Emergency in Urology [Dr. Edmond Wong]

1
Urological EMERGENCY
Dr. Edmond Wong

2
Outline
• AROU
• Loin pain
• Hematuria
• Scrotal pain and swelling
• Priapism + paraphimosis
• Trauma
• Other infective complication
• Post-operative emergency

3
AROU
• 1st
time/ recurrent?
• Painful/ painless ?
• Since when?
• Previous LUTS ?
• Able to pass catheter? 1st
cath?
– < 500ml , think otherwise
– > 800ml , chronic retention
• Spontaneous / precipitating factor?
– UTI, clot, constipation , anticholinergic , recent surgery (pelvic ,
Gyn) , hemorrhoid, neurologic history
• Any neurological sign? LL weakness, back pain ,sensation
loss, double incontinence

4
Cause
Men:
•BPH
•Ca Prostate
•Urethral stricture
•Prostatic abscess
Women:
•Pelvic mass (fibroid)
•Pelvic organ prolapse
•Urethral stricture
(previous irradiation)
•Fowler’s syndrome

5
Causes
• Hematuria with clot retention
• Pain (increase adrenergic stimulation)
• Cauda equina compression (S2-4) (due to L2/3
or L3/4 PID)
• Radical pelvic surgery
• Pelvic fracture with urethral rupture
• Others: MS, herpes, DM , tabes dorsalis,
pernicious anemia

6
Physical examination
• General: Vitals, hydration status
• Abdomen : loin mass, bladder, pelvic mass
• Female: pelvic examination
• PR everyone: stool , anal tone, prostate size and
nodule
• LL neurology: power, sensation , reflex
• Specific test for S2-4:
– Bulbocarvenous reflux (BCR): squeeze patient glan
while doing a DRE , feeling contraction of anus
– In female: tugging the foley to BN while doing DRE

7
Management
• DAT? IVF?
• BP/P
• Foley to BSB, 1st
cath? What size? Hematuria? Turbid?
• Bld: CBP, LRFT, INR
• CSU,KUB
• Monitor I/O: post-obstructive diuresis
• Medication:
– BPH: hytrin 2mg nocte  TWOC in 2/7
– UTI  antibiotic
• Require BI?
• Neurological sign: x-ray L/S spine, consult O&T  MRI

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Loin pain
• Severe pain in the loin
• Colicky (waves of increase severity and
followed by reduction, but seldom goes away
completely)
• Radiation to groin, tip of penis
• Roll around in bed
• “ worse pain ever experienced”

9
Causes
• Ureteric colic
• Acute pyelonephritis
• Emphysematous pyelonephritis
• Xanthogranulomatous pyelonephritis
• The Bad Guys:
– Leaking AAA
– Pneumonia
– MI
– Torsion of ovarian cyst, etopic pregnancy
– All other intra-abdominal emergency

10
History
• 1st
time? Recurrent?
• Hx of stone disease ? Treatment ? Are the
stone clear ?
• Onset? Severity? Side?
• Fever? Chills ? Rigor?
• UTI symptom?
• Previous treatment? Pain killer, antibiotic ?

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• High fever? Septic ?
• Patient rolling around ? Or lying still ?
• Abd:
– Feeling the loin, mass?
– Abd: T, G, R, RT, bladder?
• External genitalia: palpate the urethra, testis
• Pregnancy test

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Mx: Renal colic
• DAT? NPO?
• IVF
• BP/P
• Bld: CBP, LRFT, Ca PO4, INR, Urate
• MSU/ CSU: microscopic hematuria, LE, nitrate , crystal
• KUB
• NCCT : non- contrast CT scan of the abdomen and
pelvis
• Need to drain? RFT, Temp, Pain, stone size
• Method of drainage? PCN vs JJ

16
Advantage of NCCT
1. Greater specificity (95%) & sensitivity (97%)
for dx of ureteric stone
2. Can identify other non-stone cause of loin
pain
3. No contrast injection need (RFT)
4. Faster (min)
5. Cost equivalent to IVU in high volume center

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Mx: Renal colic
• Medication: Pain relief
– Voltaren SR 100mg QD PO PRN (RFT)
– Pepcidine 20mg BD PO
– Pethedine 50mg Q6H IM PRN
• Medication: antibiotics ?
• Medication : Medical expulsive therapy (MET)
– Hytrin 2mg nocte PO / Harnal OSCAS 0.4mg nocte PO
– Not > 4 weeks
– Indication: unilateral mid/ lower ureteric stone , 5-10mm
– CI: sepsis , unresolving pain, derange RFT, complicated
stone disease , hypotension (SBP< 100)

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Do we need to over hydrate patient?
• Reason: increase urine output to “Flush” the
stone out ?
• In fact, renal blood flow and UO fall in episode
of obstruction
• Excess fluid excretion will cause greater
hydronephrosis  further impair peristalsis

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When is drainage required?
1. Pain that fails to respond to adequate
analgesics or recurrent pain
2. Associate fever and sign of sepsis (vitals,
WBC)
3. Impaired RFT (obstructed solitary kidney /
bilateral ureteric stone)
4. Obstructed stone > 4 weeks
5. Personal occupation reasons (pilot, control
machine, driver, etc)

20
PCN or JJ?
PCN
Advantage:
•Rapid decompression
•No manipulation of ureter to
flare up sepsis
•Low failure rate
•Monitor UO from kidney
•Accessible tract for future use
Disadvantage:
•Require radiologist
•Injury to other organs
•Nephrostomy bag
JJ
Disadvantage:
•Takes time to perform
•Manipulation of ureter (sepsis and
injury)
•Failure rate (impact stone)
•Fail to monitor UO
•NO accessible tract
Advantage:
•Performed by urologist
•Able to dilate ureter for future txn
•NO risk of injury to other organ
•Internal drainage

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PCN or JJ ?
• Neither modality demonstrate superiority in
promoting more rapid recovery after drainage
[Pearle JU 1998]
• PCN require antibiotics for shorter time and JJ
stent insertion was unsuccessful in 20% of
case [Mokhmalji JU 2001]

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Pyelonephritis
• Clinical diagnosis: Fever, flank pain &
tenderness + raised WBC
• Associated with lower tract UTI: frequency,
urgency, suprapubic pain, dysuria
• Risk factor: DM, immunosuppression ,
recurrent UTI
• Organism: E coli , Enterococci, Klebsiella,
Proteus, Pseudomonas

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Mx : Pyelonephritis
• DAT/NPO/IVF
• BP/P, Temp
• Foley to BSB, UO Q4h
• Bld: CBP, LRFT, Ca PO4, INR, Glucose , C/ST (fever)
• MSU/CSU x R/M + C/ST
• KUB: gas pattern , stone
• NCCT
• Medication:
– Panadol 500mg Q6H PO PRN if fever !!!!
– Levofloxacin 500mg Q24h PO or Ciproxin 500mg BD PO x 2/52
– Gentamicin 120mg IV x1 (after RFT come back normal and high
fever)
– Step up antibiotic if no response after 24 hours

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What to look for in NCCT ?
• Site: unilateral or bilateral
• Renal cortex: fxn or non fxn kidney
• Hydronephrosis
• Peri-nephric stranding
• Stone
• Abscess collection
• Gas inside renal pelvis or parenchyma 
emphysematous pyelonephritis

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What do you need to think?
• Is the patient septic ? Any need of HDU/ ICU ?
• Any evidence of pyonephrosis? Drainage ?
• Any evidence of perinephric abscess?
Drainage ?
• Emphysematous pyelonephritis ? Drainage or
nephrectomy?

