1. What are the causes of bladder injury?

Show answer
Iatrogenic manipulation and penetrating or blunt trauma. Because of the rich detrusor blood supply, bladder injury is usually accompanied by hematuria. Other signs may include suprapubic pain, inability to void, or incomplete recovery of catheter irrigation.

2. What types of bladder injury may occur with blunt trauma?

Show answer
Laceration or perforation may be either intra- or extraperitoneal. Hematuria with a normal cystogram defines bladder contusion in the absence of upper tract injury. Extraperitoneal injuries constitute the majority of bladder trauma and tend to concentrate at the bladder base or parasymphyseal area. These can be managed conservatively with urinary catheter drainage for at least 10 days. Intraperitoneal (IP) ruptures typically occur when the bladder is distended at the time of trauma, causing a blowout of the dome of a bladder. IP vesical rupture should be surgically repaired using a two-layer closure with absorbable sutures and placement of suprapubic and urethral catheters.
KEY POINTS: MANAGEMENT OF BLADDER INJURY DUE TO BLUNT TRAUMA

1. Diagnose with CT cystography and retrograde cystourethrography.
2. Extraperitoneal injuries are more common and may be managed conservatively with a Foley catheter for 10 days.
3. Intraperitoneal injuries are more likely if the bladder is distended at the time of injury; they require surgical repair with suprapubic and Foley drainage postoperatively.

3. What is the likelihood of a bladder injury in patients with a fractured pelvis?

Show answer
Extraperitoneal bladder injury occurs in 10% of all pelvic fractures. Conversely, approximately 85% of blunt bladder injury is associated with pelvic fracture. Bladder injuries occur more often with parasymphyseal pubic arch fractures and more often with bilateral than unilateral fractures. Isolated ramus fractures produce bladder laceration in 10% of cases.

4. How is bladder injury evaluated?

Show answer
Both computed tomography (CT) cystography and retrograde cystourethrography provide great diagnostic accuracy for bladder rupture. The bladder should be filled under gravity with a total of 300-400 mL of a 50% dilution of standard radiocontrast agent using the Foley catheter. Films should include anteroposterior, lateral, and oblique views. Finally, a postvoid film should be obtained. When renal or distal ureteral injury is suspected, upper tract imaging (intravenous pyelogram [IVP] or CT scan) should precede the cystogram.

5. What are the retrograde cystourethrographic patterns of bladder injury?

Show answer
Extraperitoneal injury allows contrast agent to escape adjacent to the symphysis, but it is confined to the bladder base by the intact peritoneum. Intraperitoneal extravasation produces a “sunburst” appearance from the bladder dome, which may collect in the paracolic gutters, outline loops of bowel, or pool under the liver or spleen. It is pivotal to obtain postvoid films.

6. How is bladder rupture managed?

Show answer
Extraperitoneal lacerations can be managed with an indwelling catheter for 7-10 days, at which time cystogram usually confirms resolution of extravasation. Intraperitoneal lacerations require operative repair. Bladder contusion requires catheter drainage until gross bleeding has subsided.

7. When should urethral injury be investigated?

Show answer
The mechanism of injury (e.g., crushing or deceleration/impact, straddle injuries) and associated trauma (e.g., pelvic fracture), blood at the meatus, penile or scrotal swelling and ecchymosis, upward prostatic displacement on digital rectal examination, and inability to void or to pass a urethral catheter (do not try this) should be investigated.

8. When a patient presents with a pelvic fracture, is concomitant urethral injury a major concern?

Show answer
Yes. Urethral trauma occurs in 10% of pelvic fractures; it is more common with anterior disruption of the pelvic ring, including 20% of unilateral and 50% of bilateral parasymphyseal fractures. Posterior (prostatomembranous) avulsion is associated with potentially disabling sequelae and requirements for complex and challenging operative corrections. In contrast, more distal urethral injuries avoid impotence and incontinence issues and are more surgically accessible.

9. How is urethral injury best assessed?

Show answer
Retrograde urethrography must always be performed before inserting a Foley catheter. Incomplete urethral transection produces local contrast dye extravasation and bladder opacification. Total avulsion produces extensive local extravasation, and no contrast dye gets into the bladder. Incomplete transection is more common with anterior (50%) than posterior (10%) urethral injuries.

10. How is urethral injury managed?

Show answer
For incomplete transection regardless of site, either catheter stenting across the defect or diversion by suprapubic cystostomy permits resolution. With complete urethral transection, the bladder should be decompressed initially via suprapubic cystostomy. Early restoration of continuity by placement of a bridging urethral catheter should be performed endoscopically. A bridging catheter reduces complex scarring and avoids subsequent surgery in many patients.

11. What are the complications of urethral injury?

Show answer
Strictures, incontinence, and impotence (associated with traumatic prostatic displacement). Iatrogenic complications are associated with retropubic dissection.

12. What is the differential diagnosis in blunt scrotal trauma?

Show answer
Testicular rupture, hematocele, scrotal hematoma, intratesticular hematoma, and testicular torsion. Ultrasonography helps sort this out.

13. What is the sonographic sign of testicular rupture?

Show answer
The sign is loss of the normal homogenous echo texture of the testicle, with areas of irregular hyper- or hypoechogenicity.

14. How are patients with acute testicular rupture managed?

Show answer
Management includes surgical exploration and debridement of extruded, nonviable tubules and evacuation of the hematoma. After proper hemostasis is achieved, the tunica albuginea should be closed with running absorbable suture.

15. What is the most common cause of penile fractures?

Show answer
Penile fracture is a rupture of the corpus cavernosum, most commonly associated with sexual intercourse, masturbation, or an abnormally forced bending of the erect penis. Characteristically the patient hears a popping sound, followed by pain and detumescence.

