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Year : 2016  |  Volume : 8  |  Issue : 6  |  Page : 146-162  

Urology trauma

Date of Web Publication26-Apr-2016

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How to cite this article:
. Urology trauma. Urol Ann 2016;8, Suppl S2:146-62

How to cite this URL:
. Urology trauma. Urol Ann [serial online] 2016 [cited 2020 Oct 26];8, Suppl S2:146-62. Available from: https://www.urologyannals.com/text.asp?2016/8/6/146/181209

Advances in the diagnosis and intraoperative management of renal trauma

Joseph N. Corriere

Department of Urology, The University of Texas, Houston, Texas, USA

Using personal data, this review will try to answer two questions in patients with suspected renal failure.

Can IVPs be Eliminated in the Absence of Gross Hematuria and Hypertension? Of 862 patients with blunt trauma, 70% had only micro-hematuria and were never hypotensive. Only 60 (10%) had abnormal IVPs. Of 241 patients with penetrating trauma, 61% had similar findings. Only 16 (11%) of these had abnormal IVPs. patients with major injuries all had other reasons (physical findings) to do an IVP. Only 5 patients with minor injuries would not have been studied.

Is Medical Control of the Hilar Vessels Necessary Prior to Opening Gerota's Fascia? Of 85 operated patients, 33 (39%) had pedicle control prior to renal exploration while the other had direct lateral exploration. In only 6 (7%) of the cases was vascular occlusion performed to facilitate the surgery and all of these cases had a wound as well as a hematoma overlying the great vessels.

Conclusion: In patients with suspected renal trauma, imaging is only necessary if the patient had gross hematuria or micro-hematuria and hypotension (systolic <90) or physical evidence of major abdominal injury. Intra-operatively, preliminary pedicle control is only necessary if there is a wound and hematoma overlying the great vessels.

Presented at the: 9 th Saudi Urology Conference

King Fahad Hospital - Jeddah

14-16 November 1995

Analytical review of uro-genital injuries during a

30 months period

Mohammad Youssef, Ahmed Zein Abidine, Hisham Saidaui, R. Sayed

Department of Urology, King Faisal Hospital, Hofuf, Saudi Arabia

During a 30 month period 59 patients with urogenital trauma were treated in KFH divided as follows: 11 cases renal injuries, age ranges: 5-38 years all males; 5 at the right side, 6 at the left side; all blunt trauma (55% RTA, 27% F.D. > on the loin (1 during football play, 1 assault). In the cases of the RTA victims there were associated non-renal injuries (liver, lung, spleen). In 20% of renal injuries there were predisposing factors like hydronephrosis, polycystic kidney. 36% of the cases were treated by conservative methods and 64% were surgical methods (37% total nephrectomy, 27% partial nephrectomy, 2 cases of surgical repairs). 20 cases urethral injuries with prevalence of male sex (80% males, 20% females; age range 7-120 years); blunt trauma is the principal aetiology (35% RTA, 45% a straddle, 10% sexual abrasion, 10% pulled inflated foley catheter by themselves). All RTA caused membranous urethral injuries and were associated with fracture pelvis, 11 cases urinary bladder injuries: age range 3-37 years (73% males, 27% females); aetiology was 7 RTA, 2 Iatrogenic, 1 gunshot, 1 assault. In 82% the bladder injuries were extra-peritoneal and 18% intra-peritoneal. All cases were treated by surgical repair, 2 ureteric cases: 1 traumatic (11 years), 1 during recurrent CS (27 years). 12 cases scrotal injuries: age range was 2-50 years (84% blunt trauma, 16% penetrating trauma) 50% treated with conservative method & 50% by surgical method. 3 cases of penile trauma; 1 case of spermatic cord blunt trauma.

Presented at the: 9 th Saudi Urology Conference

King Fahad Hospital - Jeddah

14-16 November 1995

Urological trauma at King Abdulaziz Hospital and Oncology Centre

Farukh Qureshi, Omar Siddiki, Hidayatulla Hakim

Department of Urology, King Abdulaziz Hospital, Jeddah, Saudi Arabia

A total of forty-seven (47) patients with urological trauma were managed at the above mentioned hospital. These include all ages and approximately 50% of urological trauma was associated with major abdomino-pelvic injuries.

Major share of the injuries was taken by the lower urinary tract mainly the urethra. Approximately 90% of the cases with injury to the urethra were diagnosed at the time of presentation.

Blunt injuries with associated fracture pelvis was the most common aetiology in the trauma caused to the urethra. Bulbar urethra was the commonest site of injury.

Management of urethral injuries involved insertion of supra pubic catheter in about two third of cases as the initial procedure. The five (5) patients who were diagnosed as urethral trauma at laparotomy were treated by passage of urethral splint by Rail Roading. The urethral splint was removed at 3-4 weeks followed by a urethrogram. In the cases managed by supra pubic catheter alone, urethrogram was done at approximately 15-20 days after injury. The patients who developed stricture were dealt by optical urethrotomy. Three (3) cases out of the twelve (12) with stricture had a follow up to three (3) Months with no evidence of recurrence.

Most of the patients were non-Saudi's. This accounts for the limited follow up.

Presented at the: 9 th Saudi Urology Conference

King Fahad Hospital - Jeddah

14-16 November 1995

"Sliding bullet"

H. Sijani

Department of Surgery, Iranian Hospital, Dubai, United Arab Emirates

A bullet injury case in which bullet entered from the right side of pelvis causing fracture of head of femur, vesicorectal fistula formation and implantation of the bullet in left acetabulum.

After eight months it was found that the bullet was inside the urinary bladder without any surgical intervention. (Spontaneous migration of bullet). This process of migration will be presented on slides taken at different times in serial. The bullet was extracted by cystoscopic procedure.

Presented at the: 7 th Saudi Urological Conference

Riyadh Armed Forces Hospital

11-12 November 1992

Ureteroscopic ureteric injuries

I. Al Oraifi, Adel Al Dayel, E. El Sayed, A. Abu Zalat, S. Egail, M. Ezzibdeh

Department of Urology, King Fahd Military Medical Complex, Dhahran, Saudi Arabia

This is a review of our experience in managing 138 patients for different urological problems ureteroscopically, to evaluate the sequelae of ureteroscopic perforations. Patients' age ranging from 6 to 87 years (mean 42.05), 102 males, 36 females. A total of 188 ureteroscopic procedures were performed (1.36 procedure per patient). Follow up ranging from 3-86 months with a mean for 44.5 months. From the total number of 188 procedure, 12 (6.38%) had ureteric perforations, (6 lower, 1 middle, 4 upper and 1 upper and middle), and were stented intra-operatively for a period of 2-120 days. Two patients had septicaemia and were managed successfully conservatively. Follow up revealed no complication apart from one patient who had a lower ureteric biopsy and developed urinoma and lower ureteric stricture and she was managed with drainage followed by left ureteric reimplantation. This indicates that ureteric perforation if recognised and managed early will rarely lead to stricture formation.

Presented at the: 9 th Saudi Urology Conference

King Fahad Hospital - Jeddah

14-16 November 1995

Ureteral injuries in caesarian sections

C. Krishnappa, K. S. Abdul Wahab, A. Jha, S. Roshdi, T. Jacob

Department Urology, King Fahd Central Hospital, Gizan, Saudi Arabia

Introduction and Aim: Obstetrical injuries to the lower end of the ureters are not that uncommon. Ureters do get injured in very difficult Caesarian section performed third or fourth time, or in ruptured uterus where attempts were made to repair the uterus or in hysterectomy. Unlike Urologically inflicted injuries (like Ureteroscopy or basketing) the injuries sustained in obstetrical surgeries are not recognised immediately. Emphasis is given to the prevention of such injuries, immediate recognition intra-operatively or early diagnosis post-operatively and treat energetically to prevent further complications.

Materials and Methods: Eight cases of obstetrical injuries to the lower end of the ureters were treated during the past 3 years. 3 cases following Caesarian section for the 3rd and 4th time. 2 cases following rupture of the uterus where the uterus were preserved, but injuries repaired. 3 cases following rupture of the uterus where hysterectomy were performed. 3 cases presented as Urinomas. 2 cases presented with urinary fistulas, 3 cases were discovered during urological investigations for mild loin pain 6 to 12 months after obstetrical surgeries. All cases were treated surgically from simple procedure like "DJ" stenting to the Uretero neocystostomy with Boari's flap.

Summary and Conclusion: Eight cases of obstetrical injuries to the lower end of the ureters are discussed. The mode of presentation, and various forms of treatment are analysed: ways and means to prevent such injuries, and early diagnosis are suggested.

Presented at the: 9 th Saudi Urology Conference

King Fahad Hospital - Jeddah

14-16 November 1995

Management and long term results of lower urinary tract injuries

Joseph N. Corrier

Department of Urology, The University of Texas, Houston, Texas, USA

Using personal data this review will try to answer two questions in patients with lower urinary tract injuries.

