Renal exploration for trauma begins with prioritization of the injuries and determining that the initial operation is in fact the appropriate time to embark on the renal exploration (see the section “Damage Control Principles in Genitourinary Trauma”). When contemplating exploration of an injured kidney in the absence of preoperative imaging, some assessment of the presence and normalcy of the contralateral kidney should be undertaken. Palpating the contralateral renal fossa for a grossly normal kidney is certainly appropriate and is often the only assessment necessary. In select cases, an intraoperative IVP may provide more precise information. This can be performed by administering 1–2 mL/kg of iodinated contrast intravenously and then obtaining a 10-minute excretion film. This can occur while other general surgical tasks are being accomplished to avoid wasting time. While an intraoperative IVP provides some additional reassurance that a functional contralateral kidney is present when exploring an injured kidney, it is generally advised to proceed with exploration of the injured kidney based on contralateral renal palpation alone.
If it is jointly determined by the urologist and the general surgeon that renal exploration should occur, exploration is carried out through an anterior vertical incision in Gerota’s fascia. There has been some controversy regarding the importance of first obtaining vascular control of the renal pedicle prior to renal exploration, as previously described.67,68 Some proponents claim a markedly reduced nephrectomy rate if the renal vessels are first dissected and controlled with vessel loops. Others claim that this maneuver is unnecessary for successful renal exploration and repair. This controversy is probably overstated, as even those who do not believe that individual dissection of the renal vessels is essential prior to renal mobilization tend to use some other approach to control the pedicle or limit renal bleeding during examination and repair of the kidney. The bulk of the literature would suggest that the rate of otherwise unnecessary nephrectomies is minimized by having exposure and control of the renal pedicle prior to renal exploration. This can be achieved by the traditional maneuver of incising the posterior peritoneum lateral to the aorta and individually dissecting and looping the renal vessels on the side of the injury (Fig. 36-19). This can also be achieved by reflecting the colon medially first, and then clamping the pedicle if significant bleeding is encountered upon opening the Gerota’s fascial envelope (Fig. 36-20). Alternatively, the pedicle or the renal parenchyma can be compressed digitally (most applicable to polar injuries) without having individual control over the renal vessels. Certainly, if there is an injury to the pedicle suggested by a large or expanding medial hematoma in the vicinity of the great vessels, there is broad agreement that central vascular control should be the initial maneuver.
Surgical management of renal trauma: vascular control. Diagram demonstrating early vascular control prior to renal exploration. (A) The posterior peritoneum is opened over the aorta medial to the inferior mesenteric vein. (B) The renal vessels are individually dissected and surrounded with vessel loops. (C) The colon is reflected medially exposing the perinephric hematoma. Some clinicians believe preliminary control of the renal vessels is not necessary when performing renal exploration for trauma, although best renal salvage rates are reported when vascular access or control is obtained.
(A) Alternate means of obtaining vascular pedicle access prior to renal exploration. Colon is reflected medially initially. Blunt dissection lateral to vena cava allows creation of space anterior to psoas muscle for placement of pedicle clamp if necessary on renal exposure. (B) Comparable technique on the left side, creating space for pedicle clamp lateral to aorta. This approach has been used successfully in the author’s center.
Following pedicle control or access, the colon and mesocolon on the side of the injury are dissected medially following incision of the peritoneal reflection. When the anterior surface of Gerota’s fascia is fully exposed, a generous, vertical, anterior incision is made through the fascia and the kidney is fully mobilized. As indicated earlier in the section “Anatomy,” it is important to dissect in an extracapsular plane and avoid inadvertently dissecting the renal capsule away from the underlying cortex. Accomplishing this is facilitated by beginning the dissection in an area of intact parenchyma rather than directly within the laceration. Completely mobilizing the kidney is very helpful, as it allows the kidney to be lifted anteriorly into the wound for complete inspection. If significant bleeding results during this maneuver, a noncrushing vascular clamp is applied to the renal artery, renal vein, or entire renal pedicle. An initial decision must be made regarding renal salvageability and the magnitude of the reconstructive effort that would be required to repair the injury. This is based largely on the amount of devitalized parenchyma, the degree of injury to the central vasculature and central collecting system, and the condition of the patient. If the kidney is determined to be reconstructible in an unstable patient, any significant intrarenal vascular injury can be rapidly sutured and the kidney can be packed off with laparotomy pads as other surgical injuries are treated (see Chapter 41). After repair of other injuries, or at the time of a secondary surgical procedure, a formal exploration and reconstruction of the kidney is performed.
