Trauma Pediatric - part 8 pptx

Inthe pediatric population 14% of blunt abdominal trauma patients have a renal injury9.. It is well documented in the adult literature that the vast majority of patients sufferingfrom bl

19 Morse MA, Garcia VF Selective nonoperative management of pediatric blunt splenictrauma: risk for missed associated injuries J Pediatr Surg 1994; 29:23–27.

20 Nance ML, Keller MS, Stafford PW Predicting hollow visceral injury in the pediatricblunt trauma patient with soild visceral injury J Pediatr Surg 2000; 35:1300–1303

21 Miller K, Kou D, Stallion A, Dudgeon DL, Grisoni ER Pediatric hepatic trauma: doesclinical course support intensive care unit stay? J Pediatr Surg 1998; 33:1459–1462

22 Reuss L, Sivit CJ, Eichelberger MR, Taylor GA, Bond SJ Blunt hepatic and splenictrauma in children: correlation of a CT injury severity scale with clinical outcome.Pediatr Radiol 1995; 25:321–325

23 Emery KH, Babcock DS, Borgman AS, Garcia VF Splenic injury diagnosed with CT: USfollow-up and healing rate in children and adolescents Radiology 1999; 212:515–518

24 Lynch JM, Meza MP, Newman B, Gardner MJ, Albanese CT Computed tomographygrade of splenic injury is predictive of the time required for radiographic healing

29 Hoyt DB Clinical practice guidelines Am J Surg 1997; 173:32–34

30 Pasquale M, Fabian TC Practice management guidelines for trauma from the EasternAssociation for the Surgery of Trauma J Trauma 1998; 44:941–957

31 Fallat ME, Casale AJ Practice patterns of pediatric surgeons caring for stable patientswith traumatic solid organ injury J Trauma 1997; 43:820–824

32 Lund DP, Zurakowski D, Atkinson C Usual practice in the management of solid eral injuries: a survey of North American pediatric surgeons Poster presentation at the50th Annual Meeting of the Section on Surgery of the AAP, San Francisco, CA, Octo-ber 1998

visc-33 Stylianos S Controversies in abdominal trauma Semin Pediatr Surg 1995; 4:116–119

34 Hardin WD, Stylianos S, Lally KP Evidence-based practice in pediatric surgery

37 Brown RL, Irish MS, McCabe AJ, Glick PL, Caty MG Observation of splenic trauma:when is a little too much? J Pediatr Surg 1999; 34:1124–1126

38 Norotsky MC, Rogers FB, Shackford SR Delayed presentation of splenic artery doaneurysms following blunt abdominal trauma: case Reports J Trauma 1995; 38:444–447

pseu-39 Frumiento C, Sartorelli K, Vane DW Complications of splenic injuries: expansion ofthe nonoperative theorem J Pediatr Surg 2000; 35:788–791

40 Sanders DW, Andrews DA Conservative management of hepatic duct injury afterblunt trauma: a case report J Pediatr Surg 2000; 35:1503–1505

41 Hoyt DB, Bulger EM, Knudson MM, et al Death in the operating room: an analysis of

a multi-center experience J Trauma 1994; 37:426–432

42 Moulton SL, Lynch FP, Canty TG, et al Hepatic vein and retrohepatic vena caval ries in children: Sternotomy first? Arch Surg 1991; 126:1262–1266

inju-43 VanderKolk WE, Kurz P, Daniels J, et al Liver hemorrhage during laparotomy inpatients with necrotizing enterocolitis J Pediatr Surg 1996; 31:1063–1067

44 Gross M, Lynch F, Canty T, Peterson B, Spear R Management of pediatric liver ries: a 13-year experience at a pediatric trauma center J Pediatr Surg 1999; 34:811–817.

inju-45 Pryor JP, Stafford PW, Nance ML Severe blunt hepatic trauma in children J PediatrSurg 2001; 36:974–979

46 Watts DD, Trask A, Soeken K, Perdue P, Dols S, Kaufmann C Hypothermic pathy in trauma: effect of varying levels of hypothermia on enzyme speed, platelet func-tion, and fibrinolytic activity J Trauma 1998; 44:846–854

coagulo-47 Denton JR, Moore EE, Codwell DM Multimodality treatment for Grade V hepaticinjuries: Perihepatic packing, arterial embolization, and venous stenting J Trauma1997; 42:964–968

48 Richardson JD, Franklin GA, Lukan JK, Carrillo EH, Spain DA, Miller FB, Wilson MA,Polk HC, Flint LM Evolution in the management of hepatic trauma: a 25-year perspec-tive Ann Surg 2000; 232:324–330

49 Asensio JA, Demetriades D, Chahwan S, et al Approach to the management of plex hepatic injuries J Trauma 2000; 48:66–69

com-50 Shapiro MB, Jenkins DH, Schwab CW, Rotondo MF Damage control: collectivereview J Trauma 2000; 49:969–978

51 Barker DE, Kaufman HJ, Smith LA, Ciraulo DL, Richart CL, Burns RP Vacuum packtechnique of temporary abdominal closure: a 7-year experience with 112 patients JTrauma 2000; 48:201–207

52 Cogbill TH, Moore EE, Jurkovich GJ Severe hepatic trauma: a multicenter experiencewith 1,335 liver injuries J Trauma 1988; 28:1433–1438

53 Hirshberg A, Mattox KL Planned reoperation for severe trauma Ann Surg 1995;222:3–8

54 Rotondo MF, Schwab CW, McGonigal MD, et al Damage control: an approach forimproved survival in exsanguinating penetrating abdominal injury J Trauma 1993;35:375–383

55 Stylianos S, Jacir NN, Hoffman MA, et al Pediatric blunt liver injury and coagulopathymanaged with packs and silo J Trauma 1990; 30:1409–1410

56 Stylianos S Abdominal packing for severe hemorrhage J Pediatr Surg 1998; 33:339–342

57 Evans S, Jackson RJ, Smith SD Successful repair of major retrohepatic vascular ries without the use of shunt or sternotomy J Pediatr Surg 1993; 28:317–320

inju-58 Horwitz JR, Black T, Lally KP, et al Venovenous bypass as an adjunct for the ment of a retrohepatic venous injury in a child J Trauma 1995; 39:584–585

manage-59 Davies MRQ Iatrogenic hepatic rupture in the newborn and its management by packtamponade J Pediatr Surg 1997; 32:1414–1419

60 Strear CM, Graf JL, Albanese CT, Harrison MR, Jennings RW Successful treatment ofliver hemorrhage in the premature infant J Pediatr Surg 1998; 33:849–851

61 Adams JM, Hauser CJ, Livingston DH, Fekete Z, Hasko G, Forsythe RM, Deitch EA.The immunomodulatory effects of damage control abdominal packing on local and sys-temic neutrophil activity J Trauma 2001; 50:792–800