16. What are the physical examinations findings with a penile fracture?

Show answer
Injury to the tunica albuginea causes formation of hematoma and deviation of the shaft to the opposite side of injury. If Buck’s fascia is intact, the hematoma will be confined to the penis; disruption of Buck’s fascia allows spread of the hematoma under Colles’ and Scarpa’s fascia onto the perineum and abdominal wall.

17. How are penile fractures managed?

Show answer
Surgically. A retrograde urethrogram should be performed when urethral injury is suspected. Closure of the defect (or defects) along the tunica albuginea and evacuation of hematoma are performed after degloving the penis.

18. In penile amputation injuries, how should the amputated portion of the penis be preserved for transport?

Show answer
The amputated portion of the penis should be wrapped in saline-soaked gauze, placed in a plastic bag with ice slush surrounding the bag.

19. How is major scrotal skin loss managed?

Show answer
If primary repair is not possible, meshed split-thickness skin grafts may be used to cover the testis. When delayed repair is necessary, thigh pouches should be created until permanent reconstruction is feasible.

20. A 50-year-old woman complains of urine leakage from her vagina after a hysterectomy. What is the most likely diagnosis?

Show answer
Unrecognized bladder injury during hysterectomy with subsequent urine extravasation into the surgical field and drainage via the vaginal cuff suture line leads to formation of vesicovaginal fistula.

21. What is the best time to repair a vesicovaginal fistula secondary to an uncomplicated hysterectomy?

Show answer
Although 3-6 months after injury has been recommeded in the past, early repair can be successful if there is minimal inflammation and there are no complicating factors.

References
WEB SITES

1. http://www.east.org/tpg/GUmgmt.pdf
2. http://www.acssurgery.com/abstracts/acs/acs0510.htm

BIBLIOGRAPHY
1. Armstrong PA, Litscher LJ, Key DW, McCarthy MC: Management strategies for genitourinary trauma. Hosp Phys 34:19-25, 1998.
2. Jacob TD, Gruen GS, Udekwu AO, Peitzman AB: Pelvic fracture. Surg Rounds (Aug):583, 1993.
3. Jordan GH: Lower Genitourinary Tract Trauma and Male External Genital Trauma (Nonpenetrating Injuries, Penetrating Injuries, and Avulsion Injuries). In American Urological Association Update Series, Vol. XIX, Lesson 11, part 2. Baltimore, American Urological Association, 2000.
4. Kim FJ: Urologic trauma. In Feliciano DV, Moore EE, Mattox KL (eds): Trauma Companion Handbook, 4th ed. New York, McGraw-Hill, 2002.
5. McAninch JW: Traumatic and Reconstructive Urology. Philadelphia, W.B. Saunders, 1996.
6. Peterson NE: Current management of urethral injuries. In Rous S (ed): 1998 Urology Annual. New York, Appleton-Century-Crofts, 1988, pp 143-179.
7. Peterson NE: Traumatic posterior urethral avulsion. Mongr Urol 7:61, 1986.
8. Spirnak JP: Pelvic fracture and injury to the lower urinary tract. Surg Clin North Am 68:1057, 1988. Medline Similar articles

11. Is there any type of stone that cannot be seen on helical CT scan?

Show answer
Patients taking indinavir sulfate (Crixivan) for HIV infection can form stones from the crystals of the medication; these stones are not seen on CT scan.

12. What toxic substance can be produced by using the holmium:YAG laser on uric acid stones?

Show answer
Cyanide is produced from the uric acid. Although this sounds frightening, it is never a problem.

References
WEB SITE
http://www.transplantation-soc.org
BIBLIOGRAPHY
1. Menon M, Resnick M: Urinary lithiasis: Etiology, diagnosis and medical management. In Walsh PC, Retik AB, Vaughan ED, Wein AJ et al (eds): Campbell’s Urology, 8th ed. Philadelphia, W.B. Saunders, 2002, pp 3229-3305.
2. Teichman JM, Vassar GJ, Glickman RD: Holmium: YAG lithotripsy photothermal mechanism converts uric acid calculi to cyanide. J Urol 160:320-324, 1998. Medline Similar articles Full article

22. Why are complications associated with bile duct leaks?

Show answer
Bilomas (i.e., collections of bile) frequently become infected and may result in lethal peritonitis. Biliopleural fistula, a communication between the biliary system and pleural cavity, persists because of the relative negative pressure in the thorax and may result in a bile empyema.

23. What is the initial management of an established bile leak?

Show answer
Endoscopic transampullary stenting frequently allows spontaneous resolution of bile duct injuries. Extensive injuries require hepaticojejunostomy for reconstruction.

References
WEB SITES

1. http://www.acssurgery.com/abstracts/acs/acs0506.htm
2. http://www.acssurgery.com/abstracts/acs/acs0508.htm

