Grade V renal trauma management: results from the multi-institutional genito-urinary trauma study

PURPOSE

To investigate management trends for American Association for the Surgery of Trauma (AAST) grade V renal trauma with focus on non-operative management.

METHODS

We used prospectively collected data as part of the Multi-institutional Genito-Urinary Trauma Study (MiGUTS). We included patients with grade V renal trauma according to the AAST Injury Scoring Scale 2018 update. All cases submitted by participating centers with radiology images available were independently reviewed to confirm renal trauma grade. Management was classified as expectant, conservative (minimally invasive, endoscopic or percutaneous procedures), or operative (renal-related surgery).

RESULTS

Eighty patients were included, 25 of whom had complete imaging and had independent confirmation of AAST grade V renal trauma. Median age was 35 years (Interquartile range (IQR) 25-50) and 23 (92%) had blunt trauma. Ten patients (40%) were managed operatively with nephrectomy. Conservative management was used in nine patients (36%) of which six received angioembolization and three had a stent or drainage tube placed. Expectant management was followed in six (24%) patients. Transfusion requirements were progressively higher with groups requiring more aggressive treatment, and injury characteristics differed significantly across management groups in terms of hematoma size and laceration size. Vascular contrast extravasation was more likely in operatively managed patients though a statistically significant association was not found.

CONCLUSION

Successful use of nonoperative management for grade V injuries is used for a substantial subset of patients. Lower transfusion requirement and less severe injury radiologic phenotype appear to be important characteristics delineating this group.

Occupational traumatic injuries rarely affect genitourinary organs: a retrospective, comparative study

PURPOSE

To determine the mechanisms of injury associated with occupational injuries (OI) to genitourinary (GU) organs and compare GU OIs with GU non-OIs.

METHODS

A single institution, retrospective study was conducted at a level 1 trauma center between 2010 and 2016 of all patients with GU injuries. OI was defined as any traumatic event that occurred in the workplace requiring hospital admission. Types of occupations were recorded in addition to the location of injury, mechanisms of injury, concomitant injuries, operative interventions, total cost, and mortality. GU OI patients were then compared to GU non-OI patients.

RESULTS

623 patients suffered a GU injury, of which 39 (6.3%) had a GU OI. Fall (43%) was the most common mechanism of injury; followed by motor vehicle collision/motorcycle crash (31%), crush injury (18%), and pedestrian struck (8%). The adrenal gland (38%) and kidney (38%) were the most commonly injured organs. There was no difference in mortality (13% GU OI vs. 15% GU non-OI, p = 0.70) or total direct cost ($21,192 ± 28,543 GU OI vs. $28,215 ± 32,332 GU non-OI, p = 0.45). Total costs were decreased with mortality from a GU injury (odds ratio (OR) 0.3, CI 0.26-0.59; p = < 0.001) and increased with higher injury severity scores (OR 1.1, CI 1.09-1.2; p = < 0.0001). Total costs were not affected by OI status.

CONCLUSIONS

Occupational GU trauma presents with similar patterns of injury, hospital course, and direct cost as GU trauma that occurs in non-occupational settings.

The spectrum of animal related injuries managed at a major trauma centre in South Africa

BACKGROUND

Humans come into contact and interact with an array of animals in a number of areas and environments. We set out to review our experience with animal-related injuries in Pietermaritzburg, KwaZulu-Natal, South Africa.

METHOD

All patients who sustained an injury secondary to an interaction with an animal in the period December 2012-December 2017 were identified from the Hybrid Electronic Medical Registry (HEMR).

RESULTS

There were 104 patients in the study sample. The mean age of patients in the study was 32.8 years, with a range from 1 to 76 years old. 75% (n = 78) were male and 25% (n = 26) female. Out of the 104 animal-related injuries, 67 were blunt trauma, 39 penetrating trauma and 3 a combination of blunt and penetrating trauma. The species causing trauma included dogs (53), horses (29), cows (18), buffalo (1), warthog (1), impala (1) and a single goat (1). The median time from injury to hospitalisation was 46.62 hours (range from 0 to 504 hours). Injuries occurred to the head (n = 32), face (n = 9), neck (n = 32), abdomen (n = 22), urogenital system (n = 6), upper limb (n = 39) and lower limb (n = 39). The Injury Severity Score (ISS) mean for the patients was 8.16, the range 1-4, the median 9 and the standard deviation 6.88. In 49 patients the treatment was non-operative. In the remaining 55 patients, a total of 68 operative procedures were required. Operations included wound debridement/surgical washout (n = 38), laparotomy (n = 9), arterial repair/ligation (n = 8), skin graft (n = 4), craniotomy (n = 5), fasciotomy (n = 2), amputation (n = 1), and placement of an ICP monitor (n = 1). 49 of these operations were for patients with dog bite injuries. The mean hospital stay was 0.13 days with a range of 0-4 days. Four patients were admitted to the Intensive Care Unit (ICU) and two patients died.

CONCLUSION

Human interactions with animals may result in injuries which require surgical treatment. The most common animal injury is a dog bite but in the case of the larger domestic farm animals, blunt force type injuries and goring can result in significant injuries which require complex surgical interventions.

Common genitourinary catheters: a systematic approach for the radiologist

Catheters are commonly used to treat and diagnose urinary tract abnormalities in the pediatric population. This pictorial essay reviews commonly placed genitourinary catheters imaged by radiography, fluoroscopy, computed tomography (CT) and ultrasonography (US). The purpose of the catheter, how the catheter is placed, and the imaging findings associated with appropriately positioned catheters as well as misplaced and displaced catheters are described. It is important for radiologists to recognize common genitourinary catheters, and be familiar with their normal and abnormal positions as displacement is often first recognized by diagnostic imaging.

