Campbell GU Trauma 2021 Flashcards
(199 cards)
1
Q
Most important information to obtain in blunt renal injury: ___
A
Mechanism of injury
** Deceleration? Speed of car or height of fall;
** Kidney is vulnerable to decelration injury: tear at points of fixation: hilum or UPJ
2
Q
Penetrating trauma:
Anterior axillary line damages: ___
Posterior axillary line: ___
Ipsilateral rib fracture increases incidence of renal trauma ___-fold
A
AAL: renal hilum and pedicle
PAL: parenchyma
Three-fold
3
Q
Best indicators of significant GU injury: ___
A
Gross hematuria
Microhematuria (>5 RBCs/high-power field)
** Esp. when hypotensive (<90 mmHg), penetrating trauma
** Degree of hematuria does not correlate with injury severity
4
Q
Grade I renal injury
A
Contusion
Microscopic or gross hematuria, urologic studies normal
Hematoma
Subcapsular, nonexpanding without parenchymal laceration
5
Q
Grade II renal injury
A
Hematoma
Nonexpanding perirenal hematoma confined to renal retroperitoneum
Laceration
<1 cm parenchymal depth of renal cortex without urinary extravasation
6
Q
Grade III renal injury
A
Laceration
>1 cm parenchymal depth of renal cortex without collecting system rupture or urinary extravasation
7
Q
Grade IV
A
Laceration
Parenchymal laceration extending through renal cortex, medulla, and collecting system
Vascular
Main renal artery or vein injury with contained hemorrhage
8
Q
Grade V
A
Laceration
Completely shattered kidney
Vascular
Avulsion of renal hilum, devascularizing the kidney
9
Q
Indications for renal imaging
A
- Penetrating trauma with a likelihood of renal injury (abdomen, flank, ipsilateral rib fracture, significant flank ecchymosis, or low chest entry/exit wound) who are hemodynamically stable enough to have a CT (instead of going directly to the operating room or angiography suite)
- Blunt trauma with significant acceleration/ deceleration mechanism of injury, specifically rapid deceleration as would occur in a high-speed motor vehicle accident or a fall from heights
- Blunt trauma and gross hematuria
- Blunt trauma with microhematuria and hypotension (<90 mm
Hg systolic at any time during evaluation and resuscitation) - Pediatric patients greater than 5 RBCs/HPF
10
Q
Pediatric patients have higher risk for renal trauma because of the ff: ___
A
Larger comparative kidney size
Less perirenal fat
Non-ossified bones
Less relative rib coverage over the kidneys in children
11
Q
Children do not become hypotensive with major blood loss due to:
A
High catecholamine output after trauma, which maintains blood pressure until approximately 50% of blood volume has been lost.
12
Q
Best method for GU imaging in trauma
A
Contrast-enhanced CT with immediate and delayed images
13
Q
Findings on CT suspicious for MAJOR injury:
A
(1) medial hematoma, suggesting vascular injury; (2) medial urinary extravasation, suggesting renal pelvis or ureteropelvic junction avulsion injury; (3) global lack of contrast enhancement of the parenchyma, suggesting renal artery occlusion; and (4) the combination of two or more of the following: large hematoma greater than 3.5 cm, medial renal laceration, and vascular contrast extravasation (suggesting brisk active bleeding), which constitute an AAST grade IVb injury
14
Q
Main purpose of the one-shot IVP:____
How to do the one-shot IVP: ___
A
Assess the presence of a functioning contralateral kidney.
Only a single film is taken 10 minutes after IV injection (IV push) of 2 mL/kg of contrast material.
15
Q
Non-operative management is the STANDARD OF CARE in: ___
A
Hemodynamically stable, well-staged patients AAST grades I-IVa, regardless of mechanism
16
Q
Routine follow-up CT imaging for NOM of Grade IV-V renal injuries is prudent at ___ post-injury to evaluate for: ___
A
48-72 hours
Urinoma
Hematoma
** Significant complications almost always present with symptoms (fever, flank pain, decreasing hematocrit, hematuria)
17
Q
Absolute indications for operative management (4): ___
A
(1) hemodynamic instability with no or transient response to resuscitation,
(2) expanding/pulsatile renal hematoma (usually indicating renal artery laceration),
(3) suspected renal vascular pedicle avulsion, and
(4) ureteropelvic junction avulsion
18
Q
Relative indications for operative management (4): ___
A
(1) urinary extravasation with significant renal parenchymal devascularization (older data suggested a higher complication rate than average if watched, but these also can be closely observed)
(2) renal injury together with colon/pancreatic injury (these patients have a higher complication rate if their renal injury is not repaired at the time of colon/ pancreatic injury, but the renal injury may be closely observed after repair of the enteric injury)
(3) arterial thrombosis
(4) urinary extravasation from parenchymal injury
19
Q
Surgical exploration is best by ___ approach, allows inspection of: ___
A
Transabdominal approach
Intra-abdominal organs and bowel
20
Q
Principles of renal reconstruction after traumaL ___
A
Complete renal exposure
Measures for temporary vascular control
Limited debridement of nonviable tissue
Hemostasis by individual suture ligation of bleeding vessels
Watertight closure of the collecting system if necessary/possible, re-approximation of the parenchymal defect
Coverage with nearby fascio-adipose flaps (Gerota fascia or omentum) if feasible
Liberal use of drains
21
Q
For unilateral arterial thrombosis:
For bilateral arterial thrombosis:
A
UNILATERAL: revascularization rarely results in a successful salvage or a viable kidney. As long as the contra-lateral kidney is normal, observation is often the best management.
BILATERAL: revascularization should be attempted, as up to 56% of patients can potentially avoid dialysis by prompt intervention
22
Q
Basic mechanisms for arterial hypertension as a complication of trauma:
A
(1) renal vascular injury, leading to stenosis or occlusion of the main renal artery or one of its branches (Goldblatt kidney)
(2) compression of the renal parenchyma with extravasated blood or urine (Page kidney)
(3) post-trauma arteriovenous fistula.
