Urotrauma: AUA Guideline

Allen F. Morey, Steve Brandes, Daniel David Dugi III, John H. Armstrong, Benjamin N. Breyer, Joshua A. Broghammer, Bradley A. Erickson, Jeff Holzbeierlein, Steven J. Hudak, Jeffrey H. Pruitt, James T. Reston, Richard A. Santucci, Thomas G. Smith III and Hunter Wessells

From the American Urological Assocation Education and Research, Inc., Linthicum, Maryland

Purpose: The authors of this guideline reviewed the urologic trauma literature Abbreviations to guide clinicians in the appropriate methods of evaluation and management and Acronyms of genitourinary injuries. ¼ Materials and Methods: AAST American Association for A systematic review of the literature using the the of Trauma MEDLINEÒ and EMBASE databases (search dates 1/1/90-9/19/12) was con- CT ¼ computerized tomography ducted to identify peer-reviewed publications relevant to urotrauma. The review yielded an evidence base of 372 studies after application of inclusion/exclusion ICU ¼ intensive care unit criteria. These publications were used to inform the statements presented in the IV ¼ intravenous guideline as Standards, Recommendations or Options. When sufficient evidence IVP ¼ intravenous existed, the body of evidence for a particular treatment was assigned a strength MRI ¼ magnetic resonance rating of A (high), B (moderate) or C (low). In the absence of sufficient evidence, imaging additional information is provided as Clinical Principles and Expert Opinions. ORIF ¼ open reduction internal Results: Guideline statements were created to inform clinicians on the initial fixation observation, evaluation and subsequent management of renal, ureteral, bladder, PFUI ¼ pelvic fracture urethral urethral and genital traumatic injuries. injury Conclusions: Genitourinary organ salvage has become increasingly possible as a PR ¼ primary realignment result of advances in imaging, minimally invasive techniques, and reconstructive SP ¼ suprapubic surgery. As the field of genitourinary reconstruction continues to evolve, clini- SPT ¼ suprapubic tube cians must strive to approach clinical problems in a creative, multidisciplinary, evidence-based manner to ensure optimal outcomes. The complete guideline is available at http:// www.auanet.org/education/guidelines/urotrauma. Key Words: urotrauma, injury cfm. This document is being printed as submitted independent of editorial or peer review by the Editors of The Journal of UrologyÒ. THE Panel’s purpose is to review the urethral, and genital trauma. Guide- existing literature pertaining to the line statements were formed based on acute care of urologic injuries in an this literature review. effort to develop effective guidelines The AUA nomenclature system for appropriate diagnosis and inter- explicitly links statement type to vention strategies in the setting body of evidence strength and the of urotrauma. Panel’s judgment regarding the bal- ance between benefits and risks/ burdens.1 For a complete discussion METHODOLOGY of the methodology and evidence A comprehensive search of the liter- grading, please refer to the un- ature targeted the five main uro- abridged guideline available at http:// trauma topics within the scope of this www.auanet.org/education/guidelines/ guideline: renal, ureteral, bladder, urotrauma.cfm.

0022-5347/14/1922-0327/0 http://dx.doi.org/10.1016/j.juro.2014.05.004 ® THE JOURNAL OF UROLOGY Vol. 192, 327-335, August 2014 www.jurology.com j 327 © 2014 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION AND RESEARCH,INC. Printed in U.S.A. 328 UROTRAUMA

