Testicular torsion is a serious scrotal emergency having a negative impact on fertility and in its most severe presentation, there is potential loss of the testicle if not diagnosed early. The condition needs to be diagnosed promptly with immediate surgical intervention. Intermittent testicular torsion (ITT) is a forerunner or a red flag for an impending frank testicular torsion. ITT is characterized by sudden onset of testicular pain which may resolve spontaneously before further investigation and treatment. Testicular torsion in adults is usually intravaginal in location and can be diagnosed clinically if the patient presents early with typical clinical signs. A case of ITT who presented with frank unilateral testicular torsion diagnosed clinically and surgically treated with salvage of the affected testes is presented to highlight the importance of history of ITT and typical clinical features. The anatomical aspects and pathophysiology of testicular torsion including the aftermath is discussed. ITT is a forerunner to frank testicular torsion. If offered prophylactic orchidopexy then a frank episode of testicular torsion with all its sequelae can be averted.
Testicular torsion is a serious scrotal emergency having a negative impact on fertility and in its most severe presentation, there is potential loss of the testicle if not diagnosed early. The condition needs to be diagnosed promptly with immediate surgical intervention. Intermittent testicular torsion (ITT) is a forerunner or a red flag for an impending frank testicular torsion. ITT is characterized by sudden onset of testicular pain which may resolve spontaneously before further investigation and treatment. Testicular torsion in adults is usually intravaginal in location and can be diagnosed clinically if the patient presents early with typical clinical signs. A case of ITT who presented with frank unilateral testicular torsion diagnosed clinically and surgically treated with salvage of the affected testes is presented to highlight the importance of history of ITT and typical clinical features. The anatomical aspects and pathophysiology of testicular torsion including the aftermath is discussed. ITT is a forerunner to frank testicular torsion. If offered prophylactic orchidopexy then a frank episode of testicular torsion with all its sequelae can be averted.
Ureters are retroperitoneal structues which run anterior to psoas muscle and cross lateral to medial.4sites are prone where ureter can be injured and its management
Bladder injuries may result from blunt,Penetrating and Iatrogenic trauma.
Full bladder is more susceptible to injury than empty bladder.
Management varies from conservative to surgical aiming to directly repair the injury.
Ureteric injury in Gyenec Surgery, Serious complication of gynecologic surgery
Significant morbidity and long-term sequelae
Uncommon in benign gynecologic surgery
Vaginal hysterectomy has the lowest rate of ureteral injury
Laparoscopic hysterectomy has the highestThe ureters are the muscular ,thick walled narrow tubes(Right and Left)
Each measures 25-30 cm in length and extends from renal pelvis to its entry in the bladder.The ureter are located retroperitonealy and run from the renal pelvic to urinary bladder.
First part –Enter the pelvis by crossing the common iliac vessel from lateral to medial aspect at their bifurcation just medial to ovarian vessel and run downwards along with greater sciatic notch & reaches ischial spine.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
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Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
3. • Intraperitoneal injury is caused by a sudden rise in intravesical
pressure of a distended bladder, secondary to a blow to the
pelvis or lower abdomen.
• The bladder dome is the weakest point of the bladder and
ruptures will usually occur there .
4. • Extraperitoneal injury is almost always associated with pelvic
fractures.
• Usually caused by distortion of the pelvic ring, with shearing of the
anterolateral bladder wall near the bladder base (at its fascial
attachments), or by a contrecoup at the opposite side.
• The highest risk of bladder injury was found in disruptions of the
pelvic circle with displacement > 1 cm, diastasis of the pubic
symphysis > 1 cm, and pubic rami fractures.
• Occasionally, the bladder is directly perforated by a sharp bony
fragment.
5. ETIOLOGY
• Most blunt bladder injuries are the result of rapid-deceleration motor
vehicle collisions, but many also occur with falls, crush injuries, assault,
and blows to the lower abdomen.
• The main mechanisms are pelvic crush and blows to the lower
abdomen
• Most patients with blunt bladder injury have associated pelvic fractures
(60-90%) and other intra-abdominal injuries (44-68.5%)
• Bladder injury is associated with urethral injury in 5-20% of cases
• Penetrating injuries, mainly gunshot wounds, are rare except in conflict
zones and violent urban areas
7. CLINICAL SIGN & SYMPTOMS
• The principal sign of bladder injury is visible haematuria
• suprapubic pain combined with the inability to void.
