Genitourinary Tract Trauma

Wen-xuan Chen Department of urology Tianjin medical university General hospital

Introduction
About 10% of all injuries in the emergency room are genitourinary injuries. The most commonly injured organ is the kidney; the second is the urethra and the third is the bladder.

Renal Trauma

Introduction
Renal trauma is not common and occurs in approximately 1-5% of all traumas. Although the majority of renal traumas are mild,sometimes renal trauma can also be acutely life-threatening.

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.

Etiology
Blunt Trauma:
Blunt trauma directly to the abdomen,flank,or back is the most common mechanism,accounting for 80~85% of all renal injuries. Trauma may result from motor vehicle accidents, fights,falls,and contact sports.

Etiology
Penetrating Trauma:
Gunshot and knife wounds cause most penetrating injuries to the kidney. Any such wound in the flank area should be regarded as a cause of renal injury until proved otherwise. Renal injuries from penetrating trauma tend to be more severe and less predictable.

Pathologic Classification
Minor renal trauma (85% of cases)
Renal contusion of the parenchyma is the most common lesion. Subcapsular hematoma and superficial cortical lacerations are also considered minor trauma. These injuries rarely require surgical exploration.

Pathologic Classification
Major renal trauma (15% of cases)
Deep corticomedullary lacerations may extend into the collecting system,resulting in extravasation of urine into the perirenal space. Large retroperitoneal and perinephric hematomas often accompany these deep lacerations. Multiple lacerations may cause complete destruction of the kidney which may be called shattered kidney

Pathologic Classification
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 and result in total destruction of the kidney.

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 system which 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.

Description of injury
Grade 1: contusion or non-expanding subcapsular haematoma no laceration

Description of injury
Grade 2: non-expanding perirenal haematoma cortical laceration < 1cm deep without extravasation

Description of injury
Grade 3: cortical laceration>1cm without urinary extravasation

Description of injury
Grade 4: Parenchymal laceration extending through the corticomedullary junction and into the collecting system

Description of injury
Grade 4: segmental renal artery or vein injury with contained haematoma

Description of injury
Grade 5: multiple major lacerations, resulting in a shattered kidney

Description of injury
Grade 5: avulsion of the main renal artery and/or vein

Which grade?

Which grade?

Which grade?

Clinical Findings
Microscopic or gross hematuria following trauma to the abdomen indicates injury to the urinary tract. It bears repeating that stab or gunshot wounds to the flank area should alert the physician to possible renal injury whether or not hematuria is present.

Clinical Findings
The degree of renal injury does not correspond to the degree of hematuria,since gross hematuria may occur in minor renal trauma and only mild hematuria in major trauma. Patients with gross hematuria or microscopic hematuria with shock should undergo radiographic assessment;patients with microscopic hematuria without shock need not.

Clinical Findings
If physical examination or associated injuries prompt reasonable suspicion of renal injury, renal imaging should be undertaken. This is especially true of patients with rapid deceleration trauma,who may have renal injury without the presence of hematuria.

Clinical Findings
A. Symptoms:
Pain may be localized to one flank area or over the abdomen. Catheterization usually reveals hematuria. Retroperitoneal bleeding may cause abdominal distention,ileus,and nausea and vomiting.

Clinical Findings
B. Signs:
Initially,shock or signs of a large loss of blood from heavy retroperitoneal bleeding may be noted. Ecchymosis in the flank or upper quadrants of the abdomen is often noted. Diffuse abdominal tenderness may be found on palpation.

Clinical Findings
B. Signs:
A palpable mass in the flank or abdomen may represent a large retroperitoneal hematoma or perhaps urinary extravasation. The abdomen may be distended and bowel sounds absent.

Clinical Findings
C. laboratory evaluation:
Haematuria (microscopic or gross) is a hallmark sign of renal injury. But haematuria is neither sensitive nor specific for differentiating minor and major injuries and it does not correlate with the degree of injury. In case of disruption of the ureteropelvic junction,renal pedicle injuries,and segmental arterial thrombosis,no haematuria is present.

Clinical Findings
C. laboratory evaluation:
The hematocrit may be normal initially,but a drop may be found when serial studies are done. This findings represents persistent retroperitoneal bleeding and development of a large retroperitoneal hematoma. Persistent bleeding may necessitate operation.