BACKGROUND phases is preferred in order to elucidate both the Definition location of renal lacerations and the presence of contrast extravasation from collecting system in- Trauma refers to injury caused by external force juries. Standard intravenous pyelogram may be used from a variety of mechanisms, including traffic- or in rare cases where CT is not available, but is infe- transportation-related injuries, falls, assault (e.g., rior. Ultrasound may be used in children, although blunt weapon, stabbing, gunshot), explosions, etc. CT is preferred. An intraoperative one-shot IVP may Prevalence be used to confirm that a contralateral functioning is present in rare cases where the patient is Traumatic injuries are the leading cause of death in taken to the operating room without a CT scan. the United States for people ages 1-44 years, and a 4. Clinicians should use non-invasive man- significant cause of morbidity and loss of productive agement strategies in hemodynamically stable life across all ages.2 Worldwide, traumatic injuries patients with renal injury. (Standard; Evi- are the sixth leading cause of death and the fifth dence Strength: Grade B) leading cause of moderate and severe disability.3 Stable patients are defined as those who do not The kidneys are the most commonly injured geni- have vital signs consistent with shock and show tourinary organ. Civilian renal injury occurs in up stable serial hematocrit values over time. Nonin- to 5% of trauma victims,4,5 and accounts for 24% of vasive management of renal injury, which may traumatic abdominal solid organ injuries.6 consist of close hemodynamic monitoring, bed rest, ICU admission and blood transfusion, avoids un- GUIDELINE STATEMENTS necessary surgery, decreases unnecessary nephrec- tomy, and preserves renal function. Renal Trauma 5. The surgical team must perform immedi- 1. Clinicians should perform diagnostic imag- ate intervention (surgery or angioembolization ing with intravenous contrast enhanced in selected situations) in hemodynamically computerized tomography in stable blunt unstable patients with no or transient response trauma patients with gross hematuria or to resuscitation. (Standard; Evidence Strength: microscopic hematuria and systolic blood Grade B) pressure < 90 mm HG. (Standard; Evidence Hemodynamic instability despite resuscitation Strength: Grade B) suggests uncontrolled and ongoing bleeding. Imme- These criteria should allow early and accurate diate intervention (either open surgery or angioem- detection and staging of significant renal injuries. bolization) is warranted for unstable patients to Advantages of CT outweigh the risks, which include limit the need for future transfusion and prevent contrast related complications, radiation exposure, life-threatening complications. The goal of operative and the dangers of transporting a patient away from exploration is to control bleeding first, repair the the resuscitation environment. kidney (when possible), and establish perirenal 2. Clinicians should perform diagnostic im- drainage. is a frequent result when aging with IV contrast enhanced CT in stable hemodynamically unstable patients undergo surgi- trauma patients with mechanism of injury or cal exploration. physical exam findings concerning for renal Selected patients with bleeding from segmental injury (e.g., rapid deceleration, significant renal vessels may benefit from angioembolization as blow to flank, rib fracture, significant flank a minimally invasive treatment to control bleeding. ecchymosis, penetrating injury of abdomen, Patients who are hemodynamically unstable despite flank, or lower chest). (Recommendation; Evi- active resuscitation should be taken to the operating dence Strength: Grade C) room rather than angiography. Up to 34% of multisystem trauma patients may 6. Clinicians may initially observe patients have renal injury despite absence of hematuria or with renal parenchymal injury and urinary hemodynamic instability.7 A lack of these findings extravasation. (Clinical Principle) should not preclude imaging if clinicians suspect Parenchymal collecting system injuries often renal injury based on physical findings, associated resolve spontaneously. A period of observation abdominal injuries, or mechanism of injury. without intervention is advocated in stable patients 3. Clinicians should perform IV contrast where or proximal ureteral injury is enhanced abdominal/pelvic CT with immedi- not suspected. When renal pelvis or proximal ure- ate and delayed images when there is suspi- teral avulsion is suspected, prompt intervention cion of renal injury. (Clinical Principle) is warranted. CT scan of the abdomen and pelvis, using IV 7. Clinicians should perform follow-up CT contrast with immediate and delayed (10 minute) imaging for renal trauma patients having UROTRAUMA 329

