Urological Trauma for the General Surgeon

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Urological Trauma for the General Surgeon

• Key H. Stage, M.D., FACS
• Maine Chapter ACS
• Bar Harbor, Maine 2009

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Etiology and ClassificationRenal Injuries

• 80-90 renal injuries due to blunt trauma
• lt 5 of blunt injury need exploration
• gt 45 are associated with other injuries
• Liver, Small Bowel, Spleen, Stomach, and pancreas
• 10-20 renal injuries due to penetrating trauma
• The majority have associated injuries

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Initial Evaluation

• Hematuria
• Present in gt 95 of renal trauma
• Poor correlation with extent of injury
• Urinary dipstick is more sensitive and more
  economical than urinalysis
• May be absent in up to 25 of severe parenchymal
  or renal vascular injuries

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Criteria for Radiographic Assessment

• Adult
• Gross Hematuria
• Microscopic hematuria with SBP lt90mmHg
• High clinical suspicion for renal injury
• Penetrating trauma if stable

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Criteria for Radiographic Assessment

• Pediatric
• Children less than 16 years old with any degree
  of hematuria require radiological assessment

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One shot IVP
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Radiological Studies

• CT
• Most sensitive and specific
• Study of choice in stable patients
• IVP
• nephrotomograms necessary for adequate staging
• one shot IVP for emergent surgical cases
• Angiography
• Assessment of persistent or delayed bleeding
• Non-visualization

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Absolute Indications for Exploration

• Expanding hematoma
• Pulsatile hematoma
• Known grade V injuries
• Life-threatening renal bleeding
• Unstaged retroperitoneal hematoma

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Relative Indications for Exploration

• Devitalized Parenchyma
• Injuries with 25-50 devitalized segment and
  associated intraabdominal injury managed
  conservatively have 82 urologic complication
  rate.
• Surgical repair reduced postinjury complications
  from 82 to 23

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Grading of Renal InjuriesAmerican Association
for the Surgery of Trauma

• Grade I
• Renal contusion
• Subcapsular hematoma without parenchymal
  laceration
• Grade II
• Perirenal hematoma well-contained
• Renal cortex laceration lt 1cm without
  extravasation

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Grade I
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Grading of Renal Injuries

• Grade III
• Renal cortex laceration gt 1cm without
  extravasation
• Grade IV
• Renal cortical laceration into collecting system
• Main renal artery or vein injury with contained
  hemorrhage

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Grading of Renal Injuries

• Grade V
• Shattered kidney
• Avulsion of renal pedicle

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Grade V Blunt renal injury
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Management

• All blunt grade I and II injuries can be managed
  non-operatively
• Grade III and IV injuries can be managed
  non-operatively based on complete radiological
  assessment
• When laparotomy is required for other injuries,
  grade III ? and IV injuries should be explored
  and repaired

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Management

• Grade IV injuries associated with extravasation
  can be managed non-operatively
• Resolution rate of 76-87
• Open surgery needed in 9 of patients with
  extravasation
• Nephrectomy rate 4.5

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Blunt Renal Trauma
Microhematuria (gt5 RBCs/HPF) No shock (Systolic
BP gt 9o mm.)
Gross Hematuria, Shock microhematuria Pediatric
pt. gt50 RBCs/HPF
Renal imaging not necessary (except with
deceleration or multiple assoc.. injuries)
Stable
Unstable
Abdominal CT
Laparotomy, one shot IVP
Assoc. injuries, laparotomy
Normal
Abnormal, inconclusive
Observe
No assoc. injuries
Pulsatile, expanding retroperitoneal hematoma
Stable retroperitoneal hematoma
Grade III,IV, V
Grade I, II
Renal exploration
Observe
Observe
Selective renal exploration
Grade I-III
Observe
Grade IV-V,ureter,UPJ, renovascular
Selective renal exploration
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Penetrating Renal Trauma
Hematuria, Gross and Microscopic
Unstable
Stable
Exploratory laparotomy, One shot IVP
Abdominal CT
Grade I-II
Grade III
Normal IVP
Abnormal IVP, inconclusive
Grade IV-V
Laparotomy for assoc. injuries
Stable retroperitoneal hematoma
Pulsatile, expanding retroperitoneal hematoma
Yes
No
Renal Exploration
Observe
Observe
Observe
Selective renal exploration
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Surgical Reconstruction

• Early vascular control
• Mobilization and broad exposure
• Temporary vascular occlusion for brisk bleeding
• Debridement of non-viable parenchyma

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Surgical Reconstruction

• Closure of collecting system
• Reapproximation of capsular/parenchymal
• Omental pedicle flap for associated injuries
• Retroperitoneal drain placement

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Stabwound Lower Pole R Kidney
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Penetrating Renal Trauma
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Penetrating Renal Trauma Debridement
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Penetrating Renal Trauma Repair
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Dacron Mesh Wrap
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Complications

• Delayed bleeding
• Urinoma
• Abscess
• Fistula
• Hypertension

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Vascular Injuries

• Surgical revascularization for unilateral renal
  artery occlusion seldom results in a successful
  outcome
• Revascularization is indicated in pts. with
  injury to a solitary kidney, bilateral renal
  artery occlusion, or unilateral occlusion with a
  warm ischemia time of lt 5 hrs.
• Haas and Spirnak, Techniques in Urology, Vol. 4,
  No. 1, 1998, pp. 1-11

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Vascular Injuries

• Low success rate compounded by high incidence of
  associated abdominal injuries.
• Late sequelae of revascularization is
  hypertension and decreased renal function

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Renal Anomalies

• Ascent Simple renal ectopia Pelvic, iliac,
  abdominal, thoracic. Incidence 1 in 900
• Form and fusion Crossed ectopia with and
  without fusion Unilateral fused, sigmoid, lump,
  L-shaped, disc. Incidence 1 in 2000
• Horseshoe Incidence 1 in 400

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Crossed fused ectopia
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Horseshoe Kidney
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Ureteral Injury Recognition

• Many ureteral injuries recognized postoperatively
• Early signs non-specificfever, ileus,flank or
  abdominal pain
• ? drainage, hematuria, mass, anuria
• 1/3 may be asymptomatic, diagnosis delayed 10-21
  days in 2/3 of all pts.

