Trauma and Fistulas

Question 1

When should you order imaging (CT a/p with contrast immediate and delayed imaging) in a BLUNT trauma patient when you are concerned about renal trauma?

Answer 1

Guideline 1: You should order imaging in a stable patient with gross hematuria or who is unstable (systolic < 90) AND with microscopic hematuria (of any level).

In a child order CT for any child with gross hematuria or microscopic hematuria > 50 RBC/HPF (no need to be hypotensive)

Question 2

What mechanism of injury should make you suspicious of renal injury, prompting you to order imaging (CT with contrast and with delayed imaging)?

Answer 2

Guideline 2: rapid deceleration injury, significant blow to flank, rib fractures, flank ecchymosis, or penetrating injury of abdomen, flank, or lower chest.

Question 3

In hemodynamically stable patients with renal injuries, what is first line management?

Answer 3

Guideline 4: non-invasive management strategies including hemodynamic monitoring, serial H/H, reduced activity (possible bedrest).

Question 4

How do you perform a one-shot IVP?

Answer 4

Inject 2 ml/kg contrast (150 ml max) into IV and take x-ray 10 minutes later

Question 5

You can initially observe a stable patient with renal parenchymal injury. When is prompt intervention warranted?

Answer 5

Guideline 6: Endoscopic or open surgery is warranted when there is concern for renal pelvis or proximal ureteral avulsion is expected (see large medial urinoma with contrast extravasation and no distal ureteral contrast on delayed imaging.

Question 6

When should you take a renal trauma patient to surgery?

Answer 6

Guideline 5: When they are hemodynamically unstable and fail to respond to resuscitation OR are hemodynamically unstable and have a large perirenal hematoma (> 4 cm), with a deep or complex renal laceration (grade 3-5 injury).

This can be surgery or angioembolization (if patient stable enough)

Question 7

What is the 2018 AAST Renal injury grading system?

Answer 7

Grade 1: subcapsular hematoma, with or without laceration

Grade 2: superficial laceration < 1 cm, not involving the collecting system
perirenal hematoma confined to the perirenal fat

Grade 3: laceration > 1 cm, not involving the collecting system
vascular injury or active bleed confined to the perirenal fascia

Grade 4: any laceration involving the collecting system with urinary extravasation OR complete UPJ disruption OR vascular injury to a segmental renal artery or vein OR segmental infarction OR active bleeding beyond the fascia (in the retroperitoneum)

Grade 5: Shattered kidney OR avulsion of the renal hilum or laceration of the main kidney or vein causing devasularization OR devascularized kidney with active bleeding

Question 8

What renal trauma patient needs follow up CT imaging in the hospital?

Answer 8

Guideline 7: AAST grade 4 or 5 OR signs of complications (fever, worsening flank pain, ongoing blood loss, abdominal distention)

Question 9

What patient with a renal injury needs urinary drainage with a ureteral stent (which can be augmented with a perc neph and/or drain and/or foley) during observation?

Answer 9

Guideline 8: enlarging urinoma on follow up imaging, fever, increasing pain, ileus, fistula or infection

Question 10

In what trauma patient should you suspect a ureteral injury?

Answer 10

Guideline 9: complex, multi system A/P trauma patients with complex fractures or rapid deceleration injury or high velocity GSW with trajectory near the ureter

You need delayed contrast imaging to detect ureteral injuries

Question 11

In cases where imaging is not an option because the patient went straight to surgery, what should you do if you suspect a ureteral injury?

Answer 11

Guideline 10: directly inspect the ureters with an open approach or retrograde ureterogram. Do not do a IVP in this case- it does not look at the ureters well enough

Question 12

If a ureteral injury is found in a stable patient, how should you proceed acutely?

Answer 12

Guideline 10: Repair the ureteral injury at the time of laparotomy, do not delay if the patient is stable

Question 13

If a ureteral injury is found in an unstable patient, how should you proceed?

Answer 13

Guideline 10b: The patient is unstable, you need to clip the ureter to prevent extravasation and place a nephrostomy tube or externalize a ureteral catheter secured to the proximal defect.

Question 14

How do you manage a ureteral contusion found in surgery?

Answer 14

Guideline 10c: You may choose to place a ureteral stent or you may choose to repair it primarily depending on viability and scenario- approach is up to surgeon

Question 15

How do you manage an incomplete ureteral injury diagnosed postoperatively or in the delayed setting?

Answer 15

Guideline 11a: Recommended that you try to place a retrograde ureteral stent

Guideline 11b: If its not possible to pass a ureteral stent, place a percutaneous nephrostomy with delayed repair

Question 16

How should you initially manage a ureterovaginal fistula?

Answer 16

Guideline 11c: Place a ureteral stent when possible, if this fails then you may consider surgical intervention (ureteral implantation).

Stent rates are highly successful in 65-100% of cases

Question 17

How should you surgically repair a ureteral injury proximal to the iliac vessels?

Answer 17

Guideline 12a: a spatulated, tension free anastomosis over a ureteral stent is advised after all non-viable ureter as been removed

Question 18

How should you surgically manage a ureteral injury distal to the iliac vessels?

Answer 18

Guideline 12b: you should manage with ureteral reimplantation or primary repair over a stent when possible. May require a boari flap or psoas hitch

Question 19

How should you surgically manage an endoscopic ureteral injury?

Answer 19

Guideline 13a: Place a ureteral stent when possible. If this isn’t possible or fails to divert the urine, place a nephrostomy tube +/- periureteral drain unless

Guideline 13b: you may manage this with open repair if the above endoscopic measures fail to adequately divert the urine.

Question 20

How should you manage a stable patient with gross hematuria and a pelvic fracture or a mechanism concerning for bladder injury such as pelvic ring fractures?

Answer 20

Guideline 14 a/b: You should perform a retrograde cystogram (either CT or plain film). You do this by letting contrast drain in by gravity through a foley to 300 ml or whenever patient is uncomfortable. Then take a plain film. Drain all the contrast and take one more plain film.

Urethra should be cleared first to allow for placement of a foley if needed

Question 21

How should you manage intraperitoneal or extraperitoneal bladder injuries?

Answer 21

Guideline 15-17: Place a foley and let heal by itself in uncomplicated extraperitoneal bladder injuries

Perform surgical repair with 2 layer absorbable sutures in complicated extraperitoneal and intraperitoneal bladder injuries

Leave catheters in for 2-3 weeks and follow up cystography should be done to ensure the bladder injury has completely healed.

If an uncomplicated extraperitoneal bladder injury hasn’t healed by 4 weeks, you should consider taking the patient back for a formal bladder repair

Question 22

After bladder repair, should you place a suprapubic tube for good urinary drainage?

Answer 22

Guideline 18: NO, suprapubic tubes are generally not required- a foley catheter is all that is needed

( of course there are exceptions to the above: urethral injury, poorly mobilizing persons, really complex bladder repairs or severe hematuria)

Question 23

What should you do if you see blood at the urethral meatus after pelvic trauma?

Answer 23

Guideline 19: A retrograde urethrogram! (exception is gently trying to place a well-lubricated catheter if patient is unstable- must be single attempt and “experienced” team member only)

To do a retrograde urethrogram: place patient in oblique (if possible due to pelvic injuries) with foley or 60 ml luer lock syringe in meatus or foley with balloon filled with 1-2 ml water, with penis on stretch pass 20 ml undiluted contrast slowly into bladder

If a catheter was placed with blood at the urethral meatus, prior to removing the catheter, you should do a periurethral RUG.

Question 24

What is the preferred management for pelvic fracture urethral injuries?

Answer 24

Guideline 20 a/b: This is placing a percutaneous or open suprapubic tube (14F or larger) and guidelines state this should be done promptly

Primary endoscopic alignment is associated with a longer clinical course

However, Guideline 22 says you can try primary realignment in stable patients but this attempt should not be prolonged (and again, not encouraged)

Question 25

If a patient needs open reduction internal fixation for a pelvic fracture, can you place a SPT nearby?

Answer 25

guideline 21: YES. There is no evidence this increases risk of hardware infection

Question 26

After urethral injury, how long should patients be monitored for?

Answer 26

Guideline 23: Monitor patients for at least a year for stricture, ED, and incontinence. They recommend monitoring for stricture with a combination of uroflow, cystoscopy, and/or retrograde urethrogram

Good luck getting this population of young, otherwise healthy guys back in your clinic.

Question 27

A guy gets stabbed in his penis, how should you treat this?

Answer 27

Guideline 24: Penetrating trauma to the anterior penis should be treated with prompt surgical repair

Question 28

How should you manage straddle injury?

Answer 28

Guideline 25: Prompt urinary drainage by SPT or quick primary realignment- do not attempt any immediate surgical reconstruction as the injury has an indistinct border. Stricture formation is high so these patient should be monitored via uroflow, cysto or RPG

Question 29

When should you suspect a penile fracture?

Answer 29

guideline 26: you must suspect penile fracture when a patient presents with penile ecchymosis, swelling, pain, cracking or snapping sound during intercourse or manipulation and immediate detumescence

Question 30

How do you work up penile fracture?

Answer 30

Guideline 27 & 28: No workup is needed if the history and physical exam is consistent. Otherwise may consider a penile US or MRI with equivocal signs and symptoms of penile fracture

Question 31

Which patients with penile fracture should be evaluated for urethral injury?