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Emphysematous pyelonephritis

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When do we know it’s a complicated
pyelonephritis
• Patient is systemically very unwell (high fever,
shock)
• Does not response to IV antibiotic within 2-3
days
• Symptom of loin pain > 5 days before
admission

31
Xanthogranulomatous pyelonephritis
• Severe renal infection associate with
underlying stone and obstruction
• Result in destruction of renal tissue  non-
functioning kidney
• Organism: E coli , Proteus
• Pathology: Fat laden macrophages deposited
around abscess within parenchyma
• CT: grossly enlarged kidney with mass and
calcification , difficult to diff from RCC

34
Hematuria
• 1st
time? Recurrent? Since when?
• Recent history of uro surgery (TURP, TURBT, stone, ESWL)?
• PMH: malignancy, stone, bleeding tendency, TB
• Drug: aspirin , warfarin ?
• Able to pass urine? AROU ? Passage of clots?
• Whole/ early/ end stream?
• Painless/ Painful?
• Any trauma?
• Associated UTI symptom?
• Previous LUTS symptom?
• Symptom of anemia ?
• Loin pain, fever, chills, rigor, stone passage?
• Really hematuria? PV, PR, Post-menstrual spotting, Skin
abrasion ?

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• General: pallor, SOB, fever
• Vitals
• Abd: distended bladder? Loin pain or mass
• External genitalia, testis, urethral meatus
• DRE: prostate, mass, anal tone
• PV in female esp old and bedbound
• Look at the napkin, clot?

36
Causes
• General: bleeding disorder, medication
• Post-operative
• Pathology: malignancy, infection , TB, trauma,
stone
• Site: kidney , ureter, bladder, prostate,
urethra

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Management: hematuria
• DAT/NPO/ IVF
• BP/P, SaO2
• Bld: CBP, LRFT, INR (T&S?, C/ST?)
• KUB, CXR
• MSU/ CSU x RM + C/ST
• RU x1 (Foley to BSB if RU > 300ml)
• Save urine for inspection

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What to think next?
• Is the patient in shock ? Hypovolumic / septic?
• Does the patient require transfusion?
• Does the patient require clot evacuation ?
• Is bedside clot evacuation adequate ?
• Does the patient need an operation?

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Hematuria workup
• Other than the blood test
• KUB
• EMU x AFB x2
• Urine for cytology x 2
• MSU x RM + C/ST
• USG urinary system
• Early flexible cystoscopy

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Scrotal pain and swelling
• Age of the patient ?
• 1st
time? Recurrence?
• Onset? Sudden, gradual
• Progressive? Resolving?
• UTI symptom, AROU , LUTS, urethral discharge
• Trauma
• PMH: STD, orchidopexy before

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Cause
• Testicular torsion
• Torsion of the appendix testes (Torted hydatid of Morgagni)
• Acute epididymitis / orchitis
– Mumps orchitis
– Idiopathic scrotal edema (under 10 years of age)
– Varicocele
– Scrotal haematoma
– Incarcerated hernia
– Appendicitis
– Systemic disease (Henoch-Schönlein purpura)
• Hemorrhage of a testicular tumor

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• General: pain , vitals?
• Abdomen : full bladder , mass ?
• External genitalia:
– Scar for previous operation
– Torsion: Tender testis, horizontal lie, high-riding
testis, mild erythema of scrotal skin
• Absent cremasteric reflex (Rabinowitz’s sign)
– Epididymal-orchitis: swollen epididymis and testis
• Elevation of testis relief pain (Prehn’s sign)

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Mx: Scrotal pain and swelling
• DAT/ NPO/IVF
• BP/P, vitals
• Bld: CBP, LRFT, INR (C/ST)
• MSU/CSU: may not be +ve
• Urethral swab for gonorrhoea
• USG Doppler: Sn 70%, Sp 97-100%, PPV 100%, NPV
97%
• USG may be misleading if pain < 48 hour
• Useful if pain > 48hr (to see if testis necrotic)
• Radionuclide scanning (not during emergency)
– SV 98% , SN 100%

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Scrotal USG
• May also show a misleading arterial flow in
the early phases of torsion and in partial or
intermittent torsion
• Persistent arterial flow does not exclude
testicular torsion
• Better results were reported using high-
resolution ultrasonography (HRUS) for direct
visualization of the spermatic cord twist with a
sensitivity of 97.3% and a specificity of 99%

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Mx: Scrotal pain and swelling
• Acute epididymitis / orchitis
– Levofloxacin 500mg QD for 2/52
– STD? add Doxycycline 100mg BD x 1/52 (C.
trachomatis)
– Adequate pain relief: Panadol / Tramadol
– Book early USG scrotum
– Urgent USG scrotum in case of abscess formation
– Inform patient that swelling will not resolve until
4-6 weeks, and probably may not resolved
completely

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Testicular torsion
• Hx: acute onset, radiate to groin
• P/E: high riding, horizontal lie, absent
cremasteric reflex, fever with erythema
scrotal skin
• Investigat: -ve dipstick, doppler may show
hyperemia in the first 24 hour
• Bimodal distribution: 1 yr, 12-18yr

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Testicular torsion
• Intravaginal : most common adolesent & adult
– Congential high investment of the tunica
vaginalis “Bell-Clapper deformity”
– Testis and cord rotate more readily
– Often bilateral
• Extravaginal: more common in 1yr
– attachment btw TV and scrotum is loose
– Incomplete fixation of gubernaculum to scrotal
wall

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Mx: Testicular Torsion
• If in doubt  Explore !!!!!!
• Manual detorsion ? Probably not
• Early exploration: within 6 hr from symptom
• Urgent surgical exploration is mandatory in all cases of
testicular torsion within 24 hours of the onset of
symptoms
• Cag A: Scrotal exploration +/- bilateral orchidopexy +/-
orchidectomy

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Consent of scrotal exploration
1. Hematoma
2. Wound infection & subsequent orchitis
3. Bilateral orchidopexy: 40% chance of torsion in
contralateral side
4. Orchidopexy: non absorbably suture maybe palpable
5. Orchidectomy for non-viable testis to avoid abscess ,
sinus and anti-sperm antibody
6. No fixation if no torsion is found : avoid breach of
blood testis barrier (anti-sperm antibody)
7. Not affect fertility if contralateral testis normal but
no guarantee of fertility
8. Small risk of testicular atrophy
9. Small risk of retorsion despite fixation (5%)

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Scrotal exploration
• Midline scrotal incision
• Skin, dartos, ESF, CF, ISF, TV
• Testis deliver: inspect color, appendix
• No torsion  don’t fix & no need contralateral exploration
• Torsion  untwisted & look
– Viable  Bilateral orchidopexy (3 pt fixation with NA suture or dartos
pouch)
– If in doubt:
• Wrap it in warm saline gauze and wait 10min
• Open TA : observe bleeding  salvage
• Non-viable: orchidectomy and transfix at cord
• Torsion of testicular appendage: Remove testicular
appendage

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How about torsion of appendixHow about torsion of appendix
testis?testis?
• Torsion of the appendix testis can be managed
conservatively
• During the six-week-follow-up, clinically and
with ultrasound, no testicular atrophy was
revealed
• Surgical exploration is done in equivocal cases
and in patients with persistent pain

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Gangrenous testis
Torsion of testicular
appendages

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Priapism
• Definition:
– Persistent erection > 4 hours
– Not related to sexual desire (anymore)
• Types:
– Non-ischaemic (Arterial , high flow)
– Ischemic (Venous , low flow)
– Stuttering (intermittency , ischaemic)
• Two age group:
– 5-10 yo
– 20-50 yo

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Presentation
• FOUR Main questions:
1. Duration of erection > 4 hours?
2. Painful / non painful ? (Ischemic vs
nonischemic)
3. Previous history of priapism
4. Predisposing factors
• Physical examination:
– Rigid corpora cavernosa
– Flaccid Corpus spongiosum and glans penis

62
Investigation
• Blood: CBP, Hb/electrophoresis (SSD)
• Urine: C/ST , toxicology
• Penile blood gas:
– Aspirate blood directly from either corpora
• Duplex USG of carvernosal arteries:
– Ischemic ( inflow low or absent)
– Non ischemic (inflow normal or high)
• Penile pudenal arteriography: not readily available
Appearance pH PO2
(mmHg)
PCO2
(mmHg)
Low flow Dark red <7.25 <30 >60
High flow Bright red = 7.4 >90 <40

63
Treatment
• Conservative
• Medical
• Minimally invasive
• Surgical treatment
• Always warn patient about the possibility of
impotence

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Mx: Priapism
• NPO/IVF
• BP/P Q1h
• Bld: CBP, LRFT, INR, T&S, ABG
• MSU x RM + C/ST
• Penile blood gas
• Inform senior !!!