62 Saggi BH, Sugerman HJ, Ivatury RR, Bloomfield GL Abdominal compartmentsyndrome J Trauma 1998; 45:597–609

63 Chang MC, Miller PR, D’ Agostino R, Meredith JW Effects of abdominal sion on cardiopulmonary function and visceral perfusion in patients with intra-abdominalhypertension J Trauma 1998; 44:440–445

decompres-64 DeCou JM, Abrams RS, Miller RS, Gauderer MWL Abdominal compartment drome in children: experience with three cases J Pediatr Surg 2000; 35:840–842

syn-65 Neville HL, Lally KP, Cox CS Emergent abdominal decompression with patch minoplasty in the pediatric patient J Pediatr Surg 2000; 35:705–770

abdo-66 Ballard RB, Badellino MM, Enyon CA, Spott MA, Staz CF, Buckman RF Jr Bluntduodenal rupture: A 6 year statewide review J Trauma 1997; 43:729–733

67 Shilyansky J, Pearl RH, Kroutouro M, Sena LM, Babyn PS Diagnosis and ment of duodenal injuries in children J Pediatric Surg 1997; 32:880–886

manage-68 Winthrop AL, Wesson DE, Filler RM Traumatic douodenal hematoma in the pediatricpatient J Pediatric Surg 1986; 21:757–760.

69 Ladd AP, West KW, Rouse TM, Scherer LR, Rescorla FJ, Enaum SH, Grosfeld JL.Surgical management of duodenal injuries in children Surgery 2002; 132:748–753

70 Fang JF, Chen RJ, Ling BC Controlled reopen suture technique for pyloric exclusion

cholangio-82 Kim HS, Lee DK, Kim IW, Baik SN, Kwan SO, Park JW, Cho NC, Rhoe BS The role

of retrograde pancreatography in the treatment of traumatic pancreatic duct injury.Gastrointest Endocs 2001; 54:45–55

83 Boman-Vermeeren JM, Vermeeren-Walters G, Broos P, Eggermont E Somatastatin inthe treatment of a pancreatic pseudocyst in a child J Pediatric Gastroenterol Nutr 1996;23:422–425

84 Soto JA, Alvarez O, Munera F, Yepes NL, Sepulveda ME, Perez JM Traumatic tion of the pancreatic duct: diagnosis with MR pancreatography AM J Roentgenol2001; 176:175–178

disrup-85 Kouchi K, Tanabe M, Yoshida H, Iwai J, Matsunag AT, Ohtsuka Y, Kuroda H,Hishiki T, Ohavuma N Nonoperative management of blunt pancreatic injury in chil-dren J Pediatric Surg 1999; 34:1736–1738

86 Moss RL, Musemeche CA Clinical judgment is superior to diangnostic tests in themanagement of pediatric small bowel injury J Pediatr Surg 1996; 8:1178–1181

87 Jerby BL, Attorri RJ, Morton D Jr Blunt intestinal injury in children: the role of thephysical examination J Pediatr Surg 1997; 32:580–584

88 Ciftci AO, Tanyel FC, Salman AB, Buyukpamukeu N, Hicsonmez A Gastrointestinaltract perforation due to blunt abdominal trauma Pediatr Surg Int 1998; 13:259–264

89 Chandler CF, Lane JS, Waxman KS Seatbelt sign following blunt trauma is associatedwith increased incidence of abdominal injury Am Surgeon 1997; 63:885–888

90 Wotherspoon S, Chu K, Brown AF Abdominal surgery and the seat-belt sign EmergMed (Fermantle) 2001; 13:61–65

91 Stassen NA, Lukan JK, Carrillo EH, Spain DA, Richardson JD Abdominal seat beltmarks in the era of focused abdominal sonography for trauma Arch Surg 2002; 137:718–722; discussions, 722–723

92 Hara H, Babyn PS, Bourgeois D Significance of bowel wall enhancement on CT ing blunt abdominal trauma in childhood J Computer Assisted Tomography 1992;16:94–98.

follow-93 Jamieson DH, Babyn PS, Pearl R Imaging gastrointestinal perforation in pediatricblunt abdominal trauma Pediatr Radiol 1996; 26:188–194

94 Graham JS, Wong AL A review of computed tomography in the diagnosis of intestinal andmesenteric injury in pediatric blunt abdominal trauma J Pediatric Surg 1996:754–756

95 Hulka F, Mullins RJ, Leonardo V, Harrison MW, Silberberg P Significance of neal fluid as an isolated finding on abdominal computed tomographic scans in pediatrictrauma patients J Trauma 1998; 44:1069–1072

perito-96 Holmes JF, London KL, Brant WE, Kuppermann N Isolated intraperitoneal fluid onabdominal computed tomography in children with blunt trauma Acad Emer Med 2000;7:335–341

97 Patel, JC, Tepas JJ III The efficacy of focused abdominal sonography for trauma(FAST) as a screening tool in the assessment of injured children J Pediatr Surg 1999;34:44–47; discussion, 52–54

98 Albanese CT, Meza MP, Gardner MJ, Smith SD, Rowe MI, Lynch JM Is computedtomography a useful adjunct to the clinical examination for the diagnosis of pediatricgastrointestinal perforation from blunt abdominal trauma in children? J Trauma1996; 40:417–421

99 Ramos CT, Koplewitz BZ, Babyn PS, Manson PS, Ein SH What have we learnedabout traumatic diaphragmatic hernias in children? J Pediatr Surg 2000; 35:601–604

100 Koplewitz BZ, Ramos C, Manson DE, Babyn PS, Ein SH Traumatic diaphragmaticinjuries in infants and children: imaging findings Pediatr Radiol 2000; 30:471–479

101 Pitcher G Fiber-endoscopic thoracoscopy for diaphragmatic injury in children SeminPediatr Surg 2001; 10:17–19

102 Meyer G, Huttl TP, Hatz RA, Schildberg FW Laparoscopic repair of traumatic phragmatic hernias Surg Endosc 2000; 14:1010–1014

dia-103 Sola JE, Mattei P, Pegoli W Jr, Paidas CN Rupture of the right diaphragm followingblunt trauma in an infant: case report J Trauma 1994; 36:417–420

104 Cohen Z, Gabriel A, Izrachi S, Kapuler V, Mares AJ Traumatic avulsion of kidney intothe chest through a ruptured diaphragm in a boy Pediatr Emerg Care 2000; 3:180–181

105 Stylianos S, Bergman KS, Harris BH Traumatic renal avulsion into the chest: casereport J Trauma 1991; 31:301–302

106 Kadish HA, Schunk JE, Britton H Pediatric male rectal and genital trauma: accidentaland nonaccidental injuries Pediatr Emerg Care 1998; 14:95–98