• Physical signs include suprapubic tenderness, lower abdominal bruising,
muscle guarding and rigidity, and diminished bowel sounds
• Entry/exit wounds at lower abdomen, perineum or buttocks in penetrating
injuries
8. INTRA-OPERATIVE SIGNS
• External iatrogenic bladder injury include:
• extravasation of urine,
• visible laceration,
• visible bladder catheter,
• blood and/or gas in the urine bag during laparoscopy
• Direct inspection is the most reliable method of assessing bladder integrity
• Intravesical instillation of dye
• If bladder perforation is close to the trigone, the ureteric orifices should be inspected
9. • Internal iatrogenic bladder injury is recognized by cystoscopic
identification of fatty tissue, dark space, or bowel.
• It may also be detected by the inability to distend the bladder, low
return of irrigation fluid, or abdominal distension
10. POST-OPERATIVE SIGNS
• Missed bladder trauma is diagnosed by haematuria, abdominal pain,
abdominal distension, ileus, peritonitis, sepsis, urine leakage from the
wound, decreased urinary output, or increased serum creatinine.
• An IBT during hysterectomy or caesarean delivery can result in
vesico-vaginal or vesico-uterine fistulae
11. DIAGNOSTIC EVALUATION
• Absolute indications for bladder imaging include:
• visible haematuria and a pelvic fracture
• non-visible haematuria combined with high-risk pelvic fracture
• posterior urethral injury
• Clinical sign and symptoms
12. CYSTOGRAPHY
• preferred diagnostic modality for non-iatrogenic bladder injury and
for a suspected IBT in the post-operative setting
• Both plain and CT cystography have a comparable sensitivity (90-
95%) and specificity (100%)
• CT cystography is superior in the identification of bony fragments
in the bladder and bladder neck injuries, as well as concomitant
abdominal injuries
• Cystography must be performed using retrograde filling of the
bladder with a minimum volume of 300-350 mL of dilute contrast
materia
13. COMPUTED TOMOGRAPHY CYSTOGRAM DEMONSTRATES CONTRAST
MATERIAL
SURROUNDING LOOPS OF BOWEL CONSISTENT WITH INTRAPERITONEAL
BLADDER RUPTURE
14. PLAIN FLM CYSTOGRAM REVEALS EXTRAPERITONEAL BLADDER RUPTURE WITH
EXTRAVASATION INTO THE SCROTUM. SURGICAL EXPLORATION REVEALED
ANTERIOR BLADDER NECK AND PROSTATIC URETHRAL LACERATION.
15. COMPUTED TOMOGRAPHY CYSTOGRAM OF A PATIENT WITH
EXTRAPERITONEAL BLADDER RUPTURE AFTER A MOTOR VEHICLE/PEDESTRIAN
COLLISION AND EXTENSIVE
PELVIC FRACTURE. ARROW INDICATES A FRAGMENT OF BONE IN THE BLADDER
17. CYSTOSCOPY
• preferred method for detection of intra-operative bladder injuries
• can localise the lesion in relation to the position of the trigone and
ureteral orifices
• A lack of bladder distension during cystoscopy suggests a large
perforation
• Cystoscopy is recommended to detect perforation of the bladder (or
urethra) following retropubic sub-urethral sling operations
18. ULTRASONOGRAPHY
• Ultrasound alone is insufficient in the diagnosis of bladder
trauma, although it can be used to visualize intraperitoneal
fluid or an extraperitoneal collection of fluid.
19. DISEASE MANAGEMENT
PREVENTION
• Emptying the bladder by urethral catheterization in every
procedure where the bladder is at risk
• For tumors at the lateral wall, obturator nerve block or general
anaesthesia with adequate muscle relaxation can reduce the
incidence
20. CONSERVATIVE MANAGEMENT
• Comprises of clinical observation, continuous bladder drainage and
antibiotic
prophylaxis
• is the standard treatment for an uncomplicated extraperitoneal
injury due to blunt or iatrogenic trauma.
