Genitourinary Trauma

Prof. DR. Mohamed ShafikProf. DR. Mohamed ShafikUrology Department – Alexandria University

• ~10% of E.R. trauma visits

• Often associated with multi-system trauma

• Subtle presentations, easily overlooked

• Diseased GU organs susceptible to injury

GU TraumaObjectives

• ~10% of E.R. trauma visits

• Often associated with multi-system trauma

• Subtle presentations, easily overlooked

• Diseased GU organs susceptible to injury

GU TraumaGeneral Considerations

• Airway• with C-spine protection

• Breathing

• Circulation• control of external hemorrhage, 2 large bore IVs

• Disability• assessment of neurologic status

• Exposure / Environment• undress / temperature control

GU TraumaEvaluation

• Most commonly injured GU organ

• Often in association with multi-system organ injury

• Blunt >80%

• Penetrating <20%

Renal TraumaGeneral Considerations

• Most common form of renal trauma• Types of injury

– Motor vehicle accidents

– Falls from heights

– Assaults

• Mechanisms of injury– High velocity impact (contusion / hematoma / laceration)

– Deceleration injury (RA thrombosis / RV disruption / avulsion of renal pedicle)

Renal TraumaBlunt

• Uncommon form of renal trauma

• Types of injury– Gunshot wounds– Stab wounds

• Mechanisms of injury– Direct shearing force through renal tissue

Renal TraumaPenetrating

• Hematuria (gross or microscopic)– Microscopic = 5 RBCs/HPF– May be absent

• Shock (hypotension, tachycardia, oliguria)

• Flank bruising/mass

• Flank pain/tenderness

Renal TraumaPresentation

• Penetrating injuries

• Blunt injuries in association with:– Gross hematuria– Microscopic hematuria and shock (SBP < 90)– Microscopic hematuria in children– Microscopic hematuria in patient with solitary kidney– Absence of hematuria but high clinical index of suspicion of

renal injury based on Hx, Px and AXR• Rapid deceleration injury• Lower rib #• Transverse process #• Loss of psoas shadow

Renal TraumaIndications for Imaging

Consider the need for both anatomic and functional information

• IVP - “Single-shot” intra-op

• U/S - Confirm 2 kidneys

• Angiography - Used for embolization

These modalities have a limited role and have been essentially replaced by CT scan

Renal TraumaOptions for Imaging

• Provides valuable anatomic and functional information

• Provides the most definitive staging information

• Provides information on associated injuries

• Imaging modality of choice for renal trauma

Renal TraumaCT Scan

• Urinary extravasation medial to kidney– Suggests UPJ avulsion or renal pelvic injury

• Hematoma medial to kidney, displacing it laterally– Suggests pedicle injury

• Lack of contrast enhancement of kidney– Suggests arterial injury

Renal TraumaCT Findings – Major Trauma

• Many classification systems available

• Recommend:– American Association for the Surgery of Trauma (AAST)

Organ Injury Severity Scale

• Because:– Most widely used– In Campbell’s

Renal TraumaClassification

AAST

Renal TraumaClassification

Pediatric Renal TraumaConsiderations

• Occupies proportionately larger space

• Less perirenal and subcutaneous fat

• Renal capsule, Gerota’s fascia and perirenal fat less developed (? less fixation)

• Vascular pedicle more susceptible to shearing forces

• Higher catecholamine output after trauma

Pediatric Renal Trauma Controversies

• What is appropriate investigation of suspected renal injuries?

• What is the significance of degree of hematuria?

• Does the rule of microscopic hematuria and shock still fit?

Pediatric Renal TraumaSummary

• Shock not a useful parameter

• Hematuria may not be present ~10%

• Not all children with blunt trauma need to be evaluated but...