Diagnosis and management of 365 ureteric injuries following obstetric and gynecologic surgery in resource-limited settings

Introduction

Ureteric injuries are among the most serious complications of pelvic surgery. The incidence in low-resource settings is not well documented.

Methods

This retrospective review analyzes a cohort of 365 ureteric injuries with ureterovaginal fistulas in 353 women following obstetric and gynecologic operations in 11 countries in Africa and Asia, all low-resource settings. The patients with ureteric injury were stratified into three groups according to the initial surgery: (a) obstetric operations, (b) gynecologic operations, and (c) vesicovaginal fistula (VVF) repairs.

Results

The 365 ureteric injuries in this series comprise 246 (67.4%) after obstetric procedures, 65 (17.8%) after gynecologic procedures, and 54 (14.8%) after repair of obstetric fistulas. Demographic characteristics show clear differences between women with iatrogenic injuries and women with obstetric fistulas. The study describes abdominal ureter reimplantation and other treatment procedures. Overall surgical results were good: 92.9% of women were cured (326/351), 5.4% were healed with some residual incontinence (19/351), and six failed (1.7%).

Conclusions

Ureteric injuries after obstetric and gynecologic operations are not uncommon. Unlike in high-resource contexts, in low-resource settings obstetric procedures are most often associated with urogenital fistula. Despite resource limitations, diagnosis and treatment of ureteric injuries is possible, with good success rates. Training must emphasize optimal surgical techniques and different approaches to assisted vaginal delivery.

Emergency management of renal and genitourinary trauma: best practices update [digest]

In up to 10% of patients who experience abdominal trauma, renal and urogenital systems will be involved. In polytrauma patients with other potentially life-threatening injuries, renal and genitourinary trauma may be overlooked initially, but a delayed or missed diagnosis of these injuries may result in preventable complications. This review provides a best-practice approach to the diagnosis and management of renal and genitourinary injuries, with an emphasis on the systematic approach needed to identify subtle injuries and avoid long-term urinary sequelae such as hypertension, incontinence, erectile dysfunction, chronic kidney disease, and nephrectomy. [Points & Pearls is a digest of Emergency Medicine Practice.].

Fractures of the pelvic ring

Traumatic disruptions of the pelvic ring are high energy life threatening injuries. Management represents a significant challenge, particularly in the acute setting in the presence of severe haemorrhage. Initial management is focused on preserving life by controlling haemorrhage and associated injuries. Advances in prehospital care, surgery, interventional radiology and the introduction of treatment algorithms to streamline decision making have improved patient survival. As more patients with unstable pelvic injuries survive, the poor results associated with nonoperative management and increasing patient expectations of outcome are making surgical management of these fractures increasingly common. The aim of operative fracture fixation is to correct deformity and restore function. The advent of percutaneous fixation techniques has reduced the morbidity previously associated with large operative exposures and internal fixation.

[Management of genitourinary trauma]

Urogenital trauma often occurs in the context of polytrauma patients. In this article, aimed at primary care practitioners and emergency physicians, we summarise the epidemiology and aetiology of these traumas as well as their management. The goal is to allow primary healthcare professionals to become acquainted with diagnostic and therapeutic strategies in genitourinary trauma patients.

A prospective analysis of urinary tract infections among elderly trauma patients

BACKGROUND

Catheter-associated urinary tract infections (CAUTIs) have been deemed "reasonably preventable" by the Centers for Medicare and Medicaid, thereby eliminating reimbursement. Elderly trauma patients, however, are at high risk for developing urinary tract infections (UTIs) given their extensive comorbidities, immobilization, and environmental changes in the urine, which provide the ideal environment for bacterial overgrowth. Whether these patients develop CAUTI as a complication of their hospitalization or have asymptomatic bacteriuria (ASB) or UTI at admission must be determined to justify the "reasonably preventable" classification. We hypothesize that a significant proportion of elderly patients will present with ASB or UTI at admission.

METHODS

Institutional review board permission was obtained to perform a prospective, observational clinical trial of all elderly (≥65 years) patients admitted to our Level I trauma center as a result of injury. Urinalysis (UA) and culture (UCx) were obtained at admission, 72 hours, and, if diagnosed with UTI, at 2 weeks after injury. Mean cost of UTI was calculated based on Centers for Disease Control and Prevention estimates of $862 to $1,007 per UTI.

RESULTS

Of 201 eligible patients, 129 agreed to participate (64%). Mean (SD) age was 81 (8.6) years. All patients had a blunt mechanism of injury (76% falls), with a mean Injury Severity Score (ISS) of 13.8 (7.6). Of the 18 patients (14%) diagnosed with CAUTI, 14 (78%) were present at admission. In addition, there were 18 patients (14%) with ASB at admission. The most common bacterial species present at admission urine culture were Escherichia coli (24%) and Enterococcus (16%). Clinical features associated with bacteriuria at admission included a history of UTI, positive Gram stain result, abnormal microscopy, and pyuria. The estimated loss of reimbursement for 18 UTIs at admission was $15,516 to $18,126; however, given an estimated cost of $1,981 to screen all patients with UA and UCx at admission, up to $16,144 savings was realized.

CONCLUSION

Many elderly trauma patients present with UTI. Screening UA and UCx at admission for elderly trauma patients identifies these UTIs and is cost-effective.

LEVEL OF EVIDENCE

Epidemiologic study, level II.

