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Herson AB, Villacreses CA, Rehm GM, Briceno SA, Healey KD, Brown MR, Miller BT, Fountain MW. Conservative Management of Postoperative Urinary Leak and Intra-Abdominal Abscess. Cureus 2023; 15:e40039. [PMID: 37425614 PMCID: PMC10324524 DOI: 10.7759/cureus.40039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 06/06/2023] [Indexed: 07/11/2023] Open
Abstract
Ureteral injury is a rare occurrence in medical practice. Most cases encountered stem from blunt trauma or are iatrogenic, occurring during open abdominal or pelvic surgery and laparoscopic procedures. Prompt diagnosis of ureteral injury allows clinicians to avoid complications including ureteral strictures, abscess, renal failure, sepsis, and loss of the ipsilateral kidney. Treatment depends on whether the ureteral injury was discovered intraoperatively or if it was a delayed diagnosis. Several procedures can be used, including ureteroureterostomy, ureteroileal interposition, and nephrectomy. Stenting can also be a viable option as it can reestablish urinary drainage. Herein, we present the case of a 43-year-old male who presented with complaints of progressive abdominal pain that was subsequently diagnosed as a left ureteral injury and how the use of a ureteral stent allowed him to have a full recovery with optimized normal ureteral function.
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Affiliation(s)
- Andrew B Herson
- Urology, Lake Erie College of Osteopathic Medicine, Jacksonville, USA
| | | | - Gina M Rehm
- Urology, Lake Erie College of Osteopathic Medicine, Fort Myers, USA
| | - Sean A Briceno
- Urology, Lake Erie College of Osteopathic Medicine, Tavares, USA
| | - Kevin D Healey
- Urology, Lake Erie College of Osteopathic Medicine, Jacksonville, USA
| | - Matthew R Brown
- Urology, Lake Erie College of Osteopathic Medicine, Bradenton, USA
| | - Brooke T Miller
- Urology, Lake Erie College of Osteopathic Medicine, Jacksonville, USA
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Muacevic A, Adler JR, El Moudane A, Barki A. Ureteral Injury by a Retained Knife After Abdominal Trauma: A Case Report. Cureus 2022; 14:e32719. [PMID: 36686087 PMCID: PMC9850262 DOI: 10.7759/cureus.32719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2022] [Indexed: 12/24/2022] Open
Abstract
Isolated ureteral injuries are rare, occurring particularly in gunshot wounds to the abdomen. These are much rarer in the context of stab wounds. These lesions are usually silent. We report a 30-year-old man with a history of abdominal penetrating trauma with a knife, 11 years ago before the actual admission to the urology department. The patient's report describes a retained metallic foreign body in the right lumbar area. At admission, the patient presented with a four-months history of right lumbago. An abdominal computed tomography scan revealed the presence of a right para-renal small urinoma and identified the 52 x 20 mm metallic foreign body at the level of L3 and L4 vertebral bodies, with the presence of mild right ureterohydronephrosis. Ureteral injuries can lead to significant morbidity and mortality when unrecognized or mismanaged. The basis of therapy for patients with ureteral injuries is to maintain renal drainage with options depending on individual cases.
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Rajput MZ, Mellnick VM. The Role of Magnetic Resonance in Evaluating Abdominopelvic Trauma - Part 2: Trauma in Pregnancy, Vascular, and Genitourinary Injuries. Can Assoc Radiol J 2022; 73:689-696. [PMID: 35282712 DOI: 10.1177/08465371221077654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Trauma is an important cause of mortality, particularly in the young. While computed tomography (CT) is the mainstay of body imaging in the setting of trauma, magnetic resonance (MR) imaging can be useful in stable patients. Although more commonly used in spinal and musculoskeletal trauma, MR also has a role in abdominopelvic trauma. Broadly, its uses include clarification of equivocal cases, monitoring complications of trauma, particularly with solid organ injury, or as a primary imaging modality for patients with low suspicion for injury for whom avoiding ionizing radiation is a priority-namely, in pediatric and pregnant patients. In this two-part review article, we will review clinical scenarios where this may be encountered, utilizing case examples. Our second installment will focus on the use of MR in pregnant patients and in the characterization of vascular and genitourinary trauma. Body MR can be useful in pregnant patients in characterizing injuries both specific for and not specific for pregnancy. Placental injuries and hematomas in particular may be better seen on MR relative to CT, owing to its superior contrast resolution. MR angiography can be performed either without or with contrast and can be useful to monitor low-grade traumatic aortic injuries. Renal and ureteral injuries can be followed with MR to help identify urine leaks, either in a delayed presentation or in patients who have an iodinated contrast allergy. Lastly, penile injuries are often imaged with ultrasound, but may benefit from additional imaging with MR when the tunica albuginea cannot be completely seen due to overlying hematoma.