Answer 31

Guideline 29: You must perform evaluation for concomitant urethral injury in patients with penile fracture or penetrating trauma who present with blood at the urethral meatus, gross hematuria or inability to void (or bilateral corporal rupture)

Concomitant urethral injuries occur in 10-15% patients with penile fracture

Question 32

After scrotal injuries, which patients should go directly for surgical exploration and which patients should undergo testicular US with dopplers?

Answer 32

Guideline 30a-c: US for blunt injuries, prompt surgical exploration with repair or orchiectomy for penetrating scrotal injuries (US is not as sensitive)

Surgeons should perform scrotal exploration and debridement with tunical closure (when possible) or orchiectomy (when non-salvageable) in patients with suspected testicular rupture

Question 33

What should you do in general when a high risk for sexual, urinary or reproductive side effects are anticipated in urethral or scrotal or penile trauma patients?

Answer 33

Guideline 33: Clinicians should initiate ancillary psychological, interpersonal, and/or reproductive counseling and therapy (mental health therapist and/or reproductive counseling or treatment)

Question 34

How do you recognize compartment syndrome in LE? How do you assess?

Answer 34

5 “P”s

Pain
Paresthesia
Pulselessness
Paralysis
Pallor

Check pulses, cap refill
Assess strength of extremity
Sensation of leg/foot

Question 35

Patient presents with incontinence 6 weeks after abdominal hysterectomy, what else would you like to know? What tests would you consider?

Answer 35

is leakage continuous?
associated with straining/coughing/laughing
urgency, frequency, nocturia

UA, UCX

CTU (fistula/injury)

Cystogram

Double die/tampon test

Question 36

Most common cause of vesicovaginal fistula in developing countries? Developed countries?

Answer 36

Traumatic obstructed child birth

Iatrogenic (0.1-4% during pelvic operations)

Hysterectomy (60-75%)
Malignant hysterectomy (3-5%)
C-section (6%)

Question 37

Important factors when considering fistula repair?

Answer 37

diagnose and treat any underlying infections and r/o neoplasms and foreign bodies

ensure appropriate bladder size/function

ID fistula tract and adjacent structures

Optimize patient nutrition and overall health

Question 38

Repair options for fistula? Broad?

Answer 38

Conservative management, for fistula < 3 mm tracts that have not epithelialized, foley

Surgery

(uninfected can do w/in 2 weeks, otherwise wait 8 weeks)

Question 39

Surgical Approaches? Interposition flap options?

Answer 39

Transvaginal vs. Transabdominal

Flaps:

Peritoneal

Martius (posterior blood supply via posterior labial artery from internal pudendal artery)

Rectus muscle

Question 40

Describe fistula repair for vesicovaginal fistula:

Answer 40

1. ID fistula tract
   
   1. Wide dissection of the bladder from vagina
   2. Use of healthy, viable tissue for re-approximation
   3. Close fistula with absorbable suture and a second perpendicular imbricating layer of pubocervical fascia
2. Advance a segment of vaginal epithelium past the fistula the provides a third layer and avoid overlapping suture lines
3. An interposition flap can be incorporated, such as Martius flap

Question 41

First actions in trauma survey?

Answer 41

A=airway and c-spine
B=breathing
C=circulation/stop bleeding
D=disability/neuro status
E=exposure and environment

Labs Chem 18, CBC, PT/PTT, ABG, T&C, tox screen, UA

C-spine
CXR
KUB
FAST (focused assessment with sonographic trauma)

unconscious (NGT/ET tube)

Question 42

MVC stable with pelvic fracture, blood at meatus, has not voided, perineal butterfly ecchymosis, next steps?

Answer 42

RUG

Abdomen/Pelvis CT to assess extent of injuries

Question 43

Describe RUG

Answer 43

Foley with 1-2 mL in fossa navicularis
Toomey syringe
Position penis at 90 degree angle and oblique
Slowly inject contrast

Question 44

Patient with pelvic fracture, on RUG contrast doesn’t pass into prox bulbar urethra, what is this? what do you do?

Answer 44

pelvic fracture urethral distraction defect
likely with urinary retention

1. Pass foley (not blind in documented disruptions)
2. Primary realignment (endoscopic)
3. SPT (immediate)
4. Needs cystogram after drainage

Question 45

For intraperitoneal bladder rupture, what do you do? if there is a pelvic hematoma?

Answer 45

ex-lap, repair bladder in 2 layers, if cannot localize, enter at dome, inspect interior, identify UOs, pelvic drain

survey other organs for injury (bowel, liver, spleen)

if pelvic hematoma–avoid opening it due to risk of bleeding
if opened, pack, inform anesthesia, txf PRN, consult ortho for pelvic fx
if still does not stop, consider IR for embolization

Question 46

After primary endoscopic realignment how long do you keep foley?

Answer 46

4 weeks, peri-cath RUG prior to removal

cystogram if bladder injury

Question 47

Longer term complications of posterior urethral injury?

Answer 47

impotence
incontinence
urethral stricture

Question 48

Indications for CT imaging for blunt trauma in adults? peds?

Answer 48

gross hematuria
micro hematuria + shock (SBP < 90 mm Hg)
mechanism of injury or PE findings concerning for renal injury (rapid decel, rib fx, rib ecchymosis)

peds: >50 RBC/hpf or rapid decel

Question 49

Urethral injury grading system

Answer 49

Question 50

When placing foley or SPT for urinary drainage, remember this:

Answer 50

send UA and CX

perform cystogram to assess bladder integrity (blood at meatus or voided blood)

Question 51

Indications for renal exploration:

Answer 51

hemodynamic instability from ongoing bleeding
expanding pulsatile RP hematoma
high grade injuries in solitary kidney
high velocity penetrating trauma

Question 52

Indication for bladder repairs:

Answer 52

all intraperitoneal bladder perforations
complicated extraperitoneal bladder ruptures (i.e. bone fragments including into bladder, bladder neck involvement, concurrent rectal or vaginal laceration)
extraperitoneal bladder ruptures in patients undergoing other intraabdominal pelvic open surgical interventions (e.g. pelvic repair)

Question 53

Describe trauma renal exploration:

Answer 53

1. Supine, midline xiphoid to pubis incision
2. Obtain vascular control wo disturbing RP hematoma
   
   1. Transverse colon on the chest under moist sponges
   2. Expose root of small bowel mesentery, lift up and to right
   3. Make vertical incision over aorta (medial to IMV, superior to IMA) and extend to ligament of Treitz
   4. Identify the aorta, dissect upward until renal vein exposed (artery posterior)
   5. After vascular control, mobilize kidney
      
      1. Occlude renal artery if needed, ice, clamp, pressure
      2. Sparingly debride nonviable tissues
      3. Perform partial or total Nx
      4. Control bleeding vessels
      5. Close collecting system with absorbable suture
      6. Close renal parenchyma over lac
   6. Close renal parenchymal defect
      
      1. Close renal capsule over bolsters
      2. Close Gerota’s
      3. Place drain near RP, not over repair to avoid fistula

Question 54

Intraop complications of trauma exploration/renal repair/nx?

Answer 54

1. Splenic injury: minor injuries cautery, surgicel, gel-foam
2. Pancreatic injury: tail requires distal pancreatectomy, drain
3. Intractable bleeding: if attempting partial, perform simple nx
4. Bowel injury: repair with primary closure or excision and anastomosis

Question 55

How do you perform a one shot IVP for trauma?

Answer 55

2 mL/kg or 150 mL of IV contrast, wait 10 mins, KUB

Question 56

AAST Renal Trauma Rating

Answer 56

Question 57

What are next management stents for a patient with multiple GSW to abdomen, blood at meatus, stable, nonopacification of right mid and distal ureter with free air?

Answer 57

RUG

Cystogram

OR

Question 58

Patient status post MVC, pelvic fracture, urethral disruption with SPT, 2-3 days later with pelvic and perineum pain and swelling with + crepitus and erythema, next steps?

Answer 58

PE
Labs (BMP, CBC, PT/PTT, UA, UCX, BCX)

Abx (Vanco, Gent, Flagyl or very broad)
IVF
Glucose Control
OR (CT first if stable) → debridement +/- colostomy if rectal involvement

CT to evaluate pelvic/RP gas/abscess

assess for any pelvic injuries such as rectal/bladder injury, bone fragments

FOURNIER’S

Question 59

How do you manage Fournier’s debridement post op in regards to wound care? How are the testis mangaged?

Answer 59

Wound vac best choice (debride, promotes granulation, contraction, decreases edema)

Wet to dry (when they cannot hold seal)

Testis → in thigh pouch if no remaining scrotal skin

Question 60

What type of reconstruction is done for scrotum and penis for Fournier’s ?

Answer 60

split thickness skin grafts

meshed → scrotum

unmeshed → penis

Question 61

Pop during intercourse with detumesce and blood at meatus, dx? Imaging?

Answer 61

Penile fracture with urethral injury

RUG or repair and cysto/RUG at time

Question 62

Pathophysiology of penile fx?