Does the mechanism of injury in pediatric blunt trauma patients correlate with the severity of genitourinary organ injury?

INTRODUCTION

Blunt abdominal trauma can result in injury to genitourinary (GU) organs. Children may be more susceptible to some GU injuries due to anatomic differences compared to adults. Mechanism of injury (MOI) has been thought to relate to both the likelihood and severity of GU injury in children, although this has not definitively been proven. Our purpose was to determine if MOI has any correlation to the severity of GU injury in children treated at our institution.

MATERIALS AND METHODS

We reviewed records of all pediatric blunt trauma patients presenting to our institution from January 2005-December 2010 using the LeBonheur Children's Hospital Trauma Registry. All patients with GU injuries were included in this study. Data collected included demographic information, MOI, type and grade of GU injury, associated injuries, and clinical outcome. Continuous variables were tested with ANOVA and categorical variables were tested with chi-square test.

RESULTS

Records of 5151 children with blunt trauma were reviewed; 76 patients were found to have GU organ injury. There were 47 males (61.8%) and 29 females (38.2%). Categories of MOI included motor vehicle accident, sports injury, bicycle accident, all-terrain vehicle accident (ATV), pedestrian struck accident, falls, and animal injury. MOI did not have any statistically significant association with the severity of GU organ injury (p = 0.5159). In addition, there was no association between MOI and either gender or side of injury. There was a statistically significant association between MOI and patient age (p = 0.04); older pediatric patients were more likely to experience GU injury due to sports injury and ATV accidents, where as younger patients were more likely to experience GU injury due to pedestrian struck, bicycle accidents or animal bite.

CONCLUSIONS

Although specific MOI would seem to relate to presence and severity of injury in children, MOI alone does not correlate with the severity of GU organ injury in our pediatric trauma population. Age of pediatric patients is associated with the type of MOI that results in GU organ injury. The possibility of GU injury should be considered in all symptomatic pediatric patients with clinically significant blunt trauma regardless of the exact MOI.

Pediatric genitourinary injuries in the United States from 2002 to 2010

PURPOSE

We describe the epidemiological features of pediatric genitourinary injuries, and determine the products and events that may predict an increased risk of genitourinary injury during childhood.

MATERIALS AND METHODS

The National Electronic Injury Surveillance System was queried to identify children 18 years or younger who sustained genitourinary injuries and presented to emergency departments in the United States between 2002 and 2010. Demographics and injury characteristics of these children were analyzed. Analyses were performed with adjustments for sample weighting and the stratified survey design. All data are reported as national estimates along with 95% confidence intervals.

RESULTS

Based on 10,286 actual cases, an estimated 252,392 children (95% CI 205,579-299,194) sustained genitourinary injuries during the 9-year study period. Children 4 to 7 years old were most frequently injured (36.8% of all injuries), followed by those 8 to 11 years old (20.6%). Girls comprised 55% of the injured children. The yearly incidence of genitourinary injuries was stable across the period studied. The most commonly injured organs were female external genitalia (37.7%), penises (21.6%) and testicles (12%). Genitourinary injuries were most commonly associated with sporting and exercise equipment (35.7%), furniture (15.5%) and clothing items (11.9%). Of the patients 91% were treated at the emergency department and discharged home.

CONCLUSIONS

Genitourinary injuries in children result in approximately 28,000 emergency department visits yearly. Efforts should be made to decrease the risk of genitourinary injuries in children by promoting the use of protective gear and safer product selection for those at greatest risk for injury.

Prevention of pelvic sepsis in major open pelviperineal injury

Compound pelvic fractures are deemed to be one of the most severe orthopaedic injuries with an extremely high morbidity and mortality. After the initial resuscitation phase the prevention of pelvic sepsis is one of the main treatment goals for patients with an open pelvic fracture. If there is a suspicion of a rectal injury or if the wounds are in the perineal area, The Princess Alexandra Hospital's management plan includes early faecal diversion combined with vigorous soft tissue debridement, VAC(®) therapy and (if indicated) external fixation of the pelvic fracture. We present our flowchart for the treatment of trauma patients with compound pelvic fractures illustrated by a case report describing a 32 year old patient who sustained an open pelvic ring injury in a workplace accident. The aim of this paper is to underline the importance of a safe, straightforward approach to compound pelvic fractures.

Department of Veterans Affairs. Servicemembers' Group Life Insurance Traumatic Injury Protection program--genitourinary losses. Interim final rule

The Department of Veterans Affairs (VA) is issuing this interim final rule that amends the regulations governing the Servicemembers' Group Life Insurance Traumatic Injury Protection (TSGLI) program by adding certain genitourinary (GU) system losses to the TSGLI Schedule of Losses and defining terms relevant to these new losses. This amendment is necessary to make qualifying GU losses a basis for paying GU-injured Servicemembers TSGLI benefits. The intended effect is to expand the list of losses for which TSGLI payments can be made.

Genitourinary trauma

Injury to the genitourinary (GU) tract occurs in up to 10% of all traumas, with the kidneys being the most frequently affected. Trauma to different areas of the GU tract can be caused in a variety of ways, and the diagnostics and management of the injuries vary widely depending on the mechanism and location. Overall, fatalities from GU trauma are not common. However, significant morbidity can occur without prompt recognition and appropriate intervention. A basic understanding of urologic trauma is necessary for all emergency practitioners when caring for trauma patients.

Overview of genitourinary trauma

Genitourinary trauma is a common finding in the patient with multi-trauma, and includes injuries to the kidneys, bladder, ureters, urethra, penis, and scrotum. This article describes the care of the patient with genitourinary trauma focusing on assessments, diagnostic testing, and patient care. Nurses working with trauma patients need to monitor these patients carefully for genitourinary involvement because the signs and symptoms are not always clear.

