36Genitourinary Tract Trauma

8/12/2019 36Genitourinary Tract Trauma

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Genitourinary Tract Trauma

Wen-xuan Chen

Department of urology

Tianjin medical university Generalhospital


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Renal Trauma


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Introduction

Renal trauma is not common and occurs in

approximately 1-5% of all traumas.

Although the majority of renal traumas aremild,sometimes renal trauma can also be

acutely life-threatening.


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Introduction

Renal trauma is often accompanied by injury to

other organs or structures,such as rib fracture,

spleen injury or liver injury.

Kidneys with existing pathologic conditions such

as hydronephrosis or malignant tumors are

more readily ruptured from mild trauma.


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Etiology

Blunt Trauma:

Blunt trauma directly to the abdomen,flank,or

back is the most common mechanism,account-

ing for 80~85% of all renal injuries.

Trauma may result from motor vehicle accidents,

fights,falls,and contact sports.


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Etiology

Penetrating Trauma:

Gunshot and knife wounds cause most penetra-ting injuries to the kidney.

Any such wound in the flank area should beregarded as a cause of renal injury until provedotherwise.

Renal injuries from penetrating trauma tendto be more severe and less predictable.


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Pathologic Classification

Minor renal trauma(85% of cases)

Renal contusionof the parenchyma is the

most common lesion.

Subcapsular hematomaand superficial

cortical lacerationsare also considered minor

trauma.

These injuries rarely require surgical exploration.


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Major renal trauma(15% of cases) Deep corticomedullary lacerationsmay

extend into the collecting system,resulting in

extravasation of urine into the perirenal space.

Large retroperitoneal and perinephric hemato-

mas often accompany these deep lacerations.

Multiple lacerationsmay cause completedestruction of the kidney which may be called

shattered kidney


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Vascular injury(1% of all blunt trauma cases)

Vascular injury of the renal pedicle is rare but

may occur,usually from blunt trauma.

There may be total avulsion of the artery and

vein or partial avulsion of the segmental

branches of these vessels.

Vascular injuries are difficult to diagnose andresult in total destruction of the kidney.


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AAST renal-injury scaling system

The Committee on Organ Injury Scaling of the

American Association for the Surgery of Trauma

(AAST) has developed a new renal-injury

scaling systemwhich is now widely used. This scaling system is the most important variable

predicting the need for kidney repair or removal.

Renal injuries are classified as grade 1 to grade 5.


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Description of injury

Grade 1:

contusionor

non-expanding

subcapsular haematoma

no laceration


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Grade 2:

non-expanding

perirenal haematoma

cortical laceration 1cm

without

urinary extravasation


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Grade 4:

Parenchymallaceration

extending through the

corticomedullaryjunction and into the

collecting system


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Grade 4:

segmental renal artery

or vein injurywith

contained haematoma


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Grade 5:

multiple major

lacerations, resulting in

a shattered kidney


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Grade 5:

avulsion of the main

renal artery and/or

vein


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Which grade?


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Which grade?


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Which grade?


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Clinical Findings

Microscopic or gross hematuriafollowing

trauma to the abdomen indicates injury to the

urinary tract.

It bears repeatingthat stab or gunshot woundsto the flank area should alert the physician to

possible renal injury whether or not hematuria is

present.


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Clinical Findings

The degree of renal injury does not correspond

to the degree of hematuria,since gross hemat-

uria may occur in minor renal trauma and only

mild hematuria in major trauma. Patients with gross hematuria or microscopic

hematuria with shock should undergo radio-

graphic assessment;patients with microscopic

hematuria without shock need not.


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Clinical Findings

If physical examination or associated injuries

prompt reasonable suspicion ofrenal injury,renal imaging should be undertaken.

This is especially true of patients with rapiddeceleration trauma,who may have renal injury

without the presence of hematuria.


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Clinical Findings

A. Symptoms:

Painmay be localized to one flank area or over

the abdomen.

Catheterization usually reveals hematuria.

Retroperitoneal bleeding may cause abdominal

distention,ileus,and nauseaand vomiting.


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Clinical Findings

B. Signs:

Initially,shock or signs of a large loss of blood

from heavy retroperitoneal bleeding may be

noted. Ecchymosisin the flank or upper quadrants of

the abdomen is often noted.

Diffuse abdominal tendernessmay be foundon palpation.