• Can also be chosen for uncomplicated intraperitoneal injury after
TURB or other operations, but only in the absence of peritonitis and
ileus .1
• Penetrating extraperitoneal bladder injuries (only if minor and
isolated) can also be managed conservatively
21. SURGICAL MANAGEMENT
• Bladder closure is performed with absorbable sutures
• There is no evidence that two-layer is superior to watertight
single-layer closure
22. BLUNT NON IATROGENIC TRAUMA
• Most extraperitoneal ruptures can be treated conservatively
• bladder neck involvement, bone fragments in the bladder wall,
concomitant rectal or vaginal injury or entrapment of the bladder wall
necessitate surgical intervention
• an extraperitoneal rupture should be sutured concomitantly in order
to reduce the risk of infection
• pelvic ring fractures with open stabilization and internal fixation with
osteosynthetic material
• during surgical exploration for other injuries
• Intraperitoneal ruptures should always be managed by surgical repair
1
23. PENETRATING NON IATROGENIC TRAUMA
• managed by emergency exploration, debridement of devitalised
bladder wall and primary bladder repair
• A midline exploratory cystotomy is advised to inspect the bladder
wall
and the distal ureters
• In gunshot wounds, there is a strong association with intestinal
and rectal injuries, usually requiring faecal diversion
• Check for two transmural (entry & exit) injuries in case of gunshot
wounds
24. IATROGENIC BLADDER TRAUMA
• Perforations recognised intra-operatively are primarily
closed
• Bladder injuries not recognised during surgery or internal
injuries should be managed according to their location.
• The standard of care for intraperitoneal injuries is surgical
exploration and repair
25. IATROGENIC BLADDER TRAUMA
• If surgical exploration is performed after TURB, the bowel must be
inspected to rule out concomitant injury
• For extraperitoneal injuries, exploration is only needed complicated
by symptomatic extravesical collections. It requires drainage of the
collection, with or without closure of the perforation
• If bladder perforation is encountered during midurethral sling or
transvaginal mesh procedures, sling re-insertion and urethral
catheterisation (two to seven days) should be performed
26. FOLLOW UP
• Conservatively treated bladder injuries (traumatic or external IBT) are
followed up by cystography to rule out extravasation and ensure proper
bladder healing
• The first cystography is planned approximately ten days after injury
• In case of ongoing leakage, cystoscopy should be performed to rule out
bony fragments in the bladder, and a second cystography is warranted
one week later
27. FOLLOW UP
• After operative repair of a simple injury in a healthy patient, the
catheter can be removed after five to ten days without
cystography
• In cases of complex injury (trigone involvement, ureteric re-
implantation) or risk factors of impaired wound healing (e.g.
steroids, malnutrition) cystography is advised
• For conservatively treated internal IBT, catheter drainage,
lasting five days for extraperitoneal and seven days for
intraperitoneal perforations, is proposed
30. ANTERIOR URETHRAL INJURIES
• The bulbar urethra is the most common site affected by blunt trauma.
• Possible mechanisms are straddle injuries or kicks to the perineum.
• A penile fracture can be complicated by a urethral injury in
approximately 15% of cases.
• Penetrating anterior injuries are rare and are usually caused by
gunshot wounds, stab wounds, dog bites, impalement or penile
amputations
• penetrating injuries are usually associated with penile, testicular
and/or pelvic injuries
31. • Iatrogenic injury is the most common type of urethral trauma
• Incidence is 6.7 per 1,000 catheters inserted
• Instrumentation of the urethra (TURP, cystoscopy, etc.) can
traumatise all segments of it
• During penile prosthesis insertion (PPI), the risk of urethral
perforation is 0.1-4%.
32. POSTERIOR MALE URETHRAL INJURIES
• Blunt posterior urethral injuries are almost exclusively related to pelvic
fractures with disruption of the pelvic ring. (PFUI)
• divided into partial or complete ruptures
• In complete ruptures, there is a gap between the disrupted ends of the
urethra, which fills up with scar tissue.
• Injuries of the bladder neck and prostate are rare and mostly occur at
the anterior midline of both the bladder neck and prostatic urethra
• Penetrating injuries of the pelvis, perineum or buttocks can also
damage the posterior urethra
33. FEMALE URETHRAL INJURIES
• Pelvic fractures are the main cause of blunt trauma but rare &
less common than male
• Birth related injuries are rare and consist of minor (peri)urethral
lacerations during vaginal delivery.
• classified into two types:
longitudinal or partial (most frequent) injuries and transverse or
complete injuries
• iatrogenic urethral injury :Insertion of a synthetic sub-urethral
sling is complicated by an intra-operative urethral injury in 0.2-
2.5% of cases
34. CLINICAL SIGNS
• Blood at the meatus is the cardinal sign
• Inability to void with a palpable distended bladder is another classic
sign – complete rupture
• Haematuria and pain on urination – incomplete rupture
• Urinary extravasation and bleeding may result in scrotal, penile
and/or perineal swelling and ecchymosis
• Rectal examination: High riding prostate, to rule out associated
rectal injury
• Female urethral injury: pelvic fracture with blood at the vaginal
introitus, vaginal laceration, haematuria, urethrorrhagia, labial
swelling, urinary retention or difficulties passing a urethral catheter
35. URETHROGRAPHY
• Retrograde urethrography (RUG) is the standard in the early
evaluation of a male urethral injury
• injecting 20-30 mL of contrast material while occluding the meatus
• Films should be taken in a 30° oblique position
• Incomplete : extravasation from the urethra while the bladder is still
filling
• Complete : massive extravasation without bladder filling
• In females, the short urethra and vulvar oedema makes adequate
urethrography nearly impossible
36. RETROGRADE URETHROGRAM IN A PATIENT WITH A PELVIC
FRACTURE SHOWS COMPLETE DISRUPTION OF THE POSTERIOR
URETHRA.
