Urological Trauma
Dr. Mustafa Aziz Hassan
Genitourinary injureies account 10% of all abdominal trauma
Early diagnosis is essential to prevent serious complication
Initial assessment include control of hemorrhage and shock
along with resuscitation
Urethral meatus should be examined for presence of blood
before catheterization
Renal Trauma
Accounts for approximately 3% of all trauma admissions
and as many as 10% of patients who sustain abdominal
trauma
Kidney trauma can be life-threatening
Accounts for 50% of all genitourinary trauma
Blunt trauma accounts for 90% of all traumas
Both sides are at equal disposition for injury
Risk Factors
Preexisting renal abnormalities
horseshoe kidney
ectopic kidney
transplabt kidney
renal tumor or cyst
hydronephrosis
Pediatric kidney
Geriatric kidney
Mechanism of injury
Blunt ( motor vehicle crash, sports, fall)
Penetrating ( gunshot wounds, stab wounds)
Iatrogenic ( endourologic procedures,
extracorporeal shock-wave lithotripsy, renal
biopsy, percutaneous renal procedures)
Clinical Diagnosis
Diagnosis needs a high index of clinical awareness
Mechanism of injury provides the framework for
clinical assessment
Gross hematuria is the most reliable indicator for serious
urologic injury
The degree of hematuria doesn’t correlate with the
degree of injury
Others:microscopic hematuria,flank pain and
tenderness,associated injuries etc
Patient history
• PMH for pre-existing organ dysfunction and anatomical
abnormality { hydronephrosis, cyst, calculi, tumor } which
makes injury more likely
• Shock is an indictor for severe trauma, so, vital signs have to
be monitored throughout the diagnostic evaluation
Physical Ex.
Abdominal distension from retroperitoneal bleeding and
hematuria
Ecchymosis in the flank or upper quadrants of abdomen
Lower rib fractures are frequently found
Diffuse abdominal tenderness { acute abdomen }
Investigation
• Urine analysis
• CBC
• Renal function test
Imaging Studies
Ultrasonography
Computed tomography
Intravenous pyelogram (one shot)
All patients who require immediate
surgical exploration should undergo a
one-shot high dose IVP (2 mls\kg of
60% contrast followed by a single KUB
10 minutes later)
Angiography
Goal of initial imaging is to grade renal
injury
Demonstrate contralateral kidney and
preexisting renal abnormalities
Identify injury to other organs
Indications for Renal Imaging
Blunt trauma patients with gross hematuria
Patients with microscopic hematuria and shock
(systolic blood pressure of less than 90 mm Hg
any time during evaluation and resuscitation)
Penetrating injuries with any degree of hematuria
Pediatric trauma patient with gross or
significant microscopic hematuria (>50
RBC/HPF)
Associated injuries suggesting underlying renal
injury
Major deceleration injury
Renal pedicle injury
Involving artery and vein With hematoma
Delayed imaging
Injury to collecting system
with extravasation
Delayed imaging
Renal pelvis injury with leak of urine
Management
Conservetive:
Majority of renal injuries can be managed conservatively {
grade I -III }in stable patient
Supportive care with bed rest, hydration and AB till urine is
clear
Frequent vitals and Hb checking
Follow up imaging after discharge
Absolute indications for exploration
Persistent renal bleeding
Pulsatile,expanding or uncontained hematoma
Avulsion of the main renal artery or vein
Relative indications for Exploration
Significant (25%-50%) non-viable tissue
Urinary extravasation
Arterial thrombosis
Penetrating trauma
Surgical Approach
The goals of operative therapy are
hemorrhage control and renal tissue
preservation
Renorrhaphy is the most common reconstructive
technique
Midline incision,look for other injuries,central control
of vessels
Renal exploration, debridement of nonviable tissue,
hemostasis by individual suture ligation of bleeding
vessels, watertight closure of the collecting system,
and coverage or approximation of the parenchymal
defect
Indications for nephrectomy
When it is a life saving maneuver { hemodynamic
instability due to renal hemorrhage }
Grade 5 injuries
Major vascular injury particularly on the right
Complications
Early:
Urinoma, delayed bleeding, urinary fistula, infection,
abscess and HTN
Late:
AV fistula, hydronephrosis, stones, HTN and
pyelonephritis, pseudoaneurysms
Ureteral injuries
Trauma to the ureter is relatively rare { 1% }
Majority are iatrogenic injuries
Hysterectomy was responsible for the majority
Colorectal surgery
Pelvic surgery such as ovarian tumor removal
Abdominal vascular surgery
