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B. I. Shaw and S. Agarwal
54.8 Nephrectomy
When the kidney is shattered or in the context of damage
control laparotomy, nephrectomy may be inevitable. Perform
ligation of the renal artery rst with long-lasting absorbable
suture. Double suture ligation is necessary only in the presence of severe atherosclerosis. Follow with ligation of the
renal vein. Complete renal isolation by ligating the ureter in
two places close to the bladder.
54.9 Ureteral Repair
A high index of suspicion is required to diagnose ureteral
injury. Although CT scan, IVP, or retrograde pyelography
may diagnose this injury, intraoperative diagnosis via direct
inspection with or without intravenous or intra-ureteral
injection of indigo carmine or methylene blue to conrm
the integrity of the collecting system may be required to
diagnose ureteral disruption. Ureteral blast injury from
nearby intra-abdominal gunshot is more difcult to diagnose because the delayed necrosis that occurs as a result of
intimal disruption is often not apparent immediately,
although sometimes this may appear as bruising on the ureteral wall.
Immediate repair is needed when ureteral injury or devascularization is identied. Debride nonviable tissue to healthy
bleeding tissue and perform a watertight tension-free repair.
During damage control laparotomy, tying off the injured ureteral segment with a long silk suture is preferred until the
patient is stable enough for delayed ureteral reconstruction,
usually several months later. Urinary diversion via percutaneous nephrostomy drain can be undertaken postoperatively.
Alternatively, drainage of the proximal end of the disrupted
ureter with a ureteral stent or pediatric feeding tube brought
out through the skin with spatulated ureteral edges sewn to
skin, forming a stoma, is another option.
Partial ureteral transection may be closed primarily
with interrupted 4-0 or 5-0 absorbable monofilament
suture (PDS), unless the injury is caused by gunshot, in
which case more extensive debridement plus ureteroureterostomy is recommended. Handling of the ureters during mobilization should always be minimized as blood
supply is easily disrupted. Approximate the lumen with
absorbable 4-0 or 5-0 monofilament suture and place a
double-J stent when the defect is greater than 50% of the
lumen and complete the repair with interrupted sutures as
above. Remove the stent after 6weeks. A guidewire will
facilitate stent placement when placed through a side
hole of the double-J stent, directing one end of the stent
upward to the renal pelvis and the other end to the bladder. Use an omental flap to isolate the segment if the
repair is tenuous or if significant contamination is present in the peritoneal cavity. A retroperitoneal gravity
drain is strongly encouraged as it will permit early diagnosis of urinary leakage should it occur and will help
small anastomotic gaps heal.
Regardless of type of ureteral repair, bladder decompression should be continued for 7days after repair with a contrast cystography prior to removal and the double-J stent
should be removed 4–6weeks after repair.
54.10 Ureteroureterostomy
Middle and upper ureteral injuries are best repaired with ureteroureterostomy. Mobilization of proximal and distal segments should be performed gingerly to avoid disrupting
vascular supply that runs along the ureter originating from
the renal vessels or superior vesicular vessels. As above,
debride nonviable tissue to healthy bleeding tissue and spatulate the ends. Tack the pieces of each spatulation through
the opposite ureter with 4-0 or 5-0 absorbable suture, ensuring that knots are exterior. Clamps applied to the tails of
these sutures will help stabilize the eld to minimize handling. Insert a double-J stent and complete the anastomosis
with interrupted 4-0 or 5-0 absorbable suture, anterior side
rst and posterior side second (Fig.54.4). Consider an omental ap if contamination is high or infection likely. Drain retroperitoneally without suction.
If a tension-free anastomosis cannot be achieved through
direct re-approximation of proximal and distal segments,
then end-to-side transureteroureterostomy should be considered. The proximal segment of the injured ureter can be
brought through the mesentery either above or below the
IMA (depending on degree of loss), being mindful of the
potential for ureteral devascularization. Spatulate the end of
the mobilized ureter before incising the contralateral ureter
with a 2cm longitudinal medial ureterotomy. Tack the pieces
of the spatulated end to the inferior and superior poles of the
ureterotomy with a 4-0 or 5-0 absorbable suture. Start the
stitch from the ureterotomy, and then bring through the spatulated end. Insert a double-J stent and close the anastomosis
with 4-0 or 5-0 absorbable interrupted suture. Apply an
omental ap as needed and always insert a retroperitoneal
drain.
