Genitourinary Tract Injury Research Articles

Relationship between patient safety indicator events and hospital location for inpatient hysterectomy.

Previous studies suggest surgical quality outcomes are similar between rural and urban hospitals, but data about gynecology in rural hospitals is sparse. This was a retrospective cohort study utilizing the National Inpatient Sample database from the Agency of Healthcare Research and Quality. Patients who underwent benign hysterectomy for non-prolapse indications between 2012-2016 were identified using ICD-9 and 10 codes. Patients were stratified into rural or urban non-teaching groups; urban teaching hospitals were the referent group. The primary outcome was the rate of patient safety indicator (PSI) events. PSI events were identified using ICD-9 and 10 codes. Statistical analysis was performed using analysis of variance and uni- and multivariate Poisson regressions. 154,810 patients met all inclusion criteria. The cumulative rate of PSI events was 11.9% at rural hospitals, 13.9% at urban non-teaching hospitals and 16.9% at urban teaching hospitals, P<0.001. The most common PSI events were postoperative metabolic derangement, hemorrhage, and accidental puncture. The rate of transfusion was highest in urban teaching hospitals (6.7%) and similar for rural (5.1%) and urban non-teaching hospitals (5.5%), P<0.001. The rate of genitourinary tract injury was between 1.4-1.6%, and similar across sites, P=0.89. After adjusting for confounders, the risk of PSI events was similar across locations. The risk of transfusion was lower at rural hospitals (aRR=0.84, 95% CI: 0.74-0.94). Hysterectomy performed at rural hospitals, typically thought of as having low surgical volume compared to urban hospitals, is associated with similar risk of PSI events and lower risk of transfusion.

Prepubic urethral transposition, with prostatic urethral anastomosis to penile urethra, after severe membrane urethral injury in dog - case report

Rupture of the membranous urethra caused by automobile trauma in dogs, accounting for only 5% of genitourinary tract injuries. The higher prevalence in male dogs is noteworthy due to pelvic anatomy and locomotion habits. Clinical signs include edema, anuria, hematuria, pain, and uroperitoneum, requiring an emergency approach. Diagnosis is usually based on history and imaging tests such as ultrasonography and urethrocystography. Treatment varies based on the location of the injury, with surgical intervention being crucial in complete tears. Prepubic urethral transposition with terminal anastomosis from the prostatic urethra to the penile urethra, although little used in veterinary medicine, presents benefits in male dogs, providing a new urinary path without significant aesthetic changes. The case report presents the successful application of this technique in a canine patient with rupture of the membranous urethra due to automobile trauma, aiming to establish an efficient urinary flow without complications and without compromising genital aesthetics.

Ultrasound-guided extracorporeal shock wave lithotripsy with minimal x-ray exposure prevented genitourinary tract injury patients with urolithiasis in Taiwan.

This study investigated the use of ultrasound-guided extracorporeal shock wave lithotripsy (ESWL) to break stones in the genitourinary tract and prevent genitourinary injury. Our goals were to achieve accurate focusing and minimal X-ray exposure for the benefit of the patients. The LiteMed LM-9200 lithotripter with ultrasonography and fluoroscopy was used for two different procedures: autoaimed and autoperiodical. These procedures enabled dual focusing on stone localization and tracking. Out of 108 patients who underwent autoperiodical procedures, 29 had no gross hematuria. Among the 335 patients who received autoaimed procedures, 194 had no gross hematuria. The average duration of X-ray exposure during autoperiodical and autoaimed procedures was 120 and 50 s, respectively. The ultrasound-guided ESWL with minimal X-ray exposure was found to be useful in treating genitourinary upper-tract urolithiasis in the autoaimed procedure. Patients who underwent the autoaimed procedure experienced less gross hematuria compared to those who underwent the autoperiodical procedure.

