Routine preoperative "one-shot" intravenous pyelography is not indicated in all patients with penetrating abdominal trauma

Gunshot wounds to the penis and scrotum: a narrative review of management in civilian and military settings

Gunshot wounds (GSW) to the penis and scrotum are present in two thirds of all genitourinary (GU) trauma, with a growing proportion of blast injuries in the military setting. Depending on the energy of the projectile, the injury patterns present differently for military and civilian GSWs. In this review, we sought to provide a detailed overview of GSWs to the external genitalia, from mechanisms to management. We examine how ballistic injury impacts tissues, as well as the types of injuries that occur, and how to assess these injuries to the external genitalia. If there is concern for injury to the deep structures of the penis or scrotum, operative exploration and repair is warranted. Relevant history and physical examination, role of imaging, and choice of conservative or surgical treatment options in the civilian and military setting are discussed, as well as guidelines for management set forth by the American Urological Association (AUA) and European Association of Urology (EAU).

Absent Ureteral Efflux after Hysterectomy Leads to Diagnosis of Ureteral Atresia with Renal Atrophy

Iatrogenic injury to the urinary system is a known complication of gynecologic surgery; therefore, intraoperative cystoscopy is frequently performed to assess for such injuries. However, if an abnormality is seen, the differential diagnosis extends beyond iatrogenic causes. A 42-year-old patient underwent a total abdominal hysterectomy and had absent efflux from the right ureteral orifice on cystoscopy. While iatrogenic injury was initially suspected, the intraoperative workup (including intravenous pyelography (IVP)) that ensued led to an empiric diagnosis of right ureteral atresia with ipsilateral renal atrophy that was then confirmed on postoperative imaging. When an abnormality is seen on cystoscopy following gynecologic surgery, it is important to maintain a broad differential diagnosis and to pursue an intraoperative workup with early involvement and close collaboration with urology.

Urotrauma: AUA guideline

PURPOSE

The authors of this guideline reviewed the urologic trauma literature to guide clinicians in the appropriate methods of evaluation and management of genitourinary injuries.

MATERIALS AND METHODS

A systematic review of the literature using the MEDLINE® and EMBASE databases (search dates 1/1/90-9/19/12) was conducted to identify peer-reviewed publications relevant to urotrauma. The review yielded an evidence base of 372 studies after application of inclusion/exclusion criteria. These publications were used to inform the statements presented in the guideline as Standards, Recommendations or Options. When sufficient evidence existed, the body of evidence for a particular treatment was assigned a strength rating of A (high), B (moderate) or C (low). In the absence of sufficient evidence, additional information is provided as Clinical Principles and Expert Opinions.

RESULTS

Guideline statements were created to inform clinicians on the initial observation, evaluation and subsequent management of renal, ureteral, bladder, urethral and genital traumatic injuries.

CONCLUSIONS

Genitourinary organ salvage has become increasingly possible as a result of advances in imaging, minimally invasive techniques, and reconstructive surgery. As the field of genitourinary reconstruction continues to evolve, clinicians must strive to approach clinical problems in a creative, multidisciplinary, evidence-based manner to ensure optimal outcomes.

Contemporary management of renal trauma: differences between urologists and trauma surgeons

BACKGROUND

The purpose of this study was to evaluate the contemporary practice patterns of urologists (UR) and trauma surgeons (TS) regarding controversial topics in the management of renal trauma (RT).

METHODS

We conducted a national survey of all Society of Genitourinary Reconstructive Surgeons members and a random sampling of American Association for the Surgery of Trauma members between October and November 2010 via email, regarding management routines for various stages of blunt and penetrating RT.

RESULTS

Response rate was 33%. In all, 21% of TS and 3% of UR (p = 0.005) do not use any tests to confirm the presence of another kidney before exploring an expanding retroperitoneal hematoma, despite lack of preoperative imaging. To confirm the presence of another kidney, UR prefer the "one-shot" intravenous pyelogram (82%), whereas TS prefer palpation (61%; p < 0.001). TS do not obtain primary renal vascular control before opening the retroperitoneal, whereas UR do (21% vs. 71%; p < 0.001). TS utilize early angiography for the control of intravascular contrast extravasation more commonly than UR (88% vs. 55%; p < 0.001). TS overutilize ureteral stenting (50% vs. 24%; p < 0.001) for isolated collecting system injuries compared with UR. Differences in practice patterns between TS and UR tend to follow differences in published guidelines.

