Genitourinary trauma

Genitourinary (GU) organs are commonly injured in trauma patients. Although the kidney is the most commonly injured organ, other GU structures such as the bladder and urethra are also susceptible to injury. GU trauma is broadly divided into blunt and penetrative based on the mechanism of injury. Prompt diagnosis and recognition of iatrogenic GU injury are also paramount. A delay in diagnosis and treatment can have significant consequences – for example, abscess formation, fistulae and permanent renal impairment in the case of ureteric injury. Not all GU injuries require urgent surgery. Some can be managed with minimally invasive techniques (such as angiographic embolization) whilst others are managed entirely conservatively. The immediate management of these patients is geared towards haemodynamic stability. Haemodynamic shock that is resistant to the usual resuscitative measures often suggests ongoing bleeding and need for immediate intervention. The early management of most GU injuries with delayed presentation includes urinary diversion (through insertion of nephrostomy tube or suprapubic or urethral urinary catheter insertion) with delayed and definitive surgical reconstruction taking place at a later stage. Using the most up-to-date guidelines and published data we summarize the management of GU trauma by affected organ.     

Major genitourinary-related bicycle trauma: Results from 20 years at a level-1 trauma center

BackgroundEpidemiological studies have shown that bicycle trauma is associated with genitourinary (GU) injuries. Our objective is to characterize GU-related bicycle trauma admitted to a level I trauma center.Materials and methodsWe queried a prospective trauma registry for bicycle injuries over a 20-year period. Patient demographics, triage data, operative interventions and hospital details were collected.ResultsIn total, 1659 patients were admitted with major bicycle trauma. Of these, 48 cases involved a GU organ, specifically the bladder (n = 7), testis (n = 6), urethra (n = 3), adrenal (n = 4) and/or kidneys (n = 36). The median age of cyclists with GU injuries was 29 (range 5–70). More men were injured versus women (35 versus 13). GU-related bicycle trauma involved a motor vehicle in 52% (25/48) of injuries. The median injury severity score for GU-related bicycle trauma was 17 (range 1–50). The median number of concomitant organ injuries was 2 (range 0–6), the most common of which was the lungs (13/48, 27%) and ribs (13/48, 27%). The majority of GU injured cyclists were admitted to an ICU (15/48, 31%) or hospital floor (12/48, 25%). Operative intervention for a GU-related trauma was low (12/48, 25%). The most common GU organ injured was the kidney (36/48, 75%) however most were managed nonoperatively (33/36, 92%). Bladder injuries most often required operative intervention (6/7, 86%). Mortality following GU-related bicycle trauma was low (2/48, 4%).ConclusionsIn a large series of bicycle trauma, GU organs were injured in 3% of cases. The majority of cases were managed non-operatively and mortality was low.     

Urogenital injuries in childhood: A strong association of bladder trauma to bowel injuries

We analysed the inter-relationships of the cause and the type of trauma, the presence of pelvic fracture, the associated intraabdominal organ injuries,and the morbidity and mortality rates in 154 patients presenting and being treated for UGT between 1983 and 1997.The cause of injury was blunt in 77% of cases and penetrating in 13%. The most frequently injured organs were kidney followed by urethra and bladder. Bowels, liver and spleen were the most frequently associated injured organs. Moreover, bladder injuries were strongly associated with bowel injuries (p < 0.0001). Hemodynamically normal 49 children with minor or major kidney injuries were managed conservatively. Hemodynamically non-stable 11 patients were explored.The majority of urogenital injuries can be managed conservatively evenwhen associated with intraabdominal organ injuries. Solid genitourinary organ injuries may accompany more frequently to intraperitoneal solidorgan injury. Whereas, non-solid genitourinary organ injuries may more frequently associated with injuries of intraperitoneal hollow viscus. This revised version was published online in August 2006 with corrections to the Cover Date.     