If, based on the anatomy of the injury, the kidney is not considered reconstructible, a nephrectomy is performed. It is preferable to separately ligate the renal artery and vein to avoid the potential for arteriovenous fistula. A rapid search is made for accessory or polar vessels which must be ligated as well. While urologists frequently suture or simply ligate the renal artery and a long stump of vein, vascular surgeons and some urologists prefer to oversew the short right renal vein with a continuous 3-0 or 4-0 Prolene suture. For trauma nephrectomies, the ureter and adjoining vessels are ligated near the kidney while the gonadal vein is ligated and divided when necessary with no need for concern for adverse impact on the gonadal structures.
If renal reconstruction is planned, several steps are generally followed (Fig. 36-21). Following evacuation of the hematoma, the kidney is carefully examined to identify lacerated vessels, the open collecting system, and devitalized parenchyma. Large areas of lacerated, devitalized parenchyma are excised sharply, while smaller vessels are controlled with an absorbable 3-0 or 4-0 suture. In general, an absorbable suture is utilized for intrarenal suturing, as a permanent suture may create a nidus for stone formation if in contact with the collecting system. If adequate closure of the collecting system is achieved, there is no need for stenting or a nephrostomy. If repair of the collecting system is tenuous or incomplete, placement of an internal stent (complemented by a bladder catheter) or a nephrostomy tube may decrease the risk of postoperative urinary extravasation and the formation of an urinoma.
(A and B) Wedge resection of injured parenchyma. (C) Suturing of open collecting system and significant vessels with absorbable suture. (D) Capsule, if present, may be closed, or reconstructed using peritoneal patch, with absorbable gelatin sponge or local fat pedicle to aid in hemostasis.
Partial nephrectomy for polar lesions is performed using a “guillotine” technique with the transected vessels and collecting system closed as noted earlier (Figs. 36-22 and 36-23). Topical hemostatic agents may be placed within a parenchymal defect to aid in hemostasis, with the capsule closed over the defect and the hemostatic material. If the capsule can be closed with mattress sutures or absorbable bolsters following debridement or partial nephrectomy, parenchymal hemostasis is aided considerably. If capsular closure is not feasible, either due to the shape and location of the parenchymal defect or due to loss of the capsule from the injury or dissection, utilizing absorbable materials or native tissue as a patch may be helpful if hemostasis is still problematic. The argon beam coagulator has also been utilized successfully in the kidney to achieve hemostasis in the parenchyma after suturing larger vessels and closing the collecting system. Topical hemostatic agents and tissue adhesives may be used on the kidney, collecting system, ureter, and other urologic repairs to aid in hemostasis and minimize the risk of postoperative urinary extravasation.69 Some data exist to suggest that the application of fibrin sealant over a urinary tract suture line may decrease the likelihood of postoperative urinary leakage.70 At times, wrapping the decapsulated kidney in absorbable mesh material has been utilized to provide mild temporary parenchymal compression for continued venous bleeding from lacerated parenchyma (Fig. 36-24).
(A and B) Partial nephrectomy for major injury to upper pole. (C) Repair of collecting system and suturing of bleeding vascular branches. (D) Mattress sutures of 2-0 chromic gut to reconstruct parenchyma and aid in hemostasis.
Surgical management of renal trauma. (A) Partial nephrectomy for lower pole laceration due to gunshot wound. Excised fragment of devascularized, lower pole parenchyma, debrided. Bullet removed, found immediately posterior to kidney. (B) Appearance of lower pole following suture repair of vessels and repair of collecting system. Capsule has been reflected back for completion of partial nephrectomy and will be used for coverage of defect. (C) Defect covered with absorbable gelatin sponge soaked in thrombin. Note vessel loops surrounding renal vessels. (D) Defect covered with adjacent capsule and peritoneal patch, to aid in hemostasis. (E) Duodenal injury, repaired, immediately anterior to the renal injury. It is desirable to separate such injuries with viable tissue interposition, when possible, to minimize the risk of postoperative leak from either source affecting the other repair. (F) Gerota’s fascia closed over the kidney to separate the duodenal and renal injuries. Omental pedicle flaps are also very useful for this purpose. The renal repair was drained with an extraperitonealized closed-suction drain.
Surgical management of renal trauma: renal parenchymal injury due to blunt trauma. (A) Large, deep laceration through posterior parenchyma, left kidney. Bleeding sites are sutured, collecting system closed with absorbable suture. Venous bleeding continues from lacerated cortex. (B) Due to absence of renal capsule (dissected away from parenchyma by hematoma), absorbable surgical mesh is used to wrap renal parenchyma providing gentle compression to assist in achieving hemostasis.
