1. Doc. MUDr. Robert Grill PhDr.
Urologická klinika 3. LF UK a FNKV
Urological Trauma
Doc. MUDr. Robert Grill PhDr.

2. Renal trauma-aetiology and pathogenesis
Penetrating trauma
( stab wounds, gunshots injuries)
Blunt trauma
( 80-85% of all kidney´s traumas)
- direct blunt impact
- deceleration injuries
Iatrogenic
(parenchymal injury during surgery , ESWL, percutan extraction of concrement ) a b
Mechanisms of renal injury a) direct blunt impact
b) deceleration

3. Renal injury classification
AAST renal injury grading scale
Grade 1 - Contusion or non-expanding subcapsular haematoma, no laceration
Grade 2 - Non-expanding peri-renal haematoma, Cortical laceration < 1 cm deep without extravasation
Grade 3 - Cortical laceration > 1 cm without urinary extravasation
Grade 4 - Laceration through corticomedullary junction into collecting system or segmental renal artery or vein injury with contained haematoma, or partial vessel laceration, or vessel thrombosis
Grade 5 - shattered kidney or renal pedicle or avulsion.

4. Renal injury- symptomatology
Haematuria ( at 80-90% renal trauma)- no correlation between level of haematuria and degree of injury / 1/3 of wounded does not suffer by haematuria /
Abdominal tenderness extended during palpation
Abdominal abrasions
Ribs fracture
Nausea, vomiting, blockage of the intestine , acute abdomen signs
Symptoms of hypovolemic shock ( systolic pressure < 90mm Hg, P > 90/min, decreased or no urine output, pale skin color, cool, clammy skin …..).

5. Diagnosis of renal injuries
Haemodynamic stability of patient is the fundamental criterion
History of accident - background of injury (rapid deceleration, direct blow to the flank, the size of the weapon in stabbings…)
Patient´s medical history – focusing on pre-existing kidney dysfunctions and diseases
( hydronephrosis, nephrolithiasis, kidney cysts, kidney tumors, kidney surgeries )
Physical assessment - haematuria, flank abrassions, flank palpable pain, palpable mass in the kidney area, abdominal distension, acute abdomen signs, fractured ribs
Laboratory evaluation - urinalysis, regular haematocrit controlling, creatinine baseline

6. Diagnosis of renal injuries
Imaging – criteria for radiographic assessment - gross or microscopic haematuria and shock, associated major injuries
Ultrasonography - provides a quick, non-invasive, low-cost means of detecting peritoneal fluid collections, can detect degree of renal injury, eliminate solitary kidney, dopplers assessment of functional state of kidney, indication for other radiological examination
Standard IVP - offers basic information about kidney functionality, nowadays supplied by contrast CT examination. Unstable patients selected for immediate operative intervention / ,,one-shot“ IVP/ are exception for using Standard IVP.
Computed tomography – CT is a standard method used on stable patients. It is more sensitive and specific than IVP, USG and angiography. CT detects the location of injuries, evaluates details and functionality of kindneys, defines pre-existing abnormalities and associated traumas.
Magnetic resonance imaging - MRI has no advantage in compare with CT, it requires a longer imaging time, increases the cost, and limits access to patients when they are in the magnet during the examination. MRI is therefore useful in renal trauma if patient suffers with iodine allergy or renal insuficience.
Angiography - has been largely replaced by CT as the use of angiography is less specific, more time-consuming and more invasive. Angiography may be preferable when planning selective embolisation for the management of persistent or delayed haemorrhage from branching renal vessels .

7. Renal injuries- Computed tomography
Grade 5 - shattered kidney/ arrow/
Grade 3 - Cortical laceration

8. Treatment and prognosis in renal injuries
Non-operative therapy – choice for the majority stable patients with renal injuries grade 1-4
(bed-rest, hydration, antibiotics, continuous imaging examinations, hemostyptic therapy, monitoring of vital signs ).
Surgical management
Indications – haemodynamic instability
- exploration for associated injuries
- expanding or pulsatile peri-renal haematoma identified during laparotomy
- grade 5 injury
- incidental finding of pre-existing renal pathology requiring surgical therapy

9. Early and delayed complications at renal trauma
Early complications - occur within the first month after injury and can be bleeding, infection, peri-nephric abscess, sepsis, urinary fistula, hypertension, urinary extravasation, and urinoma.
Delayed complications - include bleeding, hydronephrosis, calculus formation, chronic pyelonephritis, hypertension ( less than 5% patients ), arteriovenous fistulae, hydronephrosis and pseudoaneurysms.