Can Blunt Extra peritoneal Bladder Ruptures be Treated Non-Operatively with Catheter Drainage? In a review of 111 consecutive patients with bladder rupture from external violence, 39 with extra peritoneal bladder injuries were treated with only catheter drainage. Cystograms 10 days after the injury showed 34 (87%) were healed the other injuries also eventually healed, one by day 14 and one by day 21. The other three were not studied until all other injuries had resolved but were shown to be healed by days 37, 62, 90.

What is the Long Term Outcome of Voiding and Erectile Function after Delayed Repair of a Posterior Urethral Disruption? Of 50 men who had a delayed one stage repair of posterior urethral rupture, all had a patent urethra and 38 (76%) void normally and are continent one year postoperatively. Five have an areflexic bladder and catheterise themselves, three have mild urge incontinence and four mild to moderate stress incontinence. Impotence was present pre and postoperatively in 24 (48%) but by one year only 16 (32%) were still having no erections. 18 (36%) have normal erections and 16 (32%) have less than optimal erections.

Conclusion: Extra peritoneal bladder rupture can be treated with catheter drainage only. After posterior urethral rupture repair. 76% of the patients will eventually void normally and 36% will have normal erections. The others will have some form of voiding or erectile dysfunction.

Presented at the: 9 th Saudi Urology Conference

King Fahad Hospital - Jeddah

14-16 November 1995

Iatrogenic trauma of the ureter and urinary bladder

M. S. Abomelha, M. T. Said, S. Orkubi, K. E. Al Otaibi, A. Shaaban, M. Kourah

Department of Urology, Riyadh Armed Forces Hospital, Riyadh, Saudi Arabia

We present a review of 44 patients (40 females and 4 males) with iatrogenic trauma of the ureter and urinary bladder who were managed at the Riyadh Armed Forces Hospital between 1980 and 1995. Their age range was 20-65 years with a mean of 38.2 years. 50% were outside referrals. The aetiology included 13 hysterectomies, 24 caesarian sections and 7 laparotomies. The majority of the female patients had previous obstetric and gynaecological surgery and 25% of them had failed repairs.

Ureteric trauma was recognised in 22 patients including the 4 males, resulting in 11 uretero-vaginal and 4 ureterocutaneous fistulae, 5 ureteric ligation and 2 partial injuries. These were managed by ureteric reimplantation in 13, end-to-end ureteric anastomosis in 2 and 11 stenting in 3. The result was 100% success.

The other 22 cases were bladder injuries which accounted for 15 vesico-vaginal, 3 vesico-uterine and 1 vesico-urethro-vaginal fistula. 3 vesical tears were recognised peroperatively. The fistulae were managed electively either by vaginal or transabdominal approach including interposition of healthy omentum and/or pelvic peritoneum. 3 out of 5 (60%) vaginal and 10 out of 11 (91%) abdominal repairs were successful. The 3 vesical tears which were recognised and repaired at the time of injury healed uneventfully.

It is considered that per operative awareness and recognition of iatrogenic injuries of the ureter and bladder is of paramount importance in prompt definitive management to achieve satisfactory result. This obviates subsequent patient morbidity and attendant difficult surgery. Repair of ureteric injuries is almost always successful. It appears that trans-abdominal approach with interposition of omental pedicle graft between the urinary bladder and the female genital tract is valuable and improves the chance of success.

Presented at the: 9 th Saudi Urology Conference

King Fahad Hospital - Jeddah

14-16 November 1995

Role of myocutaneous flaps in urogenital injuries

Mohamed M. Hegazy, Saud A. Taha

Division of Plastic Surgery, Division of Urology, College of Medicine and Medical Sciences, King Faisal University, Dammam, Saudi Arabia

Injury to the bulbous urethra is relatively uncommon and in particular as a complication of Thomas splint. Total penile amputation is also a rare type of trauma. Reconstruction is one of the most challenging tasks in this region. Our interest is in finding alternative sources for healthy well vascularized tissue for repair of total loss of the entire penile urethra in two unusual cases, in which gracilis myocutaneous flap was used successfully. Inferior based rectus myocutaneous flap was used in another case for total penile and urethral reconstruction as one-stage procedure.

Presented at the: 5 th Saudi Urological Conference

King Fahd Military Medical Complex

22-23 March 1989

Supramembranous urethral rupture in boys: Management by delayed transpubic urethroplasty

A. H. Kardar, S. Ahmed, T. Sundin

Department of Urology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

Ten boys with supramembranous urethral rupture were seen in a four year period. The patients were 3 to 11 years of age at a time of injury. Nine boys were run-over or crushed by a moving vehicle and one was thrown out from a car involved in an accident. All patients had a fractured pelvis and the majority also had other major injuries. All children had their initial management at the referring hospital and were received at King Faisal Specialist Hospital with a suprapubic cystostomy. Combined cystogram and urethrogram showed a urethral distraction defect from 1 cm to over 3 cm in length. Abdominoperineal transpubic urethroplasty (Turner Warwick) was performed six months to 18 months after the injury. After perineal mobilization of the bulbar urethra, suprapubic exploration was undertaken, usually requiring extensive pubectomy and excision of hematoma fibrosis. The rupture was just below the verumontanum in all cases where the distal prostatic urethra was laid open, carefully avoiding any dorsal dissection. The proximal end of the bulbar urethra was spatulated making an anastomosis with 1-1.5 cm overlap over a fenestrated catheter. A pedicle of omentum was used to fill the perianastomotic cavity and a suprapubic catheter was left in for about three weeks. Postoperative cystourethrogram showed a wide anastomosis in all cases and a closed bladder neck at rest in nine. On follow up (11-36 months), there were no strictures, seven patients were continent, and six had confirmed erections. Supramembranous urethral rupture is a common injury in Saudi Arabia. Initial management with suprapubic cystostomy at the primary hospital would appear to be appropriate. Delayed reconstruction is recommended six months after the injury for which purpose abdominoperineal transpubic urethroplasty gives satisfactory results.

Presented at the: 8 th Saudi Urological Conference

King Fahd Military Medical Complex

9-10 November 1993

Urethral realignment plus traction as an initial management of complete rupture of posterior urethra

Baher Ali Kamal, S. A. Taha, T. A. Ali, M. H. Hashish, H. Darawany, R. Anikwe

Department of Urology, King Fahad Hospital of the University, Al Khobar, Saudi Arabia

The management of post traumatic Urethral stricture is controversial reconstructive surgery for long stricture is technically demanding and difficult. The initial management of traumatic rupture of posterior urethra is critical in predicting the outcome of the length of the inevitable stricture complicating the trauma. In the 1979(s) and 1980(s) the preferred initial treatment was suprapubic catheterization alone instead of the traditional Rail Roading. We compared the 2 ways of management in 11 patients admitted to KFHU Al Khobar and found that in almost all cases treated by Rail Roading, the defect between the proximal and distal urethral stump was short and such cases were treated subsequently only by internal urethrotomy. Patients who had suprapubic catheter alone developed long strictures which were not amenable to internal urethrotomy. Such patients required extensive surgical procedures to re-establish Urethral continuity. Our experiences show that Rail Roading plus traction as an initial management of complete urethral rupture is still very effective and preferable to suprapubic catheterisation alone.

Presented at the: 9 th Saudi Urology Conference

King Fahad Hospital - Jeddah

14-16 November 1995

Stricture of the male urethra a challenge in urology

M. Munzer Aragi, Ahmed Sirwi, Duraid Yazgi, Mohammed Tarakji, Osman Khalfa, A. Fallatah

Department of Urology, King Fahad Hospital, Jeddah, Saudi Arabia

The significance of stricture of the male urethra, lies in the fact that, this common urologic disorder not only jeopardises the quality of life and the integrity of the genito-urinary system of the affected patients, but it also contributes the most serious challenges for the treating Doctor as well.

In the Urology Department of the King Fahd Hospital in Jeddah, some 508 cases of male Urethral stricture had been treated, in the period from 1405-1416. This constitutes 11.64% of all male urology patients admitted during that period.

Out of these patients, 378 were studied retrospectively. A standard protocol had been used in the diagnosis and management of these patients making the analysis easier. The commonest mode of treatment was the optical internal urethrotomy which was almost always without serious complications. The recurrence rate after this treatment was 50.15% significantly lower than that encountered after the traditional surgical repair (62.96%). The age of patient, aetiology, and site and length of stricture were some of the factors used as factors in the analysis of the two groups.

We conclude from this study that, the stricture of the male urethra is serious disease with significant morbidity and high recurrence rate, regardless of the aetiology of the mode of management. The optical internal urethrotomy is a less invasive procedure with lesser number of complications and smaller incidence of recurrence than the open surgical repair.

