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Urology Trauma & Fistulae

A 77-year-old man has a retracted stoma and clear fluid leaking from his midline incision three weeks after radical cystectomy and ileal conduit diversion. Three images from a CT loopogram are shown. The next step is percutaneous pelvic drainage and:

A) stomal catheter.
B) loop endoscopy, fulguration.
C) fascial repair.
D) stomal revision.
E) exploration, repair of leak. $&$ A
( stomal catheter. A delayed urinary leak following urinary reconstruction should lead the clinician to suspect tissue ischemia/necrosis. In these cases, the leak is unlikely to resolve with observation alone. Fascial repair is unnecessary unless signs of dehiscence are present. Maximal drainage of the reconstructed segment is essential in order to minimize the output of the leak. In this case, the CT image demonstrates leakage from the proximal end of the conduit. Given the presence of stomal retraction, catheter drainage of the conduit may decompress the leak. Given the pooling of contrast in the pelvis, a percutaneous drain is also advisable in order to control the fistula, minimize the risk of local abscess, and to protect the fascia from further dehiscence. While this patient may ultimately require stomal revision, it would not be advisable until determining if the leak will heal with conservative therapy. Early exploration and repair is difficult given the intense local inflammatory reaction, and it is likely to result in a high risk of treatment failure given the condition of the local tissues.Gitlin J, Taneja SS: Complications of Conduit Urinary Diversion, in Taneja SS, Smith RB, Ehrlich RM {eds}: COMPLICATIONS OF UROLOGIC SURGERY: PREVENTION AND MANAGEMENT. Philadelphia, WB Saunders Co, 2001, p 449. 2012 Adult Trauma & Fistulae )

A 45-year-old man has left flank pain four hours after a MVC. Physical examination is normal. His blood pressure is 110/60 mmHg, pulse is 80 bpm, and urinalysis demonstrates 5 RBC/hpf. The next step is:

A) cystogram.
B) CT scan.
C) renal ultrasound.
D) isotope renography.
E) observation. $&$ E
( observation. Most patients with blunt trauma and microscopic hematuria do not need imaging. The SIU Consensus Statement on Renal Injuries recommends imaging to detect blunt trauma only in selected patients. Adults with gross hematuria or microhematuria and hypotension have a major {e.g. Grades 3,4,5} injury rate of approximately 12.5% and thus warrant further imaging. These recommendations were derived from a number of studies including the seminal article by McAninch and associates in 1989. A review of 2,254 patients with suspected renal trauma seen from 1977 to 1992 was performed by McAninch and colleagues. Of the 1,588 blunt trauma patients with microscopic hematuria and no shock, three had significant injury but these cases were discovered during imaging or exploratory laparotomy for associated injury. Follow-up of 515 of 1,004 patients {51%} who did not undergo initial imaging revealed no significant complications. Adults with blunt renal trauma, microscopic hematuria and no shock {systolic pressure < 90 mm/Hg} or major associated intra-abdominal injuries can safely be spared radiographic imaging.Miller KS, McAninch JW: Radiographic assessment of renal trauma: Our 15 year experience. J UROL 1995;154:352-355.Santucci RA, Wessells H, Bartsch G, et al: Evaluation and management of renal injuries: Consensus statement of the renal trauma subcommittee. BJU INT 2004;93:937-954. 2012 Adult Trauma & Fistulae )

A 60-year-old man sustains an avulsion injury of the scrotum. Ninety percent of the scrotal skin is lost. The next step after one week of debridement and local wound care is:

A) rotational thigh skin flap.
B) full thickness skin graft.
C) placement of testicles in thigh pouches.
D) split thickness skin graft.
E) scrotal skin mobilization and direct closure. $&$ D
( split thickness skin graft. Scrotal reconstruction can be performed in many ways depending on the characteristics of the patient, mechanism of injury, and degree of skin loss. Limited skin loss can be managed with mobilization of remaining scrotal skin and direct closure as the scrotal skin is very pliable and will expand to cover relatively large defects. In this case a 90% loss makes this option impossible. More extensive skin loss can be managed with skin grafts, local flaps or tissue expanders. Rotational flaps provide a sensate and hair bearing scrotum but require more extensive dissection and have been generally supplanted by skin grafting. Full thickness skin grafts are reserved for selected cases where small surface areas are required and contraction is especially problematic, but not useful in this case due to 90% scrotal loss. Thigh pouches are acceptable but generally temporizing measures except in the most debilitated patients. Reconstruction is most easily accomplished with the use of split-thickness skin grafts which can cover large areas of skin loss and provide for complete scrotal reconstruction. Advantages of split thickness skin grafts include their high success rate and the fact that, when healed, they mimic the rugate appearance of the normal scrotal skin. Disadvantages include lack of hair and the fact that they may retract. Retraction can be minimized by avoiding expansion of the graft {i.e. 2:1 or 3:1 meshing}. Skin grafts should never be placed on an acute injury due to bacterial contamination that will usually result in graft loss. Delayed grafting five to seven days post-injury in the presence of a clean graft bed will result in increased graft take. Gomez R: Genital skin loss. PROB IN UROL 1994;8:290-301. Wessells H, Long L: Penile and genital injuries. UROL CLIN N AM 2006;33:117-126. 2012 Adult Trauma & Fistulae )

A 60-year-old healthy woman with recurrent UTIs has free air in the bladder and a thickened bladder wall adjacent to a loop of thickened colon see on CT scan. Cystoscopy demonstrates erythema in the bladder wall with no clear fistula. The next step is:

A) antibiotic prophylaxis.
B) high pressure cystogram.
C) CT scan with small bowel follow through.
D) MRI scan.
E) general surgery consult/exploratory laparotomy. $&$ E
( general surgery consult/exploratory laparotomy. Cross-sectional imaging, especially CT scan, has become the imaging modality of choice to demonstrate a vesicoenteric fistula. CT or MRI scans may localize the fistula track as well as the involved segment of bowel. The triad of findings on CT that are suggestive of colovesical fistula consists of {1} bladder wall thickening adjacent to a loop of thickened colon, {2} air in the bladder {in the absence of previous lower urinary tract manipulation}, and {3} presence of colonic diverticula. Cystoscopy has the highest yield in identifying a potential lesion, with some type of abnormality noted on endoscopic examination in more than 90% of cases. However, the findings on cystoscopy are often nonspecific and include localized erythema and papillary or bullous change; a definitive diagnosis by cystoscopy can be made in only 35% to 46% of cases. This patient has clear evidence of a vesicoenteric fistula and further diagnostic studies are not indicated. Should she be a poor surgical risk, long-term antibiotics could be used. Definitive colonic resection of presumed diverticulosis and repair of fistula should occur with exploratory laparotomy. General surgery may wish to proceed with colonoscopy/barium enema to evaluate the extent of the affected segment or rule-out malignancy. Rovner ES: Urinary tract fistula, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 3, chap 72, pp 2351-2352. 2012 Adult Trauma & Fistulae )

A 67-year-old woman is undergoing surgery for repair of a post-hysterectomy vesicovaginal fistula located above the trigone with communication to the vaginal vault. A vaginal repair is selected. The best flap to interpose is:

A) peritoneal.
B) omental.
C) Martius.
D) labial myocutaneous.
E) gracilis. $&$ A
( peritoneal. During a vaginal approach to a high riding post-hysterectomy fistula, a peritoneal flap is preferred. It is relatively easy to raise a well vascularized flap of peritoneum in this location. A Martius flap would be very difficult to mobilize to that location in the vagina without compromising the blood supply. An omental flap is occasionally useful from a vaginal approach if it had previously been secured in the pelvis from prior surgeries. A gracilis flap can be utilized but is typically not necessary for vesicovaginal fistulae. A labial myocutaneous flap can be utilized particularly if there is significant foreshortening of the vagina or loss of vaginal mucosa.Rovner ES: Urinary tract fistula, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 3, chap 72, pp 2339-2341. 2012 Adult Trauma & Fistulae )

After traumatic renal injury, the predictors of persistent bleeding are depth of parenchymal injury, presence of arterial blush, and:

A) urinary extravasation.
B) devitalized fragment.
C) thickness of hematoma.
D) location of laceration.
E) mechanism of injury. $&$ C
( thickness of hematoma. After renal trauma, the likelihood of renal exploration, renorraphy, and nephrectomy is associated with the grade of injury. For example, Grade 4 injuries have a 64 fold higher likelihood of needing nephrectomy than a Grade 1 injury. New literature shows that for grade 3 and 4 injuries, medial hematoma, hematoma > 3.5 cm in thickness and the presence of a vascular contrast blush are associated with increased risk of bleeding and need for intervention. The presence of such findings should alert the urologist to the potential need for angiography and selective embolization of segmental vascular injuries. While urinary extravasation and devitalized fragments increase the risk of urinoma formation, they are not associated with higher rates of bleeding. Neither location of laceration or mechanism of injury predict complications independent of grade. Dugi DD III, Morey AF, Gupta A, et al: American Association for the Surgery of Trauma grade 4 renal injury substratification into grades 4a {low risk} and 4b {high risk}. J UROL 2010;183:592-597. 2012 Adult Trauma & Fistulae )

