Committee I

Committee VIII

Lower Urinary Tract & Genitalia Trauma

Prof. Abdel Wahab Elkassaby, Professor of Urology. Ain Shams University

Prof. Samir Oraby, Professor of Urology. Alexandria University

Dr. Mohamed Zaki El Dahshoury, Professor of Urology. Aswan University

Ass. Prof. Atef Fathi, Assistant Professor of Urology, South Valley University

Dr. Ahmed Riyad, Lecturer of Urology, Sohag University

Contents
VIII.1 List of Abbreviations
  • EMBASE - Expected Media Data Base
  • EP - Extraperitoneal
  • IP - Intraperitoneal
  • MVAs - Motor vehicle accidents
  • PFUIs - Pelvic fracture urethral injuries
  • PUI - Posterior urethral injury
  • WHO - World Health Organization

VIII.2 Introduction:

VIII.2.1 Aim and objectives:
In this review, we tried to establish Egyptian Guidelines for the proper management of anterior urethral trauma to assist medical professionals.

It should be considered that guidelines constitute the best evidence-based available to the experts but following guideline recommendations will not necessarily result in the best outcome, and so the guidelines should never replace clinical expertise when making treatment decisions for individual patients.

VIII.2.2 Methods:
VIII.2.2.1 Evidence sources
During the preparation of these guidelines, new and relevant evidence sources were searched for, collected and evaluated through a structured assessment of the literature.

Databases searched included Medline, Expected Media Data Base (EMBASE), and the Cochrane Libraries, covering a time frame between 1/1/2018 till 31/12/2019. We also used data from the European Association of Urology (EAU) Guidelines for Urological Trauma and the American Urological Association Guidelines.

References used in this text are graded according to a classification system modified from the Oxford Centre for Evidence-Based Medicine Levels of Evidence (1-3):
  • The magnitude of the effect.
  • The inevitability of the results (exactness, reliability and heterogeneity).
  • The balance between desirable and undesirable outcomes.
  • The impression of patient values and predilections and the certainty of these values.

VIII.3 Definitions and Epidemiology of trauma:
VIII.3.1 Definition of trauma:
Trauma is defined as a physical injury or a wound to living tissue caused by an extrinsic agent due to diversity of mechanisms, such as traffic-related or transportation-related injuries, falls, assault, explosions, etc (4).

Globally, trauma is the sixth leading cause of death, with around 10% of all worldwide mortalities. This means around annual five million deaths even much more million disabilities (5, 6).

Nearly around half of the trauma related deaths occur in people aged 15-45 years and trauma can be considered as the leading mortality cause among this age group; especially among males (5). Death due to trauma is twice more common among males, compared to females; and this was more evident as regards motor vehicle accidents (MVAs) and interpersonal violence (7).

Therefore, trauma is a serious public health problem with substantial medical and socio-economic charge (7).

Isolated urologic injuries are usually infrequent because the kidneys, ureters, and bladder are well protected within the abdomen-pelvic cavity, and the penis and testes are physically mobile. Urologic injuries are not uncommon in case of multi-organ injuries; seen in around 10% of abdominal multi-organ traumatic injuries (4, 8, 9).

VIII.3.2 Classification of trauma
Traumatic injuries are classified by the World Health Organization (WHO) into intentional (such as interpersonal violence, war-related or self-injuries), and unintentional injuries (such as MVAs and falls). A specific type of unintentional injury is iatrogenic injuries which occurs during therapeutic or diagnostic procedures (10).

Traumatic injuries are usually divided into blunt or penetrating ones as these different mechanisms have different implications for management decisions and patients' outcomes. Explosion injuries may have features of penetrating and blunt trauma together (4). Penetrating injuries are further classified according to the velocity of the projectile into:

1. High-velocity projectiles (e.g. rifle bullets - 800-1,000 m/sec);
2. Medium-velocity projectiles (e.g. handgun bullets - 200-300 m/sec);
3. Low-velocity items (e.g. knife stab).

High-velocity weapons inflict greater damage due to temporary expansive cavitation that destroys a much larger area than the projectile tract itself. In lower velocity injuries, the damage is usually confined to the projectile tract. Blast injury is a complex cause of trauma which includes blunt and penetrating trauma and burns (10).

The most commonly used classification grading system is the AAST (American Association for the Surgery of Trauma) injury scoring scale. It is useful for managing renal trauma, but for the other urological organs, the injuries are commonly described by their anatomical site and severity (partial/complete) (10).

VIII.3.3 Genitourinary trauma
The kidney is the most commonly injured genitourinary organ. It is particularly susceptible to deceleration injuries because it is only fixed in space by the renal pelvis and vascular pedicle. Over eighty percent of renal injuries are due to blunt trauma; but penetrating trauma usually lead to more severe injuries (4, 11). Traumatic injuries to the renal vascular pedicle are uncommon but are usually associated with a multiple- organ injuries (12).

Ureteric trauma is the least common genitourinary trauma because of small size and high mobility of the ureter. The most common cause of ureteric injuries is iatrogenic trauma; accounting for about 75% of all ureteric injuries. The lower third of the ureter is most commonly injured (13-15).

Bladder injuries are uncommon and are usually associated with pelvic bone fractures (16).

The most common male external genital injuries include penile fracture, testicular rupture, and penetrating penile injury. If there is blood at the meatus or hematuria is found in addition to external genital injury, evaluation for urethral injury should also be performed (4, 15, 17).

VIII.4 General management principals
VIII.4.1 The Initial evaluation
The initial emergency assessment of a trauma patient is beyond the focus of these guidelines. It is usually carried out by emergency medicine and trauma specialized personnel following ATLS principles. Detailed further assessment involves cross-sectional imaging, laboratory analysis and specialist surgical input. The management of individual organ injury will follow in the sections below. Tetanus vaccine status should be assessed for all penetrating injuries (18).

VIII.4.2 Poly-trauma managed in major trauma centers leads to improved survival
Urological trauma is often associated with significant injuries in the poly traumatized patient. Lessons from civilian trauma networks, military conflict, and mass casualty events have led to many advances in trauma care. These include the widespread acceptance of damage control principles and trauma centralization to major trauma centers staffed by dedicated trauma teams. The re-organization of care to these centers has been shown to reduce mortality by 25% and length of stay by four days. Urologists increasingly understand their role in the context of polytrauma with the ultimate aims of improving survivability and decreasing morbidity in these patients (19).

