Lower Urinary Tract Trauma: Difference between revisions

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** '''<span style="color:#ff0000">Surgical delay of up to 7 days after the time of injury does not adversely affect the results of repair</span>'''

** Technique

*** See [https://www.youtube.com/watch?v=T0hoHpDxeCE Video]

*** Approach

****Ventral vertical penoscrotal incision

*****Usually preferred for direct exposure to the fracture because most penile fractures occur ventrally or laterally.

**** Distal circumcising incision

*****May be appropriate when the location of the fracture is uncertain because it provides exposure to all three penile compartments.

***See [https://www.youtube.com/watch?v=T0hoHpDxeCE Video]

***Equipment

****Sutures

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****25 Gauge butterfly needle

****Local anesthetic

***Place ~~stay~~ stitch on dorsal aspect of glans, close to coronal sulcus~~. Cut needle and place suture tails on clamp~~.

***Step by step with distal circumcising incision

***~~Incision~~

****Place holding stitch on dorsal aspect of glans, close to coronal sulcus.

****Options (2):

****Hold penis on stretch

***** '''Ventral vertical penoscrotal incision'''

****Use marking pen to denote a circumferential incision approximately 2cm proximal to the coronal sulcus

******Usually preferred for direct exposure to the fracture because most penile fractures occur ventrally or laterally.

*****Skin will need to be very dry for ink to be applied properly

***** '''Distal circumcising incision'''

****Use a scalpel to cut down on incision.

******May be appropriate when the location of the fracture is uncertain because it provides exposure to all three penile compartments.

*****Cut down to level of Buck's fascia

******Use marking pen to denote a circumferential incision approximately 2cm proximal to the coronal sulcus

*****Be careful near urethra

******Use a scalpel to cut down on incision~~. Hold penis on stretch~~.

**** Place holding stich at 12 o'clock on cut penile skin edge.

*******Be careful near urethra

****Deglove penis

*** Place ~~stay~~ stich at 12 o'clock on cut penile skin edge~~. Cut needle and place suture tails on clamp~~.

*****Use Metzenbaum scissors to dissect skin off of tunica albuginea. Use closed scissors and then spread. Then cut attachments.

***Deglove penis

******Be careful near urethra

****Use Metzenbaum scissors to dissect skin off of ~~tunia~~ albuginea. Use closed scissors and then spread. Then cut attachments.

*****Use gauze for blunt dissection

*****Be careful near urethra

*****Continue to deglove penis until area of fracture is exposed

****Use gauze for blunt dissection

**** Evacuate hematoma

****Continue to deglove penis until area of fracture is exposed

*****Dissection must be carried down until the hematoma within Buck's fascia is exposed and evacuated

*** Evacuate hematoma

****Identify defect

****Dissection must be carried down until the hematoma within Buck's fascia is exposed and evacuated

*****Proximal corpora is the most common site of rupture

***Identify defect

******Induction of an artificial erection with saline or colored dye may aid in locating the corporeal laceration.

****Proximal corpora is the most common site of rupture

*****Laceration usually transverse in direction

*****Induction of an artificial erection with saline or colored dye may aid in locating the corporeal laceration.

*****Obtain adequate exposure of defect

****Laceration usually transverse in direction

****Repair defect

****Obtain adequate exposure of defect

*****Repair defect in tunica albuginea with interrupted 2-0 or 3-0 PDS sutures.

***Repair defect

**** If urethral injury

****~~Closure of the tunical~~ defect with interrupted 2-0 or 3-0 PDS sutures ~~is recommended~~.

*****Partial urethral injuries should be oversewn with fine absorbable suture over a urethral catheter.

*** If urethral injury

*****Complete urethral injuries should be debrided, mobilized, and repaired in a tension-free fashion over a catheter.

****Partial urethral injuries should be oversewn with fine absorbable suture over a urethral catheter.

**** Test repair

****Complete urethral injuries should be debrided, mobilized, and repaired in a tension-free fashion over a catheter.

*****Apply tourniquet proximal to repaired defect

*** Test repair

*****Use a 25 Gauge butterfly needle to inject saline mixed with methylene blue into the corporal body distal to the defect

****Apply tourniquet proximal to repaired defect

*****If leak noted, place additional interrupted sutures.

****Use a 25 Gauge butterfly needle to inject saline mixed with methylene blue into the corporal body distal to the defect

