Renal Trauma

Non-operative management

All hemodynamically stable or stabilized minor, moderate and severe lesions.

In case of penetrating trauma, there should not be other indications for laparotomy in particular violation of the peritoneal cavity.

Angiography and Angioembolization

For hemodynamically stable or stabilized patients with arterial contrast extravasation, pseudoaneurysms, arteriovenous fistula, and non-self-limiting gross hematuria.

Repeat angioembolization might be needed.

Operative Management

Hemodynamically unstable and non-responder patients

Severe renal vascular injuries without self-limiting bleeding

Main renal vein injury without self-limiting bleeding

Notice:

Presence of non-viable tissue is not an indication for surgery alone.

Renal pelvis damage not responsive to endoscopic/percutaneous management should be considered for delayed surgery.

Ureteral Trauma

Contusions: ureteral stent

Partial lesions: stent, with or without a nephrostomy

Partial and complete ureteral transections or avulsion

If not suitable for nonoperative management, may be treated with primary repair plus a stent. In of distal lesions ureteral re-implant into the bladder might be needed. Psoas hitch or Boari flap might be needed.

Delayed Diagnosis

Ureteral stent

Percutaneous nephrostomy: if not able to place a stent.

Endoscopic Injuries

Ureteral stent and/or percutaneous nephrostomy tube.

Open repair if above measures fail.

Ureterovaginal Fistula

Stent. Additional surgical intervention: If stent doesn't help

Bladder Trauma

Intraperitoneal Bladder Rupture

Surgical repair

Extraperitoneal Bladder Injuries

Uncomplicated 

Catheter Drainage for two to three weeks.

Consider open repair if bladder injuries don't heal after four weeks.

Complicated 

Surgical repair.

Complicated cases include:

- Bladder neck injuries

- Pelvic fractures that result in exposed bone spicules in the bladder lumen 

-Concurrent rectal or vaginal lacerations

- Having open reduction internal fixation of pelvis

- Repair of abdominal injuries

Urethral Trauma

Pelvic Fracture Urethral Injury

Percutaneous or Open Suprapubic Tube

Suprapubic cystostomy can be used safely even if anterior pubic hardware is placed.

Primary Realignment

An option in hemodynamically stable patients.

Should not perform prolonged attempts.

Urethral catheter is removed after 4 o 6 weeks.

Suprapubic catheter should be kept. 

Straddle Injury to the Anterior Urethra

Percutaneous or Open Suprapubic Tube

Primary Realignment 

In less severe cases.

Uncomplicated Penetrating Trauma of the Anterior Urethra

Prompt surgical repair

Primary repair should not be undertaken if

- Patient is unstable

- If there is extensive tissue destruction or loss

Penile Fracture

Prompt surgical exploration and repair is needed.

Evaluate for concomitant urethral injury.

Ventral vertical penoscrotal incision is usually preferred.

Close the tunical defect.

Interrupted 2-0 or 3-0 absorbable sutures is advised.

Deep Penile Electrical Burns

Conservative approach.

Autopenectomy and/or death as a result of extensive concurrent injuries may happen.

Traumatic Penile Amputation

Prompt penile replantation

Penetrating Scrotal Injuries

Prompt surgical exploration with repair is needed.

Perform orchiectomy if non-salvageable.

Testicular Rupture

Perform scrotal exploration and debridement with tunical closure.

Perform orchiectomy if non-salvagable.

Extensive Genital Skin Loss or Injury

From infection, shearing injuries, or burns.

Fournier Gangrene

Limited debridement of non-viable tissue.

Tissues with marginal viability may survive due to collateral blood flow.

Multiple procedures in the operating room are needed.

Wound management options are: 

Gauze dressings

Silver sulfadiazine or topical antibiotic and occlusive dressing 

Wound vac

Early suprapubic urinary diversion

Genital Burns 

Early resection of burn eschar and coverage with split-thickness skin grafts when possible. 

Partial-thickness skin loss may be treated with silver sulfadiazine cream.