VIII.4.3 Damage control
Damage control is a life-saving strategy for severely injured patients that recognizes the consequences of the lethal triad of trauma - hypothermia, coagulopathy and acidosis. The first of a three-phased approach consists of rapid control of hemorrhage and wound contamination. The second phase involves resuscitation in the intensive care unit (ICU), intending to restore normal temperature, coagulation, and tissue oxygenation. The final stage involves definitive surgery when more time-consuming reconstructive procedures are performed in the stabilized patient (20, 21).

Urological intervention needs to be mindful of the phase of management. Temporary abbreviated measures followed by later definitive surgery are required. Complex reconstructive procedures, including organ preservation, are not undertaken. The decision to enter damage control mode is taken by the lead trauma clinician following team discussion (20).

VIII.4.4 Mass casualty events and Triage
A mass casualty event is one in which the number of injured people and the severity of their injuries exceed the capability of the faculty and staff. Triage, communication and preparedness are important components for a successful response. Triage after mass casualty events involves difficult moral and ethical considerations. Disaster triage requires differentiation of the few critically injured individuals who can be saved by immediate intervention from the many others with non-life-threatening injuries for whom treatment can be delayed and from those whose injuries are so severe that survival is unlikely in the circumstances (22) .

VIII.4.5 The role of thrombo-prophylaxis and bed rest
Trauma patients are at high risk of deep venous thrombosis (DVT). Concerns about secondary hemorrhage result in prolonged bed rest post-injury which effectively compounds this risk. Established prophylaxis measures reduce thrombosis and are recommended following systemic review. However, the strength of evidence is not high and as yet there is no evidence to suggest that mortality or pulmonary embolism risk is reduced. Compression stockings and low molecular weight heparins are favored. The risk of secondary hemorrhage is thought to be low and the practice of strict bed rest has waned in patients who can mobilize (23, 24).

VIII.4.6 Antibiotic stewardship
Single-shot antibiotic doses are common in major trauma. The indication for continuing antibiotics is governed by injury grade, associated injuries and the need for intervention. Patients with urinary extravasation tend to be kept on antibiotics but there is no evidence base for this. Antibiotics should be avoided in lesser trauma e.g. Grade 1-3 renal trauma, and a regular review undertaken for those continued on regular dosing (19).

VIII.4.7 Urinary catheterization
Prolonged catheterization is required in all forms of the bladder and urethral injury. Catheterization is not necessary for stable patients with low-grade renal injury. Patients with heavy hematuria, who require monitoring or ureteric stenting, benefit from catheterization. This can be removed once hematuria lightens and there is an improvement in the clinical situation. The shortest possible period of catheterization is advised (19).

VIII.5 Anterior Urethral Trauma
VIII.5.1 Background:
Urethral injuries are uncommon and mostly affect male patients and are usually diagnosed following blunt trauma. Urethral injuries are divided into anterior and posterior injuries (25, 26).

The Goldman classification of urethral injuries includes five types of lesions aimed at discerning anterior from posterior and complete from incomplete and at determining whether posterior urethral injuries involve the bladder neck or the rectal wall (27).

The main cause of anterior urethral injury is direct blunt trauma. Penetrating injuries to the anterior urethra are rare and are mainly caused by gunshot injuries (28, 29).

VIII.5.2 Anterior male urethral injury
Injuries to the male urethra are divided into injuries to the posterior urethra (at or above the membranous urethra) or anterior urethra (penile or bulbar urethra). Posterior urethral injuries are almost exclusively associated with pelvic fractures and occur between 1.5 and 10% of pelvic fractures (30).

Anterior urethral injures may be blunt (e.g., straddle injuries, where the urethra is crushed between the pubic bones and a fixed object) or penetrating, and the urethra may be lacerated, crushed, or disrupted (31).

The bulbar urethra is the most common site affected by blunt trauma. In bulbar injuries, the bulb is compressed against the pubic symphysis, resulting in rupture of the urethra at the site of compression (26, 28).

Possible mechanisms are straddle injuries or kicks to the perineum. A penile fracture can be complicated by a urethral injury in approximately 15% of cases. Penetrating anterior injuries are rare and are usually caused by gunshot wounds, stab wounds, dog bites, impalement of penile amputations (32-34).

Depending on the affected segment, penetrating injuries are usually associated with penile, testicular and/or pelvic injuries. Insertion of foreign bodies is another rare cause of anterior injury. It is usually a result of autoerotic stimulation or may be associated with psychiatric disorders (32-34).

Iatrogenic injury is the most common type of urethral trauma. The incidence of urethral injury during transurethral catheterization is 6.7 per 1,000 catheters inserted and can occur due to creation of a false passage by the tip of the catheter, inadvertent inflation of the anchoring balloon in the urethra or removal of the catheter with the anchoring balloon not fully deflated. A strict indication for every urethral catheterization is an important preventive measure. The importance of catheter insertion training programs, to prevent urethral injury during transurethral catheterization, have been demonstrated (34-37).

Preliminary data suggest that guidewire led catheter insertion or use of a safety valve for balloon inflation may prevent urethral trauma in difficult catheterization cases. Instrumentation of the urethra (TURP, cystoscopy, etc.) can traumatize all segments of it. During penile prosthesis insertion (PPI), the risk of urethral perforation is 0.1-4%. Proximal urethral injuries are more common than distal ones (38, 39).

VIII.5.3 Female urethral injuries
Birth related injuries to the female urethra are rare and consist of a minor (peri) urethral lacerations during vaginal delivery. Pelvic fractures are the main cause of blunt trauma; however, PFUIs in females are rare and less common than in males. This is usually attributed to the flexibility provided by the vagina and the greater inherent elasticity of the female urethra, it may also be the result of less severe and more frequent stable pelvic fractures in females. In unstable pelvic fractures in females, a high suspicion for a urethral injury should be maintained (40, 41).

Female urethral injuries are classified into two types: longitudinal or partial (most frequent) injuries and transverse or complete injuries. Concomitant bladder or vaginal injury is possible; therefore, females are at risk of developing urinary incontinence and urethrovaginal fistula (40, 42).

Insertion of a synthetic sub-urethral sling for the treatment of female stress urinary incontinence is complicated by an intra-operative urethral injury in 0.2-2.5% of cases and is an important cause of iatrogenic urethral injury (43).