67
Shunt for Priapism
• Distal shunt
– Winter (large biopsy needle , corporo-glanular)
– Ebbehoj (Scalpel, corporo-glanular)
• Lue’s modification “T-Shunt” (scalpel, corporo-glandular)
– El-Ghorab: piece of tunic albuginea excised at tips of
coprora via a dorsal transverse incision just distal to
corona
• Proximal shunt:
– Quackels /Sacher (corporo-spongiosal)
– Grayhack (corporo-saphenous)

72
Cavernosography
• Indication:
– evaluate venous problems in men with ED
– Investigation of priapism (high ﬂow)
– Assessment of penile fractures/injury to assess
cavernosal damage
– Assessment of Peyronie’s disease (rarely used)
• Contraindication:
– Hx of contrast allergy

73
Carvernosography
• Two 19–22 G butterﬂy needles inserted into the
corpora
• 60-100ml Omnipaque or urograffin infused slowly to
obtain penile pressure 90mmHg
• If penis not erection , contrast leakage
• Fluoroscopy: AP , Rt, Lt oblique view
• Normal: no contrast visualized outside the 2 corpora
cavernosa
• Abnormal: Contrast leakage or significant curvature
• Patient asked to squeeze penis for 5min to ensure
complete emptying

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• Advantage: more sensitive and accurate
compare to doppler USG for venous leakage
• Disadvantage:
– Invasive
– Can be painful
– Risk of infection
– Contrast related fibrosis within corpora
– Risk of priapism

76
Paraphimosis
• Definition:
– Foreskin retracted from over the glans of penis
– Cannot be pulled back over the glans into normal
anatomical position
• Teenagers and young men
• Elderly men after catheterization
• Occur in phimostic foreskin but also in normal
foreskin

78
Presentation
• Do you have previous circumcision before?
• Are you able to retract the foreskin usually?
• How long has the condition been?
• Physical examination:
– Painful oedematous foreskin
– Engorged with edema fluid
– Small area of ulceration if left for few days

79
Treatment
• Direct pressure
• “Ice-glove” method
• Graulated sugar
• Hyaluronidase injection
• Dundee technique [Reynard and Barua 1999]
• Dorsal slit

80
Management
• Direct pressure on foreskin and attempt
reduce over copious lubricant
• “Ice-Glove”:
– Lignocaine to glans and foreskin
– Place water & ice in glove and tie knot (base and 4
fingers)
– Place thumb of glove over penis
– Allow reduce swelling and reduction

81
• Granulated sugar:
– Reduce edema by osmotic effect
– Sugar placed in condom or glove applied over
head of penis
– Reduction may take several hours [Kerwat 1998]
• Hyaluronidase injection:
– 1 ml ;150U/cc
– 25 g needle into prepuce
– Breakdown hyaluronic acid decrease edema

82
Dundee technique
• Reynard and Barua 1999
• Oral cirpoxin 500mg PO x1
• Ring block: 10ml 1% lignocaine / 10-20ml 0.5% Marcine to skin at
base of penis
• Wait for 5 min
• Touch skin to ensure well anaesthetised
• Clean skin with antiseptic solution
• Use 25-gauge needle: 20 puncture into edematous foreskin
• Firmly squeeze foreskin  force fluid out /small jet
• Once foreskin decompressed easy to reduce
• Discharge pt with 7 day course of ciproxin
• Recommend daily bath with cleaning of skin
• Elective cricumcision

84
Dorsal slit
• GA or ring block
• Longitudinal Incision in the tight band of
constricting tissue
• Pull back and check it can move easily over
the glans
• Close incision transversely to lengthen
circumference

85
Circumcision
• Avoid immediate circumcision for gross
distortion can make it difficult and lead to less
than perfect cosmetic result

87
Trauma
• Kidney
• Ureter (on table consult)
• Bladder
• Urethra
• Penis
• Scrotum

88
Shock
• Grade 1
– Up to about 15% loss of effective blood volume (~750ml in an average adult who is
assumed to have a blood volume of 5 liters).
– Mild resting tachycardia and can be well tolerated in otherwise healthy individuals.
• Grade 2
– Between 15-30% loss of blood volume (750-1500ml) will provoke a
– moderate tachycardia and begin to narrow the pulse pressure.
– (capillary refill time) will be extended
• Grade 3
– At 30 - 40% loss of effective blood volume (1500 - 2000 ml)
– the compensatory mechanisms begin to fail and hypotension, tachycardia and low urine
output (<0.5ml/kg/hr in adults) are seen
• Grade 4
– At 40-50% loss of blood volume (2000 -2500 ml) profound hypotension will develop and
if prolonged will cause end-organ damage and death

89
Renal Trauma
• Kidney is a retroperitoneal structure and well
protected (perirenal fat, vertebral column,
spinal muscle, lower ribs, ant abd content )
• Considerable force is require to injury a kidney
• Look out for associated injury (spleen , liver,
bowel mesentry, etc)
• High index of suspicious
• Children more prone to renal trauma: relatively
greater size of kidney & small protective muscle
mass

91
Renal trauma
• History
– Mechanism of injury: rapid deceleration event (fall, high-
speed motor vehicle accidents) or a direct blow to the flank
– Penetrating: knives, gunshots, iatrogenic (PCNL)
– Pre-existing renal disease
• Physical exam
– Hemodynamic stability
– Hematuria, flank pain, bruising and abrasion, fracture ribs,
abdominal distension, mass and tenderness
• Laboratory exam:
– Urinalysis: micro hematuria: >5RBC/HPF or dipstick +ve
• Management:
– If stable  conservative ? Indication for CT?
– If unstable  OT

92
Renal trauma
• Realtionship btw presence , absence and degree of
hematuria and severity of trauma is not absolute
• Gross hematuria is absent in 40% of renal injury and
20% of pedicle injury
• Penetrating injury ant to ant auxiliary line  more
renal pedicle injury

93
Renal trauma
• Blunt (90%) and penetrating (10%) trauma

94
Renal trauma: Indication of CT
1. All penetrating injury
2. Blunt injury in adult associated with micro
hematuria and shock (SBP <90mmHg at any
1x )
3. Blunt injury in adult associated with gross
hematuria
4. Rapid Acceleration/ Deceleration injury (fell
from height)
5. Blunt injury in children associated with
micro-hematuria

95
CT: phase
• CT with Urogram phase:
• Arterial and/or portal venous phase:
– Vascular and parenchymal injury
– Hematoma
• Delay image: (10-20min)
– PUJ and collecting system

96
What to look for in CT?
• How deep is the parenchymal laceration?
• Does the kidney enhance ? Is it perfused?
• Is there extravasation of urine?
• How big and where is the retroperitoneal
hematoma?
• State of contralateral kidney ?
• Any other organs injury ?
• Preexisting pathology of the kidney?