Presented at the: 9 th Saudi Urology Conference

King Fahad Hospital - Jeddah

14-16 November 1995

Successful internal optical urethrotomy in post traumatic posterior urethral stricture

A. Al Elaiwai, S. Orkubi, M. Said, K. Al Otaibi, A. Shaaban, M. Mecci, M. S. Abomelha

Department of Urology, Riyadh Armed Forces Hospital, Riyadh, Saudi Arabia

Between 1989 and 1995, we treated 165 patients with urethral strictures at the Riyadh Armed Forces Hospital. These were 13% traumatic strictures, 36% infective, 26% post catheterisation, 20% post TURP and 2% miscellaneous. We reviewed 22 patients with traumatic urethral strictures. 21 were involved in road traffic accident with multiple trauma and one had fallen from a height. 82% of the patients were referred from other hospitals. Their age ranged from 4 to 95 years (mean 36 years). The initial management in all patients was by suprapubic catheter and 3 of the outside referrals had surgical intervention at the receiving hospital. 14 patients showed complete rupture of the bulbo-membranous urethra and the remaining 8 patients had partial urethral rupture. The definitive treatment included rail roading in 10 patients, urethroplasty in 4 and internal optical urethrotomy was undertaken in 8. all patients had been followed up from 1-184 months (mean 33 months). Assessment after definitive treatment showed one patient had no more stricture, 8 had long and 13 had short residual urethral strictures. 14 patients were cured with 1-3 subsequent internal optical urethrotomies. The remaining 7 patients are requiring regular urethrotomies at varying intervals.

We conclude that the management of disrupted traumatic urethral strictures require vigilance and multi-staged procedures. Internal urethrotomy is effective in the treatment of post traumatic urethral strictures.

Presented at the: 9 th Saudi Urology Conference

King Fahad Hospital - Jeddah

14-16 November 1995

Study of 100 cases of traumatic rupture of the posterior urethra

A. El Tahawy, M. Awadalla, H. Sidawy, E. A. El Tahawy, A. Sarwat

Department of Urology, King Fahad Hospital, Hofuf, Saudi Arabia

The aim of the study is to evaluate the different modalities of early and late management of rupture of the posterior urethra. 100 cases were referred to us between 1985-1996. Early management by urethral catheterization was tried in 40 patients and suprapubic cystostomy in 60 patients. The results: 30 cases could pass urine with fair stream and 70 cases were left with stricture of the urethra. Late management of these 70 cases included optic urethrotomy in 15 cases, transperineal urethroplasty in 50 cases and transpubic urethroplasty in 5 cases. Ascending urethrography and urodynamic study showed that all the patients are continent with fair stream and good calibre of urethra.

Conclusion: For early management of traumatic rupture of the posterior urethra: a suprapubic cystostomy to relieve retention of urine is advised and for late management: A transperineal urethroplasty for the stricture of the urethra is recommended.

Presented at the: 10 th Saudi Urology Conference

King Fahad National Guard Hospital

26-28 November 1996

Obstetric related urological trauma

K. Al Ghamdi, A. H. Kardar, M. Al Otaibi, M. Aslam, T. Merdad, H. Al Zahrani, S. Kattan, E. Lindstedt, K. Hanash

Department of Urology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

Lower urinary tract injury is well recognized in association with obstetric events in developing countries. We report a review of 56 such injuries referred to our institution and managed over a period of 25 years.

Patients and Methods: Medical records of 56 females managed over a period 25 years were reviewed retrospectively. The age range of patients varied between 18 and 56 (median 35.8) years. Fifty-three patients had fistulas: vesicovaginal (48), urethrovaginal (2), ureterovaginal (2), ureterouterine (1) and 3 had ureteric strictures. Eleven of the patients had urethrovaginal (9) and rectovesical (2) in addition to vesicovaginal fistula. Prolonged labor was the cause in 25 patients and the same number developed these injuries following caesarian section and hysterectomy. Twenty-eight patients had up to 5 attempted repairs elsewhere previously. Clinical presentation included total incontinence in 52, stress leakage in 1 and pyelonephritis in 3 patients.

Results: Fifty-three patients were treated surgically and successful repair of the fistula was achieved in thirty-two. Twenty patients had undergone urinary diversion due to the extensive injury and multiple previous unsuccessful attempts at repair. During the last ten years of the study period repair of the fistula was successful in majority of the cases and diversion was required in only six of twenty-seven patients. This may be due to less extensive tissue loss due to obstetric procedures.

Conclusion: 1. Prolonged labor is associated with lower urinary tract injuries that often require multiple surgical repairs. 2. The incidence of prolonged labor and therefore lower urinary tract injuries may be reduced with better obstetric care and public education.

Presented at the: 14 th Saudi Urological Conference

King Fahd Military Medical Complex - Dhahran

13-15 February 2001 (19-21 Dhu Al Qa'dah 1421)

Blunt urological trauma in King Fahd Military Medical Complex, Dhahran

I. Al Oraifi, E. El Sayed, S. Egail, M. Ezzibdeh, A. Abouzallat, A. Al Dayel

Department of Urology, King Fahd Military Medical Complex, Dhahran, Saudi Arabia

Off 550 consecutive cases of blunt trauma at our hospital, 24 patients (20 male and 4 female patients) had urological injury, 13 patients (54%) had renal injuries, 7 patients (29.25) had urethral injuries, 3 patients (12.5%) had combined bladder and urethral injuries and 1 patient (4.2%) had a bladder injury.

10 out of the 13 patients (77%) who had renal injuries were treated conservatively with very good outcome.

Out of the 10 patients who had urethral injuries, 8 had posterior urethral injuries. 7 of them had surgery with stricture formation in 4.

Presented at the: 12 th Saudi Urology Conference

Al Hada and Taif Armed Forces Hospitals Program

23-25 February 1999 (7-9 Dhu Al Qa'dah 1419)

Ureteric injuries: Diagnosis, management and outcome

El Fadil M. A. El Malik, A. M. Ghali, G. Ismail, A. I. Ibrahim, M. Rashid

Department of Urology, Asser Central Hospital, Abha, Saudi Arabia

Objectives: To define the current causes, the optimum method of early diagnosis and management of ureteric injuries both iatrogenic (excluding endourological) and traumatic.

Results: The study group comprised 28 patients with 32 iatrogenic injuries and seven patients with 8 external violence injuries. Gynecological procedures accounted for 63% (20/32) of the iatrogenic injuries while road traffic accidents (RTA) accounted for 75% (6/8) of the external violence injuries. The successful diagnostic rate for direct inspection (intraoperatively), IVU, retrograde and antegrade pyelograms were 33% for the former two and 100% for the latter two. Treatment consisted of primary open repair in 26 cases, a staged procedure in 7 and endoscopic stenting in five. Of 36 cases with follow up 9 developed complications (25%) seven of which were corrected surgically. Overall incidence of nephrectomy was 8% and the factors that seemed to affect the outcome adversely were: pediatric age (<12 years), injury to upper ureter, delay in recognition and the presence of an urinoma and/or associated organ injury.

Conclusions: Iatrogenic trauma is the major cause of ureteric injury. The best diagnostic method is direct ureterography in doubtful cases. The single controllable factor adversely affecting the outcome of this rather uncommon injury seems to be delayed diagnosis. Recommendation for prevention and management are presented.

Presented at the: 12 th Saudi Urology Conference

Al Hada and Taif Armed Forces Hospitals Program

23-25 February 1999 (7-9 Dhu Al Qa'dah 1419)

Evaluation and treatment of urinary tract injuries

Joseph N. Corriere

Department of Urology, University of Texas Medical School, Houston, Texas, USA

Renal Trauma: Blunt injuries account for 90% of all renal injuries. Less than 10% of these patients have associated injuries (usually liver or spleen) and only 2.5% need surgical exploration. Gunshot wounds (8%) and stab wounds (2%) account for the rest of the lesions. However, over 80% of gunshot wounds and less than 40% of stab wounds have associated injuries (liver, chest, bowel, spleen and great vessels), and essentially all of these need surgical exploration.

Diagnosis: On physical examination, signs of upper abdominal and flank trauma, mainly wounds, abrasions, contusions and masses should alert the physician to possible renal injury and suggest imaging studies of the kidneys. Hematuria is present in 98% of the patients with hematuria (2%) will have a renal artery thrombosis due to a deceleration injury.

Imaging Studies - The IVP: In the past, all patients with any degree of hematuria were said to need at least an IVP to rule out a renal injury that required close observation or surgical treatment. In most large series 90% of these IVPs are normal. There are now many series in the literature that detail the risk factors associated with significant renal injuries and allow the clinician to eliminate most unnecessary studies.

In review of 1,103 consecutive patients who had IVPs for suspected renal trauma at the University of Texas Medical School at Houston, we have corroborated these reports. We now recommend an IVP for all patients with penetrating injuries to the flank and abdomen prior to exploration but limit imaging in patients with suspected blunt renal trauma to those with gross hematuria or microhematuria and hypotension (systolic <90) or patients with evidence of major abdominal injury regardless of the blood pressure or urinalysis. (For example: an abdominal physical examination or radiographic evidence of fracture of the 11 th or 12 th ribs, transverse lumbar processes or pelvis).