VIII.5.4 Evaluation
VIII.5.4.1 Clinical signs
Blood at the meatus is the cardinal sign, but the absence of it doesn’t rule out a urethral injury. Inability to void (with a palpable distended bladder) is another classic sign and is often associated with a complete rupture. Hematuria and pain on urination may be present in incomplete ruptures. Urinary extravasation and bleeding may result in scrotal, penile and/or perineal swelling and ecchymosis, depending on the location and extent of the trauma. The presentation of these clinical symptoms may be delayed (> 1 hour) (42, 44).

Rectal examination should always be done to exclude an associated rectal injury (up to 5% of cases) and may reveal a ‘high-riding’ prostate, which is an unreliable finding. Failure to detect a rectal injury can cause significant morbidity and even mortality. A rectal injury is suggested by blood on the examining finger and/or a palpable laceration. Another sign of urethral injury is difficulty or inability to pass a urethral catheter (42, 44, 45).

A female urethral injury should be suspected from the combination of an (unstable) pelvic fracture with blood at the vaginal introitus, vaginal laceration, haematuria, urethrorrhagia, labial swelling, urinary retention or difficulties passing a urethral catheter. Vaginal examination is indicated to assess vaginal lacerations (46).

VIII.5.4.2 Urethrography
Retrograde urethrography (RUG) is the standard in the early evaluation of a male urethral injury and is conducted by injecting 20-30 mL of contrast material while occluding the meatus. Films should be taken in a 30° oblique position (45). Retrograde urethrography should be performed after pelvic or genital trauma especially when blood is seen at the urethral meatus (47).

During RUG, any extravasation outside the urethra is pathognomonic for urethral injury. A typical image for incomplete rupture shows extravasation from the urethra which occurs while the bladder is still filling. A complete rupture is suggested by massive extravasation without bladder filling. Although RUG can reliably identify the site of injury (anterior vs. posterior), the distinction between a complete and partial rupture is not always clear. Therefore, any proposed classification system based on RUG is not reliable. In females, the short urethra and vulvar edema make adequate urethrography nearly impossible (42, 48).

Before deferred treatment, a combination of RUG and antegrade cystourethrography is the standard to evaluate the site and extent of the urethral stenosis and to evaluate the competence of the bladder neck (42).

VIII.5.4.3 Cysto-urethroscopy
Flexible cystourethroscopy is a valuable alternative to diagnose an acute urethral injury and may distinguish between complete and partial rupture. Flexible cystourethroscopy is preferred to RUG in suspected penile fracture-associated urethral injury as RUG is associated with a high false-negative rate. In females, where the short urethra often precludes adequate radiological visualization, cystourethroscopy and vaginoscopy are the diagnostic modalities of choice. If before deferred treatment, the competence of the bladder neck is not clear upon antegrade cystourethrography, a suprapubic cystoscopy is advised (45, 48, 49).

VIII.5.4.4 Ultrasound and magnetic resonance imaging
In the acute phase, US scanning is used for guiding the placement of a suprapubic catheter (50).

VIII.5.5 Management
VIII.5.5.1 Male anterior urethral injuries
VIII.5.5.1.1 Immediate exploration and urethral reconstruction

This is indicated for penile fracture-related injuries and non-life-threatening penetrating injuries. Small lacerations can be repaired by simple closure. Complete ruptures without extensive tissue loss are treated with an anastomotic repair. In the case of longer defects or apparent infection (particularly bite wounds), a staged repair with urethral marsupialization is needed (33, 34).

Penetrating injuries require peri- and postoperative antibiotic treatment. The role of immediate urethroplasty in blunt injuries is controversial. Patients who underwent immediate urethroplasty had a failure rate that was not significantly different compared to those who underwent delayed urethroplasty after initial suprapubic diversion. The time to spontaneous voiding was significantly shorter in the immediate urethroplasty group (51).

A stricture rate of 14.4% following immediate repair has been reported based on 23 studies with a total of 591 patients. An analysis of direct comparative studies showed a composite stricture rate of 20% for immediate repair vs. 44.2% for early endoscopic re-alignment, but at the expense of longer hospital stays and increased blood loss (52).

Perforation of the distal urethra during penile prosthesis insertion needs to be repaired over a catheter; in this instance, the initial procedure should be abandoned (53).

VIII.5.5.1.2 Urinary diversion

Blunt anterior urethral injuries are associated with spongiosal contusion. Evaluation of the limits of urethral debridement in the acute phase might be difficult and as a consequence, it is reasonable to start with urinary diversion only (54).

If urinary diversion is performed, the therapeutic options are suprapubic diversion or a trial of early endoscopic re-alignment with transurethral catheterization (54), there is conflicting evidence as to which intervention is superior (47).

Urinary diversion is maintained for one to two weeks for partial ruptures and three weeks for complete ruptures. Satisfactory urethral luminal recanalization may occur in up to 68% after partial ruptures but is rare (14%) after complete ruptures (47).

A review of 49 Chinese studies (1,015 patients), reported a 57% success rate for endoscopic re-alignment of blunt anterior injuries (52). The wide range in success rate most likely reflects a mix of partial and complete ruptures which was not further specified in the review. Transurethral or suprapubic urinary diversion are treatment options for iatrogenic or life-threatening penetrating injuries. Minor iatrogenic urethral injuries and urethral contusions do not require urinary diversion (15, 55).

VIII.5.5.2 Female urethral injuries
Emergency room management of urethral injuries in females is the same as in males; however, subsequent management differs. Treatment options are:
  • Early repair (less than or equal to seven days): Complication rate is the lowest with the early repair; therefore, this strategy is preferred once the patient is hemodynamically stable.
  • Delayed repair (greater than seven days): Delayed repair often requires complex abdominal or combined abdominal-vaginal reconstruction with an elevated risk of urinary incontinence and vaginal stenosis (40).

The approach (vaginal, abdominal or combined) for early repair depends on the location of the injury. Distal urethral injuries can be left hypospadiac since they do not disrupt the sphincter mechanism, but a concomitant vaginal laceration must be closed. In the case of urethral injury during synthetic sub-urethral sling insertion, immediate repair is warranted with the abortion of sling insertion (43, 45, 48).