BIBLIOGRAPHY
1. Croce MA, Fabian TC, Menke PG, et al: Nonoperative management of blunt hepatic trauma is the treatment of choice for hemodynamically stable patients. Ann Surg 221:744-753, 1995. Medline Similar articles
2. Gaines BA, Ford HR: Abdominal and pelvic trauma in children. Crit Care Med 30(suppl):S416-S423, 2002.
3. Hiatt JR, Gabbay J, Busutill RW: Surgical anatomy of the hepatic arteries in 1000 cases. Ann Surg 220:50-52, 1994.
4. Meldrum DR, Moore FA, Moore EE, et al: Cardiopulmonary hazards of perihepatic packing for major liver injury. Am J Surg 170:537-540, 1995. Medline Similar articles Full article
5. Meredith JW, Young JR, Bowling J, Roboussin D: Nonoperative management of adult blunt hepatic trauma: The exception or the rule? J Trauma 36:529-534, 1994. Full article
6. Moore EE: Staged laparotomy for the hypothermia, acidosis, and coagulopathy syndrome. Am J Surg 172:405-410, 1996.
7. Moore EE, Cogbill TH, Malangoni MA, et al: Organ injury scaling. Surg Clin North Am 75:293-303, 1995. Medline Similar articles
8. Pachter HL, Hofstetter SR: The current status of nonoperative management of adult blunt hepatic injuries. Am J Surg 169:442-454, 1995.
9. Poggetti RS, Moore EE, Moore FA, et al: Balloon tamponade for bilobar transfixing hepatic gunshot wounds. J Trauma 33:694-697, 1992. Medline Similar articles
10. Sheik-Gafoor M, Singh B, Moodley J: Traumatic thoracobiliary fistula: Report of a case with an overview of current diagnostic and therapeutic options. J Trauma 45:819-821, 1998.
11. Tai NR, Boffard KD, Goosen J, Plani F: A 10-year experience of complex liver trauma. Br J Surg 89:1532-1537, 2002.
12. Verous M, Cillo U, Brolese A, et al: Blunt liver injury: From non-operative management to liver transplantation. Injury 34:181-186, 2003.

1. Why is there a different approach to stab and gunshot wounds?

Show answer
Whereas one third of stab wounds to the anterior abdomen do not penetrate the peritoneum, 80% of gunshot wounds violate the peritoneum. Furthermore, penetration of the peritoneum by a bullet is associated with visceral or vascular injuries in > 95% of cases, whereas only one third of stab wounds violating the peritoneal cavity produce significant injury. (See Figure 24-1.)

Figure 24-1 Management of patients witih penetrating abdominal trauma.

2. What is the secondary survey for a penetrating abdominal wound?

Show answer
The ABCs (i.e., airway, breathing, and circulation) are the first priority in every trauma patient. Look everywhere-watch out; it is easy to overlook synchronous injuries. This includes looking for additional entry or exit sites; evaluation for blood in the gastrointestinal (GI), genitourinary (GU), and gynecologic systems; and blunt mechanism injuries (e.g., some unfortunate patients are both stabbed and beat up). The “mechanism” of injury includes the time of injury, type of weapon, length or caliber of the weapon, depth of penetration, and estimated blood loss at the scene.

3. What are the appropriate initial studies in patients with penetrating abdominal trauma?

Show answer
In stable patients, a chest radiograph excludes hemo- or pneumothorax and determines the position of intravenous catheters (e.g., endotracheal, nasogastric, and pleural tubes). Biplanar abdominal radiographs are helpful in locating retained foreign bodies, such as bullets, and may reveal pneumoperitoneum. Entrance and exit wounds should be identified with a radiopaque marker. This may be helpful in determining the trajectory of missiles. Injuries in proximity to the rectum obligate sigmoidoscopy (see Chapter 28), whereas injuries in proximity to the urinary tract should be evaluated with computed tomography (CT) scanning (see Chapter 31).

Figure 24-2 An example of how the path of a bullet through contorted body can produce confusion when the patient is examined in the emergency department. An entrance wound will be found at the left upper arm and an exit wound at the medial aspect of the right knee. The bullet could have damaged any structure that was in between these two wounds when the patient’s body was contorted.

4. What are the indications for prompt laparotomy in patients with stab wounds?

Show answer
Abdominal distention and hypotension, overt peritonitis, and obvious signs of abdominal visceral injury (hematuria, hematemesis, proctorrhagia, evisceration; palpation of diaphragmatic defect on chest tube insertion; radiologic evidence of injury to GI or GU tracts) mandate immediate exploration.

5. What are the indications for immediate laparotomy in patients with gunshot wounds?

Show answer
Because of the high incidence of visceral injury, early exploration is indicated for all gunshot wounds that violate the peritoneum.

6. When is emergency department (ED) thoracotomy indicated for a penetrating abdominal wound?

Show answer
Almost never. But it should be considered when a patient, after penetrating trauma, presents in cardiac arrest or profound hypotension (< 60 mmHg) refractory to initial resuscitation. Thoracotomy allows open cardiac massage and access to cross clamp the descending aorta to improve coronary and cerebral perfusion as well as decrease subdiaphragmatic hemorrhage. Closed cardiac massage is ineffective when the patient is hypovolemic. (See Figure 24-3.)

7. What is the general plan for abdominal exploration in patients with penetrating trauma?

Show answer

A midline abdominal incision provides rapid entry and wide exposure; it may be extended as a median sternotomy to access the chest or continued inferiorly into the pelvis. The aorta should be palpated to assess blood pressure (BP). All findings, including a low BP, should be communicated to the anesthetist. Evacuation of blood and placement of tamponade packs into areas of suspected blood loss should be followed by exploration of the wound tract. Actively bleeding areas are digitally controlled until the culprit vessel can be occluded. Hollow visceral injuries are temporarily isolated with noncrushing clamps. The entire abdomen is systematically explored before undertaking extensive repairs so that injuries can be prioritized.

Figure 24-3 Treatment of gunshot wounds.

8. How is an anterior abdominal stab wound evaluated in asymptomatic patients?

Show answer
The first step is local exploration of the wound to determine peritoneal penetration. If the tract clearly terminates superficially, above the fascia, no further evaluation or treatment is required. If the fascia is penetrated or the peritoneum violated, diagnostic peritoneal lavage (DPL) is performed. Double-contrast (oral and intravenous) CT scanning is not routinely used because of its relative insensitivity for detecting hollow visceral injuries. Ultrasonography is useful for detecting intraperitoneal fluid but is helpful only if the results are positive. (See Figure 24-4.)

Figure 24-4 Treatment of stab wounds.