Problems in diagnosing and treating children – victims of sexual abuse, including legal aspects

Abstract Introduction. The most frequent source of information on sexual violence are the victims. It should be borne in mind that children rarely disclose sexual abuse directly, and the symptoms depend on how long they have been sexually abused, the relationship with the perpetrator, the kind of sexual activities, and factors related to the child’s development. The obvious consequences of child sexual abuse are body injuries: genitourinary tract infections and injuries to the external genitalia. Notwithstanding, the psychological consequences are more serious than the physical injuries. Aim. The study aimed to present the problem of sexually abused children including diagnostics and therapy of victims of violence. Conclusions. The effects of sexual abuse of a child include, in addition to physical trauma, also the disruption of proper psychosexual development. The task of doctors, nursing staff , educators, and psychologists is to efficiently and confidently identify the crime, enabling the initiation of therapeutic activities and legal proceedings.

Renal packing for management of transplanted kidney blunt trauma: a case report and a review of literature

The kidney is injured in up to 10% of patients who experience significant abdominal trauma and approximately 65% of genitourinary tract injuries involve the kidney. Less is known about the management of this kind of trauma in the case of a transplanted kidney, and for this reason, we performed a review of the current literature. A systematic search was performed according to Preferred Reporting Items for Systematic reviews and Meta-Analyses in all electronic databases; the inclusion criteria regarded all studies reporting on blunt trauma of a transplanted kidney, and the main outcome was the surgical or conservative management strategy of the trauma. A total of eight studies were included in the review and they were all case reports. We also reported our experience of a case of a 51-year-old patient with blunt trauma to his 18-year-old transplanted kidney, who underwent temporary packing of the renal fossa for kidney salvage. Trauma to a transplanted organ is rare, but clinicians will increasingly confront this scenario with the rise in transplantations. Although the management of renal trauma is well established, we are still far from identifying a gold standard for the treatment of transplanted kidney blunt trauma. It has been demonstrated that outcomes for trauma patients with previous organ transplants are not worse than nontransplanted patients; from this point of view, damage control surgery is considered an adequate approach and is applicable to unstable patients unfit for conservative or radiological intervention, and also in the case of a previous transplant. Data from this review and our experience demonstrate that accurate diagnostic profiling and the correct surgical management can allow the transplanted organ to be saved through a damage control approach; compliance with the most up-to-date therapeutic protocols must always guide surgical choices and, in our case, has allowed us to preserve the graft improving the patient’s quality of life.

Intra-Operative and Post-Operative Common Complications of Hysterectomy

Background: The most prevalent gynaecological surgeries in the US is the hysterectomy. With more than 600,000 procedures carried out year. This study aims to find intra-operative and post-operative common complications of hysterectomy. Methods: A study conducted that was cross-sectional in the Unit 1 Gynecological Department Services Hospital in Lahore. The purposive sampling technique was applied to collect data. Total 120 gynecologist’s participants were investigated during this research. The target demographic was between the ages of 25 and 50. Consultants, PGRs, and SRs completed the questionnaire. The information gathered was written down, compared, and then examined. Results: According to the findings of this study, the most common intra-operative complication of hysterectomy is bowel injury (16.7%), followed by genitourinary (GU) and gastrointestinal (GI) tract injury (0.8%). The most prevalent post-operative complication was anuria (19.2%). Pulmonary Embolism (Bronchitis, Pulmonary Collapse) was responsible for 8% of the problems, whereas Hematoma Formation was responsible for 19.2%. Practical implication: The research on the common complications hysterectomy in the intra and post operative settings will allow for us to plan interventions in accordance to these complications which will better the medical intervention procedure and add to the literature of the subject. Conclusion: It is clear that the most common intra-operative complication of hysterectomy is Bowel Injury, the most common post-operative complication is Anuria. Keywords: Hysterectomy, Abdominal hysterectomy, vaginal hysterectomy, Intra-operative complications, Post-operative complications, surgical procedures, operating room.

Incidence and Risk Factors for Genitourinary Tract Injury Within 1 Year After Surgery for Pelvic Organ Prolapse.

