Trauma

Renal Trauma

Epidemiology / Pathogenesis

• Most commonly injured GU organ in trauma
• Prone to deceleration injury (falls, MVC) — kidney fixed only by renal pelvis + vascular pedicle
• Pediatric kidney more susceptible
  • ↓ protective mechanisms:
    • Pliable thoracic cage
    • Weaker abdominal muscles
    • Less perirenal fat
    • Lower abdominal position
  • Also:
    • Larger kidney relative to body size, non-ossified ribs and less rib coverage
    • A high catecholamine output that maintains blood pressure until roughly 50% of blood volume is lost
    • And more congenital abnormalities (severe hydronephrosis, UPJ obstruction) where minor trauma causes significant injury
  • Children carry up to a 50% higher risk of renal trauma than adults after blunt abdominal injury
    • And a 33% higher risk of high-grade injury
  • GU malformations are at least 3× more common than in adult trauma patients
    • → hematuria out of proportion to the injury should prompt a search for one

History / Physical Exam

• Primary survey: ABCDE + X-rays (pelvis, chest, C-spine), cross-match and labs.
• Secondary survey: AMPLE (Allergy, Medications, Past history, Last meal, Events) + Foley catheter
• Take the initial urine sample for urinalysis BEFORE fluid resuscitation — resuscitated urine is diluted and gives a false-negative
• Events worth asking:
  • Seat belt
  • Ejected from the vehicle
  • Speed
  • Driver or passenger
  • Height of fall
  • Size of weapon
  • Loss of consciousness
  • Able to void
  • Able to walk
• Extent of deceleration = most important info in blunt injury
• Anterior to axillary line → hilum/pedicle injury; posterior → parenchymal injury
• Exam findings (5):
  • Flank hematoma
  • Abdominal/flank tenderness
  • Rib fractures
    • Ipsilateral rib fracture → 3× risk of significant renal trauma
  • Hematuria
    • Degree of hematuria does not correlate with injury severity — don't use as sole determinant
  • Penetrating injury to low thorax/flank

Imaging — indications

• Gross hematuria
• Microscopic hematuria + SBP <90 mmHg
• Mechanism concerning for renal injury (rapid deceleration, blow to flank)
• Exam findings concerning for renal injury (rib fracture, flank ecchymosis)
  • A lower rib fracture alone is enough to image a stable patient
• Penetrating injury of abdomen/flank/lower chest
• Any pediatric patient with more than 5 RBCs/HPF
  • Adults with microscopic hematuria, no shock and a non-suggestive mechanism can be observed without imaging — this does NOT extend to children
    • Adult observation also needs a normal examination; keep a low threshold to image if the history, exam or course changes
    • Stable child vs stable adult, both with microscopic hematuria → the child gets CT priority
      • Normal BP is falsely reassuring (catecholamines hold BP until ~50% of blood volume is lost)
• Pediatric blunt trauma — also image for GU injury if:
  • Significant mechanism (deceleration/high-velocity, fall >10 feet, flank struck by an object)
    • A significant mechanism alone → contrast CT abdomen, even with normal urinalysis and stable vitals
  • Rib, spine, pelvis or femur fractures
  • Intra-abdominal organ injury
  • Gross hematuria
  • Microscopic hematuria with shock

Imaging — modality

• CT abdomen/pelvis with IV contrast + immediate AND delayed images
  • Delayed phase at 5–20 min reliably shows lacerations and urinary extravasation
  • Trace both ureters along their whole course — ureteral injury is difficult to diagnose on CT
  • Significant renal injury on CT but no delayed phase
    • → get delayed images (ideally 10–20 min post-contrast) to look for contrast in the distal ureter and exclude UPJ disruption
• Children → US may be used, but CT preferred
  • Exception — gross hematuria after trivial trauma
    • → suspect an underlying anomaly (hydronephrosis, multicystic kidney, Wilms tumor, fusion anomaly)
    • → renal + bladder US first, not CT
• OR without prior CT → intraop one-shot IVP (2 mL/kg bolus, single image at 10–15 min) to confirm contralateral functioning kidney
  • Obtain it before any nephrectomy
• Major CT limitation: cannot define renal venous injury → medial hematoma suggests venous injury (no modality reliably diagnoses)
• FAST has poor specificity for renal injury in the adult
  • Limited by obesity, subcutaneous air and prior abdominal surgery.
  • It can confirm two kidneys and detect a retroperitoneal collection, but cannot differentiate a hematoma from a urine leak
• If CT urography does not visualize the ureter, add cystoscopy and retrograde pyelography

CT findings suspicious for significant injury (6)

• Medial laceration
• Medial hematoma (vascular pedicle injury)
• Medial urinary extravasation (renal pelvis / UPJ injury)
• Hematoma >3.5 cm
• Lack of parenchymal enhancement (main renal artery injury)
• Active intravascular contrast extravasation (brisk arterial bleed)

Fluid collection density: Hematoma >30 HU | Urinoma 0–20 HU | Abscess = rim enhancement (rare post-trauma)

AAST Renal Injury Scale

Advance one grade for bilateral injury up to grade III

• Bilateral subcapsular hematomas (each grade I) → grade II
• Grade by the higher-grade kidney — grade III is already the cap, so grade I + grade III stays grade III

Separating grade IV from grade V on CT: if there is contrast around the kidney it is at least grade IV. Then look at the kidney itself — enhancing and not shattered is IV; shattered or non-enhancing is V.

• Grade III vs IV: a laceration >1 cm is grade III regardless of hematoma size or number of lacerations
  • Unless urinary extravasation on delayed images makes it grade IV
• Complete infarction from vessel thrombosis with no active bleed = grade IV, not V
  • → observed patients need BP monitoring for up to a year (below)
• Medial contrast extravasation + no contrast in the distal ipsilateral ureter = complete UPJ disruption (grade IV)
  • Classically a child with a deceleration injury and pre-existing hydronephrosis
• A grade II perirenal hematoma tracks caudally:
  • Gerota's fascia is closed above and laterally, but the cone-shaped perirenal space opens inferiorly into the extraperitoneal pelvis
  • → a renal hematoma can present as a pelvic collection
• The scale does not distinguish blunt from penetrating injury → weigh mechanism separately when choosing management

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Management

• Shift from operative exploration → non-operative management in vast majority
• Non-op of blunt injury firmly established; penetrating + high-grade remains debatable

Hemodynamically stable → non-invasive management

• Close hemodynamic monitoring, bed rest, ICU admission, blood transfusion (when indicated), imaging (when indicated)
• Follow-up CT (after 48 h) indicated for (2):
  • Clinical signs of complications (fever, worsening flank pain, ongoing blood loss, distention)
  • Deep lacerations (Grade IV–V)
    • Grade IV–V → repeat CT for the risk of urinoma or hemorrhage; routine DMSA scans not advised
• Grade I–III → low complication risk, routine follow-up CT not advised
• Risk factors for bleeding / need for intervention in grade III–IV (3):
  • Medial hematoma
  • Hematoma >3.5–4 cm
  • Vascular contrast extravasation
• These predict intervention but do not change the AAST grade
• Delayed bleeding can occur up to weeks later, usually within 21 days
  • After a conservatively managed grade IV injury it is almost always a ruptured segmental pseudoaneurysm or AV fistula
    • → angiography + selective angioembolization

Renal artery thrombosis / devascularized kidney

• Salvageability window is 8 hours
• First line — observation.
  • For unilateral arterial thrombosis, revascularization rarely produces a salvaged or viable kidney
  • As long as the contralateral kidney is normal, observation is often best
  • Why: pre-hospital warm ischemia usually causes irreparable damage, so salvage after revascularization is poor
• Second — thrombectomy and endovascular stent (disadvantage: coagulopathy and bleeding risk)
• Third — surgical exploration (invasive, low salvageability, high risk of nephrectomy)
• Reconstruction of the main renal artery is only a primary consideration in a stable patient with a solitary kidney, or with bilateral renal arterial injuries