In our series, of 862 patients with blunt trauma who underwent IVPs, 70% had only microhematuria and were never hypotensive. Only 60 (10%) of these had abnormal IVPs (49 contusions, 10 minor and 1 major lacerations). Of 241 patients with penetrating trauma and IVPs, 61% had only microhematuria and were never hypotensive. Only 16 (11%) of these had abnormal IVPs (4 contusions, 7 minor and 3 major lacerations and 2 vascular injuries). All major injuries had other reasons (physical findings) to do an IVP. There were 4 patients with blunt injuries and 1 with a penetrating injury that had minor lacerations that would not have studied if the above guidelines had been followed.

Imaging Studies - The CT Scan: If the IVP is abnormal or indeterminate and abdominal exploration is not imminent, a CT scan is the best way to delineate the extent of the injury. Studies now support CT scans with oral, rectal and IV contrast and careful observation in stable pediatric patients and selected adults with blunt trauma as well as back and flank stab wounds. The CT scan gives all of the information necessary for the diagnosis of injury to solid organs. It may miss some bowel lesions. The pattern of contrast extravasation can help in the diagnosis. Lateral extravasation is due to a parenchymal laceration while medical extravasation plus non-visualization of the ipsilateral ureter usually means a collecting system (usually UPJ) disruption.

Remember: What the IVP does best in the trauma patient is tell you the OTHER kidney is normal. The CT scan gives the best definition of the injury but takes more time and is more expensive. Spiral CT scans are, however, faster than an IVP.

Indications for Exploration: Most people still feel all patients with penetrating injuries should be exploded. Perhaps minor stab wounds of the back and flank, using the CT studies described above, can be observed. The absolute indication for renal exploration is a bleeding, expanding, pulsatile hematoma. Relative indications are major extravasation with severe collecting system disruption, non-viable renal tissue, a vascular injury or incomplete staging by the imaging modalities employed.

Intraoperative Technique: Traditional teaching dictates that a large stable or expanding hematoma overlying the kidney hilum and great vessels requires exploration. Only if the hematoma is lateral and away from the kidney can it be left alone. It is usually further stated that prior to entering Gerota's fascia, medical control of the renal pedicle must be accomplished to prevent uncontrollable bleeding from the kidney and needless nephrectomy. Both work at our institution, and the University of Louisville dispute this dictum. When data on the cause for nephrectomy at the time of exploration for trauma is critically analyzed, it is clear that it is not the exploration nor the surgical technique that results in the nephrectomy but the injury itself.

In a review of 85 of our patients who underwent surgical exploration for suspected renal trauma, 33 (39%) had pedicle control prior to entering Gerota's fascia while the other patients had direct exploration of the kidney. In only 6 of these cases (7%), was vascular occlusion actually performed to facilitate the surgery. One patient with a blunt injury and two with gunshot wounds had shattered kidneys and underwent nephrectomies. A nephrectomy was also done on a gunshot wound that destroyed the distal (hilar) segment of the renal artery while a gunshot wound to the distal (hilar) segment of the renal vein as well as a gunshot of the deep hilar parenchyma were repaired.

All of the injuries had not only a hematoma but also a wound over the renal vessels, aorta and vena cava and preliminary vascular control was obtained. This experience as well as the series from Louisville has led us to advocate medial pedicle control first only if a wound and a hematoma overlie the great vessels. Otherwise, reflect the colon and open Gerota's fascia laterally and save up to an hour of operative time. If bleeding is encountered, simple manual parenchymal compression will control the hemorrhage and facilitate repair.

Patients with minor injuries can be treated with simple renorrhaphy, while polar injuries are best treated by partial nephrectomy. Major wounds in the middle of the kidney need major reconstruction. A sheet of Dexon mesh can be sewn into the form of an envelope to oppose the cut surfaces of the renal parenchyma. Nephrectomy is reserved for shattered kidneys.

Ureteral Injuries: The ureter transports urine from the kidney to the bladder. When it is injured it may become obstructed or a fistula may occur and lead to urinary extravasation into the retroperitoneum or the peritoneal cavity. If injury to another structure has occurred at the time of the ureteral injury, a fistula may develop to vagina, skin or bowel. If the urine is infected, life-threatening sepsis may occur.

There are two major types of ureteral injuries - those caused by external violence, usually penetrating missiles, and the more common injuries resulting from surgical misadventure. The late complications of radiotherapy or migrating foreign bodies can also cause injury to the ureter. Gunshot wound account for over 95% of ureteral injuries. Knife wounds are the next most common etiology. Rarely, patients fall and become impaled on a spike.

Ureteral injury may complicate 0.5% to 1.0% of all pelvic operations. Most of these are gynecologic but urinary tract procedures commonly account for 30%. Although radiation injury is often considered when a patient with a previously treated pelvic tumor is found to have ureteral obstruction, the incidence of radiation damage to the ureter is only 0.04%, whereas the incidence of ureteral obstruction caused by recurrent tumor in these patients is over 95%.

The most common migratory foreign bodies that perforate or obstruct the ureter are urinary calculi, bullets, and swallowed objects.

Diagnosis: The IVP is the best way to diagnose a ureteral injury. Urinary extravasation is seen on the study, as well as some decrease in visualization of the collecting system.

If the injury is first seen at surgical exploration, the ureter should be dissected from its bed and examined. If it cannot be positively determined whether an injury is present, one vial (5 ml.) of indigo carmine should be injected intravenously. Within 7 to 10 minutes, the dye will leak into the periureteral tissues if the ureter has been injured.

If the patient is not undergoing exploration, or the diagnosis is not made until many days after the injury has occurred, or if after the IVP there is still a question about the presence of an injury, the most definitive study is a retrograde ureterogram. Most of the time, this study is not feasible. In this case, a CT scan of the area best demonstrates the presence of extravasation. If a CT scan is performed, be sure to get delayed films or a lower ureteral injury (extravasation) may be missed.

Therapy: How to handle a ureteral injury will depend upon the etiology of the injury, how much tissue damage is present and how long it has been since the injury has occurred.

Contusion: This injury is discovered during exploration of a patient who has had a surgical procedure or a missile pass close to the ureter but in whom the structure has remained intact. No therapy is necessary in these patients. If a high-velocity bullet (traveling at a rate of more than 2,500 feet per second) has caused the wound, there is always the danger of late necrosis of the ureter. In this instance, placement of an internal stent and a drain in the area of the injury should be considered. A stent should also be placed if a clamp or ligature has been placed on the ureter, even if it looks "normal" when the obstruction is removed for the same reason.

Laceration: If a partial laceration is present and the ureter that is still in continuity is viable, placement of an indwelling "double-pigtail" stent and closure of the wound with interrupted 4-0 or 5-0 absorbable sutures gives the best result.

If the remaining intact ureter is of questionable viability or if there is a complete laceration of the ureter, all devitalized tissue must be excised and a suitable repair selected.

The ureteroneocystostomy has the lowest complication rate but can be performed only in the patient with an injury below the level of the iliac vessels. The kidney can usually be mobilized and lowered so that the gap between the ureter and bladder can be decreased by an additional few centimeters. A bladder flap can also be used to bring the bladder closer to the ureter. Sometimes merely suturing the bladder to the psoas fascia (psoas hitch) can avoid tension on the repair. Nonrefluxing reimplantation is most desirable but cannot always be performed. If the injury is too high to perform a ureteroneocystotomy, a ureteroureterostomy should be done.

If a major length of ureter is lost, consideration should be given to a transureterouretostomy or merely bring the cut end of the ureter to the skin as a cutaneous ureterostomy for later definitive repair. Autotransplantation of the kidney to the hypogastric vessels plus ureteroneocystostomy should also be considered. This adds major operative time and risk to the patient, but in the patient with a solitary kidney it can be lifesaving.

Ligation: If a ligation (or laceration) of the ureter is not recognized until well after the surgery has been completed, retrograde ureteral catheterization should be attempted. If it is successful, a double-J stent should be placed and the patient observed for resolution of any extravasated urine.

If the retrograde catheterization is unsuccessful, a percutaneous nephrostomy should be placed and an antegrade stent passed into the bladder. After the obstruction and extravasation nephrostomy tube placement should be done, with delayed repair planned months in the future as described above.

In summary, if ligation is diagnosed late in the course of the process, the most conservative approach is to place a percutaneous nephrostomy tube in the kidney and attempt to pass a stent antegrade past the obstruction. If stenting is successful, balloon dilation, in an effort to disrupt the suture, may be tried but is unnecessary. If the ureter has been ligated with chromic suture material, the obstruction will usually resolve in 3 to 4 weeks. If it has been ligated with polyglycolic acid suture, it may take 6 to 8 weeks to resolve. If it has not resolved in 4 to 6 months, formal repair will be necessary.

