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
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