The rate of genitourinary tract injury (GUTI) following pelvic organ prolapse (POP) surgery is presently ill-defined and based on relatively small trials with short follow-up time. Given the potential for higher risk of injury with POP, a better understanding of this type of injury is important for patient counseling. The objective of this study was to identify the incidence and risk factors of GUTI related to POP surgery. Women undergoing POP surgery between 2010 and 2019 were identified using Current Procedural Terminology codes in the Premier Healthcare Database. The primary outcome was GUTI, defined as bladder or ureteral injury, and vesicovaginal or ureterovaginal fistula within 1 year of surgery. Genitourinary tract injury was identified using International Classification of Diseases and Current Procedural Terminology codes. Patients were divided into those with and without GUTI. Differences between groups were evaluated using the Student t test, Wilcoxon rank-sum test, and Fisher exact test as appropriate. Multivariable logistic regression was used to evaluate the independent predictors of GUTI. One hundred thirty-nine thousand one hundred fifty-eight surgical procedures for POP were captured between 2010 and 2019. The rate of GUTI was 1.10%: 0.48% bladder, 0.64% ureteral injuries, and 0.01% fistulas. The most significant variables associated with any GUTI were as follows: adhesiolysis (adjusted odds ratio [aOR], 2.64; 95% confidence interval [CI], 1.07-6.51), blood transfusion (aOR, 3.67; 95% CI, 1.34-10.04), and low-volume surgeons (<12 cases per year) (aOR, 1.68; 95% CI, 1.60-1.77), nonurologic or gynecologic surgeon specialty (aOR, 1.62; 95% CI, 1.49-2.00), and uterosacral suspension (aOR, 1.30; 95% CI, 1.13-1.49). The rate of GUTI following POP surgery is lower than has previously been reported. Surgeon experience and specialty and surgical approach may affect GUTI incidence.

How does obesity class correlate with postoperative complications following benign hysterectomy?

To determine if obesity is associated with 30-day postoperative adverse events in individuals undergoing hysterectomy for benign indication. A retrospective cohort analysis was performed through the National Surgical Quality Improvement Program (NSQIP) from 2015 through 2019. Patients who underwent hysterectomy for benign indications were identified by Current Procedural Terminology (CPT) codes. Patient characteristics and perioperative data were abstracted. Patients were stratified into groups by body mass index (BMI): normal (<25 kg/m2), overweight (25-29.9 kg/m2), Class I obesity (30-34.9 kg/m2), Class II obesity (35-39.9 kg/m2) and Class III obesity (>40 kg/m2). The primary outcome was any 30-day postoperative complication; secondary outcomes included genitourinary (GU) tract injury, readmission, and reoperation. The overall cohort was characterized using descriptive statistics, and differences across BMI groups were calculated, and multivariable logistic regression was used to determine if BMI category was associated with postoperative complications while controlling for potential confounders. A total of 106,137 hysterectomies were analyzed. The mean age was 48 (standard deviation [SD]±11). The majority was white (63%). The mean BMI was 32 (SD ±8) kg/m2; 19% had a normal BMI, 28% were overweight, and 53% were obese. In the obese population, 23% of the cohort had Class I obesity, 15% had Class II obesity, and 15% had Class III obesity. The most common route of hysterectomy was laparoscopic (62%), followed by abdominal (21%) and vaginal (17%). The mean uterine weight was 250 (SD±408) g; the mean operative time was 136 (SD±64) minutes. The rate of any 30-day postoperative complication was 9%. GU tract injury occurred in 0.3% (n = 229) of cases. Readmission and reoperation rates were 3% and 1.4%, respectively. Significant differences were noted across patient weight groups in terms of any 30-day postoperative complication (p<.001). On multivariable logistic regression controlling for age, ASA class, smoking, type of hysterectomy, operative time, concurrent procedures, uterine weight and presence of endometriosis, overweight and obesity class I and II were associated with a decreased odds of complication compared to normal weight; class III obesity was not associated with complications. Compared with patients of normal weight, overweight patients and those with Class I and II obesity have a decreased likelihood of experiencing any postoperative complication in the 30-days following hysterectomy for benign indications.