Injuries to adjacent organs such as the liver, pancreas, duodenum, and colon generally do not change the indications for renal salvage versus nephrectomy,71,72 as good results have been described for renal repairs in the presence of injuries to these adjacent organs. It is desirable, however, to separate the renal injury from the adjacent visceral injury using available viable tissue. This can be accomplished by replacing the kidney within Gerota’s fascia and closing the fascial layer over the kidney or by utilizing omentum in the form of a pedicle flap. Drains for renal injury are utilized when the injury is complex, incompletely repaired injuries to the collecting system are present, or there is concern for the need to evacuate blood postoperatively. Closed-suction drains are used because there is a lower risk of contributing to postoperative infection. When an injury to an adjacent organ exists, the organ sites should be drained separately.
Certain injuries are more common in the pediatric population and deserve specific mention. Avulsions of the fornices, ureteropelvic junction, and renal pedicle are more commonly seen in the pediatric population than in the adult.73 Complete forniceal avulsion injuries are managed with nephrectomy because repair is nearly impossible. Avulsions of the ureteropelvic junction are amenable to repair through a direct anastomosis. Lacerations of the renal pelvis should also alert the trauma surgeon to the possibility of a preexisting obstruction of the ureteropelvic junction. Repair of the obstructing lesion may need to be performed with closure of the pelvis, or nephrectomy may be preferable if the kidney appears to have minimal parenchyma due to long-standing obstruction.
Renovascular injury from blunt or penetrating trauma presents certain challenges (see Chapter 37). As noted earlier, select patients are taken to laparotomy for revascularization surgery based solely on a CT scan demonstrating the classic findings of renal nonperfusion following deceleration trauma. If exploration is undertaken based on the CT findings or if arteriographic imaging has been performed, the approach is similar. The artery is dissected from its origin at the aorta toward the kidney and the arterial pulse is palpated or assessed with a Doppler instrument. The artery is clamped near the aorta and opened at the circular ring of hematoma, resected to the point of normal anatomy, and a direct end-to-end anastomosis is performed. When necessary, an autogenous vein graft or prosthetic graft is interposed. As in the pediatric population (in which the injury is more common), avulsion injuries involving the renovascular pedicle require urgent surgical intervention. Most of these patients are managed with nephrectomy although isolated vascular repairs have been described depending on the level of the avulsion. Avulsion of multiple branches from within the renal sinus is virtually impossible to repair in the trauma setting and generally requires nephrectomy as well. While current data suggest that the likelihood of achieving a favorable outcome with renal revascularization following renal injury is low,74 patient selection is critical. In the appropriate clinical setting (brief warm ischemia time and a patient in suitable condition for surgery), the effort may be worthwhile in carefully selected patients. A collaborative approach involving the vascular surgeon and the urologist is highly applicable to cases in which renovascular reconstruction is planned. In selected cases in which an intimal disruption of the renal artery is documented arteriographically but perfusion is maintained, radiologic placement of a vascular stent may be applicable. Many limited penetrating injuries to the renal vein can be repaired while arterial injuries have a high rate of nephrectomy. Injuries to branch vessels in a parenchymal laceration are ligated. When diagnosed on imaging studies in stable patients with intact parenchyma, nonoperative management is appropriate.
Bilateral renal injuries are rare and present particular problems.75 Assuming neither kidney is bleeding briskly, the kidney that seems to be less seriously injured (based on hematoma size and location, apparent orientation and location of entrance and exit wounds, etc) is assessed to ensure that renal salvage is feasible. One kidney can also be packed off temporarily after obtaining gross hemostasis while the opposite kidney is assessed in an effort to avoid nephrectomy in these cases whenever possible.
Although rarely indicated, ex vivo renal reconstructive surgery may be utilized in the trauma setting. This would be the case when a solitary (functionally or anatomically) kidney is injured and a complex reconstruction is needed for salvage.
The approach to ureteral repair depends largely on the level of the injury, the amount of ureteral loss (if any), and the condition of the local tissues. A ureteral laceration along with extensive destruction of the kidney from blunt or penetrating trauma is generally managed with nephrectomy. If the kidney is uninjured or the renal injury is limited and can be observed or repaired, ureteral repair is best performed at the time of recognition.76,77
Injuries to the ureter from blunt trauma require a high index of suspicion for diagnosis. Hematuria may be absent in such cases and a delayed presentation is not uncommon. As noted earlier, the spiral CT scanners complete the initial renal imaging survey so rapidly that, unless a delayed excretory phase is requested, the study may be completed before the contrast has opacified the collecting system or injured ureter.