10. Ureteral trauma-aetiology and pathogenesis
Very rare and accounts for only 1% of all urinary tract trauma.
Blunt trauma 18%
Penetrating trauma 7%
Iatrogenic 75%
- gynecological 73% ( hysterectomy, ovarectomy, gynecologic laparoskopy surgery…)
- surgical 14% ( colorectal surgery, abdominal vascular surgery….)
- urological 14% ( ureteroscopy, insertion of ureteral catheter )

11. AAST ureteral injuries classification
Grade 1: Haematoma only
Grade 2: Laceration < 50% of circumference
Grade 3: Laceration > 50% of circumference
Grade 4: Complete tear < 2 cm of devascularisation
Grade 5: Complete tear > 2 cm of devascularisation

12. Ureteral trauma symptoms
Varies according to aetiology and difficulty of injury :
Abdominal and flank pain
Haematuria in different levels
Faebrilia
Decreased urine output
Nausea, vomiting
Urosepsis
Acute abdomen signs

13. Diagnosis of ureteral trauma
Physical assessment
Laboratory examination (urinalysis, blood testing, renal functions )
Imaging - Ultrasonography (hydronephrosis, hydroureter, extravasation of urine )
- Plain abdominal X-rays
- IVP (delayed excretion, ureteral dilatation, ureteral deviation, extravasation of radiological contrast material)
- CT scan (delayed excretion, ureteral dilatation, extravasation of radiological contrast material, urinoma)

14. Ureteral trauma-IVP
Urinary extravasation from the middle third of the left ureter /after ureteroscopy/

15. Therapy of ureteral trauma
Treatment depends on the extent and the location of uretal trauma :
Grade 1 and 2 can be managed non-surgical with ureteral stenting or nephrostomy.
Grade 3 to 5 need a reconstructive repair. The type of reconstructive repair procedure depends on the nature and the site of the injury.
The options for repair of ureteral injuries
- Uretero-ureterostomy
- Ureterocalycostomy
- Transuretero-ureterostomy
- Boari flap and reimplantation
- Ureterocystostomy
- Psoas hitch
- Ileal interposition

16. Complications at ureteral trauma
Urinoma
Periureteral abscess
Fistula
Strictura

17. Bladder trauma - aetiology and pathogenesis
2% of all abdominal injuries, often associated with pelvic fracture
Blunt trauma - caused by direct impacts at the pelvic area or lower abdominal at patients with the full bladder, % of patiens suffer pelvic fractures at the same time
Penetrating trauma- gunshots, stub wounds
Iatrogenic trauma-1/2 of all bladder traumas (transuretral operation of prostatis, bladder, gynaecological operations, hernioplasty)

18. Bladder injury classification
Classification of bladder injury according to AAST
Grade 1 - Contusion
Grade 2 - Intraperitoneal bladder wall laceration
Grade 3 – Intersticial injury
Grade 4 - Extraperitoneal bladder wall laceration
- simple
- complicated
Grade 5 – combination of injuries intraperitoneal and extraperitoneal
Extraperitoneal bladder wall laceration

19. Bladder trauma symptoms
Lower abdominal pain
Gross haematuria most common signs
Nausea, vomiting
Paralytic ileus
Peritonitis
Inability to void
Bruises over the suprapubic region
Haemoragic shock

20. Diagnosis of bladder traumas
Physical assessment – lower abdominal pain, crepitations and instability of pelvic ring, abrassions…..
Laboratory examination – urianalysis and blood examination
Imaging
- Retrograde ureterocystography : standardly used method, sensitivity of 100%, it is neccessary to fill the bladder with a minimum of 350 ml of dilute contrast material
- CT cystography : this procedure should be performed using retrograde filling of the bladder with dilute contrast material
- IVP : is inadequate for evaluation of the bladder trauma ( dilution of the contrast material within the bladder, too low resting intravesical pressure to demonstrate a small tear )

21. Bladder trauma- Retrograde cystography
Intra and extraperitoneal bladder wall laceration
Extraperitoneal bladder wall laceration

22. Therapy of bladder traumas
Extraperitoneal bladder ruptures - managed by catheter drainage alone, ATB treatment
Indications for surgical repair :
- intraperitoneal bladder ruptures
- bladder neck injuries
- the presence of bone fragments in the bladder wall
- entrapment of the bladder wall by bone fragments
- associated injuries that require surgical intervention, are managed by interdisciplinary cooperation

23. Urethral trauma Male urethral injury
The posterior urethra - prostatic and the membranous urethra.
The anterior urethra - bulbar and penile urethra.

24. Urethral trauma – aetiology and pathogenesis
1. Posterior urethral injuries
Mostly the result of pelvic fractures
/ height falls, traffic accidents /
2. Anterior urethral injuries
Blunt trauma
Penetrating injuries
Iatrogenic injuries
Automutilation

25. Classification of urethral injuries
Classification of blunt anterior and posterior urethral injury
Grade 1 : Stretch injury. Elongation of the urethra without extravasation on urethrography
Grade 2 : Contusion. Blood at the urethral meatus, no extravasation on urethrography
Grade 3 : Partial disruption of anterior or posterior urethra. Extravasation of contrast at injury site with contrast visualised in the proximal urethra or bladder
Grade 4 : Complete disruption of anterior urethra. Extravasation of contrast at injury site without visualisation of proximal urethral or bladder
Grade 5 : Complete disruption of posterior urethra. Extravasation of contrast at injury site without visualisation of bladder
Grade 6 : Complete or partial disruption of posterior urethra with associated tear of the bladder neck or vagina

26. Symptoms of urethral trauma
Lower abdominal pain
Urethrorrhagia
Inability to void
Perineal haematoma

27. Urethral trauma diagnosis
Physical assessment – lower abdomen pain,urethrorrhagia, crepitations and instability of pelvic ring, ecchymosis, high-riding prostate, perineal haematoma
Laboratory examination – urinalysis and blood testing
Imaging
- retrograde urethrography – gold standard for evaluating urethral injury
- CT and MRI : used in defining distorted pelvic anatomy after severe injury and assessing associated injuries of other organs
- USG : useful in determining the position of pelvic haematomas, or the exact location of the bladder when a suprapubic catheter is indicated.

