Planning of Definitive Treatment

In these situations when imaging facilities are impractical and need to be held to a minimum, several conceivable urologic scenarios exist:

1. Hemodynamically unstable patients with suspected intraabdominal bleeding are urgently transferred to the operating room with no preoperative imaging. At emergency laparotomy, suspicion of bleeding originating from the retroperitoneum needs to be addressed by the urologist according to principles discussed below.

2. In stable patients with suspected renal injuries (either penetrating trauma to the upper abdomen, flanks, and lower chest or blunt abdominal trauma and gross hematuria), imaging should be delayed until the protocols of mass casualty have been canceled or when resources become sufficient to restore normal management principles. These patients should be transferred to surgical departments and reevaluated by the urologist as soon as possible.

3. Patients with suspected bladder or urethral injuries (patients with pelvic fractures, high riding prostate on rectal examination, patients with blood at the urethral meatus and who are unable to void) need to undergo an evaluation of the lower urinary tract, but these injures are not considered life-threatening in themselves. Retrograde urethrocy-stography is generally recommended by trauma management algorithms, but in scenarios of mass casualties it should be postponed. In these cases the minimal acceptable treatment will be one gentle trial of bladder catheterization or up-front insertion of a suprapubic cystostomy followed by transfer of the patient to the surgical ward and deferred radiological evaluation. Bladder injuries, both following blunt or penetrating trauma, are usually associated with other severe injuries (McAninch and Santucci 2002) and thus deserve a prioritizing surgical approach. The patients are usually unstable, as blunt bladder injuries are often encountered with associated pelvic fractures, whereas penetrating injuries are commonly found with other major pelvic and abdominal injuries. In both settings, the rupture should be quickly classified as either extraperitoneal or intraperitoneal injury in order to plan the management accordingly. Traditionally, the distinction between those two entities has dictated the choice between bladder drainage alone vs immediate surgical exploration and layered closure of the bladder wall (Pansadoro et al. 2002). However, it is noteworthy that the first priority in this scenario is the treatment of the associated life-threatening injuries and that despite there being no clear evidence supporting nonoperative management in penetrating bladder injury, a conservative approach seems to be equally efficient. In mass casualty scenarios, drainage of the bladder and delayed evaluation seems reasonable and concordant with the minimal acceptable treatment approach applied in these situations. Similar principles are true for suspected urethral injuries. Injuries of the posterior urethra are commonly associated with pelvic fractures, whereas trauma of the anterior segments is usually a consequence of severe blunt trauma (Peterson 2000). The mechanism of urethral injury therefore requires significant high-energy external forces and, understandably, often creates concomitant bladder injuries (in up to 35 % of patients) or other multiple organ damage (Krieger et al. 1984; Lynch et al. 2003). While urethral injury of any kind is never life-threatening per se, the associated injuries might render hemodynamic instability. Under these circumstances, the management of the associated injuries is more important and the definitive urologi-cal negotiation with the traumatized urethra is to be deferred. Moreover, even in the context of an isolated urethral injury, many urologists are reluctant to perform immediate repair because of the limited operative visibility and the adverse tissue conditions (Peterson 2000). Altogether, the standard intuitive urological approach to urethral injury dictates minimal early intervention by suprapu-bic catheterization, which is certainly in concordance with the principles of damage control.

4. Traumatic injuries of the external genitalia are much more common in men than in women, probably due to the anatomical differences and the different exposure to violence (Van der Horst et al. 2004). Blunt injuries of the genitalia make up 80 % of the cases, but they are often isolated and can be managed conservatively. On the other hand, penetrating injuries of the genitalia, which are rather rare (11 % of civilian injuries and 40 % - 66 % of wounds during wartime), are often associated with injuries of adjacent abdominal organs and hemodynamic instability (Archbold et al. 1981; Feliciano et al. 2000). The high incidence of genital injury during military activity can be explained by the fact that military flak jackets fail to protect the external genitalia, which are particularly exposed to fragmentation injuries, especially by mines and fragments that come from below (Abu-Zidan et al. 1999).

In mass casualty scenarios, external genital injuries should be surgically addressed when resulting in major hemorrhage that needs to be expeditiously controlled either in the shock room or in the operating room, according to the available facilities. Compression dressings or clamping and ligation of bleeding vessels are highly efficient maneuvers that require a minimum of time. When severe hemorrhage is not identified, any further diagnostic steps can be postponed and the patient can be transferred to the surgical department for later reevaluation and reconstructive procedures.

In conclusion, the urologic consultation in the emergency room of a mass casualty scenario should be performed according to the following principles:

1. Rule out undertriage by the surgeon in charge and perform a rapid primary survey of every patient.

2. Stable patients with suspected renal injuries should be transferred to the surgical ward without imaging procedures. Reevaluation is warranted if there is any change in their hemodynamic status or when possible as dictated by the objective conditions of the mass casualty event. At this time every, case should be managed according to the traditional trauma management protocols.

3. Unstable patients are transferred directly to the operating room should be evaluated and treated according to the damage control principles (as discussed below, operating room management).

4. Minimal acceptable procedures should be performed in order to enable patient transfer to the surgical wards: suprapubic drainage of the bladder when bladder or urethral injuries are suspected, clamping and ligation of bleeding vessels from external genitalia wounds. Imaging procedures such as CT scans and retrograde urethrography are discouraged in those circumstances as they are time-consuming and are not intended to diagnose immediate life-threatening conditions. These imaging studies should be performed, if still needed, after repeated evaluation of patients when protocols of mass casualties have been disabled.

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