Answer 62

when erect, corporal bodies stretch tunica albuginea to limit as well as midline septum

penis buckles during intercourse and tears tunica and possibly spongiosum

Question 63

Describe penile exploration for repair of fx and urethra:

Answer 63

1. cysto, pass wire, place foley or RUG
2. place tourniquet at base of penis
3. make circumcising and deglove or overlying incision of fx
4. evacuate hematoma
5. identify lacerated area of urethra, dissect out, excise devitalized tissue, close with water-tight 4-0 or 5-0 absorbable, close vertically to preserve length, close spongiosum
6. identify lacerated tunica albuginea, debride, close with absorbable suture
7. close skin

Question 64

How do you manage penetrating penile injuries? Amputation?

Answer 64

Penetrating:
operative exploration
like penile fx
make sure drainage established (foley/SPT)

Amputation:
clean, wrap in soaked sponge with sterile saline in ziploc bag
keep on ice
reimplantation for as long as 18 h
approximate corpora and urethra
approximate deep dorsal vein and artery
approximate nerve bundles

*microvascular repair not required

Degloving:
remove distal skin to injury
non-meshed split thickness skin graft and secure bolster dressing over

Question 65

Intraop GYN consult for vag hyst, foley balloon seen in vagina (injury), how should you assess and r/o ureteral involvement?

Answer 65

cysto and IV indigo carmine or methlylene blue

cysto and RGP (best option)

Question 66

Intraop GYN consult for vag hyst, cysto RGP shows bladder injury communicating with vaginal wall and left ureteral injury, next steps?

Answer 66

OR for explore and repair (consent next of kin)
Open transabdominal repair (distal ureter reimplant and bladder repair)

Midline or Pfannenstiel incision
Bivalve bladder dome
Explore ureter
Close anterior vag wall
Close bladder injury
Psoas if necessary to perform tension free anastomosis
Reimplant ureter (stent)

Close cystotomy
Drain

Foley

Question 67

Incontinence after ureteral and vaginal wall/bladder injury, ddx?

Answer 67

VVF
ureterovaginal fistula
both

UUI/SUI

Question 68

What is blood supply to Martius flap?

Answer 68

external pudendal artery to anterior flap and internal pudendal artery to posterior flap

one can be sacrificed depending of positioning needed

monitor serum Cr and US w/in 3-6 mo

Question 69

Hockey puck to scrotum, bruising, pain, very tender and swollen, ecchymosis, ddx? What do you do?

Answer 69

Scrotal bruising
testicular rupture

Scrotal US to define tunica albuginea

Question 70

Testicular rupture, next steps?

Answer 70

OR

even if equivocal

Question 71

Describe repair of testicular rupture:

Answer 71

urethral cath
midline scrotal incision
dissect through dartos
evacuate hematoma
identify ruptured tunica
trim back seminiferous tubules to allow closure
close with fine absorbable (PDS) 4-0 or 5-0
explore contralateral side
close dartos and skin in separate layers
consider leaving drain for 24-48 h

Return to clinic in 4 weeks

Question 72

Man s/p brachy/EBRT for CaP with air/stool in urine and drainage from rectum, ddx?

Answer 72

Rectourethral fistula

Question 73

Presenting sxs of rectourethral fistula:

Answer 73

pneumaturia
fecaluiria and/or urorrhea
fevers, chills, sepsis
palpation on PE
visualization on cysto

Question 74

Testing for rectourethral fistula? If found next steps?

Answer 74

Cysto
DRE
Near trigone, CTU or RGP to eval ureters
Plan film CT barium enema
RUG

Referral to colorectal for diverting colostomy
Foley
Nutritional optimization
Tx UTIs

Question 75

If patient has an injury to rectal sphincter what is management?

Answer 75

Permanent diverting colostomy

Question 76

Considerations when treating rectourethral fistula in patient s/p RT?

Answer 76

life expectancy
premorbid urinary and bowel function
continence
local anatomy
nutrition status
smoking status

Question 77

In general what surgical approches for rectourethral fistula?

Answer 77

perineal or abdominal/lap (higher)

key is to interposition health tissue: omentum, gracilis flap between rectum and urethra

consider cystoprostatectomy if urinary or bowel function adequate or buccal graft and repair

temporary diversion vs. permanent depending on severity of bowel function

Question 78

Post operative detection of ureteral injury, with urinoma, best management?

Answer 78

Foley
IR drain
Delayed ureteral repair - at least 2 mo

Question 79

After reimplant, patient complains of numbness on anterior thigh, what happened?

Answer 79

Injury to genitofemoral nerve (sensory nerve)

Question 80

Patient s/with extraperitoneal bladder injury with clots, requiring irrigation, next step?

Answer 80

Upsize foley
explore via midline incision, open dome, avoid RP hematoma, repair extraperitoneal injury

Cystogram 1-2 weeks

Question 81

13yo boy whose father pinned him with car, stable, diffuse abdominal pain, has not voided, next evaluations?

Answer 81

KUB (if fx, need more imaging)
labs: CBC, BMP
Blood at meatus? → RUG
RUG with extravasation → Cystogram
Rectal exam (if pelvic fx, bony fragments?)
CT A/P

Question 82

Pelvic fx and bladder neck extravasation on RUG/cystogram, mgmt?

Answer 82

Exploration and repair of bladder

DO NOT disrupt pelvic hematoma

cysto to visualize posterior urethra

Question 83

Posterior urethral injury in setting of pelvic fracture, if stricture occurs at site of injury, describe workup prior to delayed repair:

Answer 83

Cystogram via SPT
RUG
Assess stricture length and bladder neck

if contrast seen in posterior urethra and not in bladder, then VUD to assess competency of bladder neck

if not competent, may need continent stoma

Question 84

Options for repair of posterior urethral traumatic injury?

Answer 84

Graft (buccal) urethroplasty
Flap (penile fasciocutaneous) urethroplasty

EPA

Question 85

15 yo with handlebar injury, falls 5 feet, left flank pain, stable, next steps?

Answer 85

Is there microhematuria or gross hematuria?

has patient voided?

Any other ortho/thoracic injuries?

stable?

PE:
Testes
Abdomen (flank)
Meatus
Perineum
UA

Question 86

Indications for radiographic assessment in peds patient for GU trauma, non-penetrating injuries:

Answer 86

Microhematuria > 50 rbc/hpf with shock (SBP < 90 mm Hg)

Significant trauma to thoracic or intra-abdominal organs

Significant deceleration or high velocity accident, fall from > 10 feet, or strike to abdomen

Gross hematuria

Question 87

How can you minimize radiation in pediatric trauma patient in need of CT

Answer 87

Just do delayed phase after IV contrast (10-15 mins)

Question 88

What does medial extravasation of contrast and no functioning parenchyma and intravascular contrast extravasation indicate?

Answer 88

Concern for renal pedicle (hilum) injury

Question 89

What does lateral extravasation of contrast with non-visualization of distal ureter indicate?

Answer 89

UPJO
UPJ avulsion

Question 90

What does medial extravasation of contrast with functioning parenchyma but no distal ureter indicate?

Answer 90

UPJO

Question 91

What questions can be asked as a brief trauma history, pneumonic?

Answer 91

SAMPLE

signs and symptoms
allergies
past illness/LMP
last meal
events related to injury

Question 92

After ABCDE, what are the next steps before any GU injuries are evaluated? Then first steps

Answer 92

BP (serial)
Hct (current and serial)
IVF
C-spine films (r/o neck fx)
airway
pelvis stable?

Attempt foley one time vs. RUG
Can attempt OR (if going for other reasons) or bedside cysto alignment
or just SPT

Question 93

SPT for urethral injury, plan for treatment?

Answer 93

Wait 6+ weeks
RUG/VCUG

Depending on length:

2 cm or below can do EPA

vs.

Urethroplasty

Question 94

How do you evaluate/follow patient after urethroplasty?

Answer 94

symptom check
uroflow
PVR
cysto if poor uroflow, high pvr, obstructive sxs

Question 95

What is ddx of gross hematuria after blunt trauma?

Answer 95

renal injury
bladder injury (intra- or extra-)
urethral injury

Question 96

patient undergoing ex-lap and bladder repair becomes cold and coagulopathic with excessive bleeding, next steps?

Answer 96

PRBC, FFP to correct coagulopathy
Damage control, tell anesthesia
Pack pelvis and return tomorrow

Question 97

During repair of suspected penile fx, you cannot find injury in corpora, what can be done? most common site of injury?

Answer 97

artificial erection with saline or die to identify injury

most common: distal to suspensory ligament ventral or lateral

Question 98

Complications after urethral repair and repair of penile fx?

Answer 98

Urethrocorporal fistula
Penile curvature
ED
Urethral stricture

AUA guidelines say to follow of a year

Question 99

Management of linear vaginal tear in setting of extraperitoneal bladder rupture? if ortho taking patient?

Answer 99

OR to repair vaginal laceration transvaginally, can try to fix bladder through hole, but not easy

urethral catheter

Intra: repair transvesically, drain, foley, repair vagina

Answer 100

<p>C) Traumatic injuries</p>

<p>Explanation: According to the text, traumatic injuries are the leading cause of death in the United States for people ages 1-44 years.</p>

Question 101

What is the leading cause of death in the United States for people ages 1-44 years?

A) Cancer
B) Heart disease
C) Traumatic injuries
D) Stroke

Answer 101

C) Traumatic injuries

Explanation: According to the text, traumatic injuries are the leading cause of death in the United States for people ages 1-44 years.