ab
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Fig. 54.4 In ureteroureterostomy, insert a double-J stent (a, b) and
complete the anastomosis with interrupted 4-0 or 5-0 absorbable suture,
anterior side rst and posterior side second (a). The renal artery is typically reimplanted end to end to the hypogastric artery or end to side to
the external or common iliac artery. Depending on the available anatomy, the end-to-end operation is usually performed in the contralateral
iliac fossa, whereas the ipsilateral iliac fossa is used for end-to-side
54.11 Ureteroneocystostomy
operations. The iliac fossa should be exposed by reecting the peritoneum superiorly and medially so that the common iliac artery and bladder can be visualized. A self-retaining ring retractor will help maintain
exposure; however, retractor blades must be placed with caution to the
lateral femoral cutaneous nerve and inferior common iliac artery.
Lymphatic tissue must be meticulously ligated to avoid postoperative
lymphocele, because this region is rich in lymphatic channels
an internal stent (Fig.54.5). Perform an antireux procedure
at ureterocystostomy with 4-0 nonabsorbable monolament.
Distal ureteral injuries in the stable patient are best repaired
with ureteroneocystostomy. Debride the proximal ureteral
end to healthy, bleeding tissue and spatulate the end. A tunnel should be created for its insertion superior and medial to
the original distal ureteral opening at a length of three times
the ureteral diameter. Anastomose the ureter to the interior
aspect of the bladder using 5-0 absorbable sutures and place
Ligation of the original distal ureteral stump is needed only
if reux is suspected.
Other alternatives to achieve a tension-free anastomosis
include ureteral reimplantation with psoas hitch and the Boari
ap, both of which can provide additional distal length when
needed. Both are beyond the scope of this discussion and are
well described in the texts referenced at the end of this chapter.
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Fig. 54.5 In ureterocystostomy, anastomose the
tunneled ureter to the interior
aspect of the bladder using
5-0 absorbable sutures and
place an internal stent (a–c)
B. I. Shaw and S. Agarwal
a
b
c
54.12 Autotransplantation
Renal autotransplantation is rarely the best option for the
renal trauma patient, but in instances of a damaged solitary
kidney or renal artery or collecting system avulsion in the
setting of damage control surgery, renal autotransplantation
may potentially save the patient from a lifetime of dialysis or
allograft. Once the choice has been made to proceed with
autotransplantation, the kidney should be removed rapidly
with minimal surgical manipulation. Maximize length of
renal vessels and ureter. The removed kidney should be
ushed immediately with cold intracellular electrolyte solution (500mL of Collins or University of Wisconsin solution)
intra-arterially and submerged in a basin of ice slush saline
solution until transfer to an appropriate cooler if the transplant will take place at another operation.
Dissect the external iliac vein carefully from its origin to
the femoral junction. Place vascular clamps proximally and
distally on the external iliac vein and complete a narrow elliptical venotomy on the vein’s anterolateral aspect. If the hypogastric artery is to receive the renal artery, it should be occluded
proximally and ligated and divided distally. If the external iliac
artery or common iliac artery is to be used, occlude the common iliac, external iliac, and hypogastric arteries with vascular
clamps before making the arteriotomy. Inject heparin into the
recipient vessels and bring the autotransplant into the eld.
The end-to-side venous anastomosis is performed rst
using continuous 5-0 vascular suture. The arterial anastomosis is performed second using interrupted 6-0 vascular suture.
At this point, the vascular clamps should be removed to
assess for leaks and repairs performed as needed.
Finally the ureteroneocystostomy should be performed.
Using the shortest possible length of ureter to avoid kinking
and ischemia, spatulate the distal end of the donor ureter.
Make a 3cm incision at the posterolateral aspect of the bladder and incise down to expose the mucosa. Undermine the
muscular layer of the bladder slightly and make a small
opening into the bladder mucosa at the inferior pole of the
incision. Complete a mucosa-to-mucosa anastomosis
between the ureter and bladder using 4-0 chromic sutures
(continuous or interrupted). The distal-most end of the anastomosis should be anchored through the full thickness of the
bladder wall. The 3-0 chromic sutures are then used to close
the bladder muscle over the ureter.