Presented at the: 13 th Saudi Urological Conference

Riyadh Armed Forces Hospital

14-17 February 2000 (09-12 Dhu Al Qa'dah 1420)

Evaluation and treatment of lower urinary tract injuries

Joseph N. Corriere

Department of Urology, University of Texas Medical School, Houston, Texas, USA

Bladder Injury:

The majority (86%) of injuries to the bladder are due to blunt abdominal trauma secondary to motor vehicle accidents, falls or crush injuries. Up to 89% will be associated with pelvic fractures and 9% of all pelvic fracture patients will have a ruptured bladder. Penetrating injuries due to surgical misadventure, external violence (gunshot, knife, spike impalement) or internal migration of drains, prostheses or shunts make up the remaining 14% of cases.

Signs and Symptoms: All patients with a bladder injury will have hematuria and it will be gross hematuria over 95% of the time. The definitive diagnosis is made by performing a formal retrograde cystogram. The cystogram of an IVP or CT scan using intravenous contrast may be normal even though a significant injury to the bladder is present and cannot be relied upon.

Diagnosis: A proper cystogram is performed by placing a Foley catheter in the bladder and the bladder emptied of urine. A 300 ml bottle of 24-30% contrast material and a similar amount of saline are attached to a Y-connector and then to the catheter to obtain a 50-50 mixture. A scout radiograph is taken and then a second film after 100 ml are infused. If extravasation is seen the catheter is placed to straight drainage. If not, the rest of the mixture in infused and films done in at least two projections and then, after the bladder is drained of all contrast, a post drainage film obtained. Usually conventional x-ray is used to obtain the films. If the patient is in the CT scanner, a full bladder and post drainage views of the pelvis can be performed, but only after retrograde filling of the bladder.

Bladder Rupture Classification:

A. Blunt Trauma

I. Contusion - 33% mucosal, minor muscularis injury, no extravasation

II. Interstitial Rupture - Rare, incomplete tear, no extravasation

III. Intraperitoneal Rupture - 33% dome injury

IV. Extraperitoneal Rupture - 33% "teardrop" deformity

V. Combine Intra-Extraperiotoneal Rupture - 6%.

B. Penetrating Trauma

Therapy: All penetrating bladder injuries should have the missile tract explored, the wound debrided and the urine diverted with a Foley catheter or suprapubic tube for 7-10 days after formal repair. Similarly, all patients with intraperitoneal bladder injuries need surgical repair and diversion. Extraperitoneal bladder injuries, on the other hand, can be managed conservatively with Foley catheter or suprapublic diversion for 10 days even in the face of extravasation outside of the perivesical space which will be seen 42% of the time. We reported on 39 patients managed in this manner with 34 (87%) being healed in this length of time on repeat cystogram with the rest being expected to heal in about one month time.

However, if the patient is to be explored for another reason, an extraperitoneal bladder rupture should be repaired at the same time. The dome of the bladder should be opened and the bladder rent closed intravesically with a running 3-0 absorbable suture. The dome should then be closed in a similar fashion. Some surgeons advocate formal closure of all extraperitoneal bladder ruptures. Clearly, if the patient treated with conservative (catheter) drainage alone has constant or intermittent catheter obstruction, usually with clots, complications, will develop. These patients should have formal surgical closure of the bladder injury.

Intraperitoneal lesions are also closed with a running 3-0 absorbable suture after thoroughly inspecting the interior of the bladder for other lesions. All patients with a laceration of the bladder neck need formal repair. Either a urethral or suprapublic tube or both shold be placed.

Urethral Injuries:

Urethral injuries have been classically divided into anterior injuries usually due to a fall on the perineum crushing the urethra against the pelvic bone (straddle injury) or a posterior injury almost always secondary to a fracture of the bony pelvis (due to motor vehicle accidents 90% of the time, falls, crush injuries or sporting accidents). Posterior injuries have been classically subdivided, especially by radiologists, even further, into three categories based on the extent of the damage. Recently, we have developed a new classification which incorporates all of the above into a unified system presented below We found that 3.5% of patients who fracture their pelvis (usually the anterior arch) will have a ruptured urethra. Penetrating injuries, usually from urethral instrumentation, external violence, penile surgery and sexual intercourse also occur.

Classification of Urethral Injuries:

I. Posterior Urethra Intact but Stretched (Colainto and McCallum Type I) Puboprostatic ligaments ruptured

II. Pure Posterior Injury with Tear of Membranous Urethral Above the Urogenital Diaphragm - Partial or Complete (Colapinto and McCallum Type II)

III. Combined Anterior/Posterior Urethral Injury with Distruption of the Urogenital Diaphragm-Partial or Complete (Colapinto and McCallum Type III Injury)

IV. Bladder Neck Injury with Extension into the Urethra

IV(A) Injury of the Base of the Bladder with Periurethral Extravasation Stimulating Urethral Injury

V. Pure Anterior Urethral Injury - Partial or Complete.

Diagnosis: Although blood at the urethral meatus on physical examination and a high riding prostate on rectal examination are seen in most patients, the definitive diagnosis is made by performing a retrograde urethrogram and demonstrating contrast extravasation. The most important reason to do a rectal examination is to look for blood in the rectum implying a concomitant colon/rectal injury.

The urethrogram may be performed by inserting a 14 or 16F Foley catheter into the urethra with the balloon just 2 to 3 cm proximal to the meatus. One to two ml. of saline in the balloon will seal it in the fossa navicularis. Lubricants should not be used or the catheter will side out of the urethra. About 25 ml of 25-30% contrast is injected with a Toomey syringe with the patient in the steep oblique position. The exposure should be taken during active injection of the contrast. Sometimes an extraperitoneal bladder rupture near the bladder base (IVA), especially when there is diastase of the pelvis, will resemble a Type III, pure urethral injury for contrast on a static film will extravasate distally around the urethra. If the study is repeated under fluoroscopy, the proper diagnosis will be evident.

Therapy: Type I injuries occur when the puboprostatic ligaments are ruptured but the urethra is stretched but intact. A urethral catheter can be placed if the patient has difficultly voiding or urine output must be monitored.

Partial Type II and III posterior urethral ruptures are best treated with immediate suprapubic tube drainage and restudy in 2-3 weeks. Most of the time they will heal without further therapy. Complete ruptures, however, will need definitive repair. Immediate realignment is the procedure of choice if there is severe dislocation or bone fragments separating the prostate from the UG diaphragm or there is another pelvic organ injury requiring immediate exploration, or a Type IV injury is present. The puboprostatic ligaments should be cut if they are intact and vest sutures used via the prostate for repositioning.

The Type IV injury is a common injury in women and children. Associated vaginal tears and fistulas are common and must be diagnosed and repaired. Incontinence and/or strictures may develop if reconstruction is not properly carried out.

Delayed repair (6 months) is the most popular procedure. It can be done perennially 85% of the time or by the transpublic route if the surgeon prefers. The anastomosis is urethroprostatic and in our series of 51 procedures performed in this fashion we have a primary success rate of 94% with all patients eventually having a patent urethra. However, one third will have some form of voiding dysfunction. In the past few years endoscopic re-establishment of continuity by cutting blindly through the stricture with a urethrotome or resectoscope has been advocated by some authors. This procedure leave the patient with a lifetime stricture and is not recommended. Recent investigations using an internal urethral metal stent for repair has also been reported.

The initial therapy of anterior urethral ruptures (Type V) is urethral suprapubic drainage if a partial injury is present with suprapubic tube drainage for all complete ruptures. Repeat study at two weeks may demonstrate complete healing of a partial injury or a minimal stricture may be seen that can be easily handled by a visual internal urethrotomy. Complete injuries usually need repair by end to end anastomosis, patch graft urethroplasty or pedicled flap urethroplasty. This should be delayed for 4 to 6 months, and is limited by resolution of the extravasated blood and urine.

Long-term Results: One year post repair 32% of patients with a complete posterior urethral injury will still experience complete loss of erections, 36% will claim to have erections equal to their pre-injury quality, and 32% will have less than optimal but usable erections.

After primary repair of posterior urethral injuries 78-100% are reported continent and 17-68% develop strictures. The overall reported success rate is 32-83%. After delayed repair 76% void normally and are continent, 10% are areflexic, 10% have urge incontinence, 6% minimal stress incontinence and 2% stress incontinence needing therapy. The long-term stricture rate is virtually 0% After endoscopic realignment a 40-60% success rate is reported but most need long-term dilatation.

Presented at the: 13 th Saudi Urological Conference

Riyadh Armed Forces Hospital

14-17 February 2000 (09-12 Dhu Al Qa'dah 1420)

Genito: Urinary trauma

Abdellatif Benchekroun

Department of Urology, Central Hospital, Riyadh, KSA

Renal Trauma

We analyzed the causes, treatment and morbidity associated with renal injuries.

