1. Traumatic Urological Emergencies
Uğur Kaan Kalem
Gr. V

2. TOPIC PAGE Introduction 3 Renal Trauma 7 Ureteral Trauma 24 Bladder Trauma 30 Urethral Trauma 44 Sources 57
Index

3. INTRODUCTION

4. Timely identification and management of blunt genitourinary injuries minimize associated morbidity, which may include impairment of urinary continence and sexual function.

5. Except in the rare instance of a shattered kidney or major renal vascular laceration, genitourinary injuries seldom pose a threat to life.
Once life-threatening conditions are stabilized, investigation for genitourinary injury is conducted in a retrograde fashion.

6. Common mechanisms of injury include motor vehicle collisions (MVC), falls from height, and direct blows to the torso or external genitalia.
Other important mechanisms include physical or sexual assault, and penetrating injuries.
As the genitourinary tract is seldom injured in isolation, a meticulous physical examination is crucial to avoid missing occult injuries.

7. RENAL TRAUMA

9. Epidemiology & Etiology
Renal trauma occurs in approximately 1-5% of all trauma cases. Renal injuries are associated with young age and male gender, and the incidence is about 4.9 per 100,000.
Most injuries can be managed conservatively.
Decreased the need for surgical intervention and increased organ preservation.
Epidemiology & Etiology

10. Mechanism Blunt Renal Injuries: MVC Falls from height
Vehicle-associated pedestrian accidents
Direct blow to the flank or abdomen during sports activities
Assault
Mechanism

11. In general, renal vascular injuries occur in less than 5% of blunt abdominal trauma, while isolated renal artery injury is very rare ( %)

12. Penetrating Renal Injuries:
Gunshot and stab wounds (most common cause) more severe and less predictable than blunt trauma.
Bullets have the potential for great parenchymal destruction and are most often associated with multiple-organ injuries.
Penetrating injury produces direct tissue disruption of the parenchyma, vascular pedicles, or collecting system.

13. Gunshot Wound

14. AAST Renal Injury Grading Scale

16. Laboratory Evaluation
Urinalysis, hematocrit and baseline creatinine are the most important tests.
Hematuria, either non-visible or visible, is neither sensitive nor specific enough to differentiate between minor and major injuries.

17. Serial hematocrit determination is part of the continuous evaluation
Serial hematocrit determination is part of the continuous evaluation. A decrease in hematocrit and the requirement for blood transfusions are signs of blood loss.
A urine dipstick is an acceptable, reliable and rapid test to evaluate hematuria (false-negative results range from 3-10%)

18. Radiographic Assessment
Renal imaging should be undertaken in blunt trauma if there is macroscopic hematuria or microscopic hematuria and hypotension (SBP< 90 mmHg)
In patients with penetrating trauma, with the suspicion of renal injury, imaging is indicated regardless of hematuria.
Radiographic Assessment

19. Computed tomography (CT)
Ultrasonography (US)
Intravenous pyelography (IVP)
Intraoperative pyelography
Computed tomography (CT)
Magnetic resonance imaging (MRI)

20. Management

23. Complications Bleeding Infection Perinephric abscess Sepsis
Urinary Fistula
Hypertension
Chronic Pyelonephritis
Calculus Formation
AV fistula
Hydronephrosis
Complications

24. URETERAL TRAUMA

26. Epidemiology & Etiology
Ureteral trauma accounts for 1-2.5% of urinary tract trauma.
Greater incidence of penetrating external ureteral trauma (mainly gunshot wounds)
1/3 of cases by blunt trauma (mainly by MVC)
Iatrogenic (Esp. Gynecological approaches)
Epidemiology & Etiology

27. Diagnosis is challenging
Delayed Diagnosis
Flank pain
Urinary incontinence
Urinary leakage
Haematuria
Fever

28. Radiographic Assessment
Extravasation of contrast medium on CT is the hallmark sign of ureteral trauma.
Retrograde or Antegrade Urography is the gold standard for confirmation
Radiographic Assessment

29. Management

30. BLADDER TRAUMA

31. Etiology

32. Incidence of iatrogenic bladder trauma

33. Diagnostic Evaluation
Cardinal sign is visible hematuria.
Diagnostic Evaluation

34. Cystography
Cystoscopy US
Imaging

35. Cystography:
Cystography is the preferred diagnostic modality for non-iatrogenic bladder injury and for a suspected iatrogenic bladder trauma.
Both plain and CT cystography have a comparable sensitivity (90-95%) and specificity (100%)

39. Management Conservative Management
Clinical observation, continuous bladder drainage and antibiotic prophylaxis
Surgical Management
Blunt non-iatrogenic trauma
Penetrating non-iatrogenic trauma
Iatrogenic trauma
Foreign body
Management

40. Blunt non-iatrogenic trauma
Non-complicated extraperitoneal ruptures can be treated conservatively.
Other organ/tissue involvments with ext. Peritoneal ruptures may need surgical intervention.

41. Blunt non-iatrogenic trauma
Intraperitoneal ruptures are always managed by surgical repair. Otherwise, intraperitoneal urine extravasation can lead to:
Peritonitis
Intra-abdominal sepsis
Death

42. Penetrating non-iatrogenic trauma
The standard treatment is emergency exploration, debridement, and primary bladder repair.

43. Iatrogenic trauma Perforations recognised intra-operatively are primarily closed. Intraperitoneal Extraperitoneal

44. URETHRAL TRAUMA

46. The most common type of urethral trauma seen in urological practice is iatrogenic, due to catheterisation, instrumentation, or surgery.
Iatrogenic urethral trauma usually results from improper or prolonged catheterisation and accounts for 32% of strictures.
The size and type of catheter used have an important impact on urethral stricture formation. 
Etiology

49. Transurethral procedures are a common cause of iatrogenic urethral trauma.
In the presence of urethral disruption, a suprapubic catheter should be placed.

51. Clinical Signs Blood at the meatus (cardinal sign)
Inability to void (with a palpable distended bladder)
Scrotal, penile, and perineal swelling and ecchymosis
Inability to pass a urethral catheter
Hematuria and pain
Prostate displaced superiorly
Clinical Signs

52. Suspect if there is a:
Penetrating abdominal or genital injury
Anterior pelvic fracture
Open pelvic fracture
Perineal laceration

53. Retrograde urethrography (standard diagnostic investigation in acute phase)
Flexible cystoscopy is an option to diagnose and manage an acute urethral injury.
Radiography

54. Goldman classification of urethral trauma

57. European Association of Urology Urological Trauma 2016 Guidelines (
UpToDate keyword «genitourinary trauma» (
PubMed keyword «genitourinary trauma» (
keywords «ureteral trauma», «uretral trauma», «bladder trauma»
Sources