Hemodynamically unstable → immediate intervention (surgery OR angioembolization)

• Immediate intervention if large perirenal hematoma (>4 cm) and/or vascular extravasation with deep/complex laceration (AAST III–V)
• Segmental vessel bleeding → angioembolization (effective, minimally invasive)
  • Selective angioembolization for active renal bleeding when there is no other indication for immediate abdominal operation
    • High-grade blunt success 94.9% grade III, 89% grade IV
  • Post-embolization syndrome — self-limiting; in 10% presents with fever, pain, ileus
• Unstable despite resuscitation → OR, not angiography
• WSES/AAST 2019: non-op for all stable/stabilized; isolated urinary extravasation is NOT an absolute contraindication to non-op

Conservative management

• Conservative management rarely fails within the first 24 hours — about 2.7%.
  • Risk factors for failure: injury grade, non-renal abdominal injuries, penetrating mechanism.
  • Most failures need only a ureteral stent or angioembolization
• Monitor blood pressure periodically for up to a year after injury, for the rare instance of acute or delayed renovascular hypertension
• Percutaneous nephrostomy is NOT contraindicated
• Retrograde stent placement is sometimes impossible
  • Pelvic fracture urethral distraction defect
  • Severe genital trauma preventing urethral access
  • Complete ureteral transection
  • Or fractures preventing lithotomy.
• Percutaneous nephrostomy with consideration of an antegrade stent is the alternative

Delayed hematuria and flank pain after discharge — AV fistula vs pseudoaneurysm. A venous phase is required to tell them apart.

• Treat with angioembolization

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Surgical management

Absolute indications for exploration (distinct from the CT signs of significant injury)

• Hemodynamic instability with no or only transient response to resuscitation
• Expanding or pulsatile renal hematoma — usually indicates renal artery laceration
• Suspected renal vascular pedicle avulsion
• Ureteropelvic junction avulsion

Relative indications

• Urinary extravasation with significant parenchymal devascularization
• Renal injury together with colon or pancreatic injury
  • Higher complication rate if not repaired at the same time, though it may be closely observed after the enteric repair
• Arterial thrombosis
• Urinary extravasation from a parenchymal injury

Intra-operative

• The only absolute INTRA-OPERATIVE indication is a pulsatile, expanding retroperitoneal hematoma, suggesting a life-threatening renal artery laceration
  • Found at laparotomy without preoperative imaging (e.g. gunshot wound):
    • Non-expanding, non-pulsatile hematoma → one-shot IVP
    • Expanding or pulsatile → renal exploration
  • Non-expanding hematoma with renal pelvic and ureteral injury excluded → expectant management
    • Exploration risks renal loss
    • Conservative management lowers nephrectomy rates
• By transabdominal approach
  1. Small bowel mobilized outside surgical field to expose mid-peritoneum
  2. Incision above the IMA to expose renal veins
     • Retroperitoneal incision over the aorta just above the IMA, extended to the ligament of Treitz — renal vessels isolated before Gerota's fascia is opened
  3. Secure renal vein & retract cephalad to expose renal artery beneath it
  4. Then secure renal artery
  5. For large hematoma that may obscure vision → use IMV as a landmark to incise medially
     • Incising just medial to the IMV leads onto the aorta, then up to the left renal vein
  6. After securing the renal vessels, the kidney is exposed
  7. Left kidney exposure → Mattox maneuver
  8. Right kidney exposure → Cattell maneuver
• Limited debridement; suture ligation of bleeders; watertight collecting-system closure; reapproximate parenchyma; omental/Gerota flap coverage; liberal drains
• Major renovascular injury + 2 kidneys → speedy nephrectomy (vascular repair salvage rates poor)
  • If repaired, salvageability is only about 33%
  • Repair with 5-0 non-absorbable suture
• Where parenchyma is left open, cover with a pedicled omental flap where possible
  • Its vascular and lymphatic supply promotes healing and lowers delayed bleeding and urinary extravasation
  • Absorbable mesh, peritoneal graft or retroperitoneal fat also work
• Hemostatic agents (thrombin-plus-gelatin preparations) have an increasing role in genitourinary trauma
• Damage control: pack kidney, return in ~24 h after ICU stabilization (cold/acidotic/coagulopathic)
• Unstable + no damage control option → immediate total nephrectomy

Renal arterial anatomy

• The posterior segmental artery is the first and most constant branch
  • Leaves the renal artery before the hilum and passes posterior to the renal pelvis
• Segmental arteries are non-anastomosing end arteries
  • → injury to one causes segmental infarction
  • The avascular line of Brödel lies between the anterior and posterior segmental territories

Urinary extravasation

• Persistent extravasation → urinoma, perinephric infection, renal loss (rare)
• Stable + no renal pelvis/proximal ureteral injury suspected → observe (grade IV parenchymal/forniceal extravasation resolves spontaneously >90%)
• Intervention indications (4):
  • Suspected renal pelvis / proximal ureteral avulsion (large medial urinoma, contrast extravasation without distal ureteral contrast)
    • No contrast in the distal ureter on delayed CT → emergent surgery with retrograde pyelogram to confirm UPJ disruption, then repair
    • UPJ and ureter intact → non-operative management
  • Enlarging/purulent/complex urinoma
  • Complications (fever, infection, pain, ileus, fistula)
  • Continued extravasation
• Options: ureteral stent (preferred) ± Foley; percutaneous urinoma drain / nephrostomy
• Mimic — chylous ascites (lymphatic injury, e.g. after partial nephrectomy):
  • Collection triglycerides 4× serum with near-normal creatinine
    • → not a urine leak, so retrograde pyelogram not indicated
  • Treat:
    • Low-fat, high-protein, medium-chain triglyceride diet first
    • No antibiotics
    • TPN only if diet fails
    • Somatostatin for refractory cases

Hypertension post-trauma

• Rare early, can occur later.
• Mechanisms (4):
  • Renovascular stenosis/occlusion
  • Page kidney (parenchymal compression by blood/urine)
  • Post-trauma AVF
  • Ureteral/UPJ obstruction
• RAAS stimulated by partial ischemia. Treat: antihypertensives, observation, rarely nephrectomy

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Ureteral Trauma

Epidemiology / Pathogenesis

• Rare — 1% of urologic injuries
• Causes (3): iatrogenic; external violence (high-speed blunt); penetrating (stab/GSW)
• Iatrogenic procedures: hysterectomy 54%, colorectal 14%, ovarian tumor 8%
  • Nearly 62% of hysterectomy injuries are missed at the time
    • Late recognition raises the need for nephrostomy from 2.3% to 23.4%
• Ligation is the commonest ureteral injury in gynecologic surgery
• External violence causes ureteral damage in <4% of penetrating and <1% of blunt trauma
  • Associated visceral injury is common — small bowel 39–65%, large bowel 28–33%
  • 10–28% also have a renal injury, ~5% a bladder injury
• Injuries during gynecologic laparoscopy cluster around electrosurgical or laser lysis of endometriosis
  • Endometrioma can involve the ureter, adhesions obscure it, and the disease deviates it medially out of position

Mechanisms

• Intra-operative:
  • Suture ligature
  • Thermal injury
  • Freezing (cryoablation)
  • Sharp cut
  • Crush
  • Devascularization
  • Avulsion
• Extra-operative:
  • Gunshot
  • Blunt external trauma

