affected area precludes immediate ideal surgical repair.     

Cost-effective management of pelvic fracture urethral injuries

Purpose

To compare the cost-effectiveness of various treatment strategies in the management of pelvic fracture urethral injuries using decision analysis.

Methods

Five strategies were modeled from the time of injury to resolution of obstructed voiding or progression to urethroplasty. Management consisted of immediate suprapubic tube (SPT) placement and delayed urethroplasty; primary endoscopic realignment (PER) followed by urethroplasty in failed patients; or PER followed by 1–3 direct vision internal urethrotomies (DVIU), followed by urethroplasty. Success rates were obtained from the literature. Total medical costs were estimated and incremental cost-effectiveness ratios (ICERs) were generated over a 2-year follow-up period.

Results

PER was preferred over SPT placement in all iterations of the model. PER followed by a single DVIU and urethroplasty in cases of failure was least costly and used as the referent approach with an average cost-effectiveness of $17,493 per unobstructed voider. The ICER of a second DVIU prior to urethroplasty was $86,280 per unobstructed voider, while the ICER of a third DVIU was $172,205. The model was sensitive to changes in the success rate of the first DVIU, where when the probability of DVIU success is expected to be less than 32% immediate urethroplasty after failed PER is favored.

Conclusions

Management of pelvic fracture urethral injuries with PER is the preferred management strategy according to the current model. For those who fail PER, a single DVIU may be attempted if the presumed success rate is >32%. In all other cases, urethroplasty following PER is the preferred approach.

     

Diagnosis and management of female urethral diverticulum

Female urethral diverticulum is a disorder that affects 1% to 6% of women. Women with diverticula may present with a variety of nonspecific genitourinary complaints, making the diagnosis challenging. Diagnosis is made by physical examination and can be confirmed with cystourethroscopy and/or radiographic imaging. Asymptomatic women can be managed conservatively, whereas treatment for symptomatic women usually involves a diverticulectomy. Potential complications from diverticulectomy include diverticulum recurrence, de novo stress incontinence, urethrovaginal fistula, urethral stricture, and recurrent urinary tract infections. This article reviews the etiology, differential diagnoses, evaluation, and management of female urethral diverticula.     

Diagnosis and treatment of posterior urethral injury

The initial investigation and diagnosis in 28 patients with posterior urethral trauma are presented. Twenty-five patients underwent either primary realignment for complete rupture or cystostomy alone for partial rupture. The results of their management are reported.     

Posterior urethral injuries associated with pelvic fractures

The types of fracture of the bony pelvis are categorized, and a system for diagnosis and treatment is recommended which should prevent many strictures and make those which do develop, easier to repair secondarily. This system of treatment should reduce trauma to the nerves and blood vessels.