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GSW ureteruretero-duodenal fistula
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Ureteral Injuries

• Intraoperative recognition Inspection, gentle
  dissection, use of IV or intra-ureteral indigo
  carmine, intraoperative retrograde pyelogram,
  gentle ureteral occlusion
• Previous films if availableIVP, CT to assess
  function and anatomy of contralateral system

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Ureteral Injuries

• Complete transection Ureteral spatulation and
  reanastomosis over a stent with drainage. If the
  length of the injury is gt 2cm., consider
  reimplantation or TUU
• Ischemia discoloration, lack of peristalsis,
  absence of bleeding may indicate loss of adequate
  blood supply..debride to bleed, poss. use of
  flourescein

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Ureteral Injuries

• Ureteral ligation only as a last resort in a
  life-threatening situation. Follow this with a
  PCN
• Easiest bailout procedure with a compromised
  pt. and a complicated ureteral injury is
  insertion of an 8F feeding tube to the ureter,
  and brought to the skin as a cutaneous
  ureterostomy

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Ureteral Injuries

• Operative nephrostomy is almost never necessary
• If the injured ureter can be repaired at the same
  time as the injury, there is much less morbidity
  and gives the best chance for surgical success as
  compared to a staged procedure.

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Principles of Ureteral Repair

• Debridement of ureteral damage
• Watertight closure-absorbable suture
• Tension-free, spatulated anastomosis
• Ureteral stenting and drain
• Isolation of repair from contaminated or
  associated injuries

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Management of Bladder Trauma

• Extraperitoneal bladder rupture
• Conservative management
• Urethral catheter alone
• Intraperitoneal bladder rupture
• Operative management
• Suprapubic tube placement and cystorrhaphy

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Extraperitoneal Bladder rupture
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Intraperitoneal bladder rupture
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Urethral Injuries

• Anterior
• Posterior
• Blunt
• Penetrating

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Definitions

• Posterior prostatic or membranous
• Associated with pelvic fracture in gt90
• Straddle (four rami) fx with S-I diastasis 24x
  more likely to have urethral trauma
• Anterior bulbous or penile
• more commonly injured
• rarely associated with pelvic fx

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Pelvic Fracture Suspected Urologic Trauma
Blood at Urethral Meatus
Unable to pass catheter
No Blood at Urethral Meatus
Pass urethral catheter
Retrograde Urethrogram
Normal
Urethral rupture with extravasation
Hematuria (Gross or Microscopic)
No hematuria
Surgical Intervention
Observation
CT or IVP renal imaging when indicated. Evaluate
microhematuria if deceleration injury, eval. all
gross hematuria
Cystogram (gt300 cc. Contrast in bladder. Fill
and post-drain films)
No extravasation
Extravasation
Extraperitoneal
Intraperitoneal
Observation
Catheter drainage alone x 2 wks. Formal repair
if pt. has laparotomy for other reasons, or
injury to bladder neck
Surgical Intervention
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Diagnosis

• Physical examination
• Gross hematuria or anuria
• Blood at meatus or perineal swelling
• High-riding prostate
• Imaging
• Plain films (pelvic fx)
• RGUG (complete vs. partial)
• CT or IVP (bladder upper tracts)

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Type I Posterior urethra intact, stretched
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Type IIPartial or complete tear above GU
diaphragm
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Type IIIPartial or complete combined injury with
disruption of GU diaphragm
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Potential Complications

• Erectile Dysfunction
• Incontinence
• Stricture

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External Genitalia

• Scrotum
• Penis
• Testicles

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Take Home Bullet PointsRenal Trauma

• Blunt more common than penetrating
• Exploration rarely needed if adequate staging for
  blunt, explore all penetrating
• CT ideal, one shot IVP better than nothing
• Keep congenital anomalies in mindhorseshoe,
  pelvic kidney etc.

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Take Home Bullet PointsUreteral Trauma

• Recognize early if possible, remember later if
  necessary
• Use absorbable suture for repair with drain and
  stent
• Bailout for damage control PCN and/or diverting
  urostomy with feeding tube

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Take Home Bullet PointsBladder Trauma

• Gross hematuria and pelvic fracture is
  significant
• Extraperitoneal rupture Catheter alone
• Intraperitoneal rupture Explore, cystorraphy
  and SP cystostomy

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Take Home Bullet PointsUrethral Trauma

• Percutaneous or formal SP tube diversion never
  wrong
• Remember pattern of hematoma-anterior or
  posterior urethral injury
• Primary urethral alignment with SP tube for
  posterior urethral injury always ideal, even if
  delayed

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Take Home Bullet PointsExternal Genitalia Injury

• Debridement and wound care initially,
  reconstruction much later
• Thigh pouch for testicles if necessary at later
  stage
• Divert urine with SP tube if necessary
• If in doubt-EXPLORE-for scrotal injury

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Self-confidence
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Different Perspective
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Thirsty
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Helping Hand
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