1. Given a patient with a potential urinary tract injury:
1. To list and interpret key clinical findings
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2. To list and interpret critical investigations
3. Construct an initial management plan
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4. To list and specify previous genitourinary anomaly.Systems:
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Renal
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Bladder?
Urethra
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Ureter
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?External Genitalia
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Renal Trauma Overview? Most commonly injured GU organ
? 10% of all serious injuries abdominal have
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associated renal injury? Mode of injury
? Blunt renal truma
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? MVA, fall from height, assaults
? Penetrating renal injuries
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? Gunshots and stab wounds.Hematuria and Renal Injury
? Best indicator of significant injury(microscopic
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or gross)
? NOT related to the degree of injury
? Gross Hematuria is Variable and absent in :
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? 7 % of grade IV renal injury
? 36% of renal vascular injury
? 50% of UPJ injuries
Whom to work up
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? Penetrating trauma: EVERYONE
? Pediatric patients with microscopic hematuria.
? Blunt trauma: Image with CT if:
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? gross hematuria? microhematuria plus shock
? microhematuria plus acceleration/deceleration
Mee et al. (1989)
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Hardeman et al (1987
Imaging of trauma patient with
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hematuria? CT preferred
? With contrast
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? With "delayed" films (mandatory)
? Why not get CT cystogram too?
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? Standard intravenous pyelogram (IVP): Forgetit
? "One Shot" intraoperative IVP
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? 2 cc/kg intravenous contrast
? Single film at 10 minutes
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Intraoperative One Shot IVP
? Allows safe
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avoidance of renalexploration in 32%
(Morey et al, 1999)
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? Highly specific for
urinary
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extravasation? Confirms existence
of the other kidney
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AAST Organ Injury Severity Scale for
the Kidney
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AAST Organ Injury Severity Scale for
the Kidney
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Indications for renal trauma surgery? Absolute
? Hemodynamic instablity with shock
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? Expanding /pulsatile renal hematoma
? Suspected renal pedicle avulsion (grade V)
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? UPJ disruption? Relative (now rare)
? Urinary extravasation with non viable tissue
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? Renal injury together with colon /pancreatic injury
? Delayed diagnosis of arterial injury
Indications for angiography with
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embolisation
? Bleeding from renal segmental artery
? Unstable condition with grade II or IV
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? AV fistula or pseudoaneurysm? Persistent gross hematuria
? Blood loss extending 2 units in 24 hrs.
Management Options For Renal
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Trauma
? Close observation
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? Bed rest? Serial Hemoglobins
? Antibiotics if urinary extravasation
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? Radiographic Embolization
? Urinary Diversion
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? Ureteral Stenting? Nephrostomy Drainage
? Surgery
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? Renal Preservation / Reconstruction
? Nephrectomy
Surgical considerations
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? Midline transabdominal approach
? Early vascular control before opening gerotas
fascia
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? Landmark is IMA or in presense of large
hematoma ,IMV.
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Renal trauma in pediatric population? Kidneys propotinally larger and less protected
? Less retroperitoneal and peritoneal fat
? Less musculature
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? Higher sympathetic tone ie hypotention lessreliable predictor of severity of renal injury.
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Follow up? Repeat CECT within 72 hrs
? Once pt is off hematuria and ambulatory
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,discharged? Adviced to avoid strenous activity for 4-6
weeks
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? Follow up in opd after 3 weeks with USG and
Hgm.
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Bladder TraumaBladder: BLUNT: Overview
? Rarely isolated
? 80 -90 % have severe associated injuries
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? Often high-energy injuries? Associated with urethral rupture 10-29% and
pelvic fracture 6-10%
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Bladder: PENETRATING: Overview? Incidence 2%
? Associated major abdominal injuries (35%)
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and shock (22%)
? Mortality high: 12%
Bladder: Diagnosis: Physical Signs
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?
Suspicion: required in cases of penetrating trauma, based
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on trajectory?
Physical signs:
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Abdominal pain
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?Abdominal tenderness
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Abdominal bruising
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Urethral catheter does not return urine(gross hematuria inalmost al cases)
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Delayed?
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Fever?
No urine output
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?
Peritoneal signs
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?BUN / Creatinine
Bladder: Diagnosis: Hematuria
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? Most (95%) have gross hematuria
? Microhematuria does occur: usually with
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minimal injuryIndications of imaging
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? Absolute? Gross hematuria with pelvic fracture(30 % with
bladder rupture)
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? Penetrating injury of lower abdomen with any
degree of hematuria
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? Relative? Gross hematuria without pelvic fracture
? Microscopic hematuria with pelvic fracture
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Bladder: Diagnosis Plain Cystography? Nearly 100% accurate
when done properly:
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? Adequate filling with
350 cc
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? Drainage films? Use 30% contrast
? Underfilling (250 cc)
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associated with false
negatives
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Bladder: Diagnosis CT Cystography
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? Preferred, especially if already getting otherCTs
? Antegrade filling by "clamping the Foley" is
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not OK!
? Must dilute contrast (6:1 with saline, or to
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about 2-4%)Bladder: Diagnosis CT Cystography
Extraperitoneal
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Intraperitoneal
Management (extraperitoneal bladder
rupture)
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? Uncomplicated cases: conservative
management with catheter drainage.
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? Large bore (22 fr ) should be used.? Catheter removal 2 weeks after cystogram
? Complications reported with conservative
management (12% vs 5% with open repair)
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like fistula ,clot retntion and sepsis.
Management (intraperitoneal bladder
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rupture)? All penetrating and intraperitoneal injuries
should be managed with immediate open
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repair.
? Catheter removal 1 week after cystogram.
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Ureteral Injury
? No reliable Physical findings! Usually a
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retrograde diagnosis? Non specific symptoms
? Flank pain (36%-90%)
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? Fever? Ileus
? Abdominal distension
? fistula
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Etiology
? External trauma
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? High speed blunt injuries? Penetrating trauma
? Surgical injury
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? Gynecological
? Obstetric
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? General surgery( colorectal sx)? Urologic procedures
? Ureteroscopic injury
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Diagnosis
? Presense of hematuria(non specific)
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? Imaging? IVU
? CT urogram
? RGP
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? Antegrade ureterography? Intraoperative recognisation
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Hematuria and ureteral injury? Nonspecific indicator
? 25 ? 45% patients donot demonstrate even
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microscopic hematuria.
? Being suspicious for it is the only way you will
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catch it.Management
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Posterior Urethral Injuries
Posterior Urethra Trauma: Etiology
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? 4-14% of pelvic fractures
? Bilateral pubic rami fractures (straddle
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fracture) and sacroiliac diasthasis? Mostly males, but can happen in females
? Associated bladder rupture in 10-17%
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? Rectal injury can lead to urethral-rectal fistula
in 8%
Posterior Urethra Trauma: Diagnosis
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? Blood at meatus: 50%
? Inability to urinate
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? Palpable full bladder? Inability to place urethral catheter
? High riding prostate : 34%
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? Rarely, perineal hematoma (late finding)
? Rarely females develop proximal urethral
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injury? Presents with vulvar edema and blood at
vaginal introitus
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Retrograde Urethrogram
Management
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? Immediate open reconstruction(curently no
role)
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? Suprapubic cystostomy? Primary realignment
? Delayed reconstruction
? Endoscopic treatment
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? Surgical reconstructionAnterior urethral injury
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? Are often isolated? Majority after stradle injury
? Involve bulbar urethra
? Presents with blood at meatus,perenial
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hematoma,gross hematuria n urinaryretention
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Complications? Erectile dysfunction
? 50%
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? Cavernosal nerve injury? Arterial insufficiency
? Venous leak
? Direct corporal injury
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? Recurent stenosis(5-15%)? Incontinence after reconstruction <4%
QUIZ (Grades of Renal Injuries)
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Thanks