A 25-year-old man is struck by an automobile. He has a left superior and inferior pubic ramus fracture as well as a fracture of the sacroiliac joint. He has a palpable bladder. No blood is noted at the meatus and the prostate is in normal position on DRE. The next step is:

A) CT urogram.
B) retrograde urethrogram.
C) cystogram.
D) abdominal ultrasound.
E) suprapubic tube. $&$ B
( retrograde urethrogram. The most likely genitourinary injury in this patient is a prostatomembranous urethral disruption, as suggested by the type of pelvic fracture. Fractures of the pubic rami, in particular the medial inferior ramus, and pubic diastasis are independent predictors of urethral injuries. In most patients, in the absence of blood at the urethral meatus, catheterization is appropriate as the first step. However, in a high risk patient with a palpable bladder and inferior ramus fracture, a urethrogram is the easiest, most specific, and most rapid way to assess urethral injury. Upper tract imaging is not indicated in patients with pelvic fracture. Cystography may be indicated, but not before the urethra has been determined either by retrograde urethrogram or catheterization, to be intact. CT urogram is not a sensitive or specific test for urethral injury. Abdominal ultrasound may demonstrate intraperitoneal fluid but is unlikely to detect injuries to the urethra. Suprapubic cystostomy is not indicated prior to evaluation of the urethra. A gentle attempt at urethral catheterization may be appropriate prior to imaging in the unstable patient.Basta AM, Blackmore CC, Wessells H: Predicting urethral injury from pelvic fracture patterns in male patients with blunt trauma. J UROL 2007;177:571-575. 2012 Adult Trauma & Fistulae )

A 26-year-old man had blunt abdominal trauma. An abdominal CT scan revealed a deep renal laceration and urinary extravasation. After ten days of expectant management, a repeat CT scan reveals persistent urinary extravasation with a small urinoma. He remains stable and afebrile. The next step is:

A) continued observation.
B) insertion of a ureteral stent.
C) percutaneous perinephric drainage.
D) percutaneous nephrostomy drainage.
E) surgical exploration and repair. $&$ B
( insertion of a ureteral stent. Patients with blunt injuries of the kidney have been managed successfully with observation alone even when there is evidence of urinary extravasation and preliminary imaging studies. Extravasation resolves in approximately 85% of renal injuries without the need for internal or external drainage. However, patients with persistent extravasation should be managed with optimized drainage of urine with an internal ureteral stent. This may require additional decompression of the bladder to allow complete closure of the injury to the collecting system. Percutaneous nephrostomy tube placement may be difficult in a patient without hydronephrosis and percutaneous perinephric drainage is not necessary unless there is evidence of infection or large urinoma formation. Surgical exploration and repair is excessively invasive; ten days after injury such an exploration may increase the likelihood of nephrectomy due to the difficulty of renorrhaphy in the face of significant perinephric reaction to urine leakage. Matthews LA, Spirnak JP: The non-operative approach to major blunt renal trauma. SEM UROL 1995;13:77-82.Alsikafi NF, McAninch JW, Elliott SP, Garcia M: Nonoperative management outcomes of isolated urinary extravasation following renal lacerations due to external trauma. J UROL 2006;176:2494-2497. 2012 Adult Trauma & Fistulae )

A 37-year-old man sustains a high velocity pelvic gunshot wound with no obvious ureteral injury at exploration. Two days later, during a scheduled second look operation the distal ureter appears contused. There is no extravasation of I.V. indigo carmine. The next step is:

A) continued observation.
B) cystoscopy and ureteral stent.
C) percutaneous nephrostomy.
D) ureteroneocystostomy.
E) debridement and ureteroureterostomy. $&$ B
( cystoscopy and ureteral stent. Blast injury represents a complex set of events resulting in direct or indirect soft tissue damage. The initial blast can cause tissue damage, and propelled fragments can cause penetrating injuries. Falling objects or impact from blast displacing the victim's body against a stationary object usually cause blunt injuries but could also cause penetrating injuries. Additionally, victims often suffer burns from the heat discharged by the explosive device or by fire ignited by the blast. Gunshot wounds represent localized tissue damage similar to the initial blast described above. The degree of injury reflects the weapon, bullet, and distance from the projectile to the affected organ. Bullet velocity has the greatest effect on soft tissue damage; whether bullet velocity reflects tissue damage precisely is controversial. However, high-velocity weapons clearly cause extensive soft tissue damage. The greater the bullet velocity, the larger the temporary cavity created, indicating the extent of soft tissue stretch and destruction The progressive changes seen on day one post injury suggest an evolving blast injury. Minor ureteral contusions from penetrating mechanisms can be treated with stent placement. Caution must be exercised, however, as minor-appearing ureteral contusions may stricture later or break down secondary to unappreciated microvascular damage to the ureter. Thus, in this case, stenting is the next step because a more severe injury is not evident. When tissue damage appears more significant the injured portion of the ureter should be débrided and ureteroureterostomy used to repair the injury. Exceptions to this are the pelvic ureter, for which reimplantation is preferred over ureteroureterostomy due to the poor blood supply to the distal ureter. Although percutaneous nephrostomy is useful in establishing proximal diversion of urine, it is probably not yet indicated in this case; furthermore, stenting across the injured segment is strongly recommended to reduce the risk of complete obliteration.McAninch W, Santucci RA: Renal and ureteral trauma, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 2, chap 39, p 1274. 2012 Adult Trauma & Fistulae )

A 22-year-old man involved in an MVC is evaluated for multi-system trauma. CT scan shows complete enhancement of both kidneys, a 2 cm laceration in the lower pole of the left kidney, and a left perinephric hematoma. A 3 cm splenic laceration that does not extend to the hilum is also seen. He is managed with observation. Ten days later, he develops acute abdominal pain. On physical examination, he is diaphoretic and has a rigid abdomen. His temperature is 38.5%b0C, pulse 120/min, and blood pressure is 90/70 mm Hg. This clinical condition is most likely due to:

A) delayed sepsis.
B) persistent urinary extravasation.
C) delayed renal hemorrhage.
D) delayed splenic hemorrhage.
E) missed bowel injury. $&$ D
( delayed splenic hemorrhage. Associated organ injury is common in patients with renal trauma. Nonrenal trauma accounts for the majority of the morbidity and mortality that occurs in such patients. As in the case described, CT allows staging of renal injury and detection of associated organ injury. Nonoperative management of both splenic and renal injury is possible in selected patients with renal injuries associated with limited extravasation and bleeding. Development of delayed bleeding, infection, or hypertension {related to the renal injury} is unlikely. Those cases where there are nonviable renal segments are more likely to require delayed laparotomy. Although splenic lacerations may be managed nonoperatively, up to 40% of those with Type II injuries {splenic laceration not extending to hilum} may require operative intervention. Although either injury described in the case presented may require delayed laparotomy, the splenic injury is more likely. The finding of the rigid abdomen suggests an intraperitoneal process. A missed bowel injury would present within the first several days after injury.Harbrecht BG, Franklin GA, Miller FB, Richardson JD: Is splenectomy after trauma an endangered species? AM SUR 2008;74:410-412.McAninch W, Santucci RA: Renal and ureteral trauma, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 2, chap 39, p 1282. 2011 Adult Trauma & Fistulae )

A 30-year-old woman sustains a complete transection of the left ureter at the level of L5 during removal of a large ovarian cyst. Preoperative CT scan was within normal limits. The most appropriate treatment is:

A) transureteroureterostomy.
B) ureteroureterostomy.
C) nephrostomy and delayed ureteral repair.
D) psoas hitch and ureteroneocystostomy.
E) Boari flap and ureteroneocystostomy. $&$ B
( ureteroureterostomy. Hysterectomy is responsible for the majority {54%} of surgical ureteral injuries. Next most common was colorectal surgery {14%}, followed by pelvic surgery such as ovarian tumor removal and transabdominal urethropexy {8%}, followed lastly by abdominal vascular surgery {6%}. Ureteroureterostomy, or so-called end-to-end repair, is used in injuries to the upper two thirds of the ureter. It is required commonly, up to 32% of the time in large series. Simple transection of the ureter at the L5 level can be easily managed by spatulating each end of the ureter and performing an elliptical anastomosis over a stent. Transureteroureterostomy could potentially compromise the contralateral ureter. In the absence of life threatening bleeding or other traumatic injuries, injuries recognized intraoperatively should be repaired immediately; delayed repair is thus inappropriate. Psoas hitch should be reserved for defects of the distal ureter; Boari flaps are only necessary when larger defects of the distal and mid ureter preclude simpler reconstructive approaches.McAninch W, Santucci RA: Renal and ureteral trauma, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 2, chap 39, p 1278. 2011 Adult Trauma & Fistulae )

A 63-year-old man has a temperature of 39%b0C and fecaluria eight days after radical prostatectomy. A pelvic CT scan demonstrates a 5 by 4 cm heterogeneous peri-rectal fluid collection. He had received an oral bowel prep and antibiotics pre-operatively. The best management is parenteral antibiotics, percutaneous drainage of the fluid collection, and:

A) low-residual diet.
B) parenteral hyperalimentation.
C) suprapubic tube.
D) colostomy.
E) enteral hyperalimentation. $&$ D
( colostomy. Rectal injury occurs in approximately 1.5% of patients undergoing radical prostatectomy. If the injury is recognized intraoperatively and the patient has received an appropriate combination bowel prep, the injury can be repaired primarily. If the rectal injury is recognized post-operatively as a vesicorectal fistula, conservative management is not indicated. In this case, the patient also has associated infection and therefore a colostomy with delayed primary repair is indicated. In the face of a large fluid collection and active infection, less aggressive approaches are not indicated.Harpster LE, Rommel FM, Sieber PR, et al: The incidence and management of rectal injury associated with radical prostatectomy in a community based urology practice. J UROL 1995;154:1435-1438.Rovner ES: Urinary tract fistula, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 3, chap 72, p 2355. 2011 Adult Trauma & Fistulae )

A 54-year-old woman underwent radiation therapy for cervical cancer two years ago now has microscopic hematuria. TUR of a lesion 2 cm above the left ureteral orifice reveals an inverted papilloma. Three days post-operatively, she develops a vesicovaginal fistula. The best treatment is:

A) immediate transvaginal repair.
B) transvaginal repair in six months.
C) immediate transabdominal repair.
D) transabdominal repair in six months.
E) urinary diversion. $&$ C
( immediate transabdominal repair. In a woman with no evidence of abscess formation or a fluid collection, there is little need to wait an extended period of time before fistula repair. The abdominal approach provides better access to a radiation induced fistula and allows an omental pedicle flap to be interposed between the bladder and vaginal wall. Obliteration of dead space, good bladder drainage, control of infection and interposition of healthy tissue are critical elements to fistula closure. Rovner ES: Urinary tract fistula, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 3, chap 72, pp 2330-2331. 2011 Adult Trauma & Fistulae )

A 52-year-old woman underwent a percutaneous needle biopsy of the right kidney. Two months later, an abdominal bruit is heard in the right upper quadrant and a renal arteriogram demonstrates an arterio-venous fistula in the lower pole of the right kidney. She is asymptomatic with blood pressure well-controlled by medication and has a serum creatinine of 1.4 mg/dl. The next step is:

A) observation.
B) selective embolization.
C) partial nephrectomy.
D) operative ligation.
E) complete nephrectomy. $&$ A
( observation. Most traumatic AV fistulas of the kidney, such as those caused by percutaneous biopsy, are asymptomatic, small, and will close spontaneously without intervention. Symptomatic fistulas can cause hypertension, persistent hematuria, or high-output heart failure. Symptomatic AV fistula can be managed by embolization, operative ligation of the feeding vessels, or partial/complete nephrectomy depending upon their size and location.Novick AC, Fergany A: Renovascular hypertension and ischemic nephropathy, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 2, chap 36, pp 1189-1190. 2011 Adult Trauma & Fistulae )

A 47-year-old woman underwent closure of a bladder laceration at the time of an abdominal hysterectomy. Because of persistent leaking for two months, a transvaginal vesicovaginal fistula repair was required. Leaking recurs after another five months and a vaginal cuff fistula is found. CT urogram is normal and cystoscopy reveals a 1 cm fistulous tract with patchy, raised edema. The next step is:

A) serial cystoscopy and repair when edema resolves.
B) cystoscopy and biopsy of fistulous tract.
C) injection of fistula tract with fibrin sealant.
D) immediate vaginal repair with Martius flap.
E) immediate abdominal repair with omental interposition. $&$ B
( cystoscopy and biopsy of fistulous tract. In this particular patient, the presence of persistent edema and tissue changes in a patient who has failed repair five months earlier may indicate undetected malignancy. If there is any suspicion, a biopsy should be performed to rule out malignancy. If benign, surgical repair may be carried out by either a vaginal or transabdominal approach at the discretion of the surgeon when the tissue quality appears suitable for repair. This may be determined by serial cystoscopy and vaginal exams as indicated. Fibrin sealant has not been shown to be effective in repair of large fistula.Rovner ES: Urinary tract fistula, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 3, chap 72, p 2326. 2011 Adult Trauma & Fistulae )

A 42-year-old woman is undergoing a laparoscopic hysterectomy for dysmenorrhea and menorrhagia. An inadvertent 3 cm cystotomy is made at the level of the vaginal cuff. A urological consult is requested after the uterus is removed. In addition to repair, it is best to:

A) use a flap interposition.
B) place suprapubic tube.
C) perform cystoscopy.
D) perform bilateral retrograde pyeloureterograms.
E) utilize an open approach. $&$ D
( perform bilateral retrograde pyeloureterograms. Even though it may appear that only the bladder is injured, concomitant ureteral injuries must be ruled out at the time of the consult. The majority of ureteral injuries are not diagnosed intraoperatively. Laparoscopic hysterectomy is associated with higher incidence of ureteral injuries compared to open abdominal or vaginal approaches. To ensure that the ureters have not been also inadvertently divided, cystoscopy with bilateral pyeloureterograms should be performed prior to closure of the cystotomy. The other choices are reasonable to consider as part of the cystotomy closure depending on the clinical situation. However, to prevent the situation of a missed ureteral injury, it is best to perform a cystoscopy with bilateral retrograde pyeloureterograms.Ostrzenski A, Radolinski B, Ostrzenska KM: A review of laparoscopic ureteral injury in pelvic surgery. OBSTET GYNECOL SURV 2003;58:794-799.Harkki-Siren P, Sjoberg J, Tiitinen A: Urinary tract injuries after hysterectomy. OBSTET GYNECOL 1998;92:113-118. 2011 Adult Trauma & Fistulae )

A 45-year-old woman has a sudden onset of severe right flank pain. CT scan shows a right perirenal hematoma. The most likely underlying cause is:

A) renal adenocarcinoma.
B) renal angiomyolipoma.
C) renal artery aneurysm.
D) polyarteritis nodosa.
E) complex renal cyst. $&$ B
( renal angiomyolipoma. The most common cause of retroperitoneal hemorrhage is rupture of an abdominal aortic aneurysm. Renal and adrenal diseases account for the second and third most common causes respectively. Although both malignant and benign renal tumors may rupture, renal angiomyolipoma is the most common cause of a perirenal hematoma. Follow-up CT imaging after resolution of the hematoma will be necessary to rule-out the presence of an angiomyolipoma or malignant tumor that can be hidden by a retroperitoneal and/or perirenal hematoma. Zhang JQ, Fielding JR, Zou, KH: Etiology of spontaneous renal hemorrhage: A meta-analysis. J UROL 2002;167:1593-1596. 2010 Adult Trauma & Fistulae )

A 67-year-old man has persistent urinary drainage from a flank drain ten days following laparoscopic partial nephrectomy for a 3 cm upper pole mass. A retrograde ureteral stent was placed at the time of surgery. A KUB and renal image during cystography are shown. The next step is:

A) observation.
B) percutaneous nephrostomy.
C) advance drain.
D) reposition stent.
E) open surgical repair. $&$ D
( reposition stent. Following partial nephrectomy, a urinary fistula can develop in up to 17% of patients. This patient has persistent urinary drainage from his partial nephrectomy site despite placement of a ureteral stent. The radiographic studies demonstrate an incomplete duplication of the ureter with the stent in the lower pole moiety. The upper pole system {the site of the partial nephrectomy} remains unstented with persistent drainage. Observation will likely not improve the problem, and the drain should be left alone. The best treatment would be to reposition the stent into the upper pole collecting system and placement of a urethral catheter. Once the drainage stops, the urethral catheter can be removed, followed by the removal of the drain at a later date. The ureteral stent should be removed last. Greater than 99% of urinary fistula following partial nephrectomy resolve either spontaneously or with endoscopic management.Novick AC: Open surgery of the kidney, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 2, chap 50, p 1730. 2010 Adult Trauma & Fistulae )

A 43-year-old woman has a 3 cm vesicovaginal fistula on the posterior bladder wall 2 cm above the trigone three years following pelvic XRT for cervical cancer. CT urogram demonstrates normal upper urinary tracts without evidence of recurrent disease. The next step is:

A) bladder biopsy.
B) bilateral percutaneous nephrostomies.
C) immediate transvaginal repair with gracilis interposition.
D) immediate transabdominal repair with omental interposition.
E) delayed transabdominal repair with omental interposition. $&$ A
( bladder biopsy. Although less common with improved radiation techniques, radiation-induced fistulas are commonly associated with persistent or recurrent cervical cancer. Fistulas may occur during or shortly following XRT as a result of tumor necrosis in the wall of the vagina or bladder. Fistulas that develop one or more years following XRT are attributed to radiation induced endarteritis obliterans with subsequent necrosis of the vaginal and bladder wall. The most important aspect in the management of a patient with a fistula following XRT is to rule out recurrent cervical cancer. Locally recurrent cervical cancer following definitive XRT is associated with poor survival despite aggressive multimodal management. Fistula repair would not be indicated in the setting of recurrent disease. Rovner ES: Urinary tract fistula, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 3, chap 72, pp 2327-2328. 2010 Adult Trauma & Fistulae )

A 42-year-old man is undergoing laparotomy for intraabdominal injuries and bladder rupture. Bleeding is noted in the perivesical area. After repair of the bladder rupture, attempts at suture ligation do not stop the persistent bleeding. Multiple blood transfusions are given and his core temperature is 35.5°C. The next step is:

A) intraoperative arteriography.
B) ligation of the hypogastric arteries.
C) I.V. aminocaproic acid.
D) close the abdomen and place patient in anti-shock trousers(MAST).
E) pack the pelvis and close the abdomen. $&$ E
( pack the pelvis and close the abdomen. Most major bleeding from the pelvis following blunt trauma can be controlled by packing the pelvis and planned re-exploration and/or angiography with embolization in the radiographic suite. Ligation of hypogastric arteries or veins is seldom helpful in management because bleeding occurs from multiple pelvic veins. On-table arteriography is technically difficult, time consuming, and provides poor images and should therefore not be used. The use of a MAST suit in such cases has not been proven to be effective. Bleeding is due to trauma and unlikely to respond to medical therapy. Coburn M: Damage control surgery for urologic trauma: An evolving management strategy. J UROL 2002:160:13. Mucha P: Retroperitoneal injury, in Cameron JL {ed}: CURRENT SURGICAL THERAPY. St. Louis, Mosby Year Book, 1995, pp 837-843. 2010 Adult Trauma & Fistulae )

A 70-year-old man with metastatic colon cancer and indwelling ureteral stents develops profuse gross hematuria. Arteriography demonstrates a fistula between the right common iliac artery and ureter. He is hemodynamically stable. The next step is:

A) stent removal.
B) percutaneous nephrostomy.
C) embolize common iliac artery.
D) open surgical repair with ligation of the common iliac artery.
E) endovascular graft placement. $&$ E
( endovascular graft placement. The majority of arterial ureteral fistulas occur in patients who have had extensive pelvic surgery, XRT, and indwelling ureteral stents. Most fistulas involve the common iliac artery but they can also occur in the hypogastric artery. Patients can experience high volume bleeding resulting in hemodynamic instability. Emergency arteriography should be performed if this complication is suspected. While embolization of the common iliac artery will control hemorrhage, a femoral to femoral artery bypass is required to provide adequate circulation to the ipsilateral lower extremity. Placement of an endovascular stented graft or an autologous vein covered stent are less invasive options obviating the need for vascular reconstructive surgery in a patient with limited life expectancy and are the preferred treatment method. The ureteral stent should be removed and a percutaneous nephrostomy placed after this procedure to limit recurrent fistula formation. Rovner ES: Urinary tract fistula, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 3, chap 72, pp 2358-2359. Sexton WJ, Routh WD, McCullough DL, Bare RL: Hypogastric arterial-ureteral fistula. J UROL 1998;159:196-197. Kerns DB, Darcy MD, Baumann DS, Allen BT: Autologous vein-covered stent for the endovascular management of an iliac artery-ureteral fistula: Case report and review of the literature. J VASC SUR 1996;24:680. Houshiar AM, Hulbert JC, Bjarnason H, Cragg AH: Percutaneous treatment of an intraoperative arterial injury as a result of endoureterotomy. J UROL 1997;157:2249. 2010 Adult Trauma & Fistulae )

A 67-year-old man had a radical cystectomy and orthotopic diversion ten days ago. He now has feculent material draining from his urinary stents and urethral catheter after an episode of severe post-operative colitis. Within 24 hours, his temperature is 39°C, and his blood pressure is 95/50 mmHg. A CT scan of the abdomen and pelvis reveals an intraperitoneal abscess. Rectal examination is normal. The next step is:

A) percutaneous drain placement.
B) bowel rest with hyperalimentation.
C) bilateral percutaneous nephrostomy tubes.
D) fistula repair with bowel diversion.
E) proximal bowel diversion. $&$ E
( proximal bowel diversion. Nonoperative management is a viable option in selected patients with vesicoenteric fistulas, however, patients chosen for such treatment should be minimally symptomatic with benign fistulas. For those requiring surgical exploration, both one and two stage procedures have been based on clinical circumstances. The decision regarding a one or two stage procedure is influenced by the location and etiology of the fistula, the patient's general condition, the timing of the exploration relative to the original procedure, the presence of pelvic abscess, the presence of colonic obstruction, and the severity of the inflammatory response. Patients without gross fecal contamination can be treated with a one-stage procedure, whereas those with unprepped bowel, gross fecal contamination, severe inflammatory response, or abscess require a two-stage procedure.Rovner ES: Urinary tract fistula, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 3, chap 72, pp 2351-2352. 2010 Adult Trauma & Fistulae )

A 38-year-old woman with stress urinary incontinence and recurrent UTIs undergoes urethral diverticulectomy. One month following removal of the catheter, she has constant dribbling incontinence. Examination reveals a 5 mm urethrovaginal fistula in the proximal urethra. The next step is:

A) topical estrogen therapy and suprapubic cystostomy.
B) place urethral catheter and obtain VCUG in three to six weeks.
C) transurethral fulguration of the fistula tract and placement of a urethral catheter.
D) urethrovaginal fistula repair.
E) urethrovaginal fistula repair and midurethral polypropylene sling. $&$ D
( urethrovaginal fistula repair. Proximal urethrovaginal fistulae may present with constant dribbling incontinence. A large {5 mm} urethrovaginal fistula is unlikely to close with urinary drainage or fulguration. The safety of synthetic materials is not established in the setting of urinary fistula or prior urethral diverticulectomy. Surgical repair of the fistula should be undertaken two to three months post-operatively, and re-evaluation of the SUI done once the fistula is repaired. Long term indwelling urethral catheter is not recommended due to the development of chronic bacteruria and chronic inflammation.Rovner ES: Urinary tract fistula, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 3, chap 72, p 2351. 2010 Adult Trauma & Fistulae )

During an open gynecological procedure, the most common cause of a ureteral injury is:

A) uncontrolled bleeding from a uterine artery.
B) ureteral entrapment when ligating the ovarian pedicle.
C) ureteral damage during incision of the broad ligament.
D) mistaking the ureter for the round ligament.
E) ureteral damage while oversewing the vaginal cuff. $&$ A
( uncontrolled bleeding from a uterine artery. A ureteral injury occurs in 1% of gynecological procedures. This usually results from failure to identify the ureter when attempting to obtain hemostasis. Provided there is a clear surgical field, ureteral injury due to confusing it with another structure or during occlusion of the uterine or ovarian vessels is distinctly unusual.Brandes S, Coburn M, Armenakas N, McAninch JW: Diagnosis and management of ureteric injury: An evidence based analysis. BJU INT 2004;94:277-289. 2010 Adult Trauma & Fistulae )

A 37-year-old woman has low-grade fever and urinary incontinence four weeks after a robotic hysterectomy. A CT scan reveals urinary extravasation into the open vaginal cuff in the left pelvis. There is mild left ureterectasis, and a hematoma surrounds the distal left ureter that is not clearly visualized. Cystoscopy is negative and a stent could not be placed in the left ureter. In addition to I.V. antibiotics, the next step is:

A) CT-guided pelvic drain placement.
B) left percutaneous nephrostomy tube and antegrade stent placement.
C) laparoscopic exploration and repair.
D) open exploration with ureteroneocystostomy.
E) open exploration with primary ureteral repair. $&$ B
( left percutaneous nephrostomy tube and antegrade stent placement. The most common etiology of ureterovaginal fistula is surgical injury to the distal ureter, generally occurring during gynecologic procedures, most often during hysterectomy. Risk factors include endometriosis, obesity, pelvic inflammatory disease, radiation therapy and pelvic malignant disease. The most common presenting symptom is the onset of constant urinary incontinence one to four weeks after surgery. This is often preceded by several days of flank or abdominal pain, nausea, and low-grade fever, presumably because of urinoma or ureteral obstruction. The goal of therapy is expeditious resolution of urine leakage, prevention of urosepsis and preservation of renal function. Prompt drainage of the affected upper urinary tract is essential. An attempt at ureteral stenting or percutaneous nephrostomy tube decompression is warranted as soon as possible. If ureteral stenting is unsuccessful, surgical repair is indicated. The site of injury and the surrounding fibrosis and inflammation usually preclude primary repair of the fistula necessitating ureteroneocystostomy. Rovner ES: Bladder and urethral diverticula, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 3, chap 73, pp 2341-2345. 2009 Adult Trauma & Fistulae )

The most likely underlying etiology for an ileo-vesical fistula in a 35-year-old man with pneumaturia is:

A) Crohn's disease.
B) diverticulitis.
C) trauma.
D) appendiceal abscess.
E) malignancy. $&$ A
( Crohn's disease. Pneumaturia is the most common presenting symptom for a vesico-enteric fistula. Overall, the most common cause of vesico-enteric fistula is diverticulitis followed by cancer and Crohn's disease. Colo-vesical fistulas are usually due to diverticulitis. However, underlying gastrointestinal disease influences the likelihood and type of fistula. Ileo-vesical fistulas are more commonly due to Crohn's disease than cancer.Rovner ES: Urinary tract fistula, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 3, chap 72, pp 2351-2352. 2009 Adult Trauma & Fistulae )

A 63-year-old man, previously treated with pelvic radiation for colon cancer, develops localized Gleason 4%2B3=7 adenocarcinoma of the prostate. He undergoes radical prostatectomy that is complicated by a 3 cm rectourethral fistula four weeks after surgery. The best management is:

A) bowel rest and urethral catheter drainage.
B) fecal diversion and bilateral percutaneous nephrostomies.
C) transrectal fistula repair.
D) transabdominal fistula repair.
E) staged fecal diversion and fistula repair. $&$ E
( staged fecal diversion and fistula repair. The incidence of rectourethral fistula after radical retropubic prostatectomy is 1-2%. The risk of a fistula increases with a prior history of pelvic radiation therapy, rectal surgery, or TURP. Fistulas generally occur at the vesicourethral anastomosis and are often due to unrecognized rectal injury at the time of surgery. Although single and staged repairs have been described, staged repairs are recommended in cases of large fistulas and those associated with radiation therapy, uncontrolled local or systemic infection, immunocompromised states, or inadequate bowel preparation at the time of definitive repair. Conservative treatment with urethral catheterization is unlikely to be successful for large fistulas in the setting of prior radiation. Rovner ES: Urinary tract fistula, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 3, chap 72, pp 2353-2357. 2009 Adult Trauma & Fistulae )

A 23-year-old woman suffers a complex pelvic fracture in a MVC. A cystogram reveals limited extraperitoneal extravasation of contrast at the bladder neck. The bladder is compressed by a pelvic hematoma and an anterior vaginal laceration is also present. No other injuries are noted, and she is hemodynamically stable. Treatment should be:

A) urethral catheter drainage.
B) percutaneous suprapubic cystostomy.
C) open bladder repair.
D) suprapubic cystostomy and perivesical drainage.
E) repair of vaginal and bladder lacerations. $&$ E
( repair of vaginal and bladder lacerations. Urethral and bladder neck injuries in women are rare but potentially devastating in their effects on long-term continence and bladder function. The urethra is short, mobile, and protected by the pubis in women. Female urethral and bladder neck injuries occur in 4.6% to 6% of women suffering pelvic fractures. The typical presentation includes gross hematuria or blood at the introitus. Despite blood in the vaginal vault, over 40% of female bladder neck and urethral injuries are missed in the emergency department and only half will be detected on CT cystogram. As a result, one must have a high index of suspicion and low threshold for performing a vaginal examination in females with pelvic fractures. Female bladder neck injuries should undergo immediate repair with primary closure of any vaginal lacerations to prevent fistula formation. Longitudinal tears of the female bladder neck have been associated with higher rates of incontinence. Such injuries should be repaired immediately to preserve the functional integrity of the bladder neck. In one recent series, despite operative repair, 16% of women developed vesicovaginal fistulas, 43% had moderate or severe lower urinary tract systems, and 38% had sexual dysfunction.Black P, Miller E, Porter JR, Wessells H: Urethral and bladder neck injury associated with pelvic fracture in 25 female patients. J UROL 2006;175{6}:2140-2144. 2009 Adult Trauma & Fistulae )

A 22-year-old man suffered a pelvic fracture and urethral disruption five months ago. Combined retrograde urethrography and antegrade cystography reveals complete obliteration of the posterior urethra with a 2 cm defect. He cannot maintain an erection sufficient for intercourse. Prior to definitive urethral reconstruction, evaluation should include:

A) dynamic infusion cavernosometry.
B) nocturnal penile tumescence testing.
C) in office intracavernosal injection of alprostadil.
D) penile duplex Doppler ultrasound with intracavernosal injection.
E) pelvic MRI scan. $&$ D
( penile duplex Doppler ultrasound with intracavernosal injection. Erectile dysfunction {ED} is common in patients with pelvic fracture associated urethral injury. Mechanisms include neurogenic and vasculogenic injury, and the latter has implications for urethral reconstruction. Posterior urethroplasty for prostatomembranous urethral distraction defects requires mobilization of the corpus spongiosum and depends on retrograde blood flow through the dorsal arteries and glans penis to the distal urethra. Insufficiency of the spongiosal circulation is associated with failure of bulboprostatic anastomotic urethroplasty. Erectile function should be assessed and documented in such patients before attempting urethroplasty. If erections are normal, then inflow from the internal pudendal artery-common penile artery- dorsal penile arterial tree is considered to be intact. For patients with ED, in the majority erectile dysfunction is caused by disruption of the cavernous nerves with sparing of arterial inflow. However, in cases of cavernosal arterial insufficiency, the disruption of the internal pudendal artery will lead to insufficient arterial inflow to the dorsal arteries; as a result, experts recommend arterial revascularization prior to urethroplasty in cases of diminished vascular inflow to the dorsal arteries. Cavernosometry is a significantly more invasive vascular test, and is not the investigation of choice in this patient. Nocturnal penile tumescence testing is a nonspecific test that will not identify specific vasculogenic etiologies of ED. In office intracavernosal injection of alprostadil will not differentiate arterial from venous mechanisms of vasculogenic ED. A complete response is still possible in cases of arterial insufficiency. Penile duplex Doppler ultrasonography can effectively diagnose cavernosal arterial insufficiency and may allow imaging of the dorsal penile arteries as well. Pelvic MRI scan has been used to identify crural disruption post pelvic fracture but does not have the resolution necessary to delineate arterial anatomy of the pudendal vascular tree.Shenfeld OZ, Kiselgorf D, Gofrit ON, et al: The incidence and causes of erectile dysfunction after pelvic fractures associated with posterior urethral disruption. J UROL 2003;169:2173-2176. 2009 Adult Trauma & Fistulae )

A pelvic CT scan in a 34-year-old woman with recurrent UTIs reveals air in the bladder, focal bladder wall thickening, and indentation of the right lateral bladder wall. The most likely diagnosis is:

A) carcinoma of the sigmoid colon.
B) Crohn's disease.
C) carcinoma of the bladder.
D) diverticulitis.
E) emphysematous cystitis. $&$ B
( Crohn's disease. This patient has an enterovesical fistula due to Crohn's disease. In this disorder, the bladder is indented on the right lateral and/or anterior aspect and air can be seen in the bladder in 90% of cases on CT scan. Carcinoma of the sigmoid colon could cause this picture but the left wall of the bladder would be indented. Carcinoma of the bladder rarely causes enterovesical fistulae. Emphysematous cystitis is a generalized disease involving the entire bladder wall. Clinically significant diverticulitis is unlikely to occur at this patient's age.Rovner ES: Urinary tract fistula, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 3, chap 72, p 2353. 2008 Adult Trauma & Fistulae )

A 57-year-old man undergoes a left radical nephrectomy for renal cell cancer. Postoperatively, he has a prolonged ileus with nausea and vomiting and persistent abdominal pain radiating to the back. There is serous drainage from the wound. Abdominal ultrasound shows a large, left sided retroperitoneal fluid collection. In addition to percutaneous drainage, the next step is:

A) analysis of wound fluid for pH and amylase.
B) analysis of wound fluid for creatinine and BUN.
C) surgical exploration.
D) medium chain triglyceride, low fat diet.
E) gallium scan. $&$ A
( analysis of wound fluid for pH and amylase. An unrecognized injury to the pancreas may result in a pancreatic fistula. These are usually accompanied by symptoms of pancreatitis with wound drainage of fluid with a high pH and amylase content. Radiologic studies will usually show fluid in the retroperitoneum. When drained adequately, the tract will usually heal spontaneously, but hyperalimentation may be required. Surgical exploration is not yet indicated. A medium chain triglyceride, low fat diet would be useful in the setting of chylous ascites which is characterized by milky fluid high in fat content.Novick AC: Open surgery of the kidney, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 2, chap 50, pp 1718-1719. 2008 Adult Trauma & Fistulae )

A 45-year-old woman has chronic indwelling ureteral stents for bilateral ureteral strictures from radiation therapy for cervical carcinoma. During stent exchange, brisk, bloody efflux occurs upon right ureteral stent removal. After replacing the stent, the next step is:

A) observation.
B) abdominal and pelvic arteriogram.
C) abdominal and pelvic CT scan.
D) immediate open exploration.
E) nephrectomy. $&$ B
( abdominal and pelvic arteriogram. Ureteroarterial fistulas are rare with a reported mortality of nearly 40%. Thus, observation is not appropriate. Risk factors associated with the development of ureteroarterial fistulas include pelvic surgery, pelvic malignancy, pelvic irradiation, pelvic vascular disease and chronic ureteral intubation. Diagnosis is difficult in the absence of active bleeding. Despite the hemorrhage that accompanies these lesions, standard arteriography is frequently falsely negative. Still, arteriography may establish the diagnosis and then the fistula can be occluded with common iliac artery embolization followed by arterial bypass grafting. Provocative arteriography has been reported to demonstrate the fistula in almost all of cases. When clinical suspicion remains strong despite a negative arteriogram, exploratory laparotomy may be necessary to confirm the diagnosis and treat the condition. Immediate exploration is ill advised without a clear etiology of the bleeding, which will be poorly assessed with CT imaging. Nephrectomy is not indicated as the kidney is not the source of bleeding.Rodriguez L, Payne CK: Management of urinary fistulas, in Taneja SS, Smith RB, Ehrlich RM {eds}: COMPLICATIONS OF UROLOGIC SURGERY: PREVENTION AND MANAGEMENT. ed 3. Philadelphia, WB Saunders Co, 2001, pp 186-203. 2008 Adult Trauma & Fistulae )

