Urological TraumaKidney, Ureter and Bladder

Adam M. Shiroff, M.D.Associate Trauma Program Director

Division of Acute Care SurgeryUMDNJ-RWJMS

Outline Renal Trauma Ureteral Trauma Bladder Trauma

Background Mechanisms of Injury Evaluation Treatment

Grade of RecommendationsA Based on clinical studies of good quality and

consistency addressing the specific recommendations and including at least one randomized trial

B Based on well-conducted clinical studies, but without randomized clinical trials

C Made despite the absence of directly applicable clinical studies of good quality

Renal Trauma

1-5% of all trauma cases Most commonly injured GU

organ 3:1 male to female ratio Can be acutely life threatening Most commonly managed

conservatively

Mode of Injury

Blunt vs Penetrating Blunt trauma 90-95% in

rural settings Penetrating trauma

>20% in urban settings

Blunt Trauma MVC, falls, pedestrians struck, contact

sports, assaults Automobile crashes >50% of renal

injuriesFront end collisions- deceleration injurySide impact- passenger compartment

Fall from height (n=423, 10-60)18% renal injuries, no correlation with height or ISS

Blunt Trauma- Types of Injuries Renal lacerations and

vascular injuries- only 10-15%

Renal artery occlusion-rapid deceleration injury, traction tear of intima, dissection, occlusion, and thombosis

Penetrating Trauma Gunshot and stabs Kinetic energy of GSW-

increased parenchymal destruction

Multiple organs injured Military experience- 25-

33% nephrectomies

AAST Injury Classification

Diagnosis and Treatment

Initial assessment of traumaATLS

Primary survey-ABCs Resuscitation Secondary imaging

Physical Exam Penetrating Mechanism

Stab or GWS to lower thorax, flank, upper abdomen Size of wound NOT indicative of depth

Blunt MechanismHematuria Flank pain/ecchymosis/abrasionsRib fracturesAbdominal pain/distension/tenderness

Laboratory

Urinalysis Hemoglobin/Hematocrit Baseline creatinine

Hematuria

Neither sensitive nor specific Does not correlate with degree of injury

Ureteropelvic junction disruption 9% of proven renal injuries following stabs

No hematuria Urine dip false negative rate up to 10%

Imaging

Ultrasound IVP One-shot intra-op IVP CT scan MRI Angiography

Imaging Decisions Clinical findings and mechanism Effort made to minimize risk

Discomfort, radiation exposure, allergic reaction, time and expense

Microscopic hematuria and no shock after blunt trauma- may not need renal directed imaging

Any hematuria following penetrating trauma mandates imaging

Ultrasound Popular in initial trauma management Quick, non-invasive, low-cost, no radiation Operator dependent Questionable value is setting of other

injuries Can detect lacerations, provide no

functional data (infarction/urine leak)

Ultrasound

More sensitive and specific for minor injuries than standard IVP in blunt trauma

Sensitivity may decrease with increasing severity of injury compared with IVP

Useful to follow parenchymal injuries, urinomas, retroperitoneal hematomas

Decide who needs more imaging

Standard IVP No longer study of choice for

trauma If only study available:

Include nephrotomograms, delineate renal contour, visualize excretion into B/L renal pelvis and into uretersNon-visualization, contour

deformity, or extravasation = major renal injury

Standard IVP

Non-function: extensive trauma to kidney, pedicle injury (vascular avulsion or thrombosis)

Extravasation: severe injury involving capsule, parenchyma, and collecting system

One-shot Intra-op IVP Unstable patients (no CT scan) 2ml/kg of radiographic contrast

IV bolus, single plain film after 10 minutes

Some information about injured kidney

Documents presence of functioning contralateral kidney

One-shot Intra-op IVP

Advocated by experts Studies not consistent that it is necessary

In penetrating trauma: PPV 20% (80% with normal study had injuries)