107 Reinberg O, Yazbeck S Major Perineal trauma in children J Pediatr Surg 1989;24:982–984

108 Orr CJ, Clark MA, Hawley DA, Pless JE, Tate LR, Fardal PM Fatal anorectal injuries:

a series of four cases J Forensic Sci 1995; 40:219–221

109 Lickstein DA, Moriary KP, Feins NR Neonatal rectovaginal tear during cesarean tion J Pediatr Surg 1998; 33:1315–1316

sec-110 Cuschieri A, Hennessy TP, Stephens RB, Berci G Diagnosis of significant abdominaltrauma after road traffic accidents: preliminary results of a multicentre clinical trialcomparing minilaparoscopy with peritoneal lavage Ann R Coll Surg Engl 1988;70:153–155

111 Fabian TC, Croce MA, Stewart RM, Pritchard FE, Minard G, Kudsk AK A tive analysis of diagnostic laparoscopy in trauma Ann Surg 1993; 217:557–564; discus-sion, 564–565

prospec-112 Simon RJ, Rabin J, Kuhls D Impact of increased use of laparoscopy on negative otomy rates after penetrating trauma J Traum 2002; 53:297–302; discussion, 302

lapar-113 Smith RS, Fry WR, Morabito DJ, Koehler RH, Organ CH Jr Therapeutic laparoscopy

in trauma Am J Surg 1995; 170:632–636; discussion, 636–637

114 Chen RJ, Fang JF, Lin BC, Hsu Yb, Kao JL, Kao YC, Chen MF Selective application

of laparoscopy and fibrin glue in the failure of nonoperative management of blunt tic trauma J Trauma 1998; 44:691–695

hepa-115 Taner AS, Topgul K, Kucukel F, Demir A, Sari S Diagnostic laparoscopy decreases therate of unnecessary laparotomies and reduces hospital costs in trauma patients J Lapar-endosc Adv Surg Tech A 2001; 11:207–211

116 Hawegawa T, Miki Y, Yoshioka Y, Mizutani S, Sasaki T, Sumimura J Laparoscopicdiagnosis of blunt abdominal trauma in children Pediatr Surg Int 1997; 12:132–136

117 Gandhi RR, Stringel G Laparoscopy in pediatric abdominal trauma JSLS 1997;1:349–351

118 Chen MK, Schropp KP, Lobe TE The use of minimal access surgery in pediatrictrauma: a preliminary report J Laparoendosc Surg 1995; 5:295–301

119 Poletti P, Wintermark M, Schnyder P, Becker CD Traumatic injuries: role of imaging

in the management of the polytrauma victim (conservative expectation) Eur Radiol2002; 12:969–978

120 Goffette PP, Laterre PF Traumatic injuries: imaging and intervention in post-traumaticcomplications (delayed complications) Eur Radiol 2002; 12:994–1021

Bradley P Kropp and Earl Y Cheng

Department of Urology, Children’s Hospital of Oklahoma, University of Oklahoma,Health Sciences Center, Oklahoma City, Oklahoma, U.S.A

INTRODUCTION

Trauma is the leading cause of death between the ages of 1 and 44 years, andaccounts for almost 50% of deaths in children aged 1 to 14 in the United States (1).Injury to the urinary tract occurs in 3–10% of patients suffering from blunt or pene-trating trauma and is second only to the central nervous system in frequency ofchildhood injury (2,3) However, death due to genitourinary trauma is uncommon.Although the pediatric urologist is rarely involved in the initial resuscitation of thetrauma patient, the trauma surgeon relies heavily upon him to deal with complexinjuries to the urological system The team approach to management provides thehighest level of expertise in reducing morbidity and preventing mortality

The majority of clinical practice in pediatric urologic trauma is derived fromadult standards However, the anatomy and physiology of the pediatric patientdiffer in numerous ways Management of the pediatric patient should be tailored toreflect these differences There are several aspects in the evaluation of trauma patientsthat are unique to the pediatric population, and caution must be exercised in the appli-cation of adult treatment algorithms Despite these distinct differences, there is a pau-city of literature available that outlines clinical guidelines for children In this review,

we attempt to highlight the pertinent issues in genitourinary trauma in children thatallow for a more focused diagnostic approach and appropriate management plan

RENAL TRAUMA

The kidney is the most commonly injured organ in the urogenital system as well asthe most commonly injured abdominal organ (4,5) Children appear to be moresusceptible to major renal trauma than adults (6) Several unique anatomic aspectscontribute to this observation including: less cushioning from perirenal fat, weakerabdominal musculature, and a less well-ossified thoracic cage The child’s kidney

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also occupies a proportionally larger space in the retroperitoneum than does an adultkidney (7) In addition, the pediatric kidney may retain fetal loabulations, permittingeasier parenchymal disruption (6).

Renal trauma is broadly classified as being blunt or penetrating Blunt trauma

is more common, accounting for greater than 90% of injuries in some series (8) Inthe pediatric population 14% of blunt abdominal trauma patients have a renal injury(9) Blunt renal injuries are most commonly associated with rapid decelerationforces, automobile accidents, pedestrian–vehicle accidents, falls, contact sports,and personal violence The kidney, which is relatively mobile within Gerota’s fascia,can be crushed against the ribs or vertebral column, resulting in parenchymal lacera-tions or contusions Kidney tissue may also be lacerated directly by fractured ribs.Penetrating trauma accounts for 10–20% of renal injuries, yet is responsible forthe majority of major renal injuries that require surgery (10) Penetrating traumafrom stabbings or gunshot wounds are much less common in children than adults(11) Reviews of firearm injuries show a significant rise in fatalities by firearms inchildren: homicides rose by 21% and suicides by 30% among those under 16 yearsbetween 1968 and 1991 (12) Gunshot wounds produce a radiating wave of injuryand cavitation known as ‘‘blast effect,’’ which damages tissues beyond the tract ofthe projectile Blast effect may cause delayed tissue necrosis leading to bleeding,urine leak, or abscess from areas that appear viable at the time of surgical explora-tion Penetrating injuries to the chest, abdomen, flank, and lumbar regions should beassumed to have inflicted renal injury until proven otherwise (13)

Pre-existing or congenital renal abnormalities, such as hydronephrosis, tumors,

or abnormal position, may predispose the kidney to injury from relatively mildtraumatic forces Historically, congenital abnormalities in injured kidneys have beenreported to vary from 1% to 21% More accurate recent reviews have shown thatincidence rates are 1–5% (5,7,14,15) Renal abnormalities, particularly hydro-nephrotic kidneys, may be first diagnosed after minor blunt abdominaltrauma (3,16) Most often, these patients present with hematuria following blunttrauma Others may present with an acute abdomen secondary to intraperitonealrupture of the hydronephrotic kidney (17)