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54.13 Bladder Repair
While bladder injury is most commonly caused by blunt
trauma, 14–35% is due to penetrating trauma. Additionally,
approximately 4% of pelvic fractures have associated bladder injury and around 60% of bladder injuries are extraperitoneal. Extraperitoneal injuries can be managed with catheter
drainage for 2–3weeks with a cystogram prior to removing
the catheter. Contraindications to nonoperative management
include urinary infection, pelvic fractures requiring internal
xation, and bladder neck injury. Repair of intraperitoneal
bladder injuries is usually achieved through primary closure
of the defect and placement of a urethral catheter. A transperitoneal cystotomy should be made to visualize the entire
lumen, as unrecognized extraperitoneal ruptures are not
uncommon and should be repaired at the time of intraperitoneal bladder repair. If bleeding from pelvic hematoma is
encountered, as it frequently is in the context of pelvic fractures, be prepared with sponges and perform suture ligations
as needed.
The ureteral orices should be identied, and after IV
indigo carmine injection, blue urine should be observed
efuxing from each opening. If the injury is close to or
involving the ureteral opening, a ureteral stent should be
placed.
Debridement of damaged bladder tissue is usually minimal in light of its extensive blood supply. The intraperitoneal
bladder injury can be closed with running 3-0 absorbable
suture in the mucosa and running 2-0 absorbable suture in
the muscularis propria. The peritoneum should be closed
with a separate 3-0 running absorbable suture.
54.14 Bladder Neck Repair
Urethral injuries are uncommon in penetrating trauma and
present with blood at the urethral meatus. Catheter placement should be avoided because it can turn an incomplete
injury into a more extensive disruption. Such lesions are
diagnosed with retrograde urethrography, and posterior injuries should be realigned using lower midline incision and
passage of a catheter, whereas anterior injuries should
undergo surgical repair, except in the case of blunt injury
where the extent of injury can be difcult to identify.
Additionally, in stable patients endoscopic alignment is also
often an option for repair. Bladder neck injuries are notoriously difcult to repair, but repair should be attempted to
preserve continence. The injury should be exposed through a
cystotomy at the dome and all tears closed with absorbable
sutures. Placement of Foley catheter and suprapubic tube, as
described above, is recommended. Vaginal and other genital
lacerations, if present, should be repaired at the same time.
54.14.1 Postoperative Management
Patients with renal injuries who are managed nonoperatively
and those with grade IV injuries with urinary extravasation
may need follow-up imaging in 48–72 h to evaluate for
ongoing extravasation, as this could require operative exploration. If a peri-nephric uid collection is drained and tests
are positive for creatinine, the drain should be left in place
until the collection resolves and leak is not demonstrated.
Retroperitoneal drains placed during surgery should not be
placed to suction postoperatively and should be removed
within 48h unless a urine leak is demonstrated.
For urethral injuries Foley catheters should remain in
place for 4–8weeks with a voiding cystourethrogram prior to
removal.
Abdominal and pelvic trauma can cause kidney, ureteral,
urethral, and bladder injuries that, even if recognized and
treated, may result in long-term urologic dysfunction or
renal insufciency. Grade of renal injury by AAST criteria is
predictive of decrease in renal function with grade V injuries
having a sixfold relative risk of needing dialysis compared to
grade I injuries.
Important Points
• On-table one-shot IVP should be used to prove the pres-
ence of two functional kidneys and an intact collecting
system when CT scan is not possible.
• Renal vascular exposure and control should be addressed
rst, occluding vessels only as needed and only for less
than 30min.
• Partial nephrectomy is indicated for polar injuries, renor-
rhaphy for middle kidney injuries, and nephrectomy for
shattered kidneys and unsalvageable vascular injuries.
• During damage control laparotomy, nephrectomy is
appropriate with consideration for delayed autotransplan-
tation if the kidney is salvageable.
• Directly inspect the ureters for injury with a low threshold
for resection and debridement, especially in the context of
intra-abdominal gunshot injury.
• Ureteral ligation with delayed percutaneous nephrostomy
drainage and externalized ureteral stent are acceptable
temporizing measures for ureteral injury during damage
control laparotomy.
• Utilize ureteroureterostomy for proximal and middle ure-
teral injury and ureteroneocystostomy for distal injury.
• Always use a retroperitoneal drain following reconstruc-
tion without suction.
• Always use absorbable sutures in the genitourinary tract.
• Operative repair is standard for intraperitoneal bladder
injury, whereas nonoperative management with catheter
drainage is standard for most extraperitoneal bladder
injuries.
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B. I. Shaw and S. Agarwal
Acknowledgment The current chapter is a revision of the original
chapter written by Charles Acher and Suresh Agarwal in the previous
edition of the book.