Distal uretre is mostly involved
Ureteral injuries
Endoscopic procedures accounted for 79% of injuries,
while open surgery accounted for 21%
Ureteral injuries after external violence are rare,
occurring in less than 4% and 1% of penetrating and
blunt traumas, respectively
Diagnosis
Intra-operative recognition
70-80% of iatrogenic injuries are diagnosed postoperatively
The presenting signs and symptoms may include:
flank pain
fever and sepsis
fistula, urinoma
prolonged ileus
renal failure from bilateral obstruction
Silent obstruction that later presents as hypertension and nephrotic
syndrome
Physical examination may show CVA tenderness, peritoneal signs, mass, or fluid
drainage from the wound or from the vagina
Imaging
US
IVP • Extravasation of contrast
medium on CT scans or IVP
CT
is the hallmark sign of
RGP ureteral trauma
MRI
Nuclear scan
Grading
• Grade 1: hematoma only
• grade 2 : Laceration < 50 % of
circumferece
• grade 3 : Laceration > 50 % of
circumference
• grade 4 : complete tear < 2 cm of
devascularization
• grade 5 : complete tear > 2 cm of
devascularization
Managment
Treatment depends on the extent and the location ureteral trauma
{ Distal - Mid - Proximal }
Grade I -II can be managed non surgical with uretreal stent or
nephrostomy
Grade 3 - 5 needs a reconstructive repair
Management
Intra-operative recognition: treat immediately if
possible(endoscopic or open)
If late recognition: try endoscopy 1st,if failed you can
consider open repair if injury happened within 7 days and
there is no active infection otherwise consider urinary
diversion, re staging and plan definitive treatment after 3
month
Principles of repair
All nonviable tissue must be debrided
A well-spatulated, watertight, tension-free
anastomosis is important
Urinary diversion in the form of a stent and/or
nephrostomy tube should be considered (4-6 weeks)
The repair must be isolated from infection,
retroperitoneal fibrosis, and cancer.
The omentum or retroperitoneal fat can be used to
cover the repair and therefore decrease the risk of
fibrosis and increase the blood supply to the region of
the repair.
psoas hitch
Boari bladder flap
Distal ureter
Endoscopy (retrograde or antegrade)
Ureteroneocystostomy
Psoas hitch
Boari bladder flap
Middle ureter
Endoscopy (retrograde or antegrade)
Ureteroureterostomy
Transureteroureterostomy
Proximal ureter
Endoscopy (retrograde or antegrade)
Ureteroureterostomy
Autotransplantation
Ileal ureteral substitution
Nephrectomy
Bladder Trauma
60-85% are from blunt trauma and 15-40% are from a
penetrating injury
The most common mechanisms of blunt trauma are
motor vehicle accidents (87%), falls (7%), and assaults
(6%)
In penetrating traumas, the most frequent culprit is gunshot
wounds (85%), followed by stabbings (15%)
Iatrogenic injury may result from
obstetric,gynecologic,urologic and orthopedic procedures
Full bladder is more susceptible to injury
Classification
Bladder contusion
Extraperitoneal bladder rupture
Intraperitoneal bladder rupture
Combination of intraperitoneal and
extraperitoneal ruptures
Bladder contusion
Incomplete or partial-thickness tear of the
bladder mucosa resulting in localized injury
and hematoma
Contusion typically occurs in Patients
presenting with gross hematuria after blunt
trauma and normal imaging studies or Patients
presenting with gross hematuria after extreme
physical activity (ie, long- distance running)
Bladder contusions are self-limiting and require
no specific therapy, except for short- term
rest,?catheter until hematuria resolves
Clinical presentation
A triad of symptoms is often present (gross hematuria, suprapubic
pain or tenderness, difficulty or inability to void)
An abdominal examination may reveal distention, guarding, or
rebound tenderness
Absent bowel sounds and signs of peritoneal irritation indicate a
possible intraperitoneal bladder rupture
Bilateral palpation of the bony pelvis may reveal abnormal motion
indicating an open-book fracture or a disruption of the pelvic girdle
If blood is present at the urethral meatus, suspect a urethral injury
Investigations
Blood at the urethral meatus is an absolute
indication for retrograde urethrography
Conventional cystogram
CT cystogram
Ultrasonography
Intra and extra peritoneal bladder rupture
Extraperitoneal Ruptures
Can be managed safely with simple catheter drainage and
Abx
Leave the catheter in for 7-10 days, then obtain a
cystogram. Approximately 85% of the time, the laceration is
sealed and the catheter is removed for a voiding trial.