Materials and Methods: From 1986 to 1998 we report a retrospective study of 38 cases of renal trauma. Mean age was 27 years (range 20 to 60 years) with a male predominance (86.85%). The aetiology was largely dominated by road accidents (57.8), falls (23.6%) and assaults (18.4%). The clinical features were dominated by haematuria (94.4%) and low back pain (89.4%). Trauma was associated with skeletal or visceral lesions in 17 patients (44.7%). Assessment of the lesions was based on ultrasonography, IVU and CT scan.

Results: 12 patients presented with a minimal or moderate trauma (31.5%) and were treated medically. 26 patients (68.4%) were operated, 8 of them underwent total nephrectomy and 18 were treated conservatively. 7 of the operated patients subsequently developed complications (Haemorrhage 1 case, Infection 1 case, Urinary Fistula 1 case, Uretero-colique Fistula 1 case, Hypertension 1 case, Renal Lithiasis 1 case and Renal Artery Aneurisma 1 case).

Conclusion: Renal trauma remains a topical subject due to its high incidence and the fact that it still raises therapeutic problems. CT scan had a greater degree of accuracy than urography and ultrasonography in determining the extent of the injury.

Ureteral Injuries:

We analysed the causes, treatment and morbidity associated with ureteral injuries.

Materials and Methods: From 1977 to 1997 was report a series of 46 patients with ureteric trauma.

Results: There were 37 women (80%) and 9 men (20%). Mean age was 38 years (range 18 to 65 years). Obstetrical, gynecological and ureteroscopic procedures accounted for 27 (59%), 10 (22%), 3(7%) injuries, respectively. The lumbar symphathectomy was responsible in 2 cases, abdominal trauma in a 2 cases, resection of the rectum in 1 case, and retroperitoneal fibrosis excision in 1 case. Of the injuries 87% occurred in the lower third, 9% in the middle third and 4% in the upper third of the ureter. 12 ureteric lesions were diagnosed during surgery, 31 after an interval of 3 to 20 days and 3 after an interval of 3 months. Treatment consisted of ureter-vesical reimplantation in 21 cases, Boari-Kuss bladder flap in 3 cases, nephroctomy in 2 cases, double J stent in 2 cases, appendicoplasty in 1 case, simple suture in 1 case. The course was marked by the development of hydronephrosis (4 cases), ureteric stenosis (2 cases), vesico-ureteric reflux (1 case), urinary fistula (2 cases) and lengthening of the ilial graft (1 case).

Conclusion: Gyneco-obstetrical procedures are the most common of ureteral injuries in our series. Successful results were observed when ureteral injuries are identified preoperatively.

Male Urethral and Bladder Trauma:

Bladder Trauma:
Between 1986 and 1988, the authors have treated 16 patients with a mean age of 30 years (range 17 to 41 years) with traumatic rupture of the bladder. Rupture was secondary to direct trauma. The bladder was full in 1 case, pelvic trauma in 14 cases and shotgun in 1 case. Associated lesions were head injury (3 cases), chest trauma (1 case), rupture of the spleen (1 case), and small bowel perforation (2 cases). The clinical features were dominated by suprapubic pain (15 cases), haematuria (14 cases), haemorrhagic shock (6 cases) and peritoneal syndrome (3 cases). IVU confirmed the diagnosis in 8 out of 12 cases. Retrograde cystourethrography was conclusive whenever it was performed. The retroperitoneal rupture was treated by indwelling catheter for 15 days. Introperitoneal ruptures were treated surgically. The breach was situated in the dome in 11 cases and on the posterior surface in 1 case. The size of the wound ranged from 2 to 8 cm. Treatment consisted of suture of the rupture and indwelling catheter for an average of 12 days. Cure was always obtained without sequeale.

Urethral Trauma: Between 1986 and 1998, the authors report a retrospective series of 85 cases of traumatic rupture of the urethra.

Anterior Urethral Trauma: There are 23 cases, with a mean age of 29 years (range 19 to 65 years). The mechanism of the lesion was trauma by falling onto the perineum (13 cases), road accident (4 cases), sexual intercourse (6 cases). The six cases of rupture of the urethra associated with lesions of the corpora cavernosa required urgent surgical repair. In the other cases, simple urine drainage was sufficient to treat partial ruptures of the urethra (4 cases). End-to-end urethrorraphy was performed in 13 cases with total rupture of the urethra, with early failure in 2 cases.

Posterior Urethral Trauma: 62 patients presented with a fracture of the pelvis with rupture of the posterior urethra. The mean age was 34 years (range 16 to 70 years). There were 4 cases of rupture of the prostatic urethra and 58 cases of rupture of the membranous urethra including 52 complete ruptures and 6 partial ruptures. In the case of rupture of the membranous urethra, initial treatment, in 27 cases, was end-to-end urethrorrhaphy (deferred emergency: 10 cases; lately: 17 cases), optical urethrotomy in 22 cases, realignment by guiding catheter in 11 cases in deferred emergency, urethroplasty Bengt-Johanson (2 cases) lately. The results were evaluated on the maximal flow/second and the flowmetry curve, urethrocystography, and the need for dilatations or reoperations. In the cases treated by end-to-end urethrorraphy 14 of 27 patient developed secondary stenosis; they were optical urethrotomy (8 cases), penile pedicule skin flap (3 cases), penile skin graft (Baldini) 3 cases. Optical urethrotomy were failures in 14 cases of 22; they were treated by optical urethrotomy (6 cases), end-to-end urethrorraphy (6 cases), two stage urethroplasty (1 case), penile skin graft (Baldini) 1 case. In the cases treated by realingnment by guiding catheter, 1 of 11 patients developed secondary stenosis, which is treated by end-to-end urethrorraphy. Urinary incontinence was observed in only 4 patients, impotence in 12 cases.

Obstetrical Bladder Trauma: We report a retrospective study about 1000 cases of vesico-vaginal fistula treated the last 30 years. The most common aetiology was obstetrical (93.6%). These fistulas are classified in three categories according to anatomical site:

Type I: Urethra-vaginal fistula (309 cases)

Type II: Cervico-vaginal fistula (210 cases)

Type III: Trigono or retrotrigono-vaginal (481 cases).

In 109 cases, we had an associated injury: recto-vaginal fistulas, uretero-vaginal fistulas, vesico-uterine fistulas.

Easy closure was achieved for Type III fistulas.

Urethral reconstruction was necessary for the third of Type I fistulas (100/309 cases).

For Type II fistulas, cervicocystopexy with bulbocavernous and transverse perineal muscle was necessary in some incontinent patients (8 cases).


Type III Fistulas:
Success: 98%, Failure: 2%

Type II Fistulas

Success: 80% Intermediate 6.6% Failure: 13.4%

Type I Fistulas

Success (%) Intermediate (%) Failure (%)

Closure 60 5 35

Urethroplasty 60 11 29

The failures are treated by urinary diversion with hydraulic valve.

Rupture of the Corpus Cavernosum:

The authors report a series of 50 cases of rupture of the corpora cavernosa observed over a 20 years period. The patients had a mean age of 27 years (16-55 years). The commonest mechanism was sudden and forced manipulation of the erect penis (31 cases). The diagnosis is simple in view of the stereotyped clinical features, dominated by penile pain (48 cases), penile haematoma (36 cases) and crackling (25 cases). All patients were treated surgically, with evacuation of the haematoma and suture of the tunica albuginea (48 cases), suture of the corpora cavernosa and corpus spongiosum (1 case), and fascia lata corporoplasty (1 case). A favourable course was observed in 30 cases, while 11 patients had painful erection and 9 patients developed induration and deviation of the penis. All of the 9 patients had delayed surgery (mean 3.6 h). The rupture of the corpus cavernosum must be operated as soon as possible, to avoid complications like sclerosis and penile deviation.

Scrotum Trauma:

The authors report a series of 40 cases of scrotum trauma. The causes, treatment and morbidity are analysed.

Materials and Methods: Between 1986 to 1998, 40 men with 16 to 52 years old consulted for trauma of the scrotum. The trauma was closed in 36 cases (90%). It occurred by accident of traffic (16 cases), accident of work (8 cases), accident of sport (8 cases), aggression (6 cases) and brawl (2 cases). The clinical symptomatology was dominated by inflammatory big scrotum or haematoma in the tunic. Ultrasound imaging showed a contusion of the testis (5 cases), haematoma of the tunica vaginalis (5 cases), haematoma of the scrotum (10 cases) and albugineal rupture (2 cases).

Results: Thirty patients (75%) underwent surgical repair, five patients (12.5%) underwent orchidectomy. Atrophy of the tests occurred in three patients who underwent resection of the pulp (2 cases) and had haematoma in the tunica vaginalis (1 case).

Conclusion: The traumatism of the scrotum is rate. It occurred by the civil practice. The injuries are varied. The treatment should be mostly conservative.