Comparison of the results of surgical and non-surgical treatment of combat urogenital injuries in Bosnia war 1992-1995

Goal was to compare the results of surgical and non-surgical treatments of combat injuries of genitourinary system and to compare our data with data collected in the recent studies. The study was designed as a retrospective review of data collected in prospective databases. The data extracted from inpatients' medical records included demographics, mechanisms and type of injury, distribution of the lesions, clinical presentation features, applied diagnostic studies, treatment modalities, types of complication and results of treatment. Among 4.125 patients treated in the Mostar War Hospital, 111 had injury of genitourinary tract: 62 underwent a surgical and 49 non-surgical treatment. Mortality among operated patients was 16 (26%). Complications were noted in 47 patients (42%); in 33 (70%) were manifested as early complications, and 14 (30) as delayed ones (p = 0.006). Among the surgically treated patients, 40 (36%) had some complication, in comparison to 8 (7.2%) patients with complications among non-surgically treated patients; which represent a statistically significant difference (p < 0.05). In this study, there was a surprisingly high number of non-surgically treated patients, and this sub-group of UGT trauma patients had in some ways the superior treatment results in comparison with surgically treated patients. Conservatively treated patients had lower rate of complications, no mortality, and no patients with permanent disability.

Genitourinary injuries following road traffic collisions: a population-based study from the Middle East

BACKGROUND

The epidemiology of trauma to genitourinary (GU) organs following Road Traffic Collisions (RTC) is not well-studied, especially in the Middle East.

METHODS

The data of the RTC Injury Registry in Al-Ain City were collected prospectively from April 2006-October 2007.

RESULTS

Of the 1,008 patients in the registry, there were 23 GU injuries. Renal injuries accounted for 74% of injuries. Of these, 35% were severe (grade IV-V). There were two extraperitoneal bladder injuries and two membranous urethral injuries, all of which were associated with pelvic fractures. In addition, there were two asymptomatic adrenal injuries. The mean Injury Severity Score, mean total hospital stay and percentage of patients who required intensive care unit (ICU) admission were higher in patients with GU injuries compared to non-GU patients (24.9 vs. 9.0 (p<0.0001), 24.1 vs. 8.9 days (p<0.0001) and 67% vs. 17% (p<0.0001), respectively). Side-angle collision was the primary crash mechanism in 39% of GU patients vs. 16% in non-GU patients (p=0.015).

CONCLUSION

This is the first population-based study of GU injuries following RTC from the Middle East. Patients with GU organ injury tend to have more severe trauma compared to other patients. The incidence of GU injuries following RTC in the current study appears to be higher than that reported in the West.

[Sports and genitourinary traumas]

INTRODUCTION

Statistical data referring to sports-related traumas of the urinary tract are quite scarce; nevertheless, it is possible to draw general data on the relationship between sports and urological traumas.

METHODS

Literature review of peer-reviewed articles published by May 2009.

RESULTS

Urological traumas account for about 10% of all traumas, and about 13% of them is sports-related. Genitourinary traumas are among the most common cause of abdominal injuries in sports. Blunt injuries are more common than penetrating ones and renal injuries are by far the most common, followed by testicular injuries; ureters, bladder and penis injuries are much more infrequent. Considering chronic microtraumas, injuries of bulbar urethra are also common in sports that involve riding. Overall, the incidence of genitourinary trauma due to sports is low. Renal traumas in sports injuries usually consist of grade I-II lesions and usually do not require surgical treatment. Cycling is the sporting activity most commonly associated with genitourinary injuries, followed by winter sports, horse riding and contact/collision sports. Literature data suggest that significant injuries are rare also in athletes with only one testicle or kidney. General preventive measures against sport-related injuries, along with the use of protective cups for male external genitalia, are generally sufficient to reduce the incidence of urogenital trauma.

CONCLUSIONS

Overall, studies show that urogenital injuries are uncommon in team and individual sports, and that most of them are low-grade injuries. Participation in sports that involve the potential for contact or collision needs to be carefully assessed in the athletes with only one testicle or kidney, even though urogenital injuries should not preclude sports participation to an appropriately informed and counseled patient. Further research is needed to acquire more knowledge on genitourinary injuries according to age, sports type and technical skill.

[Urogenital trauma associated with pelvic ring fractures]

PURPOSE OF THE STUDY

To evaluate, in a retrospective study, injuries to the urogenital tract in patients with pelvic ring fractures. MATERIAL In the years 1998-2007, a total of 308 patients with pelvic ring fractures were treated. The study did not comprise patients with low-energy fractures, such as apophyseolysis in children, osteoporotic bone fractures or pathologic fractures. It also did not include patients with multiple injuries who died within 6 hours of admission to the hospital. The group consisted of 186 men and 122 women with an average age of 34 (range, 6 to 76) years.