Open pelvic fractures – results of a multi-institutional study

Open pelvic fractures are devastating injuries, rare, and with high mortality. Leading causes of mortality are: haemorrhage, infection and associated injuries. The aim of this paper is to point out methods of treating these injuries and great number of prognostic mortality factors. Material - in period from January 2011 to December 2015, 221 patients with pelvis ringfracture were treated in three large clinical centers of Serbia, of which 13(5%) had an open fracture type. We have classified pelvic ring fractures according to the Young - Burgess classification. We have classified injuries according to Gustilo at I, II, and III degree, and the location of the wound according to Faringer classification was distributed in zone I, II and III. Urogenital and intra-abdominal injuries were monitored, and severity of injuries was determined according to Severity Score Injury (ISS) and Trauma Score (TS). Results - there were 6(46%) women and 7(54%) men at the average age of 41(13 - 76). Injuries from traffic trauma are dominant. The most common cause of pelvic ring fracture is an anterior posterior compression - 6(46%), lateral compression - 4(31%) and vertical force in 3 (23%) patients. Dominant injuries are type I and II according to Gustilo, and zone I according to Faringer classification. There were 6 (46%) patients with urogenital injuries, and the same number with intra-abdominal injuries, of which 3(23%) patients have been treated with colon resection and diversion. Due to abundant hemorrhage and hypovolemic shock 2 patients died, and another one died after three days due to sepsis and multisystem organ failure (MSOF). Conclusion - Open pelvic fractures have high mortality rate, due to: haemorrhage, infection, associated abdominal and genitourinary tract injuries, ISS&gt; 25, TS &lt;8 and age of patient &gt;65 years.

Diagnostic capability and radiation safety of low dose CT cystography in acute post-traumatic urinary bladder injuries

Background: Genitourinary tract injuries occur in up to 5% of all traumas and at least 10% of abdominal traumas. Pelvic fractures are commonly found in patients with blunt trauma, and up to 40% of patients with bladder injuries are associated with at least one other intra-abdominal organ injury. Conventional cystography was the diagnostic modality for suspected bladder injury. Recently CT cystography is commonly used for evaluating bladder injury. For the risk of possible effects of radiation exposure associated with medical imaging procedures, the imaging centers apply the principles of ALARA. Aim of work: We aim to assess the diagnostic capability of low-dose CT cystography in the diagnosis and classification of acute post-traumatic bladder injury. Patients and methods: 44 patients with suspected post-traumatic UB injury were enrolled in this study. Non- and post-contrast CT scan was done using “160” MDCT scanner. Low and standard-dose techniques were applied, and the images were analyzed by two radiologists with at least 15 years of experience. Results: The study involved 44 patients. 20 patients scanned with low-dose CT while 24 patients scanned with the standard technique. Statistically, there was a significant difference between low and standard-dose groups regarding CTDI volume and radiation exposure (p=0.001) with a good diagnostic capability of low-dose CT. Conclusion: Low-dose CT cystography offers a good diagnostic capability of bladder injuries comparable to standard dose CT and may be recommended for the assessment of acute UB injuries.

Bilateral Testicular Evisceration Sequel to Trauma: Challenges of Management in Emergency Department