Presented at the: 13 th Saudi Urological Conference

Riyadh Armed Forces Hospital

14-17 February 2000 (09-12 Dhu Al Qa'dah 1420)

Genito-urinary tract trauma: Saudi experience

Abdullah Bakr Fallatah

Department of Urology, King Fahd Hospital, Jeddah, Saudi Arabia


To review the genito-urinary trauma (GUT) treated during the last 10 years in K.F.H. Jeddah

To review other Saudi Reports on Gut currently available in the literature.

Methods: Medical record of all patients presented with GUT in K.F.H. Jeddah from January 1988 to December 1998 were retrospectively reviewed and analyzed. In addition, a midline computer research was carried out and other six Saudi studies on GUT were retrieved from the literature.

Results: In K.F.H. Jeddah, there were 194 GUT. 96 urethral injuries (49%), 42 renal injuries (22%), 28 penile injuries (14%), 15 scrotal injuries (8%) and 13 bladder injuries (7%). The majority of the victims were young males and most of the traumas were blunt. Early presentation, proper diagnosis and prompt start of treatment are associated with excellent results. Furthermore, results of other six Saudi studies on different types of GUT from various regions of the Kingdom were reported.

Conclusion: GUT is very common in Saudi Arabia. Urethral and renal injuries represent more than two thirds of injuries. Prognosis is good provided that proper management is performed.

Recommendation: We urge Saudi Urologists to establish a Saudi Society of Genito-Urinary Trauma (SSGUT), that can organize data collected from different regions all over the KSA. Furthermore, it can plan treatment for various types of GUT.

Presented at the: 13 th Saudi Urological Conference

Riyadh Armed Forces Hospital

14-17 February 2000 (09-12 Dhu Al Qa'dah 1420)

Urological trauma after gynecological and obstetric surgeries: A single center experience over 18 years

Nasr A. El-Tabey, Bedeir Ali-El-Dein, Atallah A. Shaaban, Hamdy A. El-Kappany

Department of Urology, Mansoura University, Mansoura, Egypt

Purpose: Gynecological and obstetric surgeries are not uncommon causes of iatrogenic injury of the urinary tract. Herein, we retrospectively report our experience with these injuries over the last 18 years.

Patients and Methods: Between 1985 and 2003, 120 women with a mean age of 34.2 ΁ 13.7 years were included into this study. The types of injury were vesicovaginal fistula in 90 cases, ureterovaginal fistula in 14, ureteric ligation in 13, vesicouterine fistula in 2 and ureterouterine fistula in one. Definitive repair of such injuries either fistulae or ureteric strictures was performed in all cases except for 10 cases with recurrent vesicovaginal fistulae, who were treated by augmentation cystoplasty or urinary diversion. All patients were evaluated for the time and type of surgical intervention, early and late postoperative complications including failed primary repair.

Results: Out of the 80 cases of vesicovaginal fistulae treated by definitive repair, 12 showed recurrence of the fistula (13.3%). Early ureteric deligation and early or delayed ureteroneocystostomy or ureteric replacement was successful in all cases with ureteric injury.

Conclusion: Careful attention of the gynecologists and obstetricians to the anatomy of the urinary tract is mandatory to avoid its iatrogenic injury. Endourologic means were successful in making first aid management of some of these injuries. Early exploration is indicated in cases of ureteric obstruction, presenting early after trauma. Augmentation cystoplasty, urinary diversion or ileal replacement is indicated only in few cases.

Presented at the: 16 th Saudi Urological Conference

King Faisal Specialist Hospital & Research Centre

2-4 March 2004 (11-13 Muharram 1425)

Lower urinary tract injuries during gynecological operations

Ahmed Mohd Shelbaia

Department of Urology, Cairo University, Cairo, Egypt

Aim of the Work: To report, evaluate and manage lower urinary tract injuries during gynecological operations, and provide several guidelines for the practicing urologist.

Patients and Methods: Between May 2003 and May 2005, 20 female patients with urinary tract injuries, were discovered, diagnosed and managed intraoperatively during gynecological operations. Their ages ranged from 20-40 years. They were evaluated preoperatively by routine investigations, intra operatively by ureteric catheterization and or cystoscopy and ureteric catheterization; postoperatively they were evaluated by sonography every 3 months for one year and IVU 6 months after surgical interference.

Results: Gynecological operations were done for the 20 patients in this study (Cesarean section was done for 12 cases and hysterectomy was done for 8 cases). 6 cases had bladder injury and repaired intraoperatively with urethral catheterization. 14 cases had distal ureteral injuries and repaired by ureteric catheterization and/or ureterovesical neoimplantation.

Conclusion: Iatrogenic injuries to the urinary tract may occur during gynecological surgery. The bladder and distal ureters are the most commonly involved organs. Key factors to obtain optimal results in the management of urological injuries during gynecology surgery are the early recognition and immediate repair of damage. Ureteral catheterization via cystoscope or directly through the orifices should be considered the modality of choice to assess ureteral intactness.

Presented at the: 18 th Saudi Urological Conference

King Abdulaziz University Hospital

20-23 February 2006 (21-24 Muharram 1427)

A posterior sagittal pararectal approach for repair of posterior urethral distraction injury

Ahmed M. Abolyosr

Department of Urology, Assiut University Hospital, Assiut, Egypt

Purpose: To report our initial experience with the posterior sagittal pararectal approach in the treatment of posterior urethral distraction injuries.

Materials and Methods: Four patients with post traumatic urethral distraction injuries, aged 9 to 16 years, underwent urethroplasty using a posterior sagittal pararectal approach. One patient had associated urethrorectal fistula, 2 cases recurrent after previous transperineal repair, while the last case showed long distance urethral distraction injury.

Results: There were no complications in any patients during the immediate postoperative period follow up studies 1 to 2 years later in the all boys revealed fully patent urethral anastomosis.

Conclusions: Posterior sagittal pararectal approach is a good alternative approach for repair of complicated posterior urethral distraction injuries without immediate or remote control on the sphenectric function and without need for colostomy.

Presented at the: 19 th Saudi Urological Conference

King Khalid University Hospital - Riyadh

26 February - 01 March 2007

Penile circular fasciocutaneous skin flap is a good alternative for treatment of long anterior urethral strictures

Mohamed Taha, Ahmed Abdallah

Department of Urology, Assiut University Hospital, Assiut, Egypt

Purpose: We review the application and outcomes of penile circular fasciocutaneous flap urethroplasty for repair of long strictures pendulous and bulbar urethral strictures.

Materials and Methods: Between 62 patients underwent urethroplasty at our institute in the period between February 2003 and April 2005, 21 men age ranged 11-79 years, mean + SD (38.75 + 13.35) with long urethral strictures involved the pendulous and/or bulbar urethra >5 cm length. Average stricture length was 7.04 cm. Mean follow up was 25.61 months (range 7 to 44 months). Follow up included retrograde urethrography at 3 weeks, months, and 12 to 18 months, and thereafter when needed. Urinary flow was recorded as subjectively by the patients and objectively reported by uroflowmetry. Clinical outcome was defined as success or failure by the absence of or need for, respectively, a postoperative more than one procedure such dilation, internal optical urethrotomy or repeat open urethroplasty.

Results: The initial overall success rate was 85.7% (18 of 21 cases). Recurrent stenosis was noted in 3. Most recurrent strictures were successfully treated with a large subsequent procedure, including repeat urethroplasty in 1 case in the form of resection reanastomosis at the proximal end of the stricture and optical urethrotomy in 2, the overall long-term follow success rate was 95.2%. Ischemia and sloughing of the penile skin was noted in 1 case, and urethrocutaneous fistula occurred in 1 case which subsequently closed spontaneously.

Conclusion: Circular fasciocutaneous flap urethroplasty is a highly effective 1 stage method of reconstructing long urethral strictures. It provides ample tissues for urethral substitution. It produces very good cosmetic results.

Presented at the: 19 th Saudi Urological Conference

King Khalid University Hospital - Riyadh

26 February - 01 March 2007

Ureteral injuries during ureteroscopic stone manipulation in adults incidence, etiology, and management

Mamdouh M. Abol-Nasr, Ateeq M. Algarni

Department of Urology, Prince Salman Hospital, Riyadh, Saudi Arabia

Introduction: To investigate incidence and etiology of ureteroscopic injuries and the effects of early diagnosis and surgical treatment on the outcome in adult patients over a period of two years in a residency program teaching hospital.

Methods: 270 adult patients with ureteric stones at different levels of the ureter who underwent ureteroscopy for the first time were included in this study. The patient's mean age was 43 ΁ 11 years. Two hundred and ten patients had distal ureteral stones. Mid-ureteral and proximal ureteral stones were 42 and 18 patients, respectively.