VIII.5.6 Summary of Guidelines for the Evaluation and Management of Urethral Trauma
Table VIII:1 Guidelines for Evaluation and Management of Urethral Trauma

Guidelines

Strength Rating
Good training of urinary catheter insertion for persons involved in urethral catheterization can reduce the rate of complications Strong
Retrograde urethrography should be done for patients with blood at the urethral meatus after pelvic trauma Strong
Male urethral injury is detected as contrast extravasation during urethrography or as a mucosal laceration during cystourethroscopy Strong
Voiding cystourethrography can miss up to 50% of female urethral injury Strong
Female urethral injuries should be assessed with combined cystourethroscopy and vaginoscopy Weak
During emergency laparotomy, if an urethral injury is suspected, it should be investigated directly whenever feasible Strong
Transurethral or suprapubic urinary diversion are the treatment options for iatrogenic anterior urethral injuries Weak
With urinary diversion, urethral luminal re-canalization will succeed in up to 68% of cases after partial blunt anterior urethral ruptures Weak
Complete blunt anterior urethral ruptures cannot be cured with urinary diversion alone, and urethroplasty is mandatory. Strong
For complete blunt anterior urethral rupture, immediate and delayed urethroplasty has equal success rates. Weak
Type of urethral reconstruction should be considered according to the length of the urethral stricture. Urethral strictures longer than 3 cm are suitable for augmented urethral reconstruction Weak
Repetitive endoscopic treatments after failed re-alignment delay the time to definitive cure and increase the incidence of adverse events Weak
13. Clinicians should monitor patients for complications (e.g., stricture formation, erectile dysfunction, and incontinence) for at least one year following urethral injury. Weak
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50. Horiguchi A, Edo H, Soga S, Shinchi M, Masunaga A, Ito K, et al. Pubourethral Stump Angle Measured on Preoperative Magnetic Resonance Imaging Predicts Urethroplasty Type for Pelvic Fracture Urethral Injury Repair. Urology. 2018; 112:198-204.
51. Gong IH, Oh JJ, Choi DK, Hwang J, Kang MH, Lee YT. Comparison of immediate primary repair and delayed urethroplasty in men with bulbous urethral disruption after blunt straddle injury. Korean J Urol. 2012;53(8):569-72.
52. Zhang Y, Zhang K, Fu Q. Emergency treatment of male blunt urethral trauma in China: Outcome of different methods in comparison with other countries. Asian journal of urology. 2018;5(2):78-87.
53. Scherzer ND, Dick B, Gabrielson AT, Alzweri LM, Hellstrom WJG. Penile Prosthesis Complications: Planning, Prevention, and Decision Making. Sex Med Rev. 2019;7(2):349-59.
54. Brandes S. Initial management of anterior and posterior urethral injuries. The Urologic clinics of North America. 2006;33(1):87-95, vii.
55. Maheshwari PN, Shah HN. Immediate endoscopic management of complete iatrogenic anterior urethral injuries: a case series with long-term results. BMC Urol. 2005;5:13.

VIII.6 Posterior urethral injury (PUI)
VIII.6.1 Anatomical consideration
VIII.6.1.1 Posterior urethra is the sphincteric portion of the urethra and it is not covered by the corpus spongiosum.
It extends from the bladder neck to the perineal membrane.

It includes prostatic and membranous urethra.

VIII.6.1.2 Prostatic urethra:
In adults, it is about 3 cm in length

It extends from the bladder neck till the upper border of the Urogenital diaphragm (UGD)

The prostate lies deep in the pelvis, retropubic, and its apex is located at the lower border of pubic bone, while in children, it is small and located in the retropubic space at the upper border of pubic bone.

VIII.6.1.3 Membranous urethra:
In adults, it is about 2 cm and it’s devoid of any cover.

It is located within the urogenital diaphragm.

It starts from the anterior surface of the prostate near to the apex to the lower end of UGD

It is surrounded by inner smooth muscle and outer striated Rhabdosphincter (external urinary sphincter).

Oelrich stated that the prostate occupies the upper one third the length of urethra that extends from bladder neck to the inferior border of UGD (posterior urethra) in neonates and infants. By process of growing and mild development of the external sphincter, the prostate occupies two third of this length while in adult, with well-development of the prostate and maturation of externa sphincter, the prostate occupies the whole length above UGD and the bladder, the prostate and the UGD act as one unit.

Khan et all stated that there is a part of the urethra below the UGD and it is not covered by corpus spongiosum like the anterior urethra and so it is the inferior extension of membranous urethra that is called infra-diaphragmatic portion of the membranous urethra or the bare area of the urethra.

Also, in the modern anatomy of UGD, there is no superior fascia of UGD and only the inferior fascia covers the UDG called perineal membrane

Also, the external sphincter is not oriented in transverse fashion but in a vertical one to reach the prostate and the bladder base, this explains why in children the injury occurs to the supradiaphragmatic urethra while in adult occurs to infra-diaphragmatic urethra.

Parts of membranous urethra are:
  • Supra-diaphragmatic
  • Intra-diaphragmatic
  • Infra-diaphragmatic

Based on these anatomical considerations, you must consider the following:

In neonates and children, the most common site of injury of the posterior urethra is the supradiaphragmatic urethra as well as the bladder as it is exposed directly to the upper border of the symphysis pubis. This injury is usually in the form of:
  • Open book injury: extends vertically from the anterior bladder wall to the anterior wall of the prostate and to the urethra.
  • Uncommonly it may occur in a transverse fashion that result in complete avulsion of the bladder from the prostate or transprostatic injury or in very conditions, double level injury compromising complete separation of the prostate from the bladder above and the urethra below.

In adults, usually the injury occurs infra-diaphragmatically in the infra-diaphragmatic urethra at the bulbo-membranous junction with sparing of the external urinary sphincter and it may extend to the bulbar urethra. In rare conditions, the injury associated with pelvic fractures may injure the bulbar urethra only.

VIII.6.2 Causes of posterior urethral injury
It may be blunt trauma or penetrating trauma
  • Blunt trauma: is associated with anterior pelvic ring fractures such as fracture of pubic bone or pelvic diastasis (wide separation of symphysis pubis) or stove in fractures (tetrameric fractures of the pubic bone) usually associated with high risk injury of the lower urinary tract especially the posterior urethra. This is called stable pelvic fracture.
  • Disruption of anterior pelvic ring: as well as the posterior pelvic ring, such as sacroiliac ligament laxation or separation is usually associated with high incidence of urethral injury. This is called unstable pelvic fractures or malgaigne fracture.