23
Q
Best imaging study for detecting ureteral injuries
A
CT urography with delayed images
24
Q
CT findings suggestive of ureteral injury
A
Contrast extravasation
Delayed ipsilateral nephrogram
Ipsilateral hydronephrosis, Lack of contrast in the distal ureter
Periureteral urinoma
25
Most sensitive radiographic test for ureteral injury
Retrograde ureterogram
(RGP)
** BUT it is time-consuming and cumbersome
26
Management options for ureteral injuries:
UPPER:
MIDDLE:
LOWER:
Upper: direct ureteroureterostomy
Transureteroureterostomy
Middle:
Direct ureteroureterostomy
Transureteroureterostomy
Lower:
Reimplantation
Psoas hitch
27
Repair of the injured ureter should be performed: ___
At the SAME time as the initial laparotomy, in a stable patient
28
Principles of management of injured ureter:
1. Mobilize the injured ureter carefully, sparing the adventitia widely.
2. Debride the ureter minimally but judiciously until edges bleed
3. Repair ureters with spatulated, tension-free, stented watertight anastomosis, using fine absorbable sutures and retroperitoneal drainage afterward.
4. Retroperitonealize the ureteral repair by closing peritoneum
5. DO NOT tunnel ureteroneocystostomies but rather create a widely spatulated nontunneled anastomosis.
6. With severely injured ureters, blast effect, concomitant vascular surgery, and other complex cases, consider omental interposition to isolate the repair when possible.
7. If immediate repair is not possible, or the patient hemodynamically unstable, one management option is to ligate the ureter with long silk or polypropylene suture, and plan to repair it later,
29
Management:
Intact contused ureters: ___
Large areas of contusion that appear non-viable: ___
Intact: ureteral stenting (cystoscopy or cystotomy); maintain for 6 weeks
Large/non-viable: excision of damaged area and U-U or ureteroneocystosytomy
30
If ureter is ligated (tied but not cut): ___
Remove ligature and observe for viability
If viability questionable = ureteroureterostomy or ureteral reimplantation
31
Ureteral perforation during URS: ___
Treated by ureteral stenting
32
What is the incidence of urinary tract trauma?
10%
33
How common is renal trauma?
1-5% of all trauma
34
What is the male to female ratio when it comes to urogenital trauma?
3:1
35
How effective are airbags when it comes to renal trauma?
decreases renal injuries by 40-50%
36
How common is renal vasculary injury in renal trauma?
<5%
37
What are the indication for imaging in renal trauma?
Blunt trauma:
gross hematuria
microhematuria + hypotension
rapid desceleration injuries
Penetrating trauma:
all with hematuria
clinical suspicion (inlet or exit wound)
38
What laboratory tests should be performed on a patient who has suffered renal trauma?
Urine
Hematocrit
Creatinine (8 hrs before change can be measured)
39
When should on shot intraoperative IVP be used?
In those, unstable, subjected to laparotomy
to see the condition of the contralateral kidney
2 ml/kg contrast, single x-ray after 10 min
40
What is importernt to remember when performing a CT on a patient with a suspected urinary tract injury?
2 phase study
both a vascular phase and a
delayed phase afte 10 min to look for peri-renal or ureteral contrast extravasation
41
When should you use an MRI to evaluate a patient with suspected urinary tract injury?
CT is not availabel
Iodine allergy
CT findings are equivocal
42
When is angiography indicated for a patient with suspected urinary tract injury?
stable patient when therapeutic angio-embolization is needed
or
non enhanced cortex on CT-scan (suspection of total avulsion, renal artery thrombosis or severe concussion causing vascular spasm)
43
Renal score AAST Grade 1:
contusion or subcapsular hematoma
44
Renal score AAST Grade 2:
Cortical laceration <1 cm no extra-vasation
45
Renal score AAST Grade 3:
Cortical laceration >1 cm no extra-vasation
46
Renal score AAST Grade 4:
Laceration > 1cm with injury to the collecting system
and/or
Thrombosed artery or segmental vein injury
47
Renal score AAST Grade 5:
Shattered kidney
and/or
Renal pedicle avulsion
48
Indication for renal exploration:
continues hemodyamic instability (in spite of resuscitation)
expanding retroperitoneal hematoma
pre-existing abnormality (hydronephrosis, tumour)
49
What is the treatment when PNL has caused trauma to the colon?
```
Liberal drainage of the PCS
Keep the tube in the perinephric and pericolic spaces
Antibiotics
Stop oral feedings for 5 days
Success rate is very high
```
50
What is the most common cause of ureteral trauma?
Iatrogenic 75%
blunt 18%
penetrating 7%
51
What type of iatrogenic trauma is most common?
Gynecologic 70%
General surgery 14%
Urology 16%
52
Ureteral trauma AAST Grade 1:
hematoma and/or contusion
53
Ureteral trauma AAST Grade 2:
laceration < 50% of circumference
54
Ureteral trauma AAST Grade 3:
laceration > 50% of circumference
55
Ureteral trauma AAST Grade 4:
complete tear < 2 cm loss
56
Ureteral trauma AAST Grade 5:
complete tear ≥ 2 cm loss
57
How often is an injury to the ureter overlooked?
60%
58
What can be symptoms that leads to a late diagnosis of ureteral injury?
```
Leakage
Acute obstruction
Sepsis
Uro-ascites
Urinoma
Fistula
```
59
When should surgical repair of a urethral injury be undertaken?
Within one week
or
after 2-3 months
60
Examples of surgical techniques for re-continuity of urethers:
end to end anastomosis
Transuretero-ureterostomy
Uretero-calycostomy
Boari flap ± psoas hitch
Auto transplantation
Ileal segment interposition
61
What is the most common cause of bladder trauma?
70-80% due to pelvic fracture
62
Symptoms of bladder injury:
| + symptoms of silent rupture
Hematuria
Pain
No desire or inability to void
Urine leak and/or blood through the vagina
```
in silent rupture:
ileus
ascites
peritonitis
uremia
sepsis
toxemia
```
63
Bladder trauma AAST Grade 1:
concussion, intramural hematoma partial thickness
64
Bladder trauma AAST Grade 2:
extra peritoneal rupture < 2 cm
65
Bladder trauma AAST Grade 3:
extra peritoneal rupture > 2 cm or intra peritoneal rupture < 2 cm
66
Bladder trauma AAST Grade 4:
Intraperitoneal rupture ≥ 2 cm
67
Bladder trauma AAST Grade 5:
extra or intra peritoneal laceration extending into the bladder neck or trigone
68
Radiological diagnosis of bladder trauma:
Retrograde gravity cystography (also excludes urethral trauma)
CT can be used especially if other trauma is present
69
When is surgical repair indicated in bladder trauma?