Blunt avulsion of the proximal ureter or ureteropelvic junction is best managed with limited debridement to viable tissue and a spatulated end-to-end anastomosis using fine absorbable suture (3-0, 4-0, or 5-0). In general, ureteral repairs performed after trauma are often stented. This can be performed with an internal double-J-type stent or an externalized single-J stent. The single-J stent is usually exteriorized through a small stab incision in the anterior bladder wall and secured with a purse-string suture. Some surgeons also secure the stent to the bladder mucosa just outside the ureteral orifice with a fine absorbable suture (4-0 or 5-0). For tenuous repairs of the proximal ureter, diversion using a nephrostomy tube may be considered but is generally unnecessary.
A blunt injury to the midureter is uncommon, but when diagnosed, it is managed with a primary anastomosis. In the distal ureter (below the internal iliac artery), ureteral reimplantation into the bladder is preferred.
Injuries to the ureter from penetrating trauma also require a high index of suspicion for diagnosis. The presence of urine in the operative field may be difficult to appreciate, and the ureters, when at risk, must be thoroughly assessed by intraoperative inspection. The proximal and midureters down to the internal iliac arteries are easy to visualize and examine. For very distal injuries, a vertical cystotomy with observation of efflux from the ureteral orifices and intraoperative retrograde pyelography may be a less morbid means of assessing the area of concern rather than embarking on a difficult dissection of the ureter all the way to the bladder in the setting of a pelvic hematoma. Alternatively, intraoperative flexible cystoscopy with retrograde pyelography may be performed, avoiding the cystotomy. For proximal and midureteral injuries, limited debridement of damaged tissue and a tension-free, spatulated end-to-end anastomosis is the procedure of choice (Fig. 36-25). For very distal injuries (generally below the internal iliac artery), reimplantation into the bladder is preferred as noted earlier because the blood supply to the distal ureteral stump may be compromised. A direct anastomosis to the bladder avoids the potential ischemic complications of a very distal ureter-to-ureter anastomosis. Stenting of such repairs is routine as described previously.
Techniques of ureteral reconstruction. Debridement and primary anastomosis for ureteral transection from gunshot wound. (A and B) Mobilization of ureter superficial to adventitial plane. (C) Limited debridement of lacerated ureter to viable tissue with spatulation for repair. (D and E) End-to-end anastomosis with fine absorbable suture, over stent (not shown).
For injuries to the lower third of the ureter, it is not always possible to perform a direct anastomosis to the bladder without tension. In such cases, the bladder can be brought cephalad and lateral toward the injured side to achieve a tension-free anastomosis with the ureter by several techniques. The most commonly employed is the “psoas hitch” (Fig. 36-26). The bladder is opened anteriorly, lateral peritoneal attachments are divided as needed, and then the bladder body is displaced toward the side of the injury and sutured to the psoas muscle with 2-0 absorbable suture, taking care not to injure or entrap any major nerves. The ureter can then be reimplanted into the bladder using a tunneled antirefluxing anastomosis or the tunnel can be omitted if length is still a problem. It is important to ensure that no obstruction or acute angulation exists at the vesical hiatus where the ureter enters. If a psoas hitch cannot achieve a tension-free connection to the ureter, a bladder flap (Boari flap) can be created. This procedure has a higher complication rate than a psoas hitch and is performed only if the psoas hitch does not accomplish the required objective. The bladder flap may be performed in conjunction with the psoas hitch to maintain the cephalad extension of the bladder wall posterior to the flap. Again, a nonrefluxing tunneled or a refluxing repair can then be performed. These procedures can also be performed laparoscopically.78
(A) Ureteral reimplantation with psoas hitch for lower ureteral injury: the bladder is opened either transversely or vertically and obliquely toward the side of injury, and then hitched to the ipsilateral psoas muscle with 2-0 or 3-0 Vicryl suture. A tunneled, antirefluxing anastomosis of the ureter to the posterior wall of the bladder is performed, being certain that an adequatewidth tunnel is created to prevent obstruction. If the available ureteral length is short, antirefluxing tunneling can be eliminated. Either an internal double-J-type stent or an externalized single-J stent can be used (not shown). (B) Psoas hitch ureteral reimplantation for penetrating injury to lower ureter, performed acutely during initial laparotomy in a hemodynamically stable patient. The bladder body can be seen sutured to the left psoas muscle, with the ureter entering cephalad. A single-J ureteral stent and suprapubic cystostomy exit from the bladder in the lower part of the photograph.
More complex techniques of ureteral reconstruction include transureteroureterostomy (TUU), ileal-ureteral replacement, and renal autotransplantation (Figs. 36-27 and 36-28). TUU is relevant when anastomosis to the bladder is not feasible due to inadequate length of the ureter, condition of the bladder, or when it is desirable to move the repair away from the ipsilateral hemipelvis due to local conditions of infection, prior pelvic radiation, etc. Ureteral replacement with the ileum is seldom performed in the acute trauma setting as it is preferable to have a fully prepped bowel when performing this procedure. Renal autotransplantation may be appropriate in the acute trauma setting if appropriate vascular surgical expertise is available and less complex options for ureteral replacement are not feasible. The proximal ureter can be anastomosed directly into the bladder in the case of loss of the majority of the lower ureter, or an anastomosis can be performed to the lower ureter if it is clearly viable and not excessively distal.