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Clinical Findings

B. Signs:

A palpable massin the flank or abdomen may

represent a large retroperitoneal hematoma or

perhaps urinary extravasation. The abdomen may be distendedand bowel

sounds absent.


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Clinical Findings

C.laboratory evaluation:

Haematuria (microscopic or gross) is a hallmark

sign of renal injury.

But haematuria is neither sensitive nor specificfor differentiating minor and major injuries and it

does not correlate with the degree of injury.

In case of disruption of the ureteropelvicjunction,renal pedicle injuries,and segmental

arterial thrombosis,nohaematuria is present.


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Clinical Findings

C.laboratory evaluation:

The hematocritmay be normal initially,but a

dropmay be found when serial studies are

done. This findings represents persistent retroperi-

toneal bleeding and development of a large

retroperitoneal hematoma.

Persistent bleedingmay necessitate

operation.


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Clinical Findings

D. Staging and Imaging :

Ultrasonographyis a quick,non-invasive,low-

cost imaging modality and is popularly used in

the primary evaluationof polytrauma patients.

Ultrasound scans can detect renal lacerations

but can not definitely assess their depth and

extent and do not provide functional informationabout renal excretion.


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Clinical Findings


A CT scanwith enhancement is the best

imaging study for diagnosing and staging renal

injuries in haemodynamically stablepatients. This non-invasive technique clearly defines

parenchymal lacerationsand urinary extrava-

sation,shows the extent of the retroperitoneal

hematoma,and outlines injuries to surrounding

organs such as the pancreas,spleens,liver,et al.


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Clinical Findings


Angiography can be used for diagnosis and

simutaneous selective embolization of bleeding

vessels.


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Management

A. Emergency measures:

The objectives of early management are prompt

treatment of shock and haemorrhage,complete

resuscitation,and evaluation of associatedinjuries.


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Management

B. Conservative measures:

Stable patients,following grade 1-3 staband

low-velocity gunshot wounds after complete

staging,should be selected for expectantmanagement.


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Complications

A. Early complications:

Early complications occur within the first month

after injury which include bleeding,infection,

perinephric abscess,sepsis,and urinary extra-vasation and urinoma.

Hemorrhageis perhaps the most important

immediate complication of renal injury.


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Complications


Patients must be observed closely,with careful

monitoring of blood pressure,pulse and serial

hematocrit. Evidence of an enlarging mass in the flank

implies persistent bleeding.

Bleeding may stop spontaneously in 80~85% ofcases.


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Complications


Urinary extravasation from renal fracture may

show as an expanding mass (urinoma) in the

retroperitoneum.

These collections are prone to abscess forma-

tion and sepsis.

A resolving retroperitoneal hematoma maycause slight fever,but higher temperatures

suggest infection.


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Complications

B. Late complications:

Vascular compromise may result renal atrophy.

The blood pressure should be carefully checked

for several months because hypertension may

be presented due to renal ischemia.


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Prognosis

Most renal injureis have an excellent prognosis.

Follow up should involve physical exmination,

urinalysis, excretory urography, serial bloodpresure measurement and serum determination

of renal function.


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Injuries to the ureter


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Introduction

Ureteral injury is rare but may occur,usually

during the course of a difficult pelvic surgical

procedure or as a result of gunshot wounds.

Endoscopic basket manipulation of ureteral

calculi may also result in injury.


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Clinical Findings

A. Symptoms and signs:

If the ureter has been injured during operation,

the patient may complain of flank and lowerabdominal painon the injured side

Fever,nausea and vomitingare often present.

Anuriafollowing pelvic surgery means bilateralureteral ligation until proved otherwise


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Clinical Findings

A. Symptoms and signs:

If ureterovaginal or cutaneous fistula develops,it

usually does so within the first 10 postoperative

days. Signs and symptoms of acute peritonitis may be

present if there is urinary extravasation into the

peritoneal cavity.


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Clinical Findings

B.Laboratory Findings:

Microscopic hematuria is usually found.

Tests of renal function will be normal unlessboth ureters are occluded.


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Clinical Findings

C. X-Ray Findings Excretory urograms may show evidence of

ureteral occlusion

Extravasation of radiopaque fluid may be seen

in the region of the ureter

Retrograde urography will depict the site and

nature of the injury.