Results: Twenty four (24) patients developed ureteral injuries with an overall rate of 8.8%. Nine patients developed major ureteral injuries (3.3%) while fifteen patients developed minor ureteral injury (5.5%). The most common ureteral injury encountered was ureteral perforation (12 patients) being 4.4% of all patient and 50% of all injuries. Two patients developed intussusceptions of the distal ureter (0.7%). Minor ureteral injuries constituted 62.5% of all ureteral injuries. Ureteral false passage, ureteral abrasion, and significant bleeding developed in six, two, and two patients respectively. Site of injury was most common in the distal ureter (66%) of injuries. Laparotomy with reconstructive ureteral procedure were done in 5 patients (1.85%), while double-J stent placement with surgical drainage in 4 patients. Most of minor injuries were discovered in the early part of the procedures and endoscopically handled with termination of the procedure. Major injuries were discovered late during the procedure on insisting to complete the procedure when the safety guidelines were not followed.

Summary and Conclusion: Ureteral injuries on ureteroscopy for ureteral stones are more frequent at the distal part of the ureter. Injury is more common at site of stone location. Adherence to the safety guidelines and proper technique of ureteroscopy, proper selection of cases, and following the diagnostic rules make ureteral injuries a rare occurrence. Termination of ureteroscopy with insertion of a ureteral stent on finding a difficult situation is a wise decision.

Presented at the: 22 nd Saudi Urological Conference

King Faisal Specialist Hospital & Research Centre

15-18 March 2010

Results of buccal mucosa grafts for repairing anterior urethral

Waleed Al Taweel

Department of Urology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia

Aim: To report the results at our institution of repairing anterior urethral strictures with buccal mucosal grafts.

Methods: Between October 2004 and June 2009, a buccal mucosa graft repair was used in 28 patients with recurrent anterior urethral strictures >2 cm, uroflowmetry was used in 6 months follow up. A successful outcome was defined as normal voiding and no need for subsequent instrumentation.

Results: Median age of patients 44 (24-63). The mean (SD) preoperative maximum flow rate was 5.6 (3) mL/s. All patients had had one or more previous urethral dilatations or internal urethrotomies. Asopa technique was used in 11 patients with penile urethral stricture and a ventral onlay in 17 patients. The success rate was 92%. Both failures occurred within the first year and were managed successfully by internal urethrotomy. The mean (SD) postoperative maximum flow rate was 22 (8) mL/s. There were no medium-term donor-site complications. None of the patients had de novo impotence or urinary incontinence, and to date no patient has needed a repeat open reconstruction.

Summary and Conclusion: Our results show that in patients with anterior urethral strictures of >2 cm, urethroplasty using buccal mucosa is feasible, with very encouraging results.

Presented at the: 22 nd Saudi Urological Conference

King Faisal Specialist Hospital & Research Centre

15-18 March 2010

Treatment of non-traumatic bulbar urethral stricture: Is excision and primary anastomosis urethroplasty a valid option? Introduction

Saad Al Shahrani, Fahad Al Mashat, Mostafa Mansi

Department of Urology, King Abdulaziz Medical City, Riyadh, Saudi Arabia

Introduction: Most of non-traumatic bulbar urethral strictures are treated by visual internal urethrotomy (VIU). Our aim is to assess the result of excision and primary anastomosis urethroplasty (EPA) as an alternative for (VIU) and to determine if previous urethral dilatation or visual internal urethrotomy (VIU) would affect the end result of the anastomotic urethroplasty.

Methods: Between years 2000 to 2009, 16 adult male patients with non-traumatic bulbar urethral stricture underwent excision and primary anastomosis urethroplasty (EPA) were evaluated retrospectively. Fifteen (15) patients had multiple visual internal urethrotomy (VIU) (3-13 times). Three (3) patients presented with suprapubic catheter for urinary retention. All patients had pre-urethroplasty urine culture, uroflowmetry (UFM), and ascending urethrogram. Urethral stricture length varied from (0.8-3 cm). Patient symptoms, urine culture, and uroflowmetry were re-evaluated at 3 months. Ascending urethrogram was ordered for patients with persistent obstructive symptoms and/or obstructive (UFM). Number of previous urethral dilatation or (VIU) were also reported. Patients were followed up for 9-30 months (19.5 month).

Results: At three (3) months of follow up, only 2 patients required urethral dilatation under local anesthesia for one time only as an office procedure. Two (2) of those patients actually had a (VIU) 13 times and the third one had it 10 times. At 6 months, all the 16 patients had an improved symptoms and a satisfactory uroflowmetry (UFM). Pre-urethroplasty UFM was (5-8 ML/SEC) and post urethroplasty was (20-32 ML/SEC). No patient required further surgical intervention.

Summary and Conclusion: Excision and primary anastomosis urethroplasty (EPA) considered a valid management option for non-traumatic bulbar urethral stricture. Number of previous urethral manipulation will adversely affect the end result of urethroplasty. We recommend to refer those cases to an experienced urologist for primary urethroplasty instead of repeated, ineffective urethrotomy.

Presented at the: 22 nd Saudi Urological Conference

King Faisal Specialist Hospital & Research Centre

15-18 March 2010

Healing of traumatic urethral disruption by mucosal growth when managed by endoscopic urethral realignment

B. Kamal, A. Elsadr, H. El-Darawany

Department of Urology, University of Dammam, Dammam, Saudi Arabia

Introduction: Traumatic disruption of the urethra results in a gap in the urethral wall. We demonstrate sealing of the gap by mucosa, irrespective of its size or extent, when managed by early endoscopic urethral realignment.

Methods: Five patients (4 males and 1 female) sustained urethral injury following RTA. The injury involved 60% to 80% circumference at the area of the membranous urethra. Urethral realignment was done to all patients within 24 hours from the accident. This was followed by periodic urethroscopic assessment of the healing process of the injured urethral segment after 6 and 12 weeks. The indwelling urethral catheter was removed when healing was complete.

Results: Progressive and consistent mucosal growth was demonstrated by periodic urethroscopy. Complete sealing was achieved within 6-12 weeks depending on the degree of urethral disruption. Careful repeated urethroscopy did not compromise the site of injury or the healing process. Two male patients developed a short stricture which was successfully treated by visual urethrotomy.

Summary and Conclusion: The gap resulting from urethral disruption, and managed by urethral realignment, was sealed by new mucosa that extended from the cut mucosal edges with uneventful recovery within a maximum period of 12 weeks. This process is illustrated by video.

Presented at the: 22 nd Saudi Urological Conference

King Faisal Specialist Hospital and Research Centre

15-18 March 2010

Augmented anastomotic urethroplasty for long bulbar urethral stricture

Alaa M. Shaaban 1,2 , Husain Al-Faifi 1,2 , Mohamed Abou Farha 1,2 , Osama Abou Farha 1,2

1 Department of Urology, King Fahad Central Hospital, Gazan, Saudi Arabia, 2 Department of Urology, Tanta University, Tanta, Egypt

Introduction: Urethral stricture less than 2 cm is best managed by stricture excision and primary anastomosis. However, long strictures are not amenable to such procedure and present a dilemma. Options include staged procedures, stricture incision and flap-graft onlay or augmented anastomotic urethroplasty. We present our results and long term follow up with the later technique where most of the strictured segment is excised with floor strip anastomosis augmented dorsally by dorsal penile skin pedicled flap.

Materials and Methods: Between February 2001 and May 2008 a total of 37 patients with a mean age of 30.6 years (range 14-65 years) were included. All patients had long segment bulbar urethral stricture with a mean stricture length of 4.4 cm (range 2.5-7 cm) on retrograde urethrography. The procedure was performed through a midline perineal incision to expose the bulbar urethra which was mobilized and the strictured segment with markedly reduced lumen girth was excised (mean 2.6 cm) and the urethral ends were then anastomosed as floor strip leaving an oval dorsal defect. A wide transverse rectangular pedicled flap was then harvested from the dorsal non hairy penile skin and then mobilized to the perineal incision where it was used to augment the urethra as dorsal onlay patch. The mean flap length was 3.8 cm (range 2-6.2 cm).

Results: All patients were followed for at least 24 months. Urethrograms were done at 3 weeks, 3, 6 and 12 months postoperatively and later if the patients were symptomatic. The overall success rate at 2 years was 91.9%. Three patients have had recurrent ring stricture 12, 18 and 20 months postoperatively. They were managed successfully by optical urethrotomy. The remaining 34 patients were stricture free at a mean 49.6 month follow up (range 24-84 months). Other complications included post-void dripping of urine noticed by 7 patients (18.9%), wound infection in the flap donor site in 3 patients and new subjective erectile dysfunction in 1 patient.

Conclusion: Augmented anastomotic urethroplasty using dorsal penile pedicled skin flap is a useful and effective technique for treatment of bulbar urethral stricture that are too long to be managed by excision and primary anastomosis. Excision of most of the strictured segment is beneficial as most of the diseased urethra is excised, besides it decreases the length of skin flap required for augmentation. The durable and high success rate (more than 91.9%) with few and minor complications make it logic to recommend this procedure for patients with long bulbar urethral stricture.

Presented at the: 23 rd Saudi Urological Conference

King Fahd Specialist Hospital - Dammam

21-24 February 201


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