(A–C) Right ureteral reimplantation following extensive distal ureteral injury. Prior bladder surgery or pelvic inflammatory or neoplastic disease, among other factors, may make psoas hitch or bladder flap repair undesirable. The injured ureter is mobilized, spatulated and reimplanted to the bladder Boari flap/psoas hitch with tension-free and water-tight anastomosis. Omental wrap should be considered to decrease chances of fistulization or urine extravasation. (A) Intraoperative depiction of Boari flap/psoas hitch and ureteral reimplantation after right distal ureteral avulsion due to a gunshot wound to the abdomen and pelvis (pink shadow represents the bladder flap secure with psoas hitch and the yellow shadow represents the ureter). (B) Coronal view of CT cystogram 14 days after ureteral repair. (C) VCUG performed 6 months post-Boari flap/psoas hitch and ureteral reimplantation after right distal ureteral injury during abdominal hysterectomy.
Renal autotransplantation for reconstruction following extensive loss of midureter, making direct union of upper ureter to bladder impossible. Alternative to ileal-ureteral replacement of most of the ureter. Nephrectomy must be tailored to include as much of the renal vessels as possible to aid in anastomosis to iliac vessels (in general, vein generally transected flush with vena cava on right, with artery transected more proximally, behind vena cava, than shown here). Anastomosis of proximal ureter to viable lower ureter.
When ureteral repairs are performed in direct apposition to adjacent vascular or visceral repairs, separation of the repairs by an omental pedicle or other viable tissue is desirable to prevent a fistula or contact with urine at the site of the adjacent organ injury. External drainage of ureteral injuries, in addition to stenting or diversion, may be desirable, particularly if the repair is tenuous or the vascularity of the repaired tissues is questionable. Some urologists prefer Penrose drains to closed-suction drains. In the postoperative period, antibiotic administration may be desirable, especially if urinary extravasation persists.
As noted later, ureteral injuries are also highly amenable to damage control strategies when the patient is not in suitable condition for repair at the time of the initial laparotomy. An external stent placed through the transected proximal ureteral stump allows maintenance for control of the urinary output while the patient is undergoing resuscitation in preparation for definitive delayed reconstruction.
Surgical repair of the bladder is performed for many iatrogenic injuries, for nearly all blunt intraperitoneal injuries, and for selected cases of blunt extraperitoneal rupture. Penetrating injuries to the bladder may also be managed with operative repair.
Intraperitoneal ruptures of the bladder are approached through a midline abdominal incision or laparoscopic repair. The large laceration is nearly always in the dome of the bladder as previously described (Fig. 36-29). The interior of the bladder is palpated and inspected through the laceration to verify that no other injuries are present and that there is clear efflux from both ureteral orifices. The laceration may be extended into an anterior midline cystotomy if further assessment is needed, but this is not usually necessary. The edges of the bladder laceration may require minimal debridement to remove devascularized tags of detrusor muscle or mucosa. The laceration is then closed using two layers of heavy absorbable suture. An adequate bore bladder catheter is used to allow free drainage of initially bloody efflux that clears in the first few days. The length of catheterization time is usually 5–10 days, but the period needed for urinary efflux to clear and the ability of the patient to be ambulatory and void comfortably should be considered. It is prudent to perform a cystogram prior to removal of the catheter following any operative repair and is mandatory with nonoperative management. As a well-sutured repair carries an extremely low postoperative risk of extravasation, some practitioners remove the catheter without prior contrast imaging with excellent success. Suprapubic cystostomy catheters are not generally needed after repairs of intraperitoneal ruptures. They should be inserted only when there is a need for long-term bladder drainage, such as in a patient with a significant injury to the brain, trauma to the pelvis or a lower extremity, or other factors that would be expected to substantially delay a return to ambulation.
Intraoperative appearance of intraperitoneal bladder rupture from blunt trauma: laparascopic view. Note the locations of the blood clot and the Foley catheter.
