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Genitourinary Tract Genitourinary Tract InjuriesInjuriesInjuriesInjuries
66thth Nordic CourseNordic Course
Scott D. Steenburg, MDAssistant Professor
University of Maryland Department of RadiologyDivision of Trauma and Emergency Radiology
R Adams Cowley Shock Trauma Center
ObjectivesObjectives• Role of imaging in evaluation of
it i tgenitourinary trauma • Spectrum of GU injuries• Relevance of imaging findings in determining management
• Focus on MDCT
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Genitourinary TractGenitourinary Tract• Adrenal glands• Kidneys• Ureters• Bladder• UrethraUrethra
Genitourinary Tract TraumaGenitourinary Tract Trauma• 10% of all blunt abdominal trauma• Trend towards conservative management
• Imaging directs management and further investigation
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Adrenal GlandsAdrenal Glands• Incidence up to 4% of blunt trauma• Unilateral R>>L>bilateral• Unilateral, R>>L>bilateral• Rarely isolated• Adjacent injuries common
– Esp liver• Unilateral adrenal injuries of little clinicalUnilateral adrenal injuries of little clinical significance
• Bilateral injuries rarely cause adrenal insufficiency
Adrenal GlandsAdrenal Glands• CT imaging findings:
il d l h i– Expansile, round or oval hyperattenuating hematoma
– Irregularity or obliteration by hemorrhage,
–Periadrenal fat stranding
Enlargement due to edema or contusion– Enlargement due to edema or contusion
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Adrenal Hematoma
Adrenal Hemorrhage / Bare Area Contusion
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Adrenal injury with active hemorrhage
Renal TraumaRenal Trauma• 3‐10% of blunt trauma patients• Blunt trauma 80‐90%
–Parenchymal–Collecting system–Vascular
• 95‐98% of renal injuries managed conservatively
Alonso RC et al. Kidney in Danger: CT Findings of Blunt and Penetrating Renal Trauma. RadioGraphics 2009; 29:2033–2053Ramchandani and Buckler. Imaging of Genitourinary Trauma. AJR 2009; 192:1514–1523
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Renal Trauma Renal Trauma –– HematuriaHematuria??
• Hematuria often absentb f l h l–Absent in 10‐25% of renal parenchymal
injuries–Absent in 25‐50% of patients with ureteropelvic juntion injuries
–Ureteral tear vascular pedicle injury or–Ureteral tear, vascular pedicle injury, or ureteropelvic junction avulsion
Alonso RC et al. Kidney in Danger: CT Findings of Blunt and Penetrating Renal Trauma. RadioGraphics 2009; 29:2033–2053Kawashima A, Sandler CM, Corl FM, et al. Imaging of renal trauma: a comprehensive review. Radiographics 2001;21(3):557–74.Ramchandani and Buckler. Imaging of Genitourinary Trauma. AJR 2009; 192:1514–1523
Renal Trauma Renal Trauma –– HematuriaHematuria??
• No correlation between degree ofNo correlation between degree of hematuria and extent of renal injury
Alonso RC et al. Kidney in Danger: CT Findings of Blunt and Penetrating Renal Trauma. RadioGraphics 2009; 29:2033–2053Kawashima A, Sandler CM, Corl FM, et al. Imaging of renal trauma: a comprehensive review. Radiographics 2001;21(3):557–74Ramchandani and Buckler. Imaging of Genitourinary Trauma. AJR 2009; 192:1514–1523
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Renal Trauma: Renal Trauma: Imaging ProtocolsImaging Protocols
–MDCT primary imaging modality•Anatomy and function
–Multi‐phase acquisition•Arterial phaseArterial phase•Parenchymal phase•Delayed phase
Renal TraumaRenal Trauma
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Renal TraumaRenal Trauma• Grade I injuries
• 75‐85% of all renal injuries
• Contusions
• Non‐expanding subcapsular hematomas
Alonso RC et al. Kidney in Danger: CT Findings of Blunt and Penetrating Renal Trauma. RadioGraphics 2009; 29:2033–2053Ramchandani and Buckler. Imaging of Genitourinary Trauma. AJR 2009; 192:1514–1523
Renal Contusion / Laceration
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• Grade II injuries– Non‐expanding perinephric hematomas confined
Renal TraumaRenal Trauma
Non expanding perinephric hematomas confined to the retroperitoneum
– Superficial cortical lacerations <1 cm in depth
• Grade III injuries– Lacerations deeper than 1 cm– Extend into the medullaExtend into the medulla.
• Grade II and III lacerations spare the collecting system
Alonso RC et al. Kidney in Danger: CT Findings of Blunt and Penetrating Renal Trauma. RadioGraphics 2009; 29:2033–2053Ramchandani and Buckler. Imaging of Genitourinary Trauma. AJR 2009; 192:1514–1523
Subcapsular HematomasGrade II
Grade III
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• Grade IV injuriesL ti t di th h t
Renal TraumaRenal Trauma
– Lacerations extending through cortex, medulla and into the collecting system
– Injuries involving the main renal artery or vein with contained hemorrhage
– Segmental infarctions without associated– Segmental infarctions without associated lacerations
Alonso RC et al. Kidney in Danger: CT Findings of Blunt and Penetrating Renal Trauma. RadioGraphics 2009; 29:2033–2053Ramchandani and Buckler. Imaging of Genitourinary Trauma. AJR 2009; 192:1514–1523
• Renal infarctionSt t hi f th l t d
Renal TraumaRenal Trauma
– Stretching of the renal artery produces an intimal tear or dissection
–CT findings:
• Segmental = peripheral, well‐defined, wedge‐shaped non‐enhancingwedge‐shaped, non‐enhancing
Alonso RC et al. Kidney in Danger: CT Findings of Blunt and Penetrating Renal Trauma. RadioGraphics 2009; 29:2033–2053Ramchandani and Buckler. Imaging of Genitourinary Trauma. AJR 2009; 192:1514–1523
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Kawashima A, et al. Imaging of Renal Trauma: A Comprehensive Review. RadioGraphics 2001; 21:557–574
• Renal infarctionM t t l l i f t h l
Renal TraumaRenal Trauma
–Most segmental renal infarcts heal spontaneously to form scars
– Infarcts >50% may need surgical debridement
Alonso RC et al. Kidney in Danger: CT Findings of Blunt and Penetrating Renal Trauma. RadioGraphics 2009; 29:2033–2053Ramchandani and Buckler. Imaging of Genitourinary Trauma. AJR 2009; 192:1514–1523
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Segmental Renal Infarct
Segmental Renal Infarct
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Multi-focal Segmental Renal Infarcts
• Grade V injuriesMost severe type of renal injury
Renal TraumaRenal Trauma
– Most severe type of renal injury
– Shattered kidney
– Partial tears or complete laceration (avulsion) of the ureteropelvic junction
– Thrombosis of main renal artery or vein with d l i i f h kiddevascularization of the kidney
Alonso RC et al. Kidney in Danger: CT Findings of Blunt and Penetrating Renal Trauma. RadioGraphics 2009; 29:2033–2053Ramchandani and Buckler. Imaging of Genitourinary Trauma. AJR 2009; 192:1514–1523
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Right renal artery avulsion
Right Infarct, Left Contusion
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Right renal artery injury, renal infarct
• Shattered KidneyMultiple fragments
Renal TraumaRenal Trauma
– Multiple fragments
– 1 or more devitalized areas regions
– Excreted contrast leak
– Injuries to the collecting system
– Severe hemorrhage
– Active arterial bleeding
Alonso RC et al. Kidney in Danger: CT Findings of Blunt and Penetrating Renal Trauma. RadioGraphics 2009; 29:2033–2053Ramchandani and Buckler. Imaging of Genitourinary Trauma. AJR 2009; 192:1514–1523
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Shattered Kidney
Grade V Renal Injury with active bleeding
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Renal vein pseudoaneurysm with active bleeding
Left vein injury with active bleeding
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UreterUreter InjuriesInjuries• Ureteropelvic junction• Ureter• Ureteropelvic junction
Alonso RC et al. Kidney in Danger: CT Findings of Blunt and Penetrating Renal Trauma. RadioGraphics 2009; 29:2033–2053Ramchandani and Buckler. Imaging of Genitourinary Trauma. AJR 2009; 192:1514–1523
UreterUreter InjuriesInjuries• Ureteropelvic junction injuries
–Shearing stress at the renal pelvis• Ureter is retroperitoneal with only fixation points at UPJ and UVJ
• Hematuria absent in 25 50%• Hematuria absent in 25‐50%
Alonso RC et al. Kidney in Danger: CT Findings of Blunt and Penetrating Renal Trauma. RadioGraphics 2009; 29:2033–2053Ramchandani and Buckler. Imaging of Genitourinary Trauma. AJR 2009; 192:1514–1523
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UreterUreter InjuriesInjuries• Delayed phase essential!
–>5min
• Leak on arterial and parenchymal phases often absent
Alonso RC et al. Kidney in Danger: CT Findings of Blunt and Penetrating Renal Trauma. RadioGraphics 2009; 29:2033–2053Ramchandani and Buckler. Imaging of Genitourinary Trauma. AJR 2009; 192:1514–1523
UreterUreter InjuriesInjuries• Partial laceration vs transection
–Partial laceration = leak of excreted contrast with opacified distal ureter
–Transection = leak of excreted contrast with unopacified distal ureter
Alonso RC et al. Kidney in Danger: CT Findings of Blunt and Penetrating Renal Trauma. RadioGraphics 2009; 29:2033–2053Ramchandani and Buckler. Imaging of Genitourinary Trauma. AJR 2009; 192:1514–1523
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UreterUreter InjuriesInjuries• Partial laceration vs transection
–Partial laceration:• Treated conservatively or with stent placement
–Complete transection:• Usually requires surgical repair
Alonso RC et al. Kidney in Danger: CT Findings of Blunt and Penetrating Renal Trauma. RadioGraphics 2009; 29:2033–2053Ramchandani and Buckler. Imaging of Genitourinary Trauma. AJR 2009; 192:1514–1523
UreterUreter InjuriesInjuries• Urinary extravasation alone is not an indication for surgery
–Can spontaneously resolve –Up to 87% of patientsF ll i i d d• Follow‐up imaging recommended
Knudson MM and Maull KI. Nonoperative management of solid organ injuries: past, present and future. Surg Clin North Am 1999; 79:1357–1367. Alonso RC et al. Kidney in Danger: CT Findings of Blunt and Penetrating Renal Trauma. RadioGraphics 2009; 29:2033–2053Ramchandani and Buckler. Imaging of Genitourinary Trauma. AJR 2009; 192:1514–1523
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Uretero‐Pelvic Junction Laceration
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Proximal Ureter Laceration
Goals of Management?• Minimize hemorrhage
• Maintain urinary flow without obstruction – Preserve renal function
• Prevent urine leak– Decreases risk of local and systemic infection
Alonso RC et al. Kidney in Danger: CT Findings of Blunt and Penetrating Renal Trauma. RadioGraphics 2009; 29:2033–2053Ramchandani and Buckler. Imaging of Genitourinary Trauma. AJR 2009; 192:1514–1523