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

3. 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.

4. 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.

5. 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.

6. Diagnostic evaluation Recommendations

7. 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

8. 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

9. 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

10. 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,

11. 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.

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

13. 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

14. 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.

15. 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

16. 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

17. 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.

18. 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.

19. AAST renal injury grading scale

27. 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

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

29. 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.

31. 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.

32. Ureteral and Renal Pelvis Injuries

33. 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

34. Diagnosis Anatomy, blood supply, suspicion  lethal if unrecognized
Hematuria not reliable sign – absent in 45% of pentrat trauma and % 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

35. 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

36. Intraoperative Majority diagnosed Direct explore
Injection of indigo carmine blue dye

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

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

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

40. 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

41. 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

42. Bladder Trauma

43. 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%

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

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

46. 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

47. 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%)

48. 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

49. Thank You for Attention