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Excretory urography

demonstratingextravasation in theupper right ureterconsequent to stabwound. Note lack of

contrast (arrow) in theureter below the site ofinjury, indicatingcomplete ureteraltransection.


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Clinical Findings

D. Ultrasonography Ultrasonography outlines hydroureter or urinary

extravasation as it develops into a urinoma and

it perhaps the best means of ruling out ureteral

injury in the early postoperative period.

It has the advantages of being noninvasive and

rapid.


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Clinical Findings

E. Radionuclide Scanning:

This technique will show delayed excretion,with

an accumulation of counts in the pelvis and

renal parenchyma resulting from ureteral

obstruction

It is useful postoperatively to assess the result

of corrective surgery


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AASTs classification

Grade 1 haematoma only

Grade 2 laceration < 50% of circumference

Grade 3 laceration > 50% of circumference

Grade 4 complete tear2cm of devascularization


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Management

Prompt treatment of ureteral injuries is required.

The best opportunity for successful repair is in

the operating room when the injury occurs.

If the injury is not recognized until 7-10 daysafter the event and no infection,abscess,or other

complications exist,immediate reexploration and

repair are indicated.


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Management

If the injury is recognized late or if the patient

has significant complications that make immedi-

ate reconstruction unsatisfactory,proximal

urinary drainage by percutaneous nephrostomyor formal nephrostomy should be considered.


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Management

A. Partial injuries:

These can be defined as grade 1 to grade 2lesions.

Once recognized,they can be managed withureteral stenting or by placement of a nephros-tomy tube to divert urine.

If this technique is utilized,a bladder catheter

should be left in place for 2 days to limit stentreflux during voiding.


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Management

A. Partial injuries:

The ureteral stent should be left in place for at

least 3 weeks.

If a grade 2 or 3 injury is encountered duringimmediate surgical exploration,primary closure

of the ureteral ends over a stent may be

recommended,with placement of an external

drain adjacent to the injury.


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Management

Double J tubean indwelling stent


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Management

B. Complete injuries:

These are grade 3 to 4 injuries.

Successful repair should utilize the principles

described in below.


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Management

Principles of repair of complete injury:

Debridement of ureteral ends to fresh tissue

Spatulation of ureteral ends

Placement of internal stent

Watertight closure of reconstructed ureter with

absorbable suture

Placement of external,non suction drain

Isolation of injury with peritoneum or omentum


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Management

Uretero-

ureterostomy


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Management

The type of reconstructive

repair procedure chosen

by the surgeon dependson the nature and site of

the injury


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Management

Injuries to the upper

third of the ureter are

best managed by primaryureteroureterostomy.


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Management

Midureteral injuries

usually result from

external violence and arebest repaired by primary

ureteroureterostomy or

transureteroureterostomy


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Management

Transureteroureterostomymay

be used in lower-third injuries

if extensive urinomaand pelvic

infectionhave developed. This

procedure allows anastomosis

and reconstruction in area away

from the pathologic processes.


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Management


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Prognosis

The prognosis for ureteral injury is excellent if

the diagnosis is made early and prompt correct-

ive surgery is done.

Delay in diagnosis worsens the prognosis

because of infection,hydronephrosis,abscess,

and fistula formation.


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Injuries to the bladder

I d i


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Introduction

Bladder injuries occur most often from external

force and are often associated with pelvic

fractures.

When the bladder is filled to near capacity,a

direct blow to the lower abdomen may also

result in bladder rupture.

M h i


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Mechanism

Blunt trauma accounts for 67~86% of bladder

ruptures,while penetrating trauma for 14~33%.

The most common cause (90%) of bladder

rupture by blunt trauma is motor vehicle

accidents.

About 70~97% of patients with bladder injuries

from blunt trauma have associated pelvic

fractures.

M h i


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Mechanism

A direct blow over

the full bladder

causes increased

intravesical pressure.

If the bladder

ruptures,it will

usually rupture into

the peritoneal cavity.

Cl ifi ti


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Classification

Type Description

1 Bladder contusion

2 Intraperitoneal rupture3 Interstitial bladder injury

4 Extraperitoneal rupture

5 Combined injury

Cli i l Fi di


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Clinical Findings

A. Symptom and signs: The two most common sign and symptoms are

gross haematuria(82%) and abdominaltenderness(62%)in patients with major bladderinjuries.

Other findings may include the inability to void,bruisesover the suprapubic region andabdominal distension.