Intraperitoneal rupture or extraperitoneal rupture when drainage is not guaranteed or surgery is indicated for other injuries
70
Postoperative care after surgical treatment of bladder injury:
Antibiotics
Catheter 10 days
Retrograde cystogram before catheter removal
(if leakage, catheter for another 5 days)
71
Penile trauma AAST Grade 1:
Cutaneous laceration or contusion
72
Penile trauma AAST Grade 2:
Laceration of Buck's fascia (cavernosum) withour tissue loss
73
Penile trauma AAST Grade 3:
Cutaneous avulsion, laceration through glans or meatus
| or cavernosal or urethral defect < 2cm
74
Penile trauma AAST Grade 4:
partial penectomy
| or cavernosal or urethral defect ≥ 2 cm
75
Penile trauma AAST Grade 5:
total penectomy
76
What is the most common cause of posterior urethral trauma?
pelvic fracture
present i 4-14 % of pelvic fracture cases
males>females
77
How often is posterior urethral injury associated with bladder rupture?
10-17%
78
How common is urethro-rectal fistula after posterior urethral injury?
up to 8%
79
What clinical signs should arise suspicion of posterior urethral injury?
Blood at the meatus
Inability to urinate
Full bladder
80
Urethral injury AAST Grade 1:
Contusion: blood at the meatus
81
Urethral injury AAST Grade 2:
Stretch injury: elongation of the urethra without extravasation
82
Urethral injury AAST Grade 3:
Partial disruption: extravasation at injury site with bladder visualization
83
Urethral injury AAST Grade 4:
Complete disruption: Extravasation at the injury site without bladder visualization < 2 cm urethral separation
84
Urethral injury AAST Grade 5:
Complete disruption: Complete transection with ≥ 2 cm separation or extension to the prostate of vagina
85
How do you confirm an urethral injury?
Urethrography
86
What options are there when it comes to the timing of surgical treatment for an urethral injury?
Immediate: < 48H
Delayed: 2 days- 2 weeks
Deferred: > 3 months
87
How should a complete posterior urethral rupture be treated?
Immediate realignment (with catheter for 4-8 weeks)
then Deferred urethroplasty
sucessrate 80-98%
88
What are the most common complications from posterior urethral injuries?
Impotence
| Incontinence
89
How should you treat Anterior Urethral Trauma?
Open repair over catheter alignment
| or suprapubic tube without repair
90
What kind of trauma can cause Anterior Urethral injury?
Straddel injury
Sexual intercourse
Gunshots
Iatrogenic trauma
91
Clinical Vignette:
A 28-year-old male comes to the emergency department after a motor vehicle accident. The patient is stable but reports pain in the abdominal area. Urinalysis shows gross hematuria.
Multiple-Choice Options:
A. Perform renal imaging immediately
B. Wait for systolic blood pressure to drop below 90 mmHg before imaging
C. Do not perform renal imaging; gross hematuria is not indicative of renal trauma
D. Perform renal imaging only if the patient reports flank pain
Correct Answer:
A. Perform renal imaging immediately
Explanation:
In the case of stable blunt trauma patients with gross hematuria, renal imaging is indicated.
Memory Tool:
Remember the acronym "SGH" for "Stable + Gross Hematuria" to quickly recall this indication.
Specific Reference Citation:
Modified from Morey AF, Brandes S, Dugi DD 3rd, et al. Urotrauma: AUA guideline. J Urol. 2014;192(2):327–335.
Rationale for Importance:
Timely diagnosis of renal trauma is crucial for appropriate management and can prevent further complications.
92
Clinical Vignette:
A 40-year-old female falls from a ladder and presents with microscopic hematuria. Her systolic blood pressure is 88 mmHg.
Multiple-Choice Options:
A. Perform renal imaging immediately
B. Wait for additional symptoms before imaging
C. Only perform imaging if there is gross hematuria
D. Do not perform imaging; microscopic hematuria is not severe enough
Correct Answer:
A. Perform renal imaging immediately
Explanation:
In stable blunt trauma patients with microscopic hematuria and a systolic blood pressure of <90 mmHg, renal imaging is indicated.
Memory Tool:
Think "Micro + Low BP" to remember this indication.
Specific Reference Citation:
Modified from Morey AF, Brandes S, Dugi DD 3rd, et al. Urotrauma: AUA guideline. J Urol. 2014;192(2):327–335.
Rationale for Importance:
Microscopic hematuria combined with low blood pressure could be indicative of internal bleeding or renal trauma, necessitating quick diagnostic action.
93
Clinical Vignette:
A 22-year-old male comes to the emergency room after a skiing accident. He suffered a significant blow to his flank and shows flank ecchymosis.
Multiple-Choice Options:
A. Perform renal imaging only if there is hematuria
B. Wait and see if other symptoms develop
C. Perform renal imaging immediately
D. Only perform imaging if systolic blood pressure drops below 90 mmHg
Correct Answer:
C. Perform renal imaging immediately
Explanation:
In cases where the mechanism of injury is concerning for renal trauma, such as rapid deceleration, significant blow to the flank, rib fracture, or flank ecchymosis, renal imaging is indicated.
Memory Tool:
Use the mnemonic "RRFF" for "Rapid deceleration, Rib fracture, Flank blow, Flank ecchymosis."
Specific Reference Citation:
Modified from Morey AF, Brandes S, Dugi DD 3rd, et al. Urotrauma: AUA guideline. J Urol. 2014;192(2):327–335.
Rationale for Importance:
Identifying renal trauma is critical for management, particularly if the mechanism of injury is highly suggestive of it.
94
Question 1:
A 25-year-old male comes into the ER after a minor motorcycle accident. He complains of pain in the flank region. Lab tests show microscopic hematuria. Further urologic studies reveal no abnormalities. According to the American Association for the Surgery of Trauma Organ Injury Scale, how would his renal injury be graded?
A. Grade 1
B. Grade 2
C. Grade 3
D. Grade 4
Correct Answer:
A. Grade 1
Explanation:
This patient has microscopic hematuria with normal urologic studies, which falls under Grade 1 renal injury according to the American Association for the Surgery of Trauma Organ Injury Scale.
Memory Tool:
Think of Grade 1 as "one minor sign"—either a subcapsular hematoma that's not expanding or microscopic/gross hematuria with normal urologic studies.
Reference Citation:
Modified from Moore EE, et al. J Trauma. 1989;29(12):1664–1666; Buckley JC, McAninch JW. J Trauma. 2011;70(1):35–37
Rationale for Question:
The question targets knowledge around Grade 1 of renal injury classification. Understanding how to classify renal injuries is crucial in diagnosis and management.