• High index of suspicion based on mechanism

• “Liberal” use of imaging studies

• Conservative management for:– 90-98% of blunt renal trauma

– Up to 50% of penetrating renal trauma

• ABCs

• Admission

• Bedrest until gross hematuria clears

• Close clinical observation– Serial vital signs, CBC

Renal TraumaNon-operative Management

ABSOLUTE• Persistent renal bleeding

with hemodynamic instability

• Expanding perirenal hematoma

• Pulsatile perirenal hematoma

Renal TraumaIndications for Surgical Exploration

RELATIVE• Penetrating injuries

• Extensive urine extravasation

• Grade 5 injury– “Shattered kidney”– Pedicle injury

• Non-viable tissue (>20%)

• Arterial injury (main or segmental)

• Transabdominal midline laparotomy

• Early control of renal vessels

• Exposure of kidney– Open Gerota’s fascia– Dissect kidney from surrounding hematoma

• Decision: repair of kidney vs. removal of kidney

Renal TraumaPrinciples of Surgical Exploration

• Complete renal exposure

• Debridement of non-viable tissue

• Hemostasis– Suture ligature– Gelfoam, Surgicel– Argon beam coagulation

• Water-tight closure of collecting system

• Approximation/coverage of parenchymal defect

Renal TraumaPrinciples of Renal Reconstruction

Renal TraumaTechnique of Renal Reconstruction

• Early– Hemorrhage, shock– Urinoma

• Late– Infection– Loss of renal function– Hypertension

• BP checks with family doctor

Renal TraumaComplications

• Relatively uncommon

• Often in association with multi-system organ injury

• Significant mortality rate (10-20%)

• Have high index of suspicion of urethral disruption injury

• Bladder more susceptible to injury when full

Bladder TraumaGeneral Considerations

• Blunt

• Penetrating

• Iatrogenic

• Spontaneous rupture

Bladder TraumaEtiology

BLUNT• Most common type of bladder injury• Usually motor vehicle accidents• 2/3 contusions, 1/3 ruptures• Associated with pelvic #

– 10-25% of pelvic #’s have associated bladder injury– 85-90% of bladder injuries have associated pelvic #

PENETRATING• Less common• Often associated with major organ injuries

Bladder TraumaEtiology

IATROGENIC

• Open or laparoscopic pelvic surgery– Gynecologic, vascular, urologic or general surgery

SPONTANEOUS RUPTURE• Underlying pathology

– Cancer, obstruction, XRT, TB, sensory neurologic deficit

Bladder TraumaEtiology

• Hematuria

– 95% blunt injuries have gross hematuria

• Inability to void

• Abdominal pain

• Abdominal bruising

• Pelvic mass

• Peritoneal signs

• Shock

Bladder TraumaPresentation

• Cystogram– AP films ± obliques

– Remember drainage films• 10% of bladder ruptures detected on drainage films

• CT Cystogram– Often more efficient since most patients need CT anyway

– Provides additional helpful information about other organs

Bladder TraumaImaging

• Grade 1: Hematoma (contusion, intramural hematoma)Laceration (partial thickness)

• Grade 2: Laceration (extraperitoneal, <2cm)

• Grade 3: Laceration (extraperitoneal, 2cm)Laceration (intraperitoneal, <2cm)

• Grade 4: Laceration (intraperitoneal, 2cm)

• Grade 5: Laceration (intra- or extraperitoneal, extending into bladder neck, ureteral orifice, trigone)

Advance one grade for multiple injuries up to grade 3

Bladder TraumaAAST Organ Injury Severity Scale

• Contusion– Most common– Often diagnosis of exclusion

• Laceration/rupture– Extraperitoneal

vs. This is what we really need to know

– Intraperitoneal

Bladder TraumaPractical Classification

GENERAL PRINCIPLES

• ABCs

• Establish urinary drainage/diversion

• Antibiotics

CONTUSION– No specific therapy required

Bladder TraumaManagement

EXTRAPERITONEAL RUPTURE

• Conservative, catheter drainage x 7-14 days, cystogram

• Indications for surgical repair:– Patient already in O.R. for another reason– Associated rectal perforation or open pelvic fracture– Bone fragments projecting into bladder– Multiple/large ruptures