RESULTS

The fractures sustained were classified as type A in 5 %, type B in 57 % and type C in 38 % of the patients. The average follow-up was 71 (range, 13 to 121) months. A primary injury to the urogenital tract was recorded in 50 (16 %) patients. Injury to the urethra was found in 23 (7.5%) and urinary bladder trauma in 18 (6%) patients, vaginal injury was in four women (1%), and penis injury in three (1%) and lacerated testicles in two men (1%). Injury to the urogenital tract was associated with a pelvic ring fracture type A in 5 %, type B in 34 % and type C in 61 % of the patients. Out of the 23 patients with urethral trauma, only six (26 %) were free from functional and subjective complaints; eight (35 %) continued to receive therapy for urethral stenosis seven (30 %) reported urinary incontinence, and seven men (30 %) had erection problems. In six patients (26%) the lasting sequelae were combined. The 18 patients with injury to the bladder reported no subjective complaints at a one-year follow-up. Two patients with penis root injury had erectile dysfunction. Two patients with the loss of both testicles were in the care of a psychiatrist. The patients' satisfaction was evaluated on a 0-to10-point scale. The average value for the whole group was 4.1 points. In the patients with erectile dysfunction, the value was 0.8, and in those with isolated injury to the urinary bladder it was 9.4 points.

DISCUSSION

The increasing number of injuries to the urogenital tract associated with permanent sequelae is caused by a growing number of pelvic ring fractures as well as, and this is more important, by decreasing mortality in patients with severe trauma to the pelvic ring The extent of urogenital injury is related to the degree of dislocation of the pelvic skeleton. Injury to the male urethra is the most frequent urogenital trauma because of the male anatomy. It occurs most often in unstable C type fractures when the pelvic ring is disrupted with bone displacement due to shear force at the site of urethra attachment. The consequences are related to the quality of treatment of urogenital tract injury as well as to how the skeletal injury is managed. The lasting effects of the primary injury to nerve structures are beyond repair by therapy.

CONCLUSIONS

Injury to the urethra results in erectile dysfunction in 50 % of the injured patients it is often associated with urinary incontinence that has a strong effect on the patient's life quality. Isolated trauma to the urinary bladder has a good prognosis. The incidence of post-traumatic incontinence is not high, but reduces the patient's personal and social comfort. A prerequisite for a successful therapeutic outcome is a good cooperation of the orthopaedic surgeon and urologist. Key words: pelvic ring fractures, urogenital injury.

[Evaluation of patients with urogenital trauma managed in a urology clinic]

BACKGROUND

Ten percent of all traumas, responsible for 14% of all deaths, involve the urogenital system. We retrospectively evaluated the patients with genitourinary trauma who underwent any kind of management modality in our clinics.

METHODS

We retrospectively evaluated 108 patients (92 males, 16 females; mean age 35.8+/-17.5 years; range 6 to 87 years) with urogenital trauma between 2003 and 2007 according to age, gender, type of trauma, affected organ, grade of trauma, accompanying other-organ injuries, radiological imaging techniques, and treatment.

RESULTS

Sixty-eight patients (63%) had blunt, 25 (24%) had penetrating, and 12 (11%) had iatrogenic trauma, and 3 patients (3%) had spontaneous organ injury. When we considered the affected organ, renal trauma was determined in 34 patients (32%), ureteral trauma in 11 (10%), bladder injuries in 18 (17%), urethral trauma in 27 (25%), testicular trauma in 6 (6%), and penile trauma in 12 (10%) patients. Seventeen patients (50%) had grade 3, 11 (32%) had grade 4 and 6 (18%) had grade 5 renal injury; 6 patients of these cases underwent surgical treatment.

CONCLUSION

Our results were parallel to those available in the literature. Due to the lack of sufficient information about urogenital trauma rates in our country, it would be highly useful for reference centers to evaluate and publish their own data.

Blunt abdominal trauma: current imaging techniques and CT findings in patients with solid organ, bowel, and mesenteric injury

Imaging plays a critical role in the evaluation of patients with blunt abdominal trauma. In most institutions, computed tomography (CT) is the modality of choice when evaluating such patients. The purpose of this review is to highlight current techniques in trauma imaging and to review CT findings associated with solid organ, bowel, mesenteric, and diaphragmatic injury. In particular, emphasis is placed on the use of multidetector CT technology (MDCT), especially 64-row detector CT. The role of various techniques, including the use of oral and intravenous contrast, as well as the potential benefit of delayed imaging, is discussed.

Genitourinary trauma at a combat support hospital during Operation Iraqi Freedom: the impact of body armor

PURPOSE

This report details the occurrences of genitourinary trauma experienced during Operation Iraqi Freedom at a United States Army Combat Support Hospital, and determines if wearing body armor decreases the frequency of genitourinary and specifically kidney trauma.

MATERIALS AND METHODS

The Joint Theater Trauma Registry was used to conduct a retrospective study of 2,712 trauma admissions to a United States Army Combat Support Hospital in Baghdad, Iraq from April 1, 2005 to February 28, 2006. There were 1,216 casualties who were wearing body armor and 1,496 casualties not wearing body armor.

RESULTS

Of the 2,712 trauma admissions 76 (2.8%) had 1 or more genitourinary injuries for a total of 98 genitourinary injuries. Of the 29 kidney injuries 2 (6.9%) were explored without any treatment, 7 (24.1%) were observed, 1 (3.4%) was repaired and 19 (65.5%) casualties required nephrectomy. Casualties wearing body armor had a 2.1% rate of genitourinary injury versus 3.4% not wearing body armor (p = 0.037). Casualties wearing body armor had a 0.5% rate of kidney injury compared to 1.4% not wearing body armor (p = 0.017).

CONCLUSIONS

The percentage of casualties with genitourinary injuries and the distribution of these injuries appear similar to previous conflicts. The percentage of casualties undergoing nephrectomy appears to be greater than that observed in other recent conflicts. There was a significant reduction in overall genitourinary injuries and specifically kidney injuries in those casualties wearing body armor.