Major deceleration and flexion injuries can lead to renal artery or vein injuries due

to stretching forces on a normally fixed vascular pedicle This type of injury may bemore common in children because of their increased flexibility and renal mobility(18,19) Post-traumatic thrombosis of the renal artery occurs secondary to an intimaltear The intimal layer tears from the wall of the vessel because the media andadventitia of the renal artery are more elastic than the intima (20) The intimal tear pro-duces turbulence, thrombosis, and eventual occlusion that then results in renal ischemia

A high index of suspicion must be maintained in order to identify these injuries (21).Diagnosis

Blunt Trauma

Once the patient has been resuscitated and life-threatening injuries have beenaddressed, evaluation of the genitourinary system can be undertaken Followingany blunt injury, the presence of hematuria (microscopic or gross), palpable flankmass, or flank hematomas are obvious indications for urologic evaluations Mostmajor blunt renal injuries occur in association with other major injuries of the head,chest, and abdomen Urologic investigations should be undertaken when trauma tothe lower chest is associated with rib, thoracic, or lumbar spine fractures It should

also be undertaken in all crush injuries to the abdomen or pelvis when the patient hassustained a severe deceleration injury Since a renal pedicle injury or ureteropelvicjunction disruption may not be associated with one of the classic signs of renalinjury, such as hematuria, radiological evaluation of the urinary tract should always

be considered in patients with a mechanism of injury that could potentially injure theupper urinary tract

Gross hematuria, the most reliable indicator for serious urological injury,mandates radiographic evaluation (22,23), The need for imaging in the patient withmicroscopic hematuria is not as clear cut One must remember that the degree ofhematuria does not always correlate with the degree of injury (24) Renal vascularpedicle avulsion or acute thrombosis of segmental arteries can occur in the absence

of hematuria while mild renal contusions can present with gross hematuria (25) It

is well documented in the adult literature that the vast majority of patients sufferingfrom blunt trauma with microscopic hematuria and no evidence of shock (SBP <

90 mmHg) have minor renal injuries and do not need to be studied radiographically(25–28) Guidelines for evaluating the pediatric population are not as clearly defined.Due to the catecholamine response to trauma, children are able to maintain a normalblood pressure despite a significant loss of volume (24) Unlike adult patients, hypo-tension does not appear to be a reliable indicator of the severity of renal injury inchildren and diagnostic evaluation should not be reserved only for those in shock(23) Thus, all children with any degree of microscopic hematuria after blunt traumahave traditionally undergone renal imaging (15) Recently Morey et al in a meta-analysis of all reported series of children with hematuria and suspected renal injurynoted that only 2% (11 of 548) of patients with insignificant microscopic hematuria(<50 RBC/HPF) had a significant renal injury (29) However, it is important to notethat all 11 of these patients were found to have multiple organ trauma so that renalimaging would have been performed in the course of evaluation despite the relativelyminor amount of microscopic hematuria Detection of significant renal injury wasfound to increase to 8% with significant microhematuria (> 50 RBC/HPF), and32% in those with gross hematuria after blunt trauma The presence of multi-systemtrauma significantly increases the risk for significant renal damage (23) Theyconcluded that it is reasonable to consider observation with no renal imaging in chil-dren with microscopic hematuria of <50 RBC/HPF that are stable and without amechanism of injury that is suspect for renal injury (29)

Historically, intravenous pyelography (IVP) has been the radiographic imagingstudy of choice in determining the presence and extent of renal injury Sensitivity hasbeen reported as high as 90% in diagnosing renal injury (13) Unfortunately, IVPmisses other intra-abdominal injuries and has been shown to miss or understage renalinjury in children by 50% in comparison to computed tomography (CT), Several stu-dies now indicate that conventional IVP has an extremely low yield and rarely altersmanagement in pediatric patients with blunt renal trauma, especially in patients withisolated microhematuria (5,30–32) However, intravenous pyelography still serves animportant role in all penetrating renal and hemodynamically unstable blunt renaltrauma patients who require immediate surgical exploration without preoperativeimaging (25) A one-shot trauma IVP can be performed in the operative settingand consists of 2–3 mL/kg of non-ionic contrast injected intravenously, followed

by a single abdominal radiograph 10 minutes later The purpose of the IVP is todetermine the presence of two functioning renal units, urinary extravastion, and renalparenchymal injury (13,33) With an intra-operative one-shot IVP the need for renalexploration has been obviated in 32% of patients (34)

CT scans are now used almost exclusively as the imaging study of choice forsuspected renal trauma in hemodynamically stable adults and children (29,35) The

CT imaging is both sensitive and specific for demonstrating parenchymal laceration,urinary extravasation, delineating segmental parenchymal infarcts, determining thesize and location of the surrounding retroperitoneal hematoma, and/or associatedintra-abdominal injury (36,37) The CT scans allow for accurate staging of the renalinjury, which has important management implications which will be discussed later.With the advent of CT, evaluation of renal trauma has now become much more precise.Several classification systems of renal trauma that are in part based on CT scanfindings have been described The most commonly used staging system is from theAmerican Association for the Surgery of Trauma (Table 1) that divides renal traumainto five grades that have predictive value in the subsequent management strategy ofthese injuries: grade I renal contusion or nonexpanding subcapsular hematoma with-out a renal parenchymal laceration; grade II non-expanding perirenal hematoma or arenal cortex laceration ( < l cm) without urinary extravasation; grade III renal cortexlaceration ( > l cm) and no urinary extravasation; grade IV renal cortical lacerationextending into the collecting system (as noted by contrast extravasation), or a segmen-tal renal artery or vein injury (noted by segmental parenchymal infarct), or main renalartery or vein injury with a contained hematoma; grade V shattered kidney, avulsion

of the renal pedicle, or thrombosis of the main renal artery (Fig 1) (38) The ultimategoal of complete staging is to provide sufficient information for management thatresults in the preservation of renal parenchyma and the salvage of injured kidneys(Fig 2)

Ultrasonography also has been used to assess renal trauma However, its tivity in demonstrating renal injury in comparison to CT is only 25–70% It may alsomiss associated intra-abdominal injuries (5,39) Recently, focused abdominal sono-graphy for trauma (FAST) has become increasingly popular as a screening test forpatients with suspected intra-abdominal injury Nevertheless, FAST has been shown

sensi-to have a low sensitivity for solid organ injury in children It also provides poor mation concerning renal function or pedicle injuries Thus, renal ultrasound, atpresent, is not currently recommended as a useful screening tool for urologic evalua-tion in the setting of blunt renal trauma (40)

infor-Table 1 American Association for the Surgery of Trauma Organ Injury Severity Score forthe Kidney

I Contusion Microscopic or gross hematuria, urologic studies normal

Hematoma Subcapsular, nonexpanding without parenchymal laceration

II Hematoma Nonexpanding perirenal hematoma confined by Gerota’s fascia

Laceration <1.0 cm parenchymal depth of renal cortex without urinary

extravasationIII Laceration >1.0 cm parenchymal depth of renal cortex without collecting

system rupture or urinary extravasation

IV Laceration Parenchymal laceration extending through renal cortex, medulla,

and collecting systemVasscular Main renal artery or vein injury with contained hemorrhage

V Laceration Completely shattered kidney

Vascular Avulsion of renal hilum that devascularizes kidney

a

Advance one grade for bilateral injuries up to grade III.