either (a) deep lacerations (AAST Grade IV-V) directly to laparotomy without adequate radio- or (b) clinical signs of complications (e.g., graphic staging. Adjunctive maneuvers to identify fever, worsening flank pain, ongoing blood ureteral injuries include careful ipsilateral ureteral loss, abdominal distention). (Recommenda- mobilization and/or IV or intraureteral injectable tion; Evidence Strength: Grade C) dyes, such as methylene blue or indigo carmine. Follow-up CT imaging (after 48 hours) is prudent Retrograde pyelography may be performed in in patients with deep renal injuries (AAST Grade equivocal cases when possible. IV-V) because these are prone to developing trou- 10a. Surgeons should repair traumatic ure- blesome complications, such as urinoma or hemor- teral lacerations at the time of laparotomy in rhage. AAST Grade I-III injuries have a low risk of stable patients. (Recommendation; Evidence complications and rarely require intervention;8 Strength: Grade C) routine follow-up CT imaging is not advised for Ureteral repair should be performed at the time these injuries. of initial laparotomy, when possible, though imme- 8. Clinicians should perform urinary diate repair may not be appropriate in unstable, drainage in the presence of complications, complex polytrauma patients. such as enlarging urinoma, fever, increasing 10b. Surgeons may manage ureteral injuries pain, ileus, fistula or infection. (Recommen- in unstable patients with temporary urinary dation; Evidence Strength: Grade C) Drainage drainage followed by delayed definitive man- should be achieved via ureteral stent and may agement. (Clinical Principle) be augmented by percutaneous urinoma In damage control settings when immediate drain, percutaneous or both. ureteral repair is not possible, urinary extravasa- (Expert Opinion) tion can be prevented with ureteral ligation followed A ureteral stent is minimally invasive and alone by tube placement or may provide adequate drainage of the injured kidney. with an externalized ureteral secured to Clinicians must make adequate provision to ensure the proximal end of the ureteral defect. Definitive removal of stent in follow-up. A period of concomitant repair of the injury should be performed when Foley catheter drainage may minimize pressure the patient’s clinical situation has improved/ within the collecting system and enhance urinoma stabilized. drainage. If follow-up imaging demonstrates a uri- 10c. Surgeons should manage traumatic noma increasing in size, purulence, or complexity, a ureteral contusions at the time of laparotomy percutaneous drain may also be necessary. with ureteral stenting or resection and pri- mary repair depending on ureteral viability Ureteral Trauma and clinical scenario. (Expert Opinion) 9a. Clinicians should perform IV contrast Ureteral contusion is not uncommon in the enhanced abdominal/pelvic CT with delayed context of a gunshot wound with blast injury; com- imaging (urogram) for stable trauma patients plications may include delayed ureteral stricture with suspected ureteral injuries. (Recommen- and/or overt ureteral necrosis with urinary extrav- dation; Evidence Strength: Grade C) asation. Thus, when identified during laparotomy, Ureteral injuries should be suspected in complex, intact but contused should be primarily multisystem abdominopelvic trauma patients, such managed with ureteral stenting; resection with as those with bowel, bladder, or vascular injuries; primary repair may be performed in selected in- in those with complex pelvic/vertebral fractures; stances, depending on the severity of the contusion after rapid deceleration injuries; and when the tra- and the viability of local tissues. jectory of the penetrating injury is near the , 11a. Surgeons should attempt ureteral stent especially with high velocity gunshot wounds.9 placement in patients with incomplete ure- Absence of hematuria cannot be relied upon to teral injuries diagnosed postoperatively or in exclude ureteral injury.10 In stable patients not a delayed setting. (Recommendation; Evidence proceeding directly to exploratory laparotomy, IV Strength: Grade C) enhanced abdominal/pelvic CT with 10 minute When an incomplete ureteral injury is first delayed images should be obtained to evaluate for unrecognized or presents in a delayed fashion, ureteral injury. retrograde ureteral imaging with ureteral stent 9b. Clinicians should directly inspect the placement should be performed initially.11e13 Im- ureters during laparotomy in patients with mediate repair can be considered in certain situa- suspected ureteral injury who have not had tions if the injury is recognized within one week preoperative imaging. (Clinical Principle) (e.g., injury located near a surgically closed viscus, Direct ureteral inspection is necessary in patients such as bowel or vagina, or if the patient is being re- suspected to have ureteral injury who proceed explored for other reasons). 330 UROTRAUMA

