Surgery of urogenital trauma in condition of war or precarity
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1 Surgery of urogenital trauma in condition of war or precarity C. H. Rochat Multi-disciplinary Center for Robotic Surgery, Geneva ( Geneva Foundation for Medical Education and Research ( Faculty of Health Sciences Cotonou, Benin Geneva, 9-10 september 2008
2 Personal Experience ICRC: Peshawar, Quetta, Kabul, Border Thailand-Cambodia Médecins du Monde: Border Irak-Iran GFMER: Fistula surgeon (Africa) «Main difficulty is to have the right surgeon at the right time at the right place»
3 Urogenital lesions 1-5% of wounded persons More than 95% are associated with other lesions Rape as a weapon of war (traumatic gynecologic fistula) Following topics will be discussed Kidney Urethra Ureter External genitalia Bladder Traumatic gynecologic fistula
4 Injured organ % Distribution of urologic injuries by Conflict Vietnam (n=252) Croatia (n=110) Kidney Desert Storm (n=30) Ureter Bladder Penis/urethra Testis/scrotum Thompson, J Am Coll Surg, 1998
5 Common Principles (ICRC) Wound excision Preservation of as much viable tissue as possible Dependant drainage Diversion of the urinary flow above the site of injury Tensionfree sutures
6 Kidney Blunt Trauma Blast, Penetrating Trauma Splinter Bullet (low and high velocity) Stab wound
7 Kidney injury Consequences Retroperitoneal bleeding Hematuria Urinary leakage Diagnostic procedure Palpation Macro or microhematuria (bladder catheter) Hematocrit, blood pressure monitoring IVU (no CT available in field hospitals)
8 Kidney Blunt Trauma 10% require renal exploration Observational attitude recommended under strict control of vital signs Mee, McAninch, 1989
9 Kidney Penetrating Trauma Renal surgery is recommended in all cases of penetrating trauma in war situation Higher energy impact in war situations 98% associated with other organ injuries Radiodiagnostic facilities less available
10 Kidney : Operative Approach Midline transabdominal incision allows: Ready access to the kidney Exploration for associated injury Retroperitoneal hematoma requires: Small bowel elevation Incision is made over the aorta above the inferior mesenteric artery Placement of loops on the renal vessels Subsequently colon mobilisation and Gerota fascia opening
11 Kidney : Operative Approach McAninch, Carroll, 1989
12 Kidney : Reconstruction or Ablation McAninch, Carroll, 1989
13 Ureteral Injury 95% are due to penetrating trauma (gunshot wound>90%) Most ureteral injuries are diagnosed intraoperatively (and sometimes occured intraoperatively ) IVU highly sensitive
14 Ureteral Injury : Operative Approach Careful ureteral mobilisation Debridement of non viable tissue to the bleeding edge Mucosa to mucosa, spatulated, tensionfree and watertight anastomosis Ureteral stenting Omental interposition Retroperitoneal drainage
15 Upper and Middle Ureteral Injury Ureteroureterostomy Turner-Warwick and Chapple, 2002
16 Trans-uretero-ureterostomy Turner-Warwick and Chapple, 2002
17 Distal ureteral Injury (1) Supra-trigonal tunnel implantation Turner-Warwick and Chapple, 2002
18 Distal ureteral Injury (2) Psoas-hitch procedure Turner-Warwick and Chapple, 2002
19 Bladder Injury 80% due to pelvic fracture Penetrating trauma Diagnosis by retrograde cystogram (up to 400 cc)
20 Treatment of Extraperitoneal Bladder Injury Transurethral drainage only
21 Treatment of Intraperitoneal Bladder Injury Surgical exploration and closure + urethral catheter + suprapubic catheter + perivesical drainage ± ureteric catheterization
22 Urethral Injury Diagnosis is done by uretrography: Foley catheter injection of 2 cc saline into the balloon 2-3 cm proximal to the penile meatus patient placed oblique position cc injection of contrast material with irrigating syringe
23 Posterior Urethral Injury (Type I)
24 Posterior Urethral Injury (Type II)
25 Posterior Urethral Injury (Type III) Sandler, Corriere, 1989
26 Treatment of Posterior Urethral Injury Abdominal approach Suprapubic cystostomy Optional: Primary urethral realignment ( rail roading )
27 Anterior Urethral Injury Penetrating trauma (gunshot wound) Contusion
28 Treatment of the Anterior Urethral Injury Suprapubic cystostomy Excise the wound Leave open Inspect at time of DPC : accept permanent urethrostomy consider late repair, if minimal damage, and success can be assured (after 6 weeks) ICRC Guidelines
29 Pelvis and Urethral Injury
30 Pelvis and Urethral Injury
31 Pelvis and Urethral Injury
32 Treatment of the Anterior Urethral Injury - Late Repair End to end anastomosis
33
34 Treatment of the Anterior Urethral Injury - Late Repair Free graft - foreskin or buccal mucosa for defects up to 4 cm Barbagli, 2003
35 External Genitalia Penis primary suture (excellent vascularisation) Scrotum always drain if skin loss: meshed grafts or thigh flaps
36
37 Delayed and tricky Injuries
38 Traumatic gynecologic fistula Obstetric fistula (prolonged obstructed labor) Iatrogenic Direct traumatic tearing (violent sexual assault and rape or by the forcible insertion of objects-gun, bottle, or sticksinto the vagina)
39 Traumatic gynecologic fistula in conflicts Rape as weapon of war Young sexual slave Delayed access to health care
40 Consequences Complete incontinence (urine/feces) Social stigmatization Post traumatic stress disorder Unwanted pregnancies, STIs, HIV (rape)
41
42
43 Abandoned from their families Co-morbidity Infections Bladder stones Infertility Problem
44 Simple fistula Non-fibrotic tissue Easy to access Complex fistula Fibrotic tissue Loss of tissue Urethral involvement Retracted bladder Aberrant tract Previous failed surgery Classification
45 Complex VVF
46
47 Extended Trendelenburg position Scott retractor Headlight Sharp scissors Suture material Surgical tips Post op follow-up Cave: obstructed catheter!
48 Simple closure
49 Martius Flap
50 Symmonds / Falandry
51 Mainz II
52 Stress incontinence Junction bladder/urethra most often concerned Closure mechanismus damaged Residual stress incontinence Surgical challenge For experts and motivated surgeons
53
54 A new Web-Based Data Entry System : the GFMER Database Collection and evaluation of prospective data Demographic characteristics of fistula patients Various surgical and clinical procedures for fistula repair Social reintegration
55 A new Web-Based Data Entry System : the GFMER Database Facilitate the development of a standardized fistula classification Comparative research across surgical centers Identification of cases requiring expert fistula surgeon
56 Areas covered by the GFMER Database Circumstances leading to the occurrence of fistula Socioeconomic and preoperative health status Surgical and other medical treatments received Postoperative health status and follow-up
57
58 Transitioning to Robotics
59 Robotic Surgery GFMER Internet Data Base Web oriented interface connected to a data base Study of clinical practices of DVP Multicenter / multiple users Real time statistics Access and anonymity secured (users/patients) sdd
60 Concluding Remarks Humanitarian medicine: A global commitment and mutually beneficial Drawing Connections: Translating high tech solutions into practice in low-resource settings
61
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