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20 Laparoscopy andPenetrating Trauma

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Suggested Reading

Chelly JR, Major K, Spivak J, Hui T, Hiatt J, Margulies DR.The value

of laparoscopy in management of abdominal trauma. Am Surg. 2003;69:957–60.

Chestovich PJ, Browder TD, Morrissey SL, Fraser DR, Ingalls NK,

Fildes JJ. Minimally invasive is maximally effective: diagnostic and therapeutic laparoscopy for penetrating abdominal injuries. J Trauma Acute Care Surg. 2015;78(6):1076–85.

Gazzaniga AB, Stanton WW, Bartlett RH.Laparoscopy in the diagno-

sis of blunt and penetrating injuries to the abdomen. Am J Surg. 1976;131:315–8.

Goettler C, Bard M, Toschlog E. Laparoscopy in trauma. Curr Surg.

2004;61(6):554–9.

Gorecki P, Cottam D, Angus L, George D, Shaftan G. Diagnostic

and therapeutic laparoscopy for trauma: a technique of safe and systematic exploration. Surg Laparosc Endosc Percutan Tech. 2002;12(3):195–8.

Hope WW, Christmas AB, Jacobs DG, Sing RF.Denitive laparoscopic

repair of penetrating injuries to the colon and small intestine: a case

report. J Trauma. 2009;66:931–2.

https://www.davincisurgery.com/. Accessed December 2020. https://www.medtronic.com/covidien/en- us/support/products/wound-

closure/v- loc- barbed- sutures.html. Accessed December 2020.

Leppaniemi A, Haapiainen R. Diagnostic laparoscopy in abdomi-

nal stab wounds: a prospective, randomized study. J Trauma.

2003;55(4):636–45.

Matthews BD, Bui H, Harold KL, Kercher KW, Adrales G, Park A,

Sing RF, Heniford BT.Laparoscopic repair of traumatic diaphragmatic injuries. Surg Endosc. 2003;17:254–8.

Miles EJ, Dunn E, Howard D, Mangram A.The role of laparoscopy in

penetrating abdominal trauma. JSLS. 2004;8:304–9.

Navsaria PH, Graham R, Nicol A.A new approach to extraperitoneal

rectal injuries: laparoscopy and diverting loop sigmoid colostomy. J Trauma. 2001;51(3):532–5.

Rossi P, Mullins P, Thal E.Role of laparoscopy in evaluation of abdom-

inal trauma. Am J Surg. 1993;166:707–11.

Saribeyoglu K, et al. Laparoscopy offers diagnosis and treatment in

abdominal stab injuries. Surg Laparosc Endosc Percutan Tech. 2007;17(5):396–401.

Simon RJ, Rabin J, Kuhls D.Impact of increased use of laparoscopy

on negative laparotomy rates after penetrating trauma. J Trauma. 2002;53(2):297–302.

Spann JC, Nwariaku FE, Wait M.Evaluation of video-assisted thora-

coscopic surgery in the diagnosis of diaphragmatic injuries. Am J Surg. 1995;170:628.

Stefanidis D, Richardson WS, Chang L, Earle DB, Fanelli RD.The

role of diagnostic laparoscopy for acute abdominal conditions: an evidence-based review. Surg Endosc. 2009;23:16–23.

Streck CJ, Lobe TE, Pietsch JB, Lovvorn HN III.Laparoscopic repair of

traumatic bowel injury in children. J Pediatr Surg. 2006;41:1864–9.

Villavicencio RT, Aucar JA.Analysis of laparoscopy in trauma. J Am

Coll Surg. 1999;189:11.

Zantut LF, Ivatury RR, Smith RS, et al. Diagnostic and therapeutic

laparoscopy for penetrating abdominal trauma: a multicenter experience. J Trauma. 1997;42:825.