Genitourinary assessment: an integral part of a complete physical examination

This article provides primary care providers, including pediatric nurse practitioners, with a framework for completing a genitourinary assessment. Many primary care providers are reluctant to examine the genitalia of their patients. Routine genital examinations increase diagnostic skills, provide a baseline for future examinations, may improve parent and child compliance with the examination, and may reveal previously undiscovered anomalies or trauma. An assessment of the reproductive and urologic systems should begin with obtaining a focused history from the parent from birth to present. Techniques for performing a focused genitourinary examination will be discussed.

Imaging of genitourinary trauma

The kidney, bladder and male urethra are the organs typically injured by blunt and penetrating trauma to the urinary tract, whereas the ureter is only rarely injured. The staging of genitourinary tract trauma has recently gained tremendous significance due to improvements in ultrasound, CT and MRI, including contrast-enhanced magnetic resonance angiography, and has become a helpful tool for decision making with regard to conservative and surgical management. Furthermore, interventional radiology may be helpful to control hemorrhage from vessels in the pelvic region that may not be easily accessed by open surgery. Therefore, this pictorial essay gives examples of the radiological presentation of genitourinary trauma and describes technical details of the diagnostic imaging modalities used.

[The female urogenital system and high level sports]

High-level competition sports can have a variety of negative effects on the female urogenital apparatus. Perineal trauma is rare and is usually associated with certain sports (impalement or hydrotubation during water-skiing, indurated perineal nodules in racing cyclists, and horse-riders' perineum). Effort incontinence is seen in all sports involving abrupt repeated increases in intra-abdominal pressure that may exceed perineal floor resistance. Sportswomen should be questioned about possible incontinence and be informed of preventive and therapeutic measures.

The epidemiology of trauma of the genitourinary system after traffic accidents: analysis of a register of over 43,000 victims

OBJECTIVE

To analyse the frequency and type of injury to the genitourinary system, by user category, after traffic accidents.

PATIENTS AND METHODS

The register which forms the basis of this study is unique in Europe and includes 43,056 victims of road traffic accidents, and was compiled between 1996 and 2001. The categories of road users included: motorists, motorcyclists, cyclists, pedestrians, van and bus users, and roller skaters. The urological complication rate was analysed for each category.

RESULTS

In all, 199 cases of trauma of the genitourinary system (0.46%) were recorded. The most frequent urological complications were renal (43%) and testicular trauma (24%), the former most frequent in motorists (65%) and pedestrians (29%), and the latter in motorcyclists (41%).

CONCLUSIONS

An analysis of this register provides better knowledge of the urogenital injuries after traffic accidents. Renal and testicular injuries are the most frequent.

Black kidney sign: a new computed tomographic finding associated with the hypoperfusion complex in children

The authors describe a new CT finding associated with the hypoperfusion complex in children: complete lack of enhancement of both kidneys without renal swelling, without subcapsular cortical rim enhancement, and without peripheral wedge-shaped areas of hypoattenuation. This "black kidney sign" was found in two severely injured children who died within a few hours after the CT examination. It may help to establish a diagnosis of severe hemodynamic instability and may be a negative prognostic factor.

Akzidentelles Seitspagat als Ursache eines komplexen Beckentraumas

Complex pelvic ring fractures are defined as injuries of the pelvic ring in association with lesions of the pelvic organs or the pelvic soft tissues. These injuries are typically caused by high-energy accidents. In contrast to the typical mechanism of injury a case is described in which a low energy trauma led to a complex pelvic ring trauma. An obese woman suffered an open-book injury of the pelvis with severe open urogenital soft-tissue damage by accidentally doing forced splits. Primary stabilization of the pelvic ring with external fixation and secondary internal fixation with a double-plate osteosynthesis of the symphysis led to a good clinical outcome concerning the osseous lesion. The urogenital injuries with rupture of the bladder, the urethra and the vagina led despite immediate urological management to an incontinence, which finally required definitive urine drainage via an ileum conduit.

Urological injuries in the Civil War

PURPOSE

This study compiles all cases of urological injuries reported in the Civil War (1861 to 1865).

MATERIALS AND METHODS

Using original sources largely assembled in army surgeon reports urological injuries documented and treated during the Civil War were recorded as to frequency, type, site and outcome.

RESULTS

A total of 1,497 cases of injury involving the genitourinary organs were documented, representing 0.61% of all battle wounds, 22% of gunshot wounds of the abdomen and pelvis, and 47% of wounds restricted to the pelvis. Of these men 342 died (22% of all urological injuries and 37% of fatal pelvic wounds). Half of the kidney, bladder and prostate injuries were fatal, whereas men with injuries of the urethra, testes and penis generally recovered. Urethral wounds were often complicated by traumatic fistula and stricture.

CONCLUSIONS

Wounds involving genitourinary organs and their consequences had a significant impact during the Civil War. As the war progressed, despite the limited means at their disposal surgeons learned how to better treat devastating urological injuries, resulting in improved survival and fewer severe complications.

Open pelvic fractures: epidemiology, current concepts of management and outcome

Open pelvic fractures constitute one of the most devastating injuries in musculo-skeletal trauma and must be treated aggressively, incorporating a multidisciplinary approach. Early treatment, focusing on prevention of haemorrhage and sepsis, is essential. The management of associated soft tissue injuries must also be aggressive, including early administration of broad-spectrum antibiotics and repeated, meticulous wound debridement and irrigation. Selective faecal diversion, based on wound location, is compulsory and safe, minimising the risk of sepsis and reducing mortality rates.