97
Sinister sign
• CT finding suggestive of collecting system or
vascular injury
1. Absence of enhancement of parenchyma
2. Hematoma medial to the kidney
3. Extravasation of contrast suggest disruption
of the PUJ or renal pelvis

98
Grade I
Grade II
Grade III
Grade IV
Grade V

99
• Grade I
• Grade IV
• Grade V

100
Renal trauma: Management
• Conservative:
– 95% of blunt injury
– 50% of penetration injury
– 25% of gun shot wound
– Bed rest, T&S, repeat imaging 2-4 days
• Urinary extravasation:
– Not an indication for exploration unless also bowel injury
– JJ stent if substantial contrast extravasation
– Drain urinoma
– Or repair if peresistent leakage
• Devitalized segment: usually do not require exploration

101
What is conservative treatment?
• Stable patient
• Bedrest
• Prophylactic antibiotics
• Continuous monitoring of vital signs until
haematuria resolves
• Repeat imaging
–Fever, worsening loin pain, or dropping
haematocrit

102
Indication of renal exploration
1. A life-threatening hemodynamic instability likely
due to renal origin
2. Expanding or pulsatile perirenal hematoma
identified at exploratory laparotomy performed for
associated injuries
3. Grade V blunt injury/ Grade IV-V penetrating injury

103
What are the relative indications for
renal exploration?
• Coexisting bowel or pancreatic injuries
• Persistent urinary leakage or perinephric
abscess with failed endoscopic or
percutaneous treatment
• Renal vascular injury failed angiographic
treatment

104
On-table consult : unstable pt with retroperitoneal
hematoma, what is your approach?
• If expanding  explore
• Non expanding : Exploration increase chance of loss of kidney
(bleeding can be control only by nephrectomy)
• Decision depends on pre-op or on-table imaging
• If not expanding + no previous imaging  I will arrange one-shot
IVP
• Purpose:
– Presence or absent of renal injury (if the retroperitoneal hematoma is
cause by renal insult)
– Presence of normally functioning contralateral kidney
• How to do? 2ml/Kg contrast , single AXR at 10min (not C-arm pls)
• What next?
– If normal  no need to explore
– If abnormal  explore , prepare for nephrectomy

105
• If not expanding but with previous imaging:
– Imaging normal / abn but with single fxn kidney
• Left alone
– Imaging abnormal + contralateral kidney normal
• Explore , evacuate hematoma & repair injury

106
Principle of renal exploration
• Midline long incision
• Expose retropenritoneum by lifting the small bowel
out
• Incise peritoneum over aorta above the IMA and
dissect along it superior to left RV
• If large hematoma obscure  incise medial to IMV
• Identified left and Rt renal arteries
• Place vessel loops for early vascular control
• Reflect colon to expose kidney
• If salvagable controlled bleeding and debride non-
viable tissue

109
Mx of renovascular injury
• Arterial injuries: irreversible damage after 2-6hr
– Conservative: intimal flaps
– Reconstruction: solitary kidney , bil renal injury
– Angioembolisation : segmental injury
– Elective nephrectomy
• Venous injuries:
– Rare and difficult to identified
– Avulsion from IVC  nephrectomy + IVC repair
– Or tie renal vain and kidney drain by gonadal and adrenal
vein

110
What is the follow-up?
• Primary conservative management is associated with a
lower rate of nephrectomy without any increase in the
immediate or long-term morbidity. The failure of
conservative therapy is low (1.1%) (EAU 2010)
• Repeat imaging 2-4 days after trauma minimizes the
risk of missed complications
• Within 3 months of major renal injury, patients’ follow-
up should involve: physical examination, urinalysis,
radiological investigation, blood pressure
measurement, renal function test
• Long-term follow-up should be decided on a case-by-
case basis but should at the very least involve
monitoring for renovascular hypertension

111
Renal trauma: Complication
Early Delayed
Bleeding Bleeding
Infection Hydronephrosis
Perinephric abscess Stone formation
Sepsis Chronic pyelonephritis
Urinary fistula AV fistula
Urinary extravasation Pseudoaneuysms
Urinoma Hypertension (Goldblatt kidney)
Hypertension (Page kidney) Renal insufficiency
• AVF: Dx by arteriograpby Tx: arterial embolization
• Page kidney – perinephric hematoma compression
• Goldblatt kidney - perinephric scar formation or renal artery
stenosis

112
What is the mechanism of associated
hypertension?
• Acutely as a result of external compression from
peri-renal haematoma (Page kidney)
• Chronically because of compressive scar formation
(Goldblatt kidney)
• Renin-dependent and associated with parenchymal
injury
• Arteriography is informative in cases of post-
traumatic hypertension
• Treatment - medical management, excision of the
ischaemic parenchymal segment, vascular
reconstruction, or total nephrectomy

115
Ureteric injury
• You are call by Gyn surgeon for suspected ureteric injury
during operation
• What is your approach?
• Identify types of injury:
– Complete transaction
– Destruction: ligation , crushing , devascularization , thermal
injury
• To identified the ureter:
– Ensure adequate exposure, lighting and retraction
– Direct inspection of ureter
– Extravasation After Injection of Methylene Blue into the Ureter
or Collecting System
– On-Table Intravenous Urography (difficult)
– On-table Retrograde Ureterography: stab wound in bladder or
cystoscopy

116
On table I will:
• Look at the operative field carefully
• Look at the specimen carefully
• Injection IV indigo-carmin  when dye reach
foley , look for leakage at the operative field
• Still fail: do a cystoscopy + bilateral RP 
watch for ureteric jet  catheterize both
ureter and inject dye +/- contrast

118
What next?
• Depends on the site and severity of injury
• Crushing , contusion , ligation or partial tear:
– If identify immediately  release suture + Stenting
– Repair with non-absorbable suture
– If in doubt , trim the end then attempt UU
– If cannot : definitive repair or ligate with long suture and drain
the upper tract (pt unstable)
• Transacted:
– Ureteroneocystostomy
– UU
– TUU
– Other means: psoas hitch or Boari flap (see female urology)

119
Mx
• Grade I & II:
– Ureteral stent or PCN
– Foley 2 days to limit reflux
– IVU 3-6m
• If grade II/ III injury encountered in exploration
– Primary closure of ureteral ends over a stent
– External, non suction drain adjacent to injury
• Grade III to V injury
– Reconstructive repair procedure depends on
– nature and site of injury

124
What is the indication of
autotransplantation?
• Complete ureteral disruption
• In the presence of coincidental
gastrointestinal disease
• Or impaired renal function

125
What is the indication of immediate
nephrectomy?
• Ureteral injury complicates the repair of an
abdominal aortic aneurysm or other vascular
procedure in which a vascular prosthesis is to
be implanted
• Immediate excision of the corrupted renal
unit and its damaged ureter leads to less
chance of urinary leak, urinoma, sepsis and
graft infection

126
What is the role of endoscopic
treatment for ureteric stricture?
• Either incision or balloon dilatation
• Successful rate was quoted up to 75%
• ≥2cm has high failure rate

127
Bladder trauma
• Iatrogenic:
– TURP/ TURBT/ Cystoscopy + bx
– Gyn surgery: C section, sling surgery
• Accident:
– Penetrating trauma to lower abd or back
– Blunt pelvic trauma with pelvic fracture
• Rare:
– THR
– Rapid deceleration with full bladder
– Spontaneous rupture after bladder augmentation
• Extraperitoneal vs intraperitoneal

128
Bladder trauma
• 10 % pelvic fracture asso with bladder injury
• 80% of bladder injury due to pelvic fracture
• Associated with AP compression fracture
• 60% extraperitoneal
• 30% intraperitoneal
• 10% combine

130
Bladder trauma
• History: classic Triad
1. Suprapubic pain
2. Difficulty passage of urine
3. Hematuria
– Recent Uro or gyn surgery
• P/E:
– Abdominal distension
– Absent bowel sound (ileus)

131
What is the approach of bladder
injury?
• Pelvic # + classic triad: lower abdominal pain +
haematuria + retention of urine → immediate
cystography
• Pelvic # + microscopic haematuria > low incidence of
bladder injury > no need for cystogram
• Blood at meatus → retrograde urethrogram
• Cystogram
– Bladder fill with 350ml contrast
– plain film, filled film and post-drainage films
• CT cystogram
– Require retrograde bladder filling with 350ml contrast