It is always important to remember that major renal injuries such asureteropelvic junction (UPJ) disruption or segmental arterial thrombosis may occurwithout the presence of hematuria or hypotension Therefore, a high index of suspi-cion is necessary to diagnose these injuries Non-visualization of the injured kidney

on IVP, or failure to uptake contrast with a large associated perirenal hematoma on

CT are hallmark findings for renal artery thrombosis UPJ disruption is classicallyseen as perihilar extravasation of contrast with nonvisualization of the distal ureter(20,23,29,41)

Penetrating Trauma

Renal injury due to penetrating trauma should be suspected with entrance wounds inthe lower thorax, flank area, or upper abdomen These injuries tend to be moresevere and more unpredictable than injuries due to blunt trauma Hematuria, usuallygross, commonly accompanies major parenchymal lacerations However, renalpedicle injuries may occur as an isolated laceration without producing hematuria.Renal imaging is therefore indicated in any patient with any degree of hematuriaassociated with penetrating trauma As with blunt trauma, abdominal CT is theimaging study of choice for patients with suspected renal trauma from a penetra-ting injury Selected patients, that are accurately staged, with minor renal injuriesmay be considered for non-operative management (42,43) In unstable patientsrequiring immediate resuscitation and laparotomy, an intra-operative single-shot

Figure 1 American Association for the Surgery of Trauma Organ Injury Severity Score forthe kidney Source: From Ref 96

IVP should be performed and has been shown to accurately stage 68–72% of renalinjuries in penetrating trauma (33,44).

Management

In general, attempts should be made to manage all renal injuries conservatively, withthe exception of a grade V renovascular injury, where the risk of exsanguination man-dates expedient operation (45–49) Minor renal injuries constitute the majority ofblunt renal injuries and usually resolve without incident (9,18,48,50) The management

of major renal parenchymal lacerations, although accounting for only 10–15% of allrenal trauma patients, is currently controversial Surgery is not always mandatoryand many major renal injuries due to blunt trauma may be managed conservatively

Figure 2 Grade IV renal laceration (A) with a large retroperitoneal hematoma and parahilarextravasation of contrast due to blunt trauma The patient was managed conservatively andfollow up CT at six weeks (B) depicts nearly complete resolution of the injury

(18,23,45,51–53) When necessary, the goals of renal exploration are either to treatmajor renal injuries with preservation of renal parenchyma when possible, or to eval-uate a suspected renal injury (54) The need for surgical exploration is much higher inpatients with penetrating trauma as opposed to blunt trauma McAninch has reported,

in adults, that surgical exploration has been required in 77% of gunshot wounds, 45%

of renal stab wounds, and 2% of blunt injuries

Blunt Trauma

The indications for renal exploration vary greatly between individual trauma centers.Most centers expectantly manage grade I–III injuries with bed rest and observation.Controversies arise in the management of grade IV–V injuries The majority of bluntrenal injuries sustained are contusions and lacerations that are minor in nature.Even in the presence of gross hematuria, most blunt renal injuries will not requireexploration and will have excellent long-term outcomes (Fig 3) (53) Absolute indica-tions for renal exploration include persistent life-threatening bleeding, an expanding,pulsatile, or uncontained retroperitoneal hematoma, or suspected renal pedicleavulsion Relative indications for exploration include substantial devitalized renalparenchyma or urinary extravasation Husmann and Morris have noted thatinjuries with significant (>25%) nonviable renal tissue associated with parenchymallaceration that are managed non-operatively have a high complication rate (82%)(55) Their findings demonstrate that when such renal injuries are associated with

an intraperitoneal organ injury, the post-injury complication rate is much higherunless the kidney is surgically repaired By surgically repairing such injuries, theyreduced the overall morbidity from 85% to 23% Urinary extravasation in itselfdoes not demand surgical exploration Matthews reported that, in patients withmajor renal injury and urinary extravasation who are managed conservatively,

Figure 3 Algorithm for treatment of pediatric patients with blunt renal trauma

urinary extravasation resolved spontaneously in 87% Extravasation persisted in13% and was successfully managed endoscopically (46) Incomplete staging of therenal injury demands either further imaging or renal exploration and reconstruc-tion Most commonly pediatric trauma patients undergo renal exploration becausethey are bleeding persistently, or because they have an associated injury thatrequires laparotomy.

When conservative management is chosen, supportive care with bed rest,hydration, antibiotics, and serial hemoglobin and blood pressure monitoring isrequired for uneventful healing After the gross hematuria resolves, limited activity

is allowed for two to four weeks until microscopic hematuria ceases (9) Early plications can occur within the first four weeks of injury including delayed bleeding,abscess, sepsis, urinary fistula, urinary extravasation and urinoma, and hyperten-sion The greatest risk of delayed retroperitoneal bleeding occurs within the firsttwo weeks of injury and may be life threatening Immediate surgical exploration

com-or angiographic embolization is indicated in these instances Angiographic tion is an alternative to surgery in a hemodynamically stable patient in whom persis-tent gross hematuria signifies persistent low grade hemorrhage from the injuredkidney Persistent urinary extravasation has successfully been managed by percuta-neous drainage Hypertension in the early post-trauma period is uncommon Hyper-tension may develop in the ensuing months and in most instances requires no furthertreatment other than medical management

emboliza-Penetrating Trauma

Nearly all penetrating renal injuries should be managed operatively The exception is astable patient with no missile penetration into the peritoneum, where the injury is wellstaged by CT This is particularly true if the entrance wound is posterior to the anterioraxillary line (43,56) Superficial and peripheral stab wounds universally respond well tononoperative management In sharp contrast, one out of every four grade III–IV injuriesfrom penetrating trauma managed expectantly will be complicated by a delayed renalbleed (42) Abdominal or flank gunshot wounds producing hematuria suggest thepossibility of major renal destruction due to potential blast effect Most penetratingabdominal injuries will require laparotomy for associated injuries (61%) The presence

of an unexpected retroperitoneal hematoma upon exploratory laporotomy wherethe renal injury has not been fully staged radiographically usually warrants renalexploration