9. What constitutes a positive DPL result after penetrating trauma?

Show answer
A grossly positive tap (aspiration of >10 mL of blood or aspiration of GI or biliary contents) mandates immediate exploration. A negative initial aspirate result is followed by the instillation of 1000 mL of saline (15 mL/kg in children) into the abdomen through a dialysis catheter, followed by gravity drainage of the fluid back into the saline bag. The finding of > 100,000/mm3 red blood cells (RBCs), the combined elevation of amylase > 20 IU/L and alkaline phosphatase > 3 IU/L, or elevated bilirubin level are also indications for exploration.

10. How are stab wounds to the flank and back evaluated?

Show answer
The incidence of significant injuries is 10% for stab wounds to the back and 25% for stab wounds to the flank. However, evaluation of such wounds is problematic because the retroperitoneum is not sampled by DPL and physical examination is even less sensitive. The major concern is missed colonic perforation. At present, triple-contrast (oral, intravenous, and rectal) CT scan and serial physical examination are the two primary modes of assessment. Operative exploration is advisable if CT scanning demonstrates wound trajectory in the vicinity of the colon.
KEY POINTS: CLINICAL APPROACH TO PENETRATING ABDOMINAL TRAUMA

1. Gunshot wounds to the abdomen generally require operative exploration (> 80% violate the peritoneum).
2. Stab wounds with evisceration or hypotension are operatively explored.
3. Stab wounds in stable patients are managed with local wound exploration (66% violate the peritoneum) plus DPL, ultrasound, or CT scan. If tests are positive, the patient goes to the operating room.
4. During celiotomy, pack the upper quadrants and pelvis; then address vascular, solid organ, and alimentary tract injuries in succession.
5. Prophylactic antibiotics for the first 24 hours decrease postoperative wound infection.

11. How is a lower chest stab wound evaluated?

Show answer
The lower chest is defined as the area between the nipple line (fourth intercostal space) anteriorly, the tip of the scapula (seventh intercostal space) posteriorly, and the costal margins inferiorly. Because the diaphragm reaches the fourth intercostal space during expiration, the abdominal organs are at risk (even after what appears to be a clear “chest” wound). Stab wounds to the lower chest are associated with abdominal visceral injury in 15% of cases, whereas gunshot wounds to the lower chest are associated with abdominal visceral injury in nearly 50% of cases. Thus, wounds to the lower chest should also be managed as abdominal wounds to rule out intraabdominal injury. In the case of lower chest stab wounds, an RBC count of > 10,000/mm3 warrants laparotomy to rule out a diaphragmatic injury; thoracoscopic exploration (not thoracotomy) may also be performed for counts of 1000-10,000/mm3.

12. Which patients with abdominal gunshot wounds are managed nonoperatively?

Show answer

Stable patients with tangential missile tracts or equivocal peritoneal penetration are candidates for DPL. The cutoff for RBC counts is reduced to 10,000/mm3, above which laparotomy is indicated. Patients with a negative DPL result are observed for 24 hours. For RBC counts of 100-10,000/mm3, laparoscopy may be used to exclude intraperitoneal injury. Selective management of gunshot wounds to the back and flank are generally based on triple contrast CT.

13. What is the role for presumptive antibiotics?

Show answer
Short courses (< 24 hours) of high-dose antibiotics are initiated only when the decision has been made to perform a laparotomy. Coverage of both anaerobic and aerobic flora is desirable. Tetanus prophylaxis should be given to all patients with penetrating injuries.

1. What is the most common type of renal trauma in the United States, blunt or penetrating?

Show answer
Blunt, by far.

2. Do most kidney injuries require surgery?

Show answer
No. Fewer than 2% of blunt injuries require surgery, and many penetrating injuries can also be treated nonoperatively.

3. Are pediatric kidneys more susceptible to major injury?

Show answer
Yes. Because of children’s weaker abdominal muscles, less-ossified thoracic cage, decreased perirenal fat, and increased renal size in relation to the rest of the body, the risk for renal injury is greater in the pediatric population.

4. When should potential renal trauma be investigated?

Show answer
All blunt trauma patients with gross hematuria or with microscopic hematuria and shock (systolic blood pressure < 90 mmHg) should be closely examined. Penetrating injuries with any degree of hematuria should be imaged. For pediatric patients, liberal use of studies is advisable. When children spill < 50 red blood cells (RBCs) per high-powered field (hpf) on microscopic urinalysis, significant renal injury is rare. Furthermore, shock is not a useful guide in children.

5. When does one suspect renal trauma?

Show answer
The mechanism of injury, physical examination (e.g., flank ecchymosis, location of penetrating wounds), and associated injuries (e.g., rib fractures) should raise suspicion of renal trauma. Although the degree of hematuria does not correlate with the degree of renal injury, when hematuria is out of proportion to the history of trauma, it suggests preexisting renal abnormality (e.g., hydronephrosis, ectopic kidney, tumor, cystic disease, vascular malformation). Conversely, renal pedicle injuries (grade 4) may bleed little because of arterial interruption.

6. What imaging study is best to evaluate renal trauma?

Show answer
Computed tomography (CT) scan of the abdomen and pelvis with and without intravenous (IV) contrast should be performed, but it is pivotal that the perfusion and excretion phases (10 minutes after IV contrast is administered) are obtained during the study.

7. What is a single-shot IVP, and when do you perform it?

Show answer
It is an extremely abbreviated form of intravenous pyelogram (IVP) performed in emergent cases when a full evaluation is not permitted. A bolus (2 mL/kg contrast agent) is injected intravenously, and the first film should be obtained at approximately 10 minutes, with additional films at 10-minute intervals as necessary for diagnosis. Intraoperative IVP is recommended when renal damage is first suggested (e.g., retroperitoneal hematoma) during emergency surgery for other injuries.