95
Question 2:
A 45-year-old patient is brought to the ER after a severe car accident. Upon examination, it is found that the kidney is completely shattered. How would this renal injury be graded based on the American Association for the Surgery of Trauma Organ Injury Scale?
A. Grade 2
B. Grade 3
C. Grade 4
D. Grade 5
Correct Answer:
D. Grade 5
Explanation:
A completely shattered kidney would fall under Grade 5 renal injury, which is the most severe grade according to the American Association for the Surgery of Trauma Organ Injury Scale.
Memory Tool:
Think of Grade 5 as the "5 alarm fire"—it's the worst case scenario.
Reference Citation:
Modified from Moore EE, et al. J Trauma. 1989;29(12):1664–1666; Buckley JC, McAninch JW. J Trauma. 2011;70(1):35–37
Rationale for Question:
This question tests the ability to classify a severe renal injury. Differentiating between the grades is important for both diagnosis and treatment planning.
96
Question 3:
A 38-year-old man is admitted to the ER after a skiing accident. Imaging shows a laceration that is less than 1 cm in depth into the renal cortex. No urinary extravasation is noted. According to the American Association for the Surgery of Trauma Organ Injury Scale, what grade of renal injury does this patient have?
A. Grade 1
B. Grade 2
C. Grade 3
D. Grade 4
Correct Answer:
B. Grade 2
Explanation:
A laceration that is less than 1 cm in depth into the cortex without urinary extravasation falls under Grade 2 renal injury according to the American Association for the Surgery of Trauma Organ Injury Scale.
Memory Tool:
For Grade 2, think "two layers deep but not too deep"—meaning the laceration is in the cortex, but not deeper or involving urinary extravasation.
Reference Citation:
Modified from Moore EE, et al. J Trauma. 1989;29(12):1664–1666; Buckley JC, McAninch JW. J Trauma. 2011;70(1):35–37
Rationale for Question:
This question tests your ability to categorize renal injuries that are more severe than Grade 1 but less severe than Grade 3, focusing on laceration depth and urinary extravasation.
97
Question 4:
A 50-year-old woman falls from a ladder and is taken to the ER. Imaging reveals a renal laceration greater than 1 cm into the parenchyma. However, there is no rupture of the collecting system or urinary extravasation. How would you grade this renal injury based on the American Association for the Surgery of Trauma Organ Injury Scale?
A. Grade 1
B. Grade 2
C. Grade 3
D. Grade 4
Correct Answer:
C. Grade 3
Explanation:
A laceration greater than 1 cm into the parenchyma, without collecting system rupture or urinary extravasation, classifies as a Grade 3 renal injury.
Memory Tool:
Grade 3 can be remembered as "3 dimensions"—it goes beyond the superficial layers into the parenchyma but stops short of affecting the collecting system.
Reference Citation:
Modified from Moore EE, et al. J Trauma. 1989;29(12):1664–1666; Buckley JC, McAninch JW. J Trauma. 2011;70(1):35–37
Rationale for Question:
The question is designed to test your understanding of Grade 3 renal injuries, which involve a significant laceration depth but stop short of involving the collecting system or causing urinary extravasation.
98
Question 5:
A patient arrives in the ER after experiencing a significant blunt trauma to the abdomen. Imaging reveals parenchymal laceration that extends through the renal cortex, medulla, and collecting system. What grade would this renal injury be categorized under according to the American Association for the Surgery of Trauma Organ Injury Scale?
A. Grade 3
B. Grade 4
C. Grade 5
D. Grade 2
Correct Answer:
B. Grade 4
Explanation:
This patient's renal injury involves a parenchymal laceration extending through multiple layers including the renal cortex, medulla, and collecting system. This fits the criteria for a Grade 4 renal injury.
Memory Tool:
For Grade 4, remember "Four Layers Torn" - it involves tearing through the cortex, medulla, and collecting system.
Reference Citation:
Modified from Moore EE, et al. J Trauma. 1989;29(12):1664–1666; Buckley JC, McAninch JW. J Trauma. 2011;70(1):35–37
Rationale for Question:
This question tests the classification of Grade 4 renal injuries, which are severe and involve multiple layers, including the collecting system.
99
Clinical Vignette:
A 45-year-old male patient suffers a blunt trauma injury during a motor vehicle accident. Imaging reveals a large perirenal hematoma. You measure the hematoma and it is 4 cm in size.
Multiple-Choice Options:
A) The hematoma size is not concerning and no immediate intervention is needed.
B) The hematoma is a high-risk criterion for intervention due to its size.
C) The hematoma size is concerning only if the patient is a child.
D) The hematoma size indicates the need for immediate renal removal.
Correct Answer:
B) The hematoma is a high-risk criterion for intervention due to its size.
Explanation:
In the table, one of the high-risk criteria for intervention in Grades 4 to 5 renal injuries for adults is a large perirenal hematoma measuring more than 3.5 cm. In this case, the 4 cm hematoma is above the stated threshold.
Memory Tool:
Remember, "3.5 to Stay Alive." If a hematoma is larger than 3.5 cm in adults, it's a high-risk criterion for intervention.
Reference Citation:
Paragraph 1, Table 52.3
Rationale for Importance:
Understanding the high-risk criteria is crucial for immediate and effective intervention to minimize morbidity and mortality in severe renal injuries.
100
Clinical Vignette:
A 10-year-old girl experiences a fall from height. Imaging shows vascular contrast extravasation in the kidney.
Multiple-Choice Options:
A) This is not a high-risk criterion for intervention.
B) This indicates that the child should undergo immediate intervention.
C) Vascular contrast extravasation only matters in adult patients.
D) Immediate renal removal is needed.
Correct Answer:
B) This indicates that the child should undergo immediate intervention.
Explanation:
The table outlines vascular contrast extravasation as a high-risk criterion for intervention in both children and adults with Grades 4 to 5 renal injuries.
Memory Tool:
Think "Vascular Extravasation, Immediate Consideration."
Reference Citation:
Paragraph 1, Table 52.3
Rationale for Importance:
Recognizing vascular contrast extravasation as a high-risk factor helps to quickly triage patients for the necessary treatment, potentially saving renal function.
101
Clinical Vignette:
A 30-year-old woman comes in with a renal injury. Imaging shows a medial renal laceration.