N.B: It is well known that the elasticity or the young’s modulus of the pelvic bone is higher than the intrapelvic soft tissue. So, with anteroposterior injury of the pelvis, the pubic bone is pushed posteriorly, as well as the soft tissue behind it towards the sacrum, then it will return anteriorly by its elasticity, however, bone return back to its normal position faster than soft tissue, this results in tears of all ligaments as the pubo-prostatic ligament and other soft tissue due to traction force.

So, the presence of undisplaced anterior pelvic ring fracture doesn’t mean absence of associated injuries and you must do ascending urethrogram before any catheterization in any patient with anterior pelvic ring fracture.
  • Penetrating injury: Gun shots, transurethral resection of the prostate (TURP)

VIII.6.3 Incidence:
  • 10 -15 % of pelvic fractures are associated with urethral injuries while 85- 90% of posterior urethral injuries are associated with pelvic fractures.

VIII.6.4 Signs and symptoms:
  • Bleeding at the external urinary meatus is the pathognomonic sign of posterior urethral injury.
  • Hematuria
  • Inability to void with suprapubic fullness

VIII.6.5 Examination:
With any road traffic accident, car or train accident with the suspicion of lower urinary tract injury, you must do the following:
  • Assessment of the general condition
  • Examination of bony pelvis by:
  • Compression of both iliac bones medially
  • Palpation of symphysis pubis to detect its wide separation or stove in fracture.
  • Look for unequal lengths of the lower limbs that may be associated with vertical sheer of the bony pelvis with unstable pelvic fracture.
  • Inspect, palpate and percuss the renal angle to detect retroperitoneal hematoma.
  • Inspect and examine the perineum, rectum and scrotum (vagina in females) for any associated injuries.
  • PR examination must be done to detect:
  • The integrity of anal sphincters that denote good intact pelvic nerve.
  • The presence or absence of the prostate as it is sometimes displaced upward and backward in association with the urethral injury as it is displaced by a pelvic hematoma that gives the sensation of a boggy mass on examination.
  • Bimanual examination to detect: full bladder, pie in sky bladder or expanded large sized pelvic floor hematoma.

VIII.6.6 Lab investigations:
As in all emergency cases, a blood sample must be taken for all routine lab investigations especially ABO group, CBC, Blood urea and creatinine.

VIII.6.7 Radiological examination:
There are situations where you face a poly-trauma patient and there is inadequacy of radiological equipment in your hospital, so:

VIII.6.7.1 If the patient is stable with good vital signs:
  • Do plain x-ray first for the bony pelvis or CT to detect the type and the nature of the pelvic fracture.
  • Then, if you have a suspicion of associated urethral injury, do an ascending urethrogram before any catheterization.
  • The orthopedic state of the patient may not allow the steep lateral position to do the ascending urethrogram so the C-arm is a good choice to do a urethrogram without mobilization of the patient.
  • If the urethra is intact on the ascending urethrogram insert a urethral catheter and do ascending cystogram with post voiding film to detect associated posterior bladder wall injury.

VIII.6.7.2 Unstable patients as well as poly-trauma patients
You must resuscitate them first and maintain their vital signs then you may be faced with one of the following probabilities:
  • The patient passed to the OR for emergency control of their bleeding from the associated injury as ruptured spleen or liver. So, you can take a look to inspect the distended bladder as well as the pelvic hematoma and just insert the suprapubic tube and drain without any disturbance from the pelvic floor hematoma.
  • If the patient resuscitated and the vital signs recover inside the OR theatre, you could do an ascending urethrogram under fluoroscopy before catherization to detect the presence of associated urethral injury.
    • N.B:
  • The direction of extravasated dye doesn’t denote the site of injury as the dye pass through the weakest lacerated facial planes.
  • The degree of the trauma to the lower urinary tract is correlated with the direction and the force of the trauma itself.

VIII.6.7.3 Ascending urethrogram:
The cornerstone for the diagnosis of any urethral injury is the ascending urethrogram in steep lateral position, which means:

a) The patient is tilted 30 degrees on x-ray table with a supporting cushion.

b) The lower hip and knee must be flexed while the upper hip and knee is in normal extended position.

-Stretch the penis towards the anterior superior iliac spine of the patient and insert a small part of a 10 french polyethylene catheter stem about 3 cm (till the fossa navicularis) after lubrication using sterile KY gel,

-Then press hold the catheter in the fossa navicularis by hand and inject 15 cc of the contrast dye slowly to fill the anterior urethra

-Then ask the patient to relax the anal sphincters with simultaneous injection of 5 cc of contrast to fill the posterior urethra with simultaneous x-ray exposure.

VIII.6.8 Classification of posterior urethral injuries
Depending on the ascending urethrogram, urethral injuries could be classified into:

1-Colapinto-McCallum:

They classified posterior urethral injury into 3 types:

Type 1: in which puboprostatic ligaments are torn and the prostate and the bladder are displaced upward and backward causing stretching of intact urethra

Type 2: Injury of the urethra at the prostato-membranous junction with intact urogenital diaphragm resulting in intrapelvic extravasation of the dye.

Type 3: Injury of the posterior urethra with disruption of the urogenital diaphragm and the extravasation of the dye found intrapelvic as well as in the perineum.

2-Goldman classification:

He differentiated between the injury of the posterior urethra to above and below an intact urogenital diaphragm and he added a separate type including the bladder neck injury associated with the anterior bladder wall injury (vertical tear with the presence of the extra peritoneal extravasation as well as around the bladder neck). Also, he included bulbar urethral injury in his classification as well as bladder base injury that mimic posterior urethral injury.

3- Some authors classified urethral injury as stretch, partial or incomplete or complete injury for simplicity where:

a- Urethral stretch: the dye reaches the bladder without any extravasation, but with elongation of the urethral length.
b- Partial injury: the dye reaches the bladder on ascending urethrogram with limited extravasation at the site of injury.
c- Complete injury: of the urethra, the dye never reaches the urinary bladder and extravasation occurs which may be completely intrapelvic or perineal only or both (intra-pelvic and perineal).