8. How is renal trauma classified?

Show answer

* Grade 1: contusion
* Grade 2: superficial laceration
* Grade 3: deep laceration without collecting system damage
* Grade 4: contained renal pedicle injury or deep laceration and collecting system damage
* Grade 5: shattered kidney or avulsion of renal hilum

Grade 1, 2, and 3 injuries are safe to watch with nonoperative management, whereas grades 4 and 5 typically require operative intervention for repair or removal. Grade 4 injury (pedicle injury) is picked up by ipsilateral urographic nonfunction and nominal bleeding. Grade 5 injury is manifested by urographic nonfunction, parenchymal shattering, and significant gross hematuria.

9. What are the different kinds of renal pedicle trauma?

Show answer
The renal pedicle may be interrupted by thrombosis or complete avulsion; both events are characterized by urographic nonvisualization and minimal hematuria. The most common site of arterial interruption is the junction of the proximal and middle thirds of the main renal artery. Although hematuria is often absent, one may see transitory gross hematuria or microhematuria, emphasizing the requirement for urinalysis in all circumstances.

10. How long can a nonperfused kidney tolerate warm ischemia?

Show answer
Irreversible renal damage may be seen in kidneys after 30 minutes of warm ischemia, and after 8 hours of ischemia, renal salvage is minimal. Recently, single reports of renovascular trauma with intimal tear treated with endovascular stents have been encouraging.

11. What is the significance of delayed gross hematuria?

Show answer
This occurs 3-4 weeks after trauma and may indicate an arteriovenous fistula. Selective embolization is the next step if conservative therapy (bed rest) fails. Rarely, operative intervention, usually for partial nephrectomy, is necessary.

12. How do you deal with unexpected retroperitoneal bleeding noted at operation?

Show answer
A pulsatile hematoma suggests a major vascular injury, and exploration should be preceded by vascular control (both proximal and distal) and preparation for rapid blood replacement. Stable hematomas (above the pelvic brim) may be left undisturbed unless studies (preoperative or intraoperative) disclose severe renal damage. When doubt exists, exploration is justified, with the likelihood of losing a kidney.

13. How are patients with posttraumatic urine extravasation managed?

Show answer
When urine extravasation is caused by a major laceration into the collecting system and coexists with significant persistent bleeding, surgical correction is advised. Otherwise, urine extravasation commonly resolves promptly. Reimaging at 48-72 hours defines cases requiring drainage, stenting, or operative repair.

14. What is included in conservative management of renal trauma?

Show answer
Conservative management includes bed rest until gross hematuria has subsided. Strenuous activity is avoided until microhematuria has subsided (usually within 3 weeks). Patients followed for grade 5 renal trauma should undergo ultrasonography, CT scan of the abdomen and pelvis, or urography at 6 weeks. Hospitalization is not required during these periods.

15. What is the likelihood of subsequent hypertension?

Show answer
Documented posttraumatic hypertension occurs in < 2% of patients and is renin mediated. Onset generally occurs within the first several months of injury. The mechanisms of posttraumatic hypertension are renal artery stenosis or occlusion, renal parenchymal compression (extravasation of blood or urine), and posttrauma arteriovenous fistula.

16. How are most ureters damaged?

Show answer
In the civilian world, excluding iatrogenic injuries, penetrating trauma is responsible for 4% of ureteral injuries, and 1% are caused by blunt trauma.

KEY POINTS: PRINCIPLES OF URETERAL REPAIR

1. Primary tension-free anastomosis is preferred over stent with absorbable suture.
2. For a distal injury in the lower third of the ureter, perform ureteroneocystostomy; suspend the bladder if tension exists.
3. For middle third injuries, perform end-to-side transretroperitoneal ureteroureterostomy.
4. For proximal injury with significant length loss, use nephrostomy tube for drainage.

17. How do you evaluate and identify ureteral injury?

Show answer
The site and mechanism of trauma should prompt the surgeon to suspect ureteral injury. The clinical manifestations are characteristically subtle and often obscured by coexisting injury and complaints. The majority of gunshot wounds and stabbings that injure the ureter also injure bowel, colon, liver, spleen, blood vessels, or pancreas. Hematuria is often microscopic, but it may be absent. Extravasation of contrast may be detected with noninvasive (IVP and CT scan) and invasive (anterograde and retrograde ureteropyelogram) imaging studies. If ureteral injury is suspected during laparotomy, indigo carmine (1 vial IV bolus) should be given to identify the site of leakage (blue coloration).

18. What are the potential consequences of missed ureteral injury?

Show answer
Fever, leukocytosis, azotemia, flank pain, ileus, urinoma, or urinary fistula. Presentation is often delayed by several weeks after the injury.

19. What are the principles of ureteral repair?

Show answer
Devitalized tissue must be debrided, and the two ends of the ureters should be mobilized, spatulated, and anastomosed (tension free) over a ureteral stent using absorbable suture. Placement of a drain should be performed without rubbing on the fresh anastomosis. Distal injuries permit direct implantation of the ureter into the bladder. Midureteral injuries may be repaired by primary anastomosis. Pediatric patients are more susceptible to proximal complete ureteral disruption. Urgent surgical repair is mandatory. Rarely, when nephrectomy is not an option and ureteral damage prevents standard methods of reconstruction, other elective and more complex surgical reconstructive techniques may be applied. These include kidney autotransplantation, ileal interposition, transureteroureterostomy, Boari flap with nephropexis, and ureterocalicostomy.

20. The distal ureter is injured and ureteral reimplantation with a psoas hitch (tack up the bladder to the psoas muscle) is performed. Postoperatively, the patient complains of anterior thigh numbness. What did you do wrong?

Show answer
The genitofemoral nerve lies on the anterior aspect of the ileopsoas muscle. You caught this nerve when you synched this to the tendon of the psoas muscle.