Virtually all extraperitoneal bladder injuries heal within
3 weeks
Consider open repair if :
Bone fragment is projecting into the bladder,
Open pelvic fracture,
Rectal perforation
Patients undergoing laparotomy for other reasons
Intraperitoneal bladder rupture
Most, if not all, intraperitoneal bladder ruptures
require surgical exploration
Urine takes the path of least resistance and continues to
leak into the abdominal cavity resulting in urinary ascites,
abdominal distention, and electrolyte disturbances
Do a two-layer closure with absorbable suture, Place SP
tube and perivesical drain
Maintain patient on prophylactic Abx
Cystogram is obtained 7 to 10 days after surgery
Urethral Trauma
Classified into 2 broad categories based on the anatomical site of
the trauma { anterior or posterior }
Mechanism of injury include:blunt trauma such as MVA or
falls,penetrating injuries,straddle injuries and Iatrogenic injury
like traumatic catheter placement, transurethral procedures, or
dilation
Posterior urethral injuries commonly associated with
pelvic fractures
Anterior urethral injuries come from blunt trauma to the
perineum (straddle injuries)
Diagnosis
Urethral injury should be suspected in the setting of pelvic fracture,
traumatic catheterization, straddle injuries, or any penetrating
injury near the urethra
Symptoms include hematuria or inability to void
Physical examination may reveal blood at the meatus or a high-
riding prostate gland upon rectal examination. Extravasation of
blood along the fascial planes of the perineum is another indication
of injury to the urethra
The diagnosis is made by performance of a retrograde
urethrogram
Classification of posterior urethral injuries
Type I: Urethral stretch injury
Type II : Uretheral disruption proximal to the
genitourinary diaphram
Type III: Urethral disruption both proximal and
distal to the genitourinary diaphragm
Treatment
Aim is to have a continent patient with satisfactory
voiding and sexual function
Patient is given analgesia and antibiotic
Avoid Repeated attempts at blind catheterization
Management
The traditional intervention for men with posterior urethral
injury secondary to pelvic fracture is placement of a
suprapubic catheter for bladder drainage and subsequent
delayed repair
The suprapubic catheter can be safely placed either
percutaneously or via an open approach with a small
incision
Ultimate repair can be performed 6-12 weeks after the event,
after the pelvic hematoma has resolved and the patient's
orthopedic injuries have stabilized
Management
An attempt at primary realignment of the distraction with a
urethral catheter is reasonable in stable patients either
acutely or within several days of injury (ie, 5-7 d post
injury)
When the urethral catheter is removed after 4 to 6 weeks, it
is imperative to retain a suprapubic catheter because most
patients will, despite realignment, develop posterior
urethral stenosis
Testicular Trauma
Testicular injuries can be divided into 3 broad
categories based on the mechanism of injury
Blunt trauma
Penetrating trauma
Degloving trauma
Testicular Trauma
Blunt trauma refers to injuries sustained from
objects applied with any significant force to the
scrotum and testicles. Examples include a kick to the
groin or a baseball injury
Penetrating trauma refers to injuries sustained
from sharp objects or high-velocity missiles.
