Urologic Trauma


Kidney Trauma

  1. Initial Evaluation
    • majority of renal injuries result from blunt trauma (80:20)
    • all trauma patients should have a urinalysis: the majority of patients with a renal injury will have gross or microscopic hematuria
    • if placement of a Foley catheter is required, must rule out urethral injury first (suspected if there is blood at the meatus, a high-riding prostate, or pelvic fracture)
    • fractures of the lower ribs or transverse spinous processes are strongly associated with renal injuries

  2. Radiologic Evaluation
    1. CT Scan
      • performed only on hemodynamically stable patients
      • provides detailed information about the renal injury as well as information regarding other associated intraabdominal or retroperitoneal injuries
      • can be used to classify the injury and guide management plans
      • nonfunction of a kidney is an indication for an arteriogram

    2. FAST
      • not able to image acute kidney injuries
      • retroperitoneal bleeding will not be visualized
      • cannot differentiate between blood and urine

    3. IVP
      • in patients requiring emergent laparotomy, a ‘one-shot’ IVP can determine if the contralateral kidney is functioning, and if there is possible collecting system or ureteral injury
      • performance should not delay emergency surgery

    4. Angiography
      • super-selective coil embolization is effective at stopping bleeding in selected patients

  3. Classification of Renal Injuries

    4. Renal Trauma Grading
  4. Management
    1. Nonoperative Management
      • most renal injuries can be managed nonoperatively with bedrest, serial hematocrits, and close monitoring
      • bedrest can often be avoided unless hematuria increases or resumes after ambulation
      • if a collecting system injury is present, the kidney should be reimaged 3 – 5 days later to evaluate for persistent urine leak or urinoma formation
      • large leaks usually require an indwelling stent, and large urinomas require percutaneous drainage

    2. Angiography/Embolization
      • controversial, but some possible indications include persistent bleeding from a segmental renal artery, pseudoaneurysm or arteriovenous malformation, persistent gross hematuria, ongoing transfusion requirements

    3. Indications for renal exploration
      • expanding, pulsatile retroperitoneal hematoma
      • renal pedicle avulsion
      • life-threatening hemorrhage or shock
      • ureteropelvic junction disruption
      • failed embolization
      • renovascular hypertension

  5. Operative Approach
    1. Vascular Control
      • early vascular control of the renal artery and vein is recommended before the hematoma is opened
      • the renal arteries will be found superior and posterior to the left renal vein as it crosses the aorta
      • to identify the right renal vein will require mobilizing the duodenum

      Vascular Exposure of the Kidneys
    2. Exposure
      • colon is reflected medially to expose Gerota’s fascia
      • Gerota’s fascia is opened laterally and the hematoma evacuated

    3. Repair of Injuries
      • goal is to preserve as much renal parenchyma as possible
      • parenchymal injuries may be treated with debridement, ligation of bleeding vessels, repair of the laceration and any collecting duct injury, and drainage
      • if the defect is too large to close primarily, it may be packed with omentum
      • extensive injury to a pole of the kidney may be treated with a partial nephrectomy
      • inability to control hemorrhage is the most common indication for nephrectomy
      • segmental and main renal artery and main renal vein injuries should be repaired whenever possible; segmental renal vein injuries may be treated with ligation
      • acute renal artery thrombosis should be treated with resection of the involved segment and end-to-end anastomosis, or bypass grafting with autologous vein or synthetic graft

      Renorrhaphy
      Renorrhaphy

      Partial Nephrectomy
      Partial Nephrectomy

Ureteral Injury

  1. Initial Evaluation
    • injuries primarily result from penetrating trauma or iatrogenic injury
    • acute injuries are frequently missed until their sequelae are apparent (fistula, stricture, hydronephrosis, abscess)
    • CT scan detects ureteral injury with a high degree of accuracy
    • in the operating room IV methylene blue can be administered to detect subtle injuries

  2. Operative Management
    • principles of ureteral repair are: 1) debridement, 2) tension-free repair, 3) spatulated anastomosis, 4) ureteral stenting, and 5) drainage

  3. Sites of Ureteral Injury

    4. Common Sites of Ureteral Injury
    1. Upper Ureteral Injuries
      • injuries above the iliac vessels can usually be repaired by a primary ureteroureterostomy over a double-j stent

      Ureteroureterostomy
    2. Lower Ureteral Injuries
      • injuries below the iliac vessels are best treated with a ureteroneocystostomy
      • mobilization of the kidney and proximal ureter usually provides enough length to reach the bladder
      • if more length is needed, then the dome of the bladder is mobilized and secured to the psoas tendon (psoas hitch)
      • rarely, for longer injuries, a tube is made from the bladder (Boari flap)
      • autotransplantation of the kidney can be considered in lieu of a complicated repair

      Psoas Hitch
      Psoas Hitch

    3. Damage Control Procedures
      • if primary repair is not possible or advisable at the time of laparotomy, then the end of the ureter can be ligated and a percutaneous nephrostomy tube placed to divert the urine
      • another damage control procedure is to divert the urine over a stent to the abdominal wall
      • secondary repair can then be performed when the patient is more stable or more expertise is available

Bladder Injury

  1. Initial Evaluation and Diagnosis
    • bladder injury is strongly associated with pelvic fractures, especially diastasis of the pubis and obturator ring fractures
    • 95% of patients have gross hematuria
    • intraperitoneal or extraperitoneal injury is confirmed by CT cystogram

    Intraperitoneal and Extraperitoneal Bladder Rupture
    Extraperitoneal and Intraperitoneal Bladder Rupture

  2. Management
    1. Intraperitoneal Rupture
      • usually results from a sharp blow to the lower abdomen in a patient with a full bladder
      • requires a laparotomy to repair
      • standard closure is a 2-layer repair with a slowly absorbable suture
      • must take care not to occlude the ureteral orifices
      • Foley catheter or suprapubic tube should be left in place for 10 - 14 days, and can be removed after a follow up cystogram confirms no leak
      • closed suction drain should be left adjacent to the repair

    2. Extraperitoneal Rupture
      • most are treated nonoperatively with 7 to 10 days of catheter drainage
      • operative repair is required if there is a concomitant rectal injury, major vaginal laceration, or bone fragments in the bladder
      • need a follow up cystogram

Urethral Injury

  1. Initial Evaluation and Diagnosis
    • suspected when there is pubic diastasis or inferior pubic ramus fracture
    • signs and symptoms include blood at the meatus, difficulty or inability to void, high-riding prostate, pelvic hematoma, or associated bladder injury
    • retrograde urethrogram is the primary diagnostic x-ray

    Retrograde Urethrogram
    Retrograde Urethrogram: Normal (a), Extravasation (b)

    1. Management
      1. Suprapubic Cystostomy Tube
        • initial step
        • usually done in the ER
        • stricture rates are > 95%

      2. Urethral Realignment
        • can be done electively up to one week after injury
        • requires 2 urologists skilled in flexible endoscopy
        • stricture rates are ~ 50%







References

  1. Cameron, 11th ed., pgs 1053 – 1061, 1067 - 1069
  2. Sabiston, 20th ed., pgs 2085 - 2093