37. DEFECT IN THE URETHRA (ARROW) SEEN ON AN ANTEGRADE URETHROGRAM
IN A PATIENT AFTER PELVIC FRACTURE URETHRAL DISRUPTION AND INTERNAL
FXATION OF ANTERIOR PELVIC FRACTURE.
38. CYSTO- URETHROSCOPY
• Flexible cysto-urethroscopy is a valuable alternative to diagnose an
acute urethral injury
• Flexible cysto-urethroscopy is preferred to RUG in suspected penile
fracture-associated urethral injury
• In females, cysto-urethroscopy and vaginoscopy are the diagnostic
modalities of choice
• Prior to deferred treatment, a combination of RUG and ante grade
cysto urethrography is the standard to evaluate site and extent of the
urethral stenosis, and to evaluate the competence of the bladder neck
39. US & MRI
• US scanning is used for guiding the placement of a suprapubic
catheter
• In complex PFUIs, MRI provides valuable additional information
• a better estimation of the length of the distraction defect,
• degree of prostatic displacement and
• presence/absence of a false passage
40. MANAGEMENT: MALE ANTERIOR URETHRA
•Immediate exploration and urethral
reconstruction
• penile fracture related injuries
• non-life threatening penetrating injuries
• Small lacerations can be repaired by simple closure
• Complete ruptures without extensive tissue loss are treated with
anastomotic repair
• longer defects or apparent infection require staged repair with
urethral marsupialization
• The role of immediate urethroplasty in blunt injuries is controversial.
41. URINARY DIVERSION
• Blunt anterior urethral injuries reasonable to start with urinary
diversion only
• suprapubic diversion or a trial of early endoscopic re-alignment
with transurethral catheterisation
• Urinary diversion is maintained for one to two weeks for partial
ruptures and three weeks for complete ruptures
• Transurethral or suprapubic urinary diversion are treatment
options for iatrogenic or life-threatening penetrating injuries
42.
43. MALE POSTERIOR URETHRAL INJURIES
•Emergency room management
• Resuscitation and immediate treatment of life-threatening injuries
have absolute priority
• Penetrating injuries especially have a very high likelihood of
associated injuries requiring immediate exploration
• establish early urinary diversion to:
• monitor urinary output
• treat symptomatic retention if the patient is still conscious
• minimise urinary extravasation and its secondary effects, such as infection
and fibrosis
44. EARLY URETHRAL MANAGEMENT
<6 WEEKS AFTER INJURY
• For partial injuries, urinary diversion is sufficient as these injuries
can heal without significant scarring or obstruction
• A complete injury will not heal, and formation of an obliterated
segment is inevitable in case of suprapubic diversion alone
• To avoid this obliteration and a long period of suprapubic
diversion followed by deferred urethroplasty, the urethral ends
can be sutured (urethroplasty) or approximated over a
transurethral catheter (re-alignment)
• Includes immediate urethroplasty/early urethroplasty/early
realignment
45. IMMEDIATE URETHROPLASTY
• Urethroplasty within 48 hours after injury is difficult because of :
• poor visualisation
• the inability to accurately assess the degree of urethral
disruption
• extensive swelling and ecchymosis
• risk of severe bleeding (average 3 L) following entry into the
pelvic haematoma
• high rates of impotence (23%), incontinence (14%) and strictures
(54%)
46. EARLY URETHROPLASTY AFTER 2 DAYS UPTO 6 WEEKS
• can be performed if
• associated injuries have been stabilised,
• the distraction defect is short,
• the perineum is soft and
• the patient is able to lie down in the lithotomy position
• avoids a long period of suprapubic diversion with its discomfort and
complications 1
• Lacerations (blunt or penetrating) at the bladder neck and prostatic
urethra must be reconstructed as soon as possible 2
• For penetrating injuries with severe lesions to the prostate,
prostatectomy (bladder neck sparing) must be performed
47. EARLY RE-ALIGNMENT
• performed when a stable patient is on the operating table for other
surgery or as a stand-alone procedure in the absence of concomitant
injuries
• In a partial injury, re-alignment, and transurethral catheterisation
avoids extravasation of urine in the surrounding tissues reducing the
inflammatory response
• In complete injuries, the aim of re-alignment is to correct severe
distraction injuries rather than to prevent a stricture
• can be done by an open or endoscopic (preferred) technique 1
48. ENDOSCOPIC RE-ALIGNMENT
• Using a flexible/rigid cystoscope and biplanar fluoroscopy, a
guidewire
is placed inside the bladder under direct visual control, over this, a
catheter is placed.