No use in regards to other abdominal injuries

CT Gold standard for stable patients More sensitive and specific than

IVP, Ultrasound and Angio Accurately defines:

Location and depth of injuries, contusionsDevitalized segmentsVisualize retroperitoneum

CT Documents presence and

function of contralateral kidney

Lack of enhancement = pedicle injury

Perihilar hematoma suggest pedicle or venous injury

Delayed scan needed to detect collecting system injuries

CT

Key part of evaluation of GSW who are being considered for non-operative management

MRI

Not used in majority of renal trauma patients

Shown to be viable option to replace CT if iodine allergyMisses urinary extravasation

Angiogram

Largely replaced by CT Less specific, more invasive

and more time consuming Has ability to be therapeutic

(selective embolization) Indicated for IR control of

hemorrhage

Nuclear Medicine Scan

Can document flow Perhaps in patients with severe allergy to

dye Rarely if ever used for trauma

Treatment- Indication for Exploration

Goal to minimize morbidity and preserve renal function

Management often influenced by other injuries

Life threatening hemorrhage = exploration

Expanding or pulsatile hematoma Grade 5 injury (except one report) are

indication for exploration

Treatment- Indication for Exploration

Urinary extravasation and devitalized fragmentsControversial, may be treated expectantly Increased risk for late surgery and

complications

Operation Exploration rate is low (10% or less) Vascular control at the aorta if possible

Rarely the case, tedious dissectionDecrease blood loss, lowers nephrectomy

rate, no worse azotemia or mortality post-op Reality- bring bleeding kidney to midline Nephrectomy rate is around 13%

Mostly following penetrating trauma

Operation

Other injuries increase likelihood of nephrectomy

Mortality associated with severity of trauma, not renal injury itself

GSWs with high velocity projectiles result in nephrectomy

Reconstruction Renorrhaphy is most common Partial nephrectomy Water-tight closure of collecting system vs

closure of parenchyma debated Omental flap/fat bolster for disrupted

capsule Fibrin glue works Floseal/Tisseal- not studied in trauma

Reconstruction Vascular injuries uncommon Often associated with other major injuries,

high morbidity and mortality Blunt renal artery injury = IR/angio/stent Grade 5 repair seldom effective

Attempt in cases with solitary kidney or bilateral injuriesOtherwise, nephrectomy

Angio-Embolization

In setting of hemodynamic stability Excellent at control of hematuria, 98% Successful hemostasis in both blunt and

penetrating trauma Minimal complications, effective in grade 4

injuries, unproven in grade 5

Non-Op Management

Treatment of choice Supportive treatment, bed-rest, hydration,

antibiotics Failure rate is approximately 1% Grade 1 and 2 injures

Manage non-operatively

Non-Op Management Grade 3 injuries:

Controversial, but recent literature favors expectant

Grade 4 and 5: Long history of operative treatmentAlmost all penetrating injuries require

exploration 20% of blunt injuries require exploration

Persistent bleed is indication for OR

Non-Op Management

Low-velocity GSW or stabs Must rule out ureteral or renal pelvis injury If stab wound is posterior to anterior

axillary line, 88% can be managed non-op Stabs with Grade 3 injuries have higher rate

of delayed complications

Post-op Care Risk of non-op treatment

complications increases with grade

Repeat imaging after 2-4 days minimizes complications (grade 3-5)

Follow usual laboratory values, urinalysis, and imaging as needed

Adult Blunt Renal Trauma

Adult Penetrating Renal Trauma

Evidence Based Recommendations

Penetrating trauma with any hematuria gets radiologic evaluation

Blunt trauma with hematuria and hypotension gets radiologic evaluation

Stable patients with Grades 1-4 get managed expectantly

Evidence Based Recommendations

Surgical management in setting of:HD instability Exploration for other injuries Expanding or pulsatile hematomaGrade 5 injury

