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Purpose: We discuss the mechanisms of wound healing and our experience with the Vacuum Assisted Closure device (Kinetic Concepts, Inc., San Antonio, Texas) for complex urogenital wounds., Materials and Methods: The literature obtained from a Medline search on wound healing, wound failure and vacuum assisted closure was reviewed. In addition, we reviewed our experience with negative pressure wound therapy., Results: Wound healing is a complex interaction between the reticuloendothelial and immune systems, in addition to correctable internal and external factors. Understanding the healing process improves outcomes and decreases patient morbidity. Negative pressure wound therapy has hastened wound healing and it adds significant improvement in the arsenal of choices available., Conclusions: Vacuum Assisted Closure is a therapeutic alternative that complements surgical and medical intervention in patients with complex wounds.

Purpose: To date trauma to the female external genitalia has been incompletely characterized. At our institution a large number of such patients have been identified and many had associated urological injuries. We characterize these injuries and their association with urological injuries., Materials and Methods: We reviewed the charts of all female patients presenting with trauma to the genitalia unrelated to parturition between 1991 and 1996. Type and mechanism of injury, associated injuries and blood transfusion requirements were noted. Vaginal injuries were classified as complex (greater than 3 cm., multiple or involving deeper structures) or simple (all others)., Results: We identified 20 women a mean 20.7 years old with traumatic injuries to the genitalia, including motor vehicle accidents in 6, injury from consensual intercourse in 5, sexual assault in 4 and other penetrating injuries in 5. There were 15 patients with vaginal injuries (complex in 8 and simple in 7) and vulvar injuries in 5. Six of the 20 women (30%) had associated urological injuries (urethra in 1, bladder in 4, ureter in 1 and kidney in 3) [corrected], including 3 associated with blunt trauma (all complex vaginal injuries) and 3 associated with penetrating trauma (simple vaginal or vulvar injuries)., Conclusions: Traumatic injury to the female genitalia unrelated to parturition is more common than previously reported. Of the women with such injuries 30% have coexisting urological injuries. Thus, it is important to assess completely all women who present with external genitalia trauma for possible coexisting urological injury.

Pelvic ring disruptions are the result of high energy blunt trauma and are associated with other significant injuries in greater than 50% of the cases. These injuries may involve neurovascular structures and other organ systems. Lower urinary tract injuries may occur in as much as 25% of patients with pelvic ring disruptions. Coordinated care between the orthopaedist and urologist is required for successful treatment of the urologic and pelvic injury. Of primary importance to the orthopaedist is the potential for infection after open stabilization of the anterior arch. When contaminated urine communicates with the anterior arch, the possibility of infection exists. Early repair of bladder disruptions with simultaneous anterior arch plating minimizes this risk. The treatment of urethral disruptions and the safest method for urinary drainage remain controversial, however.

There were 142 consecutive patients with post-traumatic hematuria evaluated prospectively during a 7-month period. Of these 142 cases 22 involved penetrating injuries and 120 were secondary to blunt trauma. There were 19 patients with 24 demonstrable genitourinary injuries at urologic injury. Only 8 of the 142 patients required an operation for the urologic injuries. The degree of hematuria did not correlate with the severity of injury. Liberal use of arteriography and renal scanning is proposed to delineate precisely the urologic injury.

We evaluated prospectively 506 consecutive patients who presented with a history of blunt trauma and hematuria. All patients initially underwent excretory urography and cystography. Of the 506 patients 25 had detectable urinary tract injuries that were confirmed either by the initial studies or by computerized tomography, angiography or direct intraoperative inspection. Diagnoses included 7 renal contusions, 7 renal lacerations (1 major and 6 minor), 1 renal artery, 3 intraperitoneal and 5 extraperitoneal bladder ruptures, and 2 urethral injuries. Of the 25 patients 21 presented with gross hematuria, including all of those with lower tract injuries. One of the 4 patients who presented with microhematuria was hospitalized in shock. Of the remaining 3 patients with microhematuria and no shock 1 had a minor renal laceration and 2 had renal contusions. All 3 patients were managed conservatively and all 3 were hospitalized chiefly for associated nonurological injuries. If the patients who presented with microhematuria and no shock were excluded from initial radiographic evaluation, 1 minor renal laceration and 2 renal contusions would have been missed. If we had added 1 more exclusion criterion, that of absence of major associated injuries, we would not have missed an injury.

A computer-assisted review identified 184 patients with genitourinary tract injuries among 5,400 hospitalized for trauma. Particular attention was directed to the controversial groups of patients with blunt renal and posterior urethral injuries. Management of renal injuries was based on clinical criteria. Subsequent renal exploration was necessary in only 1 of 115 patients with renal contusions, or simple or deep lacerations who underwent initial expectant management. Followup was available in all patients with severe renal injuries and in 53 per cent with renal contusions or simple lacerations. Parenchymal loss was noted on an excretory urogram in only 1 patient and none suffered hypertension, hydronephrosis or other sequelae. A staged approach was preferable to immediate repair of posterior urethral injuries. Seven patients managed by initial cystostomy drainage followed by secondary urethral repairs did well. Primary realignment was complicated by stricture, incontinence or impotence in 3 of 6 patients.

There is no characteristic pattern of ski-related urologic injuries except those associated with major blunt abdominal trauma. Isolated urologic injuries and injuries of the lower urinary tract are relatively uncommon.

A review of some of the more important limitations and pitfalls in the interpretation of excretory urograms is presented. Although there is no infallible method of avoiding interpretive errors it is suggested that the development of good viewing habits, including an orderly and systematic appraisal of each film, coupled with a physiologically oriented approach to film interpretation will reduce mistakes significantly. Similarly, many pitfalls may be circumvented by the simple expedient of close collaboration between urologist and radiologist, and by the reluctance of either to accept urography that is suboptimal by current standards.