Intravenous methylene blue — safety

• Dose <2 mg/kg
• Avoid in pregnancy, in G6PD deficiency, and in patients taking SSRIs, SNRIs or MAOIs
  • Methylene blue is a potent monoamine oxidase inhibitor and can precipitate serotonin toxicity, and rarely serotonin syndrome and death

Intraoperative ureter assessment

• Cystoscopy with retrograde pyelography — most accurate for location and degree
  • Exam answer: the gold standard to confirm or exclude a suspected intraoperative injury; a normal study often avoids further dissection
• Cystoscopy checking ureteric efflux
  • Efflux can persist with a partial transection, so it does not exclude injury
  • Efflux can also be seen after ligation → cystoscopy alone is not enough
• Ureteroscopy
• Stenting or catheterization (no resistance suggests no significant injury)
• IVP
• Indigo carmine or methylene blue (IV, into the renal pelvis, or down a stent)
• Surgical exploration — direct dissection is the most accurate method
  • Direct inspection especially for high-velocity or thermal injury
  • GSW near the ureter's course (e.g. with an iliac vessel injury)
    • → explore the retroperitoneum and inspect the ureter directly at laparotomy, even if intraoperative IVP is normal

Factors that decide the repair:

• Location
• Mechanism
• Degree
• Patient characteristics
• The operating surgeon's experience

Endoscopic / iatrogenic

• Ureteroscopy over a wire into renal pelvis
• Perforation recognized → stop procedure, place stent
• Avoid avulsion:
  • Never basket blindly
  • Fragment stones too large to pass
  • Keep a safety wire so a stent can be placed and the case aborted
• Aortoiliac/aortofemoral bypass manipulation → hydronephrosis in 12–20% (benign; steroids if symptomatic)
• Prophylactic preop stenting does NOT reduce injury risk (RCT, gyn surgery)
  • It does help the injury be recognized intraoperatively, so it can be repaired immediately

Diagnosis

• Imaging: contrast CT with 10-min delayed films (stable, not going directly to laparotomy)
• Findings (4):
  • Contrast extravasation
  • Lack of distal ureteral contrast
  • Ipsilateral delayed pyelogram
  • Ipsilateral hydronephrosis
• No preop imaging → direct inspection at laparotomy
• Penetrating injury:
  • IVP normal or indeterminate in ~70%
  • Hematuria absent in up to 45%
  • A one-shot IVP is unreliable in a hypotensive patient

AAST Ureter Injury Scale

Advance one grade for bilateral injury up to grade III

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Management

Stable → look for the time window [less than 7 days or more than 7 days]

• Early recognition (<7 days):
  • URS: perforation → stent 4–6 wks / avulsion → immediate repair
  • Thermal / high-velocity contusion → debridement UU
    • Distal-third cautery (thermal) injury → debride + reimplant (psoas hitch or Boari flap as needed), even without extravasation — the extent of thermal damage is initially hidden
  • Small contusion → stent 4–6 wks
  • Major pelvic → reimplant ± psoas hitch (6–10 cm) / (4–5 cm) / Boari flap (12–15 cm)
    • Exam answer: the Boari flap bridges 10–15 cm — use it when the defect extends above the pelvic brim or the psoas hitch is under tension
  • Major abdominal → reimplant / UU 2–3 cm / TUU
  • UPJ → UP (pyeloplasty)
  • Loss of entire ureter → ileal ureter / nephrectomy / autotransplant
• Late recognition (>7 days):
  • Retrograde stent; if failed → antegrade stent; if failed → PCN → then wait 6 wks for final management

By grade and location

• Grades I–II — stent or nephrostomy
  • A JJ stent is better, with a lower stricture risk.
  • With ligation, remove the offending clip or suture first, then stent for 2–6 weeks
    • Follow-up imaging after removal to exclude stricture
  • An intact contused ureter found at laparotomy is primarily managed by stenting
  • A missed contusion presenting later as a leak is managed first by retrograde imaging with stent placement
  • A high-velocity gunshot causing distal ureteral contusion is best managed by re-implantation even with no leak
    • To avoid later necrosis and stenosis.
    • On a second look, a minor intact contusion needs only a stent; a large or severe one means re-implant
    • Excise the contused distal segment and reimplant (psoas hitch or Boari flap as needed) — never ureteroureterostomy
• Grades III–V, distal — ureteroneocystostomy.
  • No clear advantage to a non-refluxing anastomosis in an adult.
  • Psoas hitch, then Boari flap if short.
  • Stent 6 weeks
  • Urethral catheter 1–2 weeks (some obtain a cystogram before removal)
  • Drain
  • Ultrasound at 4–6 weeks
  • Distal = below the iliac vessels
    • Reimplant a complete injury here because trauma jeopardizes the distal ureter's blood supply
• Grades III–V, mid and proximal — above the iliacs, primary repair over a stent wherever possible.
  • Ureteroureterostomy is best for small ligation and crush injuries when stenting alone is not possible
  • Stable patient, complete mid-ureteral transection at laparotomy (stab or GSW)
    • → debride necrotic edges + immediate stented ureteroureterostomy
    • Staged repair is for the unstable patient only
• Grade V — temporize and defer.
  • Ureterocalicostomy · transureteroureterostomy · ileal ureter · autotransplantation · nephrectomy · buccal graft
  • Contraindications to transureteroureterostomy: retroperitoneal fibrosis, urothelial malignancy, nephrolithiasis, and abdominal aortic aneurysm
  • Ileal ureter
    • The delayed repair for a long defect nothing else can bridge (contralateral nephrolithiasis rules out TUU; small bladder capacity rules out a Boari flap)
    • Not recommended in the acute setting
    • Contraindications: creatinine >2 mg/dL · inflammatory bowel disease · radiation enteritis · bladder dysfunction or outlet obstruction
• Ureteroscopic avulsion
  • Proximal and mid: immediate ureteroureterostomy, as for a grade IV laceration.
  • Distal: re-implant
    • Do NOT do a ureteroureterostomy in the distal ureter, the ischemic stricture risk is too high
  • Exam answer: avulsion at ureteroscopy without a safety wire → percutaneous nephrostomy + delayed repair, not immediate repair — ischemic and thermal injury at the avulsed margins declares itself over days

Unstable → temporary urinary drainage, delayed definitive repair (4 options)

• Ureteral stent (internal double-J or exteriorized single-J)
• Short observation, reoperate when stable (~24 h)
• Exteriorize the ureter
• Tie off ureter (long silk for ID) + percutaneous nephrostomy
  • This is the damage-control option

Damage control

• Exsanguinating from the pelvis, hypothermic and coagulopathic (lethal triad: hypothermia, coagulopathy, acidosis)
  • → pelvic packing, drainage, abbreviated closure
  • Defer a suspected ureteral injury until stabilized
• 3 phases:
  • Rapid control of hemorrhage and contamination
  • → resuscitation to restore temperature, coagulation, oxygenation
  • → definitive surgery
• Complex reconstruction is never done in phase one

