Genitourinary Trauma

10thJan, 2013

By : Ext. Sirada Chittiwan

Ext. Jaipisut
Rattanakajornsak
Introduction

• 10-20% of all injured patients

• Kidney : The most common
• Life-threatening injuries first

A : airway with cervical spine protection

B : breathing
C : circulation and control of external
bleeding
D : disability or neurological status
E: exposure (undress) and
environment (temperature control)
Content

• Upper Urinary tract trauma

 Renal injuries
 Ureteral injuries
• Lower Urinary tract trauma
 Bladder injuries
 Urethral injuries
• External Genitalia injuries
 Upper
Urinary tract
trauma
Renal Injuries
RENAL INJURIES : Etiology
• The most common of all injuries to the GU
system
• Blunt trauma 80-85%
– Motor vehicle accidents, fights, falls, contact
sports
– Vehicle collision at high speed : rapid deceleration
, major vascular injury
• Penetrating : Associated abdominal visceral
injuries 80%
- Gunshot wounds
- Stab wounds
Mechanism of Renal Injuries
Clinical findings

• Pain : localized to one flank area or over the

abdomen
• Gross or microscopic hematuria
• Ecchymosis in the flank or upper quadrants of
the abdomen
• Lower ribs or transverse process fracture
• Palpable mass : large retroperitoneal hematoma
or urinary extravasation
• Generalized peritonitis
 American Association for Surgery of Trauma
Organ Injury Severity Scale for the Kidneys

Classification
Indications for Renal Imaging

• Blunt trauma with gross hematuria

• Blunt trauma with microscopic hematuria and
shock (SBP < 90 mmHg anytime)
• Penetrating injuries with any degree of
hematuria
• Pediatric patients (< 16 years)
• suspected any possible renal injury (e.g. patients
sustaining blunt trauma from rapid
deceleration )
Imaging studies

• Contrast-enhanced CT -- preferred
• Single-shot intraoperative excretory urography
• Arteriography
• Sonography
Imaging Studies : Contrast-Enhanced CT

The preferred imaging study;

• Parenchymal lacerations
• Extravasation of contrast-enhanced urine
• Associated injuries
• Degree of retroperitoneal bleeding
• Lack of uptake of contrast material in the
parenchyma suggests arterial injury
 Findings on CT that
suggest Major
injury
(1) medial hematoma : suggesting vascular injury

(2)medial urinary extravasation : suggesting renal

pelvis or ureteropelvic junction avulsion injury

(3)lack of contrast enhancement of the

parenchyma : suggesting arterial injury
 Single-shot intraoperative IVP

• Only a single film is taken 10 minutes after

intravenous injection (IV push) of 2 mL/kg of
contrast material
• If findings are not normal or near normal, the kidney
should be explored to complete the staging of the
injury and reconstruct any abnormality found
 Arteriography

• To define arterial injuries suspected on CT

• To localize arterial bleeding that can be controlled
by embolization
 Sonography

• Immediate evaluation of injuries

• Confirms the presence of two kidneys
• Can easily define any retroperitoneal hematoma
• Cannot clearly delineate parenchymal lacerations
and vascular or collecting system injuries
• Cannot accurately detect urinary extravasation in
acute injuries
MANAGEMENT
• Nonoperative Management
• Operative Management
Nonoperative Management :
Isolated Renal Injuries

• Approximately 80% to 90% of renal injuries have

major associated organ injury
• Blunt trauma can be managed nonoperatively
• Patients with grade IV parenchymal lacerations can be
observed expectantly
• Complete bed rest
• IV fluid replacement
• ATB prophylaxis
• Analgesic and Sedation
•TT prophylaxis
Operative Management

• Absolute indications
– Evidence of persistent renal bleeding
– Expanding perirenal hematoma
– Pulsatile perirenal hematoma
• Relative indications
– Urinary extravasation
– Nonviable tissue
– Delayed diagnosis of arterial injury
– Segmental arterial injury
– Incomplete staging
Renal Exploration

Surgical exploration of the

acutely injured kidney is best done by

Transabdominal approach

allows complete inspection of

intra-abdominal organs and bowel
Surgical Approach to
the renal vessels and kidney
Renal Reconstruction
Technique for Renorrhaphy
Renovascular Injuries
Indications for Nephrectomy

• Unstable patient, with low body temperature and

poor coagulation
• Extensive renal injuries when the patient’s life
would be threatened by attempted renal repair
Complications

• Urinoma – internal ureteral stent

• Perinephric abscess – percutaneous
draingage, surgical drainage
• Delayed renal bleeding
– Usuall occurs within 21 days
– Angiography and embolization
• Hypertension
Arterial Hypertension

• Renal vascular injury, leading to stenosis

or occlusion of the main renal artery or one
of its branches
• Compression of the renal parenchymal with
extravasated blood or urine
• Post-trauma arteriovenous fistula
Ureteral Injuries
URETERAL INJURIES : Etiology

• External Trauma (20%)

- After external violence are rare (<1%)
- 10 - 28% have associated renal injuries
- 5% have associated bladder injuries
• Surgical Injury (80%)
– Pelvic surgical procedure (M/C: Hysterectomy)
– Endoscopic manipulation, etc.
Clinical findings

• Post operative fever

• Flank and lower quadrant pain
• Paralytic ileus with nausea and vomitting
• Peritonitis
• Uretervaginal fistula
• Ureterocutaneous fistula
• Hematuria
American Association for the Surgery of Trauma
Organ Injury Severity Scale for the Ureter
Imaging Studies

• Excretory Urography : intraoperative one-shot

pyelography
• Computed Tomography - IVP
• Retrograde Ureterography
• Antegrade Ureterography : If retrograde stent
placement is not possible
Imaging findings

• Excretory urography
– Delayed function
– Hydronephrosis
– Extravasation
• Retrograde
ureterography
– Demonstrates the exact
site of obstruction or
extravasation
Treatment

• Repair when injury occurs

– Before 7 days  immediate Reexploration and
repair
– Delayed diagnosis  nephrostomy + repair after
3 months
Goals of ureteral repair
– Complete debridement, tension-free spatulated
anastomosis, watertight closure, ureteral
stenting, retroperitoneal drainage