Injuries to the Spleen

Background  Intra-abdominal organs, most commonly the spleen and liver, are injured in 40–50% of polytraumatized patients. Because of its important immunological functions, preservation of the injured spleen is of paramount importance. Methods  There are both conservative and surgical approaches to preservation of the spleen in trauma cases. Of the techniques available for this purpose, tissue adhesives, coagulation, partial resection, and mesh splenorrhapy are the most suitable. Results  Nonoperative management is a worthwhile option in hemodynamically stable patients. The decisive factor for successful conservative management is the degree of injury. We find that the manner in which heparin is administered plays an important role. Tissue adhesives are commonly used with good success with superficial lacerations. Coagulation techniques are also suitable for organ conservation with grade I and II injuries. Splenorraphy with resorbable mesh is the method of choice with the deep lacerations as it permits rapid and permanent hemostasis. If an injury only involves one pole or one half of the spleen, resection of that part of the organ is an option. Partial resection with a stapler is advisable for speed and effectiveness. Total fragmentation or separation of the hilus is treated with an immediate splenectomy, saving the tail of the pancreas. Conclusion  In trauma cases, every attempt should be made to save the spleen. If splenectomy cannot be avoided, the splenectomized patient should be immunized against pneumococcus and be informed of his/her resultant immune deficiency.     

Blunt Thoracic and Abdominal Vascular Trauma and Organ Injury Caused by Road Traffic Accident

OBJECTIVES: To analyse the relationship between vascular trauma and associated injuries to intra-thoracic and abdominal organs caused by traffic accidents. Design retrospective study in a university hospital. MATERIALS AND METHODS: We investigated 458 consecutive patients who were admitted with blunt thoracic and/or abdominal trauma caused by road traffic accidents between 1986 and 1999. Vascular trauma was encountered in 54 patients (12%). RESULTS: The injured vessels were located in the abdomen in 45 patients and in the chest in nine patients. Mesenteric vessels were the most frequently injured vessels (33/45) in the abdomen, while the aorta and major vessels were most frequently injured (9/9) in the chest. Injury to the large/small intestine was often associated with mesenteric vessel injury (26/27). In the 190 patients with blunt abdominal organ injury, the frequency of mesenteric vessel injury was also highest, regardless of the injured organ. Vascular reconstruction was necessary only in one of 51 patients who underwent operation. CONCLUSIONS: Our results demonstrate that the mesenteric vessels are susceptible to blunt thoracic and abdominal trauma in road traffic accidents. Vascular reconstruction may be indicated for selected patients as long as the injuries to hollow organs are assessed carefully because of their strong association with vascular injury.     

Intra-arterial thrombolysis in the carotid territory

Background: In patients who sustain abdominal trauma the liver is the most frequently injured organ. Although treatment for haemodynamically unstable patients remains urgent surgery, there has been a shift of management in haemodynamacally stable patients towards non-operative management. We performed an outcome assessment of traumatic hepatic injury.

Methods: A retrospective study was performed to assess incidence, mechanisms, management and outcome of traumatic liver injury in the region of ’s-Hertogenbosch, the Netherlands, in the period 1999–2007.

Results: A total of 47 patients were identified. Thirty-six patients had blunt hepatic trauma, eleven sustained penetrating hepatic injury. In 67% (n = 24) of the blunt hepatic trauma patients the initial intention was to treat non-operatively. Yet, two patients underwent explorative laparotomy after one and two days. In the penetrating liver trauma patients, 91% (n = 10) underwent urgent surgery. In total, 31 of 47 patients were treated conservatively.

Conclusion: Blunt hepatic trauma is the most common cause of hepatic trauma. Most patients sustaining hepatic trauma can be managed conservatively at a dedicated ICU and/or surgical trauma ward.     