Angiography andInterventional

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Radiology

MarcKalinowski

Due to technical innovations over the last decades especially in the eld of computed tomography (CT), catheter-based procedures have evolved more and more from a diagnostic modality to a primary treatment option for severely injured trauma patients. Whether remote aortic occlusion is performed to avoid a secondary cavity incision, embolization of bleeding vessels, or an endovascular stent is placed to cover a lacerated vessel, all these techniques can minimize the physiologic burden placed on patients who may have very little physiologic reserve. The application of endovascular technology to the management of penetrating and blunt traumatic vascular injuries represents an exciting and signicant advance in modern trauma centers. Utilization of these techniques to stabilize a patient in extremis or to serve as a “bridge” to future elective procedures to correct the same problem represents an attractive alternative with potentially lower morbidity and mortality rates than conventional management. It is of utmost importance that these procedures must be carried out by experienced providers in an environment conducive to such repair. A variety of imaging equipment as well as endovascular inventory must be readily available for the successful management of these injuries.

21.1 General Comments

Due to the growing availability of fast CT scanners, the diagnosis of arterial trauma should be established primarily by using this fast and noninvasive imaging modality even in unstable patients. Modern multislice CT scanners can detect bleeding rates of 0.3cm3 of blood/min, whereas digital subtraction angiography (DSA) needs a blood loss of approximately 0.5–1 cm3/min for detection. Suspicion of arterial injury is usually based on the ndings of clinical examina-

tion. Careful evaluation can detect abnormalities in patients with major arterial injuries. But it is known that arterial injuries may present with so-called soft signs (stable hematoma, adjacent nerve injury, unexplained hypotension, or proximity of the penetrating wound to the underlying major blood vessels) and may be overlooked. In case of suspected vascular injury, a contrast-enhanced CT scan (presumably a whole-body CT) denes on the best way where a patient is bleeding. Contrast extravasation on CT proves a vascular injury resulting in early intervention. Holding unstable patients in the emergency room (ER) to achieve cardiovascular stability is not wise and not needed neither for imaging nor for percutaneous interventions. Usually, patients lose more blood during stabilization, possibly resulting in a “bloody vicious cycle” (coagulopathy, acidosis, hypothermia). Therefore, imaging and interventions should be understood as a continuous process even during ongoing resuscitation.

There are some basic algorithms in case of suspected bleeding which are useful for suspected vascular trauma even if CT is not available using focused assessment with sonography for trauma (FAST) ultrasound. If CT is available, consider the following basic algorithm (Fig.21.1).

You should always keep in mind that due to the wide range of materials needed for vessel occlusion or covering (coils, plugs, glue, particles, gelatine-based embolics, and covered stents), you should be familiar with this “interventional zoo.” The complexity of these procedures reaching the bleeding target site by catheter-based procedures adds to this difculty. So think twice and check your surrounding before you jump. You also need an appropriate facility even in an operating room or an angio suite. A wide range of different materials must be immediately available, and the most crucial point in such situations is that experienced operators are on call on a 24/7 fashion.

M. Kalinowski (*) Conradia Radiologie, Hamburg, Germany

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CT scan

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“Blush” “No blush”

Embolization OR (If required)

Ongoing

hemorrhage

M. Kalinowski

superselective catheterization by microcatheters. Timeconsuming exchange of standard 0.035in. catheters should be avoided. Never lose your guidewire. Use one (or better two) French vascular sheaths greater than the catheters you use because the side port of the sheath can then be used for intraarterial blood pressure measurements during the intervention by your anesthesiologists. They will appreciate you.

21.3 Basic Imaging Aspects

There are some basic imaging principles which should be kept in mind especially when searching bleeding sites. Four different imaging patterns of injured vessels could be identied during angiography (Fig.21.2):

• Contrast extravasation “blush”

• Vascular occlusion “arterial stump”

• Pseudoaneurysms

• Arteriovenous stulas

Fig. 21.1 Basic algorithm for endovascular treatment decisions according to identiable contrast-media extravasation on CT scan

21.2 Technical Considerations

In case of penetrating trauma, there are only a handful of scenarios where percutaneous interventions may provide lifesaving bleeding control especially in areas that are difcult to access surgically. These interventions may prevent the need for reoperation in the presence of rebleeding or assist in nonoperative management. This includes head and neck injuries, extremities and pelvic trauma, and great vessel and thoracic and solid abdominal organ injuries.