Special scenarios

• Contusion → stent
  • Resection + primary repair if severe/large contusion or GSW-related (excise devitalized tissue + adjacent normal ureter for blast effect; spatulate ~5–6 mm at 180° apart)
  • Small, intact, viable contusion (e.g. low-velocity GSW) → double-J stent
    • It can later stricture or break down from necrosis
  • Severe, non-viable or high-velocity GSW contusion of the mid ureter, stable patient
    • → excise to bleeding edges + ureteroureterostomy
    • Blast effect causes delayed necrosis and stricture
  • Exam answer: spatulate each end 1–1.5 cm, in opposite orientations
• Delayed diagnosis → stent; if fails/impossible → percutaneous nephrostomy + delayed repair
  • Immediate repair if: injury near closed viscus (bowel/vagina); patient re-explored for other reasons
• Endoscopic injury → stent ± nephrostomy
  • Delayed avulsion with fever, hydronephrosis and a retroperitoneal urinoma
    • → IV antibiotics + nephrostomy + percutaneous drainage
    • Avoid exploration — the urinoma may be infected and the tissue too friable
• Ureterovaginal fistula → stent (success 64–100%); failures → reimplant ± Boari/psoas hitch or TUU
• Ligation → remove ligature, observe viability; uncertain → ureteroureterostomy or reimplant
  • Recognized intraoperatively with a viable, intact ureter → remove the suture + double-J stent
    • Removal alone leaves a crushed wall prone to necrosis or stricture
• Ureteroarterial fistula → catastrophic, diagnose + treat immediately (life-threatening hematuria)

Principles of repair

• Mobilize sparing adventitia; debride minimally until edges bleed (esp. GSW)
• Spatulated, tension-free, stented, watertight anastomosis — absorbable suture + retroperitoneal drainage
• Retroperitonealize repair; omental interposition for complex/blast/vascular cases
• Non-tunneled widely spatulated ureteroneocystostomy
  • Also stented
  • In trauma, accept the very low risk of clinically significant reflux over the higher stricture risk of a tunneled repair
• Primary ureteroureterostomy — proximal or mid defects <2–3 cm
  • Mucosa-to-mucosa anastomosis with omental cover
  • Success >90% when tension-free and watertight
  • Stricture >2 cm = (relative) contraindication to endoscopic management
    • → e.g. a 2.2 cm mid-ureteral stricture needs ureteroureterostomy
• Psoas hitch — lower-third injuries, success 95–100%
  • Suits a unilateral reimplant only
  • Residual tension → lateral relaxing incisions or a Boari flap
  • Too little mobility after peritoneal and contralateral perivesical release
    • → divide the contralateral superior vesical artery, keeping the ipsilateral supply to the hitched side
  • Fixation sutures through the psoas tendon, above the common iliac artery
    • The genitofemoral nerve on the anterior surface of psoas is most at risk
• Boari flap — limited by small bladder capacity
  • Combine with renal descensus (bridges 5–8 cm) to close a residual gap
  • Cut it somewhat longer and wider than anticipated
    • The nondistended bladder shrinks and tenses the anastomosis
  • 3:1 length-to-breadth keeps the apex well vascularized
• Nerve injury during ureteral repair
  • Genitofemoral → sensory only:
    • Numb ipsilateral scrotum or labium and upper anteromedial thigh
    • Loss of the cremasteric reflex
  • Femoral (L2–L4) — deeper
    • Emerges at the lateral edge of psoas
    • Supplies iliopsoas, quadriceps, sartorius, pectineus → quadriceps weakness
    • Cannot flex the thigh after a repair at L3
  • Ilioinguinal, genitofemoral, lateral femoral cutaneous = sensory
  • Obturator = adduction of the leg

Post-op principles:

• Remove Foley before drain
• Foley 24–48 hr post-op
• Remove drain 1 day after Foley if no high output
• Remove the stent at 6 weeks, with a retrograde ureterogram
  • Exam answer: after ureteroureterostomy, the double-J comes out at 4–6 weeks
• Lasix renogram at 10 weeks
• Renal ultrasound at 4 months — look for the ureteric jet
• For an injury found post-operatively on the ward: repair within 7 days, or after 6 weeks
  • If 7 days have passed, place a nephrostomy and repair at 6 weeks

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Bladder Injury

Background / Pathogenesis

• Usually pelvic fracture
• Burst injury at dome from blow to full bladder; penetrating
• Bladder protected by bony pelvis; blunt injury rarely isolated
• 83–95% of bladder injuries have pelvic fracture; only 5–10% of pelvic fractures have bladder injury
• Iatrogenic → obstetric/gyn most common in open surgery

AAST Bladder Injury Scale

Clinical indicators (12)

• Classic triad: lower abdominal pain · inability to void · frank hematuria
• Gross hematuria = most common indicator
• Lower abdominal bruising
• Abdominal distention
• Suprapubic pain
• Guarding/rigidity
• Inability to void
• Low urine output
• Diminished bowel sounds
• Pubic symphysis diastasis; obturator ring fracture displacement >1 cm
• ↑ Creatinine + BUN (peritoneal urine absorption); urinary ascites (intraperitoneal low-density free fluid)

Two presentations that mislead

• Alcohol intoxication means a full bladder
  • Blunt trauma in this setting usually produces an intraperitoneal injury
  • Intoxicated + blunt abdominal trauma + pain + gross hematuria → suspect bladder rupture
    • CT shows an incompletely filled bladder → catheterize + cystogram, even without pelvic fracture
• A patient with spinal cord injury or spina bifida presents differently
  • Non-specific illness or sepsis, most often from ischemic necrosis of the suture line.
  • In any neurogenic bladder patient presenting with sepsis, think spontaneous bladder rupture — or suture-line breakdown if recently operated

Imaging — indications

• Absolute: gross hematuria + pelvic fracture
  • also penetrating injury with any hematuria (absolute)
  • → retrograde cystography
    • No extravasation on excretory-phase CT (passive filling or a clamped catheter) does not exclude bladder injury
  • Pelvic fracture + gross hematuria → ~29% rupture risk; patient should not void until rupture is excluded
• Relative: gross hematuria + concerning mechanism; pelvic ring fracture + clinical indicators
• Pelvic fracture alone does not warrant bladder imaging
  • Pelvic fracture + microscopic hematuria only → no cystography
  • Image if gross hematuria or inability to void — or a stab wound over the pubis, even with microscopic hematuria

Imaging — modality

• Retrograde cystography (CT or plain film — similar sensitivity/specificity)
  • Determines presence + intra- vs. extraperitoneal
  • Equally accurate: sensitivity 90–95%, specificity 100%; CT also shows bone fragments
• Fill to 300–350 mL (or discomfort); false-negatives reported at only 250 mL
  • Negative study at only 250 mL → repeat with 350 mL
• CT cystography → dilute contrast 1:6 (mandatory, avoid scatter)
• Plain film → 2 views (max fill + post-drainage); drainage film not needed for CT
  • Exam answer: three images — scout · end-of-filling AP · post-drainage
• Extraperitoneal = flame-shaped contrast collection in pelvis
• Intraperitoneal = contrast outlines bowel loops / peritoneal cavity
  • Also fills the paracolic gutters; usually a dome rupture
• Amount of extravasation ≠ extent of injury
• CT urography is a LOW-PRESSURE study and is not sufficient to assess bladder integrity
  • Intravesical pressure must be raised by adequate distension (at least 350 mL in an adult) or the injury is easily missed.
  • Retrograde cystography remains the gold standard
• Post-operative suspicion of a bladder injury:
  • Send creatinine from the drain (raised confirms urine)
  • Cystogram
  • CT urography to assess the ureters — and if the creatinine is high, retrograde pyelography

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Management

• Blood at meatus / catheter won't pass → RUG first (urethral injury coexists in 10–30% of bladder ruptures)
  • Not needed for gross hematuria alone; blood at meatus is the trigger with a pelvic fracture

Extraperitoneal (uncomplicated) → catheter drainage

• Large-bore (22-Fr) Foley × 2–3 weeks
  • Then a healing cystogram
  • Still valid when the catheter has passed across a membranous urethral injury
  • Catheter cannot pass the membranous urethral injury → suprapubic catheter
    • Reasonable to repair the extraperitoneal bladder injury at the same time