Clinical Findings
D. Staging and Imaging :
Adequate imaging studies help define the extent of injury and dictate appropriate management. Imaging studies include Ultrasonography, Intravenous Pyelography(IVP), Computed Tomography (CT), Magnetic Resonance Imaging(MRI), and Angiography.

Clinical Findings
D. Staging and Imaging :
Ultrasonography is a quick,non-invasive,lowcost imaging modality and is popularly used in the primary evaluation of polytrauma patients. Ultrasound scans can detect renal lacerations but can not definitely assess their depth and extent and do not provide functional information about renal excretion.

Clinical Findings
D. Staging and Imaging :
A CT scan with enhancement is the best imaging study for diagnosing and staging renal injuries in haemodynamically stable patients. This non-invasive technique clearly defines parenchymal lacerations and urinary extravasation,shows the extent of the retroperitoneal hematoma,and outlines injuries to surrounding organs such as the pancreas,spleens,liver,et al.

Clinical Findings
D. Staging and Imaging :
IVP,MRI are reliable alternative methods of imaging renal trauma when CT is not available.

IVP may show extensive extravasation of radiopaque material if the kidney is lacerated.
Nonvisualization of the kidney requires immediate arteriography or CT scan to determine whether renal vascular injury exists

Clinical Findings
D. Staging and Imaging :
Angiography can be used for diagnosis and simutaneous selective embolization of bleeding vessels.

Management
A. Emergency measures:
The objectives of early management are prompt treatment of shock and haemorrhage,complete resuscitation,and evaluation of associated injuries.

Management
B. Conservative measures:
Stable patients,following grade 1-4 blunt renal trauma,should be managed conservatively with bed-rest for 2 weeks,prophylactic antibiotics,and continuous monitoring of vital signs until haematuria resolves.

Management
B. Conservative measures:
Stable patients,following grade 1-3 stab and low-velocity gunshot wounds after complete staging,should be selected for expectant management.

Management
C. Indications for surgical measures:
1. haemodynamic instability 2. exploration for associated injuries 3. expanding or pulsatile perirenal haematoma identified during laparotomy 4. a grade V injury 5. incidental finding of pre-existing renal pathology requiring surgical therapy

Complications
A. Early complications:
Early complications occur within the first month after injury which include bleeding,infection, perinephric abscess,sepsis,and urinary extravasation and urinoma. Hemorrhage is perhaps the most important immediate complication of renal injury.

Complications
A. Early 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% of cases.

Complications
A. Early complications:
Urinary extravasation from renal fracture may show as an expanding mass (urinoma) in the retroperitoneum. These collections are prone to abscess formation and sepsis. A resolving retroperitoneal hematoma may cause slight fever,but higher temperatures suggest infection.

Complications
B. Late complications:
Hypertension,hydronephrosis,calculus formation, pyelonephritis,and arteriovenous fistula are important late complications . At 3-6 months,a follow-up excretory urogram or CT scan should be obtained to be certain that perinephric scarring has not caused hydronephrosis or vascular compromise.

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.

Prognosis
Most renal injureis have an excellent prognosis. Follow up should involve physical exmination, urinalysis, excretory urography, serial blood presure measurement and serum determination of renal function.

Injuries to the ureter

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.

Clinical Findings
A. Symptoms and signs:
If the ureter has been injured during operation, the patient may complain of flank and lower abdominal pain on the injured side Fever,nausea and vomiting are often present.

Anuria following pelvic surgery means bilateral ureteral ligation until proved otherwise

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.

Clinical Findings
B. Laboratory Findings:
Microscopic hematuria is usually found. Tests of renal function will be normal unless both ureters are occluded.

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.

Excretory urography demonstrating extravasation in the upper right ureter consequent to stab wound. Note lack of contrast (arrow) in the ureter below the site of injury, indicating complete ureteral transection.

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.

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

AASTs classification
Grade 1 haematoma only Grade 2 laceration < 50% of circumference Grade 3 laceration > 50% of circumference Grade 4 complete tear<2cm of devascularization Grade 5 complete tear>2cm of devascularization

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 days after the event and no infection,abscess,or other complications exist,immediate reexploration and repair are indicated.