For all these scenarios, the common femoral artery is the recommended access site. All vascular regions of the body can be reached easily using specic catheters and guidewires. The retrograde puncture site should be located on the lower third of the femoral head seen on uoroscopy. Avoid an arterial puncture above the inguinal ligament due to an increased chance of retroperitoneal bleeding that of course is not compressible or a puncture site too low because of the same reason. Especially, in case of extensive vascular trauma and the need for aortic stentgrafts, a surgical cutdown of the groin should be performed. Percutaneous access for stentgraft placement is also possible, but specic closure devices and techniques are necessary. In shock situations where blood pressure could be extremely low, ultrasound-guided puncture is recommended due to possible collapsed and nonpulsatile arteries. You should use preferential 4F catheters with a 0.038in. inner lumen, as you can use these devices as guiding catheters for ongoing

Considering the following top ten points, you can save much time, and therefore, these tips are recommended for a successful intervention:

1. Perform angiographic series as selective as possible with

a contrast-media injector; avoid hand injections. Most of the available microcatheters are designed even for higher injection rates resulting in superior visualization of the target vessel region.

2. Perform long series including parenchymal and venous

phase for detection of even subtle contrast-media extravasation.

3. Use additional intravenous (IV) butylscopolamine in the

abdominal region to reduce bowel motion artifacts.

4. When reviewing your angio series, always look on sub-

tracted and unsubtracted images for better differentiation of possible bleeding sites and bowel motion artifacts.

5. Always look for side branch and collateral ow, because

according to specic situations, additional vessels have to be embolized for successful bleeding control.

6. The complete target region must be imaged. If the vascu-

lar region is greater than your eld of view, perform additional series. Especially, in the abdominal and pelvic regions, all visceral arteries must be selectively catheterized including the celiac trunk and both the internal iliac and common femoral arteries.

7. Look for “cutoffs.” Treat visible arterial stumps like an

active bleeding. These lacerated or dissected vessels are possibly compressed by surrounding hematoma and could rebleed after hemodynamic stabilization.

21 Angiography andInterventional Radiology

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a c

183

Fig. 21.2 Different imaging patterns of vessel injury presenting at angiographic evaluation. Contrast extravasation (a), arterial stump (b), and pseudoaneurysm (c)

8. In case of negative angio, do not use a heparin bolus or other lytics to induce articial bleeding; this is not recommended.

9. Leave the sheath in place after your intervention because in some cases, additional secondary embolizations must be performed by reopened vessels due to better cardiovascular status of your patient.

10. Avoid time-consuming negative angios and unnecessary

patient and preservation of function of bleeding organs. However, in some cases, a less selective embolization (“shower embolization”) and a surviving patient are better than an interventional “tour de force” and a dead patient.

Common causes for negative angios are local vasospasm, local thrombosis, a venous bleeding, or a wrong catheter position. Therefore, angiographic images must be reviewed extensively in every case.

interventions.

In an optimal situation, the previous performed CT images

21.4 Head andNeck Injuries

guide you to the suspected bleeding area. That means that on one hand, if you do not have suspected signs of arterial bleeding, there is no indication for further time-consuming angiographic evaluation. On the other hand, if bleeding site was identied and the following angio is negative, prophylactic embolization due to possible end-organ failure and concomitant complications should be avoided. The primary goals of interventional procedures are stabilization of the

Cervical blood vessels are the most commonly injured structures following penetrating neck injuries. Their location relative to dened anatomic landmarks dictates the diagnostic workup and therapeutic approaches of these injuries. The neck is divided into three zones: zone I (from the clavicles to the cricoid cartilage), zone II (between the cricoid cartilage and the angle of the mandible), and zone III (above the angle

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M. Kalinowski

of the mandible). Regardless of which zone is injured, any hard signs of vascular injury including overt hemorrhage, an expanding hematoma, or ongoing neurologic decits demand an operative exploration. Endovascular techniques should not be used as a rst-line therapy in these cases. Patients who present with soft signs of vascular injury, e.g., stable hematoma, are typically hemodynamically stable, and you have enough time for detailed evaluation. However, endovascular techniques may assist classical operative approaches like balloon catheter blocking until surgery is done and could potentially avoid the morbidity of median sternotomy, a high thoracic incision, difcult vertebral dissection, or dissections at the base of the skull.

