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Pediatric female genital trauma managed under conscious sedation in the emergency department versus general anesthesia in the operating room- a single center comparison of outcomes and cost

Published:December 11, 2020DOI:https://doi.org/10.1016/j.jpurol.2020.11.041

      Summary

      Introduction

      Pediatric female genital trauma (PFGT) comprises injuries to the female external and internal genitalia. Examination under general anesthesia (GA) in the operating room (OR) is traditionally recommended, however repair at the bedside under conscious sedation (CS) in the emergency department (ED) may be a safe alternative. The Genitourinary Injury Score (GIS) objectively classifies PFGT severity, but designates all vaginal and urethral injuries as Grade III.

      Objective

      To compare outcomes and cost of patients with PFGT managed under CS in the ED vs GA in the OR.

      Study design

      All patients treated by a pediatric urologist from May 2009 to September 2019 with associated ICD codes for PFGT were included. Exclusion criteria included PFGT from sexual abuse or obstetric related complications. Clinical and demographic data was extracted from the EMR. A cost analysis comparing ED vs OR management was performed.

      Results

      33 patients were identified with a median age of 6.8 years. The primary etiology was straddle trauma. Injuries were predominately GIS I-III (30, 91%) with possible urethral involvement in 6 patients. Sedation and repair in the ED was performed for 12 (36%) patients vs 21 (64%) taken to the OR. For the OR cohort, 15 (71%) were taken to the OR immediately and 6 (29%) initially underwent CS but this was aborted due to injury complexity. Aborting CS and proceeding to the OR did not result in compromised outcome or prolonged hospitalization.
      No patients in the ED cohort required post-procedural admission whereas all patients taken to the OR were admitted postoperatively. Cost of care for ED repair was less than two-thirds (60%) that of surgical repair in the OR. Using Onen GIS III or less without deep vaginal and/or urethral involvement as a cutoff for attempted bedside repair vs proceeding directly to the OR could have spared 7 (47%) patients GA and subsequent admission. A female-specific modification to the Onen GIS III criteria is proposed in light of these findings.

      Discussion

      The present study suggests CS and bedside repair of low-grade PFGTs is safe with a cost benefit. This is reflected by a proposed modification to the Onen GIS III criteria. These findings should be interpreted with caution given the retrospective nature of this single institution, small cohort study.

      Conclusion

      Summary Figure
      Graphical AbstractProposed GIS scale (a) and management pathway (b).

      Keywords

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      References

        • Iqbal C.W.
        • Jrebi N.Y.
        • Zielinski M.D.
        • Benavente-Chenhalls L.A.
        • Cullinane D.C.
        • Zietlow S.P.
        • et al.
        Patterns of accidental genital trauma in young girls and indications for operative management.
        J Pediatr Surg. 2010; 45: 930
        • Dorairajan L.N.
        • Gupta H.
        • Kumar S.
        Pelvic fracture-associated urethral injuries in girls: experience with primary repair.
        BJU Int. 2004; 94: 134
        • Onen A.
        • Ozturk H.
        • Yayla M.
        • Basuguy E.
        • Gedik S.
        Genital trauma in children: classification and management.
        Urology. 2005; 65: 986
        • Dowlut-McElroy T.
        • Higgins J.
        • Williams K.B.
        • Strickland J.L.
        Patterns of treatment of accidental genital trauma in girls.
        J Pediatr Adolesc Gynecol. 2018; 31: 19
        • Spitzer R.F.
        • Kives S.
        • Caccia N.
        • Ornstein M.
        • Goia C.
        • Allen L.M.
        Retrospective review of unintentional female genital trauma at a pediatric referral center.
        Pediatr Emerg Care. 2008; 24: 831
        • Heppenstall-Heger A.
        • McConnell G.
        • Ticson L.
        • Guerra L.
        • Lister J.
        • Zaragoza T.
        Healing patterns in anogenital injuries: a longitudinal study of injuries associated with sexual abuse, accidental injuries, or genital surgery in the preadolescent child.
        Pediatrics. 2003; 112: 829
        • Patel D.N.
        • Fok C.S.
        • Webster G.D.
        • Anger J.T.
        Female urethral injuries associated with pelvic fracture: a systematic review of the literature.
        BJU Int. 2017; 120: 766
        • Bakal U.
        • Sarac M.
        • Tartar T.
        • Cigsar E.B.
        • Kazez A.
        Twenty years of experience with perineal injury in children.
        Eur J Trauma Emerg Surg. 2016; 42: 599
        • Pokorny S.F.
        • Pokorny W.J.
        • Kramer W.
        Acute genital injury in the prepubertal girl.
        Am J Obstet Gynecol. 1992; 166: 1461
        • Thambi Dorai C.R.
        • Boucaut H.A.
        • Dewan P.A.
        Urethral injuries in girls with pelvic trauma.
        Eur Urol. 1993; 24: 371