****Repair Buck's fascia overlying defect

****If leak noted, place additional interrupted sutures.

****Obtain hemostasis

***Repair Buck's fascia overlying defect

****Reduce foreskin and reapproximate cut edges of skin with 4-0 chromic

***Obtain hemostasis

*****Start by placing stitches in 4 corners and leave tails long to use as handle

***Reduce foreskin and reapproximate cut edges of skin with 4-0 chromic

******Place box/U stitch in area of frenulum

****Start by placing stitches in 4 corners and leave tails long to use as handle

*****Position penis using stay stitches to align skin edges and perform interrupted stitches

*****Place box/U stitch in area of frenulum

****[https://www.ncbi.nlm.nih.gov/books/NBK535389/ Penile block]

****Position penis using stay stitches to align skin edges and perform interrupted stitches

*****Dorsal penile nerve block

***[https://www.ncbi.nlm.nih.gov/books/NBK535389/ Penile block]

*****Ring block

****Dorsal penile nerve block

****Apply dressing

****Ring block

***Apply dressing

***Post-operative management

****Therapy with broad-spectrum antibiotics

@@ Line 327: / Line 327: @@
 ** '''<span style="color:#ff0000">Surgical delay of up to 7 days after the time of injury does not adversely affect the results of repair</span>'''
 ** Technique
-*** See [https://www.youtube.com/watch?v=T0hoHpDxeCE Video]
+*** Approach
+****Ventral vertical penoscrotal incision
+*****Usually preferred for direct exposure to the fracture because most penile fractures occur ventrally or laterally.
+**** Distal circumcising incision
+*****May be appropriate when the location of the fracture is uncertain because it provides exposure to all three penile compartments.
+***See [https://www.youtube.com/watch?v=T0hoHpDxeCE Video]
 ***Equipment
 ****Sutures
@@ Line 337: / Line 342: @@
 ****25 Gauge butterfly needle
 ****Local anesthetic
-***Place stay stitch on dorsal aspect of glans, close to coronal sulcus. Cut needle and place suture tails on clamp.
+***Step by step with distal circumcising incision
-***Incision
+****Place holding stitch on dorsal aspect of glans, close to coronal sulcus.
-****Options (2):
+****Hold penis on stretch
-***** '''Ventral vertical penoscrotal incision'''
+****Use marking pen to denote a circumferential incision approximately 2cm proximal to the coronal sulcus
-******Usually preferred for direct exposure to the fracture because most penile fractures occur ventrally or laterally.
+*****Skin will need to be very dry for ink to be applied properly
-***** '''Distal circumcising incision'''
+****Use a scalpel to cut down on incision.
-******May be appropriate when the location of the fracture is uncertain because it provides exposure to all three penile compartments.
+*****Cut down to level of Buck's fascia
-******Use marking pen to denote a circumferential incision approximately 2cm proximal to the coronal sulcus
+*****Be careful near urethra
-******Use a scalpel to cut down on incision. Hold penis on stretch.
+**** Place holding stich at 12 o'clock on cut penile skin edge.
-*******Be careful near urethra
+****Deglove penis
-*** Place stay stich at 12 o'clock on cut penile skin edge. Cut needle and place suture tails on clamp.
+*****Use Metzenbaum scissors to dissect skin off of tunica albuginea. Use closed scissors and then spread. Then cut attachments.
-***Deglove penis
+******Be careful near urethra
-****Use Metzenbaum scissors to dissect skin off of tunia albuginea. Use closed scissors and then spread. Then cut attachments.
+*****Use gauze for blunt dissection
-*****Be careful near urethra
+*****Continue to deglove penis until area of fracture is exposed
-****Use gauze for blunt dissection
+**** Evacuate hematoma
-****Continue to deglove penis until area of fracture is exposed
+*****Dissection must be carried down until the hematoma within Buck's fascia is exposed and evacuated
-*** Evacuate hematoma
+****Identify defect
-****Dissection must be carried down until the hematoma within Buck's fascia is exposed and evacuated
+*****Proximal corpora is the most common site of rupture
-***Identify defect
+******Induction of an artificial erection with saline or colored dye may aid in locating the corporeal laceration.
-****Proximal corpora is the most common site of rupture
+*****Laceration usually transverse in direction
-*****Induction of an artificial erection with saline or colored dye may aid in locating the corporeal laceration.
+*****Obtain adequate exposure of defect
-****Laceration usually transverse in direction
+****Repair defect
-****Obtain adequate exposure of defect
+*****Repair defect in tunica albuginea with interrupted 2-0 or 3-0 PDS sutures.
-***Repair defect
+**** If urethral injury
-****Closure of the tunical defect with interrupted 2-0 or 3-0 PDS sutures is recommended.
+*****Partial urethral injuries should be oversewn with fine absorbable suture over a urethral catheter.
-*** If urethral injury
+*****Complete urethral injuries should be debrided, mobilized, and repaired in a tension-free fashion over a catheter.
-****Partial urethral injuries should be oversewn with fine absorbable suture over a urethral catheter.
+**** Test repair
-****Complete urethral injuries should be debrided, mobilized, and repaired in a tension-free fashion over a catheter.
+*****Apply tourniquet proximal to repaired defect
-*** Test repair
+*****Use a 25 Gauge butterfly needle to inject saline mixed with methylene blue into the corporal body distal to the defect
-****Apply tourniquet proximal to repaired defect
+*****If leak noted, place additional interrupted sutures.
-****Use a 25 Gauge butterfly needle to inject saline mixed with methylene blue into the corporal body distal to the defect
+****Repair Buck's fascia overlying defect
-****If leak noted, place additional interrupted sutures.
+****Obtain hemostasis
-***Repair Buck's fascia overlying defect
+****Reduce foreskin and reapproximate cut edges of skin with 4-0 chromic
-***Obtain hemostasis
+*****Start by placing stitches in 4 corners and leave tails long to use as handle
-***Reduce foreskin and reapproximate cut edges of skin with 4-0 chromic
+******Place box/U stitch in area of frenulum
-****Start by placing stitches in 4 corners and leave tails long to use as handle
+*****Position penis using stay stitches to align skin edges and perform interrupted stitches
-*****Place box/U stitch in area of frenulum
+****[https://www.ncbi.nlm.nih.gov/books/NBK535389/ Penile block]
-****Position penis using stay stitches to align skin edges and perform interrupted stitches
+*****Dorsal penile nerve block
-***[https://www.ncbi.nlm.nih.gov/books/NBK535389/ Penile block]
+*****Ring block
-****Dorsal penile nerve block
+****Apply dressing
-****Ring block
-***Apply dressing
 ***Post-operative management
 ****Therapy with broad-spectrum antibiotics