Multiple-Choice Options:
A) This is not a high-risk criterion for intervention.
B) This is a high-risk criterion for intervention.
C) This is a high-risk criterion for children but not adults.
D) Immediate renal removal is advised.
Correct Answer:
B) This is a high-risk criterion for intervention.
Explanation:
Medial renal laceration is listed in the table as a high-risk criterion for intervention in Grades 4 to 5 renal injuries for both adults and children.
Memory Tool:
Think "Medial Means Mending Needed" for medial renal lacerations.
Reference Citation:
Paragraph 1, Table 52.3
Rationale for Importance:
Prompt recognition of medial renal laceration as a high-risk criterion allows for immediate intervention, which is crucial for patient outcomes.
102
Clinical Vignette:
A 3-year-old girl presents with an asymptomatic abdominal mass. Her medical history reveals that she has Denys-Drash syndrome.
Multiple-Choice Options:
A) Less than 5% risk of developing Wilms Tumor
B) 10%–20% risk of developing Wilms Tumor
C) 50% risk of developing Wilms Tumor
D) Low but unquantifiable risk of developing Wilms Tumor
Correct Answer:
C) 50% risk of developing Wilms Tumor
Explanation:
Denys-Drash syndrome is associated with a high risk (50%) of developing Wilms Tumor, according to the table provided.
Memory Tool:
Denys-Drash and "Half Dash" - remember that Denys-Drash gives you a 50% (half) chance of dashing into Wilms Tumor.
Reference Citation:
Table 53.4, paragraph 1
Rationale for Question:
Given the high risk of developing Wilms Tumor in Denys-Drash syndrome, it is crucial for urologists to be aware of this association for diagnosis and management.
103
Clinical Vignette:
A 6-month-old boy with Beckwith-Wiedemann syndrome has been referred to you. His parents are concerned about the risk of cancer.
Multiple-Choice Options:
A) Locus 11p13
B) Locus 13q12.3
C) Locus IGF2, H19
D) Locus 17q11
Correct Answer:
C) Locus IGF2, H19
Explanation:
Beckwith-Wiedemann syndrome is associated with a moderate risk of developing Wilms Tumor and is linked to the IGF2, H19 locus.
Memory Tool:
Beck-"With"-Wiedemann, I-"G"-F2, H-"19" - associate the "with" in Beckwith to "IGF2, H19."
Reference Citation:
Table 53.4, paragraph 1
Rationale for Question:
Understanding the genetic loci associated with each syndrome can be crucial for genetic counseling and targeted screening.
104
Clinical Vignette:
A 7-year-old boy with Neurofibromatosis is undergoing routine check-up. The parents are anxious about his risk for Wilms Tumor.
Multiple-Choice Options:
A) High risk
B) Moderate risk
C) Low risk
D) Unable to determine the risk
Correct Answer:
C) Low risk
Explanation:
Neurofibromatosis is categorized under low-risk syndromes for developing Wilms Tumor, as indicated in the table.
Memory Tool:
"Neuro-Low" - Neurofibromatosis has a low risk for Wilms Tumor.
Reference Citation:
Table 53.4, paragraph 1
Rationale for Question:
This information is important to relieve parental anxiety and guide the need for further screening for Wilms Tumor in low-risk populations.
105
In traumatic rupture of the testicle, resection of devitalized testicular tissue and suture repair of the tunica albuginea is indicated:
A. Always
B. In case of haematocele
C. In case of infertility to prevent generation of spermatic autoantibodies
D. Only in cases of an atrophic or absent contralateral testicle
A. Always
106
Which treatment is recommended for penile fracture?
A. Conservatie management
B. Haematoma drainage and indwelling catheter
C. Delayed surgical intervention after antibiotic treatment
D. Early surgical intervention with closure of the tunica albuginea
D. Early surgical intervention with closure of the tunica albuginea
107
What is the gold standard diagnostic method for the radiographic assesment of stable patients with renal trauma?
A. Intravenous urogram
B. Ultrasonography
C. Magnetic resonance imaging
D. Computerised tomography
D. Computerised tomography
108
Which statement is true regarding blunt bladder rupture injuries?
A. They co-exist with urethral disruption in ±50% of cases
B. They are present in ±90% of patients with pelvic fractures
C. High mortality is primarily related to non-urological comorbidities
D. Extraperitoneal rupture is always amenable to non-operative treatment
C. High mortality is primarily related to non-urological comorbidities
109
When a bladder rupture is treated surgically, the preferred method is:
A. A single-layer vesicorraphy with absorbable sutures
B. A single-layer vesicorraphy with non-absorbable sutures
C. A two-layer esicorraphy with absorbable sutures
D. A two-layer esicorraphy withnon-absorbable sutures
C. A two-layer esicorraphy with absorbable sutures
110
The risk for erectile dysfunction after a traumatic posterior urethral rupture associated with pelvic fracture is:
A. Less than 10%
B. About 25%
C. About 50%
D. Over 75%
C. About 50%
111
3 years ago, a 50-year-old woman underwent abdominal hystero- and bilateral salpingo-oophorectomy, followed by pelvic radiotherapy for carcinoma of the cervix. 3 months ago se presented with a right-sided hydronephrosis and a double-J ureteral stent was placed. Today she presents in the emergency room with anaemia, frank hematuria and is haemodynamic instable. What is the most likely diagnosis?
A. Radiocystitis
B. Uretero-iliacal fistula
C. Vesico-vaginal fistula
D. Bladder invasion of cervical cancer recurrence
B. Uretero-iliacal fistula
112
The imaging tool of choice in evaluation and classification of a blunt renal trauma is:
A. MR urography
B. Ultrasonoghraphy
C. CT-scan with contrast
D. Renographic isotope study
C. CT-scan with contrast
113
What grade of injury is a renal cortical laceration of >1cm without urinary extravasation according to the American Association of the surgery of Trauma (AAST)?