Question 102

In what type of patient are urologic injuries more common?

A) Patients with isolated injuries
B) Patients with abdominal traumas
C) Elderly patients
D) Pediatric patients

Answer 102

B) Patients with abdominal traumas

Explanation: The text states that isolated urologic injuries are uncommon in major trauma, but urologic injuries are more common in the multiply-injured patient, and urologic organs are involved in approximately 10% of abdominal traumas.

Question 103

What is the most commonly injured genitourinary organ?

A) Testes
B) Prostate
C) Bladder
D) Kidneys

Answer 103

D) Kidneys

Explanation: The text states that the kidneys are the most commonly injured genitourinary organ.

Question 104

What is the most common method of evaluating for extravasation of urine from the collecting system in cases of renal injury?

A) Magnetic resonance imaging (MRI)
B) X-ray
C) Computed tomography (CT) scan with intravenous (IV) contrast enhancement
D) Ultrasound

Answer 104

C) Computed tomography (CT) scan with intravenous (IV) contrast enhancement

Explanation: The text states that computed tomography (CT) scan with intravenous (IV) contrast enhancement including delayed imaging remains the most common method of evaluating for extravasation of urine from the collecting system in cases of renal injury.

Question 105

What is the current standard of care for managing the vast majority of blunt renal injuries?

A) Urgent surgical exploration
B) Non-operative management
C) Percutaneous angioembolization
D) Nephrectomy

Answer 105

B) Non-operative management

Explanation: The text states that over the past few decades, management of traumatic renal injuries has changed from operative exploration to non-operative management in the vast majority of cases. While non-operative management of the vast majority of blunt renal injuries is now firmly established, non-operative management of penetrating and high-grade renal injuries continues to inspire debate.

Question 106

What is the most common cause of ureteral injuries?

A) Penetrating trauma
B) Blunt trauma
C) Motor vehicle collisions
D) Iatrogenic causes

Answer 106

D) Iatrogenic causes

Explanation: The text states that ureteral injuries tend to be iatrogenic, occurring during gynecologic, urologic, or colorectal surgery. Penetrating trauma is the most common cause of ureteral injuries originating outside of the operating room.

Question 107

What percentage of urologic injuries do ureteral injuries account for?

A) 5%
B) 10%
C) 1%
D) 25%

Answer 107

C) 1%

Explanation: The text states that ureteral injuries are rare, accounting for 1% of urologic injuries.

Question 108

What is the treatment for ureteral injuries?

A) Bed rest
B) Administration of antibiotics
C) Placement of a ureteral stent or surgical repair
D) Observation and monitoring

Answer 108

C) Placement of a ureteral stent or surgical repair

Explanation: The text states that treatment for ureteral injuries may include placement of a ureteral stent or surgical repair, depending on the severity and location of injury. Bed rest, administration of antibiotics, and observation and monitoring are not treatments specifically mentioned for ureteral injuries.

Question 109

In what percentage of blunt abdominal trauma victims do bladder injuries occur?

A) 10%
B) 1%
C) 5%
D) 20%

Answer 109

B) 1%

Explanation: The text states that bladder injuries occur in approximately 1.6% of blunt abdominal trauma victims.

Question 110

What is the most common sign of bladder injuries?

A) Back pain
B) Abdominal distension
C) Gross hematuria
D) Difficulty urinating

Answer 110

C) Gross hematuria

Explanation: The text states that gross hematuria is the most common sign of bladder injuries, present in 77-100% of injuries.

Question 111

How are most extraperitoneal bladder ruptures managed?

A) Surgically repaired
B) Antibiotics administration
C) Observation and monitoring
D) Non-operatively with catheter drainage

Answer 111

D) Non-operatively with catheter drainage

Explanation: The text states that since the 1980s, clinicians manage most extraperitoneal bladder ruptures non-operatively with catheter drainage, while intraperitoneal ruptures are surgically repaired.

Question 112

What is the most common finding in cases of urethral injuries?

A) Back pain
B) Abdominal distension
C) Blood at the urethral meatus
D) Difficulty urinating

Answer 112

C) Blood at the urethral meatus

Explanation: The text states that blood at the urethral meatus is the most common finding in cases of urethral injuries, although highly variable, present in 37-93%.

Question 113

How are posterior urethral injuries traditionally managed?

A) Immediate surgical closure
B) Antibiotic administration
C) Placement of a suprapubic tube (SPT) and delayed urethroplasty
D) Urethral urinary drainage

Answer 113

C) Placement of a suprapubic tube (SPT) and delayed urethroplasty

Explanation: The text states that traditional management of posterior urethral injuries is placement of a suprapubic tube (SPT) and delayed urethroplasty to reconnect the ruptured urethra. As endoscopic equipment and techniques have improved over the past two decades, primary realignment of posterior urethral ruptures has become more common.

Question 114

What is the immediate goal of treatment for all types of urethral injuries?

A) Erectile dysfunction prevention
B) Urinary incontinence prevention
C) Securing catheter drainage of the bladder
D) Hemorrhage control

Answer 114

C) Securing catheter drainage of the bladder

Explanation: The text states that securing catheter drainage of the bladder is the immediate goal of treatment for all types of urethral injuries. Attempts at immediate sutured repair of posterior urethral injury are associated with unacceptably high rates of erectile dysfunction and urinary incontinence.

Question 115

What is the most commonly encountered genital injury in males?

A) Penile fracture
B) Testicular rupture
C) Scrotal trauma
D) Penetrating penile injuries

Answer 115

A) Penile fracture

Explanation: The text states that the most commonly encountered genital injuries in males are penile fracture, testicular rupture, and penetrating penile injuries. Penile fracture is the most common of these injuries.

Question 116

What percentage of cases of penile fracture are associated with urethral injury?

A) 5-10%
B) 10-22%
C) 30-40%
D) 50-60%

Answer 116

B) 10-22%

Explanation: The text states that penile fracture may be associated with urethral injury in 10-22% of cases.

Question 117

What is the recommended management for blunt scrotal trauma resulting in testicular rupture?

A) Observation and monitoring
B) Antibiotic administration
C) Ultrasound-guided aspiration
D) Exploration and attempt at repair

Answer 117

D) Exploration and attempt at repair

Explanation: The text states that blunt scrotal trauma may lead to rupture of the tunica albuginea of the testicle in 50% of cases presenting for evaluation. Ultrasound may confirm or imply testicular rupture, which should prompt exploration and attempt at repair.

Question 118

What are the risks associated with CT imaging for renal injuries?

A) Hypotension and contrast-related complications
B) Radiation exposure and the dangers of transporting a patient away from the resuscitation environment
C) Nausea and vomiting
D) Hemorrhage and allergic reactions

Answer 118

B) Radiation exposure and the dangers of transporting a patient away from the resuscitation environment

Explanation: The text states that the risks associated with CT imaging for renal injuries include contrast related complications, radiation exposure, and the dangers of transporting a patient away from the resuscitation environment into the CT scanner.

Question 119

What is the AAST organ injury scale for renal trauma used for?

A) To classify and standardize renal injuries
B) To guide therapy for high-grade injuries
C) To predict morbidity and need for intervention for higher grade injuries
D) All of the above

Answer 119

D) All of the above

Explanation: The text states that the AAST organ injury scale for renal trauma is widely used to classify and standardize renal injuries. This injury grading scale has been validated as predictive of morbidity and need for intervention to treat higher grade injuries. Several authors have also proposed modification of this grading scale to better guide therapy or to address ambiguity in staging injuries.

Question 120

What is the recommended diagnostic imaging for stable blunt trauma patients with gross or microscopic hematuria and systolic blood pressure < 90mmHg?
a. Magnetic resonance imaging (MRI)
b. Intravenous (IV) pyelography
c. IV contrast-enhanced computed tomography (CT)
d. Ultrasonography

Answer 120

c. IV contrast-enhanced CT. The guideline statement recommends diagnostic imaging with IV contrast-enhanced CT in stable blunt trauma patients with gross hematuria or microscopic hematuria and systolic blood pressure < 90mmHg.

Question 121

In what type of trauma patients should clinicians perform diagnostic imaging with IV contrast enhanced CT based on mechanism of injury or physical exam findings concerning for renal injury?
a. Only patients with gross hematuria
b. Only patients with microscopic hematuria
c. Only patients with systolic blood pressure < 90mmHG
d. Stable trauma patients with mechanism of injury or physical exam findings concerning for renal injury

Answer 121

d. Stable trauma patients with mechanism of injury or physical exam findings concerning for renal injury. According to Guideline Statement 2, clinicians should perform diagnostic imaging with IV contrast enhanced CT in stable trauma patients with mechanism of injury or physical exam findings concerning for renal injury (e.g., rapid deceleration, significant blow to flank, rib fracture, significant flank ecchymosis, penetrating injury of abdomen, flank, or lower chest).

Question 122

Which diagnostic imaging modality is preferred for elucidating both the location of renal lacerations and the presence of contrast extravasation from collecting system injuries?
a) Ultrasound
b) Standard intravenous pyelogram (IVP)
c) CT scan of the abdomen and pelvis with IV contrast and immediate and delayed phases
d) MRI

Answer 122

c) CT scan of the abdomen and pelvis with IV contrast and immediate and delayed phases. This is the preferred imaging modality for detecting renal injuries and identifying the location of renal lacerations and the presence of contrast extravasation from collecting system injuries.