Open repair if

• Bone spicules exposed in lumen
• Rectal injury (concurrent)
  • Immediate repair — rectovesical fistula risk
  • Adjacent bladder + rectal repairs:
    • Avoid overlapping suture lines
    • Interpose viable tissue (omentum)
    • Fibrin sealant over the bladder closure if no tissue is available
• Bladder neck injury
  • Tears may not heal with drainage
  • With rectal injury too → fecal diversion (colostomy) + immediate repair of all three (bladder, bladder neck, rectum)
  • With pelvic fracture → more common in children, often with vaginal + rectal injury
    • If stable, repair all immediately via a combined suprapubic + perineal approach + colostomy
  • Temporary catheter drainage + delayed repair → high rates of bladder neck incompetence, urinary fistula, pelvic abscess, osteomyelitis
    • Primary diversion (nephrostomy or externalized ureteral stents) only for the unstable patient with life-threatening bleeding
• ORIF of pelvic fracture (reduce hardware infection)
• Vaginal injury (concurrent)
  • Woman with pelvic fracture: bladder neck injury + vaginal laceration → immediate bladder neck repair + primary vaginal closure (prevents fistula)
    • Not catheter drainage alone
• Abdominal injury repair (do bladder at same time)
• penetrating/iatrogenic non-urologic injury
  • Gunshot wound → exploratory laparotomy + repair even when extraperitoneal (blunt extraperitoneal → conservative)
• inadequate drainage/clots
  • Repeated clot retention → repair
    • Approach intraperitoneally if there is a pelvic hematoma
    • An extraperitoneal approach can release the contained hematoma → hemorrhage
  • Continuous bladder irrigation is contraindicated with a rupture
    • Irrigant extravasates → pelvic abscess, osteomyelitis

Intraperitoneal → prompt surgical repair

1. Lower midline laparotomy incision
   • Open repair is standard in trauma; laparoscopic only for selected isolated injuries
2. Avoid entering the pelvic hematoma
3. Assess both ureters
4. Remove all blood clots from the bladder
5. Repair in two layers with absorbable suture
   • Exam answer: a watertight single layer has not been shown inferior to two layers
6. Urethral catheter ± suprapubic tube
   • Penetrating injury: suprapubic tube unnecessary after intraperitoneal repair; no RUG if the urethral catheter passed and drains well
7. Drain

• After blunt or penetrating trauma, always repaired surgically
  • Leaked urine → peritonitis, sepsis and death
• Never touch a stable pelvic hematoma
• In any bladder trauma, and particularly a penetrating one, check the ureters
  • Lower abdominal gunshot wound with no preoperative imaging
    • → inspect the ureteral orifices + bilateral retrograde pyelograms (define ureteral anatomy better than a one-shot IVP)
  • Cesarean cystotomy already closed by the obstetrician
    • → reopen and enlarge it as needed to inspect the ureteral orifices, then close and irrigate
    • Don't rely on the other surgeon's assessment
• If an injury is suspected but not seen during exploration, perform a cystotomy to identify the area
• Post-operatively: broad-spectrum antibiotics for 3 days and again on catheter removal
• Follow-up cystography 7–10 days post-op for complex repairs

When the extraperitoneal injury does not close

• Cystogram at 14 days
• Antibiotic cover for at least a week
  • The pelvic hematoma is at risk of infection
• If the catheter stops draining well around day 10, check for clot retention
  • If there is no blockage, check catheter position with a conventional cystogram
• If the cystogram at two weeks still shows extravasation:
  • First keep the catheter several more weeks and repeat it.
  • Formal repair is the second step, not the first

Bladder perforation from cystoscopy procedure:

• Do cystogram first
• Extraperitoneal → bladder drainage
• Intraperitoneal: small → bladder drainage
• Repair if →
  • Large
  • Suspected intra-abdominal injury
  • Protruding into bladder
  • Ileus
  • Peritonitis
  • Significant bleeding
  • Or urethral catheter clogging
• What decides management:
  • Extent of post-operative hematuria
  • Need for post-operative anticoagulation
  • Significance of the perforation
  • Whether continuous bladder irrigation is anticipated
  • Whether abdominal distension developed during the endoscopy

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Urethral Injury

Classification / Pathogenesis

• Partial or complete disruption
• Male: posterior (membranous) vs. anterior (penile/bulbar)
• Posterior → almost exclusively pelvic fracture
  • Bulbomembranous junction most vulnerable (posterior urethra adherent to pubis via UG diaphragm + puboprostatic ligaments)
  • Posterior = membranous + prostatic urethra
  • Pelvic crush + shearing forces → a shearing avulsion, not a laceration:
    • The tethered prostate moves with the displaced pelvic ring while the bulbar urethra stays mobile
  • Bilateral pubic rami (straddle) fracture → most commonly a bulbomembranous urethral injury
    • That junction is more vulnerable to shear than the prostatomembranous junction
  • Highest urologic injury risk:
    • Straddle fracture of all four pubic rami
    • Vertical + rotational pelvic instability
  • Greater anterior ring displacement → ↑ urethral injury risk
  • Children → more often bladder neck + prostatic urethra (adults: bulbomembranous junction)
    • The small prepubertal prostate does not anchor the proximal urethra
• Anterior → blunt (straddle = urethra crushed against pubis) or penetrating
  • Bulbar urethra most common
  • Strictures after a straddle injury → bulbar urethra most often
    • Its fixed location beneath the pubis makes it prone to compression injury

AAST Urethral Injury Scale

Clinical indicators (5)

• Blood at the meatus = most common
• Inability to urinate; perineal/genital ecchymosis
  • Urethral injury complicates about 10% of male and up to 6% of female pelvic fractures
    • → inability to void, meatal blood, a full bladder, sometimes a high-riding prostate
• Male: high-riding prostate; Female: labial edema / vaginal blood
  • Female urethral / bladder neck injury in 4.6–6% of pelvic fractures
    • >40% missed and only half seen on CT cystogram → low threshold for vaginal examination
• Buck's fascia disrupted → "butterfly" hematoma (urine below Dartos into scrotum, up abdominal wall below Scarpa's; posterior limit = Colles')
  • Buck's intact → hematoma confined to the penis
  • Once breached it also spreads to the perineum, contained deep to Colles' and Scarpa's fascia
  • Extravasation reaching the thigh must first breach Buck's fascia
    • Dartos, Colles' and the fascia lata insertion are one continuous fascial layer

Imaging

• Retrograde urethrogram (RUG) — perform immediately when injury suspected
  • Blood at the meatus = cardinal sign of urethral injury → mandates a RUG
  • Any extravasation = pathognomonic
    • Localizes injury as anterior vs posterior but does not reliably separate partial from complete rupture → flexible cystourethroscopy can
• Avoid blind catheter passage before RUG
• Technique:
  • Oblique position (bottom leg flexed)
  • 12-Fr Foley/syringe in fossa navicularis
  • Penis on traction
  • Inject 20–25 mL undiluted water-soluble contrast
    • Exam answer: 20–30 mL contrast with the meatus occluded
  • Balloon inflated with 1–2 mL of saline in the fossa navicularis
  • Patient supine oblique, penis laterally over the proximal thigh with moderate traction
  • Films:
    • 30° LAO with the right leg abducted and knee flexed
    • Supine PA
    • 30° RAO with the left leg abducted and knee flexed
  • Spasm of the external sphincter is common and prevents filling of the deep bulbar, membranous and prostatic urethra
    • Slow, gentle pressure overcomes it
• If Foley already placed + meatal blood → pericatheter RUG (3-Fr/angiocath in fossa navicularis)
  • Foley left in place; if no meatal blood and suspicion is low → no further urethral imaging
• A RUG should be followed by a micturating cystourethrogram to demonstrate the proximal urethra
• Female suspected urethral injury → urethroscopy (in lieu of RUG)