References
WEB SITES

1. http://www.east.org/tpg/GUmgmt.pdf
2. http://www.acssurgery.com/abstracts/acs/acs0510.htm

BIBLIOGRAPHY
1. Armstrong PA, Litscher LJ, Key DW, McCarthy MC: Management strategies for genitourinary trauma. Hosp Phys 34:19-25, 1998.
2. Campbell EW Jr, Filderman PS, Jacobs SC: Ureteral injury due to blunt and penetrating trauma. Urology 40:216-220, 1992. Medline Similar articles Full article
3. Carroll PR, McAninch JW, Klosterman PW, et al: Renovascular trauma: Risk assessment, surgical management, and outcome. J Trauma 30:547-552, 1990. Medline Similar articles Full article
4. Kim FJ: Urologic trauma. In Feliciano DV, Moore EE, Mattox KL (eds): Trauma Companion Handbook, 4th ed. New York, McGraw-Hill, 2002.
5. McAninch JW: Traumatic and Reconstructive Urology. Philadelphia, W.B. Saunders, 1996.
6. McAninch JW, Santucci R: Genitourinary trauma. In Walsh PC, Retik AB, Vaughan ED, Wein AJ (eds): Campbell’s Urology, 8th ed. Philadelphia, W.B. Saunders, 2002, pp 3707-3744.
7. Moore EE, Shackford SR, Pachter HL, et al: Organ injury scaling: Spleen, liver, and kidney. J Trauma 29:1664-1666, 1998.
8. Peterson NE: Genitourinary trauma. In Feliciano DV, Moore EE, Mattox KL (eds): Trauma, 4th edition. Norwalk, CT, Appleton & Lange, 1996, pp 661-694.
9. Skinner EC, Parisky YR, Skinner DG: Management of complex urologic injuries. Surg Clin North Am 76:861-878, 1996. Medline Similar articles

1. What are the most common types of urinary stones found in North America?

Show answer

* Calcium stones (calcium oxalate, calcium phosphate, or mixed calcium stones): 70%.
* Struvite or magnesium ammonium phosphate stones, often associated with infection: 20%.
* Uric acid stones (radiolucent): 5%
* Cystine stones, often with a genetic association: 5%

2. What are the typical presenting symptoms of a patient with an obstructing stone?

Show answer

* Pain, usually colicky in the flank or radiating to the groin; patients are usually agitated and cannot get in a comfortable position
* Hematuria, gross or microscopic
* Nausea and vomiting caused by obstruction and pressure on the renal capsule

3. What studies are best to diagnose stones?

Show answer

1. Excretory urogram, or intravenous pyelogram (IVP). Ninety percent of stones are radiopaque and can be seen on a plain radiograph of the kidney, ureter, and bladder (KUB). The IVP serves as a functional study to determine the degree of obstruction, level of obstruction, and presence of a contralateral kidney.
2. Currently, rapid-sequence helical computed tomography (CT) scan has gained popularity. Helical CT can accurately identify both renal and ureteral stones. Its advantages include no need for contrast; speed; and ability to identify calcium, uric acid, and cystine stones. Disadvantages include increased cost compared with IVP and inability to distinguish between radiolucent (uric acid) stones and radiopaque (calcium-containing) stones. A KUB should be obtained if the CT has positive results, to distinguish between radiolucent and radiopaque stones.
3. Ultrasound is particularly advantageous in pregnant women.

4. When should a patient with an obstructing stone be admitted to the hospital?

Show answer

* Any sign of infection (e.g., fever, leukocytosis, bacteriuria); infection behind an obstructing stone may result in urosepsis and death
* Intractable vomiting requiring intravenous (IV) fluids
* Pain requiring parenteral analgesics
* Bilateral obstructing stones or obstruction in a solitary kidney

5. What are the treatment options for ureteral calculi?

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* Wait and watch to see if the stone passes; it usually does. Approximately 90% of stones, 3 mm in size in the distal ureter, will pass. Fifty percent of 5-mm stones will pass, and 20% of stones larger than 6 mm will pass.
* Ureteroscopy and stone basketing or intraureteral lithotripsy (stone blasting) with a laser (holmium, pulsed dye) or electrohydraulic lithotripsy (EHL)
* Extracorporeal lithotripsy (ESWL), or shock waves directed at the stone to break it into small pieces that can then pass spontaneously
* Open ureterolithotomy, now rarely used because of the success of the less invasive techniques listed above

KEY POINTS: URINARY CALCULUS DISEASE

1. The most common stones in patients in the United States are calcium stones.
2. Excretory urogram or intravenous pyelogram, rapid-sequence helical CT, and ultrasound are the imaging studies used to diagnose stones.
3. Steinstrasse is a collection of small calculi that pile up together in the ureter and cause obstruction or symptoms.

6. What are the treatment options for renal calculi?

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* Expectant management in asymptomatic noninfectious stones
* ESWL
* Ureteropyeloscopy with lithotripsy using a laser. This has become more popular with smaller, flexible, deflectable ureteroscopes, but it is still a challenging procedure for large stones.
* Percutaneous nephrostolithotomy (particularly for stone burden > 2 cm)
* Combination of ESWL and percutaneous nephrostolithotomy
* Open lithotomy (less common because of the success of less invasive treatment options)

7. What is a steinstrasse?

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Steinstrasse (German for “stone street”) is a collection of small calculi that pile up together in the ureter and cause obstruction or symptoms. This problem may occur after lithotripsy treatment.

8. What is a stent?

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A stent is a small plastic catheter that coils in the renal pelvis, traverses the ureter, and coils in the bladder. Stents are useful to relieve ureteral obstruction temporarily and possibly facilitate stone passage after the stent is removed. Stents often cause some degree of ureteral dilatation after they have been removed.