Key Points

• Direct surgical repair remains the gold standard for injuries in all neck zones.

• An occlusion balloon can be used from the groin to provide endoluminal proximal control of the great vessels, allowing surgical exposure in a more controlled fashion.

• Endoluminal therapy can be performed under local anesthesia, allowing direct assessment of the patient’s neurologic status.

21.5 Thoracic andAbdominal Aortic

Injuries

Thoracic vascular injuries carry a high mortality rate. Endovascular techniques using stentgrafts are limited to patients presenting hemodynamic stability and are useful in the treatment of delayed manifestations such as pseudoaneurysms, dissections, or arteriovenous (AV) stulas. Usually, trauma patients are often younger than patients treated with stentgrafts for aortic aneurysmal disease. In the rst cohort, the mean aortic diameter is approximately 20 mm. Some interventionalists stated that oversizing up to 40% could be performed without sequelae, but it has to be mentioned that the manufacturers recommend only a 10–15% oversize. Oversizing the graft more than 15% can possibly result in secondary complications such as graft compression, graft collapse, endoleak formation, and stentgraft pleating. According to the injury site in some cases, the left subclavian artery has to be overstented. Some authors recommend routinely overstenting of the left subclavian artery resulting in an appropriate proximal landing zone. This has proven to be a relative harmless procedure. If secondary symptoms arise, a carotid-to-subclavian artery bypass can be performed.

Vascular injuries in the abdomen remain the leading cause

of death after penetrating the abdominal aorta and typically require operative exploration to stop hemorrhage because the concomitant solid organ and gastrointestinal sites of injuries are common. Nevertheless, endovascular therapies have

some advantages in acute and delayed manifestations of abdominal aortic trauma including avoidance of aortic crossclamping and avoidance of opening the retroperitoneum, consecutively placing prosthetic material in possibly contaminated regions if the perforated viscus is present and in patients with previous abdominal surgery. Especially, for delayed manifestations, morbidity and mortality rates are dramatically lower compared to open surgical repair.

In the acute setting, aorto-monoilical prosthesis is recommended with contralateral occluders followed by femorofemoral crossover bypass grafting. If a bifurcated prosthesis is used, the patient may bleed to death due to time- consuming catheterization of the contralateral leg.

Key Points

• In preinterventional planning scenario for stentgrafting,

always check the iliac diameter. Introducer devices range

from 18 to 24 French; therefore, the external iliac diame-

ter should not be below 7–8mm.

• The length of the proximal landing zone should be not

less than 10 mm, and the stentgraft should be approxi-

mately 4cm longer than the treated segment.

• If the left subclavian artery must be overstented, watch

out for an occluded right vertebral artery, dominant or

indispensable left vertebral artery, and patients with left

internal mammarian coronary bypass.

• In acute abdominal vascular injuries, aorto-monoilical

prostheses must be on hand because you may get into

trouble if catheterization of the contralateral leg joining

the main body of bifurcated stentgrafts takes longer than

a couple of seconds (this is daily routine even in experi-

enced centers).

21.6 Extremities andPelvic Injuries

The majority of extremity vascular trauma can be controlled with direct tamponade or tourniquets. Due to the relative long-lasting ischemia tolerance of 4–6 h, there is usually enough time to address other life-threatening injuries and detailed evaluation. Lower as well as upper extremity vascular injuries can be easily approached via femoral access. In case of lower extremity injury, preferentially, use contralateral retrograde access and crossover techniques to avoid deterioration of injury by ipsilateral antegrade access. All kinds of acute or delayed injuries could be treated easily, e.g., pseudoaneurysms, AV stulas, active bleeding, or thrombosis by using embolics, covered stents, or thrombectomy devices. Iliac vessel injuries with expanding pelvic hematomas are among the most challenging to trauma surgeons. The utility of angiographic embolization of bleeding pelvic vessels is well-documented and could be reached easily by ipsi- or contralateral femoral approach.