Direction of extravasation on ascending urethrogram:

It depends on:
  • Site of injury
  • Integrity of UGD
  • Opened fascial planes with trauma

So, the results may be;
  • Intra-pelvic extravasation due to supra-diaphragmatic urethral injury with intact UGD
  • Perineal or extra-pelvic extravasation due to infra-diaphragmatic urethral injury with intact UGD
  • Combined both intra and extra-pelvic extravasation with any urethral injury associated with disrupted UGD

You must know that:
  • The dye may not reach to the bladder due to external urinary muscle spasm from associated pain from trauma or fracture itself so , you must look to the shape of bulbar cone , is it is smooth taper end as normal or shoulder shape
  • With complete separation of prostate and bladder from UGD it gives a picture of pie-in the sky appearance of the urinary bladder in the cystogram

VIII.6.9 Initial management of posterior urethral injuries:
There are controversies regarding initial management of posterior urethral injuries either early or delayed management

It includes the following:

1- Urethral stretch: no treatment or urethral catheter if the bleeding is considerable

2- Partial injuries: just do SP tube or endoscopic urethral catheter insertion with SP tube for 3 weeks

3- Complete injuries: one of the following lines of treatment:

VIII.6.9.1 Suprapubic tube alone:
It is just insertion of suprapubic catheter surgically with a drain without any disturbance of the pelvic floor hematoma.

In this technique, long segment pelvic fracture distraction defect is common (PFDD) with a lower incidence of incontinence and impotence.

VIII.6.9.2 Immediate suture repair
It is only indicated in the following situations:
  • Any type of bladder neck injuries (partial injury associated with anterior bladder wall injury or complete avulsion of the bladder neck).
  • Trans-prostatic urethral injury in children
  • Associated rectal injuries needs colostomy

VIII.6.9.3 Immediate realignment either through surgery or endoscopy.
It is only indicated in stable patient with supra-diaphragmatic urethral injury and intact UGD

It is contraindicated in patient with disrupted UGD as it will result in prolapse of the prostate through the perineum

Usually, this technique is associated with a high incidence of incontinence and impotence due to disturbed pelvic floor hematoma to visualize both ends of urethra.

It also results in short pelvic fracture distraction defect or urethral stricture.

It can be performed by sound to sound, sound to finger or catheter to catheter

Trial of fixation of the prostate to the intact UGD to maintain realignment can be done by suture of the its capsule to the periosteum of the pubic bone, pass the suture through an intact UGD to the perineum or applying weight traction on the urethral catheter

The catheter is left for 6-8 weeks and closed SP tube for another one week to be sure from good micturition

VIII.6.10 Recommendations for the evaluation and management of urethral trauma
Table VIII:2 Recommendations for evaluation and management of urethral trauma

Recommendation

Strength Rating
1. Provide appropriate training to reduce the risk of traumatic catheterization Strong
2. Evaluate male urethral injuiries with flexible cysto-urethroscopy and/or retrograde uretherography Strong
3. Evaluate female urethral injuries with cysto-urethroscopy and vaginoscopy Strong
4. Treat iatrogenic aterior urethral injuries by suprapubic or urethral cathetarisation Strong
5. Treat partial blunt anterior urethral injuries by suprapubic or urethral cathetarisation Strong
6. Treat complete blunt anterior urethral injuries in males by immediate urethroplasty Weak
7. Treat pelvic fracture urethral injuries (PFUIs) in hemodynamically unstable patients by transurethral or suprapubic catheterisation initially Strong
8. Perfom early endoscopic re-alignment in male PFUIs when feasible Weak
9. Do not repeat endoscopic treatments after failed re-alignment for male PFUIs Strong
10. Treat partial posterior urethral injuries initially by suprapubic or transurethral catheter Strong
11. Do not perform immediate uretroplasty ( <48hours) in male PFHIs Strong
12. Perform early urethroplasty (two days to six weeks) for female PFUIs with complete disruption in selected patients (stable, short gap, soft perineum, lithotomy position possible) Weak
13. Manage complete postrior urethral disruption in male PFUIs with suprapubic diversion and deferred (at least three months) urethroplasty Strong
14. Perform early repair (within seven days) for female PFUIs (not delayed repair or early re-alignment) Strong
VIII.6.11 References:
1. Koraitim MM. Pelvic fracture urethral injuries: the unresolved controversy. J Urol 1999; 161:1433-41.
2. Koraitim MM, Marzouk ME, Atta MA, et al. Risk factors and mechanism of urethral injury in pelvic fractures. Br J Urol 1996; 77:876-80.
3. Corriere JNJ, Sandler CM. Mechanisms of injury, patterns of extravasation and management of extraperitoneal bladder rupture due to blunt trauma. J Urol 1988; 139:43-44.
4. Pierce JM., Jr Management of dismemberment of the prostatic-membranous urethra and ensuing stricture disease. J Urol 1972; 107:259-64.
5. Turner-Warwick R. A personal view of the immediate management of pelvic fracture urethral injuries. Urol Clin North Am 1977; 4:81-93.
6. Johnson MH, Chang A, Brandes SB. The value of digital rectal examination in assessing for pelvic fracture-associated urethral injury: what defines a high-riding or nonpalpable prostate? J Trauma Acute Care Surg 2013; 75:913-5.
7. Khan MS, Thornhill JA, Grainger R, et al. Rupture of the male membranous urethra. Ir J Med Sci 2000; 169:208-10.
8. Mitchell JP. Injuries to the urethra. Br J Urol 1968; 40:649-70.
9. Cass AS. Urethral injury in the multiple-injured patient. J Trauma 1984; 24:901-6.
10. Flaherty JJ, Kelley R, Burnett B, et al. Relationship of pelvic bone fracture patterns to injuries of urethra and bladder. J Urol 1968; 99:297-300.
11. Sandler CM, Harris JHJ, Corriere JNJ, et al. Posterior urethral injuries after pelvic fracture. AJR Am J Roentgenol 1981; 137:1233-7.
12. Palmer JK, Benson GS, Corriere JNJ. Diagnosis and initial management of urological injuries associated with 200 consecutive pelvic fractures. J Urol 1983; 130:712-4.
13. Glass RE, Flynn JT, King JB, et al. Urethral injury and fractured pelvis. Br J Urol 1978; 50:578-82.
14. Pokorny M, Pontes JE, Pierce JMJ. Urological injuries associated with pelvic trauma. J Urol 1979;121: 455-7.
15. McAninch JW. Traumatic injuries to the urethra. J Trauma 1981; 21:291-7.
16. Kaiser TF, Farrow FC. Injury of the bladder and prostatomembranous urethra associated with fracture of the bony pelvis. Surg Gynecol Obstet 1965; 120:99-112.
17. Webster GD, Mathes GL, Selli C. Prostatomembranous urethral injuries: a review of the literature and a rational approach to their management. J Urol 1983; 130:898-902.
18. Colapinto V, McCallum RW. Injury to the male posterior urethra in fractured pelvis: a new classification. J Urol 1977;118: 575-80.
19. Al Rifaei M, Eid NI, Al Rifaei A. Urethral injury secondary to pelvic fracture: anatomical and functional classification. Scand J Urol Nephrol 2001; 35:205-11
20. Goldman SM, Sandler CM, Corriere JNJ, et al. Blunt urethral trauma: a unified, anatomical mechanical classification. J Urol 1997; 157:85-9.
21. Glassberg KI, Kassner EG, Haller JO, et al. The radiographic approach to injuries of the prostatomembranous urethra in children. J Urol 1979; 122:678-83.
22. Sandler CM, Corriere JNJ. Urethrography in the diagnosis of acute urethral injuries. Urol Clin North Am 1989; 16:283-9.
23. Koraitim MM. Effect of early realignment on length and delayed repair of postpelvic fracture urethral injury. Urology 2012;79: 912-5.
24. Turner-Warwick R. Prevention of complications resulting from pelvic fracture urethral injuries--and from their surgical management. Urol Clin North Am 1989; 16:335-8.
25. Mitchell JP. Trauma to the urethra. Injury 1975;7: 84-8.
26. Morehouse DD, Mackinnon KJ. Management of prostatomembranous urethral disruption: 13-year experience. J Urol 1980;123: 173-4.
27. Coffield KS, Weems WL. Experience with management of posterior urethral injury associated with pelvic fracture. J Urol 1977;117: 722-4.
28. Morehouse DD. Management of posterior urethral rupture: a personal view. Br J Urol 1988;61: 375-81.
29. Firmanto R, Irdam GA, Wahyudi I. Early realignment versus delayed urethroplasty in management of pelvic fracture urethral injury: a meta-analysis. Acta Med Indones 2016; 48:99-105.
30. Crassweller PO, Farrow GA, Robson CJ, et al. Traumatic rupture of the supramembranous urethra. J Urol 1977;118: 770-1.
31. Mundy AR, Andrich DE. Urethral trauma. Part II: Types of injury and their management. BJU Int 2011;108: 630-50
32. Gonzalez R, Chiou RK, Hekmat K, et al. Endoscopic re-establishment of urethral continuity after traumatic disruption of the membranous urethra. J Urol 1983; 130:785-7.
33. Devine CJJ, Jordan GH, Devine PC. Primary realignment of the disrupted prostatomembranous urethra. Urol Clin North Am 1989; 16:291-5.
34. DeWeerd JH. Immediate realignment of posterior urethral injury. Urol Clin North Am 1977;4: 75-80.
35. Salehipour M, Khezri A, Askari R, et al. Primary realignment of posterior urethral rupture. Urol J 2005;2: 211-5.