9. What is a metabolic evaluation? Who needs one?

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A metabolic evaluation involves examining both serum and 24-hour urine specimens for factors that contribute to stone formation. The goals are to identify an abnormality and to treat it medically to prevent further stone formation. Indications for metabolic evaluation include recurrent stones, multiple stones, bilateral stones, stones in children, and non-calcium-containing stones.

10. Can stones be dissolved?

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* Uric acid stones often can be dissolved by alkalinizing the urine and with hydration therapy.
* Cystine, struvite, and apatite stones sometimes can be dissolved.
* Calcium stones cannot be dissolved.

14. What is the role of laparoscopy and thoracoscopy after penetrating abdominal trauma?

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Although an intriguing diagnostic modality with additional therapeutic capabilities, laparoscopy thus far appears to have limited application after trauma. With the exception of suspected diaphragmatic injury, an isolated solid organ injury, or evaluation for peritoneal penetration, laparoscopy has yet to demonstrate advantages over the algorithm delineated above. The potential for missed injuries, poor evaluation of the retroperitoneum, and expense are major drawbacks. In patients with wounds to the lower chest with pneumothorax (and, thus, an indication for chest tube placement), thoracoscopy is reasonable to exclude diaphragmatic injury.

References
WEB SITES

1. http://www.east.org/tpg/atbpenetra.pdf
2. http://www.surgery.ucsf.edu/eastbaytrauma/Protocols/ER%20protocol%20pages/abdominal_stab.htm

BIBLIOGRAPHY
1. Chiu WC, Shanmuganathan K, Mirvis SE, Scalea TM: Determining the need for laparotomy in penetrating torso trauma: A prospective study using triple-contrast enhanced abdominopelvic computed tomography. J Trauma 51:860-868, 2001. Medline Similar articles Full article
2. Freeman RK, Al-Dossari G, Hutcheson KA, et al: Indications for using video-assisted thoracoscopic surgery to diagnose diaphragmatic injuries after penetrating chest trauma. Ann Thorac Surg 72:342-347, 2001.
3. Henneman PL, Marx JA, Moore EE, et al: Diagnostic peritoneal lavage: accuracy in predicting necessary laparotomy following blunt and penetrating trauma. J Trauma 30:1345-1355, 1990. Medline Similar articles
4. McAlvanah MJ, Shaftan GW: Selective conservatism in penetrating abdominal wounds: A continuing reappraisal. J Trauma 18:206-212, 1978. Medline Similar articles
5. McAnena OJ, Marx JA, Moore EE: Peritoneal lavage enzyme determinations following blunt and penetrating abdominal trauma. J Trauma 31:1161-1164, 1991.
6. Moore EE, Marx JA: Penetrating abdominal wounds: A rationale for exploratory laparotomy. JAMA 253:2705-2708, 1985.
7. Reber PU, Schmied B, Seiler CA, et al: Missed diaphragmatic injuries and their long-term sequelae. J Trauma 44:183-188, 1998.
8. Simon RJ, Rabin J, Kuhls D: Impact of increased use of laparoscopy on negative laparotomy rates after penetrating trauma. J Trauma 53:297-302, 2002. Similar articles Full article

1. How often is the liver injured in trauma?

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The liver is both big and central, so it is an easy target.

2. Do the liver and spleen respond similarly to injury?

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No. The liver has a unique ability to establish spontaneous hemostasis even with extensive injuries. For this reason, the majority of liver injuries in hemodynamically stable patients can be managed nonoperatively. In contrast, many splenic fractures continue to bleed; therefore, a greater percentage require operative intervention.

3. What are the determinants of mortality after acute liver injury?

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The mechanism of injury and the number of associated abdominal organs injured determine mortality. The mortality for stab wounds to the liver is 2%; for gunshot wounds, 8%; and for blunt injuries, 15%. The mortality rate for isolated grade III hepatic injuries is 2%; for grade IV, 20%; and for grade V, 65%. Retrohepatic vena cava injuries carry mortality rates of 80% for penetrating trauma and 95% for blunt trauma.

4. What history and physical signs suggest acute liver injury?

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Any patient sustaining blunt abdominal trauma with hypotension must be assumed to have a liver injury until proven otherwise. Specific signs that increase the likelihood of hepatic injury are contusion over the right lower chest, fracture of the right lower ribs (especially posterior fractures of ribs 9-12), and penetrating injuries to the right lower chest (below the fourth intercostal space, flank, and upper abdomen). Physical signs of hemoperitoneum may be absent in as many as one third of patients with significant hepatic injury.

5. What diagnostic tests are helpful in confirming acute liver injury?

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A focused abdominal sonography for trauma (FAST) examination can detect or rule out hemoperitoneum and pericardial tamponade. Diagnostic peritoneal lavage (DPL) is sensitive for hemoperitoneum (99%). Ultrasound is highly sensitive in identifying > 200 mL of intraperitoneal fluid. It is noninvasive and may be repeated at frequent intervals, but it is relatively poor for staging liver injuries. Abdominal computed tomography (CT) scan currently is used only in hemodynamically stable patients who are candidates for nonoperative management. The major shortcoming of CT is the relatively poor correlation between hepatic CT staging and subsequent risk of hemorrhage.

6. What is the role of hepatic angiography and radionuclide biliary excretion scans in the diagnosis of liver injury?

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Selective hepatic artery embolization is effective therapy for hepatic arterial bleeding, both for avoidance of surgery and for recurrent postoperative bleeding.

9. How do rectal injuries occur?

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Similar to colon injuries, most rectal injuries result from penetrating trauma. Blunt pelvic fractures should be assessed with a strong suspicion for rectal (and urethral) injury.

10. How are rectal injuries diagnosed?

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A thorough examination is crucial, and the diagnosis is suggested by the course of the projectiles and the presence of blood on digital rectal examination. If rectal trauma is suspected, the patient should undergo proctoscopy to look for hematomas, contusions, lacerations, or gross blood. If the diagnosis is in question, radiographs with soluble-contrast enemas should be performed.
11. How are patients with intraperitoneal rectal injuries treated differently from those with

extraperitoneal injuries?