CONCLUSION

There is an apparent lack of communication and differing treatment methods for RT. That there are two camps with differing "community standards of practice" indicates that there is a desperate need for reeducation and for large-scale, multi-institutional prospective studies on RT to "standardize" management.

Guidelines for the management of haemodynamically stable patients with stab wounds to the anterior abdomen

Clinical practice guidelines have been shown to improve the delivery of care. Anterior abdominal stab wounds, although uncommon, pose a challenge in both rural and urban trauma care. A multidisciplinary working party was established to assist in the development of evidence-based guidelines to answer three key clinical questions: (i) What is the ideal prehospital management of anterior abdominal stab wounds? (ii) What is the ideal management of anterior abdominal stab wounds in a rural or urban hospital without an on-call surgeon? (iii) What is the ideal emergency management of stable patients with anterior abdominal stab wounds when surgical service is available? A systematic review, using Cochrane method, was undertaken. The data were graded by level of evidence as outlined by the Australian National Health and Medical Research Council. Stable patients with anterior abdominal stab wounds should be transported to the hospital without delay. Any interventions deemed necessary in prehospital care should be undertaken en route to hospital. In rural hospitals with no on-call surgeon, local wound exploration (LWE) may be undertaken by a general practitioner if confident in this procedure. Otherwise or in the presence of obvious fascial penetration, such as evisceration, the patient should be transferred to the nearest main trauma service for further management. In urban hospitals the patient with omental or bowel evisceration or generalized peritonitis should undergo urgent exploratory laparotomy. Stable patients may be screened using LWE. Abdominal computed tomography scan and plain radiographs are not indicated. Obese and/or uncooperative patients require a general anaesthetic for laparoscopy. If there is fascial penetration on LWE or peritoneal penetration on laparoscopy, then an urgent laparotomy should be undertaken. The developed evidence-based guidelines for stable patients with anterior abdominal stab wounds may help minimize unnecessary diagnostic tests and non-therapeutic laparotomy rates.

Genitourinary trauma

Injuries to the GU system commonly occur in patients with high-energy lower abdominal or pelvic trauma. The emergency physician should be well versed in the diagnosis and management of GU trauma, although these injuries are not usually life threatening because of the potential for loss of urinary or sexual function. In the setting of hemodynamic instability, diagnosis and treatment of GU injuries is often accomplished in the operative setting. In the stable patient, diagnostic testing is directed by the type of suspected injury and must proceed in a reverse manner, i.e., external injury then urethral injury then bladder, and finally urethral and renal damage. Treatment focuses on a team approach between the emergency physician, general, orthopedic, and urologic surgeon. The decision for operative repair is often dictated more by other associated injuries than urologic injuries, and the urologic surgeon often provides temporizing measures with definitive repair at a later time. Prompt diagnosis and treatment of injuries to the external genitals results in excellent long-term outcome, minimizing the devastating consequences of impotence, urinary incontinence, and sexual disfiguration.

Diagnostic procedures for the urogenital system

In making clinical decisions concerning the urogenital system, the emergency department physician has many different diagnostic tools at his or her disposal. Choosing the appropriate diagnostic study can often be difficult. For well over a thousand years, the initial step in assessing almost any urologic condition has been to examine the urine. Thankfully, this has progressed from a gustatory approach to the modern urinalysis. There is certainly a great deal of information that may be gleaned from the urinalysis, but the physician must also be mindful of its limitations. Overuse of the urinalysis can result in unwanted and unhelpful information. Although IVP is still the study of choice in assessing the functional status of the kidney, the introduction of CT and ultrasound technology to clinical medicine has revolutionized the emergency department assessment of the urogenital tract. CT and ultrasound can help differentiate between the urologic emergencies and the various surgical conditions that can mimic them.