Introduction The Genitourinary (GU) tract injury is rare with an annual incidence of less than one percent. We present a rare case of traumatic degloving injury of male external genitalia with complete evisceration of bilateral testicles following motor vehicle accident. Case description 29-year-old lorry driver was brought to Emergency department following head-on crash of his lorry into a ravine resulting in chest, abdomen and pelvis slamming onto dashboard. The driver was trapped for 4.5 hours. On arrival, he was conscious but hemodynamically unstable. Clinical examination and Focused Assessment with Sonography in Trauma (FAST) was suggestive of left pneumothorax and no evidence of intraabdominal injury. Chest tube was inserted. Genital examination showed scrotal degloving wound with complete evisceration of bilateral testis. He also sustained open fracture of right tibia, fibula and left inferior pubic rami fracture. Upon stabilization, was sent for operation and intraoperatively found to have bilateral testicular rupture. He underwent scrotal exploration, and bilateral orchidopexy. Postoperatively, multiple dialysis sessions were done for rhabdomyolysis. Hormonal study yielded low levels of testosterone. He was discharged home after 2 weeks with testosterone pills. Discussion Challenges in Emergency Department setting would be prompt identification and management of life-threatening injuries along simultaneous management of degloving external genitalia injury and associated injuries. FAST and extended FAST play a key role in managing life threatening conditions. Conclusion Total evisceration of bilateral testis injury are rare. Although not life threatening, should be treated promptly and thoroughly in order to avoid long-term functional and psychological damage.

Habits, attitudes, and behavior of refugees and migrants in Serbia concerning oral health

Background/Aim. Open pelvic fractures are devastating, rare injuries with high mortality. Leading causes of mortality are the following: hemorrhage, infection, and associated injuries. The aim of this study was to point out methods of treating these injuries and a great number of prognostic mortality factors. Methods. In the period from January 2011 to December 2015, 221 patients with pelvis ring fractures were treated at three large clinical centers in Serbia, of which 13 (5%) patients had an open fracture type. We have classified pelvic ring fractures according to the Young-Burgess classification. We have classified injuries according to Gustilo at I, II, and III degrees, and the location of the wound according to Faringer classification was distributed in zone I, II, and III. Urogenital and intra-abdominal injuries were monitored, and the severity of injuries was determined according to Severity Score Injury (ISS) and Trauma Score (TS). Results. There were 6 (46%) women and 7 (54%) men with an average age of 41 year (13?76). Injuries from traffic trauma were dominant. The most common causes of pelvic ring fracture were anteroposterior compression ? 6 (46%), lateral compression ? 4 (31%), and vertical force in 3 (23%) patients. Dominant injuries were types I and II according to Gustilo and zone I according to the Faringer classification. There were 6 (46%) patients with urogenital injuries and the same number with intra-abdominal injuries, of which 3 (23%) patients had been treated with colon resection and diversion. Due to abundant hemorrhage and hypovolemic shock, two patients died, and another one died after three days due to sepsis and multisystem organ failure. Conclusion. Open pelvic fractures have a high mortality rate due to: hemorrhage, infection, associated abdominal and genitourinary tract injuries, ISS &gt; 25, TS &lt; 8, and the age of patients &gt; 65 years.

Cystoscopy at the time of hysterectomy performed by a gynecologic oncologist and delayed lower genitourinary tract injury

Objective: The aim of this study was to compare the rate of delayed 30-day lower genitourinary tract injury in women who underwent cystoscopy at the time of hysterectomy performed by a gynecologic oncologist for malignant or benign indications with those who did not.

Cystoscopy at the Time of Hysterectomy for Benign Indications and Delayed Lower Genitourinary Tract Injury.