Question 123

In what situations might an intraoperative one-shot IVP be used?
a) To confirm the presence of a contralateral functioning kidney
b) To detect renal injuries in patients with gross hematuria
c) To identify renal injuries in children
d) To diagnose renal injuries in patients with rib fractures

Answer 123

a) To confirm the presence of a contralateral functioning kidney. In rare cases where a patient is taken to the operating room without a preliminary CT scan, an intraoperative one-shot IVP may be used to confirm the presence of a contralateral functioning kidney, especially if surgeons are considering renal exploration or nephrectomy.

Question 124

Which imaging modality is preferred for diagnosing renal injuries in children?
a) CT scan of the abdomen and pelvis with IV contrast and immediate and delayed phases
b) Ultrasound
c) Intraoperative one-shot IVP
d) MRI

Answer 124

b) Ultrasound. While CT scan of the abdomen and pelvis with IV contrast and immediate and delayed phases is the preferred imaging modality for detecting renal injuries in adults, ultrasound is preferred in children due to concerns about radiation exposure. However, CT may still be used in children if necessary.

Question 125

How is IVP performed?

Answer 125

an intraoperative one-shot IVP (2 mL/kg IV bolus of contrast with a single image obtained 10-15 minutes later) may be used to confirm that a contralateral functioning kidney is present in rare cases where the patient is taken to the operating room without preliminary CT scan if surgeons are considering renal exploration or nephrectomy.

Question 126

What is the recommended management strategy for hemodynamically stable patients with renal injury?
a. Invasive surgical intervention
b. Non-invasive management strategies
c. Observation without any intervention
d. Immediate blood transfusion

Answer 126

b. Non-invasive management strategies

Explanation: In hemodynamically stable patients with renal injury, clinicians should use non-invasive management strategies such as close hemodynamic monitoring, bed rest, ICU admission, and blood transfusion to avoid unnecessary surgery, decrease unnecessary nephrectomy, and preserve renal function.

Question 127

What is the definition of stable patients in the context of renal injury?
a. Patients with stable renal function
b. Patients without any abdominal injuries
c. Patients without vital signs consistent with shock
d. Patients with normal hematocrit levels

Answer 127

c. Patients without vital signs consistent with shock

Explanation: Stable patients are defined as those who do not have vital signs consistent with shock and show stable serial hematocrit values over time.

Question 128

What is the advantage of using non-invasive management strategies for renal injury?
a. It avoids unnecessary surgery
b. It improves the prognosis of the injury
c. It decreases the need for blood transfusion
d. It reduces the risk of septic complications

Answer 128

a. It avoids unnecessary surgery

Explanation: Noninvasive management of renal injury, which may consist of close hemodynamic monitoring, bed rest, ICU admission and blood transfusion, avoids unnecessary surgery, decreases unnecessary nephrectomy, and preserves renal function.

Question 129

In hemodynamically unstable patients with no or transient response to resuscitation, what is the immediate intervention recommended?
a) Noninvasive management
b) Bed rest and close monitoring
c) Immediate surgery or angioembolization
d) Blood transfusion

Answer 129

c) Immediate surgery or angioembolization

Explanation: Hemodynamic instability despite resuscitation suggests ongoing and uncontrolled bleeding. Immediate intervention, either in the form of open surgery or angioembolization, is necessary to limit the need for future transfusion and prevent life-threatening complications.

Question 130

In what situation is angioembolization recommended for renal injury?
a) When the patient is hemodynamically stable
b) When the patient has a minor renal laceration
c) When experienced interventional radiologists are immediately available
d) When there is no evidence of vascular injury on CT scan

Answer 130

c) When experienced interventional radiologists are immediately available

Explanation: Selected patients with bleeding from segmental renal vessels may benefit from angioembolization as an effective yet minimally invasive treatment to control bleeding. This procedure is recommended only in centers where experienced interventional radiologists are immediately available.

Question 131

What is the benefit of performing one-shot IVP prior to renal exploration?
a) To document the function of the injured kidney
b) To establish perirenal drainage
c) To control bleeding
d) To document the function of the contralateral, uninjured kidney

Answer 131

d) To document the function of the contralateral, uninjured kidney

Explanation: Surgeons may perform one-shot IVP prior to renal exploration to document function of the contralateral, uninjured kidney using 2 mL/kg IV contrast and a single delayed image at 10-15 minutes. This is done to ensure that the patient has a functioning kidney in case the injured kidney needs to be removed or is not salvageable.

Question 132

What is the recommended intervention for hemodynamically unstable patients with radiographic findings of large perirenal hematoma (> 4 cm) and/or vascular contrast extravasation in the setting of deep or complex renal laceration (AAST Grade 3-5)?

Answer 132

Surgeons should perform immediate intervention (angioembolization or surgery).

Explanation: According to GUIDELINE STATEMENT 5B, for hemodynamically unstable patients with radiographic findings of large perirenal hematoma (> 4 cm) and/or vascular contrast extravasation in the setting of deep or complex renal laceration (AAST Grade 3-5), surgeons should perform immediate intervention (angioembolization or surgery). The size of the perinephric hematoma provides a rough radiographic estimate of the magnitude of renal bleeding, and increasing hematoma size has been incrementally associated with higher intervention rates. Intravascular contrast extravasation is another common radiographic indicator of active bleeding at various intra-abdominal sites.

Question 133

What is the recommendation in GUIDELINE STATEMENT 6 for patients with renal parenchymal injury and urinary extravasation?
a) Immediate intervention
b) Endoscopic intervention only
c) Observation
d) Nephrectomy

Answer 133

c) Observation. GUIDELINE STATEMENT 6 states that a period of observation without intervention is advocated in stable patients where renal pelvis or proximal ureteral injury is not suspected.

Question 134

What warrants prompt intervention in patients with renal parenchymal injury and urinary extravasation?
a) Large medial urinoma or contrast extravasation on delayed images without distal ureteral contrast
b) Small medial urinoma or contrast extravasation on delayed images without distal ureteral contrast
c) Large medial urinoma or contrast extravasation on immediate images with distal ureteral contrast
d) Small medial urinoma or contrast extravasation on immediate images with distal ureteral contrast

Answer 134

a) Large medial urinoma or contrast extravasation on delayed images without distal ureteral contrast. According to GUIDELINE STATEMENT 6, when renal pelvis or proximal ureteral avulsion is suspected (e.g., a large medial urinoma or contrast extravasation on delayed images without distal ureteral contrast) prompt intervention, either endoscopic or open depending on the clinical scenario, is warranted.

Question 135

In which cases is follow-up CT imaging recommended for renal trauma patients?
a) AAST Grade I-III injuries
b) AAST Grade IV-V injuries
c) Patients with uncomplicated injuries
d) Patients with hypertension

Answer 135

b) AAST Grade IV-V injuries. According to GUIDELINE STATEMENT 7, follow-up CT imaging (after 48 hours) is recommended for patients with deep renal injuries (AAST Grade IV-V) because these are prone to developing troublesome complications such as urinoma or hemorrhage. AAST Grade I-III injuries have a low risk of complications and rarely require intervention.

Question 136

Why is routine follow-up CT imaging not advised for uncomplicated AAST Grade I-III injuries?
a) It increases the risk of radiation exposure and IV contrast complications.
b) It is not likely to change clinical management in these cases.
c) It is too costly for patients.
d) It is inconvenient for patients.

Answer 136

b) It is not likely to change clinical management in these cases. According to GUIDELINE STATEMENT 7, routine follow-up CT imaging is not advised for uncomplicated AAST Grade I-III injuries because it is not likely to change clinical management in these cases. Benefits of forgoing routine follow-up imaging in low-grade renal injuries include simplicity in follow-up, decreased radiation exposure and IV contrast complications, patient convenience, and lower cost.

Question 137

What is the recommended urinary drainage method for renal trauma patients with complications?

Answer 137

The recommended urinary drainage method for renal trauma patients with complications is ureteral stent, which may be augmented by percutaneous urinoma drain, percutaneous nephrostomy or both.

Explanation: According to GUIDELINE STATEMENT 8, urinary drainage is recommended in the presence of complications such as enlarging urinoma, fever, increasing pain, ileus, fistula, or infection. The drainage should be achieved via ureteral stent and may be augmented by percutaneous urinoma drain, percutaneous nephrostomy or both. Clinicians must make adequate provision to ensure removal of the stent in follow-up. A period of concomitant Foley catheter drainage may minimize pressure within the collecting system and enhance urinoma drainage. If follow-up imaging demonstrates a urinoma increasing in size, purulence, or complexity, a percutaneous drain may also be necessary.

Question 138

What imaging modality should be used for stable trauma patients with suspected ureteral injuries?
a. Magnetic Resonance Imaging (MRI)
b. X-ray
c. IV contrast enhanced abdominal/pelvic CT with delayed imaging (urogram)
d. Ultrasound

Answer 138

c. IV contrast enhanced abdominal/pelvic CT with delayed imaging (urogram). According to guideline statement 9A, stable trauma patients with suspected ureteral injuries should undergo IV contrast enhanced abdominal/pelvic CT with delayed imaging (urogram) to evaluate for ureteral injury.