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Lower Genitourinary Injuries
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DonaldHannoun andCharlesD.Best
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55.1 Acute Scrotal andTestis Injuries
Trauma to the external genitalia can be separated into blunt
versus penetrating injury. Differentiating between these two
mechanisms will have the immediate benet of facilitating
patient care in the trauma suite. Noting the mechanism of
injury will also help you determine the likelihood of need for
eventual surgery, the potential length of convalescence, and
the possibility of injury to the contralateral testis. Particularly
with penetrating injuries, you should have a high index of
suspicion of injury to the contralateral testicle. It may also
assist in the prediction of future fertility.
Several features of the scrotum and testis make these
structures relatively resilient to trauma. The mobility of the
scrotum allows displacement from an inciting injury, and the
cremasteric reex helps move the testis superiorly upon
scrotal contact. Additionally, the testis has a relatively tough
tunica albuginea, which can help contain a developing hematoma and prevent seminiferous tubule extrusion.
The vast majority (between 75% and 85%) of scrotal/testicular injuries result from blunt trauma and are typically
unilateral. Penetrating injuries to the scrotum are typically
gunshot or stab wounds and are more likely to result in bilateral testicular injury (30%), while only 1.5% of blunt scrotal
injuries are bilateral. A detailed history and physical examination will usually indicate the likely mechanism and underlying injury, often dictating further workup and management.
We will often acquire a testicular ultrasound to determine
whether the testicle itself is injured and assess the contralateral testicle as well. Basic palpation is also a simple but very
helpful aspect of the initial physical exam. Inability to palpate the testis may suggest the presence of testicular rupture
or testicular displacement (often back towards the supercial
D. Hannoun (*) · C. D. Best
Department of Urology and Surgery, USC Institute of Urology,
USC Keck School of Medicine, LAC + USC County Medical
Center, Los Angeles, CA, USA
e-mail: dhannoun@usc.edu; dhannoun@coh.org; cbest@usc.edu
or external inguinal ring) by an expanding scrotal hematoma.
As always, you should always maintain a high index of suspicion for urethral injury, especially with penetrating trauma.
Inability to void and an expanding scrotum with or without
scrotal ecchymosis may suggest urinary extravasation and
should proceed to work-up with a retrograde urethrogram
(RUG) or gentle passage of a urethral catheter.
During the initial evaluation and work-up of scrotal or
testicular injury, you should also take into account the
patient’s clinical status and hemodynamic stability. Lower
genitourinary injuries are not often life-threatening. If the
patient is clinically stable for transfer, a scrotal ultrasound
can help identify the injury (hypoechoic testicular lesions
suggest hematoceles, disruption of the tunica albuginea suggests rupture, lack of blood ow suggests torsion, etc.).
Facilitating these diagnostic studies early in a clinically stable patient allows for early diagnosis.
If the patient is physiologically unstable, then a portable
study can be performed at the bedside in the intensive care
setting. Unfortunately, scrotal ultrasounds can have a high
false-negative rate even in the presence of an experienced
examiner. For this reason, if the index of suspicion for testicular injury is high, which is often the case with penetrating
injuries of the scrotum, explore the patient if noninvasive
diagnostic testing is unavailable or unsafe. Realistically, if
the patient is unstable, the scrotal or testicular injury is low
on the list of priorities.
The management of scrotal/testicular injury will also
often depend on the overall clinical status of the patient. In
the face of multiple medical or surgical comorbidities, the
patient may not be stable enough for transfer to the operative
suite for intervention. Communication between the primary
team and consulting services should dictate the appropriate
plan of action best suited for the patient’s overall
improvement.
In the case of multiple injuries requiring exploration, surgical intervention for scrotal or testicular injury should be as
rapid as clinically possible. Even when the involved testicle is
an isolated injury, we recommend minimizing any delay in
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
E. Degiannis et al. (eds.), Penetrating Trauma, https://doi.org/10.1007/978-3-031-47006-6_55
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D. Hannoun and C. D. Best
repair. Several studies have shown that prompt surgical intervention with testicular rupture, especially if performed within
72 h of the injury, will often prevent superinfection of the
scrotal hematoma, lessen the length of convalescence,
decrease the potential for chronic pain, and may even improve
fertility. Gross etal. reported an improvement in testicular
salvage rate from 32% to 80% if surgical exploration was performed within 3days of the inciting injury, and Jeffrey etal.
and Lupetin etal. went on to show testicular salvage rates of
90% when surgical intervention was performed within 72h.