A. Grade 2
B. Grade 3
C. Grade 4
D. Grade 5
B. Grade 3
114
Trauma imaging
Renal :
Ureteral :
Bladder :
Urethral :
Testicular:
CTU
CTU
Cystogram
RUG/Cysto
Ultrasound
115
Indications for CTU
1. ____ hematuria
2. Micro hematuria with ____
1. gross hematuria
| 2. microhematuria + hypotension
116
Must get f/up imaging for grade ____ renal lacerations
4-5
117
Non-expanding subcapsular hematoma without parenchymal laceration
Grade ___ kidney injury
1
118
Non-expanding peri-renal hematoma
Grade ___ kidney injury
2
119
<1cm in depth kidney laceration w/o urine extravasation
Grade ___ kidney injury
2
120
>1 cm in depth kidney laceration w/p urinary extravasation
Grade ___ kidney injury
3
121
Parenchymal laceration through cortex & collecting system
Grade ___ kidney injury
4
122
Injury of renal artery or vein with contained hemorrhage
Grade ___ kidney injury
4
123
Completely shattered kidney
Grade ___ kidney injury
5
124
Complete avulsion of renal hilum with devascularized kidney
Grade ___ kidney injury
5
125
Treat of XGP kidney on boards
nephrectomy
126
In unstable patients, manage ureteral injuries with ____
drainage (PCN vs stent)
127
Management of traumatic ureteral contusions
Stenting vs resection + primary repair
128
Management of ureteral injury above iliac vessels
primary repair (U-U)
129
Management of ureteral injury below iliac vessels
reimplant
130
Imaging for pt with gross hematuria + pelvic fracture
Retrograde cystogram (XR or CT)
*use 300-400cc*
131
Indications to operatively repair an extraperitoneal bladder injury
Bladder neck injury
Foreign body
+vaginal injury
Failure of bladder drainage
132
Diagnostic exam for blood at meatus after pelvic trauma
RUG
133
Immediate management of complete pelvic fracture urethral injury with no contrast reaching bladder on RUG
SPT
134
Immediate management of partial pelvic fracture urethral injury with some contrast reaching bladder on RUG
Primary realignment vs SPT
135
Penetrating trauma to scrotum - management?
Scrotal exploration
136
Ecchymosis of penis with snapping sound followed by detumescence - diagnosis?
penile fracture
137
Imaging for penile fracture if exam is equivocal
penile u/s
138
Penile fracture is due to a defect in _____
tunica albuginea
139
Always evaluate the ____ during penile fracture surgery
urethra
**9-20% of fractures have concomitant urethral injury**
140
Care for amputated penis
Wrap in saline soaked gauze, put in plastic bag, and place on ice
141
The best indication of significant urinary system injury is **gross hematuria**. However, the absence of hematuria **does/does no**t exclude a significant GU injury.
gross hematuria
does not
142
2. Evaluation of urologic trauma in children differs from adults in that children: (3).
(1) are at greater risk for renal trauma,
(2) often do not become hypotensive with major blood loss,
(3) have a higher propensity for renal anomalies.
143
**Rapid deceleration** from a fall from height or a high-velocity impact may result in injuries at points :
RAPID DECELERATIOn
## Footnote
**points of fixation such as the ureteral pelvic junction and the renal hilum (renal artery intimal disruption).**
144
. The degree of hematuria and the severity of renal injury are/are not consistently correlated.
The degree of hematuria and the severity of renal injury **are not** consistently correlated.
145
Criteria for radiologic imaging include (5)
(1) all penetrating trauma,
(2) high-impact rapid deceleration trauma,
(3) all blunt trauma with gross hematuria,
(4) all blunt trauma with microhematuria and hypotension, and
(5) pediatric patients with hematuria.
146
TF Adult patients with microscopic hematuria without shock may be observed without imaging studies.
true microscopic hematuria
147
Findings suggestive of a major renal injury on CT include: (5)
1. MEDIAL LACERATION
2. PERINEPHRIC HEMATOMA SIZE
3. INTRAVASCULAR CONTRAST EXTRAVASATION
4. MEDIAL URINARY EXTRAVASATION
5. DEVITALIZED RENAL FRAGMENTS
148
TF Nonoperative management for renal injuries is preferred in the hemodynamically stable patient, particularly with grades I to III renal injuries.
TRUE
149
Exploration of low-velocity renal gunshot wounds is not mandatory in selected cases. Such patients with isolated __ with stable and contained h\_\_\_ who are hemodynamically stable, with no ____ injury, may be observed expectantly.
renal parenchymal lacerations
hematomas
no intra-abdominal organ injury
150
10. Absolute indications for renal exploration are: (4)
(1) hemodynamic instability with shock
(2) expanding or pulsatile hematoma,
(3) suspected renal pedicle avulsion,
(4) uncontained retroperitoneal hematoma.
151
relative indications for intervention for renal trauma: perinephric ___ size, intravascular \_\_\_, ___ renal fragments, arterial \_\_\_, and ___ contrast extravasation
Perinephric hematoma size, intravascular contrast extravasation, devitalized real fragments, renal thrombosis
152
\_\_ is the management technique of immediate control of bleeding, and fecal and urinary leak only, in the unstable patient. ___ is deferred until the patient is stable and fully resuscitated. For ureter injuries this entails \_\_,\_\_, __ and \_\_.
At a staged/planned laparotomy, the ureter is \_\_
**“Damage control”** is the management technique of immediate control of bleeding, and fecal and urinary leak only, in the unstable patient. **Definitive reconstruction** is deferred until the patient is stable and fully resuscitated. For ureter injuries this entails **ligation and nephrostomy, externalizing, or stenting**. At a staged/planned laparotomy, the ureter is **later repaired.**
153
\_\_\_ - Hypertension from renal parenchymal injury
PAGE KIDNEY- Hypertension from renal parenchymal injury
154
When repairing ureteral injuries, the ureteral tissue should be debrided back to a __ to remove all \_\_\_.
When repairing ureteral injuries, the ureteral tissue should be debrided back to a **bleeding-edge** to **remove all traumatized microvascular damaged tissue.**
155
**T/F** Placement of vascular graft aneurysms in proximity of the ureter may cause a periureteral inflammatory reaction and ureteral injury/stenosis.
TRUE,be cautious when placing vascular grafts near ureter!!!
156
Ureteral injuries to the proximal and mid ureter can often be managed by \_\_. The gap being bridged is based on ureter ___ and \_\_\_.
URETROURETEROSTOMY
MOBILIZATION AND ITS ELASTICITY
157
In the stable trauma patient, distal ureteral injuries should be ___ into the bladder. In select cases, a ___ can be considered. If the gap is large, then __ or ___ is the better management.
In the stable trauma patient, distal ureteral injuries should be **reimplanted into the bladde**r. In select cases, a **ureteroureterostomy** can be considered. If the gap is large, then **psoas hitch or Boari bladder flap** is the better management.