Actual Diagnostic Strategies in Blunt Abdominal Trauma

An accurate assessment of patients with potential blunt abdominal trauma should include a safe and reliable method of determining the need for operative intervention because the mortality and morbidity of these injuries are directly dependent on the immediately valid diagnostic work-up. Since peritoneal signs are often subtle, overshadowed by pain from associated injury or masked by head trauma and intoxicants, clinical methods of diagnostics are often unreliable. Since the frequently injured liver and spleen are nowadays more frequently managed nonoperatively, an acute assessment not only of the presence of injury, but also of the nature and extent of the injuries to the intraabdominal organs, raises an increasing demand of both sensitive and specific diagnostic modalities. This article discusses the use of different diagnostic modalities including peritoneal lavage, computed tomography scanning, ultrasound and laparoscopy in the diagnosis and immediate management of blunt abdominal trauma patients, and formulates a trauma protocol for managing these patients. Received: June 21, 2001; revision accepted: February 15, 2002     

Traumatic brain injury: initial resuscitation and transfer

Traumatic brain injury (TBI) is common and is associated with significant morbidity and mortality. The initial resuscitation and management of patients with traumatic brain injury is focused on limiting secondary brain injury and this may be complex in patients with significant injuries to other organ systems. The transport of critically ill brain injured patients for definitive treatment also carries significant risks which must be managed. This review describes the initial resuscitation and transfer of patients with traumatic brain injuries.     

Retrospective analysis of 135 renal trauma cases

BACKGROUND: We review our trauma cases over the last 11 years and discuss our diagnosis and treatment modalities. METHODS: One hundred and thirty-five patients with renal injuries who had been hospitalized in the Urology and General Surgery clinics of Dicle University hospital between 1990 and 2001 were reviewed retrospectively. Patients were evaluated with regard to age, sex, cause of trauma, transport time, diagnostic methods, grade of injuries, associated organ injuries, treatments and complications. RESULTS: One hundred and forty-one renal injuries were established in 135 patients. The patients were between 5 and 65 years old; 114 (84.4%) were male and 21 (15.6%) were female. The most common cause of injuries (99 patients) was penetrating injuries. The transport time to hospital after injury was approximately 116 min. Immediate laparotomy was performed in 95 hemodynamically unstable patients. Radiological investigations were carried out in the remaining 40 patients. Most of the injuries were grade 4 (28, 19.86%) or 5 (60, 42.55%). Isolated renal injury was established in only 22 of 135 patients. Nephrorrhaphy was performed in 45 of 141 kidneys. Twelve injured kidneys were managed conservatively. Nephrectomy was performed in 66 of 141 kidneys. The remaining injured kidneys were managed with different treatment methods. Twenty-nine (21.48%) patients were lost intraoperatively or during the early postoperative period. CONCLUSION: We believe that our rates of nephrectomy and mortality were high because of the long transport time, unsuitable transport type, frequent high grade and high rate of associated organ injuries.     

The spectrum of injuries resulting from posterior abdominal stab wounds: a South African experience

Introduction

The spectrum of injury associated with anterior abdominal stab wounds (SWs) is well established. The literature on the spectrum of organ injury associated with SWs to the posterior abdomen, however, is limited.

Methods

We reviewed our experience of 105 consecutive patients who had established indications for laparotomy managed over a 4-year period in a high volume trauma service in South Africa.

Results

Of the 105 patients, 97 (92%) were male and the overall mean age was 24 years. Fifty-seven patients (54%) had immediate indications for laparotomy. The remaining 48 patients (46%) initially underwent active clinical observation and the indications for laparotomy became apparent during the observation period. Of the 105 laparotomies performed, 94 (90%) were positive and 11 (10%) were negative. Of the 94 positive laparotomies, 92 were therapeutic and 2 were non-therapeutic. A total of 176 organ injuries were identified: 50 (53%) of the 94 patients sustained a single organ injury while the remaining 44 (47%) sustained multiple organ injuries. The most commonly injured organs were the colon (n=63), spleen (n=21) and kidney (n=19).

Conclusions

The pattern of intra-abdominal injuries secondary to SWs to the posterior abdomen is different to that seen with the anterior abdomen. Colonic injury is most commonly encountered, followed by injuries to the spleen and kidney. Clinicians must remain vigilant because of the potential for occult injuries.     