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Affiliation(s)
- Mohamed Z Rajput
- Mallinckrodt Institute of Radiology, 116142Washington University School of Medicine, St Louis, MO, USA
| | - Vincent M Mellnick
- Mallinckrodt Institute of Radiology, 116142Washington University School of Medicine, St Louis, MO, USA
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Eudy M, Nowak N. Retained Bullet in the Penis. Cureus 2021; 13:e16488. [PMID: 34466303 PMCID: PMC8396406 DOI: 10.7759/cureus.16488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2021] [Indexed: 11/12/2022] Open
Abstract
Gunshot injuries to the genitourinary system are extremely rare among trauma cases and represent a complex clinical scenario to physicians. This rare case involves a 20-year-old male with a retained bullet in his penis following a close-range, low-velocity gunshot wound to the right lateral thigh. Our case report examines this unique clinical scenario and the diagnostic approach that should be taken to decrease the chances of negative cosmetic and functional outcomes.
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Affiliation(s)
- Morgan Eudy
- Surgery, Campbell University School of Osteopathic Medicine, Salisbury, USA
| | - Natalie Nowak
- Trauma and Acute Care Surgery, Team Health, Salisbury, USA
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Bernhard Z, Myers D, Passias BJ, Taylor BC, Castaneda J. Testicular Dislocation After Unstable Pelvic Ring Injury. Cureus 2021; 13:e13119. [PMID: 33728137 PMCID: PMC7935200 DOI: 10.7759/cureus.13119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Reproductive and genitourinary complications following pelvic ring injuries have been described; however, testicular dislocation is rare and can cause significant morbidity if not managed appropriately. We describe a case of testicular dislocation after pelvic ring injury and outline the subsequent management and outcome, and seek to identify areas of improvement to ensure expedient and appropriate care in the setting of these injuries. Our case describes a 29-year-old male who presented to a level-one trauma center following a motorcycle collision. An anteroposterior compression type II rotationally unstable pelvic ring was identified on imaging. He was hemodynamically unstable and computed tomography (CT) with angiography was ordered. Arterial extravasation was noted from the bilateral anterior internal iliac arteries, which were subsequently embolized by interventional radiology. However, no concomitant genitourinary injury was identified at the time of CT. After resuscitation, the pelvis was stabilized with an anterior symphyseal plate and bilateral sacroiliac screws. During the anterior pelvic approach, the patient’s dislocated testicle was surprisingly discovered inferior to the pubis. Urology was consulted intra-operatively, and the testicle was successfully relocated. At the final follow-up, the pelvic ring was healed without any noticeable urogenital complication. While testicular dislocation has been reported in the setting of pelvic ring injury, a paucity of information exists regarding management, implications, and areas for improvement in the identification of these injuries. Therefore, in cases of pelvic ring injury with significant trauma, radiologists, traumatologists, and orthopedic surgeons should adopt a multi-disciplinary approach in diligently attempting to rule out testicular dislocation pre-operatively. Intra-operatively, examination under anesthesia and careful operative technique are important in preventing iatrogenic injury.
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Affiliation(s)
- Zachary Bernhard
- Medical Education, West Virginia School of Osteopathic Medicine, Lewisburg, USA
| | - Devon Myers
- Orthopedic Surgery, OhioHealth, Columbus, USA
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Liang SY, Jackson B, Kuhn J, Shaikh F, Blyth DM, Whitman TJ, Petfield JL, Carson ML, Tribble DR, McDonald JR. Urinary Tract Infections after Combat-Related Genitourinary Trauma. Surg Infect (Larchmt) 2019; 20:611-618. [PMID: 31112074 DOI: 10.1089/sur.2019.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: We examined clinical outcomes among combat casualties with genitourinary injuries after blast trauma. Methods: Characteristics, clinical care, urologic complications, and infections for subjects enrolled in the Trauma Infectious Disease Outcomes Study (TIDOS) were collected from Department of Defense (DOD) and Department of Veterans Affairs (VA) sources. Logistic regression identified predictors for urinary tract infections (UTIs) after genitourinary trauma. Results: Among 530 TIDOS enrollees who entered VA care, 89 (17%) sustained genitourinary trauma. The majority of subjects (93%) were injured via a blast and 27% had a dismounted complex blast injury (DCBI). Sexual dysfunction was reported with 36% of subjects, whereas 14% had urinary retention/incontinence and 8% had urethral stricture. Urologic complications were comparable between patients with and without DCBIs. Nineteen (21%) subjects had one or more UTI with a total of 40 unique UTI events (25% during initial hospitalization and 75% during subsequent DOD or VA care). The UTI incidence rate was 0.89 per patient-year during initial hospitalization, 0.05 per patient-year during DOD follow-up, and 0.07 per patient-year during VA healthcare. Subjects with UTIs had a higher proportion of bladder injury (53% vs. 13%; p < 0.001), posterior urethral injury (26% vs. 1%; p = 0.001), pelvic fracture (47% vs. 4%; p < 0.001), soft-tissue infection of the pelvis/hip (37% vs. 4%; p = 0.001), urinary catheterization (47% vs. 11%; p < 0.001), urinary retention or incontinence (42% vs. 6%; p < 0.001), and stricture (26% vs. 3%; p = 0.004) compared with patients with genitourinary trauma and no UTI. Independent UTI risk factors were occurrence of a soft-tissue infection at the pelvis/hip, trauma to the urinary tract, and transtibial amputation. Conclusions: Among combat casualties with genitourinary trauma, UTIs are a common complication, particularly with severe blast injury and urologic sequelae. Episodes of UTIs typically occur early after the initial injury while in DOD care, however, recurrent infections may continue into long-term VA care.