Renal reconstruction once hemorrhage controlled

Repeat imaging 2-4 days post trauma

Ureteral Trauma

Ureteral Trauma

Injuries are uncommon Commonly with associated injuries Presentation, management and outcome

dictated by other injuries Early diagnosis is difficult (absence of

hematuria)

Diagnosis

No classic clinical symptoms or signs Must be suspected in cases of abdominal or

pelvic penetrating trauma (GSW) Blunt deceleration injuries (more common

in pediatric population) Hematuria in only 50% of patients

Ureteral trauma: patterns and mechanisms of injury of an uncommon conditionSiram, et al, AJS 2010

Imaging

Signs of upper tract obstruction Poor mans IVP (KUB 30 minutes after CT

bolus) Extravasation on delayed CT scan

Classification

Management

Partial injuries (Grade 1-2) Ureteral stenting or nephrostomy tube

No data, stenting may be superior Stabilization and reduced risk of stricture

Stent placed over wire across defect Foley for 2 days Stent for 3 weeks at least

Management

Complete injuries (Grade 3-5) Principles:

Debridement of ends to fresh tissue Spatulation Internal stent placementClosure with absorbable sutureCoverage with omentum or peritoneum

Repair Options

Upper third:Uretero-ureterostomy Transuretero-ureterostomyUreterocalycostomy

Middle third:Uretero-ureterostomy Transuretero-ureterostomyBoari flap and reimplantation

Repair Options

Lower third:Direct reimplantation Psoas hitchBlandy cystoplasty

Complete disruption: Ileal interpositionAutotransplantaion

Bladder Trauma

Bladder Trauma

2% of abdominal injuries that require repair Blunt trauma accounts for 67-86% Penetrating trauma 14-33% Most common cause is MVC (90%) 70-97% have associated pelvic rami

fractures

Evidence of anterior-posterior pelvic compression associated with bladder rupture Symphysis diastasis, SI disruption

Up to 30% of patients with pelvic fractures with have some bladder injury

Major injury in only 5-10% with pelvic fxr

25% of intraperitoneal ruptures occur without pelvic fracture

Mechanism

During MVC Seatbelt transmits forceDegree of distension

determines injury Full bladder ruptures with

minor force Empty bladder injured by

penetrating mechanism or crush injury

Combined intra- and extraperitoneal ruptures 2-20%

Simultaneous bladder and prostatic urethra rupture in 10-29% of male patients

Driving while intoxicatedBad decision, full bladder

Classification

Diagnosis

Most common sign is gross hematuria (82%)

Abdominal tenderness (62%) Inability to void Suprapubic tenderness/bruising Abdominal distension

Gross Hematuria

Indicative of urologic trauma Pelvic fracture and hematuria is an absolute

indication for cystogram Grossly clear urine eliminates bladder

rupture in all except 2-10%

Microscopic Hematuria

Paired with pelvic ring facture warrants further investigation

Amount of rbc/hpf is debated

Cystography

Retrograde cystography is standard With adequate filling and post-void images

Accuracy of 85-100%On post-void only in 10% of cases

Distension is crucial to demonstrating perforation

Must use at least 350ml of contrast

Intravenous pyelogram

Inadequate for trauma evaluation Contrast diluted Resting bladder pressure too low False negative rate of 64-84%

Ultrasound

Routinely used in initial evaluation Not routine to rule out bladder rupture Free fluid or failure to visualize bladder

suggestive

CT

Method of choice for evaluation of abdominal/pelvic trauma

Similar concerns with IVP, even in setting of clamped foley catheter

CT cystogram can be used in place of conventional cystography Sensitivity 95% and specificity