Imaging Studies in the Diagnosis of Urogenital Trauma

Polytraumatized patients often present with urological injuries. After hemodynamic stability is maintained urologists are consulted to evaluate diagnostic and therapeutic interventions. The following article describes how to handle the work-up of patients with injuries to specific urogenital organs: the importance of clinical examination, ultrasonography, computed tomography (CT), magnetic resonance imaging (MRI), angiography as well as organ-specific radiologic studies such as intravenous pyelography or cystography are discussed.

CONCLUSION

Even though injuries to the urogenital tract are rarely initially life--threatening, a fast, reliable and adequate diagnostic algorithm has to be established to avoid any delay of specific treatment. Urologists should be familiar with the indications, range and accuracy of these procedures in the diagnosis of urogenital trauma.

The Incidence of Recreational Genitourinary and Abdominal Injuries in the Western New York Pediatric Population

PURPOSE

We estimate the incidence of recreation related pediatric abdominal, testis and kidney injuries.

MATERIALS AND METHODS

Trauma registry data at the regional pediatric trauma center for 1993 to 2000 were analyzed for recreational injuries. The data were divided into the 3 age groups of 5 to 11, 12 to 14 and 15 to 18 years. The recreation, and site and severity of injury were cross referenced. Injury incidence was calculated using United States census data.

RESULTS

Of 4,921 children 34 boys and 2 girls (0.73%) had a genitourinary or abdominal injury due to recreation. Kidney injuries were the most common (44.4%), followed by spleen (36.1%) and liver (19.5%). No testicle injuries were reported. Skiing was the most common cause of injury (22.2%). Hockey, football, snowboarding, sledding and bicycling accounted for 83% of all injuries. There were no injuries related to basketball and soccer. The 12 to 14-year-old group had 50% of the injuries. Records were available for 15 kidney injuries, of which 11 were on the left side, 1 was bilateral, 3 required transfusion and 1 required nephrectomy. Injury grades were I in 2 cases, II in 5, III in 4, IV in 3 and V in 1. Kidney and spleen injury incidence due to recreation per year per million children was 6.9 and 5.6, respectively.

CONCLUSIONS

Kidney injuries were more common than spleen injuries. Skiing, sledding and snowboarding accounted for more injuries than team sports. Testicle injuries were not seen and are rare. Basketball and soccer caused no injuries. Middle school-age children appear to be at greatest risk.

[Results of treatment of isolated and combined trauma of urogenital system]

Retrospective analysis of treatment results of 608 patients with trauma of organs of urogenital system (UGS) was carried out. Beating was the cause of trauma in 55% cases, fall from height--in 17%, transport trauma--in 14.3%, knife wound--in 4.4%, gunshort wound--in 1.3%. Isolated trauma of UGS was in 481 (79.1%) patients. In other patients combined injury of UGS with injury of skeleton's bones (53), cranium and brain (25), abdominal organs (20) was diagnosed. In 29 patients severe combined trauma of UGS, abdominal organs, skeleton bones and cranium was seen. Surgeries were performed in 267 patients. Surgeries on kidney and urinary bladder due to their disruption predominated. In 44 patients these surgeries were combined with ones on abdominal organs. Surgery was performed in two stages in 25 patients with combined trauma of UGS and other organs. From 608 patients 552 (90.2%) cured. Lethal outcome was in 56 (9.2%) patients due to progressive traumatic shock.

Maternal and perinatal complications with uterine rupture in 142,075 patients who attempted vaginal birth after cesarean delivery: A review of the literature

OBJECTIVE

The purpose of this study was to determine the rate of uterine rupture and its complications as the result of trial of labor after previous cesarean delivery.

STUDY DESIGN

PubMed was searched from 1989 to 2001, with the terms "VBAC, uterine rupture," "trial of labor, uterine rupture," "cesarean delivery, uterine rupture," and "scarred uterus, rupture." For inclusion, reports had to contain data from at least 100 patients with trials of labor that included a description of adverse outcomes. Duplicate reporting from a single institution was excluded. Odds ratios and 95% CIs were calculated.

RESULTS

Seventy-two of the 361 articles (20%) that were identified met the inclusion criteria. A 6.2 per 1000 trial of labor rate of uterine rupture (total=880 uterine ruptures in 142,075 trials of labor) was determined. For every 1000 trials of labor the uterine rupture-related complication rate was 1.8 for packed red blood cell transfusion, 1.5 for pathologic fetal acidosis (cord pH<7.00), 0.9 for hysterectomy, 0.8 for genitourinary injury, 0.4 for perinatal death, and 0.02 for maternal death. The perinatal mortality rate was significantly lower among studies from the United States versus other countries (0.3 vs 0.6; odds ratio, 0.50; 95% CI, 0.26-0.94) and in series that exceeded 1000 patients (0.2 vs 1.7; odds ratio, 7.34; 95% CI, 3.94-13.69).

CONCLUSION

Although relatively uncommon, uterine rupture is associated with several adverse outcomes, depending on the time of the publication and the site and size of the population that was studied.

[Injuries of the urogenital system]

To analyse the results of treatment of isolated and concomitant urogenital injuries, a retrospective analysis was made of 608 case histories for patients treated in 1986-2000. Of them, 530 patients were males, 78 were females, the age ranged from 16 to 70 years, most of the patients were 20 to 50 (71.2%) years of age. Most frequently the injury was inflicted by beating. Fall from the height, transport accidents ranked second among the causes of injury (17 and 14.3%, respectively). Stab and gunshot injuries occurred in 4.4 and 8% cases, respectively. Ultrasound and x-ray methods were employed for examination. An isolated injury was found in 481 patients, the rest had urogenital injury and skeletal (53%), craniocerebral (25%), abdominal (20%) lesions. 29 patients had a severe concomitant wound: urogenital injury combined with abdominal, skeletal, cranial lesions. Surgery was performed in 267 patients. The rest patients received conservative treatment. Most of the operations were made on the kidney and urinary bladder because of rupture. In some patients these interventions were conducted during laparotomy and were combined with abdominal intervention (44 cases). 25 patients with the compound injury underwent 2-stage operations. 552 patients were cured. 56 (9.2%) lethal outcomes were due to progression of traumatic shock. This low percent of lethality may be explained by an optimal choice of treatment policy in the above patients.