11b. Surgeons should perform percutaneous endoscopic or percutaneous procedures are nephrostomy with delayed repair as needed in not possible or fail to adequately divert the patients when stent placement is unsuccessful urine. (Expert Opinion) or not possible. (Recommendation; Evidence Open or laparoscopic repair of endoscopic ure- Strength: Grade C) teral injuries, using techniques and principles When the ureter is completely transected or mentioned above, is necessary when endoscopic otherwise cannot be cannulated in a retrograde attempts at diverting the urine fail.11,14 fashion or if patient instability precludes attempts at retrograde treatment, a percutaneous neph- Bladder Trauma rostomy tube should be placed. If nephrostomy 14a. Clinicians must perform retrograde cys- alone does not adequately control the urine leak, tography (plain film or CT) in stable patients options then include placement of a periureteral with gross hematuria and pelvic fracture. drain or immediate open ureteral repair.11e14 (Standard; Evidence Strength: Grade B) 12a. Surgeons should repair ureteral in- Gross hematuria is the most common indicator of juries located proximal to the iliac vessels bladder injury.15e18 Pelvic fracture is the most with primary repair over a ureteral stent, common associated injury with bladder rupture;15,19 when possible. (Recommendation; Evidence however, pelvic fracture alone does not warrant Strength: Grade C) radiologic evaluation of the bladder.18 Bladder When the ureter is transected above the iliac injury is present in 29% of the patients presenting vessels, a spatulated, tension-free primary ureteral with the combination of gross hematuria and pelvic repair over a ureteral stent is advisable after all fracture; therefore, gross hematuria occurring with non-viable ureteral tissue has been judiciously pelvic fracture is considered an absolute indication debrided. In situations where the anastomosis for retrograde to evaluate for the cannot be performed without tension, mobilization presence of bladder injury.15 of the ureter should be performed in a manner that 14b. Clinicians should perform retrograde preserves maximal ureteral blood supply. If an cystography in stable patients with gross anastomosis can still not be performed after mobi- hematuria and a mechanism concerning for lization, a ureteral reimplantation can be attempted bladder injury, or in those with pelvic ring incorporating ancillary maneuvers such as a fractures and clinical indicators of bladder downward , bladder psoas hitch and/or rupture. (Recommendation; Evidence Strength: Boari bladder flap. Grade C) 12b. Surgeons should repair ureteral in- Although the majority of bladder ruptures juries located distal to the iliac vessels with (90%) will present with gross hematuria in the ureteral reimplantation or primary repair setting of a pelvic ring fracture, a number of other over a ureteral stent, when possible. (Recom- clinical scenarios should warrant retrograde cys- mendation; Evidence Strength: Grade C) tography to evaluate for bladder injury.15 A limited When the ureter is injured below the iliac vessels, number of pelvic fracture patients with bladder the distal ureter may be healthy enough to perform injuries will present with microscopic hematuria a simple in select situations, (0.6-5.0%).15,20 In general, microscopic hematuria although the surgeon should defer to direct ureteral combined with pelvic fracture is not an indication reimplantation if there is any doubt about the seg- for radiologic evaluation, but may be warranted ment’s viability. Tension-free reimplantation may in select cases with other clinical indicators of require ancillary maneuvers, such as a bladder bladder rupture, such as low urine output, abdom- mobilization with psoas hitch or flap. inal distension, inability to void, suprapubic (SP) 13a. Surgeons should manage endoscopic pain, or altered mental status.15,19,20 ureteral injuries with a ureteral stent and/or 15. Surgeons must perform surgical repair percutaneous nephrostomy tube, when possible. of intraperitoneal bladder rupture in the (Recommendation; Evidence Strength: Grade C) setting of blunt or penetrating external When a ureteral injury occurs during ureteral trauma. (Standard; Evidence Strength: , a ureteral stent should be placed. If Grade B) placement of a ureteral stent is not possible or if Intraperitoneal bladder ruptures must be surgi- stent placement fails to adequately divert the urine, cally repaired.15e18,21 Intraperitoneal ruptures then a percutaneous nephrostomy tube should be caused by blunt external trauma tend to be large placed with or without a periureteral drain. Delayed “blow-out” injuries located in the dome of the ureteral reconstruction is often necessary.12 bladder and are unlikely to heal spontaneously 13b. Surgeons may manage endoscopic with catheter drainage alone. Penetrating injuries ureteral injuries with open repair when with intraperitoneal components have smaller UROTRAUMA 331