Renal Exploration and Reconstruction

A vertical midline incision from xiphoid to pubis is made for speed in opening and ing the wound and to afford maximum exposure A complete inspection of the intra-abdominal contents is performed Repair of major vascular, spleen, liver, and bowelinjuries should generally be performed before renal exploration Obviously, if renalhemorrhage is life threatening, the kidney must be explored first

clos-Early control of the vessels has been demonstrated to increase the rate of renalsalvage (54–82%) (Fig 4) (57) When proximal vascular control is initially achievedbefore all renal explorations, nephrectomy is required in less than 12% of cases(57) When primary vascular control is not achieved and massive bleeding is encoun-tered, in the rush to control bleeding, a kidney that could have been salvaged may beunnecessarily sacrificed The surgeon must carefully identify the relationships with

the posterior abdomen and the posterior parietal peritoneum The colon is liftedfrom the abdomen in order to allow mobilization of the small bowel The inferiormesenteric vein and the aorta are identified at this point, and the posterior peritoneum

is incised medial to the inferior mesenteric vein The aorta is dissected superiorly tothe level of the ligament of Treitz, where the left renal vein is found crossing anterior

to the aorta Retraction of the left renal vein exposes both renal arteries beneath,which may now be isolated and controlled with vessel loops

Once vessel isolation is complete, an incision is made in the peritoneum justlateral to the colon The colon is reflected medially to expose the retroperitonealhematoma in its entirety and the kidney may be exposed If significant bleeding isencountered, the ipsilateral renal vessels may be occluded Warm ischemia timeshould not surpass 30 minutes (58)

Traumatized parenchyma is debrided sharply and oversewn with 4–0 absorbablesuture Severe polar injuries are best treated with guillotine amputation to minimize

Figure 4 Technique of exposure of renal vessels (A) Exposure of the root of the mesentery tovisualize the aorta (B) Relationship of the renal veins and arteries after incision of the posteriorperitoneum over the aorta Source: From Ref 97

delayed necrosis and fistula formation Openings into the collecting system are closedwith absorbable suture Injured intraparenchymal vessels may be oversewn with thesame suture Additional hemostasis may be obtained with the use of the argon beamlaser or gelatin bolsters Once the bleeding has been controlled, the open margins ofthe kidney are reapproximated and the renal capsule is closed Perinephric or omentalfat or a free peritoneal free graft may be sutured to the capsular edges to ensure againstany urinary leakage A Penrose drain is left in the dependent portion of the wound.Renal vascular injuries must be addressed promptly Major lacerations to therenal vein are repaired directly by venorrhaphy Repair of renal arterial injuriesmay require a variety of techniques, including resection and end-to-end anastomosis,bypass graft with autogenous vein or a synthetic graft, and arteriorrhaphy Traumaticrenal artery occlusion requires many of the same techniques for repair However thismust be performed in the first 12 hours from the time of injury, otherwise, the kidney

is usually nonviable following this length of ischemia

URETERAL INJURIES

The ureter is the least commonly injured portion of the genitourinary tract because

of its small caliber and mobility and since it is well protected by the surroundingback muscles and retroperitoneal fat Although blunt traumatic disruption of theureter or ureteropelvic junction is rare, this injury is more common in children thanadults (3:1) (19) Ureteral injuries are seen three times more often in the right kidneythan the left (59) The injury is believed to result from compression of the renal pelvisand upper ureter against the 12th rib or lumbar transverse processes, or by stretchingthe ureter by sudden extreme flexion of the trunk This is thought to be more com-mon in chidren since the child’s spine and trunk are considerably more mobile andelastic than the adult’s (60)

Diagnosis

A high index of suspicion is required for evaluation of all traumatic ureteral injuries It

is not uncommon for UPJ disruption to go unrecognized initially Delayed diagnosis isoften made after complications such as abscess or ileus have resulted from massiveextravasation of urine (41,61) Hematuria is a universally inconsistent indicator ofureteral injury and has only been found in 45–63% of ureteral injuries (61,62), If there

is any suspicion of potential ureteral damage because of a history of a penetratinginjury to the abdomen, retroperitoneum, or pelvis; fracture of the 11th or 12th rib;transverse lumbar process; bony pelvis; or significant abdominal or pelvic trauma,excretory urography or a CT scan must be obtained IVPs remain nondiagnostic inanywhere from 66% to 75% of studies (61–63) Delayed IVP or CT films are usuallynecessary to establish the diagnosis Hallmark radiographic findings include medialand periureteral extravasation as well as non-visualization of the ipsilateral distalureter (64) Retrograde urography and direct surgical exploration remain the mostsensitive tools with accuracy ranging from 85% to 100% However, this is rarelyperformed in the acute trauma setting (63,65)

Management

Surgical exploration and direct intravenous injection of methylene blue or indigocarmine is the best course of action whenever acute ureteral injury is suspected

Surgical intervention is dependent on the location and degree of the injury The goal

of primary repair should be a tension-free, spatulated, and water-tight anastamosis.For distal injuries below the iliac vessels, ureteral reimplantation into the bladder isthe best option Extra length for reimplantation may be obtained by tacking thebladder to the psoas musculature (a psoas hitch) or raising a flap of bladder tothe injured ureter (boari flap) The kidney may also be mobilized to create a ten-sion-free anastamosis Mid and proximal ureteral injuries are best manged by

an uretero–ureterostomy with an interrupted anastomosis over an indwelling eral stent This is performed after debriding all devitalized tissue and spatulatingboth ends When ureteral damage is too extensive, temporizing measures may be per-formed such as bringing the cut end of the ureter out to the skin (ureterostomy), or

uret-by placing a nephrostomy tube with definitive therapy at a later time when thepatient is more stable Delayed reconstruction may include ileal or appendiceal inter-position, transureteroureterostomy, or autotransplantaion of the kidney to thehypogastric vessels The retroperitoneum should always be drained following recon-structive ureteral surgery in the setting of trauma

Penetrating ureteral injuries are exceptionally rare in children However, theprinciples of management are the same as above Adequate debridement and directrepair with a ureteral stent is the preferred approach for most cases with a shortdefect In severe life-threatening cases, a nephrectomy may be performed if thepatient is known to have a normal contralateral kidney Nevertheless, nephrectomyshould be avoided if possible

In the adult population, the association between pelvic fractures and lower urinarytract injury has a reported incidence of 10–25% (66) However, a much lower incidence(1%) has recently been reported in pediatric patients with pelvic fractures (67) Thedecreased incidence may be due to the elastic nature of a child’s pelvis and its asso-ciated attachments (68)

Presentation

Intraperitoneal rupture of the bladder occurs when there is a sudden rise in sicularpressure secondary to a blow to the pelvis or lower abdomen This increasedpressure results in a rupture of the dome, the weakest and most mobile part of thebladder As stated earlier, this type of bladder injury is more common in childrenthan adults because of the intraperitoneal position of the bladder Intraperitonealbladder ruptures account for one-third of all bladder injuries in children Extra-peritoneal ruptures are almost exclusively seen with pelvic fractures In these cases,the bladder can be sheared on the anterior lateral wall near the bladder base by thedistortion of the pelvic ring disruption (69) Occasionally the bladder will also belacerated by a sharp bony spicule

intrave-Bladder injury should be suspected when physical exam reveals suprapubic andvague, diffuse lower abdominal tenderness or bruises over the suprapubic and pelvicregion The patient may report that he was unable to void Hematuria is a hallmarkfinding and is present in almost 95% of patients A Parkland review of six years’experience found gross hematuria in 98% and microscopic hematuria in 2% (70).