Management
If the injury is recognized late or if the patient has significant complications that make immediate reconstruction unsatisfactory,proximal urinary drainage by percutaneous nephrostomy or formal nephrostomy should be considered.

Management
A. Partial injuries:
These can be defined as grade 1 to grade 2 lesions. Once recognized,they can be managed with ureteral stenting or by placement of a nephrostomy tube to divert urine. If this technique is utilized,a bladder catheter should be left in place for 2 days to limit stent reflux during voiding.

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 during immediate surgical exploration,primary closure of the ureteral ends over a stent may be recommended,with placement of an external drain adjacent to the injury.

Management

Double J tube an indwelling stent

Management
B. Complete injuries:
These are grade 3 to 4 injuries. Successful repair should utilize the principles described in below.

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

Management

Ureteroureterostomy

Management

The type of reconstructive repair procedure chosen by the surgeon depends on the nature and site of the injury

Management

Injuries to the upper third of the ureter are best managed by primary ureteroureterostomy.

Management

Midureteral injuries usually result from external violence and are best repaired by primary ureteroureterostomy or transureteroureterostomy

Management
Transureteroureterostomy may be used in lower-third injuries if extensive urinoma and pelvic infection have developed. This procedure allows anastomosis and reconstruction in area away from the pathologic processes.

Management

Prognosis
The prognosis for ureteral injury is excellent if the diagnosis is made early and prompt corrective surgery is done.

Delay in diagnosis worsens the prognosis because of infection,hydronephrosis,abscess, and fistula formation.

Injuries to the bladder

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.

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.

Mechanism
A direct blow over the full bladder causes increased intravesical pressure. If the bladder ruptures,it will usually rupture into the peritoneal cavity.

Classification
Type 1 2 Description Bladder contusion Intraperitoneal rupture

3
4

Interstitial bladder injury

Extraperitoneal rupture

Combined injury

Clinical Findings
A. Symptom and signs:
The two most common sign and symptoms are gross haematuria (82%) and abdominal tenderness (62%)in patients with major bladder injuries. Other findings may include the inability to void, bruises over the suprapubic region and abdominal distension. Extravasation of urine may result in swelling in the perineum,scrotum and thighs.

Clinical Findings
B. Laboratory Findings:
Catheterization usually is required in patients with pelvic trauma but not if bloody urethral discharge is noted. Bloody urethral discharge indicates urethral injury,and a urethrogram is necessary before catheterization. When catheterization is done,gross or,less commonly,microscopic hematuria is usually present.

Clinical Findings
C. X-Ray Findings
A plain abdominal film generally demonstrates pelvic fractures. An intravenous urogram should be obtained to establish whether kidney and ureteral injuries are present.

Clinical Findings
D. Cystography:
Retrograde cystography is the standard and the most accurate radiological study for diagnosing bladder rupture.When adequate bladder filling and post-void images are obtained,it has an accuracy rate of 85-100%. Immediate cystography is required in the presence of haematuria and pelvic fracture.

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 postdrainage film. Half-filled film and obliques are optional.

Plain film

cystogram

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 blunt trauma 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 exploration and repair.

Prognosis
With appropriate treatment,the prognosis is excellent. Early diagnosis and treatment lead to low rate complications and death.

Injuries to the urethra

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 bulbous and pendulous portions; 2. the posterior urethra, consisting of the prostatic and membranous portions.

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 injuries caused by blows of blunt objects against the perineum.

Injury to the bulbous urethra

Mechanism: Usually a perineal blow or fall astride an object; crushing of urethra against inferior edge of pubic symphysis

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 or bladder

Complete disruption: extravasation of contrast at

injury site without visualization of proximal urethra or bladder

Clinical Findings
A. Symptoms and Signs:
There is usually a history of a fall,and in some cases a history of instrumentation. Bleeding from the urethra is usually present. There is local pain into the perineum and sometimes massive perineal hematoma.

Clinical Findings
A. Symptoms and Signs:
The patient may complain of pain on urination or inability to void. If voiding has occurred and extravasation is noted,sudden swelling in the area will be present. If diagnosis has been delayed,sepsis and severe infection may be present.