• If necessary, one retrograde (per urethra) and one antegrade
(suprapubic route through the bladder neck) can be used
• The duration of catheterisation is three weeks for partial and six
weeks for complete
ruptures with voiding urethrography upon catheter removal
• It is important to avoid traction on the balloon catheter as it can
damage the remaining sphincter mechanism at the bladder neck
• No evidence of increase in risk of incontinence or erectile
49. DEFERRED MANAGEMENT
(GREATER THAN THREE MONTHS AFTER INJURY)
• Prior to deferred treatment, a combination of RUG and
antegrade cysto-urethrography is the standard to evaluate site
and extent of the urethral stenosis, and to evaluate the
competence of the bladder neck
• If, prior to deferred treatment, the competence of the bladder
neck is not clear upon antegrade cysto-urethrography, a
suprapubic cystoscopy is advised 1
• The standard treatment remains deferred urethroplasty 2
• After at least three months of suprapubic diversion, the pelvic
haematoma is nearly always resolved, the prostate has
descended into a more normal position, the scar tissue has
51. • a combined abdominoperineal approach has proven helpful in
cases of severe fibrosis, fistula, previous failed anastomotic
urethroplasty, and associated bladder neck injury, and in
pediatric cases
• The overall success rate for deferred urethroplasty is 86%
• Erectile dysfunction < 7%
• Urinary incontinence about 5%
52. FEMALE URETHRAL INJURY
• Emergency room management of PFUIs in females is the same as in
males
• Early repair (less than or equal to seven days) preferred once the
patient is hemodynamically stable 1
• Delayed repair (greater than seven days) often requires complex
abdominal or
combined abdominal-vaginal reconstruction 2
• Proximal and mid-urethral disruptions require immediate
exploration and primary repair with concomitant repair of vaginal
lacerations.
• Distal urethral injuries can be left hypospadiac since they do not
disrupt the sphincter mechanism
(disruption of the pelvic circle with displacement > 1 cm or diastasis of the pubic symphysis > 1 cm
..inability to void or inadequate urine output;• abdominal tenderness or distension due to urinary ascites, or signs of urinary ascites in abdominal imaging;• uraemia and elevated creatinine level due to intraperitoneal re-absorption;• entry/exit wounds at lower abdomen, perineum or buttocks in penetrating injuries.
FLAME SIGN
the catheter’s balloon can aid in identification of the bladder
Placement of an intraperitoneal drain is advocated, especially when the lesion is larger
Because intraperitoneal urine extravasation can lead to peritonitis, intra-abdominal sepsis and death . Abdominal organs should be inspected for possible associated injuries and urinomas must be drained if detected.
Act of piercing
(mainly gunshot wounds)
sling for the treatment of female stress urinary incontinence
Unstable pelvic fractures in female
MRI before deferred treatment
in this instance the initial procedure should be abandoned
As these injuries are usually associated with other severe injuries
diversion (suprapubic or transurethral)
So it is contra indicated
1..As the results (complications, stricture recurrence, incontinence and impotence) are equivalent to delayed urethroplasty , early urethroplasty might be an option for patients fulfilling theabove-mentioned criteria. 2.. They will never heal spontaneously, will cause local cavitation (presenting a source of infection) and compromise the intrinsic sphincter mechanism (with increased risk of urinary incontinence)
1.. The open technique is associated with longer operation times, more blood loss and longer hospital stay
Overall controversial results
1..MRI gives information includes a better estimation of the length of the distraction defect, degree of prostatic displacement and presence/absence of a false passage 2… obliteration of the posterior urethra is almost inevitable in cases of complete rupture treated with SPC so urethroplasty required
Intraoperative view of normal membranous urethra after fibrotic tissue was excised during perineal bulbomembranous urethroplasty
(with or without partial pubectomy)
1..Complication rate is the lowest with early repair; 2.. elevated risk of urinary incontinence and vaginal stenosis.