Extravasation of urine may result in swellingin

the perineum,scrotum and thighs.

Cli i l Fi di


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Clinical Findings

B.Laboratory Findings: Catheterization usually is required in patients

with pelvic trauma but not if bloody urethraldischarge is noted.

Bloody urethral discharge indicates urethralinjury,and a urethrogram is necessary beforecatheterization.

When catheterization is done,gross or,lesscommonly,microscopic hematuria is usuallypresent.

Cli i l Fi di


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Clinical Findings

C. X-Ray Findings A plain abdominal film generally demonstrates

pelvic fractures.

An intravenous urogram should be obtained toestablish whether kidney and ureteral injuries

are present.

Cli i l Fi di


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Clinical Findings

D. Cystography:

Retrograde cystography is the standardand

the most accurate radiological study for

diagnosing bladder rupture.When adequatebladder filling and post-void images are

obtained,it has an accuracy rate of 85-100%.

Immediate cystography is required in thepresence of haematuria and pelvic fracture.

Cli i l Fi di


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Clinical Findings

D. Cystography:

Diagnosis should be made with retrograde

cystography with a minimum of 350 ml of gravity

filled contrast medium. For cystography,the minimum requirement

includes a plain film, filled film, and post-

drainage film. Half-filled film and obliques are

optional.


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Plain film


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cystogram


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Management


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Management

The first priority in the treatment of bladder injuries is

stabilization of the patient and treatment of associated

life-threatening injuries.

Extraperitoneal bladder ruptures caused by blunttrauma are managed by catheter drainage only.

Intraperitoneal bladder ruptures by blunt trauma and

any type of bladder injury by penetrating trauma

must be managed by emergency surgical explora-

tion and repair.

Prognosis


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Prognosis

With appropriate treatment,the prognosis is

excellent.

Early diagnosis and treatment lead to low rate

complications and death.


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Injuries to the urethra

Introduction


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Introduction

Urethral injuries are uncommon and occur most

often in men.

The urethra can be separated into 2 broad

anatomic divisions: 1. the anterior urethra,

consisting of the bulbousand pendulous

portions; 2. the posterior urethra, consisting of

the prostatic and membranousportions.


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Injuries to the anterior urethra


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Injuries to the anterior urethra

Anterior urethral injury is more ofen than

posterior urethral injury.

The majority of anterior urethral injury occurs in

bulbous urethra.

The most common cause is straddle-type

injuriescaused by blows of blunt objects

against the perineum.

Injury to the bulbous urethra


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Injury to the bulbous urethra

Mechanism:

Usually a perineal

blow or fall astride

an object;

crushing

of urethra against

inferior edge ofpubic symphysis

Classification


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Classification

Contusion:blood at the urethral meatus; no extravasation

on urethrography

Partial disruption: extravasation of contrast at injury

site with contrast visualized in the proximal urethra orbladder

Complete disruption: extravasation of contrast at

injury site without visualization of proximal urethra or

bladder


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Clinical Findings


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Clinical Findings

A. Symptoms and Signs:

The perineum is very tender,and a mass may

be found.

Rectal examination reveals a normal prostate. The patient usually has a desire to void,but

voiding should not be allowed until assessment

of the urethra is complete.

No attempt should be made to pass a

urethral catheter.

Clinical Findings


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Clinical Findings

B.Laboratory Findings: The amount of urethral bleeding correlates

poorly with the severity of injury.

A contusion or partial disruption may beaccompanied by plenty of bleeding while total

disruption may result in little bleeding.

Clinical Findings


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Clinical Findings

C. X-Ray Findings:

Retrograde urethrographyis considered the

gold standard for evaluating urethral injury.

A urethrogram,with instillation of 15-20ml ofwater soluble contrast material,demonstrates

extravasation and the location of injury.

A contused urethra shows no evidence of

extravasation.

Clinical Findings


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Clinical Findings

D. Instrumental Examination: If there is no evidence of extravasation on the

urethrogram,a urethral catheter may be passed

into the bladder. Extravasationis a contraindication to further

instrumentationat this time.

Management


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Management

General Measures: Major blood loss usually does not occur from

straddle injury.

If heavy bleeding does occur,local pressure forcontrol,followed by resuscitation,is required.