injuries but must be repaired as well. Failure to urethral meatus after pelvic trauma. (Recom- repair intraperitoneal bladder injuries can result in mendation; Evidence Strength: Grade C) translocation of bacteria from the bladder to the Given concerns for urethral injury, clinicians abdominal cavity resulting in peritonitis, sepsis, should perform retrograde urethrography after and other serious complications. pelvic or genital trauma when blood is seen at the 16. Clinicians should perform catheter urethral meatus.22 The drainage as treatment for patients with un- may demonstrate partial or complete urethral complicated extraperitoneal bladder injuries. disruption, providing guidance for how to best (Recommendation; Evidence Strength: manage bladder drainage in the acute setting. Blind Grade C) catheter passage prior to retrograde urethrogram Uncomplicated extraperitoneal bladder injuries should be avoided. can be managed using urethral Foley catheter 20. Clinicians should establish prompt uri- drainage with the expectation that the injury will nary drainage in patients with pelvic fracture heal with conservative management.17,18,21 Leaving associated urethral injury. (Recommendation; the Foley catheter in place two to three weeks is Evidence Strength: Grade C) standard, although it is acceptable to leave the Patients with pelvic fracture urethral injury are Foley catheter in longer. Cystography is advised to often unable to urinate due to their injuries.23 confirm complete bladder healing prior to cath- Because trauma resuscitations typically involve eter removal. aggressive hydration and a critical need to closely 17. Surgeons should perform surgical repair monitor patient volume status, clinicians should in patients with complicated extraperitoneal establish efficient and prompt urinary drainage in bladder injury. (Recommendation; Evidence the acute setting. For polytrauma patients with Strength: Grade C) complete urethral injuries, immediate SPT place- Complicated extraperitoneal bladder ruptures ment (percutaneously or via open technique) is should be surgically repaired in the standard advised. fashion to avoid prolonged sequelae from the injury. 21. Surgeons may place suprapubic tubes in Pelvic fractures that result in exposed bone spicules patients undergoing open reduction internal in the bladder lumen should be repaired with fixation for pelvic fracture. (Expert Opinion) removal of the exposed bone and closure of the The management of PFUI requires close coordi- bladder. Concurrent rectal or vaginal lacerations nation with orthopedic surgeons to optimize timing may lead to fistula formation to the ruptured of interventions. In such cases, concerns regarding bladder, and in this setting the extraperitoneal the use of SPT in patients undergoing open reduc- bladder rupture should be fixed. Bladder neck in- tion and internal fixation of the pubic symphysis juries may not heal with catheter drainage alone vary based on individual surgeon and institutional and repair should be considered. Bladder repair is practice patterns. No evidence exists to indicate advised in pelvic fracture patients having open that SPT insertion increases the risk of orthopedic reduction internal fixation procedures. hardware infection.24 Thus considerations of the 18. Clinicians should perform urethral urethral injury and its management should dictate catheter drainage without suprapubic (SP) the use of SPT. cystostomy in patients following surgical 22. Clinicians may perform primary repair of bladder injuries. (Standard; Evi- realignment (PR) in hemodynamically stable dence Strength: Grade B) patients with pelvic fracture associated ure- A number of studies have shown no advantage of thral injury. (Option; Evidence Strength: combined SP and urethral catheterization over Grade C ) Clinicians should not perform pro- urethral catheterization alone after repair of bladder longed attempts at endoscopic realignment in injuries. Urethral have been shown to patients with pelvic fracture associated ure- adequately drain the repaired bladder and result in thral injury. (Clinical Principle) shorter hospital stay and lower morbidity.15 The first priority in management of PFUI is There are clinical exceptions in which suprapubic establishment of urinary drainage. SPT and delayed tubes may be considered (e.g., patients requiring urethral reconstruction remains the accepted long-term catheterization, those immobilized due to treatment for the vast majority of cases. Patients orthopedic injuries, and complex bladder repairs undergoing PR of PFUI may have less severe ure- with tenuous closures or significant hematuria). thral strictures when compared to patients under- going SP diversion alone.25,26 Urethral Trauma Although the indications, benefits, and methods 19. Clinicians should perform retrograde of PR remain debatable, attempts at PR should urethrography in patients with blood at the be reserved for hemodynamically stable patients 332 UROTRAUMA