132
Bladder trauma
Investigation:
• Cystogram
– Bladder fill with 350ml contrast under gravity (children 60ml +
30mlx age)
– plain film, filled film and post-drainage films
• CT cystogram
– Require retrograde bladder filling with 350ml contrast (50:50)
Extraperitoneal: contrast limited to area surrounding bladder
• Intraperitoneal: loops of bowel maybe outline by
contrast
Management
• Extraperitoneal: catheter drainage (2w) + antibiotic
• Intraperitoneal, penetrating injury: surgery

133
Extraperitoneal Intraperitoneal

134
Extraperitoneal
Intraperitoneal

135
When is surgery require in extraperitoneal injury?
1. Associate posterior urethral injury where
open cystostomy is needed for SP catheter
placement
2. CT show bone spike protruding into bladder
3. Associated rectal injury require repair
4. Open fixation of pelvic fracture while urine
may cause infection of metal plate
5. Clot retention
6. Persistent extravastion

136
What if bladder injury missed?
1. Urinary ascites
2. Peritonitis
3. Ileus
4. Systemic sepsis
• BN involved:
1. Incontinence or stricture
2. Recto/colovesical fistula
3. VVF

138
Urethral injury
• Posterior urethra
– Prostatic
– Membranous
• Pelvic Fractures
• Anterior Urethra
– Bulbar
• Straddle injuries
– Penile

140
Goldman Classification of urethral
injury

141
A simpler Classification of posterior
urethral injury
• Recommended by Consensus on GU 2004
– Posterior urethra stretched but intact
– Partial disruption
– Complete disruption
– Complex (involves bladder neck / rectum)

142
Posterior urethral injuries - classification
• Type 1
– Stretching and elongation of urethra
– Due to pelvic haematoma & puboprostatic lig. disruption
– No disruption of urethra
• Type 2
– Complete or incomplete disruption
– Membranoprostatic junction
– Tear above intact urogenital diaphragm
• Type 3
– Complete or incomplete disruption
– Extension of injury to bulbar urethra
– Contrast above & below disrupted urogenital diaphragm

144
Posterior urethral injury
• Pelvic fracture:
– Run over or crush injury
– 20% mortality as bleeding can be severe
• P/E:
– Bladder injury: SP pain , ROU Abdomen distension, Gross hematuria
– PU injury: Blood at meatus, ROU, Palpable bladder
– Perineal or scrotal bruising
– DRE: high riding prostate, blood on glove (rectal injury), pelvic hematoma
• Management:
– ATLS: Vitals sign, LL examination, other associated injury
– Stabilize the patient
– Mechanism of injury ? Any bladder or urethral injury
– Fracture stable or unstable?
– Doest it need external fixation?

146
Tile classification of pelvic ring fracture

147
Pelvic fracture
• Unstable fracture: need fixation
– B1 (open book): 10-20%
– B2 /B3 (Closed book): 70%
– C: 10-20%
• Open book B1:
– Disruption of pubis symphysis, Ant scaroiliac L &
sacrospinous L
– AP compression injury
– Damage of bladder
• Closed book B2/3:
– # pubic rami with ilium and sacral wing compression
– Lateral compression injury
– Damage of posterior urethra

148
Open book fracture Close book fracture

149
Mechanism of injury to PU
• Essential the membranous urethra
• Shearing effect of bone disruption
• Prostate which is attached to puboprostatic
ligments move in one direction
• Membranous urethra , which is attached to
urogenital diaphragm , move in another
• PFUDD (Pelvic fracture urethral distraction
defect)

150
Injury asso with pelvic fracture
• In pelvic fracture:
– 10% have asso bladder injury
– 5-15% have asso memebranous urethral injury
– Combine 0.5%
• Bladder rupture due to blunt trauma
– 85% due to pelvic fracture
– 10% fracture of proximal femur
– 5% no bony injury

151
Management:
• Posteior: usually with pelvic fracture (90%)
– Stretching (25%)
– Partial rupture (25%)
– Complete disruption (50%)
• Investigation:
– CT abd + pelvis with contrast
– Retrograde urethrogram +/- cystogram (with draining film
to exclude BN injury)
• Gentle attempt at urethral catheterisation x1 !!!! if
no blood at meatus
• If failed  SP insertion under USG

152
‘Pie-in-the-sky’ bladder

153
Advantage of open cystostomy + SP
• Opening of bladder allow inspecting for
bladder injury and repair
• Bladder pushed upward by large pelvic
hematoma , difficult percutaneous SP
insertion
• A large size catheter is require for drainage of
hematuria

154
Management: PFUDD
• Initial management: SP + antibiotic
• If on SP found blood stained urine
– cystogram and deal with bladder injury accordingly
• If SP show clear urine :
– Up and downogram 8 weeks
– Repair 3 months (deferred txn)
• Why deferred txn:
– Let pt recover from major trauma
– Allow pelvic hematoma & urine to resolved 
reduce length of defect

155
Definitive mx: PFUDD
• Bulbo-prostatic anastomotic urethrplasty
(BPA) / Transperineal progressive approach
• Some times need abd + perineal approach
1. Urethral mobolization
2. Seperation of corporal bodies
3. Inferior pubectomy
4. Supracorporal urethral rerouting
• Defect up to 7cm can be dealt with

156
Outcome
• Success : 95%
• Recurrence: < 10%
• Incontinence: 5%
• ED : 20%

157
PFUDD – Deferred treatment
• 82 patients transperineal anastomotic urethroplasty
– 1,5,10 yr results
– 7,12&12%
Mundy 1996 Br J Urol 78: 243-247
• 600 pts transpubic /transperineal urethroplasty
– 5, 10 yr results
– 5, 7%
Turner -Warwick 1989

158
Role of early urethral realignment in
PFUDD?
• Immediate open repair:
– Re-stricture : 70%
– ED: 40%
– Incontinence : 20%
• Same poor result with endoscopic realignment
• Only indication for early realignment:
– Concomitant bladder neck or rectal injury
– Immediate open exploration & repair
– High risk of incontinence in BN involvement

159
Options of Acute mx of PUI
• 1st
determine if partial of complete tear
• 2nd
if any indication of open surgery for other reason
(Rectal injury and BN injury)
• Partial tear:
– SP or urethral foley
– 2w AU see if healing occur or stricture
– Stricture:
• < 1cm  Optical urethrotomy
• > 1cm  AU

160
Complete tear
• Controversies: Primary alignment (endo or open) or
delay repair
• 1st
, for male , do not perform:
– Immediate open urethroplasty (no indication)
– Delayed primary urethroplasty (within 2w) , that is for
female
– Delayed endoscopic incision of scar (cut-into-the-light) 
rarely indicated
• Thus the two only options are:
– Delayed formal urethroplasty (Gold standard)
– Primary realignment (open of endoscopic)

161
Primary realignment
• Aim: to realign only , no anastomosis done
• If no rectal or BN injury: primary endoscopic realignment:
– Put in SP in acute setting
– Endoscopic guided realignment within 1 week
• If rectal or BN injury: open realignment:
– Passing catheter across defect without tying suture anastomosis
– Together with rectal or BN repair & evacuation of hematoma
• Benefits:
– Lower stricture than delay repair (30% does not require 2nd
operation)
– Scarring can be managed with endoscopic procedure or dilatation
– Prostate and urethra are aligned
• Disadv:
– More ED and incontinence

162
Delay urethroplasty
• Procedure of choice and gold standard for PFUDD
• Initial SP & delay repair at 3-6m after surgery
• Preop workup:
– Urine C/ST, x-ray pelvis
– FC (stone, condition of anterior urethra)
– AU and DU (access defect & BN function)
• Adv:
– Allow healing of injury and hematoma resolve
– Allow descend of prostate to more anatomical position
• Disadv:
– SP long time

163
Comparison of result: Koraitim
Immediate or
early realignment
Primary repair Delay repair
(Gold standard)
Stricture 50% 50% 97%
Incontinence 5% 20% 5%
ED 40% 60% 20%
Restricture/ need
of urethroplasty
33% <10%

