Genitourinary trauma

[Do concomitant urological injuries in severely injured patients lead to poorer outcomes? : A multivariate risk analysis]

BACKGROUND

Severely injured patients with associated genitourinary (GU) injuries have only rarely been investigated in the current literature. If at all, analyses are commonly focussed on renal injuries, marginalising other GU traumas such as ureteral injuries. In this study, we would like to characterise patients with GU injuries and analyse the impact of such injuries on mortality and length of stay.

MATERIALS AND METHODS

The inclusion criteria for this retrospective analysis of TraumaRegister DGU® data were: Injury Severity Score ≥ 16 within the period between 2009 and 2016 with available data on age and length of stay. A descriptive analysis was used to compare patients with and without GU injuries. The impact of GU injuries on mortality and length of hospital stay was evaluated by means of multivariate regression analyses.

RESULTS

In all, 90,962 patients met the inclusion criteria; 5.9% of them had suffered GU injuries (n = 5345). The prevalence in patients with pelvic fractures was up to 19%. On average, patients with GU trauma were 10 years younger (42.9 vs. 52.2 years) and more severely injured (ISS: 31.8 vs. 26.4). The multivariate analyses demonstrated that GU injuries in severely injured patients are no independent risk factor for mortality. However, particularly bladder and genital injuries result in longer hospitalisation.

CONCLUSION

GU injuries do not represent an additional risk factor for mortality. However, after adjusting for established prognosis factors, they can cause prolonged periods of hospitalisation of severely injured patients.

Serum cystatin C as a novel marker to differentiate pseudoazotemia in the setting of intraperitoneal urine extravasation

Urinary ascites results in pseudoazotemia due to urinary creatinine reabsorption across the peritoneum. We report a case of a pyeloplasty complicated by urine extravasation, in which the diagnosis was aided by discrepant findings of an elevated serum creatinine level but a stable cystatin C level. Cystatin C is a marker of renal function but is not typically excreted into the urine and therefore can be used to differentiate pseudoazotemia from true azotemia and is a better marker of renal function in the setting of known urinary ascites. These findings are relevant for patients with potential traumatic or nontraumatic sources of urine extravasation.

Bladder neck rupture following perineal bull horn injury: a surgical challenge

Pelvic-abdominal injuries caused by goring are serious lesions which require rapid diagnosis and urgent treatment in the context of a polytraumatized patient. The simultaneous rupture of both the bladder and the prostatic-membranous urethra occurs in 10%–29% of males with pelvic fractures but bladder neck injuries in adults are rarer. Unstable pelvic fractures, bilateral fractures of the ischiopubic branches (also referred to as fractures from falling astride) and the diastasis of the pubic symphysis are those that have the greatest likelihood of injuring both the posterior urethra and the bladder. We present a case of perineal bull horn injury with muscle laceration, bone fractures, scrotal avulsion and rupture of the bladder neck involving the right ureter which required two operations to be repaired.

Genitourinary trauma

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

Urologic trauma guidelines: a 21st century update

Trauma is the leading cause of death between the ages of 1 and 44 years in the USA. While stabilization of life-threatening injuries is the primary goal in the evaluation of all trauma patients, subsequent diagnosis and treatment of secondary injuries are requirements for good trauma care. The genitourinary system is involved in 10% of trauma cases, and these injuries can be associated with considerable morbidity and mortality. Accordingly, physicians involved in the initial evaluation and subsequent management of trauma patients should be aware of the diagnosis and treatment of injuries that can occur in the genitourinary system. In 2009, the European Association of Urology provided specific recommendations for the evaluation, diagnosis and management of genitourinary trauma. Here, we review and discuss these recommendations in order to provide a concise summary for clinicians involved in the evaluation and management of trauma patients and their associated genitourinary injuries.

Urologic sports injuries in children

Sports participation is an important part of the lives of many children and adolescents. The risk of sustaining a genitourinary injury during sports is low. The published literature suggests that the specific risk to those patients with only one healthy kidney, ovary, or testicle is very low but not zero. Physicians who counsel patients and families about sports participation need to consider many factors: the type of sport, the level of play, the local sports culture, and the relative degree of risk. The published data suggest that major injuries to an ovary during sports are exceedingly rare. Major injuries to a testicle are also unusual. Significant kidney injuries, while uncommon, do occur and not necessarily only in the well-known collision sports.

Urinary tract trauma — diagnosis and management

Urological trauma is rare but is associated with significant morbidity and mortality if missed or not managed appropriately. The careful assessment and involvement of specialist investigations and treatments are paramount to a good patient outcome. This article is aimed at the non-urologist to highlight the potential pitfalls and the importance of clinical suspicion. It should be used as a guide, but should not negate the involvement of a urologist early on in the investigation and management of trauma patients.

CT evaluation of an anterior urethral tear

A retrograde urethrogram is usually performed to evaluate the urethra in patients with suspected urethral injuries. A computed tomography (CT) scan is performed after the retrograde urethrogram to evaluate for further intrabdominal injuries. We present a case in which a CT scan performed after a retrograde urethrogram in a trauma patient identified a urethral tear.

Recent advances in management of female lower urinary tract trauma

PURPOSE OF REVIEW

Abdominal and pelvic injuries are often associated with devastating lower urinary tract injuries. The literature is replete with studies involving male lower urinary tract trauma, however the diagnosis and management of similar injuries in women is not as well covered. In this article we will review recent advances in the diagnosis and management of female lower urinary tract trauma.

RECENT FINDINGS

The recent literature emphasizes the importance of diagnosing and managing female lower urinary tract injuries, both of the bladder and the urethra, caused by blunt or penetrating trauma to the lower abdomen, pelvis and perineum. Successful management of these injuries is based upon accurate diagnosis, recognition of associated injuries, and prompt treatment. Diagnosis and treatment of female bladder perforation have been well established. Reports of female urethral injuries are scarce, however, and subsequently the management is not standardized.

SUMMARY

High suspicion, accurate diagnosis and prompt treatment are key for the successful management of female lower urinary tract injuries associated with lower abdominal, pelvic and perineal trauma. A standardized algorithm for management of female urethral injuries would be helpful.