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Affiliation(s)
- Stephen Y Liang
- Washington University School of Medicine, St. Louis, Missouri
| | - Brendan Jackson
- Veterans Affairs St. Louis Health Care System, St. Louis, Missouri
| | - Janis Kuhn
- Veterans Affairs St. Louis Health Care System, St. Louis, Missouri
| | - Faraz Shaikh
- Infectious Disease Clinical Research Program, Preventive Medicine & Biostatistics Department, Uniformed Services University of the Health Sciences, Bethesda, Maryland.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland
| | - Dana M Blyth
- Brooke Army Medical Center, JBSA Fort Sam Houston, Texas
| | | | | | - M Leigh Carson
- Infectious Disease Clinical Research Program, Preventive Medicine & Biostatistics Department, Uniformed Services University of the Health Sciences, Bethesda, Maryland.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland
| | - David R Tribble
- Infectious Disease Clinical Research Program, Preventive Medicine & Biostatistics Department, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Jay R McDonald
- Washington University School of Medicine, St. Louis, Missouri.,Veterans Affairs St. Louis Health Care System, St. Louis, Missouri
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Abstract
Background: Initial management of urethral injury remains controversial concerning the use of suprapubic urinary diversion and delayed repair, primary open realignment, and primary endoscopic realignment. To our knowledge, we present the first reported case of a penetrating urethral injury because of an animal attack, without concomitant extragenitourinary system involvement, managed entirely endoscopically. Case Presentation: This is a case of an 82-year-old male who presented to the emergency department after an attack by a semidomesticated deer. He presented with a penetrating scrotal injury and gross blood at the meatus. A retrograde urethrogram was performed that revealed a urethral injury. Surgical exploration revealed an isolated 3-cm urethral defect. It was managed with primary endoscopic placement of a urethral catheter and suprapubic tube. Conclusion: Although initial management of urethral injuries remains controversial, an isolated urethral injury after a penetrating trauma because of an animal attack may be safely and effectively managed by primary endoscopic realignment.
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Affiliation(s)
- Amy Reed
- Urology Clinic, Department of Surgery, Brooke Army Medical Center, JBSA Fort Sam Houston, Texas
| | - Grant H. Evans
- Urology Clinic, Department of Surgery, Brooke Army Medical Center, JBSA Fort Sam Houston, Texas
| | - Jacqueline Evans
- Emergency Department, Brooke Army Medical Center, JBSA Fort Sam Houston, Texas
| | - Jeremy Kelley
- Urology Clinic, Department of Surgery, Brooke Army Medical Center, JBSA Fort Sam Houston, Texas
| | - David Ong
- Emergency Department, Brooke Army Medical Center, JBSA Fort Sam Houston, Texas
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Abstract
We describe the epidemiology, diagnosis, and management of adult civilian penetrating trauma to the ureter, bladder, and urethra. Trauma is a significant source of death and morbidity. Genitourinary injuries are present in 10% of penetrating trauma cases. Prompt recognition and appropriate management of genitourinary injuries, which are often masked or overlooked due to concomitant injuries, is essential to minimize morbidity. Penetrating trauma most commonly results from gunshot wounds or stab wounds. Compared to blunt trauma, these typically require surgical exploration. An understanding of anatomy and a high index of suspicion are necessary for prompt recognition of genitourinary injuries.
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Kuy S, Somberg LB, Paul J, Brown N, Saving A, Codner PA. Undetected penetrating bladder injuries presenting as a spontaneously expulsed bullet during voiding: a rare entity and review of the literature. J Emerg Med 2013; 45:e59-62. [PMID: 23714330 DOI: 10.1016/j.jemermed.2013.03.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2012] [Revised: 10/23/2012] [Accepted: 03/27/2013] [Indexed: 11/17/2022]
Abstract
BACKGROUND Patients presenting with a penetrating missile lodged in the pelvis are at risk for having a urinary tract injury. Once in the bladder, the missile can become impacted in the urethra, causing retention that requires extraction. Rarely, the missile can be expulsed spontaneously through the urethra. OBJECTIVES To describe the world literature regarding undetected penetrating bladder injuries presenting as spontaneously voided bullets and to contribute an additional case to the literature. CASE REPORT We present a case report of a 37-year-old man who sustained a gunshot wound to the right buttock, with an undetected urinary system injury and subsequent spontaneous voiding of a bullet. CONCLUSION There have been <10 cases reported in the literature of spontaneously expulsed bullets from the urethra, all of which were undetected injuries on initial presentation. Physicians should be aware of the potential for undetected urinary tract injuries in patients with penetrating missiles to the pelvis and understand the appropriate evaluation and management strategies for these injuries.
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Affiliation(s)
- SreyRam Kuy
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin 53226, USA
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