Operative and nonoperative management of blunt hepatic trauma in adults: a single-center report

Background/Purpose Liver trauma, especially that as result of road traffic accidents, still remains a complicated problem in severely injured patients. The aim of this study was to extract useful conclusions from the management in order to improve the final outcome of such patients. Methods Details for 86 patients with blunt hepatic trauma who were examined and treated in our department during a 6-year period were analyzed. We retrospectively reviewed the severity of liver injury, associated injuries, treatment, and outcome. Results Forty-nine liver injuries (57%) were of low severity (grades I and II), while 37 (43%) were of high severity (grades III, IV, and V). Liver trauma with associated injury of other organs was noted in 62 (72.1%) patients. Forty-three (50%) patients underwent an exploratory laparotomy within the first 24 h of admission. Thirty-five (71.4%) of the 49 patients with low-grade hepatic injuries were managed conservatively; no mortality occurred. Six (14%) of forty-three patients with liver trauma initially considered for conservative management required surgery due to hemodynamic instability. Five (13.5%) of 37 patients who were finally managed nonoperatively required adjunctive treatment for biloma, hematoma, or biliary leakage; no mortality occurred. The overall mortality rate was 9.3%; mortality rates of 5.8% and 3.5% were due to liver injuries and concomitant injuries, respectively. Conclusions Severe hepatic injuries require surgical intervention due to hemodynamic instability. Low-grade injuries can be managed nonoperatively with excellent results, while patients with hepatic trauma with associated organ injuries require surgery, because they continue to have significantly higher mortality.     

Lower genitourinary trauma in modern warfare: The experience from civil violence in Iraq

Background

Reports on genitourinary (GU) trauma during the Iraqi conflict have been limited to battlefield injuries. We sought to characterise the incidence, mechanism of injury, wounding pattern, and management of lower GU injuries sustained in civil violence during the Iraqi war.

Patients and methods

A total of 2800 casualties with penetrating trauma to the abdomen and pelvis were treated at the Yarmouk Hospital, Baghdad from January 2004 to June 2008. Of the casualties 504 (18%) had GU trauma including 217 (43%) with one or more injuries to the lower GU organs.

Results

Among the 217 patients there were 262 lower GU injuries involving the bladder in 128 (48.8%) patients, bulbo-prostatic urethra in 21 (8%), penis in 24 (9.2%), and scrotum in 89 (34%). Injuries to the anterior urethra and genitals were inflicted by Improvised Explosive Devices (IEDs) in 53–67% of cases and by individual firearms in 33–47%, while injuries to the posterior urethra and bladder were inflicted by IEDs in 17–22% of cases and by firearms in 78–83%. All penile wounds were repaired save 3 (12.5%) patients who underwent total penectomy. Of 63 injured testicles 54 (86%) could be salvaged and 9 (14%) required unilateral orchiectomy. The leading cause of death was an associated injury to major blood vessels in 26 (84%) of 31 patients who died.

Conclusions

Injuries to the anterior urethra and genitals were commonly caused by IEDs, while injuries to the posterior urethra and bladder were usually caused by individual firearms. Testis injury was almost always salvageable. Associated trauma to major blood vessels was the leading cause of death in these casualties.     

Animal-related injury in an urban New Zealand population

The contribution of animals to injury in urban populations is not well described. We reviewed our trauma admissions for animal-related injury to identify animals involved, risk factors and patterns of injury. Eight thousand nine hundred and fifty-four patients were admitted for trauma during the study period. One hundred and sixty-seven injuries were due to animals (1.9%). Horses were involved in 86% and dogs in 10% of injuries. Most horse riders were injured in falls. Factors associated with increased risk included being young, female and riding for leisure. Body regions most commonly injured were the head and both upper and lower extremities. Patterns of injury were identified. Horse-related injury is a significant source of traumatic injury in an identifiable at-risk subgroup of our urban population. High rates of head injury and low rates of helmet use suggest a more effective strategy to encourage use of protective headgear is needed. Further efforts aimed at injury prevention must include an improvement in skill and knowledge of horsemanship, particularly in the at-risk group of young female amateur riders. Mechanistic patterns of injury and body-region markers identified in this study may assist early recognition of severe and occult injuries in these patients.     