Question 139

Can absence of hematuria exclude ureteral injury in trauma patients?
a. Yes, absence of hematuria always excludes ureteral injury
b. No, absence of hematuria cannot be relied upon to exclude ureteral injury
c. It depends on the mechanism of injury
d. It depends on the presence of other injuries

Answer 139

b. No, absence of hematuria cannot be relied upon to exclude ureteral injury. Guideline statement 9A states that absence of hematuria cannot be relied upon to exclude ureteral injury and that ureteral injuries should be suspected in complex, multisystem abdominopelvic trauma patients.

Question 140

What findings on imaging suggest ureteral injury?
a. Contrast extravasation, ipsilateral delayed pyelogram, ipsilateral hydronephrosis, and lack of contrast in the ureter distal to the suspected injury
b. Hematuria
c. Bladder rupture
d. Bowel injury

Answer 140

a. Contrast extravasation, ipsilateral delayed pyelogram, ipsilateral hydronephrosis, and lack of contrast in the ureter distal to the suspected injury are findings that suggest ureteral injury, according to guideline statement 9A.

Question 141

In stable trauma patients with suspected ureteral injury, what diagnostic imaging should clinicians perform?
a. Ultrasound
b. CT with immediate and delayed images
c. MRI
d. CT with delayed imaging (urogram)

Answer 141

d. CT with delayed imaging (urogram). According to GUIDELINE STATEMENT 9A, stable trauma patients with suspected ureteral injury should undergo IV contrast enhanced abdominal/pelvic CT with delayed imaging (urogram).

Question 142

In patients with suspected ureteral injury who proceed directly to laparotomy without preoperative imaging, what is necessary to identify ureteral injuries?
a. Retrograde pyelography
b. Intraoperative single-shot IVP
c. Direct ureteral inspection
d. Intraureteral injectable dyes

Answer 142

c. Direct ureteral inspection. According to GUIDELINE STATEMENT 9B, direct ureteral inspection is necessary in patients suspected to have ureteral injury who proceed directly to laparotomy without adequate radiographic staging. Adjunctive maneuvers to identify ureteral injuries include careful ipsilateral ureteral mobilization and/or IV or intraureteral injectable dyes such as methylene blue or indigo carmine. Retrograde pyelography may be performed in equivocal cases when possible. Intraoperative single-shot IVP cannot reliably exclude ureteral injury and should not be used solely for this purpose.

Question 143

What is the guideline statement for repairing traumatic ureteral lacerations at the time of laparotomy in stable patients?

Answer 143

Surgeons should repair traumatic ureteral lacerations at the time of laparotomy in stable patients. (Recommendation; Evidence Strength: Grade C).

Explanation:

The guideline statement indicates that it is recommended to repair ureteral lacerations at the time of initial laparotomy in stable patients when possible. However, immediate repair may not be appropriate in unstable, complex polytrauma patients. The evidence strength for this recommendation is Grade C.

Question 144

What is the recommended management strategy for ureteral injuries in unstable patients in damage control settings?

Answer 144

Surgeons may manage ureteral injuries in unstable patients with temporary urinary drainage followed by delayed definitive management. (Clinical Principle)

Explanation: When immediate ureteral repair is not possible at the time of initial laparotomy, urinary extravasation can be prevented with ureteral ligation followed by percutaneous nephrostomy tube placement or with an externalized ureteral catheter secured to the proximal end of the ureteral defect. Definitive repair of the injury should be performed when the patient’s clinical situation has improved/stabilized. This is in accordance with Guideline Statement 10B.

Question 145

What is the recommended management approach for traumatic ureteral contusions identified during laparotomy?

A. Ureteral ligation and percutaneous nephrostomy tube placement
B. Observation and follow-up imaging
C. Ureteral stenting or resection and primary repair depending on ureteral viability and clinical scenario
D. Definitive repair of the injury when the patient’s clinical situation has improved/stabilized

Answer 145

C. Ureteral contusions identified during laparotomy should be primarily managed with ureteral stenting or resection with primary repair in selected instances, particularly after gunshot wounds, depending on the severity of the contusion and the viability of local tissues. This is recommended in Guideline Statement 10C.

Question 146

What is the recommended approach for patients with incomplete ureteral injuries diagnosed postoperatively or in a delayed setting?

A. Immediate ureteral resection and primary repair
B. Observation and serial imaging
C. Attempt ureteral stent placement
D. Proceed directly to exploratory laparotomy

Answer 146

C. Attempt ureteral stent placement. According to Guideline Statement 11A, when an incomplete ureteral injury is at first unrecognized or presents in a delayed fashion, retrograde ureteral imaging with ureteral stent placement should be performed initially. Immediate repair can be considered in certain clinical situations if the injury is recognized within one week.

Question 147

What should surgeons do when the proximal ureter is completely transected or retrograde treatment is not possible in a patient with ureteral injury?

A) Perform open ureteral repair
B) Place a ureteral stent
C) Place a percutaneous nephrostomy tube with delayed repair as needed
D) Place a periureteral drain

Answer 147

C) Place a percutaneous nephrostomy tube with delayed repair as needed

Explanation: According to GUIDELINE STATEMENT 11B, when the proximal ureter is completely transected or otherwise cannot be cannulated in a retrograde fashion, or if patient instability precludes attempts at retrograde treatment, a percutaneous nephrostomy tube should be placed. If nephrostomy alone does not adequately control the urine leak, options then include placement of a periureteral drain or immediate open ureteral repair.

Question 148

What is the initial management strategy for patients with ureterovaginal fistula?
A) Ureteral reimplantation
B) Immediate surgical intervention
C) Ureteral stent insertion
D) Open ureteral repair

Answer 148

C) Ureteral stent insertion

Explanation: According to GUIDELINE STATEMENT 11C, patients with ureterovaginal fistula should be initially managed with ureteral stent insertion, and ureteral reimplantation can be pursued if stent placement fails.

Question 149

What is the recommended surgical intervention for ureteral injuries located above the iliac vessels?

A) Ureteral ligation with percutaneous nephrostomy tube placement
B) Ureteral resection and primary repair
C) Interposition with bowel
D) Primary repair over a ureteral stent

Answer 149

D) Primary repair over a ureteral stent

Explanation: When the ureter is injured above the iliac vessels, a spatulated, tension-free primary ureteral repair over a ureteral stent is advisable after all non-viable ureteral tissue has been judiciously debrided. Ureteral resection and primary repair can be attempted if the anastomosis cannot be performed without tension, incorporating ancillary maneuvers such as bladder psoas hitch and/or Boari bladder flap. Ureteral ligation with percutaneous nephrostomy tube placement is advised if the injury cannot be managed adequately in the acute setting, followed by delayed ureteral reconstruction.

Question 150

What is the recommended management for ureteral injuries located distal to the iliac vessels?
a) Ureteral ligation with percutaneous nephrostomy tube placement
b) Ureteral reimplantation or primary repair over a ureteral stent
c) Ureteral stent placement alone
d) Interposition with bowel and autotransplant

Answer 150

b) Ureteral reimplantation or primary repair over a ureteral stent is recommended when possible for ureteral injuries located distal to the iliac vessels.

Explanation: When the ureter is injured below the iliac vessels, the distal ureter may be healthy enough to perform a simple ureteroureterostomy in select situations, although the surgeon should defer to direct ureteral reimplantation if there is any doubt about the segment’s viability. Tension-free reimplantation may require ancillary maneuvers such as a bladder mobilization with psoas hitch or flap. Interposition with bowel is not recommended in the acute setting. If the injury cannot be managed adequately in the acute setting, ureteral ligation with percutaneous nephrostomy tube placement is advised followed by delayed ureteral reconstruction.

Question 151

What is the recommended management for endoscopic ureteral injuries?

Answer 151

The recommended management for endoscopic ureteral injuries is to place a ureteral stent and/or percutaneous nephrostomy tube when possible. If placement of a ureteral stent is not possible or if stent placement fails to adequately divert the urine, then a percutaneous nephrostomy tube should be placed with or without a periureteral drain. Delayed ureteral reconstruction is often necessary. (Answer: A)

Question 152

How should surgeons manage endoscopic ureteral injuries when endoscopic or percutaneous procedures are not possible or fail to adequately divert the urine? A) Place a ureteral stent
B) Place a percutaneous nephrostomy tube
C) Perform an open or laparoscopic repair
D) Both A and B
E) Both B and C

Answer 152

C) Perform an open or laparoscopic repair

Explanation: According to GUIDELINE STATEMENT 13B, when endoscopic or percutaneous procedures fail to adequately divert the urine, open or laparoscopic repair of endoscopic ureteral injuries is necessary.

Question 153

In what situation is retrograde cystography considered an absolute indication for the evaluation of bladder injury?
a) Pelvic fracture alone
b) Gross hematuria alone
c) Both gross hematuria and pelvic fracture
d) Patient preference

Answer 153

c) Both gross hematuria and pelvic fracture. According to Guideline Statement 14A, gross hematuria occurring with pelvic fracture is considered an absolute indication for retrograde cystography to evaluate for the presence of bladder injury.

