By Dr. AHMED AL-ADL Assist Prof of Urology Urological Trauma By Dr. AHMED AL-ADL Assist Prof of Urology

Renal Trauma 1-5% of all trauma cases. The kidney is the most commonly injured. Male to female ratio of 3:1. Children are more prone to injury: Perirenal fat, Gerota’s fascia, lower ribs, kidney size.

Mode of injury Mechanisms 1 Blunt trauma 80-90%: Motor vehicle collision, falls, sports and assault. Traffic accidents  half of blunt injuries. A direct blow to the flank or abdomen during sports activities. Sudden deceleration or a crush injury  contusion or laceration of the parenchyma. Renal vascular injuries occur <5% of blunt abdominal trauma. Isolated renal artery injury is very rare and renal artery occlusion is associated with rapid deceleration injuries.

Mode of injury Mechanisms 2 Penetrating injuries 10 – 20% Gunshot and stab wounds  more severe and less predictable than blunt trauma. In urban settings, the percentage of penetrating injuries can be as high as 20% or higher. Bullets  greater parenchymal destruction and a/w multiple- organ injuries. Penetrating injury produces direct tissue disruption of the parenchyma, vascular pedicles, or collecting system.

Diagnostic evaluation Recommendations

Diagnostic evaluation Patient history and physical examination Vital signs should be recorded throughout the diagnostic evaluation. Airway With C-spine protection. Breathing. Circulation. Control external hemorrhage, 2 large bore IV sets. Disability. Assess neurologic system Exposure/Environment Undress / control temperature

Initial evaluation Hematuria is the hallmark Blunt trauma Signs: Degree doesn't correlate with extent. Seen in first void or catheter. May be absent 20-40% of renal pedicle injuries. Blunt trauma Quantify forces: fall or speed of vehicle (deceleration injury) suspect renal pedicle or UPJ. Multiple injuries Signs: Ecchymosis Fracture lower ribs Transverse spines

Penetrating trauma Firearm : SW : site and length Site from AAL Velocity High velocity extensive injury + tissue necrosis (blast effect) low velocity  minor injury SW : site and length Site from AAL Anterior & below nipple line  intra-abd injury Poster.  less likely usually minor

Laboratory evaluation Urinalysis, Hematocrit Baseline creatinine Serial Hct in combination with vital signs are used for continuous evaluation. Hct and the requirement for blood transfusions  signs of the rate of blood loss, and along with the patient’s response to resuscitation,

Indications of Renal Imaging Blunt trauma & gross hematuria. Blunt trauma, micro hematuria & shock. Micro hem >5 RBCs /HPF. Shock = SBP<90 mmHg . Major accel or deceleration (fall or motor accid) SW with Hematuria (gross or micro) after penetrating flank wound or entrance & exit inline with the kidney Pediatric <16 YO with any degree of hematuria Associated injuries & signs of (flank ecchymosis /tender, lumbar spine fracture, 11th or 12th posterior rib fracture.

Imaging Studies IVU CT US Arteriography Decisions  based on the clinical findings and the mechanism of injury.

Ultrasonography Can detect lacerations, but cannot accurately assess their depth and extent. No functional information about excretion or urine leakage. For routine follow up of parenchymal lesions or haematomas Resolution of urinomas For serial evaluation of stable injuries

Intravenous Urography Recommended only when it is the only modality available Non-function  extensive trauma to the kidney, pedicle injury, or a severely shattered kidney Extravasation  severe degree of trauma, involving the capsule, parenchyma and collecting system. Non-visualisation, contour deformity or contrast extravasation  further radiological evaluation One-shot intraoperative IVU In unstable patients undergoing emergency laparotomy,  normal functioning contralateral kidney. Bolus IV of 2 mL/kg of radiographic contrast followed by a single plain film taken after 10 minutes.

Computed tomography (CT) & IV contrast The best method for assessment of stable patients. Accurate location of injuries, Detects contusions and devitalized segments, Visualizes the entire retroperitoneum both the abdomen and pelvis and any associated hematomas It demonstrates superior anatomical details, Depth and location of lacerations and the presence of associated abdominal injuries Presence and location of the contralateral kidney No contrast enhancement = is a hallmark of pedicle injury or central parahilar hematoma Renal vein injury a large haematoma, medial to the kidney and displacing the vasculature

Magnetic resonance imaging (MRI) MRI is not commonly used. MRI requires a longer imaging time and limits access to patients during the examination. Useful if CT is not available, with iodine allergy, or in cases where CT findings are equivocal Radionuclide scans Required only in trauma patients with allergy to iodinated contrast material

A CT scan with enhancement of intravenous contrast material and delayed images is the gold standard for the diagnosis and staging of renal injuries in haemodynamically stable patients.

Classification systems AAST  The most commonly used the American Association for the Surgery of Trauma  predicts the need for intervention.  predicts morbidity and mortality after blunt or penetrating injury.