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The portion of the rectum proximal to the peritoneal reflection is called the intraperitoneal segment. Injuries of this portion are treated similar to colonic injuries.

12. What are the four basic principles for managing simple extraperitoneal rectal injuries?

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1. Diversion: either a loop or an end-sigmoid colostomy is appropriate.
2. Drainage: a retroanal incision should be used to place Penrose or closed-suction drains near the perforation site.
3. Repair: appropriate, when possible
4. Washout: irrigation of the distal rectum with isotonic solution until the effluent is clear. The role of washout remains controversial, but it may benefit patients whose rectum is full of feces.

13. How are complex extraperitoneal rectal injuries managed?

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In patients with massive pelvic trauma and an associated rectal injury, an abdominoperineal resection may be required for adequate debridement and hemostasis. An abdominoperineal resection is also required in rare instances in which anal sphincters have been destroyed.

14. What complications are associated with rectal trauma and its treatment?

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They are similar to those in colonic injuries. In addition, pelvic osteomyelitis may occur. In this case, debridement may be necessary, and culture-specific intravenous antibiotics should be administered for 2-3 months.

15. What is the role of antibiotics in colorectal trauma?

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Antibiotics are important. They should be initiated preoperatively (you need a good blood level at the time you make your incision) and ended quickly (12-24 hours postoperatively). Broad-spectrum, combination therapy is superior to single-agent therapy.

References
BIBLIOGRAPHY
1. Berne J, Velmahos G, Chan LS, et al: The high morbidity of colostomy closure after trauma: Further support for the primary repair of colon injuries. Surgery 123:157-164, 1998. Medline Similar articles
2. Burch J, Franciose R, Moore E: Trauma. In Schwartz S (ed): Principles of Surgery, 8th ed. New York, McGraw-Hill, 1999, pp 155-221.
3. Demetriades D, Murray J, Chan LS, et al: Handsewn versus stapled anastomosis in penetrating colon injuries requiring resection: A multicenter study. J Trauma 52:117-121, 2002.
4. Demetriades D, Murray J, Chan L, et al: Penetrating colon injuries requiring resection: Diversion or primary anastomosis? An AAST prospective multicenter study. J Trauma 50:765-775, 2001. Similar articles Full article
5. Velmahos G, Vassiliu P, Demetriades D, et al: Wound management after colon injury: Open or closed? A prospective randomized trial. Am Surg 68:795-801, 2002. Medline Similar articles

COLON TRAUMA

1. How do most colon injuries occur?

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Nearly all (> 95%) colon injuries are caused by penetrating trauma from gunshot, stab, iatrogenic, or sexual injury. Blunt colonic trauma is rare and usually results from seat belts during motor vehicle accidents.

2. How are colon injuries diagnosed?

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They are usually diagnosed during laparotomy for penetrating trauma. For patients in whom the need for laparotomy has not been established, chest and upright abdominal radiographs assess free air and detect the location of penetrating objects. Triple-contrast computed tomography (CT) or soluble-contrast radiographs (followed by barium, if necessary) can diagnose retroperitoneal colon injuries. White blood cells or fecal material in diagnostic peritoneal lavage (DPL) is highly suggestive of a bowel injury.

3. How are colon injuries graded?

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* Grade I-contusion hematoma without devascularization; or partial-thickness laceration
* Grade II-laceration < 50% circumference
* Grade III-laceration > 50% circumference
* Grade IV-transection of the colon
* Grade V-transection with segmental tissue loss

4. What are three surgical options for managing a colon injury?

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1. Primary repair: suturing of simple sidewall perforations or resection and primary anastomosis for more complex injuries
2. Colostomy: injured colon is exteriorized as a loop colostomy or the injured area is resected and an end ileostomy or proximal colostomy is formed
3. Exteriorized repair: a repaired perforation or anastomosis is suspended on the abdominal wall. If the suture line does not leak after 10 days, it can be returned to the abdominal cavity under local anesthesia. If the repair breaks down, it is treated like a loop colostomy.

5. What are the advantages and disadvantages of each of these options?

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1. Primary repair is desirable because definitive treatment is carried out at the initial operation and the patient is spared the morbidity of a colostomy and its reversal. The disadvantage is that suture lines are created in suboptimal conditions, so leakage may occur.
2. Proximal colostomy avoids an unprotected suture line in the abdomen but requires a second operation to close the colostomy. Stomal complications, including necrosis, stenosis, obstruction, and prolapse, may occur.
3. Exteriorized repair is similar to colostomy formation in that it avoids formation of an intraperitoneal suture line. Unfortunately, many patients require a colostomy closure, and stomal complications similar to those of colostomies may occur.

6. How are most patients with colon injuries surgically managed?

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Primary repair is safe and effective in essentially all patients with colon trauma. Handsewn and stapled anastomoses have equal complication rates.
KEY POINTS: SURGICAL MANAGEMENT OF COLON INJURIES

1. Primary repair is safe.
2. Handsewn and stapled anastomoses have equal complication rates.
3. A preoperative dose of antibiotic therapy, to be continued for 24 hours, is advantageous.

7. How should the surgical incision and penetrating wound be managed?

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Wounds should be left open (for delayed primary closure) to decrease the incidence of wound infection and fascial dehiscence.

8. What complications are associated with colonic injury and its treatment?

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* Wound infection (≤ 65% if the skin incision is closed primarily; do not be tempted to close a dirty incision)
* Intraabdominal abscess (20%)
* Fascial dehiscence (10%)
* Stomal complications (5%)
* Anastomotic leak (5%)
* Mortality (6%)