VIII.7 Bladder trauma
VIII.7.1 Introduction
Bladder trauma can be caused by a direct blow to a distended bladder, high energy injury which disrupts the pelvis, penetrating, and iatrogenic injuries. Bladder injuries are divided into broad categories of extraperitoneal (EP), intraperitoneal (IP), or combined injuries which guide the management plan. Injuries to the bladder occur in up to 10% of abdominal trauma and may be associated with significant morbidity and mortality (10% to 22%). (1)

VIII.7.2 Etiology
Motor vehicle accidents are the most common cause of blunt bladder injury, followed by falls and other accidents. Extraperitoneal injury is almost always associated with pelvic fractures (2,3). The highest risk of bladder injury was found in disruptions of the pelvic circle with displacement > 1 cm, diastasis of the pubic symphysis > 1 cm, and pubic rami fractures (4,5). Intraperitoneal injury is caused by a sudden rise in intravesical pressure of a distended bladder, secondary to a blow to the pelvis or lower abdomen. The bladder dome is the weakest point of the bladder and ruptures will usually occur there (5).

There are challenges associated with consistent results regarding bladder trauma. There is evidence that approximately 85% of bladder injuries result from blunt trauma, while incident rates can account for up to 51% of injuries result from penetrating trauma. (6,7,8). Other less common etiologies of bladder trauma include iatrogenic injuries most commonly during obstetric, gynecologic, or urologic procedures. (7,9)

VIII.7.3 Epidemiology
Extraperitoneal (EP) and intraperitoneal (IP) and injuries occur with blunt and penetrating traumas, iatrogenic bladder injuries are well-documented as well. EP bladder injuries account for 60% of bladder traumas, while 30% are intraperitoneal, and 10% are combined. (10) Iatrogenic IP bladder injuries are not uncommon. The bladder is the most frequently injured organ in obstetric/gynecologic procedures such as cesarean section and hysterectomies, with an incidence of 13.8 cases per 1000 procedures. (11)

VIII.7.4 History and Physical Examination
Bladder trauma can be suspected in the presence of pelvic instability, blood at the meatus, significant abdominal and pelvic pain, suprapubic tenderness, high riding prostate, and gross hematuria. Peritoneal signs such as rigidity, guarding, and rebound tenderness should raise the suspicion not only for perforated viscus in the abdomen but also intraperitoneal bladder injury. Evaluation of the genitals may reveal blood at the urethral meatus, in which case urethral injury needs to be ruled out before inserting an indwelling catheter. A high riding prostate on a rectal exam also concerns for urethral injury. Gross hematuria is seen in 67% to 95% of cases and is the most classical symptom associated with bladder trauma. (12)

VIII.7.5 Evaluation
Basic labs such as complete blood count, metabolic panel, coagulation panel, and urinalysis should be obtained as part of the trauma work-up. Retrograde cystography, either computed tomography (CT) or conventional X-ray, is indicated for hemodynamically stable patients with gross hematuria, blood at the meatus, inability to void, pelvic fracture with microscopic hematuria, or penetrating injury to the pelvis, buttock, or lower abdomen. (13)

According to the European Association of Urology guidelines for urogenital trauma, CT cystography is preferred over traditional X-ray cystography due to rapid turnover time and convenience and it is superior in detecting other intra-abdominal processes and bony fragments within the bladder. (14)

Imaging findings associated with EP bladder trauma are extravasation of contrast around the base of the bladder confined to the perivesical space and extravasation into the thighs, penis, perineum, or anterior abdominal wall if the urogenital fascia is violated in a complex injury. In IP bladder trauma, contrast extravasates into the peritoneal cavity, outlining the loops of bowel and filling paracolic gutters. (13)

VIII.7.6 Treatment / Management
According to the American Urological Association (AUA) and EAU guidelines for bladder rupture,

VIII.7.6.1 Conservative management
Conservative treatment, which comprises of clinical observation, continuous bladder drainage and antibiotic prophylaxis (15), is the standard treatment for an uncomplicated extraperitoneal injury due to blunt (16,17,18) or iatrogenic trauma (15).