For the selected cases in which extraperitoneal rupture of the bladder is managed with operative repair, there are several important differences when compared with intraperitoneal repairs. When operating on the injured bladder during a laparotomy following a pelvic fracture, an effort should be made to avoid entering the retropubic hematoma. This avoids potentially serious hemorrhage from a site that is often tamponaded. If repair of the bladder is necessary in this setting (see the section “Nonoperative Management of Genitourinary Injuries”), one should enter the bladder through an anterior cystotomy incision cephalad to the pelvic hematoma. The laceration, which is usually located in the lower anterior or anterolateral bladder, can be sutured transvesically by introducing Deaver or malleable retractors into the bladder and retracting them laterally. Often, only a single-layer, full-thickness closure is possible in this setting. It is useful to communicate with the orthopedic surgeons when operating on extraperitoneal bladder ruptures in the setting of a pelvic fracture to allow for coordinated care.
A penetrating injury to the bladder is most often managed operatively, although, occasional patients (as previously described) may be candidates for nonoperative management.62 If a patient is undergoing laparotomy and has gross hematuria following penetrating pelvic trauma, the peritoneal surface of the bladder is examined first. The retropubic space is then entered and an anterior, midline cystotomy is created. This may be easier to accomplish if the bladder is partly filled with irrigant. For laparotomies in which bladder surgery is likely, including the genitalia in the sterile field can facilitate whatever manipulation may be necessary without abdominal contamination. Following cystotomy, the interior of the bladder, the ureteral orifices, and the bladder neck are thoroughly examined. The urinary efflux from both orifices should be observed; if bloody or absent, further investigation for trauma to the ureters or upper tract is recommended. Penetrating injuries to the bladder are closed with two layers of absorbable suture as previously described.
In some patients, an iatrogenic or penetrating injury to the bladder may result in loss of a large portion of the detrusor of the bladder body. Closure over a bladder catheter is still recommended, as the bladder may expand to an acceptable volume with time. If minimal bladder capacity persists following a reasonable period of healing, augmentation cystoplasty can be performed electively.
As for renal and ureteral injuries, injuries to the bladder in the unstable trauma patient are amenable to damage control strategies. These include externalized stenting of the ureters with pelvic packing and delayed repair of complex lacerations.
Certain associated injuries impact the management of bladder trauma. Contiguous injury to the vagina or rectum, for example, requires close collaboration between the clinical services involved in caring for these injuries. When such injuries are suspected, it is helpful to have the patient in a modified dorsal lithotomy position so simultaneous access to the perineum and abdomen can be obtained. During surgical repair, the bladder should be separated from the rectum or vagina by placing an interposition flap of viable tissue if the loss of tissue is significant and the injuries directly overlie each other. This effort of separating the pelvic organs can be difficult in the trauma setting and, if the injuries do not directly overlie each other and tissue loss is minimal, simple transvesical closure is generally adequate. In this setting, longer indwelling catheter times, perioperative antibiotics, and radiographic imaging prior to removal of the catheter are recommended. Open pelvic fractures are among the most devastating injuries in orthopedic trauma and injury to the lower urinary tract may complicate such injuries. A close interaction between the urologist, orthopedist, trauma surgeon, and interventional radiologist is necessary for management of such patients. Chronic disability is common following these injuries.79
Avulsion injuries of the bladder neck, which more common in the pediatric population, require operative repair (Fig. 36-30).54 Repair for these complex injuries should be delayed until 24–72 hours post-injury to support a damage control strategy and to minimize the risk of excessive hemorrhage from an associated pelvic fracture.
Bladder neck avulsion injury in an adult female with pelvic fracture. Operative appearance during surgical repair. An anterior midline cystotomy had been performed (to right in photo), with the tip of a Foley catheter protruding from the avulsed bladder neck for demonstration purposes. Anastomosis to urethral stump at level of pelvic floor performed over Foley catheter. The patient was initially managed with a percutaneous suprapubic cystostomy. This repair was performed 36 hours following injury, when the patient was hemodynamically stable and risk of excessive bleeding from the pelvic fracture would be lower.
Operative management for urethral trauma includes the broad topic of elective urethral reconstruction following traumatic injuries and surgical repair of urethral strictures and there are several in-depth reviews available regarding this topic.80,81 This discussion will focus on immediate and subacute surgical intervention for urethral trauma, and clinical guidelines have recently been reported for these injuries.82
Incomplete anterior urethral injuries may be managed with the placement of a transurethral catheter or with suprapubic diversion. Endoscopic guidance for any attempt to catheterize the traumatized urethra is preferred. If a blind attempt at catheterization is performed and any resistance is encountered, an endoscopically guided procedure should follow. Complete ruptures of the anterior urethra from blunt trauma are best managed with suprapubic diversion for greater than or equal to 3 months, followed by elective end-to-end urethroplasty when the perineal hematoma and induration have fully resolved. Acute attempts at excision and repair are not recommended because it is unclear how much urethra should be resected due to the crush injury and result in tension-free healthy tissue anastomosis.