Question 154

What is the technique for plain film cystography to diagnose bladder injury?
a) Using dilute water-soluble contrast to prevent artifacts from obscuring visualization
b) Clamping a Foley catheter to allow excreted IV-administered contrast to accumulate in the bladder
c) Retrograde, gravity filling of the bladder with contrast
d) None of the above

Answer 154

c) Retrograde, gravity filling of the bladder with contrast. According to Guideline Statement 14A, the technique for plain film cystography consists of retrograde, gravity filling of the bladder with contrast. A minimum of two views is required, the first at maximal fill and the second after bladder drainage.

Question 155

What is the most common associated injury with bladder rupture?
a) Gross hematuria
b) Pelvic fracture
c) Abdominal distention
d) Renal trauma

Answer 155

b) Pelvic fracture. According to Guideline Statement 14A, pelvic fracture is the most common associated injury with bladder rupture.

Question 156

In which of the following scenarios is retrograde cystography recommended to evaluate for bladder injury?
a) Microscopic hematuria in a patient with pelvic fracture
b) Pelvic fracture without any hematuria
c) Gross hematuria in the absence of pelvic fracture
d) Gross hematuria in a patient with pelvic fracture and clinical indicators of bladder rupture

Answer 156

d) Gross hematuria in a patient with pelvic fracture and clinical indicators of bladder rupture.

Explanation: According to the guideline statement, clinicians must perform retrograde cystography (plain film or CT) in stable patients with gross hematuria and pelvic fracture. Additionally, retrograde cystography is recommended in stable patients with gross hematuria and a mechanism concerning for bladder injury or in those with pelvic ring fractures and clinical indicators of bladder rupture. Other scenarios, such as microscopic hematuria in a patient with pelvic fracture, do not necessarily warrant radiological evaluation.

Question 157

Which of the following is not an indicator of potential bladder rupture?
a) Low urine output
b) Increased BUN and creatinine
c) Presence of urinary ascites on abdominal imaging
d) Hematuria in the absence of pelvic fracture

Answer 157

d) Hematuria in the absence of pelvic fracture.

Explanation: The guideline statement mentions that other indicators of potential bladder rupture include the inability to void, low urine output, increased BUN and creatinine secondary to peritoneal absorption of urine, abdominal distention, suprapubic pain, and low density free intraperitoneal fluid on abdominal imaging (urinary ascites). However, the presence of hematuria alone in the absence of pelvic fracture or other clinical indicators does not necessarily indicate bladder injury.

Question 158

What is the recommended approach to intraperitoneal bladder ruptures caused by blunt external trauma?

Answer 158

Surgical repair is the recommended approach (Standard; Evidence Strength: Grade B). According to the guideline statement 15, intraperitoneal bladder ruptures caused by blunt external trauma tend to be large “blow-out” injuries located in the dome of the bladder and are unlikely to heal spontaneously with catheter drainage alone. Therefore, surgical repair is necessary to prevent serious complications such as peritonitis, sepsis, and other complications.

Question 159

What is the standard treatment for uncomplicated extraperitoneal bladder injuries?

Answer 159

Catheter drainage.

Explanation: According to Guideline Statement 16, clinicians should manage uncomplicated extraperitoneal bladder injuries using urethral catheter drainage with the expectation that the injury will heal with conservative management. Leaving the catheter in place two to three weeks is standard as most uncomplicated bladder injuries will heal within that time frame. Follow-up cystography should be used to confirm that the extraperitoneal bladder injury has healed after treatment with catheter drainage. Open repair is considered appropriate in patients with non-healing bladder injuries persisting after catheter drainage greater than four weeks.

Regenerate response

Question 160

What is the recommended treatment for complicated extraperitoneal bladder injuries?

A. Catheter drainage
B. Antibiotic therapy
C. Surgical repair
D. Observation

Answer 160

C. Surgical repair is recommended for complicated extraperitoneal bladder injuries. Extraperitoneal bladder ruptures are considered complex in various settings, and surgical repair is needed to avoid prolonged sequelae from the injury. Follow-up cystography should be used to confirm that the complex, extraperitoneal bladder injury has healed. Pelvic fractures that result in exposed bone spicules in the bladder lumen should be repaired with removal of the exposed bone and closure of the bladder. Concurrent rectal or vaginal lacerations may lead to fistula formation to the ruptured bladder, and in this setting the extraperitoneal bladder rupture should be fixed. Bladder neck injuries may not heal with catheter drainage alone and repair should be considered.

Question 161

When should clinicians perform urethral catheter drainage without suprapubic cystostomy in patients following surgical repair of bladder injuries?
a) Always
b) Only in select cases
c) Never
d) Depends on the severity of the injury

Answer 161

a) Always

Explanation: According to guideline statement 18, clinicians should perform urethral catheter drainage without suprapubic cystostomy in patients following surgical repair of bladder injuries as a standard practice, unless there are clinical exceptions. Studies have shown that urethral catheters are sufficient in draining the repaired bladder, resulting in shorter hospital stays and lower morbidity. Suprapubic cystostomy may be considered in select cases, such as patients requiring long-term catheterization due to severe neurological or orthopedic injuries, complex bladder repairs with tenuous closures, or significant hematuria.

Question 162

What are the clinical exceptions in which suprapubic cystostomy may be considered following surgical repair of bladder injuries?
a) Patients with normal neurological and orthopedic status
b) Patients with uncomplicated bladder injuries
c) Patients with severe neurological injuries and those immobilized due to orthopedic injuries
d) Patients with mild hematuria

Answer 162

c) Patients with severe neurological injuries and those immobilized due to orthopedic injuries

Explanation: According to guideline statement 18, suprapubic cystostomy may be considered in select cases following surgical repair of bladder injuries. These cases include patients requiring long-term catheterization, such as those with severe neurological injuries (i.e., head and spinal cord) or those immobilized due to orthopedic injuries, and complex bladder repairs with tenuous closures or significant hematuria. Therefore, option c) is the correct answer.

Question 163

When should clinicians perform retrograde urethrography?

Answer 163

Clinicians should perform retrograde urethrography after pelvic or genital trauma when blood is seen at the urethral meatus.

Explanation: According to Guideline Statement 19, retrograde urethrography should be performed when blood is seen at the urethral meatus after pelvic or genital trauma. This is because the retrograde urethrogram may demonstrate partial or complete urethral disruption, providing guidance for how to best manage bladder drainage in the acute setting. Blind catheter passage prior to retrograde urethrogram should be avoided, unless exceptional circumstances indicate an attempt at emergent catheter drainage for monitoring.

Question 164

Which of the following is a guideline statement regarding urinary drainage in patients with pelvic fracture associated urethral injury?

A) Clinicians should perform retrograde cystography in stable patients with gross hematuria and pelvic fracture.
B) Clinicians should perform catheter drainage as treatment for patients with uncomplicated extraperitoneal bladder injuries.
C) Clinicians should establish prompt urinary drainage in patients with pelvic fracture associated urethral injury.
D) Surgeons must perform surgical repair of intraperitoneal bladder rupture in the setting of blunt or penetrating external trauma.

Answer 164

The correct answer is C. The guideline statement states that clinicians should establish efficient and prompt urinary drainage in the acute setting in patients with pelvic fracture associated urethral injury. This is important as patients with PFUI are often unable to urinate due to their injuries, and trauma resuscitations typically involve aggressive hydration and a critical need to closely monitor patient volume status.

Question 165

What is the recommended initial management for most pelvic fracture associated urethral injury (PFUI) cases?
a) Urethral catheter placement
b) Open posterior urethroplasty
c) Percutaneous or open suprapubic tube placement
d) Primary endoscopic realignment

Answer 165

c) Percutaneous or open suprapubic tube placement is the recommended initial management for most PFUI cases, according to Guideline Statement 20B. SPT is the gold standard for urinary drainage in the setting of pelvic fracture associated urethral disruption.

Question 166

Why is a latex Foley catheter 14 Fr or larger preferred for SPT placement in PFUI cases?
a) It requires less frequent replacement
b) It is less expensive than other catheter types
c) It is easier to exchange at the bedside
d) It causes less discomfort to the patient

Answer 166

c) A latex Foley catheter 14 Fr or larger is preferred for SPT placement in PFUI cases because it is easier to exchange at the bedside, according to Guideline Statement 20B. Small caliber percutaneous catheters 12 Fr or less are discouraged in this setting since they often require replacement or upsizing in the setting of hematuria, prolonged use, or in preparation for future definitive surgical repair.

Question 167

What does the guideline statement 21 suggest about the use of suprapubic tubes (SPTs) in patients undergoing open reduction internal fixation (ORIF) for pelvic fracture?

A) Surgeons should always place SPTs in patients undergoing ORIF for pelvic fracture.
B) Surgeons should never place SPTs in patients undergoing ORIF for pelvic fracture.
C) The use of SPTs in patients undergoing ORIF for pelvic fracture should be based on individual surgeon and institutional practice patterns.
D) SPT insertion increases the risk of orthopedic hardware infection.

Answer 167

C

Explanation: Guideline statement 21 suggests that the use of SPTs in patients undergoing ORIF for pelvic fracture should be based on individual surgeon and institutional practice patterns. It further mentions that no evidence exists to indicate that SPT insertion increases the risk of orthopedic hardware infection, but particular circumstances such as gross fecal contamination or open fractures may suggest exceptions to these general observations.