164
Post urethral injury in men

167
Anterior urethral injury
• Causes:
1. Straddle injury (bicycle, cross road)
2. Direct injury to the penis
3. Penile fracture
4. Iatrogenic: inflating catheter balloon in the
ant urethra
5. Pentrating injury

168
A Simpler Classification of Anterior
Urethral injury
• Recommended by Consensus on GU 2004
– Partial disruption
– Complete disruption

169
Management:
• Presentation:
– Blood at meatus
– Difficulty passing urine
– Frank hematuria
– Perienal / scrotal hematoma (butterfly-wing pattern)
• Investigation: Uretrograde urethrogram
– Pt lie at 30-45 degree oblique
– bottom leg flexed at hip & knee, top leg completely straight
– Fr 12 foley at navicularis , 2ml balloon
– Brodney clamp
– 20-30ml full-strength water solube contrast (Urografin150)
inject slowly

172
Butterfly hematoma
Anterior wall Layer: from superficial to deep
• Subcutaneous fatty laser : Camper’s fascia
• Underneath is the Scarpa’s fascia:
• Insertion of Scarpa’s/ Colles’ fascia which continue with
Dartos fascia in the penis:
– Superior: coracoclavicular ligaments
– Inferior: deep fascia of thigh (fascia lata)
– Medial: continue with Colles’ fascia in perineum (posterior
edge of UG diaphragm and perineal body, inf pubic ramis,
Dartos fascia of penis and scrotum)
• In the penis , Buck’s fascia lie beneath Dartos fascia :
– Attached to base of glans, pubic rami, ischial spine and
tuberosities
• Tunica albuginea : cover the 2 copora & spongiosum

174
• Anterior urethral rupture:
– Buck’s fascia intact (e.g penile fracture)
– Hematoma confined to sleeve-like or tubular formation
along length of penis
• Buck’s fascia breached:
– Extravasation limited by attachements of Colles’ fascia
– Lateral : ischiopubic rami
– Posterior: UGD , Perineal body
– i.e BUTTERFLY shaped
• Posterior urethral injury:
– Only associated with butterfly distribution if urethral
disruption with tear below UGD into the bulbar urethra

176
Retrograde urethrogram
• Blood at meatus, no contrast extravasation
– Urethral contusion
• Contrast extravasation + contrast in bladder
– Partial rupture of anterior urethra
• Contrast extravasation + no filling of posterior
urethra or bladder:
– Complete anterior urethral disruption

177
Management
• Urethral contusion:
– Foley to insertion (Fr 12) , removed in 1 week
• Partial urethral rupture:
– Suprapubic catheterization + Antibiotic
– Up and downogram after 2 weeks
– 70% healed without stricture formation
– Stricture: Optical urethrotomy / Anastomotic urethroplasty
• Complete urethral rupture:
– Suprapubic catheterizationn + antibiotic
– Delay repair 3m:
• < 2cm anastomotic urethroplasty
• > 2cm : augmented anastomotic urethroplasty or Barbagli procedure
• Immediate surgical repair of anterior urethral injury is
only indicated in penile fracture or when there is open
wound (penile injury)

178
Ant urethral injury in men

185
Penile injury
• Cause and mechanism:
– Penile amputation (Accidental / self inflicted)
– Knife and gunshot wounds
– Penile fracture
• Diagnosis is usually obvious
• Always look for associated urethral injury

186
Skin
Dartos
Bucks Tunica albuginea

188
Penile amputation
• If penis can be retrieved (not thrown away)
• Place in wet swab inside plastic bag , then
place in another bag contain ice (bag-in-bag)
[Aboseif et al , 1993]
• Prolong survival from 6 to 24 hr
• Watch for shock as bleeding
is profuse

191
Anatomy of the penis
• Artery supply:
– Hypogastric A  internal pudendal A  common penile A
 multiple bifurcation
– Supply: corpus spongiosum , urethral , corporal bodies and
glans penis
• Venous drainage:
– Superficial dorsal system
– Deep dorsal system
– Crural vessels
• Corporal cavernosa  periprostatic plexus

192
Surgical reimplantation
• Keep patient warm and well hydrated
• Urethra repair first over a catheter (base)
• Close the tunica albuginea (4/0 abs)
• Anastomosis of dorsal artery of penis (11/0
nylon)
• Anastomosis of dorsal vein (9/0 nylon)
• Dorsal penile nerve (10/0 nylon)
• Repair of cavernosal arteries : technical difficult
and does not improve outcome
• SP catheter for additional security

193
If distal end not available
• Obtain hemostasis
• Usually skin is loss but not erectile body
• Primary grafting with STSG
• Neomeatus must be wide spatulated

195
Knife & Gunshot wound to penis
• Associated injuries is common (scrotum, major
vessels of LL )
• Primary repair in majority
• Remove debris from wound
• Derided necrotic tissue but not excessive (superb
vascularity)
• Repair tunica of corpora with suture (knot
buried)
• Repair anterior urethra over catheter with
absorbable sutures
• Board spectrum antibiotic

197
Penile fracture
• Definition:
– Traumatic rupture of tunica albuginea of the erect penis
– Result rupture of one or both corpora cavernosa
– Corpus spongiosum & urethra may also rupture
• Cause:
– Vigorous sexual intercourse
– Masturbation
– Forced bending of erect penis
– Mechanical trauma to erect penis
• Tunica Albuginea thinning (2mm  0.25mm) during
erection
• More vulnerable to rupture
• Involved urethra in 10%

198
History
• Forcible contact of erect penis with female
pubis
• Hearing a sudden snap or popping sound
• Sudden onset of pain and detumescence of
erection

199
Examination
• Penis: swollen and bruised
• If Buck’s facial rupture  bruising in butterfly
pattern
• Tender , palpable defect over site of tear
• Urethral damage: blood at meatus /hematuria
• Pain on voiding / AROU

200
Investigation
• Urine dipstick: Microscopic hematuria
• If +ve / dysuria / AROU  Retrograde
urethrogram (commonly done)
• Penile USG: difficult to interpret in edema
• MRI : demonstrate presence and site of
• Cavernosography : intracorporeal injection of
contrast rupture (not use anymore)

201
Treatment
• Conservative:
– Application of cold compression to penis
– Analgesic , antinflammatory drugs
– Abstinence for 6-8 weeks
• Surgical:
– Expose fracture site (degloving the penis via cricumcing
incision / direct over defect)
– Evacuation of hematoma
– Closing defect in tunica (bury knot)
– Non absorble suture may asso with prolong post-op pain
(Asgari 1996)
– Repair urethral rupture if present with spatulated single or 2
layer urethral anastomosis (only time when urethral injury is
repair immediately
– Urethral catheter x 3weeks

202
Surgical treatment
• In case urethral rupture:
– Repair at the same time as tunica (Marsh 1999)
– Spatulated 1 or 2 layer urethral anastomosis
– Catheter left for 3 weeks
• In short: trend towards conservative mx
• No RCT , but conservative may have higher
complication:
– Penile deformity
– Residual penile mass (scar tissue)
– Prolong penile pain
– Pulsatile cavernosal diverticulum

203
Other Penile injuries
• Animal or human bites
• “zipper’ injuries
• Industrial accidents (saw or crush injuries)
• Any thing can happen will happen

204
Mx of “Zipper” injury
• Lubricate zip with K-Y jelly
• Gently attempt to open
• If failed  cut the zipper out  spread apart
with pair of surgical clips on either side

206
Testicular trauma
• Causes:
– Blunt: sports, RTA, assaults, self-inflicted
– Penetrating: gunshot, knife, bomb blast
• History: obvious
• P/E:
– Severe pain , nausea and vomiting
– Testis not palpable: surround by hematoma
– Contralateral testis
– Bruising and swelling of inguinal and lower abd

207
Classification of testicular injury
• Testicular rupture: TA disruption
– Hematoma
• Contained intratesticular hemarrhage
(Hematocele)
– High intratesicular pressure
– Ischemia , necrosis & atrophy