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
B. Laboratory Findings:
The amount of urethral bleeding correlates poorly with the severity of injury. A contusion or partial disruption may be accompanied by plenty of bleeding while total disruption may result in little bleeding.

Clinical Findings
C. X-Ray Findings:
Retrograde urethrography is considered the gold standard for evaluating urethral injury. A urethrogram,with instillation of 15-20ml of water soluble contrast material,demonstrates extravasation and the location of injury. A contused urethra shows no evidence of extravasation.

Clinical Findings
D. Instrumental Examination:
If there is no evidence of extravasation on the urethrogram,a urethral catheter may be passed into the bladder. Extravasation is a contraindication to further instrumentation at this time.

Management
General Measures:
Major blood loss usually does not occur from straddle injury. If heavy bleeding does occur,local pressure for control,followed by resuscitation,is required.

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 catheter drainage can be done.

Management
B. Urethral disruptions:
A suprapubic cystostomy tube should be placed and maintained for approximately 4 weeks . Voiding cystourethrography is then performed and if normal voiding can be re-established and no contrast extravasation nor subsequent stricture is present,then the tube can be safely removed.

Management
B. Urethral disruptions:
Immediate repair of urethral lacerations can be performed,but the procedure is difficult and the incidence of associated stricture is high.

Complications
The potential early complications of acute urethral injuries include stricture and infections. Drainage of extensive urinary extravasation and large hematoma may be required.

Complications
Prompt urinary diversion coupled with the appropriate administration of antibiotics decreases the incidence of these complications. Urethral stricture may be managed with optical urethrotomy,anastomotic urethroplasty or flap urethroplasty.

Injuries to the posterior urethra

Posterior urethral injury commonly occur from blunt trauma and pelvic fractures. When pelvic fractures occur from blunt trauma, the membranous urethra is sheared from the prostatic apex at the prostatomembranous junction. Urinary extravasation and bleeding are periprostatic and perivesical.

Injuries to the posterior urethra

The prostate has been avulsed from the membranous urethra secondary to fracture of the pelvis. Extravasation occurs above the triangular ligament and is periprostatic and perivesical

Clinical Findings
A. Symptoms:
A history of crushing injury to the pelvis is usually obtained. Patients usually complain of lower abdominal pain and inability to urinate.

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
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 examination.

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 superiorly.

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 catheterization should not be attempted.

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 extravasation at the prostatomembranous junction. Ordinarily,there is free extravasation of contrast material into the perivesical space.

Clinical Findings
D. X-Ray Findings:
Incomplete prostatomembranous disruption is seen as minor extravasation,with a portion of contrast material passing into the prostatic urethra and bladder.

Clinical Findings
E. Instrumental Examination:
The only instrumentation involved should be for urethrography. Catheterization or urethroscopy should not be done,because these procedures pose an increased risk of hematoma,infection,and further damage to partial urethral disruptions.

Retrograde urethrogram demonstrating complete posterior urethral disruption.

Management
A. Emergency measures:
Shock and hemorrhage should be treated.

Management
B. Surgical measures:
Initial management should consist of suprapubic cystostomy to provide urinary drainage. The suprapubic cystostomy is maintained in place for about 3 months.This allows resolution of the pelvic hematoma,and the prostate and bladder will slowly return to their anatomic positions.

Management
B. Surgical measures:
Incomplete laceration of 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.

Management
B. Surgical measures:
Urethral reconstruction can be undertaken within 3 months,assuming there is no pelvic abscess or other evidence of persistent pelvic infection. Before reconstruction,a combined cystogram and urethrogram should be done to determine the exact length of the resulting urethral stricture.

Combination urethrogram and cystogram demonstrating a 2-cm urethral rupture defect (arrow).

Management
B. Surgical measures:
If the stricture is <2cm long,the preferred approach is a single-stage reconstruction with direct excision of the strictured area and anastomosis of the bulbous urethra directly to the apex of the prostate.

Complications
Late complications include urethral stricture at the site of healing. Impotence as a result of damage to local nerves or blood vessels,is permanent in about 10% of patients. Urinary incontinence seldom follows transpubic or perineal reconstruction.If present,it usually resolves slowly.