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Management — general

• Immediate goal = secure bladder drainage
• Partial disruption (contrast passes proximally) → single gentle catheter attempt by experienced team
  • Partial posterior tears usually heal over a urethral catheter placed atraumatically (e.g. over a cystoscopically inserted wire)
  • Direct penile urethral disruption → usually primary surgical repair

Male — posterior (PFUI) → immediate suprapubic tube, delayed repair

• SPC = gold standard (14-Fr or larger; US/fluoro/18-G needle aspiration to localize displaced bladder)
  • Safe even with ORIF
• Primary realignment = advance catheter across rupture
  • May ↓ stricture severity but longer course/more procedures
  • Maintain SPC while awaiting PFUI resolution
  • ED setting inappropriate for primary realignment; avoid prolonged endoscopic attempts
  • Stable patients only
  • Can be done acutely and up to about 7 days
  • Retrograde rigid and antegrade flexible endoscopy
  • Risk of infection and abscess since it is a prolonged procedure
  • Urethral catheter 4–6 weeks.
    • Keep the suprapubic tube closed after the urethral catheter comes out because of the stenosis risk — if the patient voids well, remove it at 14 days.
    • Trial of void at 4–6 weeks, clamp the suprapubic tube, remove at 1–2 weeks
  • Even after successful realignment, more than 90% develop a stricture
  • Advantages: less invasive; if it fails it brings the two ends closer.
  • Disadvantages: infection of the pelvic hematoma; high chance of failure
  • Failed realignment → keep the suprapubic tube and plan urethroplasty 2–3 months later
• Immediate sutured repair → unacceptably high ED + incontinence rates (avoid)
• Delayed reconstruction:
  • Most develop obliterative stricture → open posterior urethroplasty at ≥3 months (ambulatory, injuries stabilized; rupture defect = fibrosis-filled, stable at 3 mo)
  • Get cystogram + RUG before repair
  • Open perineal anastomotic urethroplasty (excise fibrosis + distal mobilization + primary transecting anastomosis) = best long-term outcomes
    • Limit lithotomy ≤5 h
  • e.g. a 2-cm obliterative posterior defect at 3 months → one-stage open perineal anastomotic urethroplasty

Suprapubic catheter placement

1. Trendelenburg
2. Prep and drape
3. Midline
4. Two fingers above the symphysis
5. Local anesthetic
6. Spinal needle to localize
7. Incision of skin and fascia

• If the bladder is empty and suprapubic placement fails
  • An infraumbilical incision allows direct inspection, repair of any concomitant bladder injury, and a large-bore catheter at the bladder dome
• If orthopedics plan to plate the pubic fracture
  • Keep the tube and tunnel it cranially at the infraumbilical level
  • A large-bore (24-Fr) catheter as high on the lower abdominal midline as possible, away from the plated symphysis
• Contraindications to a suprapubic catheter in trauma:
  • Vaginal laceration (fistula risk)
  • Rectal injury (fistula risk)
  • Bladder neck injury (incontinence)

Posterior urethroplasty — operative steps

• High lithotomy · midline or lambda-shaped incision
• The bulbar urethra is freed and mobilized from the rupture site to the mid-scrotum; the scar tissue of the rupture defect is excised
• The prostatic urethra is identified at the apex of the prostate; all fibrotic tissue is excised from the proximal margin
• At least a 28-Fr bougie should pass without resistance; then a tension-free bulbo-prostatic anastomosis

If the anastomosis is under tension — the ladder, in order

1. Full mobilization of the proximal urethra to the penoscrotal junction — going beyond it risks chordee
2. Corporeal splitting
3. Inferior pubectomy
4. Re-routing
5. Transpubic urethroplasty — rare, particularly for a fistula or bone deformity

Cases needing an abdominoperineal approach ± partial pubectomy

• Severe fibrosis
• Fistula
• Previous failed anastomotic urethroplasty
• Associated bladder neck injury
• Pediatric cases
• Displacement and disruption of the prostate
• Severe bone deformity.
• MRI adds information in these cases

Complications

• ED after posterior urethroplasty is mostly caused by the injury itself, recovers over 1–2 years, and is multifactorial
  • Cavernous nerve injury, arterial insufficiency, venous leak, direct corporal injury.
  • Associated factors: diastasis of the pubic symphysis, lateral displacement of the urethra, and a long urethral gap
• Patients with ED and impaired flow on penile Doppler are at particular risk from bulbar ischemia
  • Some advocate pre-operative penile arterial duplex to identify candidates for initial penile revascularization
• Also:
  • Rectal injury
    • Rectal injury at radical prostatectomy: 1–3% primary vs 6–15% salvage (post-radiation)
    • Salvage → primary repair + temporary diverting colostomy — irradiated tissue risks wound breakdown and rectourethral fistula
    • Omental interposition without diversion may suit a primary (non-irradiated) case, not a previously irradiated one
  • Bleeding
  • Infection
  • Anejaculation
  • Neuropathy from prolonged lithotomy
• Complications (3): stricture, ED (from the pelvic fracture), incontinence
  • Follow ≥1 year
  • Recurrent stenosis post-urethroplasty 5–15%
    • VIU is successful in most recurrent stenoses.
  • Incontinence after reconstruction <4%
    • Exam answer: incontinence after one-stage anastomotic posterior urethroplasty <5%
  • Children: incontinence in up to 20%, mostly after bladder neck / prostatic injuries
    • A bladder neck tear needs formal repair, with notoriously poor continence outcomes

Rhabdomyolysis after prolonged lithotomy

• Presents after a long procedure with buttock pain, tea-colored urine, a rising creatinine and hyperkalemia
  • With no wound bleeding and a normal blood count
• Confirm with a creatine kinase
• Treat with
  • Hydration
  • Urinary alkalinization
  • Management of the hyperkalemia
  • Serial electrolytes with nephrology referral
  • And pain control
• This is why lithotomy time is limited during posterior urethroplasty

Male — anterior

• Contusion / incomplete → urethral catheter alone
• Straddle → suprapubic tube (or primary realignment if mild), delayed repair
  • Immediate operative repair contraindicated (indistinct injury border); high stricture rate → surveillance
  • Delayed anastomotic urethroplasty = procedure of choice for obliterated bulbar urethra
  • Complete bulbar disruption → suprapubic tube + delayed reconstruction
    • No catheter, no antegrade or retrograde realignment, no acute perineal exploration
  • Realignment may be possible in a partial anterior injury
    • Urethrogram shows extravasation contained by the corpus spongiosum
• Penetrating → prompt primary repair (spatulated primary repair > delayed reconstruction — contrast to PFUI/straddle)
  • Not if unstable / no expertise / extensive tissue loss
  • e.g. a sharp, low-velocity cut with 70% transection → tension-free anastomosis over a catheter
  • Self-inflicted injury → also psychiatric assessment

Initial management

• Low-velocity gunshot wound with a small (about 1 cm) bulbar defect
  • → debridement + immediate spatulated, stented, tension-free, watertight primary repair with fine absorbable sutures
• After a recent gunshot wound, catheter realignment or graft / flap urethroplasty → more strictures than primary repair

Deciding the timing of repair

• Anastomotic urethroplasty is the procedure of choice for a totally obliterated bulbar urethra after a straddle injury
  • The typical scar is 1.5–2 cm and can be completely excised with anastomosis after mobilizing the two ends
• Endoscopic incision through the scar of an obliterated urethra after a saddle injury is doomed to failure
• UroLume stents are contraindicated in traumatic urethral strictures
• A traumatic urethral distraction defect is not managed with a graft
• Perineal hematoma means an anterior urethral injury with Buck's fascia disrupted