Surgical intervention is usually performed transscrotally,
with the incision made down the midline raphe of the scrotum
to allow bilateral testicular assessment and management.
Carry down the dissection through the dartos layer to the
Fig. 55.1 (a) Often with
penetrating injuries, the
testicular injury is obvious, as
is seen here where the tunica
albuginea has been disrupted
(arrow). (b) Repair the defect
with a running 4-0 suture,
prolene being the suture of
choice at our institution
a
tunica vaginalis, which may or may not be intact. Bring the
testis, epididymis, and distal spermatic cord onto the eld
and examine closely for any evidence of injury. If the testicular injury is severe and salvage is unlikely, then proceed to an
orchiectomy. Tunica albuginea violation should be apparent
once the testis is delivered from the tunica vaginalis. With
tunica albuginea disruption, you should attempt to debride
any unviable seminiferous tubule tissue. The presence of
active bleeding is a sign that remaining tissue is viable. If
there is any question about testicular viability, an intraoperative Doppler study should be performed to guide further
intervention. Repair the defect with a running 4-0 suture,
prolene being the suture of choice at our institution
(Fig.55.1b). Damage to the vas deferens should be addressed
b
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with ligation and delayed reconstruction. Vasovasostomy is
not a trivial procedure and should not be done in an acute
setting.
You should always anticipate potential postsurgical complications and should pay strict attention to hemostasis prior
to scrotal closure. In the presence of persistent bleeding or an
underlying coagulopathy, place a quarter inch Penrose drain
in the inferior/dependent portion of the scrotum to prevent
accumulation of a postoperative hematoma. The dartos closure is carried out with a running 4-0 Vicryl stitch and the
scrotal skin closure with a running or interrupted 3-0 chromic suture with locking of each suture. Leave the Penrose
drain to gravity drainage into a Kerlix roll, which is held
closely to the scrotum with a scrotal support for comfort and
elevation. Remove the drain 24–48 h postoperatively.
Antibiotics are routinely recommended for 7–10days postoperatively to prevent abscess formation or infections along
the incision line. Apply antibiotic ointment to the suture line
three times a day for 7–10days.
Genital avulsion injuries can be considered another form
of penetrating trauma to the scrotum. These injuries are sustained during rapid deceleration of the body and concomitant
shearing mechanism against the scrotum and perineum, leading to loss of the scrotal skin. In the majority of situations,
you can close the scrotal skin primarily at the time of surgery
with a running chromic suture as previously described after
copious irrigation. Even with up to 60% of the scrotal skin
lost, the skin can still often be closed primarily. Larger
amounts of genital skin loss will necessitate wet-to-dry
dressings postoperatively with delayed grafting. As always,
scrotal avulsion injuries should always be assessed for underlying testicular injury, and you should manage them
appropriately.
55.2 Penile Injury
Penetrating penile injuries are relatively rare and usually
take the form of gunshot and stab wounds. However, one can
also encounter penile avulsion injuries from motor-vehicle
or bicycle accidents as well as the occasional self-mutilating
injuries and animal or human bites. Despite the abovementioned multiple possible mechanisms of penile trauma, signicant penile injuries remain rare secondary to the tough
tunica albuginea covering of the penis. Penetrating penile
injuries may result in a tear of the tunica albuginea encasing
the corpora cavernosa, which allows extravasation of blood
from the corpora into the penile shaft. Because of the penetrating nature of the injury, blood will exit out of the wound
site, typically not extending along fascial lines as with penile
fracture. The penis may swell and have some ecchymosis,
but you usually do not see the so-called “eggplant penis”
appearance in penetrating injuries.
With penetrating injuries to the penis, you should always
suspect compromise of the tunica albuginea. The mechanism
alone will almost always mandate surgical exploration.