within the first few days after injury.27 The tech- of the disruption, degree of bladder distension, and nique may require two urologists to navigate the availability of urological expertise and endoscopic simultaneously from above and below with instrumentation. Immediate operative intervention multiple flexible or rigid cystoscopes, video moni- to repair or debride the injured urethra is contra- tors, and fluoroscopy. Prolonged attempts at endo- indicated due to the indistinct nature of the injury scopic realignment must be avoided as the process border. Stricture formation after straddle injury is may increase injury severity and long-term likely and all patients undergoing sequelae, delay other medical services the patient require follow-up surveillance using uroflowmetry, requires, and has not been shown to improve long- retrograde urethrogram and/or .34 term outcomes. Whether endoscopic realignment is successfully performed or not, patients with PFUI Genital Trauma are at high risk for developing urethral stricture; 26. Clinicians must suspect penile fracture therefore, after PR it is prudent to maintain SPT when a patient presents with penile ecchy- drainage concomitantly while awaiting resolution mosis, swelling, cracking or snapping sound of PFUI. during intercourse or manipulation and im- 23. Clinicians should monitor patients for mediate detumescence. (Standard; Evidence complications (e.g., stricture formation, erec- Strength: Grade B) tile dysfunction, incontinence) for at least one Penile swelling and ecchymosis are the most year following urethral injury. (Recommen- common signs of penile fracture. Most patients dation; Evidence Strength: Grade C) report a cracking or snapping sound followed by PFUI is associated with high rates of urethral immediate detumescence. Other symptoms may stricture formation and erectile dysfunction, while include penile pain and penile angulation. History only small numbers of men will report urinary in- and physical examination alone are often diagnostic continence.23,28 Rates of stricture after PFUI will in these patients. vary based on injury severity and management with 27. Surgeons should perform prompt surgi- PR or SPT, but in either scenario, stricture in most cal exploration and repair in patients with cases develops within a year of injury and can be acute signs and symptoms of penile fracture. treated by or direct vision internal (Standard; Evidence Strength: Grade B) .29,30 Thus surveillance strategies with In patients with history and physical signs uroflowmetry, retrograde urethrogram, cystoscopy, consistent with penile fracture, surgical repair or some combination of methods are recommended should be performed. The repair is performed by for the first year after injury. Impotence and in- exposing the injured corpus cavernosum through continence are generally considered to be caused by either a ventral midline or circumcision incision. the pelvic fracture itself rather than contemporary Tunical repair is performed with absorbable suture interventions for PFUI.31,32 and should be performed at the time of presentation 24. Surgeons should perform prompt surgi- to improve long-term outcomes.35e38 cal repair in patients with uncomplicated 28. Clinicians may perform ultrasound in penetrating trauma of the anterior urethra. patients with equivocal signs and symptoms (Expert Opinion) of penile fracture. (Expert Opinion) After a penetrating trauma to the anterior ure- Patients with equivocal signs of penile fracture thra has been appropriately staged, surgical repair may undergo imaging as an adjunct study to assist should be performed. It is expert opinion that with confirmation or exclusion of the diagnosis of spatulated primary repair of uncomplicated injuries penile fracture.39 Ultrasound is the most commonly in the acute setting offers excellent outcomes supe- used imaging modality due to wide availability, low rior to delayed reconstruction. Primary repair cost, and rapid examination times.38,40,41 If imaging should not be undertaken if the patient is unstable, is equivocal or diagnosis remains in doubt, surgical the surgeon lacks expertise in urethral surgery or exploration should be performed. in the setting of extensive tissue destruction or loss. 29. Clinicians must perform evaluation for 25. Clinicians should establish prompt uri- concomitant urethral injury in patients with nary drainage in patients with straddle injury penile fracture or penetrating trauma who to the anterior urethra. (Recommendation; present with blood at the urethral meatus, Evidence Strength: Grade C) gross hematuria or inability to void. (Stan- Crush injuries of the bulbar urethra caused by dard; Evidence Strength: Grade B) straddle injury require prompt intervention to Patients with penile fracture and gross hematu- avoid urinary extravasation.33 Establishing urinary ria, blood at the urethral meatus, or inability to void drainage by SPT, or PR in less severe cases, re- should undergo evaluation for concomitant urethral quires consideration of associated injuries, severity injury.42e44 An additional risk factor is bilateral UROTRAUMA 333

