Combined penetrating rectal and genitourinary injuries: a challenge in management.
The standard management of penetrating rectal trauma consists of perioperative antibiotics, a diverting colostomy, and presacral drainage. While providing optimal results in isolated rectal trauma, this management scheme is inadequate in combined penetrating rectal and genitourinary (GU) tract injuries. A review of more than 200 cases of penetrating rectal trauma from our institution over a 13-year period identified 17 concomitant GU tract injuries (13 bladder, three urethral, and one ureteral injury). Complications consisted of pelvic, suprapubic, or subphrenic abscesses in 3 of 17 cases (18%), rectovesical or rectourethral fistulae in 24%, chronic urinary tract infections in 18%, bladder stones in 12%, and the development of urethral strictures in 12% of patients. Factors implicated in their pathogenesis included failure to perform presacral drainage, distal rectal washout, and rectal wound repair; prolonged suprapubic drainage; and failure to separate the rectal and GU tract wounds. Careful debridement of all necrotic tissue, urinary and fecal diversion, tension-free wound closure with well-vascularized tissue, and adequate drainage and separation of the injured sites with well-vascularized tissue such as omentum should reduce the high incidence of rectourethral and rectovesical fistulae from combined rectal-GU tract trauma. Therapeutic recommendations for individualized treatment are presented.
Franko
E R
ER
Department of Surgery, Long Island Jewish Medical Center, New Hyde Park, New York.
Ivatury
R R
RR
Schwalb
D M
DM
D000293:Adolescent; D000328:Adult; D003125:Colostomy; D004322:Drainage; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009104:Multiple Trauma / Q000601:surgery*; D011183:Postoperative Complications; D012007:Rectum / Q000293:injuries* / Q000601:surgery; D012189:Retrospective Studies; D014513:Ureter / Q000293:injuries; D014521:Urethra / Q000293:injuries; D001743:Urinary Bladder / Q000293:injuries; D014566:Urogenital System / Q000293:injuries* / Q000601:surgery; D014950:Wounds, Penetrating / Q000175:diagnosis / Q000601:surgery*