Female → immediate primary repair or realignment over catheter

• Avoids urethrovaginal fistula / obliteration
• Delayed repair problematic (urethra ≈4 cm, too short to mobilize once scarred)

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External Genitalia Injury

Penile Fracture

• Definition: disruption of tunica albuginea with rupture of corpus cavernosum
  • Usually a transverse tear of the proximal ventrolateral shaft, where the tunica is thinnest
• Mechanism: most often vigorous intercourse (penis strikes perineum/pubis → buckling)
  • Tunica albuginea thins from ~2 mm flaccid to <0.5 mm erect → abrupt bending of the erect penis tears it
  • Taqaandan — forcibly bending the erect penis to force detumescence (predominant in the Middle East)
    • The audible pop is essentially diagnostic → explore + close the tunica
• Bilateral corporal tears in 10%

Applied anatomy

• Scarpa's fascia in the abdomen, Colles' fascia in the perineum and Dartos fascia in the peno-scrotum are ONE continuous layer.
• Buck's intact → hematoma stays between skin and tunica → eggplant deformity
• Buck's ruptured → extends into scrotum, perineum and suprapubic region
• A bruised penis with a butterfly hematoma means Buck's has been breached and Colles' is intact
  • Colles' is what contains it
• Butterfly boundaries:
  • Laterally the inferior pubic rami and fascia lata
  • Anteriorly it can track to the clavicles, since Dartos is continuous with Scarpa's
  • Posteriorly the perineal body
• The corpora cavernosa, tunica albuginea and posterior urethra are unlikely to be involved in a straddle injury
  • Posterior urethral injuries occur above the pelvic diaphragm and go with a pelvic fracture, not a straddle

Diagnosis — reliable on Hx + exam

• "Cracking/popping/snapping" + immediate detumescence
• Eggplant deformity (Buck's intact) or butterfly (Buck's disrupted)
• Palpable fracture line
• Deviates away from tear
  • Deviation away from the tear is from hematoma mass effect
• Mimics: false penile fracture or a ruptured penile vein — can also give the snap-pop and immediate detumescence
• Imaging only if equivocal: US (preferred — rapid, cheap, accurate); penile MRI = most accurate
  • Exam answer: exam not classic (minimal swelling, no hematoma) → penile-perineal MRI — most accurate, prevents unnecessary exploration; penile Doppler and cavernosography have high false-negative rates
• Urethral evaluation (RUG/urethroscopy)
  • Urethral injury in 10–22% (more with bilateral corporal injury)
  • Indications = blood at meatus, gross hematuria, inability to void
  • Bilateral corporal tears → check the urethra with intra-operative flexible cystoscopy even without meatal blood, hematuria or voiding difficulty
• Additional points to elicit:
  • Cracking or popping sound
  • Pain
  • Rapid detumescence
  • Discoloration
  • Shaft swelling
  • Urethral bleeding
  • Hematuria
  • Inability to urinate
  • An erection after the incident
  • Tenderness and deviation

Management → prompt exploration + surgical repair

• Benefits (7):
  • Faster recovery
  • ↓ morbidity
  • ↓ complications
  • ↓ ED
  • ↓ long-term curvature
  • ↓ cavernosal diverticulum
  • ↓ chronic pain
• Delay up to 7 days does not adversely affect repair
  • Presenting 36 h late, even with a normal RUG → still explore
• Approach: distal circumcising/degloving (uncertain location — exposes all 3 compartments) OR incision at the site of injury OR ventral midline
  • Exam answer: usually a circumferential subcoronal degloving incision; when the fracture site is known, a local longitudinal or ventral penoscrotal incision is preferred
• Repair tunica with interrupted 2-0/3-0 absorbable (Vicryl); artificial erection (saline + methylene blue) to localize/test
• Urethral injury:
  • Partial → oversew over catheter
  • Complete → debride, mobilize, tension-free repair over catheter
  • Repaired immediately
    • Small laceration → simple closure
    • Complete rupture without extensive tissue loss → anastomotic repair
• Post-op: broad-spectrum antibiotics + 1 month sexual abstinence
• The cost of managing conservatively:
  • Penile curvature
  • ED
  • Penile fibrosis
  • Abscess or debilitating plaques in 25–30%
  • Longer hospitalization and recovery
  • Fibrosis and angulation in 35% · impotence in up to 62%
    • Surgical repair gives the lowest rate of long-term sequelae

Operative sequence

1. Cystoscopy, pass a wire into the bladder, place the catheter over the wire
2. Occluding tourniquet at the base of the penis
3. Incision and degloving
4. Evacuate the hematoma
5. Lacerated urethra — dissect out, excise devitalized tissue, close water-tight with absorbable 4-0 or 5-0 in a Heineke-Mikulicz fashion to preserve lumen diameter, then close the tunica of the corpus spongiosum
6. Lacerated tunica albuginea — debride devitalized tunica, close with absorbable suture
7. Close the skin

• If the tear cannot be found intra-operatively, perform an artificial erection and look for the leak
• Injuries associated with intercourse are usually ventral or lateral, where the tunica albuginea is thinnest
• In an uncircumcised patient a distal circumcising incision may leave the distal prepuce ischemic
  • If it is required, strongly consider a limited circumcision at the end of the repair
• Avoid deep corporeal vascular ligation and excessive debridement of the delicate underlying erectile tissue
• Because urethrography is time-consuming and can be inaccurate, intra-operative flexible cystoscopy is now often performed routinely just before catheter placement when urethral injury is suspected

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Penile Penetrating / Other

• GSW: immediate exploration, copious irrigation, excise foreign matter, antibiotic prophylaxis, surgical closure
  • Low-velocity urethral injury → primary closure; high-velocity / shotgun → staged repair + SP diversion
  • Penetrating wound with a large hematoma → explore to exclude corporal injury, even if voiding normally without urethral bleeding or hematuria
  • Urethral injury occurs in 15–50% of penile gunshot wounds
    • Strongly consider RUG, especially with high-velocity injuries, blood at the meatus, difficulty voiding, or a trajectory near the urethra.
    • Low-velocity injury → RUG only for blood at the meatus, hematuria, difficulty voiding, or a wound near the urethra
    • Intra-operative retrograde methylene blue or indigo carmine may identify the site and confirm closure
    • Pericatheter injection helps if a catheter is already in
• Bites:
  • Dog → irrigation, debride, primary closure with drain + broad-spectrum antibiotics (amox/clav, cefoxitin, clindamycin+cipro) + tetanus/rabies
    • Scrotal dog bites = penetrating scrotal trauma → antibiotics, tetanus prophylaxis, exploration, irrigation, debridement, primary closure
    • Animal-bite antibiotics cover Pasteurella, Streptococcus and Staphylococcus; exclude rabies in the offending dog
  • Human bites → do NOT close primarily
    • Human bites — contaminated, often present late and infected → debride and leave open + amoxicillin-clavulanate (or moxifloxacin) + tetanus prophylaxis
• Amputation: "double bag" — distal penis rinsed in saline, wrapped in saline gauze, sealed bag in outer bag with ice; transfer to microsurgical center
  • Reimplant viable: <16 h cold OR <6 h warm ischemia
    • Replant whenever possible — stump revision or a neophallus is not indicated
  • Macrovascular repair preserves erectile/urethral function, microvascular needed for skin + sensation
  • Instructions to the referring team:
    1. Rinse the part with saline
    2. Wrap in saline-soaked gauze
    3. Seal in a sterile bag
    4. Place that bag in ice
    5. IV access, fluids, antibiotics
    • Outer bag = ice or slush — a part stored improperly in ice can suffer frost injury
  • Management involves vascular and plastic input, microvascular reconstruction, and psychiatric consultation later where the injury was self-inflicted
  • Operative steps:
    1. Suprapubic cystostomy
    2. Closure of the tunica albuginea
    3. Urethral closure over a catheter
    4. Microscopic anastomosis of the dorsal artery
    5. Microscopic dorsal vein repair
    6. Epineural repair of the dorsal nerve
    7. Skin coverage
    • Reconnects the urethra, both dorsal arteries, the deep dorsal vein and the dorsal nerves
    • The cavernosal arteries are not reconstructed — the dorsal arteries provide adequate circulation
    • Dorsal arteries supply the distal shaft skin by retrograde flow → dorsal artery + vein re-anastomosis prevents shaft skin loss
    • Dorsal nerve repair preserves sensation
• Electrical penile injury is managed with a suprapubic catheter until the full extent is known
• Artificial erection after repair — plication may be needed
• Zipper injury (boys/intoxicated): penile block, lubricate with mineral oil, single unzip attempt; failing that → bone cutter