To compare the rate of delayed 30-day lower genitourinary tract injury in women who underwent cystoscopy at the time of hysterectomy for benign indications to those who did not. This was a retrospective cohort study of patients who underwent hysterectomy without a concomitant procedure for prolapse or incontinence for benign pathology with a general obstetrician-gynecologist (ob-gyn) recorded in the National Surgical Quality Improvement Program targeted hysterectomy file between 2015 and 2017. The primary outcome was a delayed lower genitourinary tract injury in the 30 days after hysterectomy. Secondary outcomes included urinary tract infection and operative time. The exposure of interest was cystoscopy at the time of hysterectomy. Stratified analysis was performed by route of surgery. Bivariable tests were used to examine associations. We identified 39,529 women who underwent hysterectomy for benign indications with a general ob-gyn. Surgical approach was open (26%), laparoscopic or robotic assisted laparoscopic (46%), and vaginal or vaginally assisted (28%). Overall, 25% of women underwent cystoscopy at the time of hysterectomy; cystoscopy was more commonly performed in laparoscopic or robotic (32%) and vaginal hysterectomy (25%) as compared with open hysterectomy (11%) (P<.001). There was no difference in delayed lower genitourinary tract injury between patients who underwent cystoscopy at time of hysterectomy compared with those who did not undergo cystoscopy (0.27% vs 0.24%, P=.64). Patients who underwent cystoscopy were more likely to be diagnosed with a urinary tract infection (2.6% vs 2.0%, RR 1.27 95% CI 1.09-1.47). Median operative time was increased by 17 minutes in cases where cystoscopy was performed (132 vs 115 minutes, P<.001). Cystoscopy at the time of hysterectomy for benign indications does not result in a lower rate of 30-day delayed lower genitourinary tract injury compared with no cystoscopy.

BLADDER OUTLET OBSTRUCTION LEADING TO URINOTHORAX

SESSION TITLE: Disorders of the Pleura 2 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 pm - 02:15 pm INTRODUCTION: Urinothorax is the presence of urine in the pleural space as a result of genitourinary (GU) trauma or obstructive uropathy. Injury in the GU tract results in urine extravasation into the peritoneal or retroperitoneal space, which then enters the pleural space via the diaphragm or lymphatics. Pleural fluid analysis greatly aids in the diagnosis. Dyspnea is often the presenting symptom. Less than seventy cases of urinothorax have been identified in the literature. CASE PRESENTATION: A 78-year old male presented with fatigue, dyspnea, suprapubic pain, and urinary incontinence for the past two weeks. Routine workup revealed AKI and hyperkalemia. The patient had a history of CVA, hypertension, hyperlipidemia and chronic kidney disease. Computed tomography (CT) of abdomen/pelvis revealed an enlarged prostate with bladder outlet obstruction and severe hydroureteronephrosis. Additionally, a large right sided pleural effusion with near collapse of the right lower lobe was noted [Figure 1]. A thoracentesis was performed and 2020 mL of simple, serous fluid was drained. The transudative fluid had a pH of 7.2, total fluid protein < 1.0 and fluid to serum creatinine ratio >1.0, highly suggestive of urinothorax. His dyspnea resolved after thoracentesis. He ultimately required bilateral percutaneous nephrostomy tubes with improvement in his renal function and no recurrence of urinothorax or other pleural effusion as seen on subsequent imaging. Given his known obstructive uropathy, no further workup was indicated for etiology of urinothorax. DISCUSSION: Urinothorax is a rare cause of pleural effusions that is caused by GU trauma, including iatrogenic instrumentation or transplant, or obstructive uropathy, including mechanical obstruction or bladder outlet obstruction. In both etiologies, the mechanism involves high pressures that result in translocation of urine into spaces that ultimately connect with the pleural space. Diagnosis involves identifying a pleural effusion and subsequently testing pleural fluid via thoracentesis. This rare and under diagnosed condition presents as the only transudative pleural effusion with pH <7.40. Other abnormal labs include a pleural fluid to serum creatinine ratio >1.0 and/or elevated LDH in pleural fluid. The fluid to serum creatinine ratio is the most specific feature of urinothorax. CT or ultrasound imaging can help discover the cause. Although there is an association with nephrostomy, our case was due to obstructive uropathy as it was diagnosed prior to intervention. CONCLUSIONS: Urinothorax is a rare condition that can result from abdominal trauma, genitourinary tract injury or obstructive uropathy. Recognition of this rare entity is important to allow for timely alleviation of obstruction, relieve symptoms, and prevent recurrence; as was the case with our patient. Reference #1: Austin, Adam & Navin Jogani, Sidharth & Bradley Brasher, Paul & Gupta Argula, Rahul & Huggins, John & Chopra, Amit. (2017). The Urinothorax: A Comprehensive Review with Case Series. The American Journal of the Medical Sciences. 354. 44-53. Reference #2: Toubes ME, Lama A, Ferreiro L, et al. Urinothorax: a systematic review. Journal of Thoracic Disease. 2017;9(5):1209-1218. https://doi.org/10.21037/jtd.2017.04.22. DISCLOSURES: No relevant relationships by Michael Bergman, source=Web Response No relevant relationships by Ryan Richard, source=Web Response No relevant relationships by Jigna Solanki, source=Web Response