Conservative treatment is indicated for uncomplicated intraperitoneal injury after TURBT or other operations, but only in the absence of peritonitis and ileus (19,20). Placement of an intraperitoneal drain is advocated, especially when the lesion is larger (21,22). Penetrating extraperitoneal bladder injuries (only if minor and isolated) can also be managed conservatively (23,24,25).

VIII.7.6.2 Surgical management
Bladder closure is performed with absorbable sutures (23,26).

VIII.7.6.2.1 Blunt non-iatrogenic trauma

Most extraperitoneal ruptures can be treated conservatively, however bladder neck involvement, bone fragments in the bladder wall, concomitant rectal or vaginal injury or entrapment of the bladder wall necessitate surgical intervention (16). There is an increasing trend to treat pelvic ring fractures with open stabilisation and internal fixation. (27) Likewise, an extraperitoneal rupture should be sutured during surgical exploration for other injuries, in order to decrease the risk of complications and to reduce recovery time (28).

Intraperitoneal ruptures should always be managed by surgical repair (16,17) because intraperitoneal urine extravasation can lead to peritonitis, intra-abdominal sepsis and death (29). Abdominal organs should be inspected for possible associated injuries and urinomas must be drained if detected. Laparoscopic suturing of the intraperitoneal rupture is also possible (23).

VIII.7.6.2.2 Penetrating non-iatrogenic trauma

Penetrating bladder injury is managed by emergency exploration, debridement of devitalised bladder wall and primary bladder repair (31,32). A midline exploratory cystotomy is advised to inspect the bladder wall and the distal ureters (23,31). In gunshot wounds, there is a strong association with intestinal and rectal injuries, usually requiring faecal diversion (31,24). Most gunshot wounds are associated with two transmural injuries (entry and exit wounds) and the bladder should be carefully checked for these two lesions (31). As the penetrating agent (bullet, knife) is not sterile, antibiotic treatment is advised (32).

VIII.7.6.2.3 Iatrogenic bladder trauma

Perforations recognised intra-operatively are primarily closed (33). Bladder injuries not recognised during surgery or internal injuries should be managed according to their location. The standard of care for intraperitoneal injuries is surgical exploration and repair (34). If surgical exploration is performed after TURBT, the bowel must be inspected to rule out concomitant injury (35). For extraperitoneal injuries, exploration is only needed for perforations complicated by symptomatic extravesical collections. It requires drainage of the collection, with or without closure of the perforation (36). If bladder perforation is encountered during mid-urethral sling or transvaginal mesh procedures, sling re-insertion and urethral catheterisation (two to seven days) should be performed (37).

VIII.7.6.3 Follow-up
After operative repair of a simple injury in a healthy patient, the catheter can be removed after five to ten days without cystography (38,39). In cases of complex injury (trigone involvement, ureteric re-implantation) or risk factors of impaired wound healing (e.g. steroids, malnutrition) cystography is advised (163,207). For conservatively treated internal IBT, catheter drainage, lasting five days for extraperitoneal and seven days for intraperitoneal perforations, is proposed (41,42).

The first cystography is planned approximately ten days after injury (23). In case of ongoing leakage, cystoscopy should be performed to rule out bony fragments in the bladder, and a second cystography is warranted one week later (16)

VIII.7.6.4 Recommendations for management of Bladder Injury
Table VIII:3 Recommendations for management of Bladder Injury

Recommendation

Strength Rating
1. Perform cystoscopy in the presence of visible hematuria and pelvic fracture Strong
2. Perform cystoscopy in case of suspected iatrogenic bladder injury in the post-operative setting Strong
3. Perform cystoscopy with active retrograde filling of the bladder with diffuse contrast (300-350 ML) Strong
4. Perform cystoscopy to rule out bladder injuiry during retropubic sub0urethral sling procedures Strong
5. Manage uncomplicated blunt extraperitoneal bladder injuries conservatively Weak
6. Manage blunt extraperitoneal bladder injuries operatively in cases of bladder neck involvement and/or associated injuries that require surgical intervention Strong
7. Manage blunt intraperitoneal injuries by surgical exploration and repair Strong
8. Manage small uncomplicated intraperitoneal bladder injuries during endoscopic procedures sonservatively Weak
9. Perform cystoscopy to assess bladder wall healing after repair of a complex injury in case of risk factors for wounded healing Strong
VIII.7.7 Prognosis
Patients with bladder injuries may also present with a wide variety of concurrent traumatic injuries. A single-center retrospective study at a level I trauma center found a mortality rate of 10.8% among patients with bladder rupture undergoing laparotomy for trauma. [40] Untreated bladder rupture can lead to complications such as peritonitis, severe sepsis, and fistulas. Successful management requires timely evaluation, accurate diagnosis, and proper management based on the location and severity of the rupture. Most patients recover normal bladder function. Severe trauma involving the neck of the bladder, the urethra, and/or pelvic floor muscles may lead to urinary incontinence that may or may not be amenable to surgery.

VIII.7.8 Complications
  • Urinary incontinence
  • Wound dehiscence; drainage from wound site should not be confused with urine leak
  • Decreased bladder capacity from over-debridement
  • Persistent urinary extravasation
  • Hemorrhage can occur with violation of pelvic hematoma
  • Pelvic abscess can develop from infected hematoma
  • Intraabdominal infection
  • Fistula
  • Urinary tract infection
  • Urinary urgency

VIII.7.9 References
1. Bryk DJ, Zhao LC. Guideline of guidelines: a review of urological trauma guidelines. BJU Int. 2016 Feb;117(2):226-34.
2. Wirth, G.J., et al. Advances in the management of blunt traumatic bladder rupture: experience with 36 cases. BJU Int, 2010. 106: 1344
3. Matlock, K.A., et al. Blunt traumatic bladder rupture: a 10-year perspective. Am Surg, 2013. 79: 589
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