Urological trauma and severe associated injuries

Our experience with 212 cases of urinary tract injury in multiple trauma patients treated between 1972 and 1983 has been analysed and compared with data collected from 441 cases of isolated urinary tract injury during the same period. The following points are emphasised: (1) incidence and severity of urological trauma in multiple injured patients; (2) obstacles in diagnosis and the need for immediate radiographic assessment; (3) lower urinary tract injuries and the need for urinary diversion; (4) differences in therapeutic approach to renal injuries in multiple trauma patients. We paid special attention to the indication for surgical exploration in patients with a renal laceration and severe associated injuries.     

Treatment and outcome of traumatic biliary injuries in children

Background/Purpose

Traumatic biliary tract injuries in children are rare but may result in significant morbidity. The objective of this study was to review the occurrence of traumatic biliary tract injuries in children, management strategies, and outcome.

Methods

We conducted a retrospective review of patients with biliary tract injury using the trauma registry at our level 1 pediatric trauma center from 2002–2012.

Results

Twelve out of 13,582 trauma patients were identified, representing 0.09% of all trauma patients. All were secondary to blunt trauma. Mean age was 9.7 years [range 4–15], and mean Injury Severity Score was 31 ± 14, with overall survival of 92%. Biliary injuries included major ductal injury (6), minor ductal injury with biloma (4), gallbladder injury (2), and intrahepatic ductal injury (1). Major ductal injuries were managed by endoscopic retrograde cholangiopancreatography (ERCP) and biliary stent (5) and Roux-en-Y hepaticojejunostomy (1). Associated gallbladder injury was managed by cholecystectomy. In addition, the associated biloma was managed with percutaneous drainage (7), laparoscopic drainage (2), or during laparotomy (3). Two patients with ductal injuries developed late strictures after initial management with ERCP and stent placement. One of the two patients ultimately required a left hepatectomy, and the other has been managed conservatively without evidence of cholangitis. Two patients required placement of additional drains and prolonged antibiotics for superinfection following biloma drainage.

Conclusion

Biliary tract injuries are rare in children, and many are amenable to adjunctive therapy, including ERCP and biliary stent placement with or without placement of a peritoneal drain. Patients with a discrete ductal injury are at higher risk for stricture and require close follow up. Hepaticojejunostomy remains the definitive repair for large extrahepatic biliary tract injuries or transections.     

Penetrating Injuries to the Abdomen: a Single Institutional Experience with Review of Literature

Penetrating abdominal trauma forms an important component of surgical emergencies, most of the victims being young aged in the prime of their life. Over the past century, the diagnosis and management of this common problem has seen drastic changes, finally reaching the destination of selective approach. We present our experience in the management of this group of patients in the rural setup. This is a prospective observational study done at our hospital between 1 April 2013 and 31 March 2015 including patients who presented with penetrating abdominal injury. The clinical presentation, imaging features, diagnosis, management, and complications of all these patients are analyzed. The mean age was 33.5 years with majority being males. Homicidal stab injuries accounted for most of the injuries (62.5 %). Forty-eight patients underwent laparotomy, and among which, the procedure was therapeutic in 36 patients. Peritoneal penetration was the best predictor of a therapeutic laparotomy with a high sensitivity and positive predictive value (100 and 80 %, respectively). The small intestine was the most commonly injured organ. The mean postoperative stay was 8.25 days, and there was no mortality. Though the management of these patients should aim at minimizing the rate of negative laparotomies, this should not be done at the expense of delayed diagnosis and treatment. Diagnostic laparoscopy may avoid unnecessary laparotomies; however, it requires adequate skills in laparoendoscopy. Management is best tailor made for each individual based on the nature of injury, findings at presentation, and the organ injured.     