209
Investigation: USG
• sensitivity 64% and specificity 75%
• No injury: normal parenchymal echo pattern
• Testicular rupture: hypoechoic area
• Contour abnormality

210
Management
• Conservative management
– In Haematoceles smaller than three times the size of the contralateral
testis
– Ice, rest, elevation
• Exploration indicated:
– Penetrating trauma
– Blunt trauma with altered echo pattern suggestive of rupture
– Delay exploration (> 3days)  decrease testicular salvage (80% 30%)
• Scrotal exploration:
– Hematoma evacuation
– Extruded seminiferous tubules excised
– Tunica albuginea repair (4/0 absorbable suture)
– Drain
• Antibiotic for 1 week
• If hematoma not evacuated  ischemia, necrosis and atrophy of
testis

211
Other infective emergency
• Prostate abscess
• Fournier Gangrene

212
Prostate abscess
• Acute bacterial prostatitis  abscess
• History:
– Long term catheter/ DM/immunocompromised
– Systemic unwell
– Dysuria +/- hematuria
– LUTS ( both irritative and obstructive)
• P/E:
– Fever, tachycardica, hypotension
– Suprapubic tenderness + palpable bladder
– DRE: prostate extremely tender

213
Prostate abscess
• Management:
– NPO/IVF
– Bp/P Q1h
– Change foley , monitor hourly UO
– Bld: CBP, LRFT, INR, C/ST
– CSU x C/ST
– Antibiotic: cirpoxin / levofloxacin for total of 4/52
– Imaging: CT or TRUS
– OT: TUR incision + deroofing of abscess or transrectal
drainage

215
Fournier GangreneFournier Gangrene

216
Case scenarioCase scenario
• M/70
• DM
• LT-foley
• Scrotal swelling after changing foley catheter

217
HistoryHistory
• Onset and duration
• Risk factors
–Recent instrumentation
• Periurethral extravasation of urine
–Recent anogenital surgery
• Circumcision
–Lt-foley
–Immunosuppresion
• DM

218
Physical examinationPhysical examination
• Very sick or shock
• Skin necrosis
• Crepitus
• Perianal involvement signifies anorectal
source

219
InvestigationInvestigation
• Blood test
–CBC/R/LFT/T&S/blood culture/ABG
• CSU
• Pus culture
• CT to rule out source of infection

220
ManagementManagement
• ICU care
• Resuscitation
• Intravenous hydration
• Antbiotics – triple therapy (augmentin/third generation
cephalosporin such as ceftriaxone, gentamicin and
metronidazole)
– Multiple organisms
– Commonest – E.coli
– Facultative organisms – Klesiella, enterococci
– Anaerobes – bacteroides, Fusobacterium, Clostridium,
streptococci
• Prepare for surgical debridement (urology/ plastic/CRS)

221
Surgical treatmentSurgical treatment
• Multiple sessions of debridement of gangrenous tissue till
bleeding tissue
• No need orchidectomy as different blood supply
– Scrotum supplied by femoral artery
• Urinary diversion with SP catheter
• Colostomy if colonic or rectal involvement
• Hyperbaric oxygen therapy and vacuum-assisted closure
may aid in wound healing
• Plastic team involvement for skin graft later

222
PrognosisPrognosis
• 20% mortality
– Worse in DM, colorectal source of infection
• Laor scoring system [1995]
– Fournier’s gangrene severity index (FGSI score)
• At time of presentation , numerical score obtained from the
patient's temperature, heart rate, respiration rate, sodium,
potassium, creatinine, white blood count, hematocrit and sodium
bicarbonate
• At a score of less than 9, the patient has a 96% chance of survival.
• a score greater than or equal to 9, the patient has a 46% mortality
rate (sensitivity 71.4%, specificity 90%)

223
Spinal cord or Cauda equina
compression

224
SC compression
• Epidural compression from vetebral body
metastasis
• Presentation:
– Back pain (95%)
– Sensory change
– LL weakness
– Affect bowel or bladder function
• Investigation: urgent MRI

225
Txn
• High does IV corticosteroid:
– Dexamethasone 10mg x1 then
– Dexamethasone 4mg Q6H x 2-3 weeks
• RT or neruosurgical decompression

226
Cadua equina compression
• SC tapers below L2 vertebral level into conus medullaris
• Cauda equina: nerve roots of all spinal cord segment below L2 ,
run in subarachnoid space and exit in respective levels
• Pathology:
– Central intervertebral disc prolapse (15%)
– Spinal stenosis
– Malignant tumor infiltration
• Presentation:
– Urinary retention in female & young male
– Back pain
– Loss peri-anal & lateral foot sensation (S2-4)
– Reduce anal tone , priapism
• Investigation:
– MRI LS spine
– UDS: normal compliant by areflexic bladder
• Txn:
– Neurosurgical decompression
– CISC

227
Other post-op complication
• Post-TRUS sepsis / bleeding
• TUR syndrome
• Failed foley insertion
• Suprapubic catheter
• Bladder washout
• Failed removal of foley

228
Post-TRUS + bx sepsis/bleeding
• Follow protocol
• History:
– When was TRUS + bx performed?
– Fever, chills rigor
– Difficulty in voiding, AROU?
– PR bleeding ? Hematuria?
• P/E:
– Vitals
– Abdomen: palpable bladder
– DRE: active bleeding? Tender prostate
– Protoscopy
– RU x1

229
Post-TRUS sepsis
• NPO/IVF
• BP/P Q1h
• Bld : CBP, LRFT, INR, C/ST
• CSU /MSU
• ICU monitoring
• Foley to BSB if AROU, chart RU
• Panadol 500mg QID PO PRN
• Tienam 500mg Q6H IV
• Organism: E.coli, Klebsiella, Pseudomonas,
enterococci , etc

231
Post-TRUS bleeding
• NPO/IVF
• Bp/P Q1h
• Bld: CBP, LRFT,INR, T&S
• MSU / CSU
• Panadol and antibiotic as required
• Protoscopy: identify bleeding source, pack with
adrenaline gauze (Gauze roll !!!!)
• Reassess patient regularly for on-going shock or
bleeding
• Need of plication of bleeder?

232
TUR syndrome
• Incidence 0.5-2% (Mebust et al 1989)
• Mental confusion, nausea, vomiting,
hypertension, bradycardia and visual
disturbance
• Na < 125mmol/dL
• Increased risk if gland >45g, resection time
>90mins

233
What is irrigation fluid in TUR?
• 1.5% glycine
• Inhibitory amino acid
• Non-electrolyte, non-hemolytic solution (water may cause
hemolysis)
• Osmolarity: 200 mOsm/l (hypotonic to plasma)
• Absorption of rate: 20ml/min (1.2L in a 60min OT)
• Fluid absorption double when height of fluid changed from
60-70cm
• 60cm H20 is the minimal height to maintain good vision
field
• 90% metabolized in liver ammonia, glycolic acid, H20
• 10% metabolized in kidney

235
Pathophysiology Manifestation
Dilutional
hyponatremia
Osmotic shift of water from
plasma into brain
•Cerebral edema
•coning
130-135: asymptomatic
120-130: restless,
confusion
115-120: nausea
<115: seizure, coma
Fluid overload •Pulmonary edema
•Cardiac failure
Early
• hypertension (fluid
overload)
•SOB
•Chest pain
Late
•Bradycarida (glycine
Cardio toxicity)
•hypotension
Glycine and
ammonia toxicity
•Inhibitory neurotransmitter in
retina
•Direct CNS and cardiotoxicity
•Induce ANPnatriuresis
Visual disturbance
(flashing light)