Iatrogenic genitourinary system injury during gynecological and obstetric surgery: ten-year results

Purpose of investigation: The authors’ objective was to investigate the predisposing factors and treatment results of genitourinary (GU) system injuries that occur following gynecological and obstetric surgery (GOS). Materials and Methods: They evaluated retrospectively 87 consecutive patients who had GU tract injury occurring with GOS between 2005 and 2015. Results: There were 87 patients that had GU tract injury, in which 57 had bladder injury, and 30 had ureteral injury. Of the patients who had bladder injury, 38 had only bladder injury and underwent primary repair. Nineteen patients had vesicovaginal fistula and all underwent open transabdominal transvesical repair after three months. Among the 30 ureteral injuries, four were ligation, nine incomplete cut, ten complete cut, and seven fistula. Two patients who had ligation underwent nephrectomy, and two underwent deligation. Nine patients with incomplete cuts underwent primary repair and stenting; end-to-end anastomosis was performed in ten patients with incomplete cuts. Three patients with ureterovaginal fistula underwent ureteroneocystostomy and Boari flaps were performed in four patients. Conclusion: GU system injuries may occur following GOS. When treated early and properly, recovery without complications is possible.

914: A Patient Safety Initiative; The Complex Obstetric Surgery (COS) Program

A multidisciplinary Complex Obstetric Surgery program was established to regionalize patient care, improve preoperative assessment, develop a comprehensive surgical plan and reduce surgical morbidity. The COS program identifies patients at high risk for intrapartum and postpartum complications such as those with morbidly adherent placenta (MAP), placenta previa (PP), history of 4 or more cesarean sections (PCS), prior complicated abdominal surgery (AS), super-morbid obesity (SMO, BMI>50) and patients requiring Ex Utero Intrapartum Treatment (EXIT). We reviewed performance of the COS program as a quality improvement initiative. Retrospective review of patients with COS abnormalities in 7/1/14 to 6/30/17. In context of demographics and obstetric characteristics we studied core outcomes: planned versus urgent procedures, estimated blood loss (EBL), blood products administered (packed red blood cell (pRBC)/fresh frozen plasma (FFP)), intra and postoperative complications and need for re-operation. Protocol adherence (obtaining relevant consultations, delivery location, preoperative preparation) was studied. Outcomes were compared to those with similar diagnoses for the 3 years prior to program onset. We identified 67 COS patients (MAP:26, PP:17, PCS/AS: 24). Protocol adherence was 100% for all. Overall 68% of cases were performed as scheduled (62% of MAP, 47% of PP, 92% of PCS/AS). Average blood loss: MAP 2848 ml, PP 1364 ml, PCS/AS 1075ml. Mean transfusion of pRBC/FFP: MAP 4/2, PP 1/1 and PCS/AS 1/0. Intraoperative complication occurred in 7 (15%) MAP, zero (0%) PP, and 1 (4%) PCS/AS. In MAP, 85% of intraoperative complications were genitourinary tract injury. Reoperation was needed in MAP 4 times (15%), PP 3 (18%) and PCS/AS (0%). Compared to the prior 3 years, there was no difference in the selected outcomes for PP or PCS/AS. In MAP, EBL decreased by 40% (2848ml v 4725ml) and use of blood products (pRBC/FFP) fell 60-70% ( 4/2 v 10/9) with corresponding reduction in ICU time. Coordinated care of patients with complex obstetrical conditions reduces blood loss, use of blood products transfused per patient and overall surgical morbidity. Implementation of the COS program as a quality improvement project has significantly improved surgical outcomes in our own institution and provides regionalized surgical expertise to pregnant women in Maryland.