[Urological emergencies]

Urological emergencies that require specialist treatment include testicular torsion, gross hematuria, urogenital injuries and acute flank pain. After initial symptoms-adapted therapy, patients should be transferred immediately to an urological department for imaging (e.g. ultrasound, IVP, CT) and further specific examinations (e.g.blood tests, urine analysis, microbiology). Acute lower abdominal and scrotal pain in young men may be symptomatic of testicular torsion, which requires immediate urological surgery. Gross hematuria is usually not a life-threatening emergency. Nevertheless, urogenital tumor has to be ruled out by an urologist. Patients with urogenital injuries are triaged into surgical and non-surgical treatments. Differential diagnosis of acute flank pain falls into several medical fields. After initial symptom-related therapy, further diagnostic procedures have to be performed. Septic presentation may be symptomatic of infectious hydronephrosis which requires immediate urological intervention.

Surgical management of urogenital injuries at a war hospital in Bosnia-Hrzegovina, 1992 to 1995

PURPOSE

Our experience with urogenital surgery during the Bosnia-Herzegovina conflict of 1992 to 1995 is compared with data from previous wars and peacetime practice.

MATERIALS AND METHODS

A total of 5,370 wounded patients, including 136 (2.5%) with 1 or more urogenital injuries, were treated at a war hospital in northern Bosnia-Herzegovina during 37 months. The hospital was based at a village school and was poorly equipped but it was only 10 to 16 km. from the front line and average transportation time was 30 minutes.

RESULTS

Of the 136 patients 72 (52.9%) were injured by explosive weapons, while the other 64 (47.1%) had bullet wounds. The 169 urogenital injuries were to the kidney in 65 cases (38.5%), scrotum in 44 (26%), bladder in 23 (13.6%), penis in 16 (9.5%), urethra in 9 (5.3%), ureter in 6 (3.6%) and other in 6. There was associated damage to organs other than the urogenital system in 116 patients (85.3%). Preference was given to organ sparing operations when possible, but 33.8% of renal injuries required nephrectomy and orchidectomy was performed for 58.3% of testicular injuries.

CONCLUSION

In war settings when injuries are often severe and multiple, and the hospital may lack staff, instruments and other medical supplies, the surgeon frequently must improvise. Even so, the results achieved need not fall far below those of peacetime surgery provided that, as in this hospital in Bosnia-Herzegovina, wounded patients present to the surgeon rapidly, they are young and the surgeons are experienced with the management of war injury.

Fibrin sealant for the management of genitourinary injuries, fistulas and surgical complications

PURPOSE

We report our preliminary experience with the use of fibrin sealant to manage iatrogenic urinary tract injuries, complex urinary fistulas, and urological surgical complications.

MATERIALS AND METHODS

Topical fibrin sealant was used in 19 patients for iatrogenic urinary tract injury during gynecological or general surgical procedures (7), complex urinary fistulas (5) or urological surgical complications (7).

RESULTS

Successful resolution of the injury, fistula or complication was attained after a single application of fibrin sealant in the 18 patients (94.7%) in whom a direct injection technique was used. The only failure (formation of a vesicovaginal fistula) occurred with the air driven sprayed sealant delivery technique after sutured closure of iatrogenic cystotomy during vaginal hysterectomy.

CONCLUSIONS

Liquid fibrin sealant appears to be safe and prudent for use in urological "damage control" from trauma, fistulas or surgical complications. Direct injection over a sutured urinary anastomosis appears to be highly effective in preventing urinary drainage. Additional study is needed to define further the role and best use of tissue adhesives in urology.

[Urologic complications in pelvic injuries]

OBJECTIVE

Urological complications of pelvic fractures include in particular rupture of the urinary bladder (RUB), injury of the posterior urethra (IPU) and erectile dysfunction (ED). The authors present their own group of patients and in particular the diagnostic and therapeutic algorithm in IPU.

MATERIAL AND METHODS

In the Plzen Faculty Hospital in 1/1998 to 8/2002 a total of 19 patients were treated with serious urological complications of pelvic fractures--9x RUB, 11x IPU (once with RUB). RUB was in one instance intraperitoneal, in the remainder extraperitoneal.

RESULTS

IPU was without dislocation 6x, with dislocation 5x. Primary "realignment" of the urethra was made in 6 patients (in dislocations and in concurrent rupture of the bladder). In the remaining 5 an epicystostomy was established. In 4 after an interval of 3 months a posterior resection urethroplasty was made because of a distraction defect. One patient with a distraction defect was referred to the urological department of the catchment area and in another patient after-treatment is planned. Severe ED developed in 6 IPU of 10, always in dislocations of the urethra. In one patient we lack information on erections.

CONCLUSION

When IPU is suspected (urethrorhagia), dislocation of the prostate on examination p.r.) ascendent urethrography and IVU are essential. Do not catheterize before completed examination. Then needle epicystostomy is performed, in major dislocations of the urinary bladder or in associated injuries primary "realignment" of the urethra open on a catheter or endoscopically. In distraction defects after 12 weeks a posterior resection plastic operation follows.