100%

Treatment Blunt trauma: Extraperitoneal

rupture Catheter drainage alone Success rate of 90% reported

87% healed at 10 daysAll by 3 weeks

Bladder neck, bony fragments or entrapment of bladder wall necessitates surgery

Treatment Blunt trauma: Intraperitoneal

rupture Surgical exploration High degree of force Mortality 20-40% Lacerations usually large High risk of associated

abdominal injuries

Treatment

Penetrating injuries: Surgical repair Two layers,

absorbable suture

Evidence Based Recommendations

Hematuria and pelvic fractures mandate cystogram

Cystogram must be done correctly CT cysto equivalent Extraperitoneal bladder rupture = catheter Intraperitoneal or penetrating mechanism

requires surgery

Damage Control

Abbreviated operation Resuscitation in ICU Avoid hypothermia, acidosis and

coagulopathy Department of Surgery Grand Rounds

December 8, 2010

Questions?

ReferencesBaverstock, R, Simons, R, McLoughlin, M. Severe blunt renal trauma: a 7-year retrospective reviewfrom a provincial trauma centre. Can J Urol 2001;8(5):1372-6.http://www.ncbi.nlm.nih.gov/pubmed/11718633

Brandes SB, McAninch JW. Urban free falls and patterns of renal injury: a 20-year experience with 396cases. J Trauma 1999;47(4):643-9; discussion 649-50.http://www.ncbi.nlm.nih.gov/pubmed/10528597

Abu-Zidan FM, Al-Tawheed A, Ali YM. Urologic injuries in the Gulf War. Int Urol Nephrol 1999;31(5):577-83. http://www.ncbi.nlm.nih.gov/pubmed/10755347

Paquette E L. Genitourinary trauma at a combat support hospital during Operation Iraqi Freedom: the impact of body armor. J Urol 2007;177(6):2196-9; discussion 2199. http://www.ncbi.nlm.nih.gov/pubmed/17509316

Schmidlin FR, Iselin CE, Naimi A, Rohner S, Borst F, Farshad M, Niederer P, Graber P. The higher injury risk of abnormal kidneys in blunt renal trauma. Scand J Urol Nephrol 1998;32(6):388-92. http://www.ncbi.nlm.nih.gov/pubmed/9925001

Hardeman SW, Husmann DA, Chinn HK, Peters PC. Blunt urinary tract trauma: identifying those patients who require radiological diagnostic studies. J Urol 1987;138(1):99-101. http://www.ncbi.nlm.nih.gov/pubmed/3599230

36. McAndrew JD, Corriere JN Jr. Radiographic evaluation of renal trauma: evaluation of 1103 consecutive patients. Br J Urol 1994;73(4):352-4. http://www.ncbi.nlm.nih.gov/pubmed/8199819

Urological TraumaKidney, Ureter and BladderOutlineGrade of RecommendationsRenal TraumaMode of InjuryBlunt TraumaBlunt Trauma- Types of InjuriesPenetrating TraumaAAST Injury ClassificationSlide Number 10Diagnosis and TreatmentPhysical ExamLaboratoryHematuriaImagingImaging DecisionsUltrasoundUltrasoundStandard IVPStandard IVPOne-shot Intra-op IVPOne-shot Intra-op IVPCTCTCTMRIAngiogramNuclear Medicine ScanTreatment- Indication for ExplorationTreatment- Indication for ExplorationOperationOperationReconstructionReconstructionAngio-EmbolizationNon-Op ManagementNon-Op ManagementNon-Op ManagementPost-op CareAdult Blunt Renal TraumaAdult Penetrating Renal TraumaEvidence Based RecommendationsEvidence Based RecommendationsUreteral TraumaUreteral TraumaDiagnosisUreteral trauma: patterns and mechanisms of injury of an uncommon conditionSiram, et al, AJS 2010ImagingClassificationManagementManagementRepair OptionsRepair OptionsBladder TraumaBladder TraumaSlide Number 56MechanismSlide Number 58ClassificationDiagnosisGross HematuriaMicroscopic HematuriaCystographyIntravenous pyelogramUltrasoundCTTreatmentTreatmentTreatmentEvidence Based RecommendationsDamage ControlQuestions?References