A Review of Imaging Modalities Used in the Diagnosis and Management of Scrotal Trauma.

Genitourinary tract injuries account for 3 to 10% of trauma patients, and scrotal trauma is particularly prevalent in males 10 to 30years of age. Prompt diagnosis and timely surgical intervention are essential to prevent future complications of infertility, delayed orchiectomy, infection, and testicular atrophy. While clinical examination provides valuable information, it may be inconclusive due to soft tissue swelling and difficult to perform due to testicular pain with palpation. Conversely, testicular rupture does not always present with pain or tenderness. Imaging can contribute additional support for surgical evaluation in scrotal trauma. Current AUA guidelines support ultrasound in blunt scrotal trauma to confirm testicular rupture while recommending early exploration in penetrating injuries due to the high incidence of testicular rupture. This review discusses the existing literature on the use of various imaging modalities in assessment of blunt and penetrating scrotal trauma and common imaging findings.

Special urological traumatology in children and adolescents

Isolated injuries of the genitourinary tract are rare, with the kidney being the most frequently affected organ, especially in situations of polytrauma. Overall, the genitourinary tract is involved in approximately 3 % of all children suffering polytrauma accidents. The literature and international guidelines provide clear therapeutic concepts with a consensus on the diagnosis and treatment of renal trauma, both for the treatment of adults and for children and adolescents. However, the most common injuries to the external genitalia in children and adolescents are caused by blunt trauma, abrasion, bruising, and piling. For these forms of injuries there are no general recommendations in literature and guidelines regarding diagnostic or therapeutic procedures, which may be due to the wide variety of origins of the injuries. Consequently, as shown in our sequence of case reports, each type of injury to the external genitourinary system requires an individual evaluation and therapeutic approach.

Diagnosis and Therapeutic Management in Kidney, Ureter and Bladder Trauma

Trauma refers to the destruction of tissues or organs by external forces and it is the most common cause of mortality and morbidity in children (1, 2). Injuries of the genitourinary tract may be the result of blunt (falls, sport injuries, motor vehicle accidents and sexual abuse) or penetrating (stab wounds, gun shots, falling onto sharp objects) injuries. The genitourinary tract is significantly injured in 2.9% of paediatric trauma patients 4.In the paediatric population, the kidney is the most affected organ in the genitourinary tract (>60% of all genitourinary tract injuries) 4. Blunt renal trauma is the most common type of injury representing 80-90% 4. The paediatric kidney is more susceptible due to less abdominal and retroperitoneal fat, weaker trunk and abdominal muscles and a lower position in the abdomen. Preexisting renal abnormalities such as UPJ obstruction, hydronephrosis, horseshoe kidney or ectopic kidney make the kidney more vulnerable. Spiral computed tomography is the gold standard method for radiological assessment. Surgical intervention is needed only in the minority of children. Isolated ureteral injury due to trauma is very rare in children. Penetrating ureteral trauma is more common than blunt trauma in the paediatric population. Among all urological trauma cases, the incidence of ureteral injury is lower than 1% [4]. Ureteral injuries include contusion, laceration and avulsion. Because of their hyperextensible vertebral column, children are more likely to sustain deceleration injuries. Delayed films of IVP and CT are the main diagnostic tools whereas the gold standard is retrograde ureteropyelography. Ureteral injury treatment options depend on the location of injury. The bladder in children is a more abdominal organ than in adults. Lying in an exposed position above the pelvis, the bladder is more vulnerable in this age group as it is less well protected due to the less developed abdominal fat and rectus muscles. Here, too, the most common type of trauma is blunt injury. High percentages of bladder injuries are associated with pelvic fractures (70-90%) 4. The average rate of bladder injury in patients with pelvic fractures is 4% in the paediatric age group 4. Conventional or CT cystography is the gold standard method of imaging.