21 Angiography andInterventional Radiology

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Important Points

• Assure stable catheter position, and be selective as possible to avoid dislodgement of embolics and malperfusion of downstream-located regions.

• If embolization of both internal iliacs is necessary, inform patient and/or relatives if possible due to specic complications such as buttock claudication, sexual dysfunction, and gluteal necrosis.

• In case of multiple bleeding sites under these circumstances, proximal “shower embolization” could be the best and fastest procedure.

Suggested Reading

Arthurs ZM, Skohn VY, Starnes BW.Vascular trauma: endovascular

management and techniques. Surg Clin N Am. 2007;87:1179–92.

Busquets AR, Acost JA, Colon E, etal. Helical computed tomographic

angiography for the diagnosis of traumatic arterial injuries of the extremities. J Trauma. 2004;56:625–8.

Feliciano DV.Management of penetrating injuries to the carotid artery.

World J Surg. 2001;25:1028–35.

Hafez HM, Woolgar J, Robbs JV. Lower extremity arterial injury:

results of 550 cases and review of risk factors associated with limb loss. J Vasc Surg. 2001;33:1212–9.

Hoornweg LL, Dinkelman MK, Goslings JC, etal. Endovascular man-

agement of traumatic ruptures of the thoracic aorta: a retrospective

multicenter analysis of 28 cases in The Netherlands. J Vasc Surg. 2006;43:1096–102.

Huber-Wagner S, Levering R, Quick LM, etal. Effect of whole-body

CT during trauma resuscitation on survival: a retrospective, multicentre study. Lancet. 2009;373:1455–61.

Kasirajan K, Heffernan D, Langsfeld M.Acute thoracic trauma: a com-

parison of endoluminal stentgrafts with open repair and nonoperative management. Ann Vasc Surg. 2003;17:589–95.

Lin PH, Bush RL, Zhou W, etal. Endovascular treatment of traumatic

thoracic aortic injury—should this be the new standard of treatment? J Vasc Surg. 2006;43:22A–9A.

Martin MJ, Mullenix PS, Steele SR, et al. Functional outcome after

blunt and penetrating carotid artery injuries: analysis of the National Trauma Data Bank. J Trauma. 2005;59:860–4.

Mattison R, Hamilton IN Jr, Ciraulo DL, etal. Stentgraft repair of acute

traumatic thoracic aortic transection with intentional occlusion of the left subclavian artery: case report. J Trauma. 2001;51:326–8.

Mavili E, Donmez H, Ozcan N. Endovascular treatment of lower

limb penetrating arterial traumas. Cardiovasc Intervent Radiol. 2007;30:1124–9.

Sampson MA, Colguhoun KB, Hennessy EL. Computed tomogra-

phy whole body imaging in multitrauma: 7years experience. Clin Radiol. 2006;61:265–9.

Symbas PN, Sherman AJ, Silver JM, etal. Traumatic rupture of the

aorta: immediate or delayed repair? Ann Surg. 2002;235:796–802.

Velmahos GC, Toutouzas KG, Vassiliu P, etal. A prospective study on

the safety and efcacy of angiographic embolization for pelvic and visceral injuries. J Trauma. 2002;53:303–8.

White R, Krajcer Z, Johnson M, etal. Results of a multicenter trial for

the treatment of traumatic vascular injury with a covered stent. J Trauma. 2006;60:1189–95.

Imaging ofPenetrating Urologic

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Trauma

BeatSchnüriger andDonaldJ.Green

22.1 Imaging ofPenetrating Urologic

Trauma

Penetrating injury to the abdomen causes ureteral injury in approximately 2%, kidney injury in up to 8%, and injury to the bladder in up to 20%. It is important to keep in mind that microscopic or gross hematuria is unreliable as a diagnostic tool for any urological injury, with a maximal overall sensitivity of 75%. Hematuria may be even absent in cases of complete transection of one ureter. In addition, signicant penetrating injuries to the major collecting system may present without hematuria, because urine from the injured kidney exits into the retroperitoneum, preventing ureteral conduction.

