Trauma, Reconstruction, and Urinary Diversion
Renal trauma
Grade with CT. Haemodynamically stable patients, even with high-grade injuries, are managed non-operatively with monitoring. Absolute indication for exploration is haemodynamic instability; relative indications include expanding haematoma and pulsatile perirenal haematoma.
Ureteral, bladder, and urethral injury
Iatrogenic ureteral injury recognized intraoperatively is repaired immediately; delayed presentations are stented or reconstructed. Extraperitoneal bladder rupture usually heals with catheter drainage, whereas intraperitoneal rupture requires operative repair. Suspected urethral injury is evaluated with retrograde urethrography and managed with a suprapubic catheter, avoiding urethral catheterisation; acute repair is generally deferred.
Reconstruction
Options include buccal mucosa graft urethroplasty, ureteroureterostomy, ileal ureter, and pyeloplasty. Principles are tension-free anastomosis, healthy tissue, and adequate vascularity.
Diversion
Ileal conduit is non-continent; orthotopic neobladder preserves urethral voiding but risks nocturnal incontinence and retention; continent cutaneous pouches require catheterisation. Ileal conduit causes hyperchloraemic metabolic acidosis. Neobladder patients need vitamin B12 surveillance and instruction on timed voiding. Ureteroenteric anastomotic stricture is a late complication.
Traps
Catheterising a suspected urethral disruption; repairing urethral injury acutely; assuming all bladder ruptures need surgery; ignoring metabolic acidosis after diversion.
Worked example
A pelvic fracture with blood at the meatus and inability to void needs retrograde urethrography and a suprapubic catheter, not an attempted urethral catheter.