In cases of penetrating trauma, bladder perforation should be suspected with anydegree of hematuria and trauma to the lower abdomen, pelvis, or buttocks

Diagnosis

Imaging is indicated in all patients with gross hematuria Significant pubic archinvolvement, and hemodynamic instability make a bladder injury very likely (69).Cystography is the definitive study for diagnosis of bladder rupture The bladder must

be completely filled for optimal detection of extravasation In the child, bladdercapacity is variable and must be estimated [(ageþ 2)
30 cc] in order to ensure adequatedistention (71) The water soluble iodinated contrast solution is instilled by gravitythrough a Foley catheter placed in the bladder Films should include anteroposterior,lateral or oblique, and postdrain views Cystography may fail to demonstrate extrava-sation if a clot occludes the perforation If a urethral injury is suspected because of apelvic fracture, high riding prostate on rectal examination, blood at the meatus, ormarked ecchymosis and edema of the perineum, scrotum, and/or penis, a retrogradeurethrogram must be done before attempted urethral catheterization (see section onurethral injuries)

Although spiral CT alone is not adequate to evaluate for bladder rupture, CTcystography is a highly sensitive and specific test (72) CT cystogram has been shown

to be equally diagnostic to conventional cystography, with an overall sensitivity and cificity of 95% and 100%, respectively, for bladder rupture (73,74) A CT cystograminvolves actual retrograde filling of the bladder with subsequent scanning after a conven-tional CT scan has been performed to evaluate for other bladder and pelvis injuries.Characteristic radiographic findings for extraperitoneal ruptures include flameshaped areas of the extravasation that are usually confined to the perivesical softtissue If there is a large pelvic hematoma, the bladder will often be compressed intothe ‘‘teardrop deformity.’’ Intraperitoneal laceration is identified by the presence ofcontrast material in the cul-de-sac, outlining loops of bowel, and eventually extendinginto the paracolic gutter (Fig 5)

spe-Metabolic evidence of urinary extravasation may also be helpful in ting intraperitoneal from extraperitoneal rupture or, in the absence of clinicalfindings, suggest bladder perforation in children Children with intraperitonealruptures develop hyperkalemia, hyponatremia, increased serum urea, and creatininedue to peritoneal absorption of urine solutes into the bloodstream In contrast, nodifferences in the serum chemistries are detected for extraperitoneal rupture (75)

extra-rupture with large amounts of extravasation is prudent If the patient is to beexplored for other injuries or if a large extraperitoneal rupture is suspected, it is best

to open the dome of the bladder, not disturb the pelvic hematoma, repair the ruptureintravesically, close the bladder, and insert a suprapubic tube (Fig 6)

Intraperitoneal ruptures should be treated with prompt surgical repair Theperitoneal cavity should be opened, all urine and blood evacuated, the viscera andvasculature inspected for injury, and the appropriate therapy instituted The bladdershould be opened and thoroughly inspected The bladder is closed in two layers from

Figure 5 (A) Intraperitoneal bladder rupture with visualization of contrast along both colic gutters and surrounding the loops of bowel (B) Extraperitoneal rupture demonstratingextravasation of contrast into the perivesical space and extending into the scrotum

para-the inside and a suprapubic cystostomy tube is placed through a separate stab incision.The pelvic space should be drained.

All patients with penetrating injuries from external violence to the lower abdomenand/or that have radiographic and/or clinical evidence of a bladder injury shouldundergo exploration of the abdomen and the missile tract should be followed fromits entrance wound to its exit wound The peritoneal cavity should be opened even ifthe injury is thought to be entirely extraperitoneal and the abdominal viscera and majorvasculature examined for damage If the ureteral orifices are involved or there isconcern about the integrity of the ureters, 5 mL of indigo carmine should be injectedintraveneously A search for extravasation should be made and a five French cathetershould be placed in the ureter The pelvic hematoma should be evacuated in order toidentify any other pelvic injuries The bladder should be opened and fully examinedfrom the inside to determine the full extent of injury Lacerations should be closed intwo layers with absorbable suture A suprapubic cystostomy tube should be placedalong with a drain in the pelvis

it is postulated that the prepubertal puboprostatic ligament and bladder do not

Figure 6 Algorithim for treatment of pediatric patients with pelvic trauma and suspectedurologic injury

constitute a structurally stable unit as they do in the adult Clinically this is supported

by the fact that most traumatic urethral injuries in children occur below the prostate atthe membranous urethra They can also occur through the prostate or at the junction

of the prostate and bladder neck (76–78)

Urethral trauma in the female is much less common than in the male However,female urethral disruption is more common in children than in adults (79) Severepelvic fracture and bony displacement along with lacerations through the bladderneck and vagina are often present in cases of urethral trauma in the female.Posterior Urethra

Posterior urethral disruption is the most severe injury of the lower urinary tract inchildren and usually results from violent external force Strong shearing forces inhigh-speed blunt and crush injuries or high velocity penetrating trauma shear theattachment of the prostate and puboprostatic ligaments from the pelvic floor, whilethe membraneous urethra, attached to the urogenital diaphragm, is pulled in anotherdirection As a result, the prostatic urethra is torn Pelvic fracture is present in >90%

of patients with posterior urethral injuries

Diagnosis

Patients with posterior urethral injury may have attempted to void unsuccessfullybefore arrival at the hospital If the patient voids, gross hematuria is present inalmost all cases On examination, blood is present at the urethral meatus in themajority of patients with urethral trauma After laceration of the posterior urethra,the bladder and prostate ascend above the normal anatomic position and the defectfills with blood and urine Digital rectal examination should be performed in allpatients with pelvic trauma On rectal examination, a boggy fluid collection is present

in the normal location of the prostate However, in children, this is not always a usefulfinding due to the immature development of the prostate

Retrograde urethrography is indicated in all patients with suspected urethraltrauma The initial anteroposterior film of the pelvic series is utilized to identify pelvicfractures, bony displacement of the symphysis, or the presence of foreign objects.Next, the patient is placed in a 25–30 oblique position and water-soluble contrastmaterial is injected into the urethral meatus The best injection technique is with asmall catheter inserted just past the fossa navicularis with the balloon inflated with

