Trauma and Reconstruction
This domain tests injury grading, the decision between conservative and operative management, and the reconstructive ladder for urethral and ureteric strictures. Most marks come from knowing what not to do, especially catheterising a suspected urethral injury.
Renal trauma
- Grade with the AAST scale I-V. Haemodynamically stable patients, including most high-grade injuries, are managed non-operatively with observation and re-imaging.
- CT must include an excretory phase to detect collecting system injury; angiography and embolisation control active bleeding; surgery is reserved for haemodynamic instability or an expanding haematoma.
Urethral and bladder injury
- Posterior urethral injury follows pelvic fracture: blood at the meatus, inability to void, high-riding prostate, perineal haematoma. Do not catheterise. Perform a retrograde urethrogram, place a suprapubic catheter, and plan delayed urethroplasty after 3-6 months.
- Anterior urethral injury from a straddle mechanism gives a butterfly haematoma; suprapubic drainage and later repair.
- Bladder rupture: extraperitoneal from pelvic fracture is usually managed with catheter drainage; intraperitoneal rupture at the dome after a full bladder requires operative repair.
Genital trauma
- Penile fracture: audible snap, detumescence, eggplant deformity; diagnosis is clinical and immediate surgical repair reduces long-term curvature and erectile dysfunction.
- Testicular rupture with a disrupted tunica albuginea requires exploration and debridement with preservation of viable tissue.
Reconstruction
- Bulbar strictures: excision and primary anastomotic urethroplasty gives the best durability; dorsal onlay buccal mucosa graft for longer anterior strictures; repeated dilatation is not definitive.
- Ureteric reconstruction: psoas hitch, Boari flap, ileal ureter or autotransplantation for long defects; ureteroneocystostomy for distal injury.
- Diversion options include ileal conduit, orthotopic neobladder and continent cutaneous reservoir.
Worked example
A 30-year-old falls astride a frame, has blood at the meatus, cannot void and shows a butterfly perineal haematoma. Attempting a urethral catheter risks converting a partial to a complete injury. Perform a retrograde urethrogram, which shows bulbar extravasation, insert a suprapubic catheter, and plan elective urethroplasty after about 3 months, counselling that stricture recurrence after anastomotic repair is roughly 10-15 percent.
Traps that cost marks
Passing a urethral catheter in suspected urethral injury; missing intraperitoneal bladder rupture; managing testicular rupture conservatively; imaging renal trauma without an excretory phase; repeating dilatation instead of definitive urethroplasty.