Question 168

When should clinicians consider primary realignment in patients with pelvic fracture associated urethral injury?
a) In all patients
b) In hemodynamically stable patients within the first few days after injury
c) In patients with open fractures
d) In patients with gross fecal contamination

Answer 168

b) In hemodynamically stable patients within the first few days after injury. According to Guideline Statement 22, primary realignment may be considered in selected patients with less severe PFUI injuries who are hemodynamically stable within the first few days after injury to avoid urethral stricture formation.

Question 169

What is the main benefit of primary realignment in patients with pelvic fracture associated urethral injury?
a) It decreases the risk of developing urethral stricture
b) It reduces the need for delayed urethral reconstruction
c) It avoids the need for suprapubic tube placement
d) It improves long-term outcomes

Answer 169

a) It decreases the risk of developing urethral stricture. According to Guideline Statement 22, primary realignment may be attempted in selected patients to avoid the development of urethral stricture. However, prolonged attempts at endoscopic realignment must be avoided.

Question 170

What is the appropriate setting for primary realignment in patients with pelvic fracture associated urethral injury?
a) Emergency Department
b) Outpatient clinic
c) Regular urology operating room with a coordinated trauma and orthopedic surgical team
d) Inpatient ward

Answer 170

c) Regular urology operating room with a coordinated trauma and orthopedic surgical team. According to Guideline Statement 22, primary realignment is best performed in a regular urology operating room setting with the coordination of trauma and orthopedic surgeons, and not in the Emergency Department or outpatient clinic.

Question 171

What are the complications associated with urethral injury following pelvic trauma?

A) Urinary incontinence and stricture formation
B) Erectile dysfunction and incontinence
C) Erectile dysfunction and stricture formation
D) Urinary incontinence, stricture formation, and erectile dysfunction

Answer 171

D) Urinary incontinence, stricture formation, and erectile dysfunction are the complications associated with urethral injury following pelvic trauma. While the risk of urinary incontinence is small, high rates of stricture formation and erectile dysfunction are commonly seen in patients with pelvic fracture associated urethral injury. These complications can be monitored using surveillance strategies like uroflowmetry, retrograde urethrogram, cystoscopy, or a combination of methods for at least one year after the injury.

Question 172

What is the expert opinion regarding surgical repair in patients with uncomplicated penetrating trauma of the anterior urethra?

Answer 172

The expert opinion is that prompt surgical repair should be performed in patients with uncomplicated penetrating trauma of the anterior urethra.

Explanation: According to Guideline Statement 24, after a penetrating trauma to the anterior urethra has been appropriately staged, surgical repair should be performed. It is expert opinion that spatulated primary repair of uncomplicated injuries in the acute setting offers excellent outcomes superior to delayed reconstruction. However, primary repair should not be undertaken if the patient is unstable, the surgeon lacks expertise in urethral surgery or in the setting of extensive tissue destruction or loss.

Question 173

What is the recommended approach for managing crush injuries of the bulbar urethra caused by straddle injury?

A) Immediate operative intervention to repair the injured urethra
B) Observation without intervention
C) Prompt intervention to establish urinary drainage
D) Attempting primary realignment

Answer 173

C) Prompt intervention to establish urinary drainage

Explanation: Crush injuries of the bulbar urethra caused by straddle injury require prompt intervention to avoid urinary extravasation. Establishing urinary drainage by suprapubic tube or primary realignment in less severe cases is recommended, which requires consideration of associated injuries, severity of the disruption, degree of bladder distension, and availability of urological expertise and endoscopic instrumentation. Immediate operative intervention to repair or debride the injured urethra is contraindicated due to the indistinct nature of the injury border. Stricture formation after straddle injury is very high and thus all patients undergoing urinary diversion require follow-up surveillance using uroflowmetry, retrograde urethrogram and/or cystoscopy.

Question 174

What is the most common symptom of penile fracture?

Answer 174

Penile swelling and ecchymosis are the most common symptoms of penile fracture.

Explanation: According to GUIDELINE STATEMENT 26, the most common symptoms of penile fracture are penile swelling and ecchymosis. Additionally, patients may report a cracking or snapping sound followed by immediate detumescence, penile pain, and penile angulation. History and physical examination alone are often diagnostic in patients with these presenting symptoms.

Question 175

What is the recommended management for patients with acute signs and symptoms of penile fracture?

Answer:

a. No intervention needed
b. Non-surgical management
c. Prompt surgical exploration and repair
d. Watchful waiting

Answer 175

c. Prompt surgical exploration and repair.

Explanation: According to guideline statement 27, in patients with historical and physical signs consistent with penile fracture, surgical repair should be performed. The repair is performed by exposing the injured corpus cavernosum through either a ventral midline or circumcision incision. Tunical repair is performed with absorbable suture and should be performed at the time of presentation to improve long-term patient outcomes.

Question 176

What is the recommended imaging modality for patients with equivocal signs and symptoms of penile fracture?

Answer 176

Ultrasound is the recommended imaging modality for patients with equivocal signs and symptoms of penile fracture.

Explanation: According to Guideline Statement 28, patients with equivocal signs of penile fracture may undergo imaging as an adjunct study to assist with confirmation or exclusion of the diagnosis of penile fracture, and ultrasound is the most commonly used imaging modality due to wide availability, low cost, and rapid examination times. MRI can be considered alternatively in cases when ultrasound proves to be equivocal or unavailable. If imaging is equivocal or diagnosis remains in doubt, surgical exploration should be performed.

Question 177

What should clinicians do in patients with penile fracture and gross hematuria or inability to void?

Answer 177

Clinicians must perform evaluation for concomitant urethral injury in patients with penile fracture or penetrating trauma who present with blood at the urethral meatus, gross hematuria, or inability to void. Options for evaluation include urethroscopy and retrograde urethrogram, and the choice of method is the decision of the urologist based on availability of equipment and timing of the procedure.

Question 178

What is the recommended imaging modality for diagnosing testicular rupture in patients with blunt scrotal injuries?

Answer 178

Scrotal ultrasonography is the recommended imaging modality for diagnosing testicular rupture in patients with blunt scrotal injuries.

Explanation: According to Guideline Statement 30A, scrotal ultrasonography can reliably diagnose testicular rupture with a high level of accuracy in the setting of blunt scrotal trauma. It is recommended for most patients having physical findings suggestive of testicular rupture. The most specific findings on ultrasonography are loss of testicular contour and heterogeneous echotexture of parenchyma, which should prompt testicular repair. Prompt surgical exploration is indicated with sonographic findings of testicular rupture, equivocal imaging, large hematoma, or clear physical findings of testicular rupture, which results in testicular salvage rates of 80-90%.

Question 179

What is the recommended management for most penetrating scrotal injuries?

Answer 179

Clinicians should perform prompt surgical exploration with repair or orchiectomy (when non-salvageable) given the high rate of testicular injury and limited sensitivity of ultrasound in this setting (Recommendation; Evidence Strength: Grade C).

Explanation: Penetrating injuries to the scrotum require prompt exploration with debridement and primary repair of the tunica albuginea or orchiectomy, as series demonstrate a > 50% rate of testicular injury. The utility of scrotal ultrasound for the evaluation of testicular rupture in the setting of penetrating scrotal trauma is limited. Therefore, prompt surgical exploration with repair or orchiectomy is recommended for most patients with penetrating scrotal injuries. Clinicians should maintain a high level of clinical suspicion for concomitant injury to the spermatic cord structures, contralateral testicle, penile corporal bodies, and urethra.

Question 180

What is the preferred method of repair for testicular rupture following scrotal injury?

Answer 180

Repair of the ruptured testis by debriding non-viable tissue and closing the tunica albuginea is preferred when possible, according to GUIDELINE STATEMENT 30C. Tunica vaginalis flap or graft may be used to provide closure when the tunica albuginea cannot be closed primarily.

Question 181

What is the recommended initial management for patients with extensive genital skin loss or injury?

Answer 181

Surgeons should perform exploration, irrigation, and limited debridement of clearly non-viable tissue.

Explanation: According to Guideline Statement 31, initial management for patients with extensive genital skin loss or injury from infection, shearing injuries, or burns (thermal, chemical, electrical) should include operative exploration, irrigation, and limited debridement of clearly non-viable tissue. These injuries require multiple procedures in the operating room prior to definitive reconstructive procedures. Wound management can include a variety of methods, including gauze dressings with frequent changes, silver sulfadiazine or topical antibiotic and occlusive dressing, or negative pressure dressings. Reconstructive techniques for definitive repair include primary closure and advancement flaps, placement of skin grafts, free tissue flaps, and pedicle based skin flaps.

Question 182

What is the recommended initial management for traumatic penile amputation according to Guideline Statement 32?

A) Immediate penile replantation
B) Transfer to a center with microvascular repair capabilities
C) Consultation with a microvascular surgeon
D) Wrap the amputated appendage in a plastic bag

Answer 182

D

Explanation: According to Guideline Statement 32, the amputated appendage should be transported to the hospital in a two-bag system, with the penis wrapped in saline-soaked gauze, placed in a plastic bag, and then placed on ice in a second bag. Immediate penile replantation is recommended, but the primary focus of this statement is on the transport and surgical repair of the amputated appendage. Transfer to a center with microvascular repair capabilities can be considered to improve outcomes, but the initial management is to wrap the amputated appendage in a plastic bag.