Penetrating injuries to the anterior urethra may be managed with local exploration and repair or with suprapubic diversion. With stab wounds or gunshot wounds from low-velocity missiles, performing limited debridement and repair with a spatulated anastomotic technique is usually simple. If the patient is not an appropriate candidate for immediate repair due to more serious injuries, etc, suprapubic diversion or endoscopically guided insertion of a transurethral catheter is performed. Extensive loss of the urethra from penetrating trauma or industrial trauma may require a staged repair.
The management of disruption or distraction injuries of the posterior urethra remains controversial. In recent years, there has been increasing interest in early catheter realignment for such injuries. Techniques utilized have included endoscopic guidance, open surgical approaches, and, historically, the use of interlocking magnetic sounds (Fig. 36-31).83,84,85 A potential advantage of endoscopic realignment is the possibility that the injury will heal free of intractable stricture. This would obviate the need for late urethroplasty, shorten the period of urinary intubation, and may improve the anatomic result as compared with the nonintubated state by reducing malalignment. The potential disadvantages of this approach are the risk of infecting the retropubic hematoma because of the indwelling catheter, which can adversely impact late continence and sexual function and there is a high likelihood that a stricture will form regardless. When selected, catheter realignment should be performed by an experienced team in the operating room with endoscopic and fluoroscopic capability. Results are better for incomplete disruptions than they are for complete disruptions. Most patients managed in this manner develop a stricture that will require endoscopic intervention, often involving multiple procedures. Overall, patients managed with catheter realignment may avoid a subsequent urethroplasty about 50% of the time.
(A) Urethral realignment with complete posterior urethral injury. (B) Endoscopic realignment under fluoroscopy using flexible and rigid cystoscopies as well as a super stiff guide wire (black arrow).
The traditional approach to a posterior urethral distraction injury is diversion with a suprapubic cystostomy, followed by a period of observation of 3–6 months while the pelvic hematoma resolves and the anatomy stabilizes. Repeat antegrade and retrograde urethrograms are then performed, and definitive reconstructive surgery is planned. The ultimate success rate of this approach is over 90%; however, the need for a long-term indwelling suprapubic tube while awaiting surgery may be frustrating for the patient. Nevertheless, endoscopic techniques such as catheter realignment can be performed successfully without the need for suprapubic catheters.86
Penis, Testis, and Scrotum
Penile trauma is primarily managed through operative exploration and repair.87 For blunt penile fractures, the penis is explored through either a ventral midline penoscrotal incision or a circumcising subcoronal incision. The defect in the tunica albuginea is exposed and closed with absorbable suture (Fig. 36-32). The outcomes following early operative repair of penile fractures are far superior to those resulting from nonoperative management. Deformity, painful erection, pseudoaneurysm, and loss of erectile function are common in nonoperative management of such injuries (Fig. 36-33).63
Penile fracture. Appearance of penis during surgical exploration for penile fracture sustained during sexual intercourse. Patient reported classic findings of pain, swelling, and detumescence following sudden marked bending of erect penis. Note marked swelling of distal phallus with subcutaneous hematoma. Penis is explored through a ventral, midline, penoscrotal incision. Dissection to area of palpable irregularity along penile shaft reveals transverse laceration of tunical albuginea of corpus cavernosum. A penile tourniquet, utilizing a Penrose drain, is in place to reduce bleeding during repair. The hooks are part of a ring-retractor system commonly used in genital surgery. The tunica albuginea defect is closed with running 3-0 Vicryl suture. Early exploration and repair for penile fracture injuries produces the best results. Circumcising, subglanular incision is preferred by some surgeons for this type of exploration and repair.
Delayed presentation following penile fracture. (A) Note marked angulation to left with mass effect on right lateral side of penile shaft following untreated rupture. Patient presents 6 weeks postinjury; the subcutaneous hematoma has resolved, while the defect in the corpus cavernosum remains, resulting in angulation and pain with erection. (B) Appearance of penis at surgical exploration through circumcising incision. Note large encapsulated hematoma under Buck’s fascia, which, on incision, still communicates with cavernosal space. Defect repaired with correction of deformity.
Similarly, penetrating penile injuries should be managed with operative exploration and repair (Figs. 36-34 and 36-35).88 As combined cavernosal and urethral injury occurs in roughly 10% of penile fractures, a preoperative urethrogram or flexible cystoscopy is useful in planning the repair.
Gunshot wound to penis with entrance at dorsal penile base. (A) Extensive injury to skin and subcutaneous tissues and laceration of tunica albuginea of corpus cavernosum. Penile tourniquet in place to allow injury assessment while minimizing bleeding. (B) Tunica albuginea has been conservatively debrided and closed with running Vicryl suture. (C) Appearance of penis following reconstruction of glans and skin tube. Subsequent scar revision was necessary for necrosis of skin edges (not shown). Preservation of soft tissues and conservative debridement demonstrated.