236
How to manage TUR syndrome
1. Prevention
• Identify patient at risk (>45g, resection time> 90 mins), consider open if
glands> 100g
• Keep height of irrigating fluid to minimum
• Try to finish TURP if capsule breached
• Prophylactic administration of diuretics
• Use bipolar or laser resection with NS irrigation
2. Detection
• Spinal anaesthesia to detect early features: visual, nausea, vomiting,
confusion
• Hypertension, arrhythmia, decreased oxygen saturation
• 1% ethanol in irrigant  check breath ethanol level assess amount of
fluid absorbed
3. Treatment
• Check serum electrolyte
• Loop diuretic, eg 40mg lasix
• Quick hemostasis and finish TURP
• Central line and arterial monitoring in ICU
• Fluid restriction, diuretics and Hypertonic saline solution
• corrrection of 1mmol /litre per hour to avoid central pontine myelinolysis

237
Post TURP bleeding
• Emergency  attend patient immediate
• ATLS : resuscitate + ICU + bld + O2 + x-match
• Check catheter , manual irrigation
• Inflated to 50ml balloon  traction
• If failed  return to OT for endoscopic washout +
hemostasis
• Call for help
• Open surgical exploration + packing of prostatic fossa
• Super-selective internal iliac artery embolisation

238
Haemorrhage during TURP
• Common sites of arterial bleeding: BN
– 1 & 11: Flocks
– 5 & 7 : Badenochs
• Capsule perforation – what are the features
– Prostate looks longer
• Bladder perforation
– Unable to inflate the bladder

240
Colonic injury during PCNL?
• More on left side, lower pole , to lateral puncture
• Prevention: Avoidance of puncturing the kidney lateral to the
posterior axillary line
• Presentation:
– Intraop-: contract outline of colon
– Postop:
• Early: fever, WBC, Abd pain , ileus
• Late: PRB, pneumoperitoneum, feces in PCN , CT scan
• Txn:
– Triple antibiotics (ampicillin , gentamicin ,matronadzaole)
– NPO + TPN
– Intraop: PCN withdrawn to colon and allow colon to heal
– Post-op:
• PCN or JJ to drain kidney
• Draining of colon by withdrawn the PCN to colon , further withdrawn to allow
lateral colonic injury to heal
– Delay presentation:
• Remove PCN , penrose drain to pericolonic space for 1 wee
– Intraperitoneal perforation: open surgical intervention

242
PCNL: bleeding
• Serious bleeding: 1%
• Intra-op: bleeding from tract
– Finish the procedure ASAP
– Large bore nephrostomy tube
– Clamping the nephrostomy tube  clot
tamponade
• Post-op: AVF or pseudoaneurysm:
– Renal arteriography and embolization
– If fail  renal exploration

244
Flow diagram of treatment for
stricture after radical prostatectomy
CaP Tx: ~ 1.1-8.4%
Highest risk with radical prostectomy / brachytherapy + EBRT
Robot = conventional radical prostatectomy

245
Flow diagram for treatment for
stricture after major abdominal
surgery or radiotherapy

246
Failed foley insertion
• Case scenario:
– Long term foley patient , failed CNS change foley
today
– “AROU” , failed foley insertion in A&E
– Previous/recent TUR surgery with AROU
– Foley need to be inserted for UO monitoring or
whatever reason

247
Failed foley insertion
• What is the indication? Other options (Paul’s
tube)
• Really in retention ? Check RU
• Painful or painless retention?
• Why urethra could not admit foley?
– Stricture: sub-meatal, anterior , posterior , BN
– False tract: violated too many times by others
– Underlying cause: post-RP, TURBT , TURP,
instrumentation

248
Foley insertion
• Proper patient position: height of bed, patient on side of bed,
adequately exposed (ask for help)
• Get ready everything
• Cleaning of skin and draped
• Choose appropriated size foley: start with Fr 12-14
• Adequate lubrication : ask for the whole tube
• Allow time for lubrication to work
• Straighten penis
• Gentle but persistent pressure: narrowing at external
sphincter and acute angle at bulbous urethra
• Wait for urine return before you inflate balloon

249
Stricture
• Sub-meatal: dilated with artery forcep with LA
• Other stricture:
– Blind dilatation with whatever instrument is
discourage
– Try a smaller catheter (Fr 10/12 silicon)
– Try a stiffer catheter (Fr 10/12 Nelaton)
• Suprapubic catheter
• FC guide insertion of foley

250
False tract
• Bleeding from urethra
• Usually at bulbous urethra
• Try a larger catheter (Fr 18-20) , hope that it
will bypass the false tract
• Try an angulated catheter (Tieman Catheter)
• Tip directed to 12 oc
• SP or FC guide foley

251
Suprapubic catheter
• Indication:
– Failed foley insertion per- urethra
– Preferred options of long term foley
• Cautions:
– Patient with clot retention
– Underlying malignancy or hugh BPH with
intravesicle extension
– Previous lower midline incision (bowel adhesion)
– Pelvic fracture (may pass into hematoma)

252
Suprapubic catheterization
Add-a-cath
Cystofix

253
Suprapubic catheterization
• Preparation:
– Palpate the abdomen + Check RU
– USG if possible
• Procedure:
– Position: Bed height, toward bed side, head down
– Location: 2FB above pubic symphysis, mid line
– 1% lignocaine in 10ml syringe to skin and rectus shealth
– Confirm location of bladder by aspiration of urine
– 1cm incision with sharp blade
– Hold trocar handle in right hand, steady needle end with left hand
– Push trocar in same direction as previous needle
– Notice urine issues from trocar, insert 0.5cm more to ensure shealth is
inside bladder
– Removed trocar
– Insert catheter as far in as possible
– Inflate balloon
– Peel away the side of the shealth and remove it
– Secure catheter with silk suture

254
Bladder washout
• Complain: Clot retention after TURP / TURBT
• Management:
– Attend patient ASAP
– Check: Vitals, GSC, Temp, in pain
– Look at the patient: bladder distended / pain
– Look at the in/out chart: In>> out (+ve balance)
– Look at the set: irrigation fluid, clamp, catheter inlet,
catheter outlet, bebside bag (kinking or compression)
– Look at the OT record : any particular difficulty
encounter ? Uncontrolled bleeding, undermining of BN?
Severe blood loss?
– Stop the irrigation

256
Bladder washout
• Ask the nurse to prepare:
– A new 3-way foley (Fr 22/24) or hematuria
catheter or Fr 20 Nelaton catheter (orange)
– Foley insertion set
– Lignocaine gel x 2
– Bladder syringe (50ml)
– NS (plentiful)
– Mug for clots
– Pethedine 50mg IM stat (for pain relief)

257
Bladder washout
• Initially fill up bladder syringe with 20-30ml NS
• Gentle infuse into bladder (to dislodge small clot)
• Pull back to suck out clot or chips
• Observe if flow restart
• If not: try again with 40ml NS
• Still failed  deflated the balloon and change a catheter
• Clot removal by alternate irrigation and sucking back on the
syringe to remove clot
• Repeat until the return fluid is pink without clot
• Reconnect the irrigation set and restart BI
• Have in your mind how much fluid is infused , always keep
OUT >>> IN

258
Bladder washout
• If failed to removed clot  return to OT
• Complication:
– Repeated clot retention (not your fault)
– False tract formation during in-out catheter
– Urethral rupture
– Bladder perforation (when suddenly bladder
cannot be distended)

259
Failed removal of foley
• History:
– When was the foley last change?
– Is the foley not functioning?
– Any evidence of sepsis or clot retention ?
– What size and type of foley
• P/E: distended bladder
• Investigation:
– KUB (look for encrustation around foley catheter)
– Bld and CSU workup

260
Failed to remove foley
• Ensure the balloon is fully deflated by aspirating the valve
• Inject a little bit more water into the balloon and aspirate
balloon again
• Leave a syringe firmly to the channel for ~30min
• Use a needle to puncture proximal to the valve
• Cut the valve of the inflation channel
• Insert a the GW of a Fr 3 ureteric catheter into the inflation
channel and puncture the balloon
• Female: Transvaginal puncture of balloon while tugging the
catheter towards BN
• USG of the bladder and percutaneous puncture of the
balloon
• FC along side of catheter and puncture the balloon

Emergency in Urology [Dr. Edmond Wong]

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