Examples include gunshot and stab wounds
Degloving injuries (or avulsion injuries) are less
common. With these, scrotal skin is sheared off,
for example, when a testicle becomes trapped in
heavy machinery
Testicular Trauma
Testicular rupture or fractured testis refers to a rip or tear in the
tunica albuginea resulting in extrusion of the testicular contents
Clinical diagnosis
Patients typically present to ER with a straight forward history of
injury
Symptoms include extreme scrotal pain, frequently associated
with nausea and vomiting
Physical examination often reveals a swollen, severely
tender testicle with a visible hematoma
Scrotal or perineal ecchymosis may be present
When evaluating a patient with a clinical history of only minor
trauma, do not overlook the possibility of testicular torsion or
epididymitis
Clinical diagnosis
Screening urinalysis is important to rule out urinary tract
infection or epididymo-orchitis
Scrotal ultrasound imaging with Doppler studies is valuable for
diagnosing and staging testicular injuries
The presence of a disrupted tunica albuginea is
pathognomonic for testicular rupture
Management
Institute conservative treatment for patients with
minor trauma in which the testes are spared and the
scrotum has not been violated
The usual treatment consists of scrotal support,
nonsteroidal anti-inflammatory medications, ice
packs, and bed rest for 24-48 hours
Indications for scrotal exploration
Uncertainty in diagnosis after appropriate
clinical and radiographic evaluations
Disruption of the tunica albuginea
Large hematocele
Absence of blood flow on scrotal ultrasound
images with Doppler studies
Scrotal exploration
Clinical hematoceles that are expanding or of considerable
size (eg, 5 cm or larger) should be explored
Collections of smaller size are also often explored,
because it has been shown that such practice allows for
more optimal pain control and shorter hospital stays
If the testis is fractured, testicular debridement and
surgical closure of the tunica albuginea are
necessary
Etiology
penile fracture usually occurs during
sexual intercourse when the penis slips
out of the vagina and strikes the
perineum or the pubic symphysis
Other potential causes include
industrial accidents, masturbation,
gunshot wounds, penile manipulation to
achieve detumescence
Penile Fracture
Sudden blunt trauma or abrupt lateral bending of the penis in an
erect state can break the markedly thinned and stiff tunica
albuginea, resulting in a fractured penis
One or both corpora may be involved, and concomitant injury to
the penile urethra may occur
Urethral trauma is more common when both corpora cavernosa are
injured
Trauma during sexual relations is responsible for approximately
one third of all cases
Clinical presentation
Based on history and physical examination
Patients describe a popping, cracking, or snapping sound with
immediate detumescence. They may report minimal to severe
sharp pain, depending on the severity of injury
Clinical presentation
On physical examination there is significant penile deformity,
swelling, and ecchymosis (the so-called "eggplant" deformity).
The penis is abnormally curved, often in an S shape.
If the urethra has also been damaged, blood is present at the meatus.
If the Buck fascia is intact, penile ecchymosis is confined to the penile
shaft
If the Buck fascia has been violated, the swelling and ecchymosis are
contained within the Colles fascia. In this instance, a "butterfly-pattern"
ecchymosis may be observed over the perineum, scrotum, and lower
abdominal wall
Management
Surgical Exploration and Repair
Surgical therapy has consistently resulted in fewer
complications
Principles of surgical therapy
Optimize the surgical exposure
Evacuate the hematoma
Identify the site of injury
Correct the defect in the tunica albuginea with 1-0 braided
nonabsorbable suture in an interrupted fashion; Invert the
sutures so the knots will not be palpable
Repair the urethral injury
Complications
Erectile dysfunction,
Abnormal penile curvature,
Painful erections,
Formation of fibrotic plaques,
Penile abscess,
Urethrocutaneous fistula,
Corporourethral fistula, and
Painful nodules along the site of injury.
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