158
For delayed ureteral injury, the best diagnostic radiographic test (in the stable patient) to confirm injury, is a \_\_\_
RETROGRADE UROGRAM
159
Ureteral transections should be repaired ___ of the injury, or the repair should be delayed for\_\_\_
WITHIN A WEEK
6 weeks or more
160
It is prudent to isolate the ureteral repair from other injured organs (such as colon) with __ and \_\_
OMENTUM OR PERITONEUM
161
Ureteral injury noted during ureteroscopy should be managed by \_\_\_. When a stent cannot be placed or inadequately diverts the urine, then a \_\_\_should be placed.
ureteral stent placement
nephrostomy tube
162
Ureteral injury occurring during vascular surgery should be repaired and ___ from the graft with normal tissue such as \_\_.
Ureteral injury occurring during vascular surgery should be repaired and i**solated** from the **graft with normal tissue such as omentum.**
163
The basic mechanisms for arterial hypertension as a complication of trauma are (1) renal vascular injury, leading to stenosis or occlusion of the ___ or one of its branches (\_\_ kidney)
(2) compression of the renal parenchyma with extravasated blood or urine (\_\_\_ kidney);
(3) post-trauma ___ fistula.
In these instances, the ___ axis is stimulated by \_\_\_, resulting in hypertension
**GOLDBLATT KIDNEY** -\> stenosis or occlusion of the MAIN RENAL ARTERY or one of its branches
**PAGE KIDNEY**--\> Compression of the renal parenchyma with extravasated blood or urine
**Post trauma arteriovenous fistula**
In these instances, the **reninangiotensin axis** is stimulated by **partial renal ischemia**, resulting in hypertension
164
40 / M Blunt injury, noted hematuria (microscopic) then on BP \<90 SBP--\> abdominal exloration done, on assesment of retroperitoneal hemtoma noted pulsatile hematoma --\> next process
RENAL EXPLORATION INDICATED
165
The indications are uncommon for shot ivp is uncommon, such as
surgeon encounters an ___ hematoma surrounding a kidney during abdominal exploration in an ___ patient without a \_\_\_, and are contemplating renal exploration or nephrectomy.
unexpected retroperitoneal
UNSTABLE TRAUMA
CT SCAN
166
The main purpose of the one-shot IVP is to assess the presence of a **functioning contralateral kidney**.
**functioning contralateral kidney**
167
ONE SHOT IVP Only a single film is taken 10 minutes after IV injection (IV push) of 2 mL/kg of contrast material. The study can also be helpful in assessing for \_\_\_\_extravasation. If the study is normal, exploration of the injured side may \_\_\_. If findings are not near normal, ___ is recommended or the kidney explored to complete the \_\_\_
**10 minutes**
**2 mL/kg of contrast material**
**may be avoided**
**further imaging**
**staging of the injury**
168
Anterior axillary line injury --\> possible damage to : \_\_\_
(renal hilum and pedicle)
169
•Posterior axillary line --\> \_\_
parenchymal renal injury
170
\<1 cm parenchymal depth laceration of renal cortex without urinary extravasation on **bilateral kidneys**
grade 3! Grade 2 ang injury but...
ALWAYS ADVANCE ONE STAGE FOR BILATERAL INJURIES
171
\_\_\_ observation is warranted for patients with renal injury and urinary extravasation such injuries often resolve spontaneously in over 90%, unless (*what kind of avulsion*) is present.
Medial extravasation of contrast from the kidney, with lack of contrast in the distal ureteral on delayed CT imaging, \_\_\_\_
initial
renal pelvis avulsion or proximal ureteral avulsion injury
UPJ AVULSION
172
Urinomas can be distinguished from hematomas by their radiographic characteristics: urinomas range from **\_\_\_(HU)**, whereas hematomas typically are **\_\_(HU)**
0 to 20 Hounsfield units (HU)
greater than 30 HU
173
Surgical exploration of the acutely injured kidney is best by a \_\_\_, which allows complete inspection of intra-abdominal organs and bowel.
transabdominal approach
174
URETERAL INJURY GRADING:
Complete transection with \<2 cm devascularization bilateral ureter
GRADE 4 only
bilateral ureteral injuries are upstaged up to grade iii only
175
Patients with penetrating trauma with any \_\_
or a wound pattern that suggests the possibility of genitourinary injury \_\_
**degree of hematuria**
**should be imaged**
176
\_\_ with delayed images is the best study for detecting ureteral injuries
**CT urography** with delayed images is the best study for detecting ureteral injuries
177
**\_\_** is the most sensitive radiographic test for ureteral injury Although accurate in demonstrating site, presence, and location of extravasation, retrograde ureterography is often __ Thus, it often has a limited role in the **\_\_**, especially if the patient is unstable. Retrograde ureterography is most commonly used to **\_\_\_** because it allows the simultaneous placement of a ureteral stent if possible.
**Retrograde ureterogram** is the most sensitive radiographic test for ureteral injury Although accurate in demonstrating site, presence, and location of extravasation, retrograde ureterography is often **time consuming and cumbersome**. Thus, it often has a limited role in the a**cute trauma setting**, especially if the patient is unstable. Retrograde ureterography is most commonly used to **diagnose initially missed ureteral injuries**, because it allows the simultaneous placement of a ureteral stent if possible.
178
In cases in which ureteral injury is discovered, and retrograde stent placement is not possible (usually secondary to a large gap in the two ends of the transected ureter), **\_\_** and stent placement at the time of **\_\_**, should be performed, when possible
In cases in which ureteral injury is discovered, and retrograde stent placement is not possible (usually secondary to a large gap in the two ends of the transected ureter), **anterograde ureterography** and stent placement at the time of **percutaneous nephrostomy placement**, should be performed, when possible
179
PRINCIPLES OF URETERAL REPAIR
1. Mobilize the injured ureter carefully, **\_\_**, so as not to **\_\_** the ureter further.
2. Debride the ureter minimally but judiciously **\_\_\_**, especially in high-velocity gunshot wounds.
3. Repair ureters with **\_\_, \_\_\_, ___ anastomosis**, using fine **\_\_\_ sutures** and **\_\_\_ drainage** afterward.
4. **Retroperitonealize** the ureteral repair by closing peritoneum over it if possible.
5. Do not tunnel ureteroneocystostomies but rather create a w**idely ___ nontunneled anastomosis.**
6. With severely injured ureters, blast effect, concomitant vascular surgery, and other complex cases, consider __ to isolate the repair when possible.