Microsurgical and macrosurgical

• Erectile outcome is equal between the two — about 50% in each group will have ED
  • Erection depends on corporal reapproximation; microsurgery is what preserves shaft skin and sensation

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Testicular Trauma

• Consider rupture in all blunt scrotal trauma (rupture of tunica albuginea)
• Testicular injury is blunt in about 75% of cases
• Hematoma degree does not correlate with injury
• US reliable for blunt (limited for penetrating): heterogeneous parenchyma + tunica albuginea contour disruption
  • Normal/equivocal US should not delay exploration if exam suggests rupture
  • These two signs (heterogeneity often with hypoechoic areas; loss of contour) are the most specific for rupture → explore without further MRI or Doppler
• Complex scrotal avulsion injuries are initially observed for 24 hours to allow clear demarcation of tissue viability
• Cyclist with posterior scrotal numbness → perineal nerve (pudendal branch, S2–S4) compressed between saddle and pelvis
  • Anterior scrotal numbness → L1 nerves

Differential diagnosis of the acute traumatic scrotum

• Hematocele without rupture — though 80% of hematoceles are caused by rupture
• Reactive hydrocele · hematoma of the epididymis or spermatic cord
• Dislocation — can often be replaced manually
  • A non-palpable testis in a trauma patient should raise the possibility of dislocation OUT of the scrotum
    • Typically after motorcycle crashes, into the superficial inguinal pouch in 50%, or a pubic, penile, pelvic, abdominal or perineal location
    • Treat with manual or surgical reduction
    • An impalpable testis after blunt trauma (large hematoma or dislocation out of the scrotum) → explore, don't image
• Intratesticular hematoma — needs exploration and drainage to avoid pressure necrosis, atrophy and delayed orchiectomy
• Torsion of the testis or an appendage
  • Bell-clapper deformity (adolescent torsion) — tunica vaginalis attaches high on the cord instead of the posterolateral testis → excess mobility
  • High-riding, transverse testis + absent cremasteric reflex
    • But the reflex is present in up to 10%, so a convincing picture → immediate exploration

Scrotal exploration indications (6)

• Imaging findings of rupture
• Equivocal imaging but suspected rupture
• Large hematoma (explore + drain even without rupture → prevent pressure necrosis/atrophy)
• Clear physical findings
• Penetrating scrotal injury (>50% have rupture)
  • GSW → 30% injure both testes → consider contralateral exploration
    • Ligate injured vas with non-absorbable suture, delayed reconstruction
      • Transected vas: no immediate vasovasostomy in a contaminated field
• Significant hematocele (up to 80% from rupture)

Repair

• Early exploration + repair benefits (6):
  • ↑ salvage
  • ↓ ischemic atrophy
  • ↓ infection
  • Preserved fertility/hormonal function
  • ↓ convalescence
  • Faster return
• Salvage >90% if repair within 72 h; orchiectomy 3–8× higher with delayed surgery
  • Conservative management raises orchiectomy rates too; delayed surgery ends in orchiectomy in 45–55%
• Complications of managing a rupture conservatively:
  • Infection
  • Atrophy
  • Necrosis
  • Chronic unrelenting pain
  • Delayed orchiectomy
• Technique:
  • Transverse scrotal incision
  • Remove necrotic/extruded tubules
    • Evacuate clot and hematoma before excising necrotic tubules
  • Close tunica albuginea with small absorbable suture
    • Even with ~20% non-viable, extruded parenchyma → excise it and close the tunica primarily — small defects left open keep extruding tubules
  • Tunica vaginalis flap/graft for large defects
  • Orchiectomy if non-salvageable
• Large tunical defects:
  • Excise testicular tissue and close
  • If still not closable, cover with a tunica vaginalis flap.
  • Synthetic grafts are NOT recommended

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Genital Skin Loss

• Most common cause of extensive loss = Fournier gangrene (polymicrobial necrotizing infection)
• Exploration + limited debridement (genital skin well vascularized, marginal tissue may survive)
  • Multiple OR trips before definitive reconstruction
• Burn + urethral catheter → remove after 72 h (prevent urethral slough/fistula)
  • Genital burns are usually full-thickness (thin penile skin) → significant sloughing of the penis and urethra in the days after injury
  • Extensive penile burns, incl. electrical → early suprapubic cystostomy (remove any urethral catheter) to protect the urethra and simplify wound care
    • Debridement waits until the full extent is known
• Penile reconstruction:
  • Thick (0.012–0.015"), non-meshed split-thickness graft (meshed contracts)
    • Exam answer: circumferentially denuded shaft after Fournier gangrene → thick STSG 0.45–0.6 mm — more dermis, less graft contraction
    • Exam answer: shaft graft applied unmeshed or meshed 1:1 without expansion — higher mesh ratios increase contraction
  • Excise residual subcoronal skin (avoids lymphedema)
  • Foreskin flap best for small distal loss
  • Shaft grafts never regain normal sensation (glans sensation preserves function)
• Scrotal reconstruction:
  • Defects up to 60% closed directly
    • Exam answer: skin loss up to 50% — even from a gunshot or dog bite — is closed primarily after debridement, with drainage (the scrotum is very elastic); grafts and thigh pouches are seldom needed
    • With tension despite being within the directly-closable range → local scrotal advancement flap, or healing by secondary intention
    • Beyond it, or extending beyond the scrotum → split-thickness graft with or without tissue adhesive, or flap reconstruction
  • Meshed STSG preferred
    • A meshed graft lets exudate escape, conforms and mimics rugae (better cosmesis)
  • Extensive → testes in thigh pouches/vacuum dressing (not in active infection)
    • Wet-to-dry dressings of exposed testes make thigh pouches rarely necessary
  • Machinery avulsion → debridement, saline wet-to-dry dressings, delayed grafting
    • Don't reapply the avulsed skin (its intrinsic vessels are damaged) or graft the contaminated wound immediately
• If there is penile skin necrosis, debride and cover
  • Split-thickness graft, or bury the phallus in the scrotum and leave it buried for 8 weeks
• For genital skin loss or infection, strongly consider early suprapubic urinary diversion in extensive injuries
  • To simplify wound care and prevent the urethral complications of prolonged catheterization

Circumcision trauma

• Excess penile skin removed → wet-to-dry dressings plus antibiotic ointment, healing by secondary intention
• If totally degloved, the penile shaft skin can often be salvaged, defatted and replaced as a full-thickness graft
• If the skin is lost or cannot be salvaged, use a split-thickness graft
• Partial glans amputation → suture the amputated part back onto the glans; careful repair often gives a good cosmetic result, with or without microvascular reanastomosis