1 or 2 mL of water If a urethral catheter already was inserted into the bladder, itshould not be removed In such cases, a retrograde urethrogram may be obtained

by inserting an angiocatheter into the urethral meatus and injecting contrast alongsidethe urethral catheter

The mildest form of posterior uretheral injury (type I) is stretching and elongation

of the urethra, owing to pelvic hematoma without rupture Type II urethral injury is

a partial or complete rupture of the prostatomembranous urethra Extravasation onthe retrograde urethrogram is confined below the urogenital diaphragm Type III is apartial or complete rupture of the prostatomembranous urethra as well as rupture ofthe urogenital diaphragm and bulbous urethra Extravasation of contrast material isseen in the pelvis and perineum Type III urethral injury is the most severe and is twice

as common as each of the other injuries

Boone and coworkers reported on 24 boys with rupture of the posteriorurethra who were followed through puberty (80) The level of rupture was pros-tatomembranous in 67%, supraprostatic in 17%, and transprostatic in 17% of

cases In contrast, nearly all urethral ruptures above the urogenital diaphragm inadults occur at the prostatomembranous level In children, the level of injury(i.e., prostatomembranous versus higher) correlated with specific complications asfollows: impotence 31% versus 75% intractable structure 12% versus 75% and inconti-nence 0% versus 25% Thus, all three complications have a higher incidence when theinjury is above the prostatomembranous level Given this, children are at a higher riskthan adults for the development of impotence, structure, and incontinence followingposterior urethral injury.

Management

Urethral catheterization for three to five days is recommended for patients with atype I injury since the hematoma distorting the urethra may produce incompletevoiding or urinary retention These mild injuries usually heal without sequelae Inpatients with a minor type II injury (partial tear) one can attempt to pass a catheterinto the bladder If successful, the catheter is maintained for 7–14 days, and a void-ing cystourethrogram is obtained when the catheter is removed Many of these inju-ries will heal without any structure or with a mild structure that is amenable to eitherperiodic dilatation or endoscopic incision

Management of patients with complete rupture of the posterior urethra is one

of the most difficult and controversial areas of genitourinary trauma The goal oftherapy is adequate urinary drainage with the least negative impact on long termstructure formation, incontinence, and impotence Historical approaches to thepatient with posterior urethral rupture emphasized primary exploration and directurethral realignment However, the rates of structure, incontinence’ and impotencewere unacceptably high Therefore, avoidance of instrumentation at the time ofinjury and suprapubic cystostomy alone have been the preferred initial management

of nearly all cases of posterior urethral rupture for approximately 25 years (81).Delayed definitive repair is undertaken three to six months after the initial injurywhen the pelvic hematoma has resolved This has resulted in lessened rates of bothincontinence and impotence

However, in some select patients immediate open surgical realignment is theprocedure of choice These patients include those who (1) are going to have immediatepelvic exploration for a concominant vascular or rectal injury, (2) have a severeprostatourethral dislocation with perhaps fixation of a ‘‘pie-in-the-sky’’ bladderand prostate due to a displaced comminuted bone fragment by the puboprostatic liga-ments, (3) have major bladder neck lacerations or prostatic fragmentation (seen fre-quently in children), or (4) female patients (82–85) In such patients immediateexploration is preferable to delayed repair with respect to eventual continence atthe level of the bladder neck

Advances in endoscopic techniques with flexible cystoscopy and the use ofguide wires and Seldinger technique are producing a reappraisal of both the initialmanagement of posterior urethral rupture and the delayed repair of urethral struc-ture Immediate endoscopic realignment may have a role in adults (82,86–88) How-ever, in children, the smaller instrumentation that is required and the associatedtechnical difficulty may limit the use of primary endoscopic techniques Thus, untilfurther experience with immediate realignment is adequately evaluated in children,delayed repair continues to be the gold standard for the management of male chil-dren with posterior urethral disruption without concominant bladder neck or rectalinjuries (89,90)

Anterior Urethra

Injuries of the anterior urethra are more common than posterior injuries in childrenand result most often from blunt trauma, owing to urethral straddle injuries crushingthe bulbous urethra against the pelvic arch Anterior urethral injury may also occur as

a result of penetrating wounds from gunshots, stabs, or iatrogenic instrumentation.Either blunt or penetrating trauma to the anterior urethra may produce partial orcomplete disruption of the integrity of the urethra and its fascial coverings Buck’sfascia tightly surrounds the erectile bodies and the corpus spongiosum of the urethrafrom the suspensory ligament proximally to the coronal sulcus distally Urethral rup-ture contained by Buck’s fascia leads to dissection of blood and urine along the penileshaft creating a hematoma that appears as a sleeve of the penis Urethral rupture withextravasation of urine, blood, or pus into the scrotum and contained by Colles’ fasciaproduces a characteristic butterfly hematoma configuration in the perineum.Diagnosis

Retrograde urethrography should be performed on all patients in whom the history orphysical examination suggests possible injury to the anterior urethra These findingsinclude blood at the urethral meatus and evidence of penile, scrotal, or perineal contusion,hematoma, or fluid collection

Management

Minor blunt contusions of the anterior urethra, without disruption, may be treated by

a few days of catheter drainage When the injury is more involved, or penetrating innature, surgical exploration, debridement and direct repair are indicated The incision

is placed in the perineum for injuries of the distal bulbar or proximal pendulousurethra A circumcising incision with degloving of the penile shaft may be moresuitable for injuries to the distal urethra Partial urethral lacerations are debridedand closed over a urethral catheter, which is maintained for 7–10 days Complete dis-ruptions of the distal bulbous or pendulous urethra are repaired by direct end-to-endreanastomosis whenever possible Meticulous care must be taken to debride allnonviable tissue to the healthy margins of the urethra

Devastating blowout injuries may occur from shotgun blasts, power machineavulsions, or high-speed blunt contusion Initial management consists of meticuloushemostasis, careful debridement and proximal urinary diversion by suprapubiccystostomy The goal of the initial debridement of massive wounds of the perineum

is to establish proximal urinary and fecal diversion and to approximate viable tissue

in such a manner as to end up with a posterior urethral opening which may berepaired in a few months by staged urethroplasty (76)

TESTICULAR INJURIES

Rupture of the testis can be seen with either blunt or penetrating trauma (91).Physical exam reveals a variable amount of scrotal swelling, hematoma, andtenderness, making the testis and epididymis indistinct Immediate exploration isindicated if the testicle is to be salvaged Most simple scrotal hematomas in theabsence of rupture can be observed if the injury appears stable (92) However,patients with large hematoceles will generally recover faster with prompt incisionand drainage (93) The best radiographic method to evaluate boys with a suspectedtesticular rupture is ultrasonography Scrotal ultrasound is a rapid, non-invasive