However, if the diagnosis is in question, further imaging
studies are available, although with highly variable results
and inter-interpreter variations. Cavernosograms can be performed with injection of contrast material into the corpus
cavernosum, with serial radiographs taken to identify the site
of extravasation. The false-negative rate is unfortunately
very high with this modality, as the tear can be too small to
see, and often the presence of a clot at the tear site will mask
the extravasation. False-positive studies result when the
physiologic egress of contrast through emissary veins is misinterpreted as extravasation. Similarly, penile ultrasound
cannot consistently identify the site of tear unless in the
hands of a very skilled examiner. MRI in the T1 phase,
although more sensitive than cavernosography and ultrasound, has a limited role secondary to the time required, the
difculty with transportation, and the frequent clinical instability of the patient. These studies have no role in signicant
penetrating injuries. They have value in cases of penile fracture, when there is an atypical presentation. You should
always suspect underlying urethral injury with any penetrating penile trauma. If the patient has not spontaneously voided
clear urine or has hematuria, either gross or microscopic, an
RUG should be performed prior to surgical exploration to
assess for urethral injury.
Tunical violation injuries of the penis should ideally be
surgically corrected within 36 h of sustaining the injury.
Exploration is mandatory to prevent the sequelae of infected
hematomas, impotence, and penile curvature that may result
without prompt operative intervention. Again, other more
life-threatening injuries should be identied and addressed
rst.
Once the patient has reached the operative suite, the
appropriate area is prepped and draped in standard sterile
fashion. Insert a urethral catheter at the beginning to ensure
ease of passage into the bladder. You can then use this catheter for the retrograde instillation of saline/dye during the
procedure to evaluate for any urethral discontinuity. First
make a circumferential (“degloving”) incision, which allows
access to the length of the corpora cavernosa and spongiosum. Place a tourniquet at the base of the penis as it can aid
with hemostasis and dissection (Fig.55.2a). Carry out evacuation of the hematoma, and localize the site of tunical violation after you dissect free Buck’s fascia. Once you have
identied the defect, debride the wound edges and do copious irrigation, particularly important with gunshot injuries or
bites. Carry on primary closure of the defect with 4-0 prolene
suture in a gure-of-eight fashion. We prefer to do this with
the knots buried to decrease the chance of the patient potentially feeling the suture under the thin penile skin (Fig.55.2b).
Avoid any signicant length of running suture, as any cinch-
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D. Hannoun and C. D. Best
Fig. 55.2 (a) Place a
tourniquet at the base of the
penis as it can aid with
hemostasis and dissection. (b)
Debride the wound edges and
do copious irrigation,
particularly important with
gunshot injuries or bites.
Carry on primary closure of
the defect with 4-0 prolene
suture in a gure-of-eight
fashion, and avoid any
signicant length of running
suture, as any cinching of the
tissue may result in penile
curvature. In this gure, a
corporal injury is present with
the bullet visible (arrow)
a
b
Dorsal
neurovascular
bundle
ing of the tissue may result in penile curvature. If there has
been any rupture of the tunica albuginea close to 1cm or
larger, perform an articial erection after the repair. This is
necessary to determine if any curvature has resulted from the
repair. Do this by applying a tourniquet at the base of the
penis and injecting one of the cavernosal bodies, via a buttery needle, with normal saline until appropriate turgor is
achieved. If there is any notable curvature, a plication of the
tunica on the opposite side of the defect may be necessary.
Repair any urethral injuries over a urethral catheter as mentioned in the chapter section to follow. After you have reapproximated the skin, place a compressive dressing and
remove it the evening of surgery or the following morning.
Leave the catheter in place until the following morning
unless a urethroplasty is performed. Administer antibiotics
for 7–10days following the repair to prevent penile abscess
development.
Surgical exploration may be unnecessary if the penetrating penile injury fails to result in tunical violation. Relatively
small penile tears can be locally irrigated, debrided, and
repaired with simple, interrupted closure and an absorbable
2-0 or 3-0 suture. With larger defects, initially perform local
irrigation and debridement. Evaluate the wounds later for
either primary closure with reapproximation or reconstruction with delayed grafting. These wounds are frequently contaminated, and all patients should be placed on a 10-day
55 Lower Genitourinary Injuries
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antibiotic course with an antibiotic that provides adequate
coverage of typical skin ora, such as cephalexin. For
penicillin- allergic patients, you can use chloramphenicol.
Penile amputation injuries can be accidental or selfinicted. The timing of the incident and the presence and
handling of the severed penis are crucial to the initial management. The severed penis should be wrapped with salinesoaked gauze, placed into a sterile bag (if possible), and
immediately placed in ice water. The ice should never be in
direct contact with the penis to prevent necrosis. If possible,
the amputated penis should be reimplanted within 24h of the
injury. Transfer to a tertiary medical center is usually required
for the expertise of microvascular anastomoses that is often
necessary. After appropriate medical and psychosocial issues
have been addressed and other more life-threatening injuries
have been ruled out, the patient is taken to the operating
room immediately for reimplantation. It is extremely important to have an experienced team of urologists, plastic surgeons, and OR staff in order to have a good result. Of primary
importance is the cavernosal and spongiosum/urethral
reanastomoses. A urethral catheter is inserted prior to the
urethral anastomosis. Microsurgical techniques can be used
to reapproximate the dorsal arteries and nerve of the penis to
improve the recovery of postoperative perfusion and sensation, respectively. Next, the tunica should be reconstructed.