corporal body fracture.35,45,46 Options for evaluation possible to perform microscopic repair of dorsal ar- include urethroscopy and retrograde urethro- teries, veins, and nerves. The amputated appendage gram.39,47 Neither method is superior for diagnosis. should be transported to the hospital in a two-bag The choice of retrograde urethrogram or cystoscopy system with the penis wrapped in saline-soaked is the decision of the urologist based on equipment gauze, placed in a plastic bag, and then placed on availability and procedure timing. ice in a second bag. 30. Surgeons should perform scrotal explo- ration and debridement with tunical closure Conflict of Interest Disclosures (when possible) or orchiectomy (when non- All panel members completed COI disclosures. Re- salvagable) in patients with suspected testic- lationships that have expired (more than one year ular rupture. (Standard; Evidence Strength: old) since the panel’s initial meeting, are listed. Grade B) Those marked with (C) indicate that compensation Testicular rupture after blunt or penetrating was received; relationships designated by (U) indi- scrotal injuries may be suggested by scrotal ecchy- cate no compensation was received. Consultant or mosis and swelling or difficulty in identifying Advisor: Jeffrey M. Holzbeierlein: Janssen (C); the contours of the testicle on physical exam. The Allen F. Morey, MD: American Medical Systems most specific findings on ultrasonography are loss (C); Meeting Participant or Lecturer: Steven B. of testicular contour and heterogenous echotexture Brandes, MD: American Medical Systems (C), of parenchyma, which should prompt testicular Astellas (C); Jeffrey M. Holzbeierlein, MD: repair.48 Repair of the ruptured testis by debriding Janssen (C), Amgen (C); Allen F. Morey, MD: non-viable tissue and closing the tunica albuginea American Medical Systems (C), Glaxo Smith Kline is preferred when possible.49,50 Expert opinion is (C), Coloplast (C), Pfizer (C) (Expired); Hunter that tunica vaginalis grafts may be used to provide Wessells, MD: National Institutes of Health closure when the tunica albuginea cannot be closed Scientific Study or Trial: Steven Benjamin primarily. For penetrating scrotal injuries, imme- Brandes, MD: Allergan (U); Joshua A. Brog- diate exploration with debridement and repair is hammer, MD: Trauma Urologic Reconstructive encouraged to prevent complications. Network (U), Hunter Wessells, MD: National 31. Surgeons should perform exploration Institutes of Health (U); Other: Joshua A. and limited debridement of non-viable tissue Broghammer, MD: American Medical Systems in patients with extensive genital skin loss or (C); Hunter Wessells, MD: National Institutes of injury from infection, shearing injuries, or Health (U). burns (thermal, chemical, electrical). (Stan- dard; Evidence Strength: Grade B) Disclaimer Initial management in these patients should This document was written by the Urotrauma include operative exploration, irrigation, and limited Guidelines Panel of the American Urological Asso- debridement of clearly non-viable tissue. Typically, ciation Education and Research, Inc., which was these injuries require multiple procedures in the created in 2013. The Practice Guidelines Committee operating room prior to definitive reconstructive (PGC) of the AUA selected the committee chair. procedures. Wound management can include a va- Panel members were selected by the chair. Mem- riety of methods including gauze dressings with bership of the committee included urologists and frequent changes, silver sulfadiazine or topical other clinicians with specific expertise on this dis- antibiotic and occlusive dressing, or negative pres- order. The mission of the committee was to develop sure dressings. Reconstructive techniques for recommendations that are analysis-based or definitive repair include primary closure and consensus-based, depending on Panel processes and advancement flaps, placement of skin grafts, free available data, for optimal clinical practices in the tissue flaps, and pedicle based skin flaps. treatment kidney stones. 32. Surgeons should perform prompt penile Funding of the committee was provided by the replantation in patients with traumatic penile AUA. Committee members received no remunera- amputation, with the amputated appendage tion for their work. Each member of the committee wrapped in saline-soaked gauze, in a plastic provides an ongoing conflict of interest disclosure bag and placed on ice during transport. to the AUA. (Clinical Principle) While these guidelines do not necessarily estab- Urologists should perform reanastomosis of lish the standard of care, AUA seeks to recommend macroscopic structures, including the corpora cav- and to encourage compliance by practitioners with ernosa, spatulated repair of the urethra, and skin, current best practices related to the condition being when the amputated penis is available. A micro- treated. As medical knowledge expands and tech- vascular surgeon should be consulted whenever nology advances, the guidelines will change. Today 334 UROTRAUMA

these evidence-based guidelines statements repre- to carefully follow all available prescribing infor- sent not absolute mandates but provisional pro- mation about indications, contraindications, pre- posals for treatment under the specific conditions cautions and warnings. These guidelines and described in each document. For all these reasons, best practice statements are not in-tended to pro- the guidelines do not pre-empt physician judgment vide legal advice about use and misuse of these in individual cases. substances. Treating physicians must take into account var- Although guidelines are intended to encourage iations in resources, and patient tolerances, needs, best practices and potentially encompass available and preferences. Conformance with any clinical technologies with sufficient data as of close of the guideline does not guarantee a successful outcome. literature review, they are necessarily time-limited. The guideline text may include information or rec- Guidelines cannot include evaluation of all data on ommendations about certain drug uses (‘off label’) emerging technologies or management, including that are not approved by the Food and Drug those that are FDA-approved, which may immedi- Administration (FDA), or about medications or ately come to represent accepted clinical practices. substances not subject to the FDA approval process. For this reason, the AUA does not regard tech- AUA urges strict compliance with all government nologies or management which are too new to be regulations and protocols for prescription and use addressed by this guideline as necessarily experi- of these substances. The physician is encouraged mental or investigational.

REFERENCES

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