Management


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Management

A. Urethral Contusion: The patient with urethral contusion shows no

evidence of extravasation,and the urethra

remains intact. After urethrography,the patient is allowed to

void;and if the voiding occurs normally,without

pain or bleeding,no additional treatment is

necessary.If bleeding persists,urethral catheterdrainage can be done.

Management


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Management

B. Urethral disruptions:

A suprapubic cystostomy tube should be placed

and maintained for approximately 4 weeks .

Voiding cystourethrography is then performedand if normal voiding can be re-established and

no contrast extravasation nor subsequent

stricture is present,then the tube can be safely

removed.


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Complications


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Complications

The potential early complications of acute urethralinjuries include stricture and infections.

Drainage of extensive urinary extravasation and

large hematoma may be required.

Complications


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Complications

Prompt urinary diversion coupled with theappropriate administration of antibioticsdecreases the incidence of these complications.

Urethral stricture may be managed with optical

urethrotomy,anastomotic urethroplasty or flapurethroplasty.


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Injuries to the posterior urethra


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Injuries to the posterior urethra

The prostate has beenavulsed from the

membranous urethra

secondary to fracture of

the pelvis.Extravasation occurs

above the triangular

ligament and is

periprostatic and

perivesical

Clinical Findings


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Clinical Findings

A. Symptoms: A history of crushing injury to the pelvis is

usually obtained.

Patients usually complain of lower abdominalpainand inability to urinate.

Clinical Findings


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Clinical Findings

B. Signs: Blood at the urethral meatus is the single most

important sign of urethral injury.The importance

of this finding can not be overemphasized,because an attempt to pass a urethral catheter

may result in infection of the periprostatic and

perivesical hematoma and conversion of an

incomplete laceration to a complete one.

Clinical Findings


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Clinical Findings

B. Signs: The presence of blood at the meatus indicates

that immediate urethrogram is necessary to

establish the diagnosis. Suprapubic tenderness and the presence of

pelvic fracture are noted on physical examina-

tion.

Clinical Findings


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Clinical Findings

B. Signs: A large developing pelvic hematoma may be

palpated perineal or suprapubic contusions are

often noted. Rectal examination may reveal a large pelvic

hematoma with the prostate displaced super-

iorly.

Clinical Findings


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Clinical Findings

C. Laboratory Findings: Anemia due to hemorrhage may be noted.

Urine usually can not be obtained initially,since

the patient should not void and catheterizationshould not be attempted.

Clinical Findings


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Clinical Findings

D. X-Ray Findings: Pelvic fractures are usually present.

A urethrogram (using 20-30 ml of water-soluble

contrast material) shows the site of extravasa-tion at the prostatomembranous junction.

Ordinarily,there is free extravasation of contrast

material into the perivesical space.

Clinical Findings


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C ca d gs

D. X-Ray Findings:

Incomplete prostatomembranous disruption is

seen as minor extravasation,with a portion of

contrast material passing into the prostaticurethra and bladder.

Clinical Findings


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g

E.Instrumental Examination:

The only instrumentation involvedshould be forurethrography.

Catheterization or urethroscopy should not bedone,because these procedures pose an

increased risk of hematoma,infection,and further

damage to partial urethral disruptions.


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Retrograde urethrogram demonstrating complete posterior urethral disruption.

Management


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g

A. Emergency measures:

Shock and hemorrhage should be treated.

Management


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g

B. Surgical measures: Initial management should consist of suprapubic

cystostomy to provide urinary drainage.

The suprapubic cystostomyis maintained inplace for about 3 months.This allows resolu-

tion of the pelvic hematoma,and the prostate

and bladder will slowly return to their anatomic

positions.

Management


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g

B. Surgical measures: Incomplete lacerationof the posterior urethra

heals spontaneously,and the suprapubic

cystostomy can be removed within 2-3 weeks. The cystostomy tube should not be removed

before voiding cystourethrography shows that

no extravasation persists.


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Combination urethrogram and cystogram demonstrating a 2-cm urethral

rupture defect (arrow).

Management


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g

B. Surgical measures: If the stricture is


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p

Late complications include urethral strictureatthe site of healing.

Impotenceas a result of damage to local

nerves or blood vessels,is permanent in about

10% of patients.

Urinary incontinenceseldom follows trans-

pubic or perineal reconstruction.If present,it

usually resolves slowly.

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36Genitourinary Tract Trauma