Finally, the debrided skin should be sewn together, much like
any other supercial anastomosis. It is not unusual to have
delayed sloughing of the penile skin. This does not necessarily imply that the reimplant as a whole has not survived.
Delayed skin grafting may be all that is necessary. If the severed penis is not available, then overclosure of the corpus
cavernosum with advancement of the urethral stump can be
performed to allow voiding while standing. An inadequate
distal urethral remnant may obviate the need for perineal
urethrostomy with delayed genital reconstruction pending
complete psychosocial evaluation.
55.3 Urethral Injury
As with other traumatic genitourinary injuries, the mechanism of urethral injury can be divided into blunt versus penetrating. Urethral injuries can be further subdivided into
posterior (prostatic/membranous urethra) and anterior (bulbar/pendulous urethra) in location. These subdivisions not
only classify the location of the injury but also dictate further
management. Penetrating anterior and posterior urethral
injuries are usually secondary to gunshot and stab wounds.
These injuries are much more prevalent in males than females
owing to the shorter urethral length, greater urethral mobility, and lesser pubourethral attachments in females.
The diagnosis of urethral injury would ideally be elicited
from a detailed history and physical examination. For obvi-
ous reasons, this is not always the case. Often, the urologic
team becomes involved after prior failed attempts have
already been made in the emergency department (ED) to
place a urethral catheter. This often culminates in improper
catheter placement with possible conversion of a partial urethral tear to a full and circumferential urethral tear. We try to
emphasize not attempting blind urethral catheterization if
there is any suspicion of urethral injury. The mechanism of
injury should prompt the initial suspicion for urethral injury.
Failure to void since the incident or suprapubic fullness/distention should be assumed to represent urethral injury until
proven otherwise. Gunshot wounds with either an entrance
or exit from the perineum or penis should alert any diagnostician to a possible urethral injury.
The classical nding of a urethral injury on examination
is the presence of blood at the meatus, though its presence is
not denitive evidence and its absence is not exclusionary.
Severe or expanding scrotal swelling, with or without ecchymosis, may also suggest urinary extravasation. Perineal
hematomas, which can take on the classic “buttery” hematoma pattern, should also alert the clinician for further urethral workup. Hematoma along the entire penile shaft
(so-called sleeve hematoma) can be secondary to penile, urethral, or testicular injury.
With any of the aforementioned history or physical examination ndings (suspected mechanism of injury, penetrating
injury, blood at the meatus, and scrotal/perineal hematoma),
one should proceed with a retrograde urethrogram (RUG) or
attempt gentle catheter placement. The RUG can be performed in several ways and can be done either in a formal
radiology suite with the combination of uoroscopy, in the
ED, operating room, or at the bedside. A 12–14 Fr catheter
can be inserted just into the fossa navicularis, with only
1–2cm3 instilled into the balloon to tamponade the urethra
and prevent the antegrade leakage of contrast. Next, inject
about 15–20cm3 of contrast, with the radiograph being performed at the end of the injection to ensure adequate urethral
distention. Alternatively, the aforementioned procedure can
be performed with a 60cm3 catheter tip syringe (lled with
contrast) inserted very gently into the urethra until a snug t
is obtained. At our institution, the RUG is performed by placing the patient in a slightly lateral (about 30–45°) decubitus
position. The penis is appropriately sterilized with a Betadine
preparation and sterile draping placed underneath the penis.
Next, about 20cm of a small Kerlix roll is cut, soaked with
water/saline, and then tied to the subcoronal position of the
penis with a simple tie. This maneuver will allow penile traction during contrast instillation to help delineate the entire
urethra, as well as appropriately shield the examiner’s hands/
body from the radiation eld. A separate catheter tip is then
lubricated and placed on a 60cm3 Luer-Lok syringe prelled
with contrast, and the injection is performed. The radiograph
is taken after 20cm3 of contrast has been instilled. Urethral
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