AAST renal injury grading scale

Disease management Conservative management nonoperative Strict bed rest  clear urine. Vital signs monitor Hct/6 Hrs Broad-spectrum Abx Bl Transf to keep Hct stable  if > 4-6 units /24 hrs  repeat imaging & possible arteriography & embolization or surgical explore For grade IV – re-image 3 to 5 days for persistent urine leak

Indications for renal exploration include: Haemodynamic instability; Exploration for associated injuries; Expanding or pulsatile peri-renal haematoma identified during laparotomy; Grade 5 vascular injury.

Reconstructive principles Broad exposure Temp vascular occlusion Sharp excision of devitalized parenchyma Meticulous hemostasis Water tight closure of C S. Parenchymal defect closure capsule and Gelfoam bolster, omentum, perinephric fat peritoneum of mesh Inter-position of omentum between injured organ and kidney Ureteric stent Retroperitoneal drainage.

Complications after renal trauma Usually within 1 month of injury Early complications Prolonged urine extravasation Small  no intervention Large  urinoma and abscess  Perc cath drainage Shock Renal infarction Abscess formation Late complications Delayed bleeding, AV fistula abscess urinary fistula  managed accordingly usually minimal Renovascular hypertension  transient if persist (renin –mediated) Perinephric fibrosis  PUJO  hydronephrosis At 3 to 6 months do CT or IVU  hydro , vascular compromise of renal atrophy.

Ureteral and Renal Pelvis Injuries

Mechanisms of injury External trauma Surgical trauma Penetrating injury rare 2.5% of all abd GSWs High velocity missiles a/w severe edema due to blast effect After deceleration injury in the kidney  UPJ and pedicle injury Surgical trauma Pelvic operations Iatrogenic urologic, URS, Gynecological op., pelvic vascular surgery Most common  hysterectomy at uterine vessels and cardinal ligament

Diagnosis Anatomy, blood supply, suspicion  lethal if unrecognized Hematuria not reliable sign – absent in 45% of pentrat trauma and 30- 60% of blunt trauma Missed ureteral injury : suspect if Prolonged ileus Elevated BUN Persistent abd or flank pain, palpable abd mass Prolonged urine drainage Urine obstruction Sepsis, abscess or peritonitis

Imaging Preoperative IVU CT Incomplete visualization of ureter Ureteric deviation or dilatation Extravasation Hydronephrosis Delayed or non-visualization of injured renal unite Retrograde pyelograpgy RPG not for acute trauma CT Medial perirenal extravasation & no filling of ipsilateral ureter If hypotension ? Not seen

Intraoperative Majority diagnosed Direct explore Injection of indigo carmine blue dye

Management Should not be missed during laparotomy Location Mechanisms Avulsion (UPJ) Contusion Transection, crush, ligation Associated injuries Penetrating  90% multiorgan Blunt 77%

Distal ureter below iliac vessels Ureteroneocystostomy Vesic-psoas hitch Transureterouretrostomy (TUU) Other procedures : Iliac interposition Boari flap Renal displacement Stenting

Midureteral injury Ureteroureterostomy : spatulated and water-tight, tension -free anastomosis DJ stenting.

Upper ureteric injury Ureteroureterostomy UPJ injury: Laceration or contusion  conserve Avulsion (children )  1ry surgical repair with ureteric stent and RP drain Unstable patient  no time for reconstruction – Cutaneous ureterostomy with single J stent NO PCN TUBE Reconstruct after 2 weeks

Management of complications Usually delayed recognition in 8 – 57% Sepsis, abscess, hydronephrosis & loss of renal function 50% Stricture & fistula Extravasation and urinoma If diagnosed within 2 weeks  surgical exploration and repair Ligation  repair and stent After 2 weeks - Proximal diversion by PCN tube or antegrade stent Definitive repair after 3 months

Bladder Trauma

Mechanism BLUNT Rare: PENETRATING <2% of all injuries requiring surgery Often with a severe associated injuries Associated with urethral rupture 10-29% and pelvic fracture 6-10% PENETRATING 2% Associated major abdominal injuries (35%) and shock (22%) Mortality high: 12%

Diagnosis Physical signs: Abdominal pain Abdominal tenderness Abdominal bruising Urethral catheter does not return urine Delayed? Fever No urine output Peritoneal signs  BUN / Creatinine

Hematuria 95% have gross hematuria Microhematuria  usually with minimal injury

Diagnosis: Plain Cystography 100% accurate when done properly: Adequate filling with 350 cc Drainage films Use 30% contrast Underfilling (250 cc) associated with false negatives

CT Cystography Preferred with other CTs Antegrade filling by “clamping the Foley” is not OK! Must dilute contrast (6:1 with saline, or to about 2-4%)

Main Points: Bladder Trauma Get a CT cystogram if pelvic fracture Most extraperitoneal ruptures can be managed conservatively, BUT: Consider treating extraperitoneal bladder ruptures OPEN, especially if undergoing laparotomy Microhematuria (no gross hematuria) usually means no significant injury to bladder

Thank You for Attention