Computed tomography and nonoperative treatment for blunt abdominal trauma

Studies were undertaken to determine if computed tomography (CT) could reliably assist physical examination in the initial assessment of blunt abdominal trauma, and also to examine how various abdominal injuries were managed with the guidance of CT. A total of 255 patients underwent emergency abdominal CT following blunt abdominal trauma over a period of seven years. One hundred and fifty two patients had abnormal CT scans, including 58 hepatic, 36 renal, 25 splenic and 9 pancreatic injuries as well as 67 patients with intra-abdominal hemorrhage and 21 patients with free abdominal air. A comparative study on the detection of pneumoperitoneum revealed CT to be far superior to plain radiography. One hundred and three patients had normal CT scans, all of whom were managed nonoperatively, except for three false-negative cases and two nontherapeutic cases. The patients with injury to the parenchymal organs were given nonoperative treatment if they had stable vital signs and no evidence of associated injuries demanding immediate surgery and the majority of these patients were managed well nonoperatively. CT was thus found to be a useful adjunct in the management of victims of blunt abdominal trauma, since in a rapid and noninvasive fashion, CT accurately defined the extent of parenchymal organ injury and also disclosed any other abdominal injuries.     

Fecal continence following complex anorectal trauma in children

Background

Complex injuries involving the anus and rectum are uncommon in children. We sought to examine long-term fecal continence following repair of these injuries.

Methods

We conducted a retrospective review using our trauma registry from 2003 to 2012 of children with traumatic injuries to the anus or rectum at a level I pediatric trauma center. Patients with an injury requiring surgical repair that involved the anal sphincters and/or rectum were selected for a detailed review.

Results

Twenty-one patients (21/13,149 activations, 0.2%) who had an injury to the anus (n = 9), rectum (n = 8), or destructive injury to both the anus and rectum (n = 4) were identified. Eleven (52%) patients were male, and the median age at time of injury was 9 (range 1–14) years. Penetrating trauma accounted for 48% of injuries. Three (14%) patients had accompanying injury to the urinary tract, and 6 (60%) females had vaginal injuries. All patients with an injury involving the rectum and destructive anal injuries were managed with fecal diversion. No patient with an isolated anal injury underwent fecal diversion. Four (19%) patients developed wound infections. The majority (90%) of patients were continent at last follow-up. One patient who sustained a gunshot injury to the pelvis with sacral nerve involvement is incontinent, but remains artificially clean on an intense bowel management program with enemas, and one patient with a destructive crush injury still has a colostomy.

Conclusions

With anatomic reconstruction of the anal sphincter mechanism, most patients with traumatic anorectal injuries will experience long-term fecal continence. Follow-up is needed as occasionally these patients, specifically those with nerve or crush injury, may require a formal bowel management program.     

Genitourinary trauma

Genitourinary trauma occurs in about 10–20% of multiply injured patients and occurs in conjunction with other life-threatening injuries that require immediate attention. Initial assessment should include securing the airway, controlling external bleeding and resuscitation of shock. In many cases the patient is attended by a team where examination and resuscitation is carried out simultaneously. Recognition of genitourinary trauma with appropriate investigations is necessary to select patients for immediate intervention or conservative measures. We discuss the assessment and management of these patients.     

MANAGEMENT OF TRANSECTED PANCREAS IN CHILDREN

The pancreas is the fourth most commonly injured intra-abdominal organ in children who sustain blunt abdominal trauma. Appropriate management of the injured pancreas has been controversial. With the advent of the computerized tomography scan, paediatric surgeons have tended to manage pancreatic injuries non-operatively. However. if pseudocysts develop. non-operative management may necessarily entail a long hospital course involving total parenleral nutrition. drainage procedures and attendant morbidity. The critical element in planning therapy is to determine the status of the pancreatic duct. We have recently encountered five children who suffered blunt pancreatic injury where the main pancreatic duct was determined to have been transected. These children underwent spleen preserving distal pancreatectomy with resultant shorter hospital stays and minimal long-term morbidity. We suggest that in children with pancreatic injury where the main pancreatic duct has been transected early operative management rather than non-operative therapy is the procedure of choice. Endoscopic retrograde cholangiopancreatography should be used to determine the status of the pancreatic duct. This modality can be both diagnostic and therapeutic in appropriate circumstances.