28. Urethral trauma- retrograde urethrography
Normal retrograde urethrography
Disruption of posterior urethra

29. Therapy of urethral traumas
I. Anterior urethral injuries therapy
Grade 1 – no treatment is neccessary
Grade 2 and 3 - urethral catheterisation or suprapubic cystostomy
More complicated injuries -suprapubic derivation, delayed optic uretrotomy, urethral dilatation, longer defects of the anterior urethra should be repaired by an end-to-end anastomosis, defects over 1cm by flap urethroplasty
Open injuries
- primary urethral suturing
- defects of more than 1 cm in length a two-stage urethral repair
II. Posterior urethral injuries therapy
Partial urethral rupture - suprapubic or urethral catheter.
Complete urethral rupture - primary endoscopic realignment, immediate open urethroplasty ,
- delayed primary urethroplasty,
- delayed formal urethroplasty,
- delayed endoscopic incision

30. Female urethral injuries
Only the posterior urethra exists in the female
Rare injuries due to length and limited connection to pubic bone
Most often during the delivery, iatrogenic trauma, pelvic fracture, fracture of ventral part of pelvic ring
Symptoms are similar to male urethral trauma
In diagnostic,urethroscopy is prefered to technically hard performed urethrography
Most female urethral disruptions can be sutured primarily either transvaginally or transvesically

31. Complications at urethral trauma
Urinary incontinence
Erectile dysfunction
Urethral stricture
Fistulae or urethral pseudodiverticula

32. Genital trauma Penile trauma Prostate and seminal vesicles trauma
Scrotal trauma

33. Penile trauma Aetiology
Blunt trauma – penile fracture, ischemic gangrene, thermal and chemical injuries
Penetrating trauma – gunshots wounds, stab, cuts
Sympthoms
Pain, haematoma, inability to void, bleeding
Diagnosis
Physical assessment /palpable tenderness, haematoma, haematuria /
USG, Retrograde urethrography / to eliminate an injury of urethra/
Therapy
In penile fracture- surgical intervention
Reimplantation in case of total penile amputation
In associated injury of urethra-epicystostomia, urethral catheterisation

34. Prostate and seminal vesicles trauma
Aetiology
Injury of the prostate and posterior urethra associated with pelvic trauma
Iatrogenic-prostate biopsy
Symptoms
rectorrhagia
Perineal pain
Urethrorrhagia, hematuria
Fever, septic shock
Diagnosis
Physical assessment -digital rectal examination/pain, oedema, fluctuation /
USG, NMR true Pelvis
Therapy
ATB, hemostyptic drugs, rectum tamponade, incision and drainage of prostatic abscess

35. Scrotal trauma Aetiology Blunt trauma
Penetrating trauma / rare injuries /
Iatrogenic trauma
Symptomatology
Depends on the extent of the injury / pain, bleeding, swollen /
Diagnostic
Physical assessment –inspection, palpation
USG, CT, NMR
Therapy
Depends on the extent of the injury / from conservative management to reconstruction of scrotum /
Complications
Post-traumatic testicular atrophy
Testicular cancer

36. Adrenal trauma-aetiology
Vary in infants and adults
Blunt trauma
Penetrating trauma
Iatrogenic trauma
Infants post-delivery trauma

37. Adrenal trauma - symptoms
Haemoragic shock
Palpable resistance
Acute adrenal insufficiency /tachypnoe,
fever, petechiae and purpura, metabolic collapse, abdominal pain, vomiting and diarrhoea, spasm and cyanosis/ most common in infants with bilateral adrenal injury

38. Adrenal trauma-diagnosis
Physical assessment / palpable resistance, hypovolemic shock symptoms /
Abdominal X-ray /kidney dislocation, contour calcification/
IVP
CT with urography
Umbilical Vein Angiography
Nefroblastoma(Wilms`Tumor ) in differential diagnosis

39. Adrenal trauma-therapy
Conservative management with blood loss compensation, corticoid substitute, correction of metabolic interference
Surgical intervention in cases unable to treat non-operative – exploration, nephroadrenalectomy

40. Thank you for your attention
Literature - Traumata urogenitální soustavy Doc. MUDr. Robert Grill, Ph.D. - Urologie 2009 Kawaciuk et kolektív - Všeobecná urologie 2006 Emil A. Tanagho, Jack W. McAninch - EAU Guidelines on urological trauma N. Djakovic, E. Plas, L. Martínez-Piñeiro, et kol Teaching Atlas of Urologic Imaging Older / Bassignani
Thank you for your attention