7. If immediate repair is not possible, or the patient hemodynamically unstable, one management option is to **\_\_\_\_ with long silk or polypropylene suture, and plan to repair it later, or place a nephrostomy tube after ICU resuscitation (damage control**). The other option is a **temporary cutaneous ureterostomy** over a single-J stent or pediatric feeding tube with a suture tied around the ureter proximal to the injury site, in order to secure the stent in place, and to prevent urinary leakage.
1. Mobilize the injured ureter carefully, s**paring the adventitia widely**, so as not to **devascularize** the ureter further.
2. Debride the ureter minimally but judiciously **until edges bleed**, especially in high-velocity gunshot wounds.
3. Repair ureters with s**patulated, tension-free, stented** **watertight anastomosis**, using fine **absorbable sutures** and **retroperitoneal drainage** afterward.
4. **Retroperitonealize** the ureteral repair by closing peritoneum over it if possible.
5. Do not tunnel ureteroneocystostomies but rather create a w**idely spatulated nontunneled anastomosis.**
6. With severely injured ureters, blast effect, concomitant vascular surgery, and other complex cases, consider **omental interposition** to isolate the repair when possible.
7. If immediate repair is not possible, or the patient hemodynamically unstable, one management option is to l**igate the ureter with long silk or polypropylene suture, and plan to repair it later, or place a nephrostomy tube after ICU resuscitation (damage control**). The other option is a **temporary cutaneous ureterostomy** over a single-J stent or pediatric feeding tube with a suture tied around the ureter proximal to the injury site, in order to secure the stent in place, and to prevent urinary leakage.
180
30/M blunt trauma, ureteral injury left on CT UROGRAM --\> delayed
nephrogram, ureteral nonopacification or extravasation
what to do next?
explore ureter
181
most common associated injury with bladder trauma is
pelvic fracture
182
•-triad of blood at the meatus, inability to urinate, and palpably full bladder --\> next step
URETHRAL INJURY
urethral meatus --\> RUGM
183
•PRIAPISM: Unwanted erection of
\> 4 hrs
184
•Indicators of bladder injury
* Suprapubic pain
* Free intraperitoneal fluid
* Inability to void or low urine output
* Clots in urine
* Enlarged scrotum
* Abdominal distention or ileus
185
Extraperitoneal Bladder imaging
## Footnote
* Do not forget to (**1)**
* Properly done **(2**)
* Inflate bladder with at least (**3)**
* At least 3 films, **(4)**
•
* CT cystogram
* Bladder **(5)**
**(6)**
•**(7)** not required
Extraperitoneal Bladder imaging
## Footnote
* Do not forget to **assess upper tracts**
* Properly done **cystogram**
* Inflate bladder with at least **350cc**
* At least 3 films, **plain, with contrast, drainage**
•
* CT cystogram
* Bladder **filled via catheter**
**•2-4% dilution**
•**Drainage film** not required
186
•Open repair of extraperitoneal bladder rupture is done in the presence of complicating features that may result to complications such : (3)
fistula, abscess and prolonged leakage.
187
Intraperitoneal Rupture
## Footnote
* Generally results in large rent in **\_\_**
* Formal surgical repair with **\_\_**
* **\_\_** only applicable in minimal iatrogenic (e.g. Resectoscopic) injuries
Intraperitoneal Rupture
## Footnote
* Generally results in large rent in **dome**
* Formal surgical repair with **absorbable suture is the standard of care**
* **Catheter drainage alone** only applicable in minimal iatrogenic (e.g. Resectoscopic) injuries
188
**\_\_\_**- all four pubic rami
•Fractures resulting in vertical and rotational pelvic instability
à Highest risk of urologic injury
•“Straddle Fracture”-
189
20/M came into er from penetrating injury, palbable bladder unable to void, noted blood at meatus, RUGM DONE showed partial anterior urethral injury,what is next step?
Primary uretrhal repair
penetrating,always primary open repair,if unable then STC
190
•Initial __ is the treatment of choice for major straddle injuries involving the urethra
suprapubic cystotostomy
191
\_\_\_ is the treatment of choice for major straddle injuries involving the urethra
**•Initial suprapubic cystostomy** is the treatment of choice for major straddle injuries involving the urethra
192
GSW Injury to urethra
## Footnote
* Low velocity: **\_\_\_**
* High velocity: **\_\_\_**
* Low velocity: **Primary surgical repair**
* High velocity: **Initial suprapubic urinary diversion , delayed reconstruction**
193
what to do with amputated penis?
§Amputated portion, cleaned and placed in a double bag with ice
§Reconstruction of the urethra and corporeal bodies with microsurgical repair of dorsal penile vessels and nerves
194
•Penile Fracture mgt
•Immediate surgical exploration, repair of tunica albuginea tear
195
penile fracture
A rolling sign is the**\_\_\_** over the site of rupture,may be felt as a discreet firm mass over which the penile skin may be rolled. Patients with a rupture of the **\_\_\_** of the penis can present with findings similar to those of a penile fracture
penile fracture
A rolling sign is the **palpation of the localized blood clot** over the site of rupture,may be felt as a discreet firm mass over which the penile skin may be rolled. Patients with a rupture of the **deep dorsal vein** of the penis can present with findings similar to those of a penile fracture
196
Clssification of priaprism
ISCHEMIC, NON-ISCHEMIC and STUTTERING
ISCHEMIC, NON-ISCHEMIC and STUTTERING
197
•Ischemic/ Low Flow blood gas
PO2, PCO2 and PH
* Ischemic/ Low Flow blood gas
* PO2= \<30 mmHg
* PCO2= \>60 mmHg
* pH-below 7.25
**\*non ischemic/HIGH FLOW:**
PO2= \>90 mmHg
PCO2= \< 40 mmHg
pH= 7.4
**Mixed venous blood**
PO2= 40 mmHg
PCO2= 50 mmHg
Ph= 7.35
198
Medical management priapism
•Evacuation of blood and irrigation of the corpora cavernosa along with intracavernous injection of an ____ agent
**\_\_\_** is the agent of choice
* Medical management
* Evacuation of blood and irrigation of the corpora cavernosa along with intracavernous injection of an **alpha adrenergic sympathomimetic agent**
**•Phenylephrine** is the agent of choice
199
surgical management priapism
* Surgical management
* Distal shunting (Winter’s or El Ghorab)
* Proximal shunting (Quackles or Sacher)