An 18-year-old man injured in a MVC has blood at the external urethral meatus. An indication for urethral catheter drainage of the bladder, without further surgical exploration, is:

A) retrograde urethrogram demonstrating disruption of the penile urethra.
B) retrograde urethrogram demonstrating partial tear of the posterior urethra.
C) extraperitoneal bladder perforation in association with pelvic fracture requiring surgical repair.
D) extraperitoneal bladder perforation with bone fragment penetrating the bladder wall.
E) intraperitoneal bladder perforation with only microscopic hematuria. $&$ B
( retrograde urethrogram demonstrating partial tear of the posterior urethra. Direct injury to the penile urethra is usually best managed with primary surgical repair. In contrast, partial injuries to the posterior urethra will usually heal well over a urethral catheter if one can be placed atraumatically. While extraperitoneal bladder injuries can usually be managed by urethral catheter drainage of the bladder, indications for primary surgical closure of the bladder and placement of a suprapubic cystostomy include co-existing open pelvic fracture, patients undergoing laparotomy or open surgical repair of pelvic fracture, rectal perforation, and bone fragment projecting into the bladder. Intraperitoneal ruptures require primary surgical exploration and repair.Morey AF, Rozanski TA: Genital and lower urinary tract trauma, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 3, chap 83, pp 2657-2661. 2008 Adult Trauma & Fistulae )

The optimal dose of 30%25 iodinated contrast material for an intraoperative IVP in a non-obese adult patient suspected of having renal trauma is:

A) 0.5 ml/kg.
B) 1.0 ml/kg.
C) 2.0 ml/kg.
D) 2.5 ml/kg.
E) 3.0 ml/kg. $&$ C
( 2.0 ml/kg. Intraoperative IVP is performed in unstable trauma patients who can't undergo a radiographic evaluation in the emergency room. A film is taken ten minutes after contrast is administered intravenously. A 2 ml/kg dose of contrast material is recommended for this study.Morey AF, McAninch JW, Tiller BK, Duckett CP, Carroll PR: Single shot intraoperative excretory urography for the immediate evaluation of renal trauma. J UROL 1999;161:1088-1092. 2008 Adult Trauma & Fistulae )

A 58-year-old obese man has 400 ml of bile-stained fluid coming from his drain two days following transperitoneal laparoscopic unroofing of a large right renal cyst. He is afebrile and his bowel sounds are normal. The leakage persists over the next five days despite nasogastric suction. KUB and upright abdominal x-rays are normal. The next step is:

A) feeding jejunostomy tube.
B) laparotomy.
C) parenteral nutrition.
D) somatostatin.
E) small bowel suction(Kantor) tube. $&$ C
( parenteral nutrition. Immediate reoperation for fistula closure is not indicated as most fistulae heal with parenteral nutrition. Immediate operative intervention is not indicated unless the patient has signs of peritonitis or an acute abdomen. Parenteral nutrition has significantly improved the prognosis of patients with enterocutaneous fistula and has not only increased the rate of spontaneous fistula closure but also improved nutritional status of patients needing repeated operations. Rovner ES: Urinary tract fistula, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 3, chap 72, p 2322. 2008 Adult Trauma & Fistulae )

A 26-year-old schizophrenic man is evaluated two hours after self-amputation of his phallus at its base with a knife. The amputated organ has been preserved at room temperature. The next step is suprapubic cystotomy, debridement, and:

A) stump closure with distal spatulation of urethra.
B) stump closure with perineal urethrostomy.
C) leave stump open to heal by secondary intention.
D) creation of neophallus with abdominal pedicle flap.
E) reimplantation of phallus. $&$ E
( reimplantation of phallus. Reimplantation of the amputated phallus is usually successful even after two hours ischemia without ice. In fact, many organs may be damaged through frost injury if improperly stored in ice. The edges should be debrided and the corpora and urethra re-approximated without attempting reanastomosis of the cavernosal arteries. Microsurgical technique should be employed to re-anastomose the dorsal nerves, arteries and veins. Skin loss frequently occurs but it can be managed later with skin grafting. Morey AF, Rozanski TA: Genital and lower urinary tract trauma, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 3, chap 83, pp 2651-2652. 2008 Adult Trauma & Fistulae )

A 22-year-old man develops severe hemorrhagic cystitis ten days following bone marrow transplantation for acute myelocytic leukemia. He had received cyclophosphamide prior to his transplantation. He requires numerous transfusions despite therapy with hydration, continuous bladder irrigation, and a single intravesical instillation of 3%25 formalin. The next step is:

A) bilateral percutaneous nephrostomy drainage.
B) intravesical irrigation with 1%25 aluminum potassium sulfate.
C) intravesical instillation of 1%25 silver nitrate.
D) hypogastric artery embolization.
E) administration of sodium 2-mercaptoethane sulfonate(Mesna). $&$ A
( bilateral percutaneous nephrostomy drainage. Severe hemorrhagic cystitis, defined as requiring transfusion of more than six units of packed red blood cells to maintain hemodynamic stability and refractory to conservative measures, is life-threatening. Intravesical administration of silver nitrate or alum is unlikely to be effective following the failure of formalin. Hypogastric artery embolization has been utilized but complications including gluteal claudication and necrosis of the bladder have been reported. Mesna is only effective when administered at the time of cyclophosphamide therapy since it binds to the active metabolite. Bilateral percutaneous nephrostomy tubes divert urine away from the bladder and facilitate application of more aggressive intravesical therapy. Russo P: Urologic emergencies in the cancer patient. SEMIN ONCOL 2000;27:284-298. 2008 Adult Trauma & Fistulae )

The optimal tissue for early coverage of the perineum following an avulsion skin injury is a(n):

A) island skin flap.
B) musculocutaneous flap.
C) full thickness skin graft.
D) split thickness skin graft.
E) dermal graft. $&$ D
( split thickness skin graft. A split thickness skin graft takes much more readily than a full thickness skin graft or a dermal graft because capillary ingrowth into the graft is more rapid. Skin flaps and musculocutaneous flaps have no role in the acute management of avulsion injuries. Michielsen D, Van Hee R, Neetens C, et al: Burns to the genitalia and the perineum. J UROL 1998:159{2}:418-419. Morey AF, Metro MJ, Carney KJ, Miller KS, McAninch JW: Consensus on genitourinary trauma: External genitalia. BJU INTERN 2004;94{4}:507-515. 2010 General Trauma & Fistulae )

Clear fluid with a high amylase content begins to drain from a suction catheter two days after difficult excision of a large left adrenal tumor. There is no fever and minimal leukocytosis. Two weeks later, the drainage remains copious but the overall clinical condition is stable. The next step is:

A) nasogastric suction and parenteral hyperalimentation.
B) endoscopic intubation of the pancreatic duct.
C) continued observation.
D) distal pancreatectomy.
E) medium chain triglyceride diet. $&$ A
( nasogastric suction and parenteral hyperalimentation. In this case the clinical findings are most consistent with a pancreatic fistula resulting from unrecognized intraoperative injury to the tail of the pancreas. These fistulas usually close with conservative management {bowel rest and hyperalimentation}. Endoscopic intubation of the pancreatic duct likely will not be helpful as this structure is not obstructed. Distal pancreatectomy would be considered a last resort only after less invasive interventions have failed. Medium chain triglycerides are used in the management of chylous ascites. Chow GK, Blute ML: Surgery of adrenal glands, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 2, chap 54, pp 1885-1886. 2009 General Trauma & Fistulae )

When renal exploration for penetrating trauma is performed without initial renal vascular control, the result, compared to early vascular control, is:

A) decreased operative time.
B) increased blood loss.
C) increased renal loss.
D) increased blood transfusions.
E) decreased mortality. $&$ A
( decreased operative time. Traditionally, it has been taught that early vascular control of the renal hilum allows for safe renal exploration. It has been assumed that early vascular control decreases blood loss, renal loss, need for blood transfusions and mortality. Most data, however, are anecdotal and based on literature review. A randomized prospective study of 56 patients during a 53 month period was undertaken comparing outcomes of those patients with early vascular control versus those with renal exploration without initial renal vascular control. Those patients who underwent early vascular control required increased operative time and required more blood transfusions due to increased blood loss. There was no increase in mortality in those patients explored without first obtaining vascular control. Renal loss was similar between the two groups. The thinking that penetrating renal trauma should be approached after establishing hilar control may not only increase operative time but may increase the risk of blood loss and need for blood transfusions. These observations may not hold true for blunt trauma or less severe kidney injuries, in which the risk of nephrectomy is lower.Gonzalez RP, Falimirski M, Holevar MR, Evankovich C: Surgical management of renal trauma: Is vascular control necessary? J TRAUMA: INJURY, INFECTION & CRITICAL CARE 1999;47{6}:1039-1044. Santucci,RA, Wessells H, Bartsch G, et al: Evaluation and management of renal injuries: consensus statement of the renal trauma subcommittee. BJU INTERN, 2004;93:937-954. 2009 General Trauma & Fistulae )

A seven-year-old boy is a restrained front seat passenger in an MVC in which air bag deployment is noted. In the ER, he has right flank pain. Physical exam reveals mild right sided abdominal and CVA tenderness. No hypotension was noted in the field or in the ER. Hgb is 12.5 and urinalysis shows 25 RBC/hpf. The next step is:

A) observation.
B) serial CBC and urinalysis.
C) abdominal ultrasound.
D) abdominal CT scan with contrast.
E) cystogram. $&$ D
( abdominal CT scan with contrast. The kidneys in children, as compared to those in adults are believed to be more susceptible to trauma for numerous reasons including a more pliable thoracic cage, weaker abdominal musculature, less perirenal fat, and lower position in the abdomen. Although there has been past controversy regarding the indications for imaging in children with blunt renal trauma, most studies now suggest that children should be radiographically evaluated in a similar fashion to adults. Thus, they should be imaged when one of the following four criteria are present: 1. A significant deceleration or high-velocity injury such as a high speed MVC, or fall from more than 15 feet, or significant blow to the abdomen, 2. Significant trauma that has resulted in fractures of the surrounding rib cage or spine, 3. Gross hematuria, or 4. Microscopic hematuria {< 50 RBC/hpf} associated with shock {systolic blood pressure less than 90 mm Hg}. CT scans are the best form of imaging. In this child, the degree of microscopic hematuria and the absence of shock does not fulfill the criteria for imaging. However, the mechanism of injury where airbag deployment was noted suggests a significant deceleration injury which mandates the need for imaging; thus a CT scan should be performed. The mechanism of injury is probably the most important factor in helping to determine whether imaging is necessary in borderline cases. Husmann D: Pediatric genitourinary trauma, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 4, chap 132, p 3930. 2012 Pediatric Trauma & Fistulae )

An eight-year-old boy undergoes PCNL. An intraoperative nephrostogram shows contrast in the large bowel. The best management is ureteral stent and:

A) diverting colostomy.
B) primary colonic repair.
C) remove nephrostomy and low residue diet.
D) retain nephrostomy and perform barium enema.
E) withdraw nephrostomy into colon. $&$ E
( withdraw nephrostomy into colon. The child has suffered a colonic perforation. Although rare, this complication due to a retrorenal colon is more common in patients with neurogenic bowel. The majority of these injuries can be managed nonoperatively with a double-J stent, tube drainage of the colon, low residue diet and broad-spectrum antibiotics. The tube is left in the colon for seven to ten days. If a contrast study at that time shows no evidence of extravasation or fistula formation, the tube can be removed. Open exploration is reserved for patients with intraperitoneal perforation, peritonitis, or sepsis.Gupta M, Ost MC, Shah JB, McDougall EM, Smith AD: Percutaneous management of the upper urinary tract, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 2, chap 46, p 1548.Assimos DG: Complications of stone removal, in Smith AD, Badlani GH, Bagley DH, et al {eds}: Smith's Textbook of Endourology. St. Louis, Quality Medical Publishing Inc, 1996, vol 1, chap 21, pp 302-303. 2012 Pediatric Trauma & Fistulae )

A 15-year-old boy presents with a 22-caliber gunshot wound to the left flank. Evaluation reveals an entrance wound posterior to left anterior axillary line, no exit wound seen. Vital signs are stable and there is no sign of peritoneal irritation. CT scan reveals a grade 2 left renal injury, right kidney within normal limits, no air is noted in the peritoneal cavity; no associated organ injuries are noted. Distal ureters are intact bilaterally. The next step is initiate intravenous antibiotics and:

A) observation.
B) retrograde ureteropyelogram.
C) intravenous indigo carmine and local exploration of wound.
D) retroperitoneal exploration and renorrhaphy alone.
E) exploratory laparatomy, retroperitoneal exploration and renorrhaphy. $&$ A
( observation. Approximately 10% of traumatic pediatric genitourinary injuries are due to penetrating trauma with gun shot wounds to the trunk causing a genitourinary injury approximately 15% of the time. In patients with GU trauma secondary to a gunshot wound, the kidney is the site of injury in approximately 60% of the patients, the bladder in 20%, the urethra in 5%, the ureter in 2%. Two or more genitourinary injuries occur in 13%. If a genitourinary structure is traumatically damaged due to a gunshot wound the likelihood of associated organ injury is approximately 90%. In most cases gunshot wounds to the abdomen will result in a hemodynamically unstable patient with multiple associated organ injuries, requiring urgent laparotomy. The need for emergent surgery excludes the ability to adequately stage the renal injury. However, several studies have shown that a selective nonoperative approach to the management of patients with stab wounds and in very select cases, low velocity gun shot wounds, can be safely implemented. Specifically, in hemodynamically stable patients with a penetrating wound posterior to the anterior axillary line, intravenous antibiotics are initiated to cover the contamination induced by a penetrating foreign object. and a screening triphasic abdominal and pelvic CT scan is obtained. If the patient has an isolated grade 1 or 2 renal injury the vast majority of patients can be managed successfully with a non-operative approach with only minimal complications. In these patients surgical exploration is indicated for persistent blood loss, the presence of air in the peritoneum, signs of developing peritonitis, or radiographic findings consistent with a ureteral injury.Velmahos G, Demetriades D: Is nonoperative management of abdominal gunshot wounds reasonable? ADV IN SUR 2002;36:123-140. Heyns C: Renal trauma: Indications for imaging and surgical exploration. BR J UROL INT 2004;93:1165-1170.Santucci R, Wessells H, Bartsch G, et al: Evaluation and management of renal injuries: Consensus statement of the renal trauma subcommittee. BR J UROL INT 2004;93:937-954. 2011 Pediatric Trauma & Fistulae )

An eight-year-old boy is an unrestrained passenger in a MVC. He complains of left abdominal pain and has left upper quadrant tenderness on physical examination. He is hemodynamically stable and has microscopic hematuria. CT scan shows a normal right kidney. The left kidney is markedly hydronephrotic and there is perinephric contrast extravasation. The left ureter is not visualized. The next step is:

A) observation and antibiotics.
B) renal scan.
C) retrograde pyelogram.
D) percutaneous nephrostomy.
E) renal exploration. $&$ C
( retrograde pyelogram. This boy likely has an injury to the collecting system in a chronically obstructed kidney. The most likely sites of extravasation are the dilated pelvis or fornix. However, a UPJ disruption is also possible and needs to be excluded. The radiographic sign of importance is the absence of distal ureteral filling during the CT scan. Renal salvage is enhanced by early diagnosis which may be best confirmed by retrograde pyelography in preparation for a definitive repair. Prior to any type of open exploration, the status of the ureter needs to be defined. At the time of the retrograde pyelogram, a stent may be left in the ureter distal to the disruption to facilitate surgical dissection. Casale AJ: Urinary tract trauma, in Gearhart JP, Rink RC, Mouriquand PDE {eds}: PEDIATRIC UROLOGY. Philadelphia, WB Saunders Co, 2001 chap 59, pp 923-943.Husmann D: Pediatric genitourinary trauma, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 4, chap 132, p 3936. 2011 Pediatric Trauma & Fistulae )

A six-year-old girl has a pelvic fracture from a MVC. Her perineal examination shows blood at the vaginal introitus. A CT scan with contrast shows normal kidneys and a pelvic hematoma. The next step is:

A) urethral catheter.
C) retrograde urethrogram.
D) cystoscopy, vaginoscopy and cystogram.
E) suprapubic tube bladder drainage. $&$ D
( cystoscopy, vaginoscopy and cystogram. This girl is at risk for having sustained a significant urethral, vaginal, rectal, or bladder injury that may be underestimated by initial examination. Examination under anesthesia is essential to evaluate the extent of injury. Cystography is also needed to rule-out a bladder injury. Retrograde urethrography is unnecessary and technically difficult in a female. Suprapubic tube placement would not be necessary before the urethra is evaluated. A VCUG would be helpful if a catheter can be passed easily, however, will not rule-out a vaginal injury. A urethral catheter may be able to be passed in a very cooperative patient, however, the possibility of a vaginal injury would still need to be evaluated. If an unrecognized bladder neck or urethral injury is found, immediate reconstruction will be necessary to avoid complications such as pelvic abscess, urinary fistulization, and increased risk of incontinence.Husmann D: Pediatric genitourinary trauma, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 4, chap 132, pp 3943-3944.O'Neill JA, Grosfeld, JL, Fonkalsrud EW, et al {eds}: Abdominal and genitourinary trauma, in PRINCIPLES OF PEDIATRIC SURGERY, ed 2. St. Louis, Mosby, 2004 chap 13, p 174.Lynch JM, Gardner MJ, Albanese CT: Blunt urogenital trauma in prepubescent female patients: More than meets the eye. PED EMER CARE 1995;11:372. 2011 Pediatric Trauma & Fistulae )

A 12-year-old boy with blunt abdominal trauma has a CT scan that shows a left renal fracture with a small subcapsular hematoma. He is managed with observation. Six days after injury he has a temperature of 38.4°C and increased hematuria with clots. His hematocrit has decreased from 30 to 24 in the last day. The CT scan on day six is shown. The next step is:

A) observation.
B) retrograde ureterogram.
C) arteriogram.
D) percutaneous nephrostomy.
E) open surgical exploration. $&$ C
( arteriogram. This child likely has a delayed bleed from a renal laceration. The CT demonstrates devitalized areas of the kidney with a collection of blood and urine. This is best managed by embolization after confirmation by arteriogram. Open surgery will more likely result in nephrectomy or heminephrectomy. Percutaneous nephrostomy or retrograde ureterogram will not treat the continued bleeding. A retrograde study would be indicated if one were suspecting a pelvic tear or a UPJ disruption because of medial extravasation. McAninch W, Santucci RA: Renal and ureteral trauma, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 2, chap 39, p 1282. 2010 Pediatric Trauma & Fistulae )

An eight-year-old boy is involved in a MVC. A CT scan confirms a right UPJ disruption. He has had a right ureteral reimplant at the age of four years. The next step is:

A) percutaneous nephrostomy.
B) primary ureteropyelostomy.
C) transureteroureterostomy.
D) ileal ureter.
E) nephrectomy. $&$ B
( primary ureteropyelostomy. Disruption of the ureteropelvic junction in a child secondary to trauma is a prime indicator for operative intervention. His kidney should be salvaged and a percutaneous nephrostomy tube may not be diverting. While the distal blood supply of the ureter has been disrupted due to his previous surgery, his ureter should still have an adequate blood supply from the middle ureteral vessels. A primary repair is the best treatment option. Transureteroureterostomy would potentially put the contralateral renal unit at risk unnecessarily and not likely to be technically feasible.Casale AJ: Urinary tract trauma, in Gearhart JP, Rink RC, Mouriquand PDE {eds}: PEDIATRIC UROLOGY. Philadelphia, WB Saunders Co, 2001, chap 59, pp 923-943. Husmann D: Pediatric genitourinary trauma, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 4, chap 132, p 3936. 2010 Pediatric Trauma & Fistulae )

A two-year-old girl has abdominal tenderness 24 hours after minor flank trauma. Her initial hematocrit was 33%25 and decreased to 28%25. She remains hemodynamically stable. Her urine is clear. Images from an abdominal CT scan without and with contrast are shown in exhibits 1 and 2. Chest x-ray is normal. The best definitive management is:

A) observation.
B) transfusion of packed RBCs.
C) renal arteriography.
D) flank exploration and repair.
E) nephrectomy. $&$ E
( nephrectomy. The CT images show a complex mass of the left kidney. This is not simply a renal fracture. Renal tumors, particularly a Wilms' tumor are more susceptible to injury. The child remains stable and therefore does not need to be transfused. A renal arteriogram is premature. This is not a simple renal fracture and therefore exploration and repair is not warranted. The child will need a nephrectomy once stabilized in order to treat her tumor.Casale AJ: Urinary tract trauma, in Gearhart JP, Rink RC, Mouriquand PDE {eds}: PEDIATRIC UROLOGY, Philadelphia, WB Saunders Co, 2001, chap 59, pp 923-943. Husmann D: Pediatric genitourinary trauma, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 4, chap 132, p 3929. 2009 Pediatric Trauma & Fistulae )

A 17-year-old girl underwent ileocystoplasty for neurogenic bladder four years ago. During an emergency cesarean section for dystocia, the vascular pedicle to the cystoplasty segment is divided. The next step is:

A) revascularization of the pedicle.
B) excise ileal patch; immediate ileal augmentation.
C) excise ileal patch; delayed sigmoid augmentation.
D) place suprapubic tube and drain.
E) observation with follow-up urodynamics. $&$ E
( observation with follow-up urodynamics. Experimental studies have shown that the augmented bowel segment receives collateral blood flow from the native bladder. Interruption of the vascular pedicle may cause some decrease in the size of the augmented segment, but the neobladder remains intact. Intraoperative assessment of blood flow to the augmented segment immediately after ligation of the pedicle demonstrates decreased perfusion. However, perfusion returns to normal after eight weeks. Observation of the patient with repeat urodynamic studies is indicated. If this shows a significant decrease in functional capacity, consideration can be given to revision of the ileocystoplasty. Primary revision with sigmoid in this patient would be ill advised without a bowel prep. There should be no need for a suprapubic tube as extravasation is not likely. Immediate re-augmentation may not be indicated unless there is a demonstrable reduction in capacity or compliance.Adams MC, Joseph DB: Urinary tract reconstruction in children, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 4, chap 124, p 3686. 2009 Pediatric Trauma & Fistulae )

At the time of a newborn circumcision, the distal one-half of the glans penis is amputated, including the urethra. The prepuce and glans have been kept in iced saline for four hours. The best management is:

A) primary anastomosis.
B) graft of preputial skin for coverage.
C) discard glans tip and allow secondary healing.
D) discard the glans tip and re-configure remaining glans.
E) primary anastomosis with microvascular reconstruction. $&$ A
( primary anastomosis. The length of time from injury and having had the tissue maintained in cold saline should permit adequate healing of the re-anastomosed tip. The urethra should be stented. The are no vessels of sufficient size to permit microvascular re-anastomosis. When the repair is performed within 8 hours after the injury, the penis usually heals nicely. A graft of preputial skin for coverage would result in a poor cosmetic appearance. Similarly, reconfiguration of the remaining glans will not result in an ideal cosmetic effect.Elder JS: Abnormalities of the genitalia in boys and their surgical management, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 4, chap 126, p 3748. 2009 Pediatric Trauma & Fistulae )

Twenty-four hours after a newborn circumcision, a 1.5 cm skin separation is noted. The best management is:

A) immediate reapproximation.
B) delayed reapproximation.
C) split thickness skin graft.
D) full thickness skin graft.
E) healing by secondary intention. $&$ E
( healing by secondary intention. Minor degrees of separation of circumcision edges are common. Complete separation as described is uncommon. This incision should be considered contaminated in the baby's diaper. Therefore, immediate closure is not recommended. Skin grafts are not indicated because of the contaminated bed and would have a high risk of infection. Since the length of the skin was adequate at the time of circumcision, observation is the best choice. Usually this complication rapidly heals well and nothing further will be necessary. If an undesirable scar develops, it can be revised or grafted electively at a later time.Elder JS: Abnormalities of the genitalia in boys and their surgical management, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 4, chap 126, pp 3748-3750. 2008 Pediatric Trauma & Fistulae )

A 13-year-old boy is undergoing a laparoscopic colectomy for ulcerative colitis during which the lower half of the left ureter is resected with the colon. The procedure has been converted to an open technique for completion. The next step is:

A) ileal ureter.
B) cutaneous ureterostomy.
C) transureteroureterostomy.
D) auto transplantation and ureteroneocystostomy.
E) nephrectomy. $&$ C
( transureteroureterostomy. With loss of the distal half of the ureter and the inflammatory process of the ulcerative colitis, a primary anastomosis with a psoas hitch would not be possible. Because of his bowel disease, creating an ileal ureter would not be ideal. A left auto transplantation is possible but not worth the post operative risks. A cutaneous ureterostomy would only be temporizing and require another open procedure. It would be best to perform a transureteroureterostomy. If the left ureter does not reach to the right, the right ureter can be mobilized, passed to the left and reimplanted into the bladder. A nephrectomy should be avoided as the initial management.McAninch W, Santucci RA: Renal and ureteral trauma, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 2, chap 39, pp 1287-1292. 2008 Pediatric Trauma & Fistulae )

A three-year-old boy lost one-half of his scrotal skin after a dog attack two hours ago. His testicles, penis and urethra are spared. Best management includes antibiotics, debridement, and:

A) split thickness skin graft.
B) full thickness skin graft.
C) placement of testicles in the thigh.
D) scrotal closure with drainage.
E) secondary scrotal closure. $&$ D
( scrotal closure with drainage. Skin grafts and placement of the testicles in the thigh are seldom required when half of the scrotal skin remains. Secondary closure for such a recent injury is unnecessary. The best choice for management is a tetanus immunization if he is not up to date, antibiotics, debridement, and primary closure with drainage. If grafting is required, a meshed split thickness graft is preferable because the meshing allows exudate to escape and gives improved cosmesis. Thigh pouches are rarely required as wet to dry dressings of the exposed gonads can be effective in critically ill patients until reconstruction is feasible. Morey AF, Rozanski TA: Genital and lower urinary tract trauma, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 3, chap 83, p 2655. 2008 Pediatric Trauma & Fistulae )

During exploration of a retroperitoneal hematoma from blunt renal trauma, the best anatomic landmark for the left renal artery is the:

A) inferior mesenteric artery.
B) left renal vein.
C) right renal artery.
D) left gonadal vein.
E) left ureter. $&$ B
( left renal vein. The left renal artery originates from the aorta just lateral and superior to the left renal vein. Identifying the left renal vein as it crosses the aorta provides the best anatomic landmark for the left renal artery. The right renal artery is retrocaval and not a good landmark. The inferior mesenteric artery is caudad to the renal artery. The inferior mesenteric vein is a good landmark for the location of the aorta during emergent exploration. An incision is made medial to the inferior mesenteric vein. This is extended cephalad to the ligament of Treitz. The aortic dissection is carried cephalad to the left renal vein allowing identification of the renal arteries.McAninch W, Santucci RA: Renal and ureteral trauma, in Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA {eds}: CAMPBELL'S UROLOGY, ed 9. Philadelphia, Saunders Elsevier, 2007, vol 2, chap 39, pp 1278-1280. 2008 Pediatric Trauma & Fistulae )

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