Gunshot wound to mons pubis region, cephalad and to left of penile base. (A) No palpable abnormality of penis is recognized. Small left scrotal hematoma present. (B) Surgical exploration of wound via oblique scrotal neck incision extends toward groin. Bleeding sites in left spermatic cord were controlled (not shown), followed by evacuation of hematoma resulting in significant bleeding. Dissection revealed complete transection of left corpus cavernosum at penile base, which was repaired. Case demonstrates importance of surgical exploration of penetrating injuries in proximity to male genitalia.
In cases of penetrating penile injury, a similar surgical approach is utilized with conservative debridement, repair of cavernosal and urethral injury, and microsurgical repair of dorsal neurovascular structures when possible. For limited injuries, direct wound exploration may be a preferable approach. The possibility of an adjacent nonurologic injury (thigh, femoral vessels, pelvic organs) must always be considered in cases of penetrating genital injury.
Penile strangulation injuries due to constricting bands or other devices are managed with removal of the constricting object in the most atraumatic manner possible. Distal penile skin, glans, cavernosal, or urethral necrosis can occasionally occur in such cases. A conservative approach to debridement of tissues of questionable viability and diversion with a suprapubic cystostomy tube (if the urethra is compromised) are principles of management.
Patients with traumatic amputation of the penis require specialized management (Fig. 36-36). Often, patients who suffer traumatic amputation through self-mutilation are psychotic and/or are involved in substance abuse and require psychiatric as well as urologic intervention.89 The severed organ should be cleansed, kept in cold saline-soaked gauze within a sealed bag, and then placed in ice. Replantation surgery is well described by Jordan et al.90 In sequence, anastomosis of the corpora cavernosa, urethra, dorsal blood vessels, and nerves should be performed with appropriate microsurgical expertise. Functional outcomes are variable with such replantation efforts, largely reflecting the condition of the severed organ and the time that elapses prior to replantation.
Subtotal penile amputation injury due to assault with knife. (A) Photograph demonstrates complete transection of body of penis with right-sided skin bridge attaching distal phallus to body. Left testis is exposed as well. (B) Preparing for surgical reconstruction—minimal debridement of corpora cavernosa and urethra, following extensive irrigation. (C) Corpora cavernosal anastomosis has been completed; urethral anastomosis about to be completed after spatulation and mobilization of distal ends to avoid tension on repair. Following completion of urethral repair over Foley catheter, microsurgical anastomosis of deep dorsal arteries, deep dorsal vein, and adjacent nerves was performed (not shown).
Scrotal trauma should be explored if there is a concern about testicular rupture. In blunt trauma, a testicular ultrasound may be helpful in deciding if operation is indicated. In penetrating trauma, we often utilize an oblique upper scrotal incision that provides access to the groin, spermatic cord, penile base, and scrotal contents. Most scrotal injuries should be explored with the goal of evacuation of the hematoma, debridement of devitalized tissue, and repair and salvage of the testicle (Figs. 36-37 and 36-38). Reproductive outcomes are favorable following such management.91
Testis: testicular rupture due to blunt trauma. (A) Scrotal hematoma post straddle injury. (B) Scrotal exploration: Tunica albuginea rupture with extravasation of testicular tissue. (C) Post testis repair with minimal tissue debridement.
Scrotal exploration and testicular repair following gunshot wound to scrotum. (A) Entrance wound visible lateral to base of penis on left, exit just to the right of the median raphe; note marked left hemiscrotal swelling from hematoma. Surgical exploration is mandatory and preoperative scrotal imaging is unnecessary. (B) Scrotal exploration performed through high oblique scrotal incision for optimal exposure of scrotal contents and possible extension to groin if further spermatic cord exposure proves necessary. Entrance into tunica vaginalis visible. Testis introduced out of scrotum on spermatic cord pedicle. (C) Appearance of left testis demonstrating complex laceration of tunical albuginea with extruded testicular parenchyma. (D) Appearance of testis following limited parenchymal debridement and reconstruction of tunica albuginea. Testis is then returned to scrotum following evacuation of hematoma and extensive irrigation; Penrose drain placed through inferior stab incision in left hemiscrotum (not shown).
Cases of scrotal and other soft tissue loss in the genital region should be managed with a conservative approach to debridement of marginally vascularized skin and soft tissues. Delayed primary closure or reconstruction of significant scrotal loss using meshed split-thickness skin grafting produces favorable results. Human bite wounds have a very high infection rate and should be left open if presenting in a delayed fashion (see Chapter 49).