Maintain a high index of suspicion for urinary tract

involvement in all penetrating injuries to the abdomen, ank, pelvis, and perineum. For all gunshot injuries to the trunk, stab wounds to the ank, and cases where the length of the knife may reach the retroperitoneum, you should proceed with further investigations to rule out urinary tract injury.

About half of the patients with injuries to the urinary tract

are hypotensive on presentation, indicating the overall severity of trauma and not the urologic injury itself. These patients require immediate laparotomy without delay. Additionally, nearly all gunshot injuries with involvement of the urinary tract are associated with signicant concomitant injuries. The decision-making regarding diagnostic procedures and treatment of penetrating urologic trauma clearly depends on the hemodynamic status and associated injuries of the patients. As soon as the patient is stable, an evaluation of the urinary tract should follow as part of the secondary survey. The vast majority of urologic injuries is not life-threatening.

B. Schnüriger (*) Acute Care Surgery Team, Department of Visceral Surgery and Medicine, Bern University Hospital, Bern, Switzerland e-mail: beat.schnueriger@insel.ch

D. J. Green Department of Surgery, University of Arizona Medical Center, Tucson, AZ, USA

However, failure of diagnosis and delay in treatment may lead to signicant patient morbidity. The unique consequence of a penetrating injury to the urinary tract is extravasation of urine with the risk of local and systemic intra- or extraperitoneal subsequent infection.

Fortunately, the urinary tract has an amazing ability to heal itself. If the ow of urine can be maintained without obstruction, then healing of the injury is likely. To examine the integrity of the urinary tract, a wide spectrum of radiologic investigations is available.

22.2 Computerized Tomography

In hemodynamically stable, clinically evaluable patients without peritoneal signs, perform computerized tomography (CT) scan routinely as part of the secondary survey after penetrating trauma to the trunk. A properly performed contrastenhanced CT scan of the abdomen and pelvis is highly sensitive to detect vascular and parenchymal injuries of the kidneys as well as proximal urine leaks and urinomas (Fig.22.1). Acquisition of multiple thin overlapping slices provides excellent 2D and 3D visualization of the entire urinary tract and improves its sensitivity in detecting urinary tract lesions.

Initially, an early-phase intravenous contrast CT scan of the abdomen and pelvis is performed. This investigation is highly sensitive in diagnosing parenchymal or vascular injuries to the kidneys as well as in detecting associated injuries (Fig.22.1). To fully evaluate the collection system, a second CT scan is performed, approximately 10min after intravenous contrast injection. This technique is known as CT intravenous pyelography (CT-IVP). These delayed-phase images are highly sensitive in diagnosing parenchymal injuries and proximal urine leaks or urinomas and in conrming bilateral functional renal moieties (Fig.22.2). However, with a low sensitivity of 37% to detect subtle ureteral injuries, small leaks at this location might be missed. Nevertheless, failure of the distal ureter to opacify on a contrast-enhanced CT

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Fig. 22.2 Urinoma (white arrow) detected on IV contrast-enhanced CT scan after a stab wound to the right upper quadrant. The knife went through the right portion of the liver into the right kidney, where it perforated the major collection system

22.3 Pyelography

Fig. 22.1 (a) Grade IV right kidney injury with retroperitoneal hema-

toma (zone II) after multiple gunshot injuries to the back. IV contrastenhanced CT scan of the abdomen is highly sensitive in diagnosing parenchymal injuries to the kidneys as well as in detecting active extravasation and associated intra-abdominal injuries. (b) Early contrast- enhanced abdominal CT scan after stab wound to the left ank. There is no contrast enhancement of the left kidney due to a renal arterial lesion

scan should raise concern of an injury and should lead to further investigations or intraoperative evaluation of the affected ureter.

To further improve the value of the initial CT workup and to save time, a CT cystogram can be easily done simultaneously. CT cystography is equally as sensitive as conventional cystography for the detection of bladder rupture. Immediately before the CT scan, the urinary bladder is gently lled with approximately 350mL of diluted iodine contrast through the urethral catheter. In the absence of a urethral injury, this procedure is safe and provides an accurate visual assessment of the integrity of the bladder. A urethral injury should be suspected in patients with pelvic fractures or penetrating injuries to the perineum. In these cases, you should consider a retrograde urethrogram before placing a urethral catheter.

Pyelography can be performed either as an excretory pyelography or as a retrograde pyelography. With a sensitivity of approximately 30%, excretory pyelography is relatively insensitive for the diagnosis of renal injuries and urine leaks. However, in initially unstable patients, excretory pyelography may be useful to investigate the urinary tract intraoperatively after completion of the damage control procedure (Fig.22.3). In the presence of hematuria or a suspicious penetrating injury tract, a “single shot” excretory IVP is performed intraoperatively. Ten minutes after intravenous injection of 2cm3/kg of contrast, a single abdominal plain lm is taken. This investigation has been shown to obviate renal and ureteral exploration in 32%.

A retrograde pyelography is extremely sensitive in identi- fying ureteral injuries. However, in the emergency setting of patients sustaining abdominal penetrating injury, its value and practicability are limited. As an adjunct to CT-IVP or to conrm and further delineate the extent of a ureteral injury postoperatively, it is very helpful. Additionally, this investigation should be considered when planning further secondary surgical management of urinary tract injuries.

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Fig. 22.3 Intraoperative excretory pyelography with complete proximal ureteral disruption. This intraoperative investigation of the urinary tract was made after completion of the damage control procedure

22.4 Cystography

All patients with abdominal gunshot wounds or pelvic fractures are at risk of having a ruptured bladder. Gross hematuria is very common in case of a bladder injury, occurring in over 95% of cases. Imaging of the bladder using only excreted contrast material by CT scan or by conventional radiography is not adequate and has been shown to result in false-negative studies. The only denitive study to rule out a ruptured bladder is a retrograde static cystogram. The bladder is gently lled with approximately 350 mL of diluted iodine contrast through a urethral catheter. After that, an extravasation of contrast is captured by conventional plain lm or, as described previously, by CT scan. In patients with a suspected urethral injury, a retrograde urethrogram should be considered before placing a urethral catheter. If a urethral rupture is found, the bladder is lled through a suprapubic tube.

22.5 Retrograde Urethrogram

The most common clinical nding in patients with urethral injuries are gross hematuria or blood at the meatus. Retrograde injection of contrast medium into the urethra is safe and has a high sensitivity for making the diagnosis of urethral rupture (Fig.22.4). Multiple techniques have been described in the literature. We have had good results by inserting a 14-Fr Foley catheter at the meatus for about 3–4 cm to the fossa navicularis where the balloon is then gently inated with 2–3 cm3 of sterile water. A Toomey

Fig. 22.4 Retrograde urethrography. Large extravasation of contrast into the extraperitoneum including scrotum without lling of the bladder indicates a complete disruption of the urethra. The distended bladder is lled with excreted contrast material from the previous IV-enhanced CT scan

syringe is then used to administer 30–40cm3 of water- soluble contrast, and a plain conventional lm is obtained, while the last 10cm3 is instilled. A large extravasation without lling of the bladder indicates a complete disruption, whereas partial lling of the bladder with some extravasation is indicative of partial disruption of the urethra. If there is no extravasation, the catheter should be advanced into the bladder, and a cystogram should be added.

Important Points

• Penetrating injuries to the abdomen, ank, pelvis, and

perineum involve the urinary tract in up to 20%.

• Hematuria may be absent even in signicant upper uri-

nary tract injury.

• The diagnostic procedure and treatment of penetrating

urologic trauma clearly depends on the hemodynamic sta-

tus and associated injuries of the patient.

• In patients with suspected urethral injury, a retrograde

urethrogram should be considered before placing a ure-

thral catheter.

• By adding a CT-IVP and a retrograde CT cystogram, the

initial CT workup can be improved and accelerated

signicantly.

• In initially unstable patients, intraoperative excretory

pyelography is useful to investigate the urinary tract and

may obviate unnecessary renal and ureteral surgical

exploration.

• A retrograde pyelography is time-consuming but

extremely sensitive in identifying ureteral injuries in the

tertiary survey of the patient.

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