Bladder TraumaManagement

INTRAPERITONEAL RUPTURE

• Surgical repair– Midline laparotomy/cystotomy– Multi-layer closure of bladder injury– Bladder drainage

• Foley catheter ± suprapubic catheter

– Perivesical drain

Bladder TraumaManagement

• Intraperitoneal– Urinary frequency– Shock– Peritonitis– Azotemia

• Extraperitoneal– Shock– Pelvic abscess

Bladder TraumaComplications

• 46 y/o woman undergoes TAH-BSO for severe endometriosis– Significant bleeding intra-op, requires 4 units pRBCs

• POD# 4:– Still not able to tolerate solids– C/o R flank pain– T=38.6°C

• What would you do now?

Case #3

R kidney

L kidney

• External trauma very rare– <4% of penetrating trauma– <1% of blunt trauma– Look for concomitant visceral injuries (SB, LB, K, B)

• Usually surgical trauma– Gynecologic, vascular, urologic or general surgery

• Open• Laparoscopic

– Ureteroscopy

Ureteral TraumaEtiology

• At time of external trauma

• If unrecognized intra-op, then:– Low grade fever, ileus– Flank pain– Fluid drainage from incision, drain sites

• Hematuria may be absent

Ureteral TraumaPresentation

• Methylene blue– IV or renal pelvic injection– For suspected intra-op ureteral injury– Allows localization of injury

• IVP

• CT scan

• Ureteropyelogram– Retrograde– Antegrade

Ureteral TraumaDiagnostic Tests and Imaging

• Grade 1: Contusion (without devascularization)

Hematoma (without devascularization)

• Grade 2: Laceration (<50% transection)

• Grade 3: Laceration (50% transection)

• Grade 4: Laceration (complete transection with <2cm devascularization)

• Grade 5: Laceration (avulsion with >2cm devascularization)

Advance one grade for bilateral injuries up to grade 3

Ureteral TraumaAAST Organ Injury Severity Scale

• Factors to consider in determining treatment:– Etiology– Level of ureter involved– Immediate vs delayed Dx– Severity (contusion vs. complete transection)– Clinical status of patient

• Temporary PCN• Remove suture/clip• Ureteral stent insertion

Ureteral InjuryManagement

• Ureteroneocystostomy– ± Psoas hitch

– ± Boari flap

• Ureteroureterostomy• Transureteroureterostomy• Renal descensus• Ileal interposition• Autotransplantation• Nephrectomy (last resort)

Ureteral InjurySurgical Options

• Early– Hydronephrosis– Urinoma– Infection

• Late– Stricture– Loss of renal function– Stone formation

Ureteral InjuryComplications

• Usually due to blunt trauma– Sports, fights

• Testis involved in 1-2% of gunshot wounds• Pain, scrotal hematoma, bruising• Physical exam often difficult due to pain and

degree of swelling• U/S most useful investigation

– To determine if ruptured– May miss tunical fracture

Testis Trauma

• Grade 1: ContusionHematoma

• Grade 2: Subclinical laceration of tunica albuginea

• Grade 3: Laceration of TA with <50% parenchymal loss

• Grade 4: Major laceration of TA with 50% parenchymal loss

• Grade 5: Total testicular destruction or avulsion

Advance one grade for bilateral injuries up to grade 5

Testis TraumaAAST Organ Injury Severity Scale

• Most cases are low grade injuries (contusions or hematomas) and are therefore managed non-operatively– Ice, analgesics, bedrest/activity restrictions

• Indications to operate:– Rupture of tunica albuginea– Expanding or large hematocele– Intratesticular hematoma

• Surgery